Ulcerative-necrotizing gingivitis, or Vincent's stomatitis, is a severe form inflammatory disease gums, which is accompanied by necrosis of periodontal tissues. Manifests itself as a complication catarrhal gingivitis, is rare and without medical care not cured.
Characteristic signs: painful gums, bleeding, ulcers with a whitish coating and a strong putrid odor from the mouth. More often, this pathology manifests itself in the winter-spring period and at a stressful time for a person. The sudden appearance of Vincent's gingivitis is one of the first signs of HIV infection.
The cause of the development of ulcerative necrotic gingivitis is bacterial infection V pathogenic microflora. The causative agents are anaerobic bacteria, spirochetes and fusobacteria.
“Flocks” of such pests live in everyone’s mouth healthy person, but their number is negligible, they are not dangerous.
If a person does not follow the rules of hygiene or his immunity weakens, anaerobic spirochetes and fusobacteria begin to actively multiply. Toxic products their vigorous vital activity “poisons” the periodontal area.
Microcirculation of fluid in tissues is disrupted, they do not receive the necessary nutrients. Necrosis occurs - destruction and “death” of cells.
Develops against the background of conditions and diseases that cause weakening immune defense body:
Other reasons - acute poisoning, including heavy metals (mercury, lead, bismuth), smoking, drug use, poor nutrition.
The peak incidence occurs in the winter-spring period, when the body lacks vitamins and is weakened by seasonal diseases- colds, flu, sore throat, etc. For students - during sessions from high stress load.
The lesion first appears in the area of one to three teeth. In a matter of days it spreads to the entire gingival margin.
TO local symptoms joins general malaise. The face takes on an earthy color, the skin turns pale. Body temperature rises to 37.5-39 degrees, submandibular lymph nodes enlarge and become painful.
Patients complain about:
IN general analysis blood can be seen elevated white blood cells and ESR (erythrocyte sedimentation rate) - a laboratory indicator, changes in which indicate inflammatory pathological process in the body.
Symptoms of pathology are visible upon visual examination. To confirm, a scraping is taken from the surface of the ulcers and the samples are checked for the presence of anaerobic and fusobacteria, spirochetes.
Task differential diagnosis- to distinguish Vincent's stomatitis from ulcerative inflammation of the gums, which manifests itself against the background of blood diseases - leukemia, infectious mononucleosis and agranulocytosis. To do this, they take a peripheral blood test - from the vascular bed, that is, the usual finger prick blood test.
To differentiate ulcerative-necrotizing gingivitis from allergic stomatitis An additional bacterioscopic examination - a smear - will be required. If it is suspected that inflammation has developed due to mercury poisoning, a urine test is performed.
The first sign is strong sharp pains in periodontal tissues. The mucous membrane becomes bright red, and it becomes difficult to chew due to swelling and pain.
Symptoms of a chronic course are not as pronounced as acute symptoms. The mouth smells bad when medical examination Small ulcers and lesions are found in the area of the gingival margin and gingival papillae. Chronic form occurs in adolescents who systematically ignore hygiene rules.
Therapy is aimed at eliminating the manifestations of the disease and eliminating the causes. It is carried out only by a periodontist in a clinical setting.
Anesthesia
The procedures are performed only under application and infiltration or conduction anesthesia.
Tartar removal
Soft plaque and hard deposits can be removed by professional cleaning.
Treatment of ulcers
Necrotic masses are removed by application of enzymes: trypsin, iruxol, etc., the area under them is thoroughly disinfected with antiseptic and antimicrobials- chlorhexidine, asepta, listerine, gel with metronidazole, sanguarine.
The doctor prescribes antibiotics: metronidazole, doxycycline, trichomonacid, penicillin.
Complete refurbishment oral cavity
Treatment will help prevent germs from entering vulnerable tissues after procedures.
After eliminating the source of infection, patients rinse at home antiseptic solutions and apply Metrogil-Denta gel to the affected areas of the mucosa until the wounds are completely healed.
After local procedures, patients are prescribed a diet - easily digestible food high in protein, phosphorus and fluorine, drinking plenty of fluids. Vitamin complexes are also prescribed.
At proper therapy patients feel better within a day or two: swelling goes away, pain subsides, appetite and the ability to chew appear. Normally, after 3-6 days, signs of inflammation disappear. In the chronic form, this occurs a little later. After one or two months - a follow-up visit to the doctor. You will then need to visit your dentist every six months for a year.
Despite the optimistic prognosis, dead mucosal tissue cannot be restored. IN extreme cases Gingivoplasty will be required.
The disease can only be treated with traditional dental medicine. Folk remedies will help complement the main treatment and speed up healing.
To relieve inflammation after dental procedures, rinsing with decoctions and tinctures based on:
(ulcerative stomatitis, fusospirochetal stomatitis, “trench” mouth, Vincent’s stomatitis) - an infectious alterative-inflammatory disease of the oral mucosa, which occurs against the background of reduced reactivity of the body in the presence of unfavorable conditions in the oral cavity, develops as immune reaction according to the type of Arthus phenomenon in response to sensitization of oral mucosa tissue by anaerobic fusospirillary microflora and is characterized by necrosis and ulceration.
The disease occurs under the influence of fusospirillary infection - a symbiosis of the Vincent spirochete and the fusiform bacillus. This symbiosis in normal conditions is a saprophyte of the oral cavity and is found in interdental spaces, periodontal pockets, in the depths of carious cavities, root canals of teeth and tonsil crypts. Fusospirillary infection is significantly activated during inflammatory processes and, being anaerobic and serophilic, is capable of penetrating deep into tissues up to 300 microns.
Vincent's stomatitis quite often develops against the background of hypothermia, stress, trauma, surgical interventions. The development of the disease is largely associated with such local irritants as sharp edges of decayed teeth, deep-set artificial crowns, and difficult eruption of wisdom teeth. The development of ulcerative-necrotic stomatitis is facilitated by unhygienic maintenance of the oral cavity, especially unsanitized, smoking, working in a highly dusty industrial environment, etc.
