TOPIC 143: Acute herpetic stomatitis. Acute aphthous stomatitis.

Etiology, pathogenesis,
clinical manifestations, diagnosis, treatment, prevention.
1.

Questions for control of knowledge:

1) Etiology and pathogenesis of acute herpetic stomatitis.
2) The clinic, diagnosis of acute herpetic stomatitis.
3) Differential diagnosis of acute herpetic stomatitis.
4) Treatment of acute herpetic stomatitis, prevention.
5) Etiology and pathogenesis of acute aphthous stomatitis.
6) The clinical manifestations of acute aphthous stomatitis.
7) Differential diagnosis of acute aphthous stomatitis.
8) Treatment of acute aphthous stomatitis, prevention.

Acute herpetic stomatitis (stomatitis acuta herpes) - is an acute infectious viral disease.
Etiology. Infection caused by Herpes simplex virus is so common in man that one can speak
about a complete population immunity rate. Primary infection usually occurs at the age of 1-5 years.
There are two types of the virus - Type 1 (HSV-1) and Type 2 (HSV-2). The virus is transmitted by a
direct contact with the infected person. Type 1 is usually transmitted by oral secretion whereas Type 2 is
transmitted by genital secretion. The areas afflicted by both types of viruses will gradually combine. After
infection with HSV-1 and HSV-2 (whether clinically noticeable or not), specific neutralizing and
complement fixing antibodies will be produced in about 1 week in the body. However, the virus will
survive in the latent, without clinical symptoms. But under the influence of provoking factors, which
reduce immune, reactivity of virus becomes active and causes damage of the mucous membrane of the
mouth (MMM). Such factors may include: influenza, malaria, pneumonia, stress, allergies, surgery,
intoxication, excessive insolation, menstruation.
In the pathogenesis of the disease is observed such periods: incubation, prodromal (catarrhal),
the period of development, fading and period of clinical recovery (reconvalescence).
Clinic. The incubation period of acute herpetic stomatitis lasts 6-8 days. The disease begins
acutely: first the general malaise, headache, increased body temperature to 37-41 C, pale skin, nausea,
and vomiting. Then to these symptoms attached a pain in the mouth within 24-48 hours, which increases
during conversation and eating. Further develop catarrhal period and the period of the rash of
morphological elements.
Oral mucosa becomes hyperemic, edematous. In the area of the lips, cheeks, tongue, floor of the
mouth, palate, tonsils there are small (like millet grain) bubbles that are placed in groups (from 2-3 to
several dozen). They are filled with a clear liquid, which becomes cloudy. The bubbles quickly burst, and
in their place is formed erosion, similar to the aphthae. A few bubbles can coalesce and burst in 2-3 days,
are formed a wide bright red color erosion, with a finely-festoon outline, covered with a whitish-gray
coating. Elements of lesions mostly localized on the hard palate in adults.
Herpetic stomatitis is characterized by catarrhal or ulcerative gingivitis and accompanied with
changes in the periodontium. Also frequently damaged red border of lips and skin which borders on it.
Regional lymph nodes in the prodromal period, enlarged, painful and saved after epithelialization
of erosions additional 5 days.
Obligatory symptom of herpetic stomatitis is hypersalivation, and bad breath. In catarrhal period
of acute herpetic stomatitis occurs pronounced gingivitis, which in severe course can purchase erosive
and ulcerative character.
In blood indications of nonspecific inflammation.
Sometimes urine is detected protein (for severe disease).
First saliva is determined shift of pH to the acidic side, then to the alkaline. Saliva dont have
interferon, content of lysozyme is reduced. Humoral factors, phagocytosis are also reduced.
Depending of the degree of prevalence in the oral cavity, temperature reaction and toxic reactions
disease can be forms: mild, moderate and severe.
During the acute herpes infection lasts from 3 to 5 days, and sometimes delayed up to 10-14 days.
Erosions heal without scarring.
Diagnosis of acute herpetic stomatitis is based on clinical manifestations of the disease and the
history of life, serology, cytology and express-method, immunofluorescence, method of identification of
viral genome by molecular hybridization (MG), virological examination by infecting animals or cell

