Necrotizing Ulcerative Gingivitis

[Prepared by Dr Sukanta Sen, IIMSAR, Haldia]

Necrotizing ulcerative gingivitis (NUG) is a typical form of periodontal diseases. It

has an acute clinical presentation with the distinctive characteristics of rapid onset of
interdental gingival necrosis, gingival pain, bleeding, and halitosis.
Systemic symptoms such as lymphadenopathy and malaise could be also found.
There are various predisposing factors such as stress, nutritional deficiencies, and immune
system dysfunctions, especially, HIV infection that seems to play a major role in the
pathogenesis of NUG.
Presentation
Population: Usually young adults (age 18-30)
Signs
 Can be localized or generalized with rapid/sudden onset and intense pain
 Acute clinical presentation with distinctive characteristics of rapid onset of:
o Ulcerated and necrotic papillary and marginal gingiva and cratering (punched
out) of papillae (Figs. 1 and 2)
o Intense gingival pain
o Bleeding gingiva with little or no provocation
 Secondary features:
o Fetid breath, yellowish-white or grayish slough “pseudomembrane” covering
ulcerated papilla, lymphadenopathy, fever and malaise
o Bacterial involvement: fusiform bacteria, Prevotella intermedia, and
spirochetes invade the gingival tissues

Figure 1: Generalized punched out papillae with pseudomembrane. Detached midline

papillae
Figure 2: Mild NUG case with erythematous marginal and interproximal gingival with slightly
cratered papillae.
Symptoms
 Intense/excruciating pain
 Predisposing factors:
o Psychological stress and anxiety
o Smoking
o Pre-existing gingivitis and trauma
o Poor oral hygiene
o Deficient nutrition
o HIV-positive
 All the factors above lead to immunosuppression: depressed polymorphonuclear
leukocytes, antibody response, and lymphocyte mitogenesis.
Investigation
 Thorough medical history, including nutrition and health habits
 Medical consult if immunosuppressive disease is suspected
 Dental history; pain (constant, intense onset)
 Extraoral examination; look for lymphadenopathy of the head and neck
 Intraoral examination; look for clinical features of NUG and presence of pasty saliva
Diagnosis
Based on the clinical examination, a diagnosis of NUG is determined.
Differential Diagnosis
 Primary herpetic gingivostomatitis
 Desquamative gingivitis
 Agranulocytosis
 Cyclic neutropenia
 Leukemia
 Ascorbic acid deficiency and gingivitis
The treatment of NUG is organized in successive stages: first, the treatment of the acute
phase that should be provided immediately to stop disease progression and to control patient's
feeling of discomfort and pain; second, the treatment of the preexisting condition such as
chronic gingivitis; then, the surgical correction of the disease sequelae like craters.
Common Initial Treatments
 Perform debridement under local anesthesia
 Remove pseudomembrane using cotton pellet dipped in chlorhexidine
 Provide patient with specific oral hygiene instructions to use a prescription
antibacterial mouthwash: chlorhexidine 0.12% twice daily
  Control pain with analgesics: ibuprofen 400-600 mg 3 times daily
 Patient counselling should include instruction on proper nutrition, oral care,
appropriate fluid intake, and smoking cessation
 Prescribe antibiotics if patient is immunocompromised (e.g., AIDS, leukemia, cyclic
neutropenia) or in case of systemic involvement like fever, malaise and
lymphadenopathy
 Follow up with a comprehensive periodontal evaluation after resolution of the acute
condition
 For any signs of systemic involvement, the recommended antibiotics are:
o Amoxicillin, 250 mg 3 x daily for 7 days and/or
o Metronidazole, 250 mg 3 x daily for 7 days
 Assess treatment outcomes in 24 hours, then every other day until signs and
symptoms are resolved and gingival health and function are restored (Figs. 3 and 4).
o Residual interdental soft tissue craters are more susceptible to further clinical
attachment loss; evaluate possible surgical treatment of these areas.
o Sites that are nonresponsive to treatment may occur and may be characterized
by recurrence and/or progressive destruction of the gingival and periodontal
attachment.
o Reasons for nonresolution include the failure to remove the causes of
irritation, incomplete debridement, inaccurate diagnosis, patient
noncompliance, and/or underlying systemic conditions.
o Additional therapy and/or medical/dental consultation may also be indicated
for nonresponding patients. These conditions may have a tendency to recur;
therefore, frequent periodontal maintenance visits and meticulous oral hygiene
are necessary.

Figure 3: 24 h post treatment presenting Figure 4: Closer view 24 h after treatment.

reduction of erythematous margins and
edema.