What is Trench Mouth (Necrotizing Ulcerative Gingivitis) and what are its causes?
Necrotizing ulcerative gingivitis, also commonly referred to as Trench mouth, is a severe form of gum disease.
Trench mouth is characterised by a rapid onset of pain, bleeding, and death (necrosis) of gum tissue, specifically affecting the interdental papillae, which are pieces of gums that fill the space between two adjacent teeth [1].
Causes of trench mouth
Trench mouth is an opportunistic infection, meaning that it occurs when a pathogen identifies a favourable condition for its growth. This is a result of a systemic change in the environment (in this case the mouth), such as:
- poor oral hygiene,
- stress and/or inadequate sleep,
- recent and/or ongoing illness,
- smoking and/or alcohol use,
- and a weakened immune system (which can happen in conditions such as HIV or cancer) [2].
The disease is associated with a specific bacteria (these are the opportunistic pathogens), such as:
- the species Prevotella intermedia,
- fusiform bacteria,
- spirochetes.
Additionally, some studies have suggested that trench mouth could also occur as a result of ischemia (insufficient blood supply to the tissue) [3].
Diagnosis of trench mouth
The diagnostic process for trench mouth relies heavily on a physical examination. The patient will present with pain and bleeding of the gums, and signs of necrosis including uneven appearance, ulceration (presence of lesions), bruising or darkening, and a foul odour [2, 4].
The clinician will also enquire about the common risk factors, such as poor oral hygiene and smoking [1, 5, 6].
Furthermore, tests can be performed to rule out systemic illness or immunodeficiency - in these cases, the presence of trench mouth may be a symptom rather than a disease by itself [4]. This would then require to involve the patient in a different diagnostic and therapeutic pipeline.
Trench mouth itself can be further diagnostically confirmed by studying the microbial composition of the mouth (microbiome) for elevated population of Prevotella, fusiforms and spirochetes, the most common causative agents of necrotising ulcerative gingivitis [5, 7].
Treatment options for necrotizing ulcerative gingivitis
The treatment for trench mouth should be tailored to the individual patient's needs.
The first line of treatment is improving oral hygiene and removal of the bacterial plaques. Approaches to remove the plaque include scaling and root planing. This is commonly paired with antimicrobial rinses with 0.12% chlorhexidine [8].
This can be further supplemented with antibiotic treatment if needed - this is particularly a consideration in pediatric patients that are immunocompromised [9].
Another treatment option is the use of a diode laser (980 nm) to control pain and accelerate wound healing [10]. Alternatively, photodynamic therapy as an adjunct to oral debridement has also been shown to improve clinical parameters, reduce bacterial counts, and alleviate pain [11].
Success of treatment
Generally, trench mouth can be successfully treated in most cases. The success of the treatment depends on timeliness of the intervention and adherence of the patient to the treatment regimen.
For instance, a case report showed that a regimen of supragingival plaque and calculus removal, along with at-home use of 0.12% chlorhexidine gluconate mouthrinse twice a day for 30 days, resulted in the control of the acute phase and maintained the patient's periodontal health over a 10-year follow-up period [12].
Another study showed that implementation of the photodynamic therapy alongside debridement resulted in better outcomes than debridement alone in terms of reducing bacterial counts and alleviating pain [11].
However, in severe cases, necrotizing ulcerative gingivitis (trench mouth) can progress to necrotizing periodontitis, where the infection spreads beyond the gums to the periodontal attachment apparatus (the structure that holds the tooth in place), which can lead to complications such as tooth loss and bone infections to the jaw. The infection can be hard to control in individuals with a HIV infection or other condition compromising the immune system - this happens due to the high speed of bacterial overgrowth as the immune system in the mouth is unable to control the bacterial populations.