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Acute Necrotizing Ulcerative Gingivitis Antibiotics

History Of Present Illness:

ANUG | Acute necrotizing ulcerative gingivitis |

A 34-year-old human immunodeficiency virus positive female presented to the emergency department with a three-week history of swollen, painful gums. She had difficulty eating and chewing, along with aches and general malaise. The patient was an everyday smoker and was not taking any antiretroviral medication.

Is Trench Mouth A Common Condition

Trench mouth affects about 0.5% to 11% of the population. It typically affects people age 18 to 20. Trench mouth is more common in places where people dont have access to dental care. People who have immune system diseases, particularly human immunodeficiency virus , are at increased risk for trench mouth.

Symptoms And Signs Of Anug

The usually abrupt onset may be accompanied by malaise or fever. The chief manifestations are

  • Acutely painful, bleeding gingivae

  • Excessive salivation

  • Sometimes overwhelmingly foul breath

Ulcerations, which are pathognomonic, are present on the dental papillae and marginal gingiva. These ulcerations have a characteristically punched-out appearance and are covered by a gray pseudomembrane. Similar lesions on the buccal mucosa and tonsils are rare. Swallowing and talking may be painful. Regional lymphadenopathy often is present.

Often, ANUG can manifest without a significant odor, and it also may manifest as a localized condition.

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How Is Acute Necrotizing Ulcerative Gingivitis Diagnosed

Visit your dentist or a periodontist immediately if you notice any of the symptoms of Acute Necrotizing Ulcerative Gingivitis. Although the initial symptoms may look like that it is a common gingivitis, they should not be ignored especially by patients who belong at the high risk groups for developing ANUG. Even if the condition proves not to be trench mouth disease but another condition such as gingivitis or periodontitis, it is important to get treatment as soon as possible to prevent any damage to teeth or gums.

Acute Necrotizing Ulcerative Gingivitis can progress rapidly into serious mouth problems like loss of gum tissue and tooth loss.

The Truth About Trench Mouth In Stressed Out People

Acute Necrotizing Ulcerative Gingivitis (ANUG)

Periodontal Associates of MemphisPeriodontal DiseasePeriodontal Risk FactorsTrench Mouth

Acute Necrotizing Ulcerative Gingivitis , more commonly known as trench mouth for its common occurrence among soldiers in the trenches during World War I, is a painful gum disease caused by the gram negative bacteria known as spirochetes.

Trench mouth is commonly associated with stress and acute anxiety, which, for teens, can take place around exam times, but it can occur in anyone going through an acute period of stress if the underlying conditions are right.

It is often associated with an underlying or pre-existing minor gingivitis in individuals who may have not been taking good care of their oral health, brushing, flossing and getting regular dental checkups and cleanings. ANUG is also commonly associated with smoking, which seems to dry the mouth and change the bacterial flora the normal bacteria that reside in the mouth, and is even necessary for health.

Trench Mouth Symptoms:

  • Swollen lymph nodes around your head, neck or jaw

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Symptoms And Signs Of Acute Necrotizing Ulcerative Gingivitis

The usually abrupt start may be accompanied by despair or fever. The primary symptoms are acutely painful, bleeding gingivae, excessive salivation, often extremely foul breath .

Ulcers, which are pathognomonic, are present on the dental papillae and marginal gingiva. These ulcers have a characteristically punched-out appearance and are covered by a gray pseudomembrane.

Similar sores on the buccal mucosa and tonsils are unusual. Swallowing and talking may hurt. Regional lymphadenopathy often is present.

Typically, ANUG can manifest without a significant odor, and it also might manifest as a localized condition.

Also read: Gingivitis in Adults

Deterrence And Patient Education

Healthy gums are extremely important to a patient’s overall health. Maintaining good oral hygiene is the most effective way to avoid developing destructive gum disease such as gingivitis. There are many steps to take to keep gums healthy, including twice-daily brushing, daily flossing or interdental cleaning, and visiting a dentist regularly. Health conditions like HIV infection, diabetes, and cancer can reduce a person’s ability to fight infection, which can increase the risk of developing gum disease. Other factors that can affect the gums are medications, such as anti-seizure medications and some blood pressure medications, hormonal changes, and the use of tobacco. Thus, it is very important for pregnant patients and patients meeting any of these criteria to see a dentist regularly. Keeping gums healthy and preventing disease is possible with daily care and regular visits to a dentist.

