Ministry of Health of Ukraine Ukrainian Medical Stomatological Academy

MINISTRY OF HEALTH OF UKRAINE UKRAINIAN MEDICAL STOMATOLOGICAL ACADEMY

Guidelines for independent work of students for preparation for a practical lesson and during the practical studies

Academic discipline Therapeutic dentistry Module number 5 Deepening the clinical thinking of students. Modern methods of diagnosis, treatment and prevention of major dental diseases. Clinical examination of patients at the dentist. Topic of the lesson 30 Differential diagnosis of the manifestations of viral and bacterial diseases on the oral mucosa. Diphtheria, tuberculosis, syphilis, gonorrhea. Tactics dentist. Course V

Faculty Foreign students training faculty (dentistry)

Poltava 2020

М.5/Т.30 1. Actuality of theme. Due to changes in social conditions in recent years, diseases of diphtheria, gonorrhea, syphilis, tuberculosis, began to occur much more often, and sometimes become epidemic. Due to the fact that the initial manifestations of these diseases are often localized on the mucous membranes of the oral cavity, which requires a dentist to clearly know the general and local manifestations of these diseases, both in order to prevent self-infection, and in order to timely identify and treat the patient together with infectious disease specialists, TB specialists and dermatovenerologists.

2. Specific goals. - Learn to diagnose manifestations of diphtheria, tuberculosis, syphilis and gonorrhea in the oral cavity and determine the tactics of a dentist in identifying these diseases in the oral mucosa. - Know the general information about the causative agents of each disease and the route of infection. - Explain the features of the manifestations and elements of the lesion in each disease of the oral mucosa. - Interpret the results of laboratory studies of patients with diphtheria, tuberculosis, syphilis and gonorrhea. - Analyze the obtained clinical and laboratory studies and determine the further tactics of the dentist in identifying these diseases. - Select medications for symptomatic oral therapy for diphtheria, tuberculosis, syphilis and gonorrhea. 3. Base knowledge, abilities, and skills, necessary for a study theme (interdisciplinary integration).

Name of previous disciplines Acquired skills Normal anatomy Describe the anatomical features of the structure of SOPR Propaedeutics of therapeutic Own examination methods for a dental patient dentistry Identify the primary and secondary elements of Dermatovenerology the lesion on the skin and OCR. Identify pathogens and pathways of infection in syphilis and gonorrhea, as well as general symptoms of the disease Phthisiology Describe the causative agent and ways of infection with tuberculosis, the general Infectious diseases symptoms of the disease Describe the causative agent of diphtheria, pathways of infection and general symptoms of the disease

4. Tasks for independent work in preparation for the lesson and in the lesson. 4.1. The list of basic terms, parameters, characteristics that a student must learn in preparation for the lesson:

Terminology Definition Infectious diseases morbidity with pathogens with the possibility of infection from a sick person or animal

Tuberculosis chronic infectious disease caused by Mycobacterium tuberculosis (Koch's bacillus)

Syphilis chronic spirochete-borne infectious disease

Gonorrhea acute gonococcal infection of the oral mucosa

Diphtheria acute infectious disease caused by Leffler's bacillus

4.2. Theoretical questions for the lesson: 1. Provide the concept of tuberculosis. What are the types of manifestations of tuberculosis in the oral mucosa? 2. Provide the concept of syphilis. What are the manifestations of primary, secondary and tertiary syphilis in the oral cavity? 3. Give an explanation of diphtheria the main symptoms of diphtheria in the oral cavity. 4. Give the concept of gonorrhea. What are the main symptoms of its manifestations in the oral cavity? 5. Determine the doctor’s tactics in case of suspected tuberculosis of the oral mucosa. 6. Determine the tactics of the doctor when detecting manifestations of syphilis in the oral cavity. 7. Determine the doctor’s tactics for suspected diphtheria in the oral cavity. 8. Determine the tactics of the doctor with suspected gonorrhea in the oral cavity. 4.3. Practical work (tasks) that are performed in class: 1. Work out the doctor’s tactics in case of suspected tuberculosis or diphtheria. 2. Work out the tactics of the doctor when detecting manifestations of syphilis or gonorrhea in the oral cavity. 3. Supervise a dental patient with suspected bacterial infections in the oral cavity. 4. Conduct differential diagnosis with similar manifestations in the oral cavity. 5. Make a plan for examination and treatment of a patient with suspected bacterial infections in the oral cavity. 6. Obtain medical records. 3

