Necrotizing periodontal diseases is one of the seven categories of

periodontitis Periodontal disease, also known as gum disease, is a set of inflammatory conditions affecting the tissues surrounding the teeth. In its early stage, called gingivitis, the gums become swollen and red and may bleed. It is considered the main caus ...

as defined by the

American Academy of Periodontology The American Academy of Periodontology (AAP) is the non-profit membership association for periodontists-dental professionals specializing in the prevention, diagnosis, and treatment of diseases affecting the gums and supporting structures of the te ...

1999 classification system and is one of the three classifications of periodontal diseases and conditions within the 2017 classification. Necrotizing periodontal diseases are a type of inflammatory periodontal (gum) disease caused by bacteria (notably

fusobacteria Fusobacteriota are obligately anaerobic non-sporeforming Gram-negative bacilli. Since the first reports in the late nineteenth century, various names have been applied to these organisms, sometimes with the same name being applied to different s ...

and

spirochaete A spirochaete () or spirochete is a member of the phylum Spirochaetota (), (synonym Spirochaetes) which contains distinctive diderm (double-membrane) gram-negative bacteria, most of which have long, helically coiled (corkscrew-shaped or s ...

species). The diseases appear to represent different severities or stages of the same disease process, although this is not completely certain. These diseases usually have a sudden onset, and so the term acute is often added to the diagnosis. The mildest on the spectrum is

necrotizing ulcerative gingivitis Necrosis () is a form of cell injury which results in the premature death of cells in living tissue by autolysis. Necrosis is caused by factors external to the cell or tissue, such as infection, or trauma which result in the unregulated dige ...

(NUG), followed by the successively more severe conditions necrotizing ulcerative periodontitis (NUP), necrotizing stomatitis and finally

cancrum oris Noma (also known as necrotizing ulcerative stomatitis, gangrenous stomatitis, or cancrum oris) is a rapidly progressive and often fatal infection of the mouth and face. This disease predominantly affects children between the ages of two and six y ...

(noma), which is frequently fatal.

Necrotizing ulcerative gingivitis

Necrotizing ulcerative gingivitis, (NUG), or simply necrotizing gingivitis (NG), is a common, non-contagious infection of the gums. Acute necrotizing ulcerative gingivitis (ANUG) is the acute presentation of NUG, which is the usual course the disease takes. If improperly treated NUG may become chronic and/or recurrent. In developed countries, ANUG occurs mostly in young adults with predisposing factors such as psychological stress, sleep deprivation, poor oral hygiene, smoking, immunosuppression and/or

malnutrition Malnutrition occurs when an organism gets too few or too many nutrients, resulting in health problems. Specifically, it is "a deficiency, excess, or imbalance of energy, protein and other nutrients" which adversely affects the body's tissues a ...

. In developing countries, ANUG occurs mostly in malnourished children. Due to shared predisposing factors in a population (e.g. students during a period of examinations, armed forces recruits) ANUG is known to occur in epidemic-type patterns. This has led to the popular belief that ANUG is contagious, but this is not the case. The main features of NUG are painful, bleeding gums and ulceration and necrosis of the

interdental papilla The interdental papilla, also known as the interdental gingiva, is the part of the gums (gingiva) that exists coronal to the free gingival margin on the buccal and lingual surfaces of the teeth A tooth ( : teeth) is a hard, calcified struct ...

. There may also be intra-oral

halitosis Bad breath, also known as halitosis, is a symptom in which a noticeably unpleasant breath odour is present. It can result in anxiety among those affected. It is also associated with depression and symptoms of obsessive compulsive disorder. Th ...

, cervical

lymphadenitis Lymphadenopathy or adenopathy is a disease of the lymph nodes, in which they are abnormal in size or consistency. Lymphadenopathy of an inflammatory type (the most common type) is lymphadenitis, producing swollen or enlarged lymph nodes. In cli ...

(swollen lymph nodes in the neck) and

malaise As a medical term, malaise is a feeling of general discomfort, uneasiness or lack of wellbeing and often the first sign of an infection or other disease. The word has existed in French since at least the 12th century. The term is often used ...

. Treatment of the acute disease is by

debridement Debridement is the medical removal of dead, damaged, or infected tissue to improve the healing potential of the remaining healthy tissue. Removal may be surgical, mechanical, chemical, autolytic (self-digestion), and by maggot therapy. In p ...

and antibiotics, usually

metronidazole Metronidazole, sold under the brand name Flagyl among others, is an antibiotic and antiprotozoal medication. It is used either alone or with other antibiotics to treat pelvic inflammatory disease, endocarditis, and bacterial vaginosis. It is ef ...

