Necrotizing gingivitis: symptoms, causes, diagnosis, treatment, and prevention of complications

Necrotizing gingivitis is an acute infectious and inflammatory lesion of the gums, characterized by rapid pain, bleeding, and areas of necrosis, most often on the interdental papillae. Unlike regular gingivitis, this condition develops rapidly, is accompanied by severe discomfort, and requires urgent dental treatment, as without treatment, it can progress to deeper necrotizing periodontal lesions. [1]

In older literature, this condition was often referred to as "ulcerative necrotizing gingivitis," "Vincent's angina," or "trench mouth." The term "trench mouth" originated during World War I, when a similar condition was often observed in soldiers in harsh conditions, with poor nutrition, stress, and inadequate oral hygiene. [2]

The modern classification classifies necrotizing gingivitis as a necrotizing periodontal disease. This group also includes necrotizing periodontitis and necrotizing stomatitis, and in the most severe cases, the process can progress to noma, that is, destructive orofacial necrosis. [3]

The key difference between necrotizing gingivitis and necrotizing periodontitis is the depth of the lesion. In necrotizing gingivitis, necrosis is limited to the gingiva, primarily the interdental papillae, and with timely treatment, the condition is potentially reversible. In necrotizing periodontitis, attachment loss and destruction of the tissues supporting the tooth have already begun. [4]

This condition shouldn't be dismissed as "regular bleeding gums." If your gums suddenly become painful, start bleeding, develop gray-white or dirty-gray plaque, have an unpleasant odor, and the interdental papillae appear "pocked out," you should see a dentist promptly rather than wait for a routine checkup in a few weeks. [5]

Sign	Common gingivitis	Necrotizing gingivitis
Start	Gradual	Often sudden
Pain	Usually moderate or absent	Often expressed
Bleeding	When cleaning or probing	Light bleeding, sometimes spontaneous
Interdental papillae	Swollen, red	Necrosis, ulcers, "knocked out" contour
Bad breath	May be	Often sharply unpleasant
General well-being	Usually does not suffer	Possible symptoms include malaise, fever, and lymph node swelling.
Loss of attachment	No	No, not with isolated gingivitis, but present when it progresses to periodontitis.
Urgency	Scheduled inspection	Quick dental examination

Source for the table: Necrotizing gingivitis is diagnosed by the combination of sudden pain, bleeding, and necrosis of the interdental papillae; ordinary gingivitis is limited to the soft tissues of the gums without loss of attachment. [6]

Code according to ICD 10 and ICD 11

In the International Classification of Diseases, 10th revision, acute necrotizing ulcerative gingivitis is not coded as usual acute gingivitis K05.0: the official browser of the World Health Organization for K05.0 lists an exception - acute necrotizing ulcerative gingivitis is classified as A69.1. The code A69.1 corresponds to other Vincent's infections and includes necrotizing ulcerative gingivitis and necrotizing ulcerative gingivostomatitis. [7]

In the International Classification of Diseases, 11th revision, the category 1C1H "Necrotizing ulcerative gingivitis" is used for necrotizing ulcerative gingivitis, and in the periodontal diseases block, necrotizing periodontal diseases DA0C.3 are also distinguished. This reflects the clinical duality of the condition: it is an infectious necrotizing process of the gum and, at the same time, part of the spectrum of necrotizing periodontal diseases. [8]

System	Code	Formulation	Practical commentary
ICD 10	A69.1	Other Vincent infections	Basic code for acute necrotizing ulcerative gingivitis
ICD 10	A69.0	Necrotizing ulcerative stomatitis	Can be used for more widespread mucosal lesions
ICD 10	K05.0	Acute gingivitis	The official version excludes acute necrotizing ulcerative gingivitis
ICD 10	K05.6	Periodontal disease, unspecified	An undesirable option if it is possible to clarify the diagnosis
ICD 11	1C1H	Necrotizing ulcerative gingivitis	Direct heading for the disease
ICD 11	1C1H.0	Other Vincent infections	Child code within a category
ICD 11	1C1H.Z	Necrotizing ulcerative gingivitis, unspecified	Used when there is a lack of detail
ICD 11	DA0C.3	Necrotizing periodontal diseases	Block for the spectrum of necrotizing periodontal diseases

