Acute necrotizing ulcerative gingivitis (ANUG), also known as Vincent angina or trench mouth, is commonly seen in HIV-infected patients. It is a distinct and rapidly progressive ulceration typically starting at the tip of the interdental papilla, spreading along the gingival margins, eventually destroying the periodontal tissue. The triad associated with ANUG is oral pain, halitosis, and ulcerations. Other signs and symptoms include “metallic taste,” “wooden teeth” sensation, tooth mobility, fever, adenopathy, and malnutrition. The cause of this aggressive, destructive process in HIV patients is a polymicrobial infection by oral anaerobes (Treponema, Selenomonas, Fusobacterium, Porphyromonas, Prevotella). ANUG represents a spectrum of disease from mild ulcerations to severe cellulitis and spread of the infection to the soft tissues, cheeks, lips, and bones.
Management and Disposition
ANUG is most frequently seen in four population groups: (1) HIV patients, (2) malnourished children, (3) young adults who are under a great deal of stress, and (4) polysubstance abusers. The first steps for the emergency physician are to eliminate other potentially more serious life-threatening infections and to address hydration status. Treatment includes (1) eliminating contributing factors (stress, poor nutrition, poor sleep, alcohol, and tobacco use), (2) chlorhexidine rinses twice a day, (3) surgical debridement by an oral surgeon if needed, and (4) oral penicillin and metronidazole.
Beware of Ludwig angina (brawny submandibular induration and tongue elevation) associated with severe progression of ANUG as acute airway compromise is possible.
Noma (cancrum oris, gangrenous stomatitis), a rare disease of childhood associated with malnutrition, is characterized by an anaerobic destructive infectious process of the orofacial tissues that can clinically resemble ANUG.
Acute Necrotizing Ulcerative Gingivitis (ANUG). ANUG (Vincent angina or “trench mouth”) caused by spirochetal and fusiform bacteria in an HIV patient. Note the punched-out ulcerations of the interdental papillae, which are pathognomonic. (Photo contributor: Department of Dermatology, National Naval Medical Center, Bethesda, MD.)