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Treatment Of Acute Necrotizing Ulcerative Gingivitis

The main goals of the treatment of Acute Necrotizing Ulcerative Gingivitis are to stop the infection, relieve the symptoms and restore the damaged gum tissue using:

It is recommended that any cause of irritation to the gums, such as smoking, eating spicy foods and drinking alcohol should be avoided. Treatment of trench mouth with regular brushing and flossing, professional tooth cleaning and antibiotics is generally effective. In mild cases of Acute Necrotizing Ulcerative Gingivitis complete healing is expected in a couple of weeks.

However, if the underlying or pre-disposing conditions that led to ANUG are not eliminated, the condition may become chronic and start to affect the deeper structures becoming chronic necrotizing ulcerative periodontitis, which leads to both gum tissue and tooth supporting bone loss.

Does Trench Mouth Go Away

Acute Necrotizing Ulcerative Gingivitis

Trench mouth requires treatment. It wont go away on its own. While treatment usually cures trench mouth, there are times when treatment doesnt work.Some common reasons for treatment failing to work include:

  • Your treatment didnt remove the infections root cause.
  • Theres still some dead or diseased tissue remaining after treatment.
  • You have underlying medical issues that make it difficult to cure trench mouth.
  • You didnt follow provider guidance regarding good dental hygiene and general good health.

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What Are The Symptoms Of Acute Necrotizing Ulcerative Gingivitis

The first symptoms of Acute Necrotizing Ulcerative Gingivitis are similar to those of common gum disease including:

  • Painful gums .
  • Foul taste in the mouth and bad breath.
  • Mild gum bleeding

The more serious symptoms of Acute Necrotizing Ulcerative Gingivitis may appear suddenly and develop rapidly:

  • Gum bleeding in response to gentle pressure or irritation.
  • Severe discomfort when eating or swallowing
  • Crater-like ulcers on the gums between the teeth, filled with plaque and food debris.
  • Grayish film on the gums, created by decomposed gum tissue, is one of the most characteristic symptoms of trench mouth.
  • Destruction of gum tissue around the teeth. Gum tissue between teeth becomes infected and dies.
  • Swollen lymph nodes of the head and neck.
  • Mild fever and fatigue

How Do Healthcare Providers Diagnose Trench Mouth

Providers diagnose trench mouth by:

  • Asking about your medical history, including issues that may affect your immune system, your diet and your overall health.
  • Asking about your dental history, including your access to dental care.
  • Checking the lymph nodes for signs of swelling.
  • Checking the inside of your mouth for infection, swelling and pasty saliva.
  • Doing blood tests to see if you have certain bacteria linked to trench mouth.

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How Do Healthcare Providers Treat Trench Mouth

Providers typically treat trench mouth by preventing the disease from spreading and managing any pain you may have because of the condition. They may use an ultrasonic instrument or chemicals to clean your teeth and remove any dead tissue from your gums. They may prescribe antibiotics and pain medication. Sometimes, people who have trench mouth need gum surgery to fill in any craters between their teeth.

What Questions Should I Ask My Healthcare Provider

Acute Necrotizing Ulcerative Gingivitis (ANUG)

Trench mouth isnt common, so you may be surprised to learn you have a gum disease that became notorious during World War I. Here are some questions you may have:

  • What caused my trench mouth?
  • Can you cure my trench mouth?
  • Will I need gum surgery?
  • Will my trench mouth come back?
  • What can I do to keep my trench mouth from coming back?

A note from Cleveland Clinic

Trench mouth is a serious gum disease that often affects people whose immune systems are under stress or who dont have access to good dental hygiene and care. Fortunately, healthcare providers can effectively treat trench mouth. Most people begin to feel better within days of treatment. Some people, however, may need gum surgery. You can prevent developing trench mouth by having good dental hygiene. Ask your provider what you can do to prevent trench mouth. Theyll be happy to help.

