Ulcerative gingivitis

Symptoms and Diagnosis of Ulcerative Gingivitis

Clinical Presentation

The clinical picture of ulcerative gingivitis (ANUG) is quite typical and is characterized by an acute and painful onset. Patients commonly complain of:

• Intense Gingival Pain: Often spontaneous and severe, making eating and oral hygiene difficult.
• Gingival Bleeding: Gums bleed easily, even with slight provocation or spontaneously.
• Putrid Breath (Fetid Halitosis): A characteristic foul odor due to tissue necrosis and bacterial activity.
• Metallic Taste: Some patients report an unpleasant metallic taste.
• Increased Salivation.

Systemic manifestations are also common in patients with ulcerative gingivitis:

• Malaise and Weakness: A general feeling of being unwell.
• Fever: Body temperature may rise, sometimes significantly.
• Headache.
• Decreased Performance/Lethargy.
• Loss of Appetite.

Upon examination of the oral cavity, the following findings are characteristic of ANUG:

• Necrotic Ulcerations: The gingival margin, especially the interdental papillae, is covered with a grayish, easily removable pseudomembrane or slough (fetid plaque). Removal of this plaque exposes a raw, bleeding, and sharply painful ulcerated surface.
• "Punched-Out" Papillae: The tips of the interdental papillae appear cratered or "punched out" due to necrosis, and the normal contours of the gingival margin are broken or blunted.
• Erythema and Edema: The surrounding gingiva is often intensely red and swollen.
• Poor Oral Hygiene: Patients typically have abundant non-mineralized dental deposits (plaque) and often "tartar" (calculus).
• Regional Lymphadenopathy: The submandibular and sometimes posterior auricular (behind the ear) lymph nodes may be enlarged and painful on palpation.

Diagnostic Evaluation

During the acute period of ulcerative gingivitis, the diagnostic process involves:

1. Patient Interrogation (History): Detailed medical and dental history, including onset and nature of symptoms, predisposing factors (stress, smoking, recent illness, poor oral hygiene).
2. Clinical Examination: Thorough intraoral examination to assess the characteristic gingival lesions, extent of necrosis, presence of plaque/calculus, and halitosis.
3. Palpation of Regional Lymph Nodes.
4. Measurement of Body Temperature.
5. Laboratory Tests (if systemic involvement is significant):
   • Complete Blood Count (CBC): May reveal leukocytosis (increased white blood cell count) and an increase in the erythrocyte sedimentation rate (ESR), indicating systemic inflammation.
   • Urinalysis: Protein may occasionally be found in the urine of patients with severe systemic effects of ulcerative gingivitis.
6. Microbiological Smears (less common for routine diagnosis): While characteristic fusospirochetal bacteria are involved, diagnosis is usually clinical. Smears are not typically needed unless the presentation is atypical or unresponsive to initial treatment.

After the acute inflammatory phenomena of ulcerative gingivitis have subsided, it is advisable to conduct an in-depth examination of the patient. This aims to identify and address any underlying reasons for the decrease in the body's resistance and the development of the disease (e.g., nutritional deficiencies, systemic conditions, chronic stress, ongoing poor oral hygiene) to prevent recurrence.

Treatment of Ulcerative Gingivitis

The treatment of ulcerative gingivitis (ANUG) should be initiated promptly and actively, ideally at the patient's first visit to the dentist or periodontist. With correct and timely management, patients often experience significant improvement within 12-24 hours.

The treatment goals are to alleviate pain, control the acute infection, remove necrotic tissue and local irritants, and address underlying predisposing factors to prevent recurrence.

Initial (Acute Phase) Management - Typically by a Dental Professional

1. Anesthesia: Local anesthesia is performed on the gum areas affected by ulcerative gingivitis to allow for comfortable debridement. Topical anesthetics applied via applications or gentle oral baths with 0.5-2% solutions of novocaine (procaine), lidocaine, or another suitable local anesthetic are often used initially.
2. Debridement of Necrotic Tissue: Gentle but thorough removal of the necrotic gingival tissue (pseudomembrane and slough) is essential. This can be done with cotton pellets soaked in hydrogen peroxide, curettes, or ultrasonic scalers. Application of proteolytic enzymes (e.g., chymopsin, chymotrypsin - historical mention) to the gums was thought to aid in dissolving necrotic tissue, but mechanical debridement is primary. The aim should be to remove all visible necrotic plaque from the gums during the first visit.
3. Removal of Local Irritants: Gross dental deposits (plaque and calculus, "tartar") are carefully removed. Any sharp edges of teeth or restorations that may be injuring the mucous membrane are smoothed off.
4. Antimicrobial Irrigation/Application: After cleansing the gums of necrotic masses, topical antimicrobial agents are applied. This can include:
   • Irrigation or gentle rinsing with 0.12% chlorhexidine gluconate solution (modern standard) or historically 1% hydrogen peroxide solution.
   • Application of metronidazole suspension or gel directly to the affected areas.
   • Sanguinarine-containing products (herbal antiseptic, less common now).
   These can be delivered via applications or gentle oral baths.

