Trench mouth is an inflammatory, destructive disease of gums. Other names of trench mouth are acute necrotizing ulcerative gingivitis, Vincent’s infection and acute ulceromembranous gingivitis. Swelling and ulcers of gums occur in case of trench mouth. It is an acute infection and causes destruction of supportive structures of teeth. When bone loss also occurs, then that condition is known as necrotizing ulcerative periodontitis. It is called as trench mouth as it was frequently seen in soldiers in trenches during the First World War. Painful ulcers, constant radiating, gnawing pain, profuse bleeding along with bad odor occurs in case of necrotizing ulcerative gingivitis. It is basically a bacterial infection and can occur as acute, sub acute and recurrent form. Treatment for Trench mouth varies on basis of whether severe systemic conditions like severe fever or lymphadenopathy are present or not.
Definite cause of trench mouth is not known. According to studies, it has been stated that trench mouth is caused by complex of bacterial organisms. Fusiform bacillus, Bacteroides intermedius and spirochete organisms are known to cause necrotizing ulcerative gingivitis. Punched out, crater like depressions occur in case of acute necrotizing ulcerative gingivitis.
Various Predisposing Factors which Cause Trench Mouth are:
1. Pre-existing gum disease: Deep periodontal pockets, periodontitis, pericoronal flaps are more susceptible for occurrence of trench mouth. It offers favorable conditions for bacteria to grow.
2. Injury to the gums: Areas of injury of gums are frequent sites for acute necrotizing ulcerative gingivitis.
3. Smoking and Emotional stress: Smoking and stress are other risk factors of trench mouth.
4. Nutritional deficiency: Nutritional deficiency of vitamin B and C is a predisposing factor for acute necrotizing ulcerative gingivitis.
5. Debilitating disease: Debilitating disease such as blood disorders, GIT problems also predispose the patient to develop trench mouth.
Incidence of trench mouth is less. It mostly affects people in age group of 15-35 years.
Necrotizing ulcerative gingivitis is sudden in onset or may occur following debilitating illness or acute respiratory tract infection.
1. Punched out, crater like depressions are seen on gums between teeth (Crest of Interdental papilla extending to marginal gums and rarely attached gums). These craters are covered by a pseudomembrane. Gray film occurs on surface of gums and it is separated from remaining mucosa by linear erythema.
2. Lateral ulcerations and necrosis or deep ulcerations and necrosis can occur in trench mouth.
3. Profuse bleeding occurs from gums even on slight stimulation.
4. Patient will experience more of saliva mouth along with bad breath. Pasty saliva is present.
5. Ulcers will be extremely sensitive to touch.
6. There is constant radiating, gnawing pain present in case of trench mouth. Pain is aggravated on taking spicy or very hot foods.
7. Metallic taste will be present in acute necrotizing ulcerative gingivitis.
Apart from these oral symptoms, slight elevation of temperature, enlargement of lymph nodes also occurs in acute necrotizing ulcerative gingivitis. In severe cases, high fever, increased pulse rate, loss of appetite occurs. In very rare cases, acute necrotizing ulcerative gingivitis may progress and cause noma or gangrenous stomatitis, peritonitis, toxemia.
Diagnosis of trench mouth is mainly established on basis of clinical findings. Bacterial culture may also be done for diagnosis of trench mouth. Diagnosis can be made by crater like ulcers between teeth, swollen gums and gray film and necrosis of gums. Dental x-rays will also help to determine as to how much destruction has taken place.
Treatment varies on the basis of whether severe systemic complications like severe fever or enlargement of lymph nodes are present or not.
If severe systemic symptoms are present, then on first day, the grey membrane that is the pseudomembrane is removed by cotton which has hydrogen peroxide. Penicillin or metronidazole may be prescribed to the patient and patient is advised to take rest. Patient should rinse his mouth with 3% diluted hydrogen peroxide after every 2 hours. In subsequent visits, if the condition of patient improves, superficial deposits are removed by ultrasonic scalers. Deep cleaning and curettage is not done as it can cause extension of infection in deeper tissues. They are done in later visits. In case of severe pain, over the counter pain meds and pain relieving gel can be applied by the patient.
If severe symptoms are not present, then in first visit, topical anesthesia is applied and after that, area is swabbed with cotton pallet to remove the gray membrane and loose deposits. After cleaning the area, by use of ultrasonic scalers, superficial deposits are removed. In case of mild lymphadenopathy or gum diseases, antibiotics are given to the patient. Patient is instructed to avoid smoking and rinse with hydrogen peroxide and warm water for every 2 hours. Bland dentifrice or tooth paste is used for cleaning and patient should use a floss and mouth wash. In second visit, scaling and root planning is done and patient is instructed to maintain god oral hygiene. In third visit, scaling and root planning are repeated and use of hydrogen peroxide mouth rinses should be discontinued by patient.
For treatment of acute necrotizing ulcerative gingivitis, it is important that patient maintain good oral hygiene. To remove plaque and calculus deposits, patient should brush and floss regularly. Gingivoplasty procedure may or may not be required in subsequent visits.
To prevent recurrence of acute necrotizing ulcerative gingivitis or trench mouth, patient should take nutritious diet and should reduce stress or anxiety. If patient is a smoker, then he should quit smoking and should maintain a good oral hygiene. Patient should visit his dentist regularly and should get dental cleaning done once in 6 months. Vitamin supplements may be prescribed to the patient.
Severe pain occurs in trench mouth which usually regresses by treatment. Infection in case of acute necrotizing ulcerative gingivitis usually responds to treatment. Soft tissue may get affected if treatment is not done.
If no treatment is done for trench mouth, then infection may spread from gums to periodontal ligament and bone and cause necrotizing ulcerative periodontitis. Necrotizing stomatitis or noma may occur as complication of trench mouth. If necrosis of skin of cheeks occurs, then that condition is known as noma.
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