Makindo Medical Notes

Acute Necrotizing Ulcerative Gingivitis (ANUG) 🦷

Definition: A rapid-onset, painful gingival infection characterised by punched-out interdental papillae, grey pseudomembrane, spontaneous bleeding, and fetid halitosis. It’s a dysbiosis-driven anaerobic infection (classically Fusobacterium, spirochaetes) that emerges when host defences dip (stress, poor oral hygiene, smoking, malnutrition, intercurrent illness, immunosuppression).

Pathophysiology (why it looks/acts this way): Tissue hypoxia and heavy anaerobe load → necrosis of papillae and surface epithelium → exposed nerve endings (marked pain) and superficial ulceration covered by a necrotic slough. Inflammatory oedema plus fibrinous debris produce the classic grey film and metallic taste. Without treatment, lesions can extend to periodontium (necrotizing periodontitis) and rarely to fascial planes (Vincent’s angina/Ludwig’s angina).

Who is at risk? 👀

• Poor oral hygiene, recent stress/viral illness, sleep deprivation.
• Smoking, alcohol excess; malnutrition, dehydration.
• Immunosuppression (e.g., HIV, chemotherapy, steroids), diabetes.

Key clinical features 🧭

• Severe gingival pain, spontaneous bleeding, punched‑out interdental papillae.
• Grey pseudomembrane over ulcers, fetor oris, metallic taste.
• Regional lymphadenopathy; low‑grade fever may occur.

Red flags 🚩 (urgent dental/maxfax input)

• Trismus, dysphagia, odynophagia, floor‑of‑mouth swelling, voice change.
• Facial/neck swelling or systemic toxicity (rigors, high fever, hypotension).
• Extension beyond gingivae (necrotizing stomatitis/periodontitis).

Assessment 🩺

• Diagnosis is clinical. Document distribution, bleeding, halitosis, papillary loss, pseudomembrane.
• Screen contributors: smoking, stress, nutrition, recent illness, diabetes control, immunosuppression.
• Vitals if unwell; check for dehydration. Consider HIV testing if appropriate and consented.

Management (as per request) 💊🪥

Principles: Antibiotics plus immediate oral‑hygiene measures and prompt dental debridement. Analgesia and hydration are essential.

1. Antibiotics (7 days):
   • Co‑amoxiclav (Augmentin) 625 mg PO three times daily plus metronidazole 400 mg PO three times daily for 7 days.
   • Notes: Avoid alcohol with metronidazole; caution in severe hepatic impairment. If penicillin‑allergic, discuss alternatives (e.g., metronidazole‑based regimen with macrolide support) with dental/maxfax/ID as per local guidelines.
2. Oral‑hygiene & local care (start immediately):
   • Gentle debridement by a dentist as soon as pain allows (often within 24–48 h).
   • Chlorhexidine gluconate 0.12–0.2% mouthwash, 10–15 mL for 30 s twice daily for up to 1–2 weeks (spit out).
   • Warm saline rinses after meals; soft toothbrush; avoid alcohol‑containing mouthwashes.
   • Analgesia: paracetamol ± NSAID if not contraindicated; topical LA gel short‑term for procedures.
3. Supportive measures: Smoking cessation advice, optimise hydration and nutrition, address stress/sleep, review diabetes control and immunosuppressants where safe.

Follow‑up & safety‑netting 📞

• Dental review within 24–48 h to complete debridement and plan periodontal care.
• Return urgently if fever, spreading swelling, dysphagia, or worsening pain/bleeding.
• Assess for recurrence risks and reinforce brushing technique once pain subsides.

Differentials 🔍

• Herpetic gingivostomatitis, aphthous ulcers, candidiasis.
• Leukaemia‑related gingival changes (if atypical bleeding/pallor/systemic features).
• Desquamative gingivitis (lichen planus/pemphigoid), ANCA‑vasculitis oral lesions.

Complications (if untreated) ⚠️

• Necrotizing periodontitis → attachment loss and tooth mobility.
• Spread to orofacial spaces (rare): Vincent’s angina, Ludwig’s angina, sepsis.

Prescribing notes 📝

• Metronidazole–alcohol interaction: Avoid alcohol during treatment and for 48–72 h after the last dose.
• Pregnancy/breastfeeding: Metronidazole short courses are generally considered compatible; co‑amoxiclav commonly used—check local guidance.
• Renal/hepatic impairment: Consider dose adjustments/monitoring as per BNF.

Patient advice 💬

• Brush gently twice daily with a soft brush; expect transient bleeding which improves with healing.
• Do the mouthwash/rinses after meals; keep well hydrated; avoid smoking.
• Finish the 7‑day antibiotic course even if improved, unless side‑effects occur—seek advice.

Local dental/Trust protocols may vary; this article reflects the requested regimen (co‑amoxiclav + metronidazole for 7 days) alongside standard oral‑hygiene measures.