5. The content of the topic: Tuberculosis is a chronic infectious disease caused by mycobacterium tuberculosis (Koch's bacillus). It enters the mucous membrane of the mouth by the hematogenous, lymphogenous or exogenous route. In the oral mucosa, tuberculosis occurs in the form of a secondary lesion and manifests itself in the form of: lupus erythematosus tuberculosis, miliary ulcerative tuberculosis, colic tuberculosis (scrofuloderma). Tuberculosis lupus. The main element of the lesion is lupoma, a specific tuberculous tubercle (tuberculum), red or yellow-red, soft consistency with a diameter of 1-3 mm. Lupomas are located in groups, fresh ones are formed on the periphery, and those in the center are prone to decay, after which ulcers with soft, uneven, saped edges, swollen and less painful form. The bottom of the ulcer is covered with yellow-red raspberry-like growths that bleed easily. Stages of the process: infiltrative, hilly, ulcerative and cicatricial. Localization of the elements of the lesion: red border of the upper lip, gums and alveolar process of the upper jaw in the region of the front teeth and fangs. Sometimes the process moves to a hard and soft palate. Regional lymph nodes are enlarged, dense, bundled. Diagnosis: a symptom of "apple jelly" during dioscopy and a symptom of a probe failing in a lupoma (Pospelov phenomenon). The reaction of Pirke is positive. Histological examination reveals epithelioid cells, giant Pirogov-Lanhgans cells and peripheral lymphocytes. Differential diagnosis: manifestations of tertiary syphilis (tubercle syphilis), leprosy, lupus erythematosus. Miliary - ulcerative tuberculosis. It occurs in patients with severe forms of pulmonary tuberculosis or larynx. Mycobacterium tuberculosis with the sputum of the patient settles in the places of the oral mucosa, which is prone to injuries (back of the tongue, mucous membrane of the cheeks along the line of closure of the teeth, soft palate, clear). The microflora multiplies, and typical tuberculous tubercles arise, which decay in the center and form shallow ulcers, which are creeping in nature, with uneven soft undercut edges. The bottom and edges of the ulcer are granular (due to tubercles), covered with a yellow-gray coating. Small abscesses (Trill grains) are determined. Inflammation around the ulcer is weak. Lymph nodes are enlarged, tight - elastic, painful. Diagnosis: the general condition of the patients is important (weight loss, excessive sweating, shortness of breath, fever) elevated ESR in the blood, leukocytosis, lymphocytosis. In scrapings from ulcers, Pirogov-Lanhgans cells are found, with bacteriological examination - Koch bacilli. Differential diagnosis: performed with a gummy ulcer in syphilis, Vincent’s necrotic stomatitis, radio mucositis, a traumatic chronic ulcer, trophic, cancer ulcer and manifestations of secondary syphilis. 4

Colquatic tuberculosis (scrofuloderma) a form of secondary tuberculosis. The main element of the lesion is the node that forms in the deep layers of the mucous membrane. 3 time, the nodes disintegrate and ulcers of irregular shape, soft consistency arise, with eaten sap edges and sluggish granulations at the bottom. Ulcers are slightly painful; uneven shaggy scars form during healing. Differential diagnosis: gummous, cancerous, trophic ulcers, Seton's stomatitis, actinomycosis. Tactics of the dentist: if the dentist diagnosed the patient with tuberculosis, he should send him for a consultation with a TB doctor. When confirming the diagnosis, treatment is carried out in a tuberculosis dispensary. Syphilis is a chronic infectious disease caused by a pale spirochete (spirochete palida). In the oral cavity, it manifests itself in all stages of the disease: primary, secondary and tertiary syphilis. Primary syphilis is a hard chancre that can be localized in various parts of the oral cavity, mainly on the lips, tongue, and corners of the mouth. The incubation period lasts 14-20 days. Clinically. First, erosion of a bright red color occurs, then a defect in the form of an ulcer. An infiltrate forms around the lesion. The edges of the ulcer are raised, roll-shaped, in connection with which the solid chancre rises above the level of the mucous membrane. On palpation, a painless cartilage seal is felt. Regional lymph nodes are dense, mobile, painless. Diagnostics. When bacteriological examination of the lesion is found pale spirochete. Differential diagnosis: tuberculous ulcer, trophic, decubital, cancer ulcer. Secondary syphilis in the oral cavity manifests itself in the form of individual roseola, or erythema (roseolous syphilis), or papules (papular syphilis) and less often pustules - pustular syphilis. Diagnosis of secondary syphilis is confirmed by the presence of pale treponema in the lesions and positive serological reactions. Differential diagnosis: lichen planus, leukoplakia, allergic stomatitis. Tertiary syphilis manifests itself in the oral cavity: in the form of gum, tubercular syphilis, sclerosed glossitis. Gumma is a node that clearly protrudes above the level of the oral mucosa the size of a bean, red in color with a dense consistency. Gradually, the color gains a bluish tint, an infiltrate is created, which turns into bone necrosis of the hard palate, a sequestration develops, which exfoliates and a message forms between the oral cavity and the nose. If the gumma on the tongue, then it is laid in the linguistic muscles. When it decays, an ulcer forms, which has inclined and dense edges. The ulcers are deep, painless, and crater-like, with a dirty gray bottom. With the reverse development, they heal with the formation of deep retracted scars. 5

Differential diagnosis: with cancer, tuberculous ulcers and decubital. Sclerosing glossitis from the folded tongue. Treatment of patients is carried out in a dermatovenereological clinic. Diphtheria is an acute infectious disease that is transmitted by airborne droplets. The causative agent is Leffler's diphtheria bacillus, the pathogenic properties of which are determined by its exotoxin. Clinically the incubation period is 2-10 days. Then there is a sore throat, t- 38-390 C, general weakness, heart pain, lack of appetite. From the first hours of the disease, hyperemia and swelling of the mucous membrane of the tonsils (diphtheria angina) develops. Then massive fibrinous films of white or grayish-white color are formed, which extend to the mucous membrane of the nasal part of the pharynx, the hard palate and can spread to the gums, mucous membrane of the cheeks, tongue. The film coating is tightly soldered to the underlying tissues, has a sweetish smell and is very difficult to remove, exposing the bleeding surface. The occurrence of films is associated with a fibrinous form of inflammation and is a local reaction to the deepening of Leffler's bacillus and its toxins. Diagnosis of the disease is based on data from a bacteriological study, conducting a passive hemagglutination reaction. Differential diagnosis - manifestations of scarlet fever, infectious mononucleosis, Simanovsky-Vincent sore throat, acute herpetic stomatitis, erythema multiforme exudative, acute candidiasis, leukemia. Treatment of patients is carried out in a hospital! infectious diseases hospital, and consists in the introduction of diphtheria antitoxin, anti-inflammatory drugs, vitamins, heart drugs. Locally use antiseptics, antibiotics, enzymes, painkillers and keratoplastic agents. For the prevention of diphtheria, toxoid vaccinations are important. Gonorrhea is an acute infectious disease of the oral mucosa caused by gonococcus. The incubation period is from 1 day to 1 month. After 3-4 days, gonococci that enter the oral mucosa reach the subepithelial layer of connective tissue through the intercellular spaces and cause an inflammatory reaction with the formation of purulent exudate, considered as migration of neutrophils and plasmocytes to the pathogen invasion site. Complaints of patients are absent. The mucous membrane of the lips, gums, lateral and lower surface of the tongue and the bottom of the oral cavity, pharynx, tonsils, larynx is brightly hyperemic and covered with a dirty - gray, sometimes greenish purulent coating with an unpleasant odor. Often, unilateral arthritis of the jaw-temporal joint develops, characterized by significant pain, then acute inflammation of the joint develops, swelling appears, the skin in the joint area turns red; it becomes tense and sharply painful. Diagnosis is confirmed by the presence of gonococcus with exudate microscopy. 6

Differential diagnosis is carried out with diphtheria, drug allergic stomatitis, erythema multiforme exudative, ulcerative stomatitis, fungal stomatitis. General and local treatment consists in taking antibiotics (ceftriaxone, cefazolin, cefabid, ciprinol) for 1-2 weeks. Topically applied enzymes, antiseptic irrigation. The main therapy is carried out by a dermatovenerologist. 6. Materials for self-control: A. Test tasks for self-control: 1. What is the likely causative agent of tuberculosis? A. Mycobacterium B. Corynebacterium C. Spirochete D. Fusobacteria E. Gonococcus 2. Is it tuberculosis? A. Bacterial, infectious disease B. Viral, infectious disease C. Clinical condition D. Acute, infectious disease E. Emergency 3. What is the primary element of the lesion observed in tuberculosis? A. Spot B. Bubble C. Bugorok D. Node E. Papula 4. What periods of the course of syphilis emit? A. Acute, chronic, delayed, pointed B. Primary, secondary, tertiary C. Initial, developed, final D. Incubation, primary, secondary, tertiary E. Prodromal, primary, secondary, tertiary 5. What is the likely causative agent of syphilis? A. Koch's wand B. Hansen's wand C. Spirochete Vincent D. Pale treponema E. Wand Leflevra 6. What cells are characteristic of tuberculosis in microscopic examination of pathological tissues? A. Tzanka cells B. Giant multinucleated cells C. Giant Pirogov-Langhans cells 7