Ulcerative necrotizing stomatitis can be a symptom of blood diseases, in particular leukemia, intoxication with salts of heavy metals, gastrointestinal pathology, food toxic infections, diseases endocrine system, kidneys, liver, radiation injuries, immunodeficiency, scurvy and HIV infection.
When the hygienic condition of the oral cavity is unsatisfactory, gram-negative bacteria (B.vincenti, B.fusiformis, B.buccalis) and bacteroids (B.melaninogenicus, veilloncllae) multiply in the accumulated plaque against the background of reduced immunity and barrier function of the mucous membranes. Microorganisms and their toxins slowly penetrate the connective tissue of the mucous membranes and gums, where pathogens multiply. If this condition continues for weeks or months, chronic catarrhal stomatitis or gingivitis develops, which is a delayed-type immune lesion of the oral mucosa. If even more bacteria enter this moderately balanced fight, gingivitis intensifies: at the site of contact between plaque and microflora, more and more small lymphocytes, plasma cells and cells of nonspecific inflammatory infiltrate gather. Plasma cells form IgM, IgG, which fix complement. The complement system is activated, leading to blood clotting, stasis, thrombosis and regional necrosis. Interaction of antigen with IgM, IgG causes immune tissue damage III type- Arthus reaction: superficial vasculitis, thrombosis, necrosis. These phenomena are accompanied by the Sanrelli-Schwartzman phenomenon caused by bacterial toxins,
According to the nature of the course of the disease, acute, subacute, chronic ulcerative-necrotic stomatitis and relapse are distinguished; according to the severity of the course - mild, moderate and severe forms.
Necrotizing ulcerative stomatitis in its course has a number of typical signs of an infectious disease. In the prodromal period, patients are concerned about weakness, headache, low-grade fever body, aching joints. In the oral cavity - bleeding gums, burning sensation and dryness. Depending on the shape clinical course this period can last several days in mild cases and only a few hours in severe cases, after which it enters the phase of advanced clinical manifestations of the disease. In this case, patients complain of increased general weakness, increased body temperature, headache, and decreased ability to work. In the oral cavity, the pain increases sharply at the slightest touch, the tongue is inactive during conversation. Eating and hygienic oral care are almost impossible. Salivation increases, enlargement and soreness are observed in the regional lymph nodes, a sharp putrid odor appears from the mouth, which is very morally depressing for patients. When the lesion is localized in the retromolar region, which mainly happens when eruption is impaired lower teeth wisdom, the above-mentioned complaints are accompanied by limited opening of the mouth - lockjaw.
Most often, ulcerations begin from the gums, and always from those areas where there are local irritating factors: tartar, deep-set artificial crowns or destroyed crowns of gangrenous teeth, in areas with deep periodontal pockets. Subsequently, the resulting lesion spreads to the oral mucosa, which borders on primary focus ulcerations (on the lateral surfaces of the tongue, on the cheeks - along the line of closure of the teeth, soft palate, tonsils). In most patients, the course of ulcerative necrotic stomatitis is of moderate severity: with moderate high temperature body (37.5 - 380C) and moderate pronounced signs general intoxication. In this case, patients complain of general weakness, headache, insomnia, increased body temperature, aching joints and muscles, lack of appetite, as well as severe pain and severe bleeding gums, a sharp putrid odor from the mouth, the inability to bite and chew food, sometimes trismus, the inability to take hygienic care of the oral cavity.
On examination, as a rule, these are people young(19-27 years old), their mood is depressed. The skin of the face is pale, sometimes covered with small beads of sweat. The red border is dry, sometimes with traces of dried blood. Such patients speak slowly, being careful not to touch the teeth or affected gums with the affected tongue. Even from a distance, a putrid odor can be felt from the patient’s mouth. Saliva is secreted into large quantities and flows spontaneously from the oral cavity. Regional lymph nodes are enlarged and painful.
The marginal zone of the gums and interdental papillae undergo special changes. The gums are swollen, loosened, hyperemic, sharply painful, and bleed easily with slight touch. First, necrosis affects the apices of the interdental papillae, and then covers its body and marginal zone. Over time, necrotic masses become white-gray, gray-brown or gray and are held quite firmly on the surface of the dead papillae. The latter lose their characteristic scalloping (resemble a truncated cone). Some patients experience spontaneous bleeding from the surface of the ulcers. The saliva released in significant quantities is viscous, viscous, contains streaks of blood, and has an unpleasant odor.
For light form Ulcerative necrotic stomatitis is characterized by a limited spread of the process. More often, only the tips of the interdental papillae in a certain group of teeth become necrotic. General health does not change significantly. Working capacity, as a rule, is not impaired.
In contrast to mild and medium forms - when severe course Ulcerative-necrotizing stomatitis (gingivostomatitis) the general condition of the patient is characterized by high temperature (38.5-40°C) and severe symptoms of general intoxication. Ulcerations spread over a significant area of the oral mucosa, and the depth of the ulcer can reach muscle tissue, tendons, bones, often with the development of osteomyelitic lesions of the alveolar process.
Quite often, ulcerative-necrotic lesions are localized on the mucous membranes of the cheeks in the retro-molar region and along the line of closure of the teeth, on the tongue (mainly on its lateral surfaces in the area of the traumatic factor), on the mucous membranes of the lips and the floor of the oral cavity. When the ulcerative necrotic lesion spreads to the palate and tonsils, stomatitis is called Simanovsky-Plaut-Vincent angina.
Acute necrotizing ulcerative stomatitis with insufficient treatment and implementation rehabilitation measures may recur and become chronic. This transition is more often observed against the background of chronic somatic pathology, as well as with an unsanitized oral cavity.
Pathohistologically, with ulcerative necrotic stomatitis, 2 lesion zones are identified: superficial - necrotic and deep inflammatory.
The superficial layer of necrosis is rich in microflora (spirochetes, fusobacteria, rods, cocci); in the deeper layers that are adjacent to living tissues, fusospirillary microflora significantly predominates. The underlying tissues are in a state acute inflammation, there is little microflora here, only spirochetes are found that penetrate into the middle of living tissue.
