Acute Necrotizing Ulcerative Gingivitis (ANUG)

The usually abrupt onset may be accompanied by malaise or fever. The chief manifestations are

Ulcerations, which are pathognomonic, are present on the dental papillae and marginal gingiva. These ulcerations have a characteristically punched-out appearance and are covered by a gray pseudomembrane. Similar lesions on the buccal mucosa and tonsils are rare. Swallowing and talking may be painful. Regional lymphadenopathy often is present.

Often, ANUG can manifest without a significant odor, and it also may manifest as a localized condition.

Rarely, tonsillar or pharyngeal tissues are affected, and diphtheria or infection due to agranulocytosis must be ruled out by throat culture and complete blood count when the gum manifestations do not respond quickly to conventional therapy.

Treatment of ANUG consists of gentle debridement with a hand scaler or ultrasonic device. Debridement is done over several days. The patient uses a soft toothbrush or washcloth to wipe the teeth.

Rinses at hourly intervals with warm normal saline or twice a day with 1.5% hydrogen peroxide or 0.12% chlorhexidine may help during the first few days after initial debridement.

Essential supportive measures include improving oral hygiene (done gently at first), adequate nutrition, high fluid intake, rest, analgesics as needed, and avoiding irritation (eg, caused by smoking or hot or spicy foods). Marked improvement usually occurs within 24 to 48 hours, after which debridement can be completed.

If debridement is delayed (eg, if a dentist or the instruments necessary for debridement are unavailable), oral antibiotics (eg, amoxicillin 500 mg every 8 hours, erythromycin 250 mg every 6 hours, or tetracycline 250 mg every 6 hours) may help to provide relief and can be continued until 72 hours after symptoms resolve.

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