Topic 145: Acute ulcerative stomatitis. Etiology, pathogenesis. classification.

clinic, diagnostics,
treatment and prevention.
1. Questions for knowledge control:
1) Etiology and pathogenesis of the acute ulcerative stomatitis.
2) Clinical picture, diagnostics of the acute ulcerative stomatitis.
3) Differential diagnostics of the acute ulcerative stomatitis.
4) Treatment of the acute ulcerative stomatitis, prevention.

Ulcerative gingivostomatitis (gingivitis ulcerosa, gingivostomatitis ulceronecrotisans,

Vincents stomatitis)
It is assumed that this disease is caused by mixed bacterial microflora of the subgingival plaque,
particularly Gram-negative rods of the genus Bacteroides, Prevotella, Porphyromonas, Fusobacterium,
Actinobacillus, and by oral spirochetes of the genus Treponema. It is assumed that microorganisms
multiply in predisposed individuals, with the simultaneous involvement of multiple local (dental plaque,
improperly made fillings, semiretained teeth, etc.) and general factors (age, hormone changes, immune
imbalance, mental stress). However, it is currently assumed that general factors do not play a major role.
Typically, it affects young people of both genders, at the age of 18-30 years (the disease is unlikely to
occur at the age outside this range!).
Clinical picture: General symptoms are not part of the disease. In the absence of prodromal symptoms
(the differential diagnostic sign in contrast to gingivostomatitis herpetica is important!), the disease
presents suddenly in a completely healthy individual as acute catarrhal gingivitis localized in some part
of the dentition. The typical localization of the disease is in the frontal section of the dentition around
incisors and canines, or in the region of lower third molars. Major changes are found at sites with the
local irritation of the gingiva. Initially, the gingiva is red, very painful (spontaneously and also on
touch), and bleeds slightly.
Later, the picture will change, showing greyish necrotic areas on the tips of interdental papillae
progressing to the whole marginal gingiva (circumdentally). After the separation of necrotic tissue, the
ulcerated margin with typical bevelled interdental papillae can be found. The process is usually
limited only to the gingiva but it can also spread to the alveolar, buccal, lingual and palatine mucosa.
It can heal spontaneously without the initiation of adequate therapy (risk of recurrence), or it can
become chronic either as painless ulcerative gingivostomatitis or very painful ulcerative
gingivoperiodontitis associated with the fast destruction of the alveolar bone. The swelling of
submandibular nodes is an accompanying symptom. Hypersalivation and mouth odour are also typical.
Major subjective difficulties occur during eating a meal or when performing oral hygiene that can be
very difficult or even impossible. This may further deteriorate the condition.
Dg.: The diagnosis can be established on the basis of a clinical finding (changes on the papillae occur on
the 2nd or 3rd day). For differential diagnosis, it is necessary to check the blood count (leukemia,
agranulocytosis, etc.) and anti-HIV antibodies!
Therapy: Depending on the intensity, extent and duration of the disease, therapy is either local or
general. Local therapy is based on the effect of oxygen from the air on anaerobic bacteria. The dentist
will remove the necrotic covering using a cotton swab soaked with 3 % of hydrogen peroxide whereas
early patches are washed by 3 % H2O2 using a syringe with a blunt cannula. Treatment is repeated every
day for 2-5 days. When the condition is acute, surgical procedures in the oral cavity, including the
removal of dental plaque, are contraindicated. In home care, the patient can wash the oral cavity with 11,5% H2O2,. Treatment can also include antiseptic washes (hexetidine, chlorhexidine) with the
application of a local anaesthetic in spray before a meal. A pulpy and non-irritating diet is
recommended. When subjective difficulties disappear, local irritating factors such as dental crowns and
overhanging fillings are removed. The main goal is to reduce the subgingival plaque.
In chronic forms of the disease, it is recommended that local therapy is combined with general
antibiotics (PNC, tetracyclines, macrolides) or nitroimidazoles (metronidazol) at normal dosage.
Dif. dg: Acute viral stomatitis usually begins with the prodromal stage and does not affect
largely the gingiva (except for herpetic gingivostomatitis!). Hyperplasia and lesions in other sections of
the oral mucosa are found in patients with blood diseases. The major alteration of the general condition

