Rosen & Barkin's 5-Minute Emergency Medicine Consult (476 page)

• 608.83 Vascular disorders of male genital organs
  
• 728.86 Necrotizing fasciitis
  
• 785.4 Gangrene
  

BASICS

• Periodontal disease
  
• Characterized by the “punched-out” appearance of the gingival papillae
  
• Synonym(s):
  
  • Acute necrotizing ulcerative gingivitis
    
  • Trench mouth
    
  • Vincent disease
    
  • Fusospirochetal gingivitis
    
• Not contagious
  
• Occurs most often in children and young adults in developing nations
  
• Mainly occurs in sub-Saharan Africa
  
• Rare; seen mostly in severely immunocompromised patients
  
• Males > females
  
• Can progress to more advanced disease:
  
  • Necrotizing stomatitis:
    
    • Similar to necrotizing ulcerative gingivitis with extension to the tongue and buccal mucosa
      
  • Necrotizing ulcerative periodontitis:
    
    • Similar to necrotizing ulcerative gingivitis with periodontal attachment loss and alveolar bone involvement
      
  • Orofacial gangrene
    

• Caused by an overgrowth of oral flora
  
• Prevotella intermedia
  
• Spirochetes
  
• Predisposing factors (not required for diagnosis):
  
  • Poor oral hygiene/gingivitis
    
  • Immunodeficiencies (e.g., HIV)
    
  • Immunosuppression
    
  • Malnutrition
    
  • Smoking
    
  • Emotional and physical stress
    
  • Possible association with direct contact to certain chemicals (e.g., MDMA or ecstasy)
    

DIAGNOSIS

• Essential clinical features:
  
  • Painful gingival lesions
    
  • “Punched-out,” crater-like ulcers of the papillae
    
  • Ulcers bleed easily or spontaneously
    
• Nonessential clinical features:
  
  • “Pseudomembrane” of necrotic debris covering the ulcerated area
    
  • Foul breath
    
  • Fever/malaise
    

• Acute, generalized oral pain
  
• Bleeding gums:
  
  • Spontaneous or with minimal manipulation
    
• Foul breath
  
• Malaise
  
• Low-grade fever
  

• Loss of interdental papillae (key clinical feature)
  
• “Punched-out,” crater-like ulcers of the papillae
  
• Necrotic debris often present over ulcerated surfaces
  
• “Pseudomembrane” of inflammatory and necrotic cells
  
• Covers ulcerative lesions
  
• Leaves a bleeding surface when removed
  
• Lymphadenopathy, particularly submandibular
  
• Foul breath
  
• Low-grade fever
  

• Consider systemic disease:
  
  • Neutropenia
    
  • HIV
    
• Other reasons for immunosuppression or immunocompromise
  
• Rule out complications:
  
  • Progression to necrotizing stomatitis or ulcerative periodontitis
    
  • Lesions extending to periodontal ligament and alveolar bone
    
  • Alveolar bone destruction
    
  • Progression to orofacial gangrene (noma)
    

Lab tests not clinically helpful

Generally not indicated

• Other diseases rarely have the essential clinical feature of “punched-out” interdental papillae with ulcerations.
  
• Acute herpetic gingivostomatitis:
  
  • Affects entire gingival, not just papillae
    
  • Low-grade fever commonly present
    
  • Contagious
    
• Viral:
  
  • Viral infections: Epstein–Barr, varicella zoster virus
    
• Thrush
  
• Actinomycosis
  
• Streptococcal/gonococcal gingivitis/stomatitis
  
• Secondary syphilis
  
• Diphtheria
  
• Vesiculobullous disease
  
• Pemphigoid
  
• Pemphigus
  
• Oral lichen planus
  
• Systemic lupus erythematosus
  
• Trauma:
  
  • Toothpicks
    
  • Vigorous toothbrushing/flossing
    
• Immunocompromise:
  
  • Leukemia
    
  • Agranulocytosis (malignant neutropenia)
    
  • HIV
    

TREATMENT

IV fluids for dehydration

• Administer systemic and topical pain management:
  
  • Narcotics rarely necessary
    
  • Viscous lidocaine
    
• Debride pseudomembrane:
  
  • Use gauze or cotton-tipped applicator soaked in diluted H
    ₂
    O
    ₂
    
• Antibiotics (penicillin/metronidazole or clindamycin) when indicated:
  
  • Fever
    
  • Lymphadenopathy
    
  • Consider broad-spectrum antibiotics, antifungals, and antivirals in the immunosuppressed patient
    
• Institute outpatient therapy:
  
  • Remove predisposing factors
    
  • Dilute hydrogen peroxide rinses
    
  • Chlorhexidine gluconate (Peridex)
    
  • Antibiotics if indicated
    
  • Avoid irritants (spicy foods, hot beverages)
    
  • Analgesics for pain control
    
  • Improve oral hygiene with daily brushing and flossing of teeth
    

• Oral rinses:
  
  • Chlorhexidine gluconate (Peridex): 15 mL swish/spit BID
    
  • Hydrogen peroxide (3% solution diluted in half): Rinse up to 12 times daily
    
• Viscous lidocaine
  
• Pain control:
  
  • NSAIDs (e.g., ibuprofen), acetaminophen
    

• Metronidazole: 250–750 mg (peds: 30 mg/kg/24h) PO QID × 7 days
  
• Penicillin VK: 500 mg (peds: <12 yr, 25–50 mg/kg/24h) PO QID. × 10 days
  
• Clindamycin: 300 mg PO (peds: 6–8 mg/kg/24h) TID
  
• Narcotic pain control
  

FOLLOW-UP

• Extensive disease with systemic signs
  
• Severe dehydration/inability to tolerate PO fluids
  
• Evidence of orofacial gangrene (noma): Infection of mouth/face:
  
  • 70% mortality with no treatment
    

Able to maintain hydration

Urgent referral to a dentist or periodontist for deep scaling and debridement

• Consider HIV or immunosuppression
  
• If untreated, can progress rapidly
  

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CODES