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The Epidemiology, Etiology, and Pathophysiology of Acute Necrotizing Ulcerative Gingivitis Associated with Malnutrition

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The Epidemiology, Etiology, and Pathophysiology of Acute Necrotizing Ulcerative Gingivitis Associated with Malnutrition The Epidemiology, Etiology, and Pathophysiology of Acute Necrotizing Ulcerative Gingivitis Associated with Malnutrition Abstract Acute Necrotizing Ulcerative Gingitivitis (ANUG) is a distinct and specific disease. This disease entity has been described as far back as the days of Hippocrates and is known by many synonyms. With the advent of antibi- otics and with improved nutritional status, the incidence has decreased and even become extinct in developed countries. However, with the increasing incidence of severe immunodeficiency states such as seen in Acquired Immunodeficiency Syndrome (AIDS) the lesion has once more, become a well recognized and often encoun- tered clinical entity in developed countries. In developing countries, however, the condition is still a commonly diagnosed clinical lesion because of the persistently poor nutritional status. Because of the current campaign for increased focus on global health issues, ANUG, a lesion of significant interest for the developing countries where malnutrition is high and for developing countries because of the AIDS, a global pandemic has resurfaced as a topic for discussions and study. This literature review will provide a better understanding of the epidemiol- ogy, etiology, and pathophysiology of ANUG associated with malnutrition. Keywords: Acute Necrotizing Ulcerative Gingivitis, ANUG, epidemiology, etiology, pathophysiology Citation: Folayan MO . The Epidemiology, Etiology, and Pathophysiology of Acute Necrotizing Ulcerative Gingivitis Associated with Malnutrition. J Contemp Dent Pract 2004 August;(5)3:028-041. © Seer Publishing 1 The Journal of Contemporary Dental Practice, Volume 5, No. 3, August 15, 2004 Introduction scourge” of children in Sub-Saharan Africa.1,7 Acute Necrotizing The increasing focus on global health issues has Ulcerative Gingitivitis made ANUG a lesion of significant interest for (ANUG), now clas- developing countries where malnutrition is high sified as Necrotizing and because of HIV/AIDS, a global pandemic. Periodontal Disease according to the 1999 Epidemiology American Academy of Periodontics classification ANUG was well known in Europe and North system, is a distinct and specific disease charac- America some centuries ago. These Western terized by rapidly progressive ulceration typically Countries reported ANUG especially among starting at the tip of the interdental papilla, spread- military personnel. As far back as 401BC, ing along the gingival margins, and going on to Xenophon8 described a clinical entity similar to acute destruction of the periodontal tissue. ANUG in the mouths of his soldiers. Bergeron9 in 1859 also described a similar disease entity This disease entity has been described as far amongst French troops he served with. The few back as the days of Hippocrates and is known by cases reported in the literature in Europe and many synonyms such as trench mouth, Vincent’s North America before its association with AIDS disease, and Vincent’s gingivostomatitis. A rapid was usually among military personnel.10-12 progression of the lesion can lead to cancrum oris1,2 which, in turn, is very disfiguring and poten- However, with the HIV infection so widespread, tially fatal. With the advent of antibiotics and with ANUG has become widely recognized as a lesion improved nutritional status, the incidence has which is strongly pathognomonic of the infection, decreased and even become extinct in developed especially when seen in healthy looking young countries. Although, with the increasing incidence adults.13,14 Reports of the prevalence of ANUG of severe immunodeficiency states such as seen in among HIV infected patients vary between 4.3% Acquired Immunodeficiency Syndrome (AIDS) the to 16.0%.14-16 lesion has once more, become a well recognized and often encountered clinical entity in developed In marked contrast, the disease is still frequently countries.3 seen in developing countries, especially in Sub- Saharan Africa where it occurs almost exclusively In developing countries ANUG remains a com- among poor children usually between the ages monly diagnosed clinical lesion. This is because of 3 years and 10 years from low socio-economic of the existing poor nutritional status, stressful backgrounds.1,4,13,17-20 Similar observations have living conditions, poor oral hygiene, and a state also been reported in India.22 In Nigeria, hospital of debilitation often resulting from endemic conta- based studies within the past decade suggest the gious diseases.1,4-6 incidence of ANUG is increasing among children with a prevalence as high as 23% in children This lesion is important in the light of