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Vincent Stomatitis
Steven A. House, MD, FAAFP, FAAHPM, HMDC
image BASICS
DESCRIPTION
  • Inflammatory oral infection of the gingiva, characterized by gingival necrosis, bleeding, and pain
  • Disease caused by Fusobacterium, Prevotella intermedia, spirochetes, and heavy growth of oral flora
  • Concomitant infection with Epstein-Barr virus, herpes simplex virus, and type 1 human cytomegalovirus is common.
  • Organisms invade gingiva and oral papillae with the formation of a pseudomembranous exudate.
  • Clinical presentation includes ulceration, halitosis, pain, bleeding, and necrosis. It is differentiated from other periodontal diseases in that onset is rapid, papillae are ulcerated and appear “punched out,” and there is interdental necrosis (1).
  • Synonym(s): Vincent angina; trench mouth; acute necrotizing ulcerative gingivitis
EPIDEMIOLOGY
Incidence
  • Predominant age: 18 to 30 years in developed countries
  • 3 to 14 years of age among malnourished children
Prevalence
  • A Chilean study of 9,203 students aged 12 to 21 years revealed a prevalence of 6.7%.
  • Overall prevalence decreases with age.
ETIOLOGY AND PATHOPHYSIOLOGY
  • Impaired host immunologic response due to immunocompromise or malnutrition
  • Loss of integrity of the oral mucosa
  • Increased bacterial attachment with herpesvirus active infection
RISK FACTORS
  • Poor oral hygiene
  • Orthodontics (2)
  • Infrequent or absent dental care
  • Malnutrition
  • Tobacco use
  • Herpesvirus infection
  • Immunosuppression
  • Psychological stress
  • Diabetes, especially if uncontrolled (3)
  • Down syndrome
  • Pregnancy (3)
GENERAL PREVENTION
  • Regular dental care
  • Proper oral hygiene
  • Appropriate nutrition
  • Prompt recognition and institution of therapy
  • Stress management
COMMONLY ASSOCIATED CONDITIONS
  • Bacteremia
  • Osteomyelitis
  • Tooth loss
  • Noma/cancrum oris, which can be life-threatening.
  • Aspiration pneumonia
image DIAGNOSIS
PHYSICAL EXAM
  • Ulceration of the oral papillae
  • Inflamed, erythematous gingiva
  • Formation of gray, pseudomembranous exudate
  • Necrotic tissue on gingiva and surrounding structures
  • Cervical lymphadenopathy
DIFFERENTIAL DIAGNOSIS
  • Herpes simplex virus
  • Periodontitis
  • Pericoronitis
  • Medication side effects
  • Oral malignancy
  • Xerostomia
  • Diphtheria
  • Lymphoma/leukemia
  • Primary syphilis
  • Ascorbic acid deficiency
  • Gingivitis
  • Behçet disease
DIAGNOSTIC TESTS & INTERPRETATION
Initial Tests (lab, imaging)
  • Diagnosis is primarily based on clinical exam, but if systemic illness or localized spread to surrounding tissues is suspected, the following studies should be considered:
    • Aerobic and anaerobic cultures of inflamed or debrided tissue
    • Group A strep rapid antigen detection assay
    • Group A strep throat culture
    • Blood cultures if systemic involvement
    • Dental radiographs
    • Facial radiographs or CT of the neck and sinuses if infection has progressed
P.1119

image TREATMENT
MEDICATION
  • Decision regarding locus of treatment (outpatient or inpatient) and route (PO or IV) depends on the degree of systemic illness present and on the involvement of structures in the neck.
  • Medication regimens provided below are for outpatient treatment.
First Line
  • Penicillin V K 500 mg q6h for 7 to 10 days (4)[C] or
  • Amoxicillin 500 mg TID for 7 days or
  • Amoxicillin-clavulanate 875 mg q12h for 7 to 10 days if more concerned regarding complications
Second Line
  • Metronidazole 500 mg q8h for 7 to 10 days or
  • Erythromycin 500 mg BID for 7 days (if PCN allergy) (4)[C] or
  • Clindamycin 450 mg q8h for 7 to 10 days (if PCN allergy) (1)[C]
ISSUES FOR REFERRAL
Patients can be evaluated and treated by oral surgeon, dentist/periodontist, or ear, nose, and throat specialist depending on patient preference and severity of infection.
ADDITIONAL THERAPIES
  • Chlorhexidine gluconate 0.12% BID or salt water rinses (2)[C]
  • Pain management with NSAIDs (5)[C]
SURGERY/OTHER PROCEDURES
  • Débridement of inflamed and necrotic tissue
  • Dental extraction
INPATIENT CONSIDERATIONS
Admission Criteria/Initial Stabilization
  • Failure of oral antibiotics and disease progression
  • Need for parenteral antibiotics and analgesia
  • Inability to meet nutritional and/or hydration needs
IV Fluids
May be required if patient is unable to tolerate oral fluids
Discharge Criteria
  • Arrest of disease progression and improvement at site
  • Ability to tolerate oral antibiotics and fluids
  • Oral analgesia is effective.
image ONGOING CARE
FOLLOW-UP RECOMMENDATIONS
Frequent dental cleanings and examinations
DIET
  • Proper nutrition
  • Multivitamin supplementation
PATIENT EDUCATION
  • Proper nutrition
  • Appropriate oral hygiene
  • Tobacco cessation
  • Stress management
REFERENCES
1. Atout RN, Todescan S. Managing patients with necrotizing ulcerative gingivitis. J Can Dent Assoc. 2013;79:d46.
2. Sangani I, Watt E, Cross D. Necrotizing ulcerative gingivitis and the orthodontic patient: a case series. J Orthod. 2013;40(1):77-80.
3. Silk H. Diseases of the mouth. Prim Care. 2014;41(1):75-90.
4. Edwards PC, Kanjirath P. Recognition and management of common acute conditions of the oral cavity resulting from tooth decay, periodontal disease, and trauma: an update for the family physician. J Am Board Fam Med. 2010;23(3):285-294.
5. Hodgdon A. Dental and related infections. Emerg Med Clin North Am. 2013;31(2):465-480.
Additional Reading
&NA;
  • Carlson JA, Dabiri G, Cribier B, et al. The immunopathobiology of syphilis: the manifestations and course of syphilis are determined by the level of delayed-type hypersensitivity. Am J Dermatopathol. 2011;33(5):433-460.
  • Lopez R, Fernandez O, Jara G, et al. Epidemiology of necrotizing ulcerative gingival lesions in adolescents. J Periodontal Res. 2002;37(6):439-444.
  • Marik PE. Pulmonary aspiration syndromes. Curr Opin Pulm Med. 2011;17(3):148-154.
  • Porter SR. Diet and halitosis. Curr Opin Clin Nutr Metab Care. 2011;14(5):463-468.
  • Slots J. Herpesviral-bacterial synergy in the pathogenesis of human periodontitis. Curr Opin Infect Dis. 2007;20(3):278-283.
Codes
&NA;
ICD10
A69.1 Other Vincent's infections
Clinical Pearls
&NA;
  • Poor oral hygiene and immunosuppression are key factors in infection.
  • Early recognition and institution of therapy decrease complications.
  • Penicillin is the drug of choice for patients not systemically ill.