6/30/17

Anug: Aetiology, host factors, Treatment and other predisposing factors.

   This is a disease characterized by rapidly progressive ulceration starting at the tips of the interdental papillae, spreading along the gingival margins and going to acute destruction of the periodontium.
   
Anug - diagnosed , Prevention and treatment

  Anug also known as trench mouth is a common, non-contagious infection of the gums with sudden onset. The main features are painful, bleeding gums, and ulceration of inter-dental papillae (the sections of gum between adjacent teeth).

Aetiology of Acute Necrotising Ulcerative Gingivitis

   Fusospirocheatal - Borrelia vincenti and fusobacterium nucleatum. Although there are other organisms which has been reported to reduce the oxygen tension for the anaerobes to grow. Gram negative organism has been reported to release endotoxins which causes vasoconstriction favouring the necrosis of the tissues.

What are the host factors?

  - Bad oral hygiene.

Other predisposing factors of ANUG.

  - Smoking.
  - Malnutrition.
  - Pychological stress.
  - Chronic anxiety .
  - Upper respiratory infections.
  - Immosuppressive drugs.
  - Leukemia or other cancers.
  - Malaria.

Causes of ANUG

  - Hiv / Aids.

 What are the clinical features of ANUG? 

INTRAL ORAL 

  - Bleeding from gums after minor trauma.
  - Increased salivation.
  - Bad breath.
  - Difficulty in mastication.
  - Bad oral hygiene.
  - Ulcers which are found at the tips of interdental papilla with the edges sharply defined by erythema and oedema of the margins. The surface is covered by a grayish or yellowish tenacious slough, removal of slough lead to free bleeding . It is very tender.

How does Acute Necrotising Ulcerative Gingivitis Spread?

  1. Laterally along gingival edge.
   
  2. Deep to involve interdental soft and hard tissues.

  3. Across to involve attached gingival.

  4. There can be contact ulcer on buccal mucosa and much more.
   
   In Africa where there is predominance of Malnutrition, malaria and debilitating diseases the necrosis and infection may spread to cause rapid destruction of facial tissues which may perforated the cheek and lips. This is called cancrum oris. It is common in northern Nigeria.
   Cancrum oris (Noma) is a devastating infectious disease which destroys the soft and hard tissues of the oral and para-oral structures. The dehumanizing oro-facial gangrenous lesion affects predominantly children ages 2 to 16 years, particularly in sub-Saharan Africa, where the estimated frequency in some communities varies from 1 to 7 cases per 1000 population. 

  The risk factors are poverty, malnutrition, poor oral hygiene, residential proximity to livestock in unsanitary environments, and infectious diseases, particularly measles and those due to the herpesviridae. Infections and malnutrition impair the immune system, and this is the common denominator for the occurrence of noma.    Acute necrotizing gingivitis (ANG) and oral herpetic ulcers are considered the antecedent lesions, and ongoing studies suggest that the rapid progression of these precursor lesions to noma requires infection by a consortium of micro-organisms, with Fusobacterium necrophorum (Fn) and Prevotella intermedia (Pi) as the suspected key players. Additional to production of a growth-stimulating factor for Pi, Fn displays a classic endotoxin, a dermonecrotic toxin, a cytoplasmic toxin, and a hemolysin. Without appropriate treatment, the mortality rate from noma is 70-90%. Survivors suffer the two-fold afflictions of oro-facial mutilation and functional impairment, which require a time-consuming, financially prohibitive surgical reconstruction.

Other complications of Cancrum oris

   
   - Toxemia.
  
   - Disfigurement.
   
   - Otitis media.

Treatment of ANUG

  1. Oral hygiene measures: Scaling and polishing and counseling on maintenance of good oral hygiene.
  2. Chemotherapy: metronidazole 200mg thrice daily for 5 days.
  3. Oral toileting and debridement - use of hydrogen peroxide mouth washes or most importantly warm saline mouth wash as many times as possible in a day for many days.
  4. Underlying systemic problem must be treated.
  5. If there are facial defects or temporomandibular joint Ankylosis surgery should be done.

References

  Us national library of medicine - Cancrum oris ( Noma)

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