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Pertinent Studies And Ongoing Trials

There have been studies of various suspected risk factors associated with acute necrotizing ulcerative gingivitis. Approximately two-thirds of the observed studies on ANUG have been surveys or case reports, the remaining being case-control studies. Only a few longitudinal and population-based studies are available, mostly in high-risk populations. The findings of many of these studies pertain to gingivitis in general rather than acute necrotizing ulcerative gingivitis specifically. Other existing studies are based on small numbers or solely on case histories without the inclusion of control subjects, which leaves much to be desired in this field of research. However, as mentioned above, the epidemiology and low observed prevalence of ANUG in the population severely limits most longitudinal studies at this time.

Trench Mouth Disease Treatment

ANUG is very treatable and completely reversible if caught early. Most importantly, contact your dentist or a periodontist , to confirm that this is indeed what you have. Although ANUG is quite easy to diagnose by a trained professional, there are other conditions that it could be confused with, which range from viral infection to localized malignancy .

Treatment is aimed first at relieving the symptoms and then the underlying or predisposing conditions that led to it. Non-steroidal anti-inflammatory and pain controlling medication of the aspirin and ibuprofen family are ideal for this situation, in addition to prescription antibiotics. Metronidazole is an antibiotic that works well to kill the specific bacteria associated with ANUG amoxicillin is broad-spectrum penicillin that also works well in treating the acute phase. These are antibiotics that must be taken orally to work their way through the body. Taken together with chlorhexidine, a prescription antibacterial mouthrinse, and saline rinses, symptoms should abate within 24 to 48 hours.

Therefore, it is very important to see your dentist or periodontist immediately to have this treated before the condition becomes serious.

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Prevention Of Acute Necrotizing Ulcerative Gingivitis

Prevention of trench mouth disease is based on maintaining good oral health, good nutrition and good overall health habits.

  • Practice good oral hygiene. Do not forget to brush and floss your teeth at least twice a day and especially after every meal. Visit your dentist every 6 months for regular dental cleanings.
  • Don’t smoke or use other tobacco products. Tobacco products are a leading factor in the development of trench mouth.
  • Eat a healthy diet. Include plenty of fruits and vegetables. whole grains, lean meats and low-fat dairy foods.
  • Reduce stress. Learn some relaxation techniques and exercise.

Additional Therapies For All Patients

Acute Necrotizing Ulcerative Gingivitis AKA TRENCH MOUTH
  • Chlorhexidine 0.01% oral rinse BID
  • Hydrogen peroxide swishing
  • Ibuprofen 400-600mg 3 times daily for pain
  • Magic Mouthwash – 300cc of 1:1:1 viscous lidocaine 2%, Maalox, diphenhydramine 12.5mg/5ml elixir

For pain management, can consider inferior alveolar block or viscous lidocaine diluted and spread across the gums.

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What Is Trench Mouth

Trench mouth is a serious gum infection. Its a more advanced and serious form of gingivitis, a common gum disease. Trench mouth makes your gums bleed, hurt and swell. It also causes ulcers or lesions between your teeth and kills gum tissue. Trench mouth is linked to conditions and activities that affect your immune system. Without treatment, trench mouth can destroy gum tissue and then spread into nearby tissues such as your cheeks, lips or jawbones.

Effective Management Of Acute Necrotizing Ulcerative Gingivitis With Proper Diagnosis And Immediate Treatment

  • Received : 2015.12.18


Necrotizing periodontal diseases, especially acute necrotizing ulcerative gingivitis , it should be noted, occur abruptly and progress rapidly, eventually causing severe soft-tissue and alveolar bone loss. This report presents the cases of two ANUG patients and provides a brief treatment protocol for easy and effective clinical management. After proper diagnosis, sequential treatment with cessation of mechanical brushing, along with a prescription of systemic antibiotics and chlorhexidine as a mouth rinse, scaling, root planing, and supportive periodontal therapy, was utilized. In all cases discussed in this report, there was marked improvement in a few days. ANUG, though an uncommon disease, can be efficiently managed with proper diagnosis and immediate treatment.


