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PART II
Soft Tissue Lesions
Features The disease can occur at any age, but the majority of cases affect patients between 17 and 35 years of age, with an average of 23.9 years. IOI ANUG does not show a predilection for either gender and occurs more commonly in whites than biacks. lol Stress and poor oral hygiene play an etiologic role.IOI.I02 The patient frequently complains of tenderness, discomfort, or increasingly intense pain in the gingivae. Lassitude, fever, bad taste, a fetid odor, and an inability to eat properly are also frequent symptoms. The ulcerative and necrotic process commences at the tips of the papillae and expands around the gingival crest. The ulcerative process is covered by a necrotic grayish-white pseudomembrane (Fig. 8-44 and Plates E, 10 and E, I I). ANUG may extend widely, and severe cases have postinfection cratering of the papil1ae.
If the necrotic gangrenous process expands beyond the gingiva, the diagnosis changes to diffuse gangrenous stomatitis, which is suggestive of serious systemic di.ease and a weakened defense system.
Management Severe cases The first phase of treatment calls for the brief use of oxygenating mouthrinses as well as analgesics and amoxicillin or metronidazole. The second phase calls for careful scaling, curetting, and debtidement as soon as patient comfort pemlits. Patient education conceming home care should be given and the patient monitored. Reconlouring of the gingiva after regression of the disease may be necessaf). Mild to moderate cases The first phase of treatment should generally be eliminated, except for the oxygenating mouthrinse, and phase two is implemented immediately.
Differential Diagnosis
CANDIDIASIS
The picture of destructive lesions that have produced punched-out defects of the interdental papillae is practically pathognomonic for ANUG as long as the process has not affected other areas of the mucous membrane. Somewhat similar lesions may occur in sickle cell anemia (see Fig. 11-14, B), but this disease may be readily identified by a special sickle cell blood preparation or by the electrophoretic examination of the hemoglobin. Oral changes in uremia can also be similar to ANUG (see Fig. I 1-14, C-D). Occasionally, severe contact allergy can mimicANUG.
Candidiasis is discussed in detail in Chapter 5. but the necrotic, sloughing pseudomembrane type is discussed here. Generally this type is so acute that it destroys the superficial tissue.
Features The patient with pseudomembranous candidiasis may complain of a burning sensation, tenderness. or sometimes pain in the area of the affected mucosa. Spicy foods cause occasional discomfort because of the increased sensitivity of the affected mucosa. These infections are more common in women and in patients over 40 years of age. 1m
A A
B
Fig. 8-44. A UG. A., The tips of the interdental papillae are destroyed first. B, In this severe case, the necrotizing process has extended to the remaining marginal gingiva and to the alveolar mucosa. (B courtesy J. Keene, Omaha.)
Fig. 8-45. A, Pseudomembranous candidiasis on the soft palate of an HIV-positive patient. B, Lesions on the buccal mucosa of a patient who had used tetracycline mouthrinse. (A courtesy M. Glick. Philadelphia.)