the severe under 10 years of age having been reported.1,19,20 irreversible disabilities that results when its pro- gression is unchecked. The highlighted risk fac- This probable high association of ANUG with kids tors are highly controllable, especially where the in Sub-Saharan Africa may have to do with poor issue of malnutrition is concerned. In developing welfare programs for children in these countries nations where the standard of living is gradually as the health the child is not given any priority. on the decline, this disfiguring oral lesion becomes These children, therefore, become exposed to very important clinically as more and more children identified risk factors which predisposes them are exposed to the risk factors which lead to the to ANUG. development of ANUG. Etiology and Pathophysiology In recent years, there has been increasing recogni- tion for the need to further study ANUG, particu- Microbiology larly in view of its contribution to the incidence of The precise etiology of ANUG is not known, cancrum oris – which has been described as a however, it is believed to be a polymicrobial infec- “neglected third world disease” and a “neglected tion with the implicated organisms being normal 2 The Journal of Contemporary Dental Practice, Volume 5, No. 3, August 15, 2004 commensals of the oral cavity. However, when array of various bacterial types. Loesche believes the local resistance of the human gingival area this association of the bacteroides species with becomes reduced, the organisms then become ANUG is particularly significant, especially when pathogenic.4 experimental metronidazole treatment caused a prompt resolution of the clinical symptoms Vincent and Plaut were the first which coincided with a significant reduction of to recognize the fusiform-spiro- the Treponema species, B. melaninogenicus spp chete nature of ANUG.22 They intermedius, and fusobacterium. recognized the fusiform-spiro- chete nature of this disease in Earlier research by Chung et al.32 who reported 1890. Vincent identified Borrelia significantly higher lgG and IgM antibody titre to vincentiii (a spirochete) and intermediate sized spirochetes and higher IgG Bacillus vincentii (a fusiform) microscopically as titre to B. melaninogenicus spp. intermediuss in pathognomonic of the lesion. This led to the lesion ANUG patients when compared with age and sex been formerly known widely as Vincent’s disease.23 matched healthy and gingivitis control groups sup- This evidence of the fusiform-spirochete compo- ported Loesche’s hypothesis. They stated these nent of the disease was reinforced by other light high antibody titre “suggest that these bacteria are microscopic evidence24-26 and later through electron pathologically significant agents and not merely microscopic evaluation.27 However, the significant secondary invaders of ANUG lesion.” However, role of these organisms became doubtful as these the Wilton et al.33 study found no differences in bacterial forms were present without exception in serum antibody levels to bacterial antigen includ- other oral inflammatory lesions as well as in the ing B. melaninogenicuss in patients with ANUG oral cavity of periodontally healthy individuals. when compared with controls. This result may, Their ubiquitous occurrence, therefore, disqualified however, be due to the selection of different sero- them as organisms of importance in the diagnosis types of bacteria for testing. of ANUG. The exact role of these fusiform and spirochete microbes was also complicated by The main anaerobic organisms currently reports from MacDonald et al.28, who found that implicated in ANUG are fusobacterium spirochetes and fusiform were non essential in the necrophorum; Bacteroides meaningenicus spp. production of the infections in guinea pigs but later Intermedius, now known as Prevotella intermedia; found Bacteroides melaninogenicuss as the essen- Fusobacterum nucleatum; porphyromonas tial pathogen in their inoculation mixture.29 gingivaliss as well as trepanomaa and selemonas spps.7,34 These bacteroides species produce Hampp and Mergenhagen30 also found the small a wide range of destructive metabolites, e.g., treponemas, B. vincentii, and B. bucaliss were collagenase, fibrinolysin, endotoxins, hydrogen capable of producing localized infections and sulfide, indole ammonia, fatty acids, protease abscess formations in the skins of rabbits and capable of degrading immunoglobins, and guinea pigs. They, therefore, suggested that complement factors as well as substances ANUG was a complex mixed infection involving at inhibiting neutrohpil chemotaxis.35,36 least four organisms. Fusobacterum necrophorumm has been suggested More light was shed on the bacterial nature of to be the possible key micro-organism in causing ANUG by Loesche et al.31 when they did quantita- ANUG to progress to cancrum oris.4,7,37 This is tive cultures of plaque samples from ANUG sites because
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