Home Care and Systemic Medications (Prescribed by Dentist/Physician)

Therapeutic measures for patients with ulcerative gingivitis to follow at home typically include:

• Systemic Antibiotics: Metronidazole (e.g., 250-500 mg 2-3 times a day) is often the antibiotic of choice due to its effectiveness against anaerobic bacteria. Penicillin or amoxicillin may also be used.
• Analgesics/Anti-inflammatories: Acetylsalicylic acid (aspirin - use with caution in certain populations) (e.g., 0.5 g up to 3 times a day) or other NSAIDs like ibuprofen for pain and inflammation.
• Antihistamines (if significant swelling or allergic component suspected): Diphenhydramine (e.g., 0.05 g each morning and evening) was historically used, though less common now for this specific indication unless allergy is a factor.
• Antiseptic Mouth Rinses: Frequent gentle rinsing with antiseptic solutions such as 0.12% chlorhexidine gluconate, dilute hydrogen peroxide (e.g., 1.5%), or historically, furacilin. Warm saline rinses are also beneficial.
• Herbal Decoctions: Rinsing with decoctions of herbs like chamomile, sage, or calendula for their mild anti-inflammatory and soothing properties.
• Supportive Measures:
  • Plentiful fluid intake.
  • A soft, nutritious, non-irritating diet (avoiding spicy, acidic, or hard foods).
  • Avoidance of smoking and alcohol.
  • Stress reduction.

Subsequent (Healing Phase) Management - By Dental Professional

From the second visit onwards, as the patient's general condition and local oral status improve, treatment focuses on promoting healing and tissue regeneration:

• Continued gentle debridement if needed.
• Applications of agents that promote epithelization of ulcerated surfaces. Examples include:
  • Sea buckthorn oil or rosehip oil.
  • Carotolin (a carotenoid-rich preparation).
  • Solcoseryl (a deproteinized calf blood extract - use varies by region).
  • Oil solutions of vitamins A and E.
  • Actovegin (another deproteinized hemodialysate - use varies).

Comprehensive Oral Rehabilitation

After the acute inflammation of ulcerative gingivitis is relieved, thorough debridement of the oral cavity is performed. This includes:

• Complete scaling and root planing to remove all remaining plaque and calculus.
• Correction of any plaque-retentive factors (e.g., overhanging restorations, poorly fitting prostheses).
• Comprehensive oral hygiene instruction and reinforcement.
• Addressing any underlying predisposing factors (e.g., nutritional counseling, stress management referral, smoking cessation).
• Gingival contouring (gingivoplasty) may be necessary in some cases after healing if "punched-out" craters persist, to restore normal gingival architecture and prevent plaque accumulation.

Long-term follow-up is important to monitor gingival health and prevent recurrence.

Differential Diagnosis of Acute Gingival Lesions

Ulcerative gingivitis must be differentiated from other conditions that can cause acute gingival inflammation, ulceration, or pain:

Complications and Predisposing Factors

If ANUG is not treated promptly or if host resistance is severely compromised, the infection can progress to more severe forms of necrotizing periodontal disease:

• Necrotizing Ulcerative Periodontitis (NUP): Involves destruction of the periodontal ligament and alveolar bone, leading to tooth mobility and loss.
• Necrotizing Stomatitis: Spread of necrosis to involve broader areas of oral mucosa beyond the gingiva.
• Noma (Cancrum Oris): A rare, devastating gangrenous infection that can spread rapidly to destroy facial tissues, primarily seen in severely malnourished children in impoverished regions.

Recurrence of ANUG is possible if underlying predisposing factors (poor oral hygiene, smoking, stress, systemic conditions) are not adequately addressed.

Prevention and When to Seek Dental Care

Prevention of ulcerative gingivitis centers on:

• Maintaining Good Oral Hygiene: Regular and effective brushing, flossing, and interdental cleaning to control plaque.
• Regular Dental Check-ups and Cleanings: Professional removal of calculus and plaque.
• Healthy Lifestyle: Balanced nutrition, adequate sleep, stress management.
• Smoking Cessation.
• Management of Systemic Conditions: Proper medical care for any underlying diseases that compromise immunity.

It is important to seek **prompt dental care** if you experience symptoms of ulcerative gingivitis, such as:

• Sudden onset of severe gum pain.
• Bleeding gums, especially with a foul odor.
• Grayish film on the gums or ulcerations between teeth.
• Fever or general malaise accompanying these oral symptoms.

Early diagnosis and treatment by a dentist or periodontist are crucial to alleviate pain, control the infection, prevent tissue destruction, and avoid recurrence.