Source for the table: codes and exceptions in the International Classification of Diseases, 10th revision, and headings of the International Classification of Diseases, 11th revision. [9]

Causes and risk factors

Necrotizing gingivitis is not associated with a single "special microbe," but with an imbalance between the oral microbial biofilm and the body's defenses. Mixed anaerobic flora, including spirochetes and fusobacteria, is often found in the tissues, but microbiological analysis alone rarely resolves the diagnosis, as similar microbes can be found in other gum conditions. [10]

The main prerequisite for the development of the disease is a weakening of local or systemic immune defense. StatPearls notes that necrotizing periodontal diseases are particularly associated with immunodeficiency, including human immunodeficiency virus infection, leukemia, neutropenia, diabetes mellitus, and long-term immunosuppressive therapy. [11]

Classic behavioral and lifestyle factors include poor oral hygiene, smoking, severe psychological stress, lack of sleep, poor nutrition, and difficult living conditions. The MSD Manual also notes that the disease is more likely to develop in people with pre-existing gingivitis after a stressful event, and is more common among smokers than non-smokers. [12]

In children and adolescents, necrotizing gingivitis requires particularly careful attention to nutrition, immune status, and social conditions. A 2024 review of pediatric patients describes necrotizing gingivitis as an acute inflammatory process with ulcerative-necrotic lesions of the interdental gingiva, pain, and bleeding, and notes the role of systemic and social risk factors. [13]

It's important to understand that the disease is not considered contagious in the everyday sense. The MSD Manual clearly states that acute necrotizing ulcerative gingivitis is not contagious; the problem occurs due to an overgrowth of normal oral bacteria due to unfavorable conditions and decreased defenses. [14]

Risk factor	Why is it important?	What to do practically
Poor oral hygiene	Supports bacterial biofilm	Urgent professional cleaning and care training
Smoking	Associated with higher risk and poorer healing	Discuss quitting smoking
Severe stress	May reduce immune resistance and impair care	Normalize sleep and routine
Lack of sleep	Reduces inflammation recovery and control	Restore sleep patterns
Malnutrition	Impairs mucosal protection and healing	Assess diet, protein, deficiencies
Human immunodeficiency virus	Increases the risk of severe disease	Medical examination and monitoring of immune status
Diabetes mellitus	Impairs immune response and healing	Blood glucose control
Immunosuppressive therapy	Increases the risk of necrotizing infections	Co-management with a specialist

Source for table: Key risk factors include immunodeficiency, poor hygiene, smoking, stress, lack of sleep and malnutrition. [15]

Symptoms and signs of danger

The diagnosis is typically based on three key features: sudden mouth pain, bleeding gums, and necrosis or ulcerative destruction of the interdental papillae. StatPearls emphasizes that these three components are the basis of the clinical diagnosis, and laboratory tests are usually not necessary to confirm the typical case. [16]

Externally, the interdental papillae may appear "cut" or "punched out," with a gray-white or gray pseudomembrane of necrotic tissue. The gums are often bright red, swollen, painful, and bleed easily when touched, talking, eating, or brushing. [17]

Bad breath associated with necrotizing gingivitis is often pungent and unpleasant. Patients may also complain of increased salivation, a metallic taste, painful swallowing, difficulty eating, and an inability to brush their teeth properly due to pain. [18]

Systemic symptoms are not present in everyone, but their presence increases the urgency. These may include malaise, enlarged and painful lymph nodes under the jaw, a low-grade or higher fever, severe weakness, and signs of widespread inflammation. [19]

Particularly dangerous are rapid spread of ulcers, severe facial swelling, high fever, inability to drink or eat, signs of dehydration, immunodeficiency, poorly controlled diabetes, severe weakness, or lack of improvement in the first days of treatment. In such situations, urgent in-person medical evaluation is necessary, as necrotizing lesions can progress. [20]

Symptom	What could it mean?	Urgency
Sharp pain in the gums	Acute necrotizing process	Urgent dental examination
Bleeding	Active inflammation and ulceration	Inspection coming soon
"Knocked out" interdental papillae	Typical papillary necrosis	Urgent treatment
Gray-white film	Pseudomembrane of necrotic tissue	Do not rip it off yourself
A pungent smell	Anaerobic infection and necrosis	Treat the cause, not mask it
Temperature and weakness	Systemic reaction	See a doctor immediately
Enlarged lymph nodes	Spread of inflammatory reaction	Severity assessment needed
Rapid deterioration	Risk of progression to deeper damage	Urgent Care

