Oral Ulcerations

Author Affiliation
Brandon Fetterolf, DO Madigan Army Medical Center, Department of Emergency Medicine, Tacoma, Washington
Alexandra Zaballa, BS University of Washington School of Medicine, Seattle, Washington
Jared Strote, MD, MS University of Washington, Division of Emergency Medicine, Seattle, Washington



Acute Necrotizing Ulcerative Gingivitis

Intravenous vancomycin, piperacillin/tazobactam, and fluconazole were initiated. Oral-maxillofacial surgery was consulted and performed debridement. Continued intravenous antibiotics and chlorhexidine rinses were recommended.

The patient was admitted to the medicine service for three days. Herpes simplex and syphilis studies, sent to rule out other causes of the patient’s ulcers, were negative. His oral infection improved and his absolute neutrophil count, ultimately thought to be low due to acute infection, normalized. He was discharged with outpatient oral antimicrobial therapy and was ultimately lost to follow up.

Necrotizing periodontal disease presents as interdental necrosis with “punched out” ulcerative papilla, gingival bleeding, and pain. It usually affects young adults, commonly military and college students.1,2 Secondary features of disease include foul-smelling breath, yellowish-white or grayish “pseudomembrane,” lymphadenopathy, and fever.1 Risk factors include immunosuppression, psychological stress, smoking, poor oral hygiene, and poor nutrition.1 Common organisms include Bacteriodes, Prevotella, Fusebacterium, and Selenomonas but fungal infections also occur.2 Treatment usually involves debridement, oral antimicrobial rinses, and antibiotics for any signs of systemic involvement.1


Section Editor: Sean O. Henderson, MD

Full text available through open access at http://escholarship.org/uc/uciem_westjem

Address for Correspondence: Jared Strote, MD, MS, Division of Emergency Medicine, Box 356123, University of Washington Medical Center, Seattle, WA 98195. Email: strote@uw.edu 12 / 2015; 16:1196 – 1197

Submission history: Revision received August 5, 2015; Accepted August 24, 2015

Conflicts of Interest: By the WestJEM article submission agreement, all authors are required to disclose all affiliations, funding sources and financial or management relationships that could be perceived as potential sources of bias. The authors disclosed none.


1. Atout R, Todescan S. Managing Patients with Necrotizing Ulcerativve Gingivitis. J Can Dent Assoc. 2013;79:d46.

2. Wade DN, Kerns DG. Acute Necrotizing Ulcerative Gingivitis-Periodontitis: a literature review. Military Medicine. 1998;163(5):337-342.

Lower lip and gums with inflammation and ulceration.