Chronic ulcerative-necrotizing stomatitis develops mainly in areas of the skin where “old” deposits of tartar are observed or other chronic local irritants are detected. It often occurs as a result of acute inflammation with insufficiently effective local treatment. The vast majority of patients experience light form. Only during an exacerbation do some general symptoms and stomatitis shows signs of disease medium shape gravity. A characteristic feature of the chronic course of stomatitis is the absence of a severe form. In addition to a sluggish course, chronic ulcerative necrotic stomatitis is characterized by roller-like thickening of the gum edge, the formation of interdental pockets (due to the loss of interdental papillae), and ulceration. Pain and bleeding are moderate. The ulcers are covered with a small amount of necrotic tissue. In the area of ulceration, resorption of the edge of the alveolar process is observed. At proper treatment ulcers heal with the formation of scars.
Since the causative agent of necrotizing ulcerative stomatitis, the mechanism of development of the disease and its symptoms are known, then complex therapy, both local and general (etiotropic, pathogenetic and symptomatic) can be carried out completely and will ensure recovery. However, the effectiveness of treatment of this disease is mainly determined by local therapy, which is carried out according to the principles surgical treatment infected wounds. That's why therapeutic tactics with ulcerative necrotic stomatitis has the following sequence:
a) in the hydration phase:
Anesthesia of the surgical field (dicaine, anesthesin, lidocaine, pyrocaine - applications, oral baths, aerosol);
Antiseptic treatment of the oral cavity and lesions with agents that adversely affect anaerobic microflora (hydrogen peroxide, potassium permanganate, metronidazole, metrogil, trichopolum, trichomonacid, dioxidin), or antibiotics (penicillin, gentamicin, etc.) in combination with proteolytic enzymes (trypsin , chymotrypsin, terrilitin);
Surgical treatment of the surgical field: removal of necrotic tissue (with a hook, scalpel, excavator) and elimination of local irritating factors (except for removal of the roots of decayed teeth) with constant irrigation of the surgical field with solutions antiseptics in combination with anesthetics;
Necrolytic agents in combination with antibiotics wide range actions;
Anti-inflammatory drugs (sodium mefenamate, pyramidant);
Proteolysis enzyme inhibitors (trazylol, contrical, pantrypin, ambel);
Agents of osmotic action (nitazol, hypertonic solutions of sodium bicarbonate and sodium chloride);
Means of sorption therapy - (Regencur, PMS, Szilard, etc.);
b) in the dehydration phase:
Stimulators of reparative processes in tissues and preparations of keratoplastic action (solcoseryleryl, erbisol, askol, tezana liniment, vitamin A, sea buckthorn oil, rosehip oil, olazol, romazulan, citral, sodium mefenamate, metacil, pyramidant, Kalanchoe juice, aloe);
Sanitation of the oral cavity.
General therapy of necrotizing ulcerative stomatitis is subject to the same goals:
Etiotropic treatment - antibacterial agents inhibition of fusospirillary microflora:
a) antibiotics (penicillin, cephaloridine, cloferan, ampicillin, ampiox, carbenicillin, tetracycline, morphocycline, metacycline, neomycin, monomycin, kanamycin, gentamicin, erythromycin, oleandomycin, oletethrin, lincomycin, etc.);
b) antiprotozoal drugs (tiberal (ornidazole), fazizhin, metronidazole, Trichopolum, Klion, etc.).
Pathogenetic treatment. For the purpose of regulation pathogenetic mechanisms development of the disease is prescribed:
a) anti-inflammatory drugs (aspirin, butadione, mefenamic acid);
b) hyposensitizing agents (calcium preparations - gluconate, chloride; antihistamines - fenkarol, tavegil, pipolfen, diphenhydramine, loratidine);
c) vitamins ( ascorbic acid, ascorutin);
d) means of detoxification therapy (hemodesis enterodeses, enterosorbents).
Symptomatic treatment - analgesics, antipyretics, cardiotonic drugs, etc.
Ulcerative-necrotic stomatitis of Vincent (stomatitis ulceronecroticans Vincenti)- inflammation of the oral mucosa caused by spindle-shaped bacilli Bacillus fusiformis and Borellia vincentii.
Described under different names: ulcerative gingivitis, ulcerative stomatitis, ulcerative membranous stomatitis, fusospirochetous stomatitis, Plaut-Vincent stomatitis, “trench mouth”, ulcerative membranous stomatitis, etc. By modern classification the disease is called "Vincent's ulcerative necrotic stomatitis" or "Vincent's stomatitis". In case of gum damage, the disease is defined as Vincent gingivitis; with simultaneous damage to the gums and other areas of the oral mucosa - Vincent's stomatitis, and when the process is localized in the area of the palatine tonsils - Simanovsky-Plaut-Vincent's angina.
Vincent's ulcerative necrotizing stomatitis caused by the symbiosis of the spindle-shaped rod and Vincent's spirochete. Under normal conditions, these microorganisms are representatives of the resident microflora of the oral cavity and are detected in small quantities in all people with teeth. They are found mainly in the gingival groove, periodontal pockets, carious cavities, and crypts of the palatine tonsils. In an unsanitized oral cavity, with poor hygienic condition, as well as with periodontitis, the number of fusobacteria and spirochetes increases sharply.
The development of Vincent's ulcerative-necrotic stomatitis is associated with a sharp decrease in the body's resistance to infection due to previous viral diseases(acute respiratory infections, herpetic stomatitis, pneumonia, etc.), vitamin deficiencies, stress, overwork, malnutrition. Necrotizing ulcerative gingivitis often complicates the course of severe general diseases (leukemia, agranulocytosis, pneumonia, infectious mononucleosis). It can occur as a complication of exudative erythema multiforme and erosive allergic stomatitis. When specific and nonspecific defense mechanisms in the body are disrupted, the virulence of fusobacteria and spirochetes increases. Their number increases to such an extent that they become dominant compared to other microflora. A decrease in the overall resistance of the body negatively affects the resistance of the oral mucosa. It cannot act as a reliable barrier to the introduction of infection, and the violation of its integrity in an unsanitized oral cavity due to the presence of local traumatic factors (sharp edges of teeth, dentures, tartar deposits, etc.) creates conditions for the introduction of fusobacteria and spirochetes. Therefore, Vincent's ulcerative necrotizing stomatitis often develops in people with an unsanitized oral cavity.
This disease is considered non-contagious, although there are known cases of group incidence of Vincent's stomatitis (in military units, schools, kindergartens). Similar cases are explained by similar unfavorable conditions everyday life (malnutrition, lack of vitamins, lack of hygiene measures for oral care, etc.).
Mostly young people (17-30 years old), mostly men, are affected. A provoking factor in the development of necrotizing ulcerative stomatitis
Vincent's disease is often caused by hypothermia, which explains the highest frequency of its occurrence in autumn and winter. The maximum number of cases occurs between October and December.
Clinically, acute and chronic courses are distinguished, and according to severity - mild, moderate and severe forms of Vincent's ulcerative-necrotic stomatitis.
The disease begins acutely with an increase in body temperature to 37.5-38 °C. Regional lymph nodes enlarge, become denser, become painful on palpation, and remain mobile. Patients are bothered by headaches, general weakness and soreness of the oral mucosa appear, which intensifies when eating or talking; bleeding gums, hypersalivation, putrid breath. There is pallor skin faces with a grayish tint due to severe intoxication of the body.
Catarrhal phenomena on the oral mucosa quickly turn into ulcerative ones. The process most often begins on the gums, and then moves to other areas of the mucous membrane. The gums become swollen, hyperemic, sharply painful and bleed when touched. The epithelium of the gum margin and interdental papillae becomes cloudy and then necrotic. As a result, the gingival margin looks as if it were cut off, with uneven jagged edges; its surface is covered with an easily removable grayish-yellow coating. Subsequently, the affected gum edge is not completely restored and remains deformed.
The area near the lower eighth teeth is most often and to a greater extent affected. Necrosis from the alveolar process quickly spreads to the buccal mucosa and retromolar region, causing in some cases trismus and pain when swallowing. Ulcers on the buccal mucosa can reach large sizes(up to 5-6 cm in diameter) and depth. Their edges are uneven and soft. The bottom is covered with a thick grayish-greenish necrotic coating, which has a putrefactive foul odor. After removing the plaque, the bleeding bottom of the ulcer is exposed. There is no compaction in the area of the base and edges of the ulcer. The mucous membrane around the ulcer is swollen and hyperemic. If there are local traumatic factors in the oral cavity (roots of decayed teeth, sharp edges of teeth or dentures), other areas of the mucous membrane (hard and soft palate, arches, tonsils, tongue) may also be affected.
Oral ulcers can be single or multiple. When the ulcer is localized on the hard palate, necrosis of all layers of the mucous membrane develops quite quickly and the bone is exposed. Isolated lesion of the pharynx (Simanovsky-Plaut-Vincent angina), as a rule, is unilateral, and is rare in dental practice. 2-3 weeks after the onset of ulcerative necrotic stomatitis, the process usually resolves with complete epithelization of the ulcerative surfaces.
In rare cases, when treatment is not carried out or is ineffective, a chronic form of Vincent's ulcerative-necrotizing stomatitis develops, in which there are no general symptoms. Patients are concerned about constant bleeding and sore gums, as well as bad breath. The clinical picture of the disease is blurred. The gum is stagnant, hyperemic, edematous, its ulcerated edge is often compacted, necrotic areas are located mainly in the interdental spaces and can be visible during a cursory examination. Upon careful examination and probing of the gingival margin, exposed bone tissue is determined. Only some teeth have affected areas. Lymph nodes(submandibular, submental) are compacted, slightly painful and, with a disease duration of 4-8 months, acquire a cartilage-like consistency.
During pathohistological examination of areas of ulcerated gum edges, two zones are revealed: superficial - necrotic and deep - inflammatory.
In the surface layers of necrotic gum tissue, an abundant diverse microflora is found (cocci, rods, fusobacteria, spirochetes, etc.). Fusobacteria and spirochetes predominate in the deeper layers). Underlying layers connective tissue inflamed, swollen, blood vessels dilated. Blood cells are found in the perivascular inflammatory infiltrate. Inside the intact tissue in the same zone of inflammation, only spirochetes that have penetrated between the epithelial cells are detected.
The cytological picture of scrapings from ulcerative surfaces of the mucous membrane in patients with Vincent's ulcerative necrotic stomatitis corresponds to that of a nonspecific inflammatory process. At the onset of the disease, an abundance of structureless masses, a sharp predominance of neutrophils, mainly in a state of decay, and erythrocytes (due to severe bleeding) are determined. In the second period of the disease, when healing begins, along with decayed neutrophils, full-fledged phagocytic cells and many macrophages appear. During the period of beginning epithelization, layers of young epithelial cells are found, the number of fusobacteria and spirochetes decreases.
At chronic course In Vincent's ulcerative-necrotizing stomatitis, the relative amount of fusobacteria and spirochetes decreases and the number of cocci increases, but fusospirochetes still predominate.
The diagnosis of Vincent's ulcerative-necrotic stomatitis is made on the basis of a characteristic clinical picture and the detection of an abundance of spindle-shaped fusobacteria and spirochetes in scrapings from the surface of the ulcers.
Local treatment consists of removing traumatic factors, necrotic tissue, influencing the microflora and stimulating regeneration processes of the oral mucosa.
Treatment of the oral cavity should begin with application or injection anesthesia. For this purpose, anesthesin, pyromecaine, trimecaine, lidocaine are used. Then all mechanical irritants are eliminated: sharp edges of teeth and dentures are ground, tartar and plaque are removed. Carious cavities are treated with antiseptic solutions. Removal of decayed teeth should be postponed until the ulcers are epithelialized, since this intervention in the infected oral cavity of a patient with necrotizing ulcerative stomatitis is fraught with serious complications (alveolitis, periostitis, abscess, phlegmon). Ulcerative surfaces are cleaned of necrotic tissue using proteolytic enzymes: trypsin, chymotrypsin, lysoamidase, deoxyribonuclease.
The entire oral cavity is treated with warm antiseptic solutions (0.5% hydrogen peroxide solution, 0.25% chloramine solution, 0.5% ethanium solution), as well as antimicrobials: 0.02-0.06% solution of chlorhexidine and its combined forms (lizoplak, parodium), 0.5% solution of metronidazole (Flagyl, Metro Gil, Klion), 1% solution of sanguiritrin. Gelmetrogil denta (a combination of metronidazole and chlorhexidine) is applied to the area of the affected oral mucosa in the form of applications 2 times a day for 15 minutes for 7-10 days.
Gum pockets, the surface of the ulcer, interdental spaces and sub-hood spaces are best rinsed with a high-pressure jet. On the first visit, the entire oral cavity should be treated. Subsequently, daily processing is carried out. The patient is prescribed oral baths with antimicrobial agents and Gildent metro applications to the affected areas of the mucous membrane at home.
For mild ulcerative-necrotizing stomatitis of Vincent local treatment enough. In more severe cases, it is necessary to carry out general treatment.
As antibacterial therapy Metronidazole (Trichopol, Flagyl, Klion) is prescribed orally, 0.25 g 2 times a day for 7-10 days. Broad-spectrum antibiotics are also used: chloramphenicol 0.5 g 3-4 times a day, course of treatment is 7-10 days; sumamed according to the scheme for 5 days; Rulid 150 mg 2 times a day for 7-10 days.
Assign antihistamines(tavegil, suprastin, fenkarol, diazolin), as well as multivitamins.
With proper treatment, patients' condition improves within 24-48 hours: pain decreases or disappears, patients can eat and sleep. Swelling and hyperemia of the oral mucosa decrease, epithelization of ulcers begins, which, when mild degree disease and satisfactory condition of the oral cavity ends by the 3-6th day. In an unsanitized oral cavity, epithelization of ulcerative surfaces proceeds more slowly. After the general condition of the patient has improved and acute inflammatory phenomena have disappeared, it is necessary to carry out a thorough sanitation of the oral cavity with the removal of tartar, tooth roots, treatment carious teeth and periodontal diseases.
Relapses of necrotizing ulcerative stomatitis can occur if foci of chronic infection remain in the oral cavity (periodontal pockets, hoods over incompletely erupted third large molars) or traumatic factors (overhanging fillings, carious cavities, roots of decayed teeth, tartar, low-quality dentures, etc.). The cause of relapse may be unsatisfactory hygienic condition of the oral cavity.
Treatment of symptomatic necrotizing ulcerative stomatitis for blood diseases, allergic conditions, mercury intoxication consists mainly of general treatment of the underlying disease causing these changes.
With timely and correct treatment, the prognosis is favorable. Epithelization of ulcer surfaces during acute process occurs in 3-6 days, in chronic cases - somewhat later. In an unsanitized oral cavity in the presence of many traumatic factors and untimely or improper treatment Recession (retraction) or deformation of the gums, resorption may occur bone tissue alveolar process. These changes contribute to the further progression of periodontitis.
Patients who have had Vincent's stomatitis are subject to active monitoring for a year. The first examination is carried out after 1-2 months, subsequent examinations after 6 months.
Maintaining oral hygiene, regular sanitation, complete and timely treatment of infectious and other diseases leading to decreased immunity protect against the development of Vincent's ulcerative necrotizing stomatitis.
Therapeutic dentistry. Textbook Evgeniy Vlasovich Borovsky
11.3.2. Vincent's ulcerative necrotizing stomatitis
Vincent's ulcerative necrotic stomatitis (stomatitis ulceronecroticans Vincenti) is an infectious disease caused by fusiform rods (Bacillus fusiformis) and Borellia vincentii.
It is described under various names: ulcerative gingivitis and ulcerative stomatitis, ulcerative membranous stomatitis, fusospirochetous stomatitis, Plaut-Vincent stomatitis, “trench mouth”, ulcerative membranous stomatitis, etc. According to the modern classification, the disease is called “Vincent ulcerative-necrotic stomatitis”, or "Vincent's stomatitis." In case of gum damage, the disease is defined as Vincent gingivitis; with simultaneous damage to the gums and other areas of the mucous membrane - Vincent's stomatitis, and when the process is localized in the area of the palatine tonsils - Simanovsky-Plaut-Vincent angina.
Etiology. Vincent's ulcerative-necrotizing stomatitis is caused by a symbiosis of the spindle-shaped rod and Vincent's spirochete. Under normal conditions, these microorganisms are representatives of the resident microflora of the oral cavity and are detected in small quantities in all people with teeth. They are found mainly in the gingival groove, periodontal pockets, carious cavities, and crypts of the palatine tonsils. In an unsanitized oral cavity, with poor hygienic condition, as well as with periodontitis, the number of fusobacteria and spirochetes increases sharply. The development of Vincent's ulcerative-necrotizing stomatitis is associated with a sharp decrease in the body's resistance to infection, which can occur as a result of viral diseases (acute respiratory infections, herpetic stomatitis, pneumonia, etc.). vitamin deficiencies, stress, overwork, malnutrition. Ulcerative-necrotizing gingivitis often complicates the course of severe general diseases (leukemia, agranulocytosis, pneumonia, infectious mononucleosis). It may occur as a complication of exudative erythema multiforme and erosive allergic stomatitis. When specific and nonspecific defense mechanisms in the body are disrupted, the virulence of fusobacteria and spirochetes increases. Their number increases to such an extent that they become dominant compared to other microflora. A decrease in the overall resistance of the body negatively affects the resistance of the oral mucosa - it cannot act as a reliable barrier to the introduction of infection, and a violation of its integrity, which always occurs in an unsanitized oral cavity, due to the presence of local traumatic factors (sharp edges of teeth, dentures, tartar deposits, etc.) creates conditions for the introduction of fusobacteria and spirochetes. Therefore, Vincent’s ulcerative-necrotizing stomatitis often develops in people with an unsanitized oral cavity and poor hygiene.
Despite the fact that there are known cases of group incidence of Vincent's stomatitis (in military units, schools, kindergartens), this disease is considered non-contagious, and such cases are explained by similar unfavorable living conditions (malnutrition, lack of vitamins, lack of hygienic measures for oral care and etc.).
Clinical picture. Mostly young people (17–30 years old), mostly men, are affected.
The provoking factor in the development of Vincent's ulcerative-necrotizing stomatitis is often hypothermia, which explains the highest frequency of its occurrence in the autumn-spring period; the maximum incidence occurs between October and December.
Clinically, acute and chronic courses of Vincent's ulcerative-necrotizing stomatitis are distinguished, and according to severity - mild, moderate and severe forms.
The disease begins acutely with an increase in body temperature to 37.5-38 °C. Regional lymph nodes enlarge, become denser, become painful on palpation, and remain mobile. Patients are bothered by headaches, general weakness, soreness of the oral mucosa, which increases with eating and talking, bleeding gums, hypersalivation, and putrid breath.
Catarrhal phenomena on the oral mucosa quickly turn into ulcerative ones. The process most often begins on the gums, and then moves to other areas of the mucous membrane. Gums become edematous, hyperemic mi, sharply painful and bleed when touched. The epithelium of the gum margin and interdental papillae becomes cloudy and then necrotic. As a result, the gingival margin looks as if it were cut off, with uneven jagged edges, and its surface is covered with an easily removable grayish-yellow coating. Subsequently, the affected gum edge is not completely restored and remains deformed. Most often and to a greater extent, the area at the lower eighth teeth is affected, where necrosis from the alveolar process quickly spreads to the mucous membrane of the cheek and the retromolar region, causing in some cases trismus and pain when swallowing. Ulcers on the mucous membrane of the cheeks can reach large sizes (up to 5–6 cm in diameter) and depth (Fig. 11. 1 5). Their edges are uneven and soft. The bottom is covered with a thick grayish-greenish necrotic coating, which has a putrid, fetid odor, after removal of which the bleeding bottom of the ulcer is exposed. There is no compaction in the area of the base and edges of the ulcer. The mucous membrane around the ulcer is swollen and hyperemic. If there are local traumatic factors in the oral cavity (roots of decayed teeth, sharp edges of teeth, dentures), other areas of the oral mucosa (hard and soft palates, arches, tonsils, tongue) may also be affected. Oral ulcers can be single or multiple, various sizes and depth. When the ulcer is localized on the hard palate, necrosis of all layers of the mucous membrane develops quite quickly and the bone is exposed. Isolated pharynx lesion(Simanovsky-Plaut-Vincent angina), as a rule, is unilateral, and is rare in dentist practice. 2–3 weeks after the onset of ulcerative necrotic stomatitis, the process usually resolves with complete epithelization of the ulcerative surfaces.
Rice. 11.15. Acute ulcerative necrotic stomatitis of Vincent. An extensive ulcer of the mucous membrane of the cheek along the line of closure of the teeth in the area of large molars, covered with necrotic plaque.
In rare cases, when treatment is not carried out or is ineffective, a chronic form of Vincent's necrotizing ulcerative stomatitis develops, in which there are no general symptoms. Patients are concerned about constant bleeding and sore gums, as well as bad breath. The clinical picture is erased, the gum is congestive-hyperemic, edematous, its ulcerated edge is often compacted, necrotic areas are located mainly in the interdental spaces and can be visible during a cursory examination. Upon careful examination and probing of the gingival margin, exposed bone tissue is determined. Only some teeth have affected areas. Lymph nodes (submandibular, submental) in patients with chronic ulcerative necrotic stomatitis of Vincent are compacted and slightly painful. When the disease lasts 4–8 months, the lymph nodes acquire a cartilage-like consistency.
Rice. 11.16. Histological picture of Vincent's ulcerative necrotic stomatitis. Area of tissue necrosis in the superficial layers (1), maturing granulation tissue (2), edema and small cell infiltration (3).
During pathohistological examination of areas of ulcerated gum edges, two zones are revealed: superficial - necrotic and deep - inflammatory (Fig. 11.16). In the surface layers of necrotic gum tissue, an abundant diverse microflora (cocci, rods, fusobacteria, spirochetes, etc.) is revealed. In the deeper layers, fusobacteria and spirochetes sharply predominate (Fig. 11.17). The underlying layers of connective tissue are inflamed: they are swollen, the vessels are dilated. Blood cells are found in the perivascular inflammatory infiltrate. In the same zone of inflammation, inside undamaged tissue, only spirochetes are found that have penetrated between the epithelial cells.
The cytological picture of scrapings from the ulcerative surfaces of the mucous membrane in patients with Vincent's ulcerative-necrotizing stomatitis corresponds to a nonspecific inflammatory process. At the onset of the disease, an abundance of structureless masses, a sharp predominance of neutrophils, mainly in a state of decay, and erythrocytes (due to severe bleeding) are determined. In the second period of the disease, when healing begins, along with decayed neutrophils, full-fledged phagocytic cells and many macrophages appear. During the period of beginning epithelization, layers of young epithelial cells appear, the number of fusobacteria and spirochetes decreases.
Rice. 11.17, Acute necrotizing ulcerative stomatitis. Fusospirochetosis. Scraping from the ulcer. Fusobacteria and spirochetes (1), neutrophils in the stage of deep decay (2). Cytogram. x 700.
In the chronic course of Vincent's ulcerative-necrotizing stomatitis, the relative number of fusobacteria and spirochetes decreases and the number of cocci increases, but fusospirochetes still predominate.
The diagnosis of Vincent's ulcerative-necrotic stomatitis is made on the basis of a characteristic clinical picture and the detection of an abundance of spindle-shaped fusobacteria and spirochetes in scrapings from the surface of ulcers.
Differential diagnosis. Vincent's ulcerative-necrotizing stomatitis must be differentiated primarily from ulcerative lesions for blood diseases (leukemia, agranulocytosis, infectious mononucleosis). Along with clinical differences (pallor of the oral mucosa, the presence of hemorrhages, leukemic infiltrates, pronounced and prolonged bleeding gums in diseases of the blood) in this case, the detected changes in the peripheral blood in leukemia, agranulocytosis, as well as infectious mononucleosis.
Vincent's ulcerative-necrotizing stomatitis is differentiated from allergic stomatitis on the basis of anamnesis data, characteristics of clinical manifestations and the results of bacterioscopic examination.
An ulcerative-necrotic process in the oral cavity, similar to Vincent's stomatitis, can occur with mercury intoxication. If exposure to mercury is detected, urine is tested for mercury levels.
It should be remembered that ulcerative-necrotic lesions of the oral mucosa can complicate the course of specific infections(syphilis, HIV infection) or malignant tumors(cancer, sarcoma). To avoid diagnostic errors in these cases, you should carefully collect anamnesis, take into account not only local, but also general clinical manifestations diseases and carry out the necessary laboratory tests (clinical analysis blood, serological Wasserman tests or for the detection of HIV infection, cytological, bacterioscopic, pathohistological, etc.).
Treatment. Volume therapeutic measures with Vincent's ulcerative-necrotizing stomatitis is determined mainly by the severity of its course. Since the disease often occurs in young people, most of whom are practically healthy, local treatment becomes crucial. The earlier and more thoroughly the oral cavity is treated, the faster the patient’s condition improves. High-quality treatment of the oral mucosa and removal of traumatic factors are decisive in the further course and outcome of the disease.
Local treatment consists in removing local traumatic factors, necrotic tissues, influencing the microflora and stimulating regeneration processes of the oral mucosa. Treatment of the oral cavity should begin with anesthesia. For this purpose, application and injection anesthesia with solutions of pyromecaine, trimecaine, and lidocaine are used. After this, all mechanical irritants are removed: sharp edges of teeth and dentures are ground, tartar and plaque are removed. Carious cavities should be treated with antiseptic solutions. Removal of damaged teeth should be postponed until the ulcers are epithelialized, since the removal of teeth in the infected oral cavity of a patient with necrotizing ulcerative stomatitis is fraught with serious complications (alveolitis, periostitis, abscess, phlegmon). Cleansing ulcer surfaces from necrotic tissue is carried out using proteolytic enzymes: trypsin, chymotrypsin, lysoamidase, deoxyribonuclease.
The entire oral cavity is treated with warm antiseptic solutions (0.5% hydrogen peroxide solution, 1% chloramine solution, 0.06% chlorhexidine solution, 0.5% ethonium solution, potassium permanganate solution 1:5000, etc.). Gum pockets, the surface of the ulcer, interdental spaces and sub-hood spaces are best rinsed with a high-pressure jet. On the first visit, the entire oral cavity should be treated. Subsequently, daily processing is carried out. The patient is prescribed warm antiseptic rinses at home: 3% hydrogen peroxide solution (2 tablespoons per glass of water), 0.25% chloramine solution, potassium permanganate solution (1:5000), 0.06% chlorhexidine solution or other antiseptic drugs every 3–4 hours
For mild ulcerative-necrotizing stomatitis of Vincent, local treatment is sufficient. In more severe cases, it is necessary to carry out general therapy. For the purpose of antimicrobial action, metronidazole (Trichopol, Flagyl, Klion) is prescribed orally, 0.25 g 2 times a day for 7-10 days. Metronidazole is also used for local treatment (liquid aqueous paste is applied to ulcerative surfaces after removal of necrotic tissue). In severe cases, broad-spectrum antibiotics are sometimes used (bicillin-3, 300,000 units once every 3 days or 600,000 units once every 6 days; erythromycin, oletethrin, oxytetracycline in daily dose 800,000-1,000,000 units for 5-10 days). For any degree of severity, it is recommended to prescribe B vitamins, ascorutin (0.1 g orally 2 times a day, for 10–14 days).
With proper treatment, improvement in the condition of patients with Vincent's ulcerative-necrotizing stomatitis occurs within 24–48 hours, pain decreases or disappears, patients can eat and sleep. Swelling and hyperemia of the oral mucosa decrease, epithelization of ulcers begins, which, with a mild degree of the disease and satisfactory condition of the oral cavity, is completed by the 3-6th day. In an unsanitized oral cavity, epithelization of ulcerative surfaces proceeds more slowly. After the general condition of the patient has improved and acute inflammatory phenomena have disappeared, it is necessary to carry out a thorough sanitation of the oral cavity with the removal of tartar, tooth roots, and treatment of carious teeth and periodontal diseases.
Relapses of ulcerative-necrotic stomatitis can occur if foci of chronic infection remain in the oral cavity (periodontal pockets, hoods over incompletely erupted third large molars), or traumatic factors (overhanging fillings, carious cavities, roots of decayed teeth, tartar, poor-quality dentures and etc.). The cause of relapse may be unsatisfactory hygienic condition of the oral cavity.
Treatment of symptomatic ulcerative necrotic stomatitis for blood diseases, allergic conditions, mercury intoxication consists mainly of general treatment of the underlying disease causing these changes.
Forecast. With timely and correct treatment, the prognosis is favorable. Epithelization of ulcerative surfaces in an acute process occurs after 3–6 days, in a chronic process - somewhat slower. In an unsanitized oral cavity, in the presence of many traumatic factors and untimely or improper treatment, receding (retraction) or deformation of the gums, resorption of bone tissue of the alveolar process can occur. These changes contribute to the further progression of periodontitis.
Patients who have had Vincent's stomatitis are subject to active monitoring for a year. The first examination is carried out after 1–2 months, subsequent examinations after 6 months.
Prevention. Consists of maintaining oral hygiene, regular sanitation, complete and timely treatment infectious and other diseases leading to decreased immunity.
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Oral diseases cause a lot of inconvenience, forcing us to develop complexes, hide our smiles, and avoid communicating with people because of unpleasant odor from the mouth. Moreover, they can lead to serious consequences. To avoid becoming a victim serious illness and pathologies, read this article, which discusses Vincent’s stomatitis.
