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Bad Breath, Painful Gums, ‘White Stuff’

Wiler, Jennifer L. MD, MBA

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doi: 10.1097/01.EEM.0000441171.96629.7d

    A 35-year-old man presents to the ED with a complaint of foul breath, painful gums that bleed easily, and “white stuff” on his gums and tongue that began about three days earlier.


    He denies any medical problems and HIV risk factors. He also denies night sweats, unintentional weight loss, rash, and sore throat.

    Here is what you see on examination. What is the diagnosis, and how would you treat this condition?

    Diagnosis: Acute Necrotizing Ulcerative Gingivitis

    Acute necrotizing ulcerative gingivitis (ANUG), also known as Vincent's angina or trench mouth, is a severe form of gingivitis. This noncontagious condition likely received its colloquial name after its widespread development in soldiers who served in World War I. Reports of the condition trace back to Greek soldiers in the 4th century BC, however. Uncommon in developed nations, it is seen more often in nations with high malnutrition rates.

    Gingivitis is an inflammatory process of the mucosal epithelial tissue of the gums, and is classified by duration (acute vs. chronic), etiology (hormone-induced, infectious, etc.), and clinical appearance (ulcerative, hemorrhagic, etc.). ANUG is part of a spectrum of necrotizing periodontal diseases, and is one of seven broad categories of periodontal diseases. (Ann Periodontol 1999;4[1]:1.)

    The etiology of the most common gingivitis is by local inflammation related to microbial plaque proliferation. ANUG is a different condition from acute infection by aggressive bacteria; that type results in accelerated tissue destruction. The etiology of ANUG is typically anaerobic bacteria, and it is most commonly caused by Fusobacteria and Spirochaeta but also can include Peptostreptococcus, Prevotella, and Bacteroides species. The most aggressive form of necrotizing ulcerative periodontitis is cancrum oris (noma), which is characterized by spread into the face and mouth.

    Risk factors for developing ANUG include immunosuppression, poor oral hygiene, smoking, malnutrition, recent illness, and psychological stress. Young white adults also appear to be at increased risk for unclear reasons. (Epidemiol Rev 1988;10:191.)

    Diagnosiing ANUG is clinical, characterized by painful gums that bleed easily, blunting and ulceration/necrotic sloughing of the interdental papillae (gum tissue between teeth) and gingiva. It is often associated with intraoral fetid halitosis (foul breath), and patients occasionally complain of a metallic taste in the mouth.

    The extension of disease beyond the mucogingival junction (causing destruction of the epithelium, connective tissue, and interdental papillae with subsequent loss of the periodontal attachment and invasion into bone) characterizes necrotizing stomatitis. Patients with ANUG rarely have systemic symptoms, but those with necrotizing stomatitis may have fever, fatigue, malaise, and regional adenopathy. (J Orthod 2013;40[1]:77.) Chronic periodontitis is rarely painful, which is an easy way to differentiate the two conditions. The differential diagnosis also includes herpetic stomatitis and acute leukemia.

    Treatment includes irrigation and debridement of necrotic areas, and referral to a dentist or peridontist is important. (J Can Dent Assoc 2013;79:d46.) Topical treatment with antimicrobial oral rinses (hydrogen peroxide 3% solution, chlorhexidine 0.12% oral rinse, etc.) can help recovery. (J Periodontol 2006;77[8]:1380; J Clin Periodontol 2006;33[8]:561.) Antibiotics to cover anaerobic bacteria (metronidazole) are reserved for patients with signs of systemic illness. (J West Soc Periodontol Periodontal Abstr 2001;49[2]:37.) Counseling about prevention including improved oral hygiene is important. Analgesics including topical anesthetics and nonsteroidal anti-inflammatory drugs (NSAIDs) are often required for patients to perform good oral care. (J Clin Periodontol 1993;20[10]:723.)

    If left untreated, ANUG can spread to the surrounding local tissue of the jaw and facial soft tissue, and result in devastating disfigurement. This is uncommon, however, in a nourished immunocompetent individual.

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