Clinical case
A 21-year-old university student presents with sudden-onset severe gingival pain, spontaneous bleeding when brushing, halitosis, and difficulty eating. He reports recent examination stress, poor sleep, smoking, and reduced oral hygiene. On examination, the interdental papillae are “punched out,” ulcerated, and covered by a grey-yellow pseudomembrane. The lesions bleed readily on gentle probing, but there is no clear evidence of attachment loss or alveolar bone loss
Pathophysiology
Necrotising ulcerative gingivitis (NUG) is thought to arise from an opportunistic polymicrobial infection of the gingiva in a susceptible host.
Anaerobic organisms and spirochaetes are strongly implicated, with organisms such as Treponema, Fusobacterium, and other anaerobic species commonly associated.
The disease is not simply due to plaque quantity alone; rather, it reflects a breakdown in host defence combined with local plaque accumulation and systemic or behavioural stressors.
Tissue necrosis produces the characteristic ulcerated papillae and fibrinous pseudomembrane.
Epidemiology and Risk Factors
NUG is now uncommon in high-income settings, with reported prevalence generally below 1%, though it remains clinically important because of its rapid onset and potential progression. It is seen more often in young adults under stress, smokers, patients with poor oral hygiene, and immunocompromised individuals.
Non-modifiable | Modifiable |
|---|---|
Immunocompromised patients, for example:
| Smoking |
Diabetes mellitus | |
HIV | |
Poor plaque control | |
Psychological stress | |
Sleep deprivation |
Clinical Features
Symptoms | Signs |
|---|---|
Severe gingival pain | "Punched-out" necrosis of interdental papillae |
Spontaneous or provoked gingival bleeding | Inflamed marginal gingiva |
Halitosis | Grey or yellow pseudomembrane over necrotic areas |
Bad or metallic taste | Tenderness on gentle probing |
Difficulty eating or brushing | Spontaneous or easy bleeding on manipulation |
Fever is possible but uncommon |
Investigations
Primary investigations:
Clinical examination including periodontal examination with gentle probing
Assessment of oral hygiene and plaque retentive factors
Review of risk factors
Gold standard investigation:
There is no laboratory gold standard investigation for NUG, the diagnosis is primarily clinical
Investigations to consider:
Periapical or bitewing radiographs
Full periodontal charting once acute pain settles
Blood tests and further medical assessment if the disease is severe, recurrent or atypical, suggesting potential underlying immunosuppression
Differential diagnosis
Primary herpetic gingivostomatitis
Desquamative gingivitis
Streptococcal or gonococcal gingivitis
Erythema multiform
Pemphigus vulgaris
Acute leukaemia
Management
Acute Treatment (Day 1-3)
Gentle Debridement: Remove loose necrotic tissue and supragingival plaque using ultrasonic instruments (often requires local anaesthesia). Avoid aggressive probing or subgingival scaling initially.
Antimicrobial Rinses: Advise rinsing twice daily with 0.12%-0.2% Chlorhexidine gluconate or 1.5%-3% Hydrogen peroxide (diluted 1:1 with warm water) to reduce bacterial load.
Systemic Antibiotics: Prescribe only if systemic involvement (fever, malaise, lymphadenopathy) or severe immunodeficiency is present.
First Choice: Metronidazole 400mg-500mg, 3 times a day for 3–5 days.
Alternative: Amoxicillin 500mg, 3 times a day for 3 days.
Pain Relief & Supportive Care: Recommend analgesics (NSAIDs like Ibuprofen or Paracetamol). Recommend rest, high fluid intake, and avoiding tobacco, alcohol, and spicy foods.
Oral Hygiene Instruction (OHI): Advise gentle brushing with a soft toothbrush.