Article
Necrotizing gingivitis associated with COVID-19 infection: causation or coincidence?
We present here a case of a patient with necrotizing gingivitis associated with a suspected COVID-19 infection.
Necrotizing gingivitis is characterized by the three acute clinical features (papilla necrosis, bleeding and pain) and are strongly associated with impaired host immune responses.
Necrotizing gingivitis, also known as Trench-mouth, was typically seen during World War I; and was ostensibly due to multiple risk factors, including poor oral hygiene, psychological stress and malnutrition. In more recent times, it has presented with a lesser frequency within the general population, often seen in an immunocompromised patient, such as those suffering from HIV.
A 35-year-old woman attended the King's College Hospital dental emergency unit reporting a history of fever, intense gingival pain, bleeding gums and halitosis. The fever presented first followed by the oral symptoms 3 days later. She reported no other systemic symptoms or symptoms suggestive of COVID-19. As a result of the pain, the patient was having difficulty eating. The pain was constant, affecting her sleep, and paracetamol did not provide any analgesic benefit. She was medically fit and well, with no known allergies and taking no regular medication. She was a non-smoker, working from home as an auditor for a global advisory firm. She had no risk factors for HIV. She followed good oral hygiene habits, brushing twice daily and flossing once a day, and had started using an alcohol-containing mouthwash. Her last dental visit was 12 months previously, which included a session with the hygienist.
On examination, her temperature was recorded as 37.5°C using a tympanic thermometer. Submandibular lymphadenopathy was evident bilaterally and there was no trismus. Severe halitosis was noted, with generalized erythematous and oedematous gingivae, with loss of interdental papillae in both the maxillary and mandibular labial sextants. Spontaneous bleeding was noted from the gingival sulcus and there were no signs of any attachment loss.
A clinical diagnosis of necrotizing gingivitis was made, according to the presence of primary clinical symptoms: loss of interdental papillae, spontaneous gingival bleeding and intense pain. The patient was prescribed oral antibiotic (400 mg metronidazole three times daily for 5 days) and oral mouthrinse (0.12% chlorhexidine twice daily for 10 days). Oral hygiene and general nutritional advice was given and, following national guidance on COVID-19, she was advised to return home immediately to self-isolate for 7 days.
The patient was called 5 days later and she reported a significant improvement in her symptoms. She was advised to see her general medical practitioner in the near future for blood-borne viral screening and her dentist for further periodontal support.
In December 2019, an outbreak of a severe acute respiratory syndrome started in Wuhan, China, and has since been declared a pandemic by the WHO. Many cases of COVID-19 are acute and resolve, but the disease has been seen to be fatal. Considering the immunocompromised status of individuals with COVID-19, patients may initially present to dental emergency hubs with acute periodontal conditions. It is important to raise awareness on the primary presentation of necrotizing gingivitis as a manifestation of COVID-19, and to be aware of the current guidance on managing necrotizing gingivitis, with consideration to the national guidance on self-isolation.