Source for table: Major signs include sudden pain, bleeding, interdental papillae necrosis, foul odor, pseudomembrane, lymphadenopathy, and malaise.[21]

Diagnosis and differential diagnosis

Necrotizing gingivitis is primarily a clinical diagnosis. The dentist evaluates the patient's complaints, the rate of symptom development, pain, bleeding, the nature of the interdental papillae, the presence of a pseudomembrane, odor, lymph nodes, and the general condition of the patient. [22]

Microbiological examination is usually not required for typical presentations. StatPearls notes that Gram staining can support the diagnosis but is not mandatory, and the microbial profile may overlap with normal flora, gingivitis, and periodontitis. [23]

Radiographs are not necessary to confirm necrotizing gingivitis itself, but they are important if the clinician suspects progression to necrotizing periodontitis, bone loss, pre-existing periodontitis, or another dental problem. Guidelines for the management of periodontal disease in patients with human immunodeficiency virus (HIV) indicate that radiographs help determine the severity of bone loss in necrotizing lesions. [24]

Differential diagnosis is necessary because ulcers and gum pain can occur not only with necrotizing gingivitis. The doctor must distinguish it from primary herpetic gingivostomatitis, candidiasis, traumatic ulcers, aphthous stomatitis, pemphigus, pemphigoid, leukemic gingival infiltration, agranulocytosis, and necrotizing periodontitis. [25]

If ulcers do not heal, spread rapidly, have an unusual appearance, are accompanied by severe weakness, bleeding beyond the gums, frequent infections, or unexplained weight loss, the dentist may refer the patient to a specialist in another specialty. This is important to rule out immunodeficiency, blood diseases, severe diabetes, and other systemic causes. [26]

State	What is similar?	How to distinguish
Common gingivitis	Bleeding and swelling of the gums	There is no papillary necrosis or sharp pain.
Necrotizing gingivitis	Pain, bleeding, necrosis	No loss of attachment in isolated form
Necrotizing periodontitis	Pain and necrosis	There is loss of attachment and bone tissue
Herpetic gingivostomatitis	Pain and ulcers	Often multiple vesicles and ulcers in different areas of the mucous membrane
Aphthous stomatitis	Painful ulcers	Usually there are no “knocked out” interdental papillae
Traumatic ulcer	Local pain	There is a connection with trauma, prosthesis, sharp edge
Candidiasis	Plaque and burning	Plaque is usually removed differently; an assessment of the fungal nature is required.
Blood diseases	Ulcers, bleeding, infections	A complete blood count and medical evaluation are required.

Source for the table: necrotizing gingivitis is a clinical diagnosis, but in case of an atypical picture it is necessary to exclude other ulcerative-inflammatory, infectious and systemic diseases. [27]

Treatment in the acute phase

Treatment must be initiated promptly because the goal of the acute phase is to halt tissue destruction, reduce pain, and decrease the bacterial load. StatPearls describes treatment as a sequential process: acute care, treatment of predisposing conditions, correction of sequelae, and transition to the maintenance phase. [28]

The first stage of dental care is the gentle removal of soft plaque, necrotic tissue, and superficial calculus, as much as pain allows. Guidelines for the management of necrotizing ulcerative gingivitis and periodontitis recommend performing superficial cleaning of infected areas, scaling, root planing as indicated, and rinsing with an antimicrobial solution as soon as possible. [29]

During the first few days, brushing can be very painful, so your dentist may recommend a soft brush, gentle scrubbing, saline rinses, or antiseptic solutions. The MSD Manual recommends that treatment begins with a gentle professional cleaning, sometimes with hydrogen peroxide or chlorhexidine rinses. In the first few days, rinses may temporarily replace regular brushing due to gum sensitivity. [30]

Chlorhexidine can be used as an adjunctive antiseptic, but it does not replace mechanical removal of plaque and necrotic tissue. Clinical guidelines for necrotizing lesions recommend topical antimicrobial rinses, including 0.12% chlorhexidine, and the need for follow-up home care and follow-up visits. [31]

