What is ANUG?

Acute Necrotizing Ulcerative Gingivitis, also referred by its acronym ANUG, is known with several other terms such as ‘acute membranous gingivitis’, ‘fusospirochetal gingivitis’, or by the names Vincent’s stomatitis, Vincent’s angina, or Vincent’s infection after the French bacteriologist Jean Hyacinthe Vincent (1862-1950) who is credited with the discovery of the organisms that cause the disease.

Another common name for Acute Necrotizing Ulcerative Gingivitis is ‘trench mouth’ which comes from World War I, when many soldiers suffered from the disease as they were fighting in the trenches under extremely stressful conditions and without the means to take proper care of their teeth and gums.

Acute Necrotizing Ulcerative Gingivitis is a much more severe condition than normal gingivitis, which can finally lead the death of gum tissue. The infection may lead to rapid destruction of the periodontal tissues and can spread into nearby tissues such as the cheeks, lips or jawbone (developing into necrotizing stomatitis). It can also spread to the tonsils and pharynx.

Although it can lead to serious complications if left untreated, treatment of trench mouth disease is, in most cases, simple and effective. It is now rare in developed countries, affecting mostly people with a weakened immune system. ANUG occurs much more commonly in developing nations with poor nutrition and poor living conditions and no access to dental care. Acute Necrotizing Ulcerative Gingivitis is a no contagious infection.

The main cause of Acute Necrotizing Ulcerative Gingivitis is the excessive growth of certain harmful bacteria in the mouth, resulting in severe infection of the gums.

A variety of micro-organisms normally exist harmlessly in the human mouth. External factors that disturb the balance between the various micro-organisms of the natural flora of the mouth, may allow some of the harmful bacteria to grow out of control. This overgrowth causes a painful infection of the gums, which can seriously damage or destroy the periodontal tissues that support the teeth (periodontal ligament and gums).

Several factors can increase the risk of developing trench mouth by disrupting the normal balance of bacteria in the mouth :

• Lack of dental care and overall poor dental hygiene allows the build-up of dental plaque on the gums and contributes to the development of ANUG.
• Emotional stress and acute anxiety are considered as a significant aggravating factor e.g. teens during exam times.
• Poor nutrition reduces the ability of the body to fight the infection.
• Weakened immune system due to other conditions like AIDS or cancer, also favors the development of Acute Necrotizing Ulcerative Gingivitis.
• Drug addiction. ANUG is a problem that appears often in users of methamphetamine and ecstasy. Meth mouth is a condition which combines Acute Necrotizing Ulcerative Gingivitis with aggressive tooth decay.
• Mouth, tooth, or throat infections, such as an existing untreated gingivitis can easily progress into trench mouth disease in a matter of days e.g. in a patient with a compromised immune system under a stressful condition.

Other risk factors increasing the possibility of developing ANUG include:

• Smoking or chewing tobacco
• Lack of sleep
• Age under 35 years

The first symptoms of Acute Necrotizing Ulcerative Gingivitis are similar to those of common gum disease including:

• Painful gums (the gums are red, inflamed or/and swollen).
• Foul taste in the mouth and bad breath.
• Mild gum bleeding

The more serious symptoms of Acute Necrotizing Ulcerative Gingivitis may appear suddenly and develop rapidly:

• Gum bleeding in response to gentle pressure or irritation.
• Severe discomfort when eating or swallowing
• Crater-like ulcers on the gums between the teeth, filled with plaque and food debris.
• Grayish film on the gums, created by decomposed gum tissue, is one of the most characteristic symptoms of trench mouth.
• Destruction of gum tissue around the teeth. Gum tissue between teeth becomes infected and dies.
• Swollen lymph nodes of the head and neck.
• Mild fever and fatigue

Visit your dentist or a periodontist (a dentist specializing in the diagnosis and treatment of gum diseases) immediately if you notice any of the symptoms of Acute Necrotizing Ulcerative Gingivitis. Although the initial symptoms may look like that it is a common gingivitis, they should not be ignored especially by patients who belong at the high risk groups for developing ANUG. Even if the condition proves not to be trench mouth disease but another condition such as gingivitis or periodontitis, it is important to get treatment as soon as possible to prevent any damage to teeth or gums.

Acute Necrotizing Ulcerative Gingivitis can progress rapidly into serious mouth problems like loss of gum tissue and tooth loss.

The main goals of the treatment of Acute Necrotizing Ulcerative Gingivitis are to stop the infection, relieve the symptoms and restore the damaged gum tissue using:

• Antibiotics and Pain Relief Medications. Dentists often prescribe antibiotics in order to fight the bacterial growth and prevent infection from spreading. Over-the-counter or prescription pain relievers are also recommended.
• Professional dental cleaning. A gentle cleaning of teeth and gums by the dentist is usually the first step in the treatment of trench mouth. The dentist will also remove any dead gum tissue. As soon as the pain is reduced the dentist will perform a more thorough cleaning procedure called tooth scaling and root planing.
• Oral hygiene. Following a proper daily oral hygiene routine is essential for the treatment of Acute Necrotizing Ulcerative Gingivitis. Teeth should be brushed gently with a soft toothbrush at least twice a day after very meal and flossed at least once a day. If the gums feel very painful for brushing, an antiseptic mouthwash may be used for a few days for the home treatment of ANUG, until the pain subsides enough to allow brushing and flossing. Salt water rinses and hydrogen peroxide mouthwashes can also help soothe the pain of sore gums.
• Impoved diet. Proper diet is important for restoring the proper function of the immune system and the body’s ability to fight infections.
• Gum surgery. If the damage to the gums is extensive, dental cleaning and oral hygiene may not be enough to restore the gum tissues. In this case, the treatment may require gum surgery (periodontal surgery) in order to restore the normal shape of the gums.

It is recommended that (at least during ANUG treatment) any cause of irritation to the gums, such as smoking, eating spicy foods and drinking alcohol should be avoided. Treatment of trench mouth with regular brushing and flossing, professional tooth cleaning and antibiotics is generally effective. In mild cases of Acute Necrotizing Ulcerative Gingivitis complete healing is expected in a couple of weeks.

However, if the underlying or pre-disposing conditions that led to ANUG are not eliminated, the condition may become chronic and start to affect the deeper structures becoming chronic necrotizing ulcerative periodontitis, which leads to both gum tissue and tooth supporting bone loss.

Prevention of trench mouth disease is based on maintaining good oral health, good nutrition and good overall health habits.

• Practice good oral hygiene. Do not forget to brush and floss your teeth at least twice a day and especially after every meal. Visit your dentist every 6 months for regular dental cleanings.
• Don't smoke or use other tobacco products. Tobacco products are a leading factor in the development of trench mouth.
• Eat a healthy diet. Include plenty of fruits and vegetables. whole grains, lean meats and low-fat dairy foods.
• Reduce stress. Learn some relaxation techniques and exercise.