Back to Basics - Acute Necrotizing Ulcerative Gingivitis

Acute necrotizing ulcerative gingivitis 


Presentation: Usually rapid onset of pain, bleeding from gums, ulceration/necrosis of interdental papilla and sometimes foul-smelling breath. Interdental papillae become ulcerated with “punched-out” appearing ulcers and necrotic tissue with gray pseudo membrane formation 




Microbiology:Often polymicrobial, most common causes include spirochetes and gram-negative bacteria, commonly Bacteroides and Fusobacterium species  


Risk factors: Immunosuppression (HIV, immunosuppressive medications), stress, lack of sleep, poor oral hygiene, preexisting gingivitis, alcohol use, and tobacco use  


Differential diagnosis:Herpetic gingivostomatitis, gonococcal or streptococcal gingivitis, agranulocytosis, leukemia, and pemphigus vulgaris  


Treatment: Removal of necrotic gum tissue. Chlorhexidine gluconate mouth rinse. Antibioticoptions include 7-10 days of: Metronidazole (500 mg TID) and Augmentin (875mg BID), Clindamycin (300mg TID), or Ciprofloxacin 500mg BID (if penicillin allergic). If immunocompromised, consider adding antifungal agent (nystatin rinses or fluconazole PO).  





Aaron SL, DeBlois KW. Acute Necrotizing Ulcerative Gingivitis. [Updated 2021 Sep 14]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: 


Malek R, Gharibi A, Khlil N, Kissa J. Necrotizing Ulcerative Gingivitis. Contemp Clin Dent. 2017;8(3):496-500. doi:10.4103/ccd.ccd_1181_16 


Todescan S, Atout RM. Managing Patients with Necrotizing Ulcerative Gingivitis. J Can Dent Assoc 2013;79:d46.  


Levine, BJ. EMRA Antibiotic Guide. 19th Edition. EMRA; 2020.