Acute Necrotizing Ulcerative Gingivitis


Acute Necrotizing Ulcerative Gingivitis is a polymicrobial, endogenous infection.

Causes of acute necrotizing ulcerative gingivitis

This condition is caused by Fusiform and spirochaete bacteria.


  • In developing countries, seen almost exclusively in children
  • Related to poverty and malnutrition (predisposing factors)
  • In industrialized countries, most common in young adults with neglected mouths; smoking and stress have been associated

Symptoms and clinical features of acute necrotizing ulcerative gingivitis

  1. Crater ulcers striating at the tips of the interdental papillae
  2. Ulcers spread along gingival margins
  3. Gingival soreness and bleeding
  4. Foul breath
  5. Metallic taste
  6. Increased salivation
  7. Cervical lymphadenopathy and fever in advanced cases

Differential diagnoses

  • Primary herpetic gingivo-stomatitis
  • HIV-associated acute ulcerative gingivitis
  • Gingival ulceration in acute leukaemia or aplastic anaemia


Smears from ulcers show predominantly
spirochaetes and gram-negative fusiform

Treatment for acute necrotizing ulcerative gingivitis

Treatment objectives

  • Treat infection
  • Restore oral health

Non-drug treatment

Oral hygiene (debridement) is essential

Drug treatment


Adult: 200 mg orally 8 hourly for 3 days 3 days;


  • 1-3 years: 50mg orally every 8 hours forĀ  3 days
  • 3-7 years: 100mg every 12 hours;
  • 7 – 10 years: half adult dose

Supportive therapy

Ascorbic acid

Adult: not less than 250 mg orally daily (in divided doses)


  • 1 month – 4 years: 125 – 250 mg in 1 to 2 divided doses
  • 4-12 years: 250-500 mg daily in 1 to 2 divided doses;
  • 12-18 years: 500 mg – 1 g daily in 1 – 2 divided doses

Ferrous sulfate

Adult: 200 mg orally three times daily taken before food


  • 6-12years: half adult dose

Follow-up treatment

  1. Rehabilitation of the mouth
  2. Once the acute phase has subsided, oral hygiene should be brought to as high a standard as possible to lessen the risk of recurrence
  3. Sequestrectomy

Adverse drug reactions

  • Metronidazole: nausea, vomiting,
    unpleasant taste; disulfiram-like effect with alcohol.

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