(tiredness!) occurs at the same time. General diseases should be taken into account particularly in
individuals with a untypical age (children, elderly) and when the condition does not improve upon
adequate therapy (blood count!). It may happen that it will not be possible to distinguish HIVperiodontopathies if there are no other signs present in the oral cavity during HIV (the serological test to
detect anti-HIV antibodies!)
2. The practical skills on the topic:
1) to be able to work on the dental equipment;
2) to be able to work with dental instruments, to know of the rules of sterilization;
3) to be able to make recording and reporting documentation for therapeutic dentist and to make
analysis of performance;
4) to be able to conduct the clinical examination of the patient with oral mucosa pathology in
the mouth, to make correctly of the medical history, to make plan of examination and
treatment of patient;
5) to be able to perform and assess condition of hygiene in the mouth;
6) to be able to take the material for bacteriological tests, to analyze the results;
7) to be able to analyze the results bacteriological tests of the bacteriological tests of patient,
clinical analysis of blood, urine, biochemical analysis of blood on the glucose;
8) to be able to perform application and non-infiltration nerve block anesthesia;
9) to be able to perform application, irrigation and instillation medical drugs;
10) to be able to write down the recipe, to appoint physiotherapy treatment;
11) to be able to perform professional hygiene of oral cavity;
12) to be able to make recommendations about choice of means and objects of the hygiene of
oral cavity, prevention of complications.
3. Terminology: stomatitis ulceronecrotica Vincenti
4. Questions for knowledge control:
5) Etiology and pathogenesis of the acute ulcerative stomatitis.
6) Clinical picture, diagnostics of the acute ulcerative stomatitis.
7) Differential diagnostics of the acute ulcerative stomatitis.
8) Treatment of the acute ulcerative stomatitis, prevention.
Tests:
1. What ages for arises of the acute ulcerative stomatitis do you know?
A. 10-15 years
B. 18-30 years
C. 7-10 years
D. 35-40 years
E. 2-3 years
2. How many periods of the diseases for patients with acute ulcerative stomatitis do you know?
A. 3
B. 5
C. 2
D. 4
E. 6
3. What periods absent of the diseases with acute ulcerative stomatitis?
A. Incubation
B. Prodromal
C. Period of clinical manifestations
D. Period of decrease of the diseases
E. Period of clinical recovery
4.

Which microorganisms are etiological factor in acute ulcerative stomatitis?

A.
B.
C.
D.
E.

Streptococci, staphylococci
Fungal flora
Fusobacterium and Vincents spirochetes
Viruses
Actinomycetes

5. What type of gingival papillae are in acute ulcerative stomatitis?

A. Rounded
B. Flattened
C. Truncated
D. Unchanged
6. What type of ulcers are in acute ulcerative stomatitis?
A. The margin is smooth, painful
B. The margin is tight, painless
C. The margin is jagged, painful
D. The margin is pitted, painless
7. What ulcers carried out the differential diagnosis of acute ulcerative stomatitis?
A. Cancerous
B. TB
C. Syphilitic
D. Traumatic
E. With all of the above
8.

A patient working as a driver complains of severe pain in the mouth, throat, malaise, fever up
to 38,6C, occurred after exposure. At present made atonement for a work shift. Objectively:
the gums of the lower anterior teeth and the palate mucosa are hyperemic, edematous,
necrosis of gingival edge and enlarged tonsils. Smear: Fusobacterium and Vincents
spirochetes symbiosis. In the blood: erythrocytes. - 4.5 - 1012 / l; L. - 7.2 - 109 / l, ESR - 18
mm / hour. What is the next tactics of dentist?
A. To provide treatment and send to the working shift
B. Referral to an ENT specialist
C. To provide treatment and to issue certificate stating
D. Referral to treatment in the hospital
E. To prescribe treatment and to give sick leave

9.

A 37-year-old patient complains of severe pain in the gums, shortness of chewing, halitosis,
overall weakness, headache, temperature 37,9. Objectively: the abundance of soft plaque,
gingival contours violated the gingival margin is covered with malodorous gray plaque.
Diagnosed with necrotizing ulcerative stomatitis. What microorganisms are prevalenced of
soskobe in the differential diagnosis?
A. Fusobacterium
B. Streptococci
C. Staphylococci
D. Actinomycetes
E. Pneumococci

10.

A 55-year-old female patient complains of pain and bleeding in the gums, halitosis. The
symptoms appeared after acute respiratory illness. OBJECTIVE: swollen gums, hyperemic
all over, gingival margin ulcerated, the top of the gingival papillae covered with dirty gray
necrotic plaque. Diagnosed with necrotizing ulcerative stomatitis. What is necessary to apply
drug for removing of necrotic films to avoid damaging healthy tissue?
A. 1% trypsin

B.
C.
D.
E.
11.

12.

3% hydrogen peroxide
0,05% chlorhexidine bigluconate
3% sodium hypochlorite
2% chloramine

A 55-year-old female patient complains of pain, bleeding in the gums, halitosis.