Pain relief is selected individually, taking into account age, stomach, kidney, and liver disease, cardiovascular risk, pregnancy, drug interactions, and allergies. Self-cauterization of ulcers, aggressive scraping of the gray film, alcohol solutions, concentrated hydrogen peroxide, and random antibiotic use can worsen the condition or mask the problem. [32]

Treatment stage	What does a doctor or patient do?	Why is this necessary?
Urgent assessment	Examination of gums, pain, necrosis, general condition	Confirm diagnosis and severity
Professional cleaning	Removal of plaque and necrotic masses	Reduce bacterial load
Washing	Antiseptic irrigation as indicated	Reduce germs and debris
Anesthesia	Selecting a safe drug	Provide opportunities to eat, drink and take care of the oral cavity
Gentle home hygiene	Soft bristle brush, gentle care	Prevent plaque buildup
Antiseptic rinses	Chlorhexidine or other prescribed agents	Temporary assistance in the acute phase
Risk factor control	Sleep, nutrition, smoking, stress, immune status	Reduce the likelihood of relapse
Return visit	Healing assessment and additional cleansing	Don't miss the progression

Source for table: Treatment includes immediate dental cleaning, antimicrobial rinse, home care, pain control, and follow-up. [33]

When are antibiotics needed?

Antibiotics should not be the sole treatment for necrotizing gingivitis. The mainstay remains dental removal of plaque, necrotic tissue, and causative factors, as without mechanical cleansing, the infectious focus and biofilm persist. [34]

Systemic antibiotics are considered in cases of severe disease, severe systemic symptoms, failure to respond to topical treatment, disseminated infection, immunodeficiency, or failure to promptly and thoroughly cleanse the gums. Guidelines for patients with human immunodeficiency virus (HIV) recommend prescribing systemic antibiotics for severe or unresponsive necrotizing ulcerative gingivitis or periodontitis. [35]

The MSD Manual notes that if dental treatment is delayed, oral antibiotics effective against typical oral flora may provide temporary relief until full treatment is completed. However, this does not mean the patient should self-administer antibiotics without an examination, as the diagnosis and severity must be confirmed by a physician. [36]

Metronidazole is often mentioned in various guidelines and clinical materials because it is effective against anaerobic bacteria involved in necrotizing lesions. However, the specific drug, dosage, duration, and need for combination with other agents are determined by the physician, taking into account age, pregnancy, liver disease, alcohol, drug interactions, allergies, and the severity of the infection. [37]

If symptoms persist, ulcers spread, high fever, severe weakness, facial swelling, difficulty swallowing, or a suspected systemic disease develop, a re-evaluation is necessary. In some situations, further diagnostics, referral to a periodontist, infectious disease specialist, hematologist, or hospitalization are required. [38]

Situation	Antibiotics are usually not necessary or essential.	Antibiotics may be needed
Mild local lesion	If the cleanse is completed and there are no systemic symptoms	If there is a deterioration or no response
Severe pain	Cleansing and pain relief are needed.	If there are signs of severe infection
Temperature	Needs evaluation	Often an indication
Lymph nodes	Requires severity assessment	Possible with systemic reaction
Immunodeficiency	A cautious approach is needed	Often considered earlier
Delay in dental treatment	An antibiotic does not replace a visit	It can be a temporary measure until treatment
Ineffectiveness of primary treatment	A reassessment of the diagnosis is needed	Systemic therapy is possible
Spread into deep tissues	Not a home situation	Urgent medical care

Source for table: Antibiotics are considered in severe, systemic, unresponsive to local measures or complicated cases, but do not replace dental cleaning. [39]

Recovery, monitoring and relapse prevention

Treatment does not end after the acute inflammation subsides. Predisposing factors must be eliminated: plaque, tartar, traumatic restoration margins, smoking, lack of sleep, stress, poor nutrition, and possible immune or metabolic disorders. [40]

Periodontal disease management guidelines recommend assessing healing within 7 days after treatment and performing additional cleanings if necessary. A reassessment is also recommended after 2 months to determine whether further interventions are needed, such as correction of soft tissue defects or treatment of underlying periodontitis. [41]

Following necrotizing gingivitis, the interdental papillae may remain deformed, with crater-like areas where plaque more readily accumulates. If such defects persist and interfere with oral hygiene, a dentist or periodontist may discuss additional measures after the acute phase has completely subsided. [42]

