Acute Necrotizing Ulcerative Gingivitis

Acute necrotizing ulcerative gingivitis (necrotising gingivitis) is a painful, rapidly progressive gingival infection characterised by necrosis and ulceration of the interdental papillae, spontaneous bleeding and a foul odour. It is caused by a fusiform and spirochaetal flora (Fusobacterium, Prevotella intermedia, Treponema species, Selenomonas) overgrowing in a host with impaired defence.

The disease is uncommon in healthy populations (under 1 percent) but is a marker of immunosuppression. Associated factors are:

• HIV with low CD4 count
• severe malnutrition
• psychological stress
• smoking
• poor oral hygiene
• recent illness
• sleep deprivation

In young children with malnutrition and infections, in Sub-Saharan Africa, it can progress to noma (cancrum oris), a gangrenous destruction of facial tissue with a mortality of up to 90 percent without treatment.

Progression to necrotising periodontitis involves loss of attachment and bone, and necrotising stomatitis involves the mucosa beyond the gingiva.

• Sudden onset of severe gingival pain, with a punched out, crater like interdental papilla covered by a grey pseudomembrane.
• Spontaneous or easily provoked gingival bleeding, marked halitosis (fetor oris), metallic taste, excessive salivation.
• Low grade fever, malaise, cervical lymphadenopathy.
• Difficulty eating, tooth mobility if periodontitis is present.
• Noma: foul necrotic mucosal lesion progressing to cheek, lip, and facial skin, with a black eschar and large facial defect.
• Red flags: facial swelling or discolouration, trismus, spreading necrosis, dehydration, severe malnutrition, fever above 38.5 degrees C, and HIV-related immunosuppression.

• Clinical diagnosis from the triad of papillary necrosis, gingival bleeding and pain.
• Assess nutrition (weight for height, mid-upper arm circumference below 11.5 cm in children), hydration, temperature and the extent of necrosis.
• HIV test (with CD4 count), full blood count, glucose, and malaria test in endemic areas.
• Swab for microscopy and culture only if atypical; Gram stain shows fusiform bacilli and spirochaetes (not necessary for diagnosis).
• Periapical or panoramic radiographs for bone loss in necrotising periodontitis.
• Exclude primary herpetic gingivostomatitis, desquamative gingivitis, leukaemia, agranulocytosis, Stevens-Johnson syndrome, vesiculobullous disease, and scurvy.

• Local debridement under local anaesthetic (lidocaine 2 percent with adrenaline 1:80 000, up to 4.4 mg/kg) with gentle ultrasonic scaling; repeat after 2 to 3 days; full scaling after the acute phase.
• Antimicrobial rinse: chlorhexidine gluconate 0.2 percent mouthwash 10 mL for 1 minute twice daily for 7 to 14 days, or hydrogen peroxide 3 percent diluted 1:1 with warm water, rinsed for 1 minute 3 times daily for up to 5 days.
• Metronidazole 400 mg orally 3 times daily for 3 to 5 days in adults (children: 7.5 mg/kg three times daily; maximum 400 mg per dose); avoid alcohol during and for 48 hours afterwards. Alternative: amoxicillin 500 mg orally 3 times daily for 5 days.
• Analgesia: paracetamol 1 g orally every 6 hours (children 15 mg/kg every 6 hours); ibuprofen 400 mg every 8 hours with food.
• Noma and severe necrotising stomatitis in malnourished children: admit; amoxicillin 25 mg/kg orally or intravenously every 8 hours plus metronidazole 7.5 mg/kg every 8 hours for 7 days; correct dehydration with oral rehydration; therapeutic feeding (F-75, then F-100); zinc 20 mg daily for 10 days; vitamin A 200 000 units once; antiseptic mouth care; treat malaria, tuberculosis and HIV; reconstructive surgery after the acute phase (6 to 12 months).
• HIV: antiretroviral therapy initiation, and testing of household contacts.
• Hygiene: soft toothbrush, fluids, high protein diet, vitamins B and C, smoking cessation, stress reduction.
• Follow up: review in 24 to 48 hours, then weekly until healed; plaque control and treatment of underlying gingival deformity (craters) later.
• Prevention: oral hygiene, nutritional programmes, early treatment of measles and HIV, and community education on early recognition of noma.