OBJECTIVE: papilla and marginal part of the gums in the area of 33, 34, 35, 36 teeth
destroyed ulcerative process, covered necrotic plaque. Gums in the area of the teeth are
hyperemic and bleeding when touched tools. The diagnosis: acute ulcerative stomatitis. What
drugs with local action are shown for this patient in the final stages of treatment?
A. Trypsin
B. Metronidazole
C. Hydrogen peroxide
D. Karotolin
E. Dekamin
A 23-year-old patient complains of overall weakness, headache, shortness of chewing, body
temperature rise up to 38,0oC. OBJECTIVE: gingival papillae on the upper and lower jaws
ulcerated, covered with dirty gray necrotic plaque, which after removal of the exposed
surface of the bleeding and painful. After careful examination the dentist has established a
preliminary diagnosis of necrotizing ulcerative stomatitis. What additional methods of
examination will establish the final diagnosis?
A. Cytological examination and blood chemistry
B. Microbiological investigation and reoperiodontography
C. Bacteriological examination, complete blood count
D. The reaction of adsorption of microorganisms and polarography
E. CBC and luminescent investigation

13. A 43-year-old patient after acute respiratory disease complains of overall weakness, severe
pain and bleeding in the gums, halitosis. Objective: increase and painful lymph nodes, the
gums are hyperemic, swollen, there are multiple ulcerative lesions covered with a gray
necrotic plaque. What is the first discovered in the microscopic investigation in the soskobe
from lesions gums?
A. A significant amount of red blood cells, actinomycetes.
B. A mixed flora with a significant amount Fusobacterium and spirochetes.
C. Neisseria, veylonelly, colibacteria, epithelial cells.
D. Neutrophils under disintegration, epithelial cells, Staphylococcus.
E. Streptococci, staphylococci, lactobacillus, epithelial cells
14. A 23-year-old male patient complains of pain, halitosis, body temperature rise up to 38,0oC.
Patient is pale, adynamic, regional lymph nodes are enlarged and painful. Gums swollen,
hyperemic, with ulcers covered with necrotic plaque. The tartar is all surfaces in the teeth.
What additional methods of examination to be carried out for the diagnosis?
A. Cytology.
B. Luminescent.
C. Blood count.
D. Bacterioscopic.
E. Histological.
15. A 22-year-old patient diagnosed as necrotizing ulcerative stomatitis by Vincents. Surface
treatment of ulcers necrotic plaque on the surfaces of ulcers is removed difficulty. What
drugs should be used?
A. Keratolitic drugs.
B. Proteolitic enzymes.
C. Keratoplastic drugs.

D. Antibiotics.
E. Antiseptics.
16. A patient 19-year-old complains of malaise, fever, pain in the gums and oral mucosa. He has
been ill two days ago. Objective: body temperature 38,8C, regional lymph nodes on the right
are enlarged, painful, movable. The mucous membrane of the mouth is hyperemic, swelling,
gingival papillae are bleeding, gray-white patches on the edge, ulcers with jagged edges on the
buccal mucosa are painful, covered with grayish-white coating. What microorganisms are most
likely to be found in microbiological research?
A. Virus.
B. Fusobacterium and Vincents spirochetes symbiosis.
C. Diphtheria bacillus.
D. Fungal pathogens.
E. Colibacteria
17.

A patient 30-year-old complains of severe pain, bleeding gums during eating and talking,
halitosis, impaired general condition. Objectively: general condition of the patient is
satisfactory, the body temperature of 38,2C, halitosis. The marginal gingiva is swelling,
necrosis, sharply painful, bleeding during touched all through. The regional lymph nodes are
enlarged, painful on the palpation, mobile. Diagnosed with severe ulcerative stomatitis. What
diseases for differential diagnostics do you know?
A. Acute aphthous stomatitis
B. Leucosis and agranulocytosis
C. AIDS
D. Cancerous ulcer
E. All of the above

18.

A patient 25-year-old complains of pain in the gums, which is increased during eating,
halitosis, bad health. He has been ill two days ago after hypothermia. OBJECTIVE: gums
upper and lower jaws are hyperemic, edematous and easily bleeding during touched. The
ulcerations with dirty gray necrotic plaque are situated according to the gingival margin of
the destroyed 46, 47 and 48 teeth. Significant subgingival dental plaque is all surfaces in the
teeth. In smears - Fusobacterium and Vincents spirochetes symbiosis. What is the most
likely preliminary diagnosis?
A. AIDS
B. Erythema exsudativum multiforme
C. Vesicular diseases
D. Acute ulcerous stomatitis
E. Acute aphthous stomatitis

19.

A 16-year-old teenager complains about halitosis, general weakness, body temperature rise
up to 37,6oC. These symptoms turned up two days ago, the boy had a history of recent angin
A. Objectively: oral hygiene is unsatisfactory, the teeth are coated with soft dental deposit.
Gums are hyperemic, gingival papillae are covered with greyish deposit. Specify the
causative agent of this disease:
A. Herpes viruses
B. Fusobacteria, spirochetes
C. Yeast fungi
D. Staphylococci
E. Streptococci