cultures of the material which taken from patient, serological testing by detecting titers of antibodies,
cytological method for study smears with elements of the rash.
Immunofluorescence method is identificated antigen in the material due to specific hyperimmune
sera. In the case of connections antigen with an specific immune serum proteins in fluorescent
microscopy appears illumination of cells which have antigen.
Cytological method is detected multinucleated giant cells, polymorphonuclear neutrophils in
various stages of necrobiosis.
Differential diagnosis carried out with:
- drug stomatitis,
- erythema multiforme,
- diphtheria,
- gangrene,
- foot and mouth disease,
- pemphigus,
- lichen planus of erosive-ulcerative form,
- traumatic stomatitis,
- AIDS,
- acute aphthous stomatitis.
Treatment of acute herpetic stomatitis need to be general and local.
General treatment includes a nutritious diet:
antivirals: 0.05 rimantadine (3 times a day for 5-10 days); Artbidol (200 mg four times a day for
5 days), Valtrex (500 mg two times a day for 5 days), interferon, acyclovir;
desensitizing treatment: dimedrol (0,05- 2 times a day), Suprastinum (0,25 two times a day)
Tavegilum (from 0, 001 two times a day) Phencarolum (0,025 - 3 times a day after receiving food),
calcium gluconate (0, 5 - 3 times a day), Tsetrin (1 tab. 1 time daily);
strengthening therapy: vitamin C ( to 2,0 a day), calcium (calcium gluconate 0,5 - 3 times a day,
calcium glycerophosphate, 0,5 - 3 times a day, calcium lactate, calcium chloride), drugs which increase
the body's resistance - Eleutherococcus, ginseng (1 teaspoon 2-3 times a day);
sedatives - Valerian tincture, medicine of Pavlova, Quater, motherwort tincture;
analgesic, antipyretic and anti-inflammatory drugs: analgin, sodium salicylate 0,5 - 4 times a
day for 5 days;
immunomodulating drugs gamma-globulin or gistoglobin (from 2 ml i/m 2 times a week, per
course -3-7 injections), imunal (5 - 25 drops 3 times a day for 3 weeks); nukleinat sodium, metatsil,
pentoksil (0,25 - 3 times a day).
Local therapy includes:
anesthetic and antiseptic for oral mucosa (0,5-1% solution of trimekaini, 5% emulsion of
anestesini, 10% spray of lidocaine, 0.01% sodium Dimexidum, 0.1% sodium etoniya etc.; antiseptics with
analgesic drugs (1:1) as irrigation, trays, 3-4 applications per day);
application of proteolytic enzymes, trypsin, chymotrypsin, lysozyme, dezok-siribonuclease
(anti-inflammatory and anti-viral effect);
3-4 antiviral ointment 2 times a day for 20 minutes (1% florenalic ointment, 0,5% tebrofenic,
1% riodoksolic, 1-2% oxolinic, and 3% liniment gossypol, 5% interferon ointment, zovirax, acyclovir,
gerpevir);
on the 4th day of illness since the beginning of epithelialization of erosions prescribed
application of keratoplasty drugs (2-3 times a day for 20 minutes: oil solution of vitamin A and E, or
Vinylinum, Shostakovskogo balm, aloe juice and juice of Kalanchoe, 1% solution of citral, karotolin oil,
rose hips), aerosols "Livian," "Levovinizol", "Olazol", "Gi-pozol", "Panthenol".
From the physiotherapy methods prescribed irradiation of helium-neon laser and UV from 1 to 5
sessions. UFO is appointed after determining individual biodozy, starting from 1/4 biodozy.
In order to prevent the disease, patients should be isolated from the collective. It is necessary to
eliminate the chronic foci of infection. During the epidemic of influenza should be used antiviral ointment
(to put it into the nose 1-2 times a day). Interior application with arbidol, rimantadine (1 table 2 times a
day). Should be used de-sensitization drugs during a flu epidemic. Assign also herpetic polyvaccine (0,10,2 ml intramuscularly 2 times a day, a course of injections 10).
Acute aphthous stomatitis (stomatitis acuta aphtosa).

Etiology and pathogenesis. Acute aphthous stomatitis - autoinfectious disease, that occurs on the
background of reduced reactivity of the organism under the influence of conditionally pathogenic
streptococci and staphylococci and accompanied by acute onset, fever and rash of aphtae on the mucous
membrane of the mouth.
Most disease can found in children (up to 79 %), in adults - from 20 to 29 years.
During development of immunodeficiency streptococci and stafilococci microflora penetrates into
the oral mucosa, causes the formation of antibodies and immunoglobulins. After re-entry microflora
(antigens) in the mucosa starts to developing immune reaction (delayed-action) by type of Arthus or reaction
of Schwartzman with the formation of the AFL in the immune response. There are small-diameter necrotic
epithelial lesions with grayish or yellowish-white in color. Aphthae are round or oval in shape and
surrounded by a rim of hyperemia.
Necrotizing epithelium is impregnated with fiber-net mass of fibrin, which is tightly soldered
with the underlying layers of tissue, and its violent abruption is accompanied by pain and bleeding.
Clinic. In the clinic of acute aphthous stomatitis there are some periods: prodromal, period of
rashes, fading and clinical recovery.
The prodromal period can last for 1-3 days, and sometimes - 5-15 days. Patients complain on
chills, headache, sore throat, bleeding from the gums, general malaise, fever.
The period of development of the disease is accompanied by numerous rashes of aphtas on the
background of diffuse hyperemia of the mucous membrane of the mouth and gums.
Aphthas are located on the lip mucosa, the anterior third, the back and side surfaces of the tongue,
buccal mucosa, hard and soft palate. The rash may be on the tonsils, rear wall of pharynx and even wall
of larynx. Aphthas very painful, their number can vary from 20 to 100, depending on the severity of the
disease. They are round, oval and elongated shape, size 2-5 cm, yellowish-white or gray due to fibrin
deposition and surrounded by a bright red rim.
In some cases, especially in the severe forms of the disease, aphthas coalesces, patients have bad
smell from a mouth, there is intensively salivate, can be increased body temperature to 39 ~ 40 C. In
debilitated patients can develop ulcerative gingivitis, kerato-conjunctivitis, damage of the somatic organs.
The regional lymph nodes are enlarged, mobile, painful, not soldