This article looked into the aetiology, prevalence and treatment of gingivitis, Trench Mouth or Necrotising Ulcerative Gingivitis (NUG) as it is now known,1 and Vincent's angina. It was instigated on the suggestion of the Director General of the Army Medical Services (DGAMS) and the Pathological Committee of the War Office. The authors examined patients in military hospitals in England during the period from July 1918 to April 1919.

NUG is still seen in the British army to this day (Dufty JR, Donos N, Petrie N, et al. A Service Evaluation of the Diagnosis and Management of Necrotizing Ulcerative Gingivitis in the British Armed Forces—unpublished data, 2013). It is an infection that is ‘characterized by gingival necrosis, presenting as punched out papillae, with gingival bleeding and pain’.2 It was first documented in 401 BC in Xenophon's War Diaries3 but did not receive much further attention as a disease in its own right until the late 1800s, with the work of Plaut and Vincent.4

Vincent is widely credited with the discovery of this disease, which was first described as a fusospirochetal infection of the palatine tonsils and throat (Vincent's Angina), and only later was the separation from the gingival infection (known as Vincent's Infection, now NUG) made.5

The perceived high prevalence reported during the First World War led to the introduction of the term, Trench Mouth, a term which is still well known to military clinicians.6^–8 Yet, the literature from this era is not easily accessible and many authors quote the same studies repeatedly. It can also be difficult to determine which disease is being described, as NUG has over thirty synonyms and there is often no dissociation made between the tonsillar and gingival disease types.8 Hence, obtaining good data and studies on Trench Mouth from the First World War is not as straightforward as one might think, and this is where my interest in this article lies.

This article, by Semple et al, is not one of those that are regularly quoted, and by hopefully bringing it to light in the J R Army Med Corps, it can be added to the historical evidence base for this rare disease.

This prevalence rate is in line with other studies of the British military, which showed a prevalence rate of between 0.3% and 0.7%,7 ,9 although recent research has shown the prevalence to be lower (0.11%). (Dufty JR, Donos N, Petrie N, et al, unpublished data, 2013)

Predisposing factors associated with NUG including smoking, psychological stress, malnutrition and poor oral hygiene10 ,11 were, no doubt, rife in troops during the First World War, and may be why NUG has been described more regularly in military populations.12

Despite over a century of investigation into NUG, we still know relatively little about its true aetiology. To date, the spirochete that is associated with NUG has not been identified.12 This paper, following the earlier work of Plaut and Vincent,13 further adds to the evidence demonstrating that NUG is an opportunistic fusospirochetal infection resulting from the commensal oral flora.14 ,15

The treatment suggested by Semple et al, although primarily for gingivitis, is clear with the key suggestions being for improving the oral health of soldiers of all ages.

Treatment regimes for NUG have changed dramatically from the earlier use of topical iodine, mercury and silver compounds, and arsenicals, to the current use of metronidazole and local debridement of the infected area.2 ,11 However, oral hygiene instruction, as described above, remains a key component in the treatment of gingivitis and NUG.

Subsequent influence on opinion

Unfortunately, much as Hirschfeld, in his excellent review on Vincent's Infection, notes the lack of corroboration of evidence between the French and British medical and dental communities regarding NUG,3 it would seem that the work of Semple et al was not widely available and, unfortunately, was then not able to contribute to the study of this disease.

What do we do differently now?

Non-surgical periodontal therapy, performed by the Dental Officer or Dental Hygienist, has been recommended as a first-line treatment, where the patient can tolerate it, with antimicrobials prescribed where there is evidence of systemic involvement, such as lymphadenopathy, fever or malaise.11

Oral hygiene instruction is of great importance especially to prevent the recurrence of the disease.

The authors

Lieutenant Colonel Sir David Semple, MD RAMC (1856–1937), had a distinguished medical career that included the foundation of the Pasteur Institute at Kasali, India, and as director of the Central Research Institute at Kasali. He also served as the assistant Professor of Pathology at the Army Medical School, Netley, and as Director General of the Public Health Department in Egypt, from which he was promoted to Colonel (having left the left the army some 10 years earlier) as a member of the Standing Sanitary Board of the Egyptian Expeditionary Force. His decorations included the Kaisar-i-Hindi medal, the Order of the Nile and a Knighthood.16 His main areas of interest were in typhoid, rabies (for which he developed the Semple vaccine), cholera and malaria. Captain Cecil Price-Jones, MB RAMC, was a haematologist whose work on the size of blood cells led to ‘his name being known in every civilized country’.17 No information on the third author, Miss L Digby, is available.