Acute necrotizing ulcerative gingivitis

Necrotizing gingivitis (NG) is a severe and rapidly progressing form of gingivitis characterized by painful ulceration, necrosis of the gingival tissues, and halitosis. It is a form of necrotizing periodontal disease and is often associated with bacterial infection, compromised immunity, and poor oral hygiene.

Pathophysiology

Necrotizing gingivitis is primarily caused by an overgrowth of pathogenic anaerobic bacteria, particularly species of Fusobacterium, Prevotella, and Treponema. These bacteria infiltrate the gingival tissue, leading to:

• Tissue necrosis – Destruction of gingival papillae and ulcer formation.
• Pain and inflammation – Due to bacterial invasion and host immune response.
• Foul odor (halitosis) – Resulting from necrotic tissue breakdown.
• Pseudomembrane formation – A yellowish-white layer of dead tissue over the gingiva.

If left untreated, necrotizing gingivitis can progress to necrotizing periodontitis and even necrotizing stomatitis, affecting deeper tissues, including the alveolar bone.

Causes and Risk Factors

Several factors contribute to the development of necrotizing gingivitis, including:

• Poor oral hygiene – Lack of proper brushing and flossing leads to bacterial overgrowth.
• Smoking and tobacco use – Impairs immune response and reduces blood flow to the gums.
• Malnutrition – Deficiency of essential nutrients, particularly vitamin C, may predispose individuals to infection.
• Psychological stress – Increases levels of cortisol, which can suppress the immune system.
• Immunosuppression – Conditions such as HIV/AIDS, diabetes mellitus, or chemotherapy can weaken the immune system.
• Previous history of gingivitis or periodontitis – Increases susceptibility to necrotizing forms of disease.

Clinical Presentation

Patients with necrotizing gingivitis commonly present with:

• Sudden onset of intense gingival pain – Especially in the interdental papillae.
• Spontaneous gingival bleeding – Often occurring with minimal provocation.
• Necrotic and ulcerated papillae – Typically affecting anterior teeth first.
• Halitosis – Characterized by a distinctive foul odor.
• Metallic taste – Reported by some patients.
• Fever and malaise – May be present in severe cases.

Diagnosis

The diagnosis of necrotizing gingivitis is primarily clinical, based on characteristic signs and symptoms. Common findings include:

• Necrosis of interdental papillae with crater-like lesions.
• Pain and spontaneous bleeding upon examination.
• Pseudomembranous covering over necrotic tissue.
• Systemic symptoms in severe cases.

A differential diagnosis should be considered to distinguish NG from:

• Herpetic gingivostomatitis – Viral infection causing widespread oral ulcers.
• Leukemia-associated gingival enlargement – Seen in hematologic malignancies.
• Necrotizing stomatitis – More extensive tissue destruction beyond the gingiva.

Treatment

The primary goals of treatment for necrotizing gingivitis are infection control, pain relief, and prevention of progression. Management typically includes:

• Mechanical debridement – Removal of necrotic tissue and bacterial deposits by a dental professional.

Antimicrobial therapy:

• Chlorhexidine mouth rinse (0.12% or 0.2%) – Used for daily rinsing.
• Systemic antibiotics in severe cases:
  • Metronidazole – Effective against anaerobic bacteria.
  • Amoxicillin – Used in combination with metronidazole.
• Pain management – Nonsteroidal anti-inflammatory drugs (NSAIDs) for pain relief.
• Improved oral hygiene – Use of soft toothbrushes and gentle brushing.
• Nutritional support – Addressing deficiencies such as vitamin C and B complex.
• Stress management – Reducing contributing psychological factors.

Prognosis

With prompt treatment, necrotizing gingivitis can be effectively managed with full recovery. However, if left untreated, the infection may progress to necrotizing periodontitis or even necrotizing stomatitis, leading to severe tissue destruction and possible systemic involvement.

Prevention

Preventive measures for necrotizing gingivitis include:

• Maintaining good oral hygiene – Regular brushing, flossing, and professional cleanings.
• Avoiding smoking and tobacco use – Reducing risk factors for periodontal disease.
• Managing systemic conditions – Controlling diabetes and other immunocompromising disorders.
• Reducing stress levels – Implementing stress-reducing strategies.
• Adequate nutrition – Ensuring a well-balanced diet rich in essential vitamins.

Related Pages

• Gingivitis
• Periodontitis
• Necrotizing periodontal disease
• Oral microbiome
• Dental plaque