ANUG vs scurvy

With great enthusiasm I read the article published by Devan Raindi on ‘Nutrition and Periodontal Disease’ (Dent Update 2016; 43: 66–72). The work of the author is commendable. It would be appropriate to add here that among the nutritional deficiencies the most commonly encountered deficiencies include the vitamin A, B-complex and vitamin D. Vitamin A deficiency (VAD) is a major problem in many developing countries which include India.¹ It is generally associated with a decrease in the intake of this vitamin in the diet and also due to infectious diseases like measles, respiratory tract infection and diarrhoea that are highly prevalent.²

Vitamin C deficiency has been seen more in Indian men than in women and increases with age, use of tobacco and in the presence of noncommunicable disease.³ Severe Vitamin C deficiency causes scurvy. The common features of this include bright red, boggy gingiva that bleeds easily on gentle provocation and loosened teeth. The deficiency of this nutrient is known to alter the immune response and will also be detrimental on the cellular products such as oxygen radicals.⁴

It is characterized by the increase in capillary permeability, hyporeactivity of the contractile elements in blood vessels in the periphery, and there is sluggishness in the blood flow. Characteristic features during the prodromal period which existed in a scurvy patient was described by Shklar and McCarthy. It consisted of loss of weight, weakness, malaise and also lassitude.⁵ Presence of ecchymosis in the lower extremities indicated that vascular disorder of some form was likely to exist. If the scurvy was untreated then the haemorrhage was likely to occur in the joints.

Scurvy is often confused with acute necrotizing ulcerative gingivitis and forms a diagnostic and management dilemma. In the abovementioned article by Devan Raindi, Table 1 (Some beneficial nutrients and their potential effects on the periodontium), the author mentions that Vitamin C deficit is associated with necrotizing ulcerative gingivitis. This can cause some confusion among the readers, it is therefore necessary here to delineate the two diseases of the periodontium.

John Hunter, in 1778, is credited with making the first clinical differential diagnosis between gingival lesions, now recognized as representing ANUG and the oral symptoms of scurvy.⁶ The bacterial nature of acute necrotizing ulcerative gingivitis was first recognized by Vincent and Plaut. Light microscope analysis determined the presence of the fusiform and spirochetes on the ulcerated lesion surfaces.⁷ By thorough history and examination, acute necrotizing ulcerative gingivitis and the scorbutic gingivitis due to severe Vitamin C deficiency can be differentiated based on the systemic signs and symptoms.⁸

According to Barnes et al,⁷ there are several signs which are pathognomonic to the disease and the final diagnosis of ANUG can be done based on the clinical findings. Schluger⁷ provided the pathognomonic signs of ANUG that is accepted widely and recognized: ‘the mucosa is highly inflamed, with engorgement of the interdental papillae. Ulceration of the interdental papillae is seen occasionally and often covered with grey pseudomembrane, which on removal leaves a raw bleeding surface. The papillae is inverted and presents a crater like appearance which shows characteristic fetid odor due to the accumulation of the detritus.' These signs in the disease were also supported by Pindborg et al.⁶ High fever, leukocytosis, general fatigue, appetite loss and increased pulse rate are the systemic manifestations in severe cases.^6,9