Home prevention is based on daily gentle brushing, careful interdental cleaning, regular professional cleaning, and early consultation if pain or bleeding recur. What's important is not aggressive care, but regular removal of biofilm without damaging healing gums. [43]

If the patient has human immunodeficiency virus, neutropenia, leukemia, diabetes mellitus, immunosuppressive therapy, or recurrent necrotizing lesions, prophylaxis should be multidisciplinary. In such cases, dental treatment should be combined with control of the underlying disease and regular medical monitoring. [44]

Goal after the acute phase	Practical action	Why is it important?
Check the healing	Control within 7 days	Don't miss the progression
Remove residual plaque	Additional professional cleaning	Reduce bacterial load
Restore home care	Soft brush and interdental products	Prevent recurrence
Assess papillae defects	Inspection of crater-shaped areas	These zones hold plaque
Check the periodontium	Probing and imaging as indicated	Prevent loss of attachment
Control smoking	Tobacco cessation plan	Improve healing
Assess nutrition and sleep	Correction of deficiencies and regimen	Support the immune response
Rule out systemic causes	Tests and consultations as indicated	Important in case of relapses and severe course of treatment

Source for the table: after the acute phase, monitoring of healing, additional cleansing, home hygiene, correction of risk factors and re-evaluation after 2 months as indicated are necessary. [45]

Possible complications and prognosis

When treated promptly, necrotizing gingivitis often responds well to therapy because the lesion is limited to the gums and has not yet been accompanied by attachment loss. However, the prognosis worsens significantly if the patient presents late, continues to smoke, has poor nutrition, is immunocompromised, or does not follow maintenance care. [46]

The main complication is the development of necrotizing periodontitis, when inflammation destroys the dental ligaments and alveolar bone. StatPearls describes necrotizing periodontal diseases as stages of a single pathological process, where necrotizing gingivitis can progress to necrotizing periodontitis and stomatitis. [47]

If the process extends beyond the gums, deep ulcers, soft tissue necrosis, bone damage, and severe forms of necrotizing stomatitis are possible. In the most severe cases, especially with severe malnutrition and severe immune compromise, necrotizing lesions may be associated with a risk of noma. [48]

A long-term consequence, even after successful treatment, is a change in the shape of the gingival papillae. Crater-like defects between teeth can impair aesthetics, trap food and plaque, increase the risk of recurrent inflammation, and require more meticulous interdental hygiene. [49]

A favorable prognosis depends on four factors: prompt treatment, high-quality professional cleaning, risk factor control, and regular monitoring. If the condition recurs or becomes severe, it's important not just to treat the gums again, but to identify the underlying cause: immunodeficiency, blood disease, uncontrolled diabetes, severe stress, malnutrition, or persistent poor hygiene. [50]

Complication	What's happening	How to reduce the risk
Transition to necrotizing periodontitis	Loss of attachment and bone tissue occurs	Treat periodontitis quickly and control it
Necrotizing stomatitis	The process extends to deeper tissues	Urgent help in case of deterioration
Noma	Severe orofacial destruction under extremely unfavorable conditions	Early treatment, nutrition, monitoring of immune status
Crater-shaped defects of the gums	The interdental papillae do not fully regain their shape.	Maintenance hygiene and correction as indicated
Relapses	The disease returns	Look for risk factors and systemic causes
Weight loss due to pain	The patient eats poorly	Pain relief, soft nutrition, rapid inflammation control
Spread of infection	Fever, swelling, and weakness appear	Do not delay medical attention
Psychological discomfort	Pain, odor, aesthetic defects	Treatment, monitoring and restoration of gums

Source for the table: complications are associated with the progression of necrotizing periodontal diseases, residual gingival defects and systemic risk factors. [51]

Frequently asked questions

Is necrotizing gingivitis contagious? No, it is not considered contagious in the typical everyday sense. The disease is associated with an overgrowth of bacteria that may be present in the mouth but are activated by poor hygiene, stress, smoking, lack of sleep, poor nutrition, or a weakened immune system. [52]

How does it differ from regular gingivitis? Regular gingivitis typically involves redness, swelling, and bleeding, but does not involve necrosis of the interdental papillae or sharp, ulcerative pain. Necrotizing gingivitis typically presents with sudden pain, bleeding, and necrosis or ulceration of the interdental gums. [53]