D. Blast cells E. Langerhans cells 7. Diagnosed with primary syphilis. What element of the lesion is found? A. Roseola B. Spot C. Papule D. Pustule E. Ulcer 8. What is the most effective method for diagnosing gonorrhea? A. Complete blood count B. Cytology of the smear C. Smear microscopy D. Urinalysis E. Biochemistry of blood and urine 9. The patient was suspected of diphtheria. What will be your tactics? A. Call an ambulance B. Refer to the infectious disease specialist C. Refer to a TB doctor D. Refer to a family doctor E. Prescribe treatment 10. What disease are the Pospelov phenomenon and the symptom of apple jelly positive? A. Tuberculosis B. Diphtheria C. Syphilis D. Gonorrhea E. Measles B. Tasks for self-control: 1. The patient is 40 years old, went to the clinic with complaints about the presence of soft consistency on the gums of the upper jaw. Objectively: on the gums of the upper jaw, tubercles of soft consistency, red, 5 mm in diameter, painless. When pressed with glass, they become bloodless and in the middle a yellow-brown formation is visible. What is the most likely diagnosis? A. Gummy ulcer B. Tuberculosis lupus C. Cancer D. Miliary ulcer tuberculosis E. Lupus erythematosus 2. The patient is 35 years old, complains of the presence of a painful ulcer on the cheek, weight loss, weakness. Objectively: against the background of the edematous mucous membrane of the cheek, an ulcer with uneven, soft edges is covered with a yellow-gray coating. The bottom and edges of the ulcer are granular 8 in nature. Lymph nodes are enlarged, tightly elastic, painful. What is the most likely diagnosis? A. Cancer ulcer B. Aft Setton C. Miliary ulcer tuberculosis D. Decubital ulcer E. Trophic ulcer 3. A patient of 18 years turned to the dentist with complaints of inflammation of the mucous membrane. Objectively, the temperature of 36.7 ° C on the mucous membrane of the cheek is reddening during painful palpation with fissures with a gray coating and purulent-blood discharge. Bad breath is noted. What is the most likely diagnosis? A. Syphilis B. Tuberculosis C. Cyrus D. Gonorrhea E. Influenza 4. Patient A., 43 years old, complains of pain in the mouth, hoarseness, weight loss, cough, fever, and sweat for 2 months. On SOP of the pharynx, larynx against the background of minor hyperemia, edema, and multiple painful lesions covered with fibrinous plaque. Upon examination: the CD4 lymphocyte fraction is normal, L-8x109 / l, Hb 100 g / l, ESR 28 mm / h., in scraping: single Candida albicans cells, IBT - negative. Of the several courses of antibiotic therapy, there has been a significant improvement with rifampicin. Set a preliminary diagnosis: A. Syphilis B. AIDS C. Candidiasis D. Leprosy E. Tuberculosis 5. Patient N., 28 years old, with an objective examination revealed a crack in the corner of the mouth on the left. When opening the mouth, the crack looks like oval erosion of meat-red color with smooth edges, painless on palpation. The submandibular lymph nodes on the left are enlarged, the cartilage-like consistency. The oral mucous and the red border of the lips - without pathological changes. Determine the diagnosis. A. Ariboflavitaminosis B. Primary syphilis C. Mycotic angular cheilitis D. Streptococcal angular cheilitis E. Chronic lip crack 6. A 18-year-old patient came to the dentist with complaints of general malaise, increased body t, pain when swallowing. Objectively: inflammation of the oral 9 mucosa in the throat, palatine arches and tongue. On the tonsils, the fibrinous films are tightly fused with the underlying tissues. The submandibular lymph nodes are enlarged, painful. Determine the preliminary diagnosis. A. Vincent's ulcerative stomatitis B. Diphtheria stomatitis C. Allergic stomatitis D. Agranulocytosis E. Gonorrheal stomatitis 7. Patient complains of an unusual form of oral mucosa. An objective examination revealed that of the gums, lateral and lower surfaces of the tongue, the bottom of the oral cavity, tonsils and pharynx are covered with a large amount of green- purulent plaque, erosive surfaces are not formed. A cytological examination of plaque reveals a large number of neutrophils and plasmocytes. Establish a preliminary diagnosis. A. Gonorrheal stomatitis B. Chronic hyperplastic candidiasis C. Vensan's necrotic necrotic gingivostomatitis D. Gangrenous stomatitis E. Pemphigus, leaf-shaped 8. A 31-year-old patient came to treat teeth, a round ulcer d = 1 mm, with distinct, raised edges and a deep inflammatory infiltrate at the base, was found on the back of the tongue. The bottom is flat, crisp, red meat. Regional lymph nodes of cartilage-like density, mobile, painless. An ulcer, a week ago, did not bother the patient. What kind of ulcer should a doctor think first? A. Trophic B. Traumatic C. Tuberculosis D. Syphilitic E. Cancer 9. Patient S., 27 years old, was referred by a dentist-dentist for endodontic treatment of 45 teeth. Objectively: the crown of the 45 tooth is destroyed, has a jagged sharp edge. On the lateral surface of the tongue and on the CO cheeks in the area of direct contact with the 45th tooth, plaques of macerated epithelium of gray color are observed, they slightly rise above the surface of the CO, in addition, the tongue and palatine arches are stagnant red in color, and in the hard palate - papules surrounded by a red rim and covered with grayish epithelium. Submandibular, cervical, supraclavicular, subclavian lymph nodes are enlarged, painless. What is your diagnosis? A. Chronic recurrent stomatitis B. Secondary syphilis C. Lupus erythematosus, plaque formation stage D. Mild Leukoplakia 10

