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Painful Gums In Teens & Adults

Referred to as ANUG, it is more commonly called “trench mouth”

A Consultation with Dr. Alan L. Morris

Dear Doctor,
My teen is very stressed right now, and suddenly her gums have started bleeding. The little peaks of gum tissue between her teeth are yellowish and she has really bad breath. What is this and what should she do?

Anug or trench mouth.

Dear Julie,
The most likely explanation for what you are describing is a condition called Acute Necrotizing Ulcerative Gingivitis (ANUG), more commonly known as “trench mouth” for its common occurrence among soldiers in the trenches during World War I. It was also named Vincent's disease or Vincent's angina, after H. Vincent, a French physician of the same era.

Thus it is commonly associated with stress and acute anxiety, which, for teens, can take place around exam times, but it can occur in anyone going through an acute period of stress — if the underlying conditions are right.

It is often associated with an underlying or pre-existing minor gingivitis (“gingiva” – gum; “itis” – inflammation) in individuals who may have not been taking good care of their oral health, brushing, flossing and getting regular dental checkups and cleanings. ANUG is also commonly associated with smoking, which seems to dry the mouth and change the bacterial flora — the normal bacteria that reside in the mouth, and is even necessary for health. General health and nutrition may also be compromised leading to reduced resistance to disease. Thus when the conditions are just right (or just wrong), ANUG can take hold.

Acute Necrotizing Ulcerative Gingivitis (ANUG), also known as “trench mouth,” is commonly associated with stress and acute anxiety.

ANUG, Acute – painful and appearing quite suddenly; Necrotizing – actually refers to tissue death; Ulcerative – the gum tissue, notably the papillae, the little triangular peaks of gum tissue between the teeth actually become ulcerated and yellowish; Gingivitis, in this case the gum tissues become acute, red, and bleed spontaneously. These are the common signs of this condition. The symptoms also include very bad breath and taste, which to a trained clinician is very characteristic. The condition is associated with a bacterial infection by organisms known as “fusiforms” and “spirochetes,” which respond well to particular local (oral) treatment and antibiotics.

What Should She Do

Don't be alarmed — this is very treatable and completely reversible if caught early. Most importantly, contact your dentist or a periodontist (a dentist specializing in the diagnosis and treatment of gum diseases), to confirm that this is indeed what she has. Although ANUG is quite easy to diagnose by a trained professional, there are other conditions that it could be confused with, which range from viral infection to localized malignancy (cancer).

Treatment is aimed first at relieving the symptoms and then the underlying or pre-disposing conditions that led to it. Non-steroidal anti-inflammatory and pain controlling medication of the aspirin and ibuprofen family are ideal for this situation, in addition to prescription antibiotics. Metronidazole is an antibiotic that works well to kill the specific bacteria associated with ANUG; amoxicillin is broad-spectrum penicillin that also works well in treating the acute phase. These are antibiotics that must be taken orally to work their way through the body. Taken together with chlorhexidine, a prescription antibacterial mouthrinse, and saline (mild saltwater) rinses, symptoms should abate within 24 to 48 hours.

Treatment is aimed first at relieving the symptoms, and then the underlying or pre-disposing conditions that led to it.

It is also important to treat the underlying conditions that led to the ANUG in the first place. Good oral hygiene including training in brushing and flossing technique, together with treatment for any underlying chronic gingivitis, generally by thoroughly and meticulously removing stain, bacterial biofilm and calculus (tartar) from the teeth, will allow the gums to heal. In addition, if there is underlying periodontal disease this should also be treated. Quitting smoking, getting rest and maintaining good nutrition are also important.

If only the acute symptoms are relieved, or only the acute phase is treated, the condition can become chronic. The papillae, which initially becomes ulcerated and necrotic, will not heal and will become permanently lost or blunted. Chronic necrotizing ulcerative gingivitis can affect the deeper structures becoming chronic necrotizing ulcerative periodontitis (“peri” – around; “dont” – tooth; “itis” – inflammation), particularly if there is a pre-existing periodontitis, with both gum tissue and tooth supporting bone loss.

Don't delay! Bring her to your general dentist or a periodontist right away to get the right diagnosis and treatment. A little attention to stress or anxiety relief will probably help a lot too.