Can this be treated at home with mouthwashes? No, mouthwashes can temporarily reduce plaque and discomfort, but they are not a substitute for professional plaque and necrotic removal. Treatment should begin with a dental examination and gentle cleaning of the affected areas. [54]

Are antibiotics always necessary? No, antibiotics are not always necessary. They are considered in cases of severe disease, systemic symptoms, immunodeficiency, disseminated infection, lack of response to topical treatment, or delayed dental treatment. However, the mainstay of treatment remains professional cleaning and risk factor control. [55]

Why does bad breath occur? The odor is associated with tissue necrosis, anaerobic bacterial activity, and inflammatory discharge. Masking it with chewing gum or mouthwash isn't enough, as necrotic tissue and bacterial biofilm must be removed. [56]

Is it okay to brush your teeth if your gums hurt a lot? Brushing can be painful during the first few days, so your dentist may recommend temporarily using a very soft brush, gentle brushing, and antiseptic rinses. You shouldn't stop brushing your teeth completely, but your technique should be gentle and discussed with your dentist. [57]

When should you urgently seek medical attention? You should seek immediate medical attention if you experience severe pain, bleeding, a gray coating, protruding papillae, fever, severe weakness, enlarged lymph nodes, facial swelling, inability to eat or drink, or if you have immunodeficiency or poorly controlled diabetes. [58]

Can necrotizing gingivitis progress to periodontitis? Yes, without treatment, the process can progress deeper and develop into necrotizing periodontitis, which involves attachment loss and destruction of the bone supporting the teeth. Therefore, early diagnosis and treatment are critical. [59]

Should you be tested for human immunodeficiency virus (HIV) or other diseases? Not everyone, but if the condition is severe, recurrent, unusual, or has risk factors, your doctor may recommend a medical examination. Necrotizing periodontal disease is more common in immunodeficiency and certain systemic conditions, so recurrent episodes should not be ignored. [60]

How can a recurrence be prevented? The main measures include regular hygiene, professional cleaning, smoking cessation, normal sleep, a balanced diet, stress management, and treatment of underlying medical conditions. After an episode, it is important to return for follow-up, even if the pain has subsided. [61]

Key points from experts

David Herrera González, professor of periodontology at the Complutense University of Madrid, is a researcher of acute periodontal lesions. His key thesis on this topic is that necrotizing periodontal diseases should be recognized as acute lesions with a direct impact on prognosis and treatment, and not as a variant of simple bleeding gums. [62]

Panos N. Papapanou, Professor of Dental Medicine at Columbia University, is a participant in the World Workshop on the Classification of Periodontal and Peri-implant Diseases. His contribution is significant because the current classification identifies necrotizing periodontal diseases as a separate category with a characteristic clinical triad: papillary necrosis, bleeding, and pain. [63]

Mariano Sanz, Professor and Head of Periodontology at the Complutense University of Madrid and Professor at the Faculty of Dentistry at the University of Oslo, is a clinical researcher at the University of Oslo. His practical thesis is that the treatment of acute gum lesions must be integrated into long-term control of biofilm and risk factors, otherwise, even a successfully treated episode may recur. [64]

Iain LC Chapple, Professor of Periodontology and Head of the School of Dentistry at the University of Birmingham, emphasizes that clinical gingival health and inflammation must be assessed in the context of the entire periodontium: it is important to understand whether the lesion is limited to the gum or whether there is already attachment and bone loss. [65]

Brief conclusions

Necrotizing gingivitis is an acute, painful condition characterized by rapid bleeding and necrosis of the interdental papillae. It cannot be treated like regular gingivitis: prompt dental diagnosis, gentle cleaning of the affected areas, antiseptic support, pain relief, and risk factor assessment are required. [66]

Antibiotics are not always used and do not replace professional treatment. They are considered in cases of severe, systemic, unresponsive to local measures, or complicated progression, as well as in cases of immune-related risks or delays in full-fledged dental intervention. [67]

The main prevention of relapse is to restore control over the biofilm and the body as a whole: brush your teeth without injury, treat gingivitis and periodontitis, quit smoking, normalize sleep and nutrition, control stress, diabetes and immune disorders. [68]