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).  

Sources:  

Aaron SL, DeBlois KW. Acute Necrotizing Ulcerative Gingivitis. [Updated 2021 Sep 14]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK562243/ 

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.