Supported by : Pusan National University Hospital


  • Armitage GC. Development of a classification system for periodontal diseases and conditions. Ann Periodontol. 1999 4: 1-6.
  • Herrera D, Alonso B, de Arriba L, Santa Cruz I, Serrano C, Sanz M. Acute periodontal lesions. Periodontol 2000. 2014 65: 149-77.
  • Albandar JM. Aggressive and acute periodontal diseases. Periodontol 2000. 2014 65: 7-12.
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    What Is Another Name For Trench Mouth

    Trench mouth goes by many names, including Vincent stomatitis, acute necrotizing ulcerative gingivitis and necrotizing ulcerative periodontitis. People started using the term trench mouth during World War I, when soldiers living and fighting in battlefield trenches developed severe gum infections linked to poor diet, poor oral hygiene and intense psychological stress.

    Specific Organisms And Therapeutic Regimens

    Acute Ulcerative Necrotizing Periodontitis (ANUP)

    Necrotizing ulcerative gingivitis is a rare disease, a study by Dufty et al finding, for example, a prevalence of 0.11% in the British armed forces. Organism-specific therapeutic regimens for acute necrotizing ulcerative gingivitis are provided below, including those for Peptostreptococci, Prevotella, Bacteroides, and Aggregatibacter actinomycetemcomitans.

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    Enhancing Healthcare Team Outcomes

    Acute necrotizing ulcerative gingivitis and the wide-range of gum disease presentations pose a diagnostic dilemma to clinicians and is best managed by an interprofessional team approach. Though there are specific diagnostic criteria to diagnose ANUG, patients may exhibit non-specific signs and symptoms or only meet some of the diagnostic criteria. Regardless of the specific presentation, recognition of potential necrotizing gum disease is the most critical action. Many studies emphasize the prevention of periodontitis and the need for intervention to be tailored to the individual’s needs. One meta-analysis identified critical actions that may help in the implementation of preventive programs. The first critical action is communication to the public of the importance of gingival bleeding as an early sign of periodontal disease. The second critical action is the implementation of universal periodontal screening by the oral health care team. Third, we must understand the role of health promotion as well as understanding the limitations of self-medication with oral health care products. The final critical action is facilitating access to appropriate and effective professional preventive care.

    How Deal With Acute Necrotizing Ulcerative Gingivitis

    General steps to treat ANUG are debridement, rinses , improved oral health and sometimes oral antibiotics. Treatment of ANUG includes gentle debridement with a hand scaler or ultrasonic device.

    Debridement is done over several days. The patient uses a soft toothbrush or washcloth to wipe the teeth. Rinses at hourly intervals with warm normal saline or twice/day with 1.5% hydrogen peroxide or 0.12% chlorhexidine might help during the first couple of days after preliminary debridement.

    Essential encouraging measures include enhancing oral health , appropriate nutrition, high fluid consumption, rest, analgesics as needed, and preventing inflammation . Marked enhancement normally takes place within 24 to 48 h, after which debridement can be completed.

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    Acute Necrotizing Ulcerative Gingivitis

    Other names ANUG, Trench mouth
    A fairly mild presentation of acute necrotizing ulcerative gingivitis at the typical site on the gums of the anterior mandibular teeth.
    Infectious diseases, oral medicine

    Acute necrotizing ulcerative gingivitis is a common, non-contagious infection of the gums with sudden onset. The main features are painful, bleeding gums, and ulceration of inter-dental papillae . This disease, along with necrotizing periodontitis is classified as a necrotizing periodontal disease, one of the seven general types of gum disease caused by inflammation of the gums .

    The often severe gum pain that characterizes ANUG distinguishes it from the more common chronic periodontitis which is rarely painful. If ANUG is improperly treated or neglected, it may become chronic and/or recurrent. The causative organisms are mostly anaerobic bacteria, particularly Fusobacteriota and spirochete species.

    Did You Know

    Acute necrotizing ulcerative gingivitis/periodontitis: ANUG/ANUP
    • Acute necrotizing ulcerative gingivitis used to be called trench mouth, a term that comes from World War I, when many soldiers in the trenches developed the infection.

    The infection is caused by an abnormal overgrowth of the bacteria that normally exist harmlessly in the mouth. Poor oral hygiene usually contributes to the development of ANUG, as do physical or emotional stress, poor diet, and lack of sleep. The infection occurs most often in people who have gingivitis Gingivitis Gingivitis is a mild form of periodontal disease characterized by inflammation of the gums . Gingivitis results most often from inadequate brushing and flossing but may result from… read more and then experience a stressful event . Acute necrotizing ulcerative gingivitis is far more common among smokers than nonsmokers.

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