. Poor oral hygiene and other predisposing factors may need to be corrected to prevent recurrence. ANUG is also known as trench mouth, as it was observed to occur in the mouths of front line soldiers during World War I.

Necrotizing ulcerative periodontitis

Necrotizing ulcerative periodontitis (NUP, or simply necrotizing periodontitis, NP) or acute necrotizing ulcerative periodontitis (ANUP) is where the infection leads to attachment loss (destruction of the ligaments anchoring teeth in their sockets), but involves only the

gingiva The gums or gingiva (plural: ''gingivae'') consist of the mucosal tissue that lies over the mandible and maxilla inside the mouth. Gum health and disease can have an effect on general health. Structure The gums are part of the soft tissue lini ...

periodontal ligament The periodontal ligament, commonly abbreviated as the PDL, is a group of specialized connective tissue fibers that essentially attach a tooth to the alveolar bone within which it sits. It inserts into root cementum one side and onto alveolar b ...

and alveolar ligament. Usually this spectrum of diseases result in loss of attachment, and therefore many ANUG diagnoses may be technically termed NUP, although ANUG is the term in most common use. NUP may be an extension of NUG into the periodontal ligaments, although this is not completely proven. In the meantime, NUG and NUP are classified together under the term necrotizing periodontal diseases.

Necrotizing stomatitis

Progression of NUP into tissue beyond the

mucogingival junction A mucogingival junction is an anatomical feature found on the intraoral mucosa. The mucosa of the cheeks and floor of the mouth are freely moveable and fragile, whereas the mucosa around the teeth and on the palate are firm and keratinized. Where ...

characterizes necrotizing stomatitis, which has many features in similar with cancrum oris.

Cancrum oris

Cancrum oris (also termed noma) is a necrotizing and destructive infection of the mouth and face, and therefore not strictly speaking a periodontal disease. In modern times, this condition usually occurs in malnourished children in developing countries. It may be disfiguring and is frequently fatal. It has been suggested that all cases of cancrum oris develop from pre-existing NUG, but this is not confirmed. Furthermore, the vast majority of cases of NUG and NUP will not progress to the more severe forms, even without treatment.

Vincent's angina

Strictly speaking, Vincent's angina is not a necrotizing periodontal disease. However, Vincent's angina is widely confused with

(previously also called "Vincent's gingivitis"). Vincent's angina is

tonsillitis Tonsillitis is inflammation of the tonsils in the upper part of the throat. It can be acute or chronic. Acute tonsillitis typically has a rapid onset. Symptoms may include sore throat, fever, enlargement of the tonsils, trouble swallowing, and en ...

and

pharyngitis Pharyngitis is inflammation of the back of the throat, known as the pharynx. It typically results in a sore throat and fever. Other symptoms may include a runny nose, cough, headache, difficulty swallowing, swollen lymph nodes, and a hoarse voice ...

, and does not typically involve the gums. Many publications using the term "Vincent's angina" date from the twentieth century, and the term is not so common in modern times. The condition is named after

Jean Hyacinthe Vincent Jean Hyacinthe Henri Vincent (22 December 1862 – 23 November 1950) was a French physician who was a native of Bordeaux. He was an associate professor at Val-de-Grâce, as well as medical inspector general with the French Army. Later he attaine ...

, a French physician who was working at the Paris

Pasteur Institute The Pasteur Institute (french: Institut Pasteur) is a French non-profit private foundation dedicated to the study of biology, micro-organisms, diseases, and vaccines. It is named after Louis Pasteur, who invented pasteurization and vaccines f ...

. Vincent described a fusospirochetal infection of the pharynx and palatine tonsils, causing "ulcero-membranous pharyngitis and tonsillitis", which later became known as Vincent's angina. Later in 1904, Vincent described the same pathogenic organisms in "ulceronecrotic

gingivitis Gingivitis is a non-destructive disease that causes inflammation of the gums. The most common form of gingivitis, and the most common form of periodontal disease overall, is in response to bacterial biofilms (also called plaque) that is attached ...

References

* J Lindhe, NP Lang, T Karring (editors) (2008) "Clinical periodontology and implant dentistry" 5th edition, Blackwell Munksgaard, pp. 413,459 * MG Newman, HH. Takei, PR Klokkevold, FA Carranza (editors) (2012) "Carranza's clinical periodontology" 11th edition, Elsevier/Saunders, p. 165 {{Gram-negative non-proteobacterial bacterial diseases Periodontology Periodontal disorders