ANUGCase: A 19 year old male with no past medical history presented with 4 days of painful oral lesions, swollen gums that bled easily, and fever. His temperature was 38.5C. Which of the following is true regarding this patient’s diagnosis?

Poll Results

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It is treated with chlorhexidine and metronidazole


Acute necrotizing ulcerative gingivitis (ANUG), also known as trench mouth, is an acute infectious intraoral disease characterized by red, ulcerated gingiva, halitosis, friable mucosa and punched out interdental papillae. Fever, malaise, and lymphadenopathy are often present.1

The term “trench mouth” was coined during World War I when the disorder was seen in trench-bound young soldiers.2 It is most common in young males, and is associated with malnutrition, smoking, stress, immunosuppression, and poor personal hygiene. The infection is generally polymicrobial.3,4

Treatment includes local mouth care with hydrogen peroxide or chlorhexidine oral rinses. If systemic symptoms are present, oral antibiotics (metronidazole or penicillin) are indicated. Follow up with a dental clinic needs to be arranged to help reduce the likelihood of recurrence.4

Master Clinician Bedside Pearls5–7

Stacey L. Poznanski, DO
AWAEM President 2015-2016
Assistant Professor
Associate Program Director & EM Clerkship Director
Wright State University Boonshoft School of Medicine
Department of Emergency Medicine

Prabu Selvam, MD contributed significantly to the content of the podcast.

Sangani I, Watt E, Cross D. Necrotizing ulcerative gingivitis and the orthodontic patient: a case series. J Orthod. 2013;40(1):77-80. [PubMed]
Laughlen G, Warner W, Holmes H. So-Called Trench Mouth and other Manifestations of Vincent’s Disease as a spreading Infection in Canada. Can Med Assoc J. 1919;9(4):345-350. [PubMed]
Murrell G. Trench mouth. Otolaryngol Head Neck Surg. 2010;143(4):599-600. [PubMed]
Hodgdon A. Dental and related infections. Emerg Med Clin North Am. 2013;31(2):465-480. [PubMed]
Srour ML, Wong V, Wyllie S. Chapter 29: Noma, Actinomycosis and Nocardia. In: Manson’s Tropical Diseases Edition: 23rd Edition. 2014:379-384.e1.
Beaudreau RW. Chapter 240. Oral and Dental Emergencies. In: Tintinalli JE, Stapczynski J, Ma O, Cline DM, Cydulka RK, Meckler GD, T. eds. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 7e. New York, NY: McGraw-Hill; 2011.
Atout R, Todescan S. Managing patients with necrotizing ulcerative gingivitis. J Can Dent Assoc. 2013;79:d46. [PubMed]
Jeff Riddell, MD

Jeff Riddell, MD

Assistant Professor of Clinical Emergency Medicine
Co-Director, Medical Education Fellowship
LA County + USC Emergency Medicine Residency, Department of Emergency Medicine
Keck School of Medicine of the University of Southern California