Bored (Review) in the Trenches

It’s another bucolic day in NYC, and you’re stuck in the trenches of the ER with 10 deep to be seen. You pick your next patient, a 23 year-old guy, history of HIV, undomiciled, with a chief complaint of “mouth pain.” You go to the patient and ask what’s wrong, and as soon as he opens his mouth to speak you smell a stench more powerful than Bed 17HW on a Friday night. He tells you his whole mouth and his teeth “hurt like the fire of a thousand suns.” You peer into his mouth and see really horrible dentition, some gum-bleeding, and a membranous film over his teeth and gums. Exam is also notable for fever to 100.4 and cervical lymphadenopahy.

What's the Diagnosis?

This patient has TRENCH MOUTH, aka Acute Necrotizing Ulcerative Gingivitis (ANUG). ANUG is characterized by intense mouth pain, punched out / ulcerative interdental papilla, and gingival bleeding from ulcerative sloughing of the gums. You’ll also see pseudomembranous film, smell some seriously fetid breath, and patients may complain of a metallic taste. It’s caused by opportunistic anaerobic bacteria. As you may guess (you’re so smart!) this was a common affliction of young soldiers in the trenches of World War One.

Who is at risk and what are the complications?

ANUG classically affects young people who are immunocompromised, stressed, malnourished, with alcohol abuse, and poor oral care. Complications include spread of the disease to deeper tissue, Ludwig angina, loss of teeth and alveolar bone destruction.

What is the treatment?

Pain control (NSAIDs are good for anti-inflammatory properties). Chlorhexidine 0.1% mouth wash BID. Metronidazole 500mg BID. Patients must be seen by a dentist for regional anesthesia and debridement, and should have dental xrays to ensure no bony spread of the disease.

What is the Christmas Truce?

On Christmas Day of 1914 during WWI, German and British soldiers held a cease-fire and met in the middle of no-man’s-land to exchange gifts (probably not toothbrushes), play games, and sing carols. They even had a christmas tree!

References

Tintinalli’s 7th edition

Uptodate.com

Ferri’s Clinical Advisor 2016

By Kylie Birnbaum

Special Thanks to Dr Willis. And to Dr. Aherne for his endless trivial pursuit