E. Exudative erythema multiforme 10. Patient S., 18 years old, came to the dentist with complaints of general malaise, increased body t, pain when swallowing. Clinically: inflammation of the oral mucosa in the throat, palatine arches and tongue, swelling of the tonsils. Massive fibrinous film coating is tightly fused with tissues and spreads to soft and hard palate. Films are also placed on the gums and tongue. The submandibular lymph nodes are enlarged, painful. Specify the causative agent of this disease? A. Wand Leffler B. Pale treponema C. Fusospirillary symbiosis D. Gonococcus E. Koch's wand

7. Literature. Basic sources 1. Nikolishin A.K., Ilenko N.N., Geranin S.I. Oral mucosa diseases: methodical recommendations for self-work V-yeas students. – Poltava 2009. – 228 р. 2. Oral mucosa diseases: Textbook / M. Yu. Antonenko, O.F. Nesyn, S. A. Shnayder [et al.]; by ed. A. V. Borysenko. — Odesa: Print house, 2015. - 328 p. 3. Petrushanko T.O. Academic case history of therapeutic stomatology/ T.O. Petrushanko, I.Y. Lytovchenko, I.Y. Popovich - Poltava, 2015. – 60 p. 4. Stomatology: in 2 books. — Book 2: textbook (IV a. l.) / M.M. Rozhko, I.I. Kyrylenko, O.H. Denysenko et al.; edited by M.M. Rozhko. - К.: Всеукраїнське спеціалізоване видавництво «Медицина», 2018. – 960 с.

Additional sources 1. Michael W. Finkelstein, Emily Lanzel, John W. Hellstein A Guide to Clinical Differential Diagnosis of Oral Mucosal Lesions. – 2017. – 47 p. 2. Ruocco V., Gombos F. Sintesi dermatostomatologica.- Padova, 1988. – 359 p. 3. Strasburg M., Knolls G. Diseases of the Oral Mucosa a color atlas. – Chicago, 1994. – 803 p. 4. Odell E.W. Cawson’s Essentials of Oral Pathology and Oral Medicine. – Elsevier, 2017. - 545 p.

Еlectronic resources: 1. Еlectronic resource: [http://www.stomatkniga.ru/index.php?start=48] 2. Еlectronic resource: [https://www.booksmed.com/stomatologiya] 3. Еlectronic resource: [https://studfile.net/search/?q] 4. Еlectronic resource: [http://mirknig.com/knigi/nauka_ucheba/ 1181309066- terapevticheskaya-stomatologiya-uchebnik.html] 5. Еlectronic resource: [https://books.google.com.ua/books?]

Guidelines prepared Associate Professor, Department of Therapeutic Dentistry Ph.D. Nikolishyna E.V.