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Clinical Summary

Painful, severely edematous interdental papillae are characteristic of acute necrotizing ulcerative gingivitis (ANUG), or trench mouth. Other associated features include the presence of ulcers with an overlying grayish pseudomembrane and a “punched out” appearance. The inflamed gingival tissue is friable and necrotic and represents an acute destructive disease process of the periodontium. Fever, malaise, and regional lymphadenopathy are commonly associated signs. Patients may also complain of foul breath and a strong metallic taste. Poor oral hygiene, emotional stress, smoking, and immunocompromised states (eg, HIV, steroid use, diabetes) all predispose for ANUG. Anaerobic Fusobacterium and spirochetes are the predominant bacterial organisms involved. The anterior incisor and posterior molar gingival regions are the most commonly affected oral tissues. Acute herpetic, gonococcal, or streptococcal gingivostomatitis, aphthous stomatitis, desquamative gingivitis, and chronic periodontal disease may mimic ANUG.

Management and Disposition

Initial management includes warm saline irrigation, analgesics, topical anesthetics, 0.12% chlorhexidine oral rinses, and antibiotic treatment with oropharyngeal coverage. Follow-up within 1 to 2 days is recommended. Patients with more advanced disease may require admission and oral surgical consultation.


  1. Dramatic relief of symptoms within 24 hours of initiating antibiotics and supportive treatment is characteristic.

  2. Periodontal abscesses and underlying alveolar bone destruction are common complications of ANUG and require dental follow-up.

  3. Gingivitis is a nontender inflammatory disorder and is not synonymous with ANUG.

  4. Consider underlying medical condition (immunodeficiency, nutritional deficiency).


Acute Necrotizing Ulcerative Gingivitis. Note the inflamed, friable, and necrotic gingival tissue. An overlying grayish pseudomembrane or punched out ulcerations of the interdental papillae are pathognomonic. (Photo contributor: David P. Kretzschmar, DDS, MS.)


Acute Necrotizing Ulcerative Gingivitis. Excessive purulent drainage was associated with this patient’s ANUG. (Photo contributor: R. Jason Thurman, MD.)


Severe Acute Necrotizing Ulcerative Gingivitis. Note the extensive gingival necrosis in this advanced case of trench mouth. (Photo contributor: David Effron, MD.)

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