Necrotizing ulcerative stomatitis or Vincent's stomatitis(lat. stomatitis ulceronecroticans Vincenti) is an infectious disease that is caused by spindle-shaped bacillus and spirochete (Borrelia) Vincenti. In the world literature it is mentioned under the following names: ulcerative stomatitis, ulcerative-necrotic form of stomatitis, ulcerative-membranous form of stomatitis, fusospirochetous form of stomatitis, “trench mouth”, Botkin-Simanovsky-Plaut-Vincent angina, etc.
When the gums are affected, the disease is defined as Vincent gingivitis, when the gums and other areas of the mucous membrane are affected - stomatitis, when transferred to tonsils- Vincent's sore throat.
When the gums are affected, the disease is defined as Vincent gingivitis.
The sources of Vincent's disease are attributed to the resident flora of the oral cavity and are found in normal quantities in all people who have even healthy teeth, in particular, in the gingival groove. At improper care and periodontitis, number pathogenic bacteria increases sharply.
Fusobacteria and Vincent's Borrelia are opportunistic microorganisms. The main role in the formation of the disease is played by a decrease in the body's tolerance to infections. It manifests itself especially often during hypothermia, as a consequence of a general illness, overload, stress, and abnormal nutrition.
Preceding factors are also a violation of the integrity of the mucous membrane, which creates conditions for the proliferation of microorganisms. This happens with injuries, especially chronic ones, for example, with sharp edges of teeth, with difficulty cutting through soft fabrics third molars. Breakdown of the epithelial barrier also worsens the situation.
Vincent's ulcerative-necrotizing stomatitis occurs most often with improper hygiene care behind the oral cavity against the background of previously developed inflammatory processes gums, with the deposition of tartar, which interferes with the natural process of desquamation of the skin, irritates the gums and, by closing the entrance to the periodontal pocket, creates conditions for the development of infection.
Fusobacteria Vincent's ulcerative-necrotizing stomatitis can occur as a complication after viral infection(influenza, herpetic stomatitis), erosive allergic stomatitis, exudative erythema multiforme, some severe general diseases- leukemia, agranulocytosis, infectious mononucleosis, joins with intoxication with salts of heavy metals, scorbuta. Oncological ulcers and syphilides in the mouth are often also complicated by fusospirochetosis.
According to the nature of the disease, they are divided into:
By severity:
Symptoms appear gradually:
The disease affects mainly young people (18 - 35 years old), most often men. Peak occurs in December. Pain in the mouth begins, especially when eating, bleeding gums, excessive salivation, bad breath, weakness. The patient looks pale due to severe poisoning. Lymph nodes become enlarged, hardened, and painful on palpation.
The process begins from the gums and manifests itself in the form of foci of necrosis of the gum edge and papillae. Necrosis then spreads to other areas of the mucosa. The area of the lower third molars is often affected, where necrosis quickly spreads to the buccal mucosa and retromolar area, causing trismus and pain when swallowing. In some cases, inflammation causes severe facial asymmetry due to tissue swelling.
In severe cases, necrotic lesions form on the lateral surface and tongue, as well as on the hard and soft palate. They have soft edges irregular shape, a dense, stinking necrotic plaque of a blue-green color, after removal of which a loose, bleeding bottom is exposed. On the hard palate, processes quickly lead to necrosis of all layers of the mucosa and exposure of bone tissue.
The general well-being of the patient during the acute process worsens: the temperature in the first 2 - 3 days rises to 37.5 - 38 ° C, but may be normal, and a headache appears. Anxious dream, difficulty eating, intoxication weaken the patient’s body.
Frequent fainting occurs, there may be no noticeable changes in the hemogram, but leukocytosis is often observed, and in severe cases, toxigenic granularity of neutrophils. The chronic form of this disease develops with improper treatment or its absence, but can also occur independently, without an acute process.
The diagnosis is made on the basis of the clinical picture and the identification of fusospirillary symbiosis.
Biopsy analysis reveals two zones:
In the superficial layer of necrosis, the flora is rich and diverse (cocci, rods, fusobacteria, spirochetes, etc.), in the deeper layer, which is adjacent to living tissues, fusospirochetosis sharply predominates. These tissues are in the phase of acute inflammation. Inside living tissue there are only spirochetes.
The cytological picture of a scraping from an ulcer with Vincent's stomatitis is similar to specific process inflammation.
First you need to exclude the possibility of HIV infections. In addition, Vincent's ulcerative necrotizing stomatitis is differentiated from ulcerative lesions due to blood diseases (leukemia, agranulocytosis, infectious mononucleosis), mercury poisoning, and scurvy. Fusospirochetosis is also found in large quantities in necrotic ulcers.
Frequent rinsing with antiseptics (chlorhexidine solution, hydrogen peroxide) is necessary. The prognosis with quick and adequate treatment is positive.
On acute stage which is associated with difficult eruption of third molars, is not recommended surgical interventions. With correct treatment, epithelization occurs in an acute process after 3-4 days, and in a chronic process - a little slower.
Advanced cases of Vincent's ulcerative-necrotic stomatitis, especially relapses, when treatment is carried out untimely or incorrectly, will entail irreversible changes: bone resorption, subsidence (retraction) of the gums, severe forms of periodontitis.
After healing, the gingival papillae may disappear, conditions for food retention are formed, and periodontitis progresses. In other areas of the mucous membrane, except the gums, tissues are usually restored during treatment, only after deep and severe ulcers scars remain.
Patients who have had Vincent's stomatitis should be monitored for dispensary observation for at least 1 year, with the first examination carried out after 2 months. The prognosis for Vincent's stomatitis is positive, although in some situations, in the absence of proper therapy, the disease drags on and can last for several months. There may be cases of relapse.
To prevent fusospirillosis, it is recommended to regularly carry out procedures for sanitation of the oral cavity, observe hygiene standards, especially during the period infectious diseases, lowering protective properties, as well as when using bismuth preparations.
Think about your health today - get diagnosed by a dentist to find out if you have progressive hidden diseases. Maintain good oral hygiene, eat right, and avoid bad habits and fast food to please yourself and your loved ones with a healthy smile for as long as possible.
