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 gin- tial development of resistant strains in thenormal oral givoplasty to correct reversed gingival architecture flora.^' may require the sacrifice of healthy tissue from the facial and lingual marginal gingiva. In anterior areas, where esthetics are an important consideration, such Current treatment surgery might accentuate unesthetic open gingival em- The most frequent eonsequence of single or recurrent brasures and elongate the clinical crowns. episodes of ANUG is the destruction of gingival pa- The last decade has witnessed a resurgence of re- pillae and the formation of an interdental gingival ports documenting the effectiveness of nonsurgical crater (Fig 1). Many researchers believe that recurrent therapy in the management of periodontal diseases. attacks of ANUG occur at these gingival cra- This therapy, consisting primarily of seahng and root ters. ^''•^^•^'•" Repeated curettage and the establishment planing, has an obvious advantage in the esthetic re- of good plaque control may result in regeneration of sult when eompared with most surgieal modes, espe- destroyed papillae-''-* However, the most common rea- eially in anterior segments, Shapiro'"" has proposed a son for failure in the treatment of ANUG is premature technique, developed by Kramer, that uses periodic termination of therapy after the acute symptoms have curettage to stimulate regeneration of the interdental subsided,'' Once the acute symptoms have resolved, papillae to eliminate or lessen the need for surgical patients with ANUG may not comply with prescribed intervention in the management of ANUG, This therapy and subsequent dental appointments. There- method requires approximately 9 months of aetive fore, the patient must be properly informed at the therapy for maximal gingival regeneration to oeenr initial presentation of the potential risk of permanent and has varying and unpredictable degrees of success. gingival deformities and a high recurrence rate and Some papillae may regenerate to a convex, or flat the importance of follow-up therapy- If treatment is form, while others may not respond at all. sought early, and is prompt and thorough, gingival Recently, a major emphasis has been placed on the deformities can be prevented. Crater formation will role of topical antimicrobial agents in periodontics. most hkely result if there is a delay in therapy or re- Currently, chlorhexidine gluconate is the tnost effec- peated exacerbations occur, as is often the case. tive topical chemotherapeutic agent'^-* available for
Quintessence International Volume 23, Number 2/1991 97 Periodontics
Fig 2 Preoperative view ot a 17-year-old boy witti ANUG. Fig 3 Same patient as in Fig 2 immediately following gross Infiammation, bleeding, necrosis of the interdental papilla, debridement at fhe initial visit. Patient was instructed in and crater formation are present. Poor orai hygiene, stress, piaque control, including brushing, fiossihg, and 0.12% smoking, and alcohoi abuse contribute to the catjse in this chlorhexidine rinses, twice daiiy. patient
Fig 4 Same patient at 4 months. Gingival health has im- Fig 5 Finai resuit 7 months postoperatively. Regeneration proved and early signs of papillary regeneration are pres- of the interdental papilla is completed with return of para- ent. Area was retreated with scaling and root pianing and bolic gingival architecture. These changes occurred in spite the previous plaque-control regimen was reinforced. of marginal gingivitis.
Fig 6 A 32-year-oid HIV-positive man exhibiting signs ol HIV-associated periodontifis, including inflammation, se- vere attachment loss, soft tissue ulcération into the aiveolar mucosa, and advanced bone loss.
98 Quintessence Internationai Volume 22, Number 2/1991 Pehodontics the control of plaque and gingivitis. It has been ac- giva. Traditional therapy has emphasized the impor- cepted by both the Council on Dental Therapeutics tance of surgical elimination of these local predispos- of the American Dental Association and the Food and ing factors (craters), which are thought to serve as a Drug Administration. Although no controlled studies nidus for leeurrent episodes common after the reso- have testeti the efficacy of chlorhexidine treatment in lution of the acute symptoms. The second phase of ANUG patients, we have found it to be quite prom- surgical correction, although an attempt to eliminate ising. Periodic chlorhexidine rinses may complement negative gingival architecture, would often amplify mechanical plaque control during the crucial period displeasing esthetics. An alternative therapeutic mode of wound healing of the damaged gingiva after scaling involving nonsurgical treatment—periodic scaling or curettage. Figures 2 to 5 illustrate the potential and root planing combined with daily rinses with benefits of combining scaling and root planing with chlorhexidine—is prescribed. Satisfactory results can daily rinses of 0.12% chlorhexidine in the treatment often be achieved using this conservative approach to of ANUG and the associated gingival deformities. therapy
Acquired immunodeficiency syndrome and ANUG
Patients with acquired immunodeficiency syndrome Acknowledgments exhibit neutrophil abnormalities, as well as lympho- The authors gratefully acknowledge the editorial assistance of Dr cyte and mononuclear phagocyte defects, and often Mark Patters and Dt Hiram Fry in the preparation of this tnanu- have a severe form of ulcerative periodontal disease.^' scripl. Recent data suggest that ANUG may be an early sign of infection with human immunodeficiency virus (HIV)'*-^** and that ANUG occurs in about 20% of References patients with acquired immunodeficiency syndrome.'' t. Proceedings of the World Workshop in Clinicat Periodonlics.Chi- Silverman et aP^ reported a high incidence of rapidly cago, American Academy of Periodontology, 1989, p 1-3. progressive periodontal disease in a group of 375 male 2. Barnes GP, Bowles WF, Carter HG: Acute necrotizing ulcerative homosexual patients. This has heen termed HlV-re- gingivitis: a surved of 218 cases. / Periodomol 1973;44:35^2. lated gingivitis and often initially manifests itself as 3. Miller SC: Te--iihooii of Periodontia. ed 3. Philadelphia, The ANUG or a chronic persistent erythematous gingi- Blakiston Co, 1950, p 4R4. 4. Listgarten MA: Electron microscopic observations on the bac- vitis. These lesions can quickly progress to HlV-as- terial flora of acute necrotizing ulcerative gingivitis. J Peri- sociated penodontitis characterized by inflammation, odontol 1965:36:328-332. cratered papillae, attachment loss, soft tissue ulcéra- 5. Courtois GJ, Cobb CM, Killoy WJ: Acute necrotizing ulcerative tion and necrosis, advanced bone loss, and a tendency gingivitis: a transmission electron microscope study. J Peri- odomol t983;54:67l-679. toward spontaneous bleeding (Fig 6). A recent report 6. Falkler WA Jr, Martin SA. Vincent JW, et al: A clinical, de- by Murray et al"" found the microorganisms associated mographic and microbiological study of ANUG patients in an with HIV-periodontitis and HIV-associated gingivitis urban dental school. J CIm Periodonttd ti*87; 14:307-314. to he similar to those of classic adult periodontitis. 7. Loesche W, Syed SA, Langhon BE, et al: The bacteriology of acute necrotizing ulcerative gingivitis. / Periodomol 1982; Eariy detection and treatment of HIV gingivitis may 53:223-230. prevent rapid tissue destruction associated with HIV- 8. Shields W: Acute necrolizmg ulcerative gingivitis, A study of periodontitis. Recommended treatment is similar to some contributing factors and tlieir validity in an army popu- that of non-HIV ANUG: oral hygiene, local debride- lation. J Periodomol 197 7 ;4 8:346-349. ment, and rinses with antimicrobials such as chlor- 9. Kardachi ßJR, Clarke NG: Aetiology of acute necrotizing ul- cerative gingivitis: a hypothetical explanation. J Periodonloi hexidine and povidone-iodine. Ultrasonic use has not 1974;45:830. been recommended in this group of patients because 10. Schoor RS, Havrilla J: Acute necrotizing ulcerative gingivitis: of the contaminated aerosol produced- Systemic an- etiology and stress relationships, Int J Psychowm 1586;33(2):35. tibiotics are usually avoided to prevent an increase in tl. Moulton R, Ewen S, Theiman W: Emotional factors in peri- the risk of opportunistic infections. odontal disease. Oral Surg Orai Med Oral Palhol 1952;5:833- 860. 12. Cohen-Cole SA, Cogen RB, Stevens AW, et al: Psychological and endocrine aspects of acute necrotizing ulcerative gingivitis. Summary Psychiatr Med í9S2;l:215. 11. Cogen RB, Sevens AW, Cohen-Cole S, et al: Leukocyte function Interdental craters that result from ANUG can be in the etiology of acute necrotizitig ulcerative gingivitis. J Peri- permanently disfiguring, especially in the anterior gin- odontot 1983:54:402-^07.
Quintessence International Volume 22, Number 2/1991 99 Periodontics
14. Oliver WM, Fletcher JP: Oral hygiene in the treatment of acute ment of Vincent's disease with metroni
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