45 year old male presents to your emergency department with severe/diffuse dental pain associated with gingival bleeding.  After careful physical exam you suspect Acute Necrotizing Ulcerative Gingivitis ​(ANUG) without systemic involvement.  What is the next best step in management of this patient?  (scroll down for the answer) 

1. Discharge home with chlorhexidine rinses and dental follow up 
2. Discharge home with chlorhexidine rinses, PO metronidazole, and dental follow up 
3. Admit for IV ampicillin-sulbactam and non-emergent OMFS evaluation 
4. Admit for IV ampicillin-sublactam and emergent OMFS evaluation 

The correct answer is B) Discharge home with chlorhexidine rinses, PO metronidazole, and dental follow up.

The treatment for Acute Necrotizing Ulcerative Gingivitis without systemic involvement involves chlorhexidine rinses, PO antibiotics (commonly amoxicillin, metronidazole, or clindamycin), and discharge home with dental follow up. 

Acute Necrotizing Ulcerative Gingivitis (ANUG) Pearls 

• Aka Vincent’s disease or trench mouth
• Triad: pain, ulcerated “punched out” interdental papillae, gingival bleeding
• VIP to differentiate from herpes gingivostamatitis 
• Opportunistic infection common in immunocompromised hosts (HIV, malnutrition, recent illness, alcoholic, etc.)
• Commonly involves anaerobic bacteria (Treponema, Selemonas, Fusobacterium, Prevotella)
• Tx: chlorhexidine rinses, oral antibiotics (commonly amoxicillin, metronidazole, or clindamycin), dental follow up 

 Stapczynski, J. Stephan,, and Judith E. Tintinalli. Tintinalli's Emergency Medicine: A Comprehensive Study Guide. 7th ed. New York, N.Y.: McGraw-Hill Education LLC., 2011.