Penodontics The treatment of acute neerotizing ulcerative gingivitis Anne C. Hartnett* / Jacob Shiloah** The destruction of tbe interdental papillae and formation of permanent gingiva! craierx are common sequelae of acute neerotizing uleerative gingivitis. These craters ean be disfiguring, especially in the anterior gingiva, and ean act as a nidus for recurrent epi- sodes. Traditional therapy has emphasized a stirgieal approach for elimination of Ihese defects, often increasing the esthelie problems. The pwpose of this paper is to review the treatment modalities of acitte neerotizing itlcerative gingivitis and ¡Ilústrate an al- ternative treatment approach of periodic sealing, root planing, and antimicrohiai rinses with 0.12% chlorhexidine. With this therapeutic regimen, the disease proeess ean be reversed and damaged papillae may regenérale. (Quintessence Int 1991:22:95-100.) Introduction chetes, fusifonn bacteria, and species of Bacteroides are the organisms most frequently cultivated from Acute neerotizing ulcerative gingivitis (ANUG) is a these lesions,' a definitive periodontal pathogen has rapidly destructive, noncommunicable, gingival infec- yet to be tmplicated in the onset or progression of tion of complex etiology. It is characterized by necrosis ANUG. A susceptible animal model in which to study of the crest of the gingival papillae, spontaneous ANUG has not been found. bleeding, pain, and halitosis. If left untreated, it may Previous studies have speculated on the importance spread laterally and apically to involve the entire gin- of secondary predisposing etiologic factors,*'' such as gival complex, including the alveolar mucosa and stress,'" '^ impaired chemotaxis,'^ poor oral hygiene,'^ bone, leading to neerotizing ulcerative periodontitis alcohol consumption, smoking" general debilitation, (NUP).' Although known since ancient times by a and malnutrition.'^ In the past, differing criteria for multitude of names, ANUG was first described by diagnosis have led to confusion and to highly variable Plaut in 1894 and Vincent in 1896.--^ While nearly a results as to the epidemiology, demography, and mi- century of investigation has shed some light on its crobiology of ANUG."'* In 1984, Stevens et al'^ out- etiology, pathogenesis, and treatment, many aspects lined a triad of criteria that are diagnostic for ANUG. of this disease remain obscure. In fact, current theories These included acute necrosis and ulcération of the of causative mechanisms differ httle from those pro- interdental papillae, pain, and bleeding. While these posed by Vincent: that of an endogenous, opportu- are the generally accepted criteria, other signs may be nistic fusospirochetal infecfion,"*^ Although spiro- present, including halitosis, pseudomernbrane, lymph- adenopathy, and elevated body temperature. The study of ANUG has been as diverse as its complex and tnultifactorial nature. Several reviews on the epidemiology, diagnosis, and etiology of ANUG"'*"*^-' have been written. Although relatively * Senior Resident. Postgraduate Periodontology, University of few reports focusing on treatment modalities have Tennessee, College of Dentistry, 875 Union Avenue, Memphis, been published,"-^-''treatment recommendations have Tennessee 38163. been as varied as the developing etiologic theories. ** Professor, Department of Periodontology, University of Ten- nessee. The purpose of this paper is to review the treatment Address all correspondence to Dr Jacob Shiloah. of ANUG and to illustrate the therapy currently used Quintessence International Voiume 22, Number 2/1S91 95 Periodontics by the authors for papillary regeneration: ,';caling, root ognized that when penicilhn was employed as the only planing, and antimicrobial rinses with 0,12% chlor- mode of therapy, the condition could reappear or lapse hexidine. into a chronie state, Curettage alone, he noted, was a more definitive treatment modality. Tn 1945, a report of the Research Commission of the Ameiucan Dental Historical aspects of treatment Association on Vincent's infection relegated chemo- Early reports on the treattnent of ANUG focused on therapy to the role of an adjunct to rational treat- management of the microbial aspects of the disease ment," with available antimicrobial and chemical agents. Ini- Goldhabcr-^ warned that antibiotics are not anal- tially, arsenicals were used becattse of their effective- gesics and should not be prescribed simply to mini- ness against spirochetes associated with venereal dis- mize the discomfort of local therapy Discriminating ease. Vincent^'^ employed topical iodine applications use of these potentially life-saving drugs was recom- and rinses of boric acid solution. In the first two dec- mended due to the possibility that the host might de- ades of this century, oxidizing agents, especially velop resistant strains of bacteria or hypersensitive chromic acid, were a popular mode of therapy, since reactions. As a result, antibiotics were recommended the involved microorganisms are anaerobtc.-' Mercury, only for patients with systemic signs and symptotns silver compounds, and anihne dyes were also used,-' (fever, lymphadenopathy, and/or malaise) or in acute In 1930, Hirschfeld"" recommended debridement fulminating cases that were slow to respond to local and use of sodium perborate rinses until the infiatn- therapy. However, these symptoms may be an indica- mation subsided. This approach was in direct conñict tion of other systetnic conditions (acute herpetic gin- with the widely held behef that instrumentation of the givostomatitis, blood dyscrasias) if antibiotics therapy infected tissues eotild cause bacterial transmission into is not effective,^'"'''-* uninvolved areas^* and possibly even lead lo hfe- Several antibiotics have been proposed for the treat- threatening Vincent's angina. In 1949, Schluger" re- ment of ANUG,^' Reports in the mid-1960s advocated ported treatment of his patients by deep and thorough the use of metronidazole,-'''"-^' originally described for curettage, followed by hydrogen peroxide and water treatment of trichomonal infections of the vagina. mouthrinses six to eight times a day,^^ However, be- This drug was usually effective in alleviating the acute cause of the preconceived notions of potential bacter- phase of ANUG in 48 hours,^" The recommended reg- emia and spread of infection, scaling and root planing imen consisted of 200 mg, three times a day, for 7 did not gain wide acceptance by the profession as a days. After comparing the effectiveness of five rec- treatment of choice for ANUG. In fact, tn 1944, Fish ommended drugs for the management of ANUG, recommended resting the tissues beneath periodontal Wade et al'° concluded that penicillin was the anti- dressings,^^ and, as late as 1950, Miller's text' rec- biotic of choice. Forty-eight hours following tbe initial ommended very careful scaling to prevent systemic dose, patients responded well to penicilhn therapy, spreading of infection. whereas one patient out of eight that received met- In the early 1960s, Fitch et aP^ suggested that ultra- ronidazole did not show any improvement, Loesche sonic instrumentation was effective in managing et al' found that metronidazole treatment was effective ANUG. Goldhaber,^' in 1968, proposed repeated in all eight patients studied, providing prompt reso- gentle scalings, diluted hydrogen peroxide rinses, and lution of clinical symptoms and decreased proportions establishtnent of good oral hygiene programs. He stat- of Treponema. Bacieroides intermedius. and Fusobac- ed that "the more meticulous and complete the subgin- terium Species for 2 to 3 months post treatment. How- gival curettage, the more complete will be the re- ever, hke penicillin treatment, metronidazole does not sponse,"^'' eliminate local contributing etiologic factors or the gingival deformities (craters) resulting from ANUG, Consequently, systemic antibiotics are recommended The role of antibiotics in ANUG only as an adjunct to compliment local treatment of ANUG, namely scahng and root planing, and not as Given the microbial basis of ANUG, antibiotics a substitute for local therapy seemed a logical treatment option when they became available. Penicillin was first used to treat ANUG in Topical antibiotics have also been widely used. Re- military personnel in the mid 1940s, Its dramatic ef- ports in the hterature include local application of pen- fects were quickly realized. However. Schluger" ree- icillin, vancomycin, metronidazole, and the sulfon- 96 Quintessence Internationai Volume 22. Number 2/1991 Periodontics Fig la Permanent destruction farrows) of the interdental Figib Gingival craters and compromised esthetics (ar- papilla in a 36-year-oid woman 15 years following ANUG, rows) are common results ol ANUG, Plaque retention is evident. amides,''-" As many as 40% of patients treated with Because of the relationship of recurrences of ANUG topical penicillin have reported local irritations, chei- to persistent gingival deformities, emphasis has been litis, and glossitis,' Side effects from the use of topical placed on surgical elimination of these gingival de- metronidazole include the oecurrence of black tongue, fects, Gingivoplasty has often been recommended as generalized erythema, and thrush,-' Generally, the top- early as 1 month after the acnte infection, to permit ical mode of antibiotic therapy is not recommended adequate plaque control and lo recreate a physiologic because of the increased risk of sensitivity and poten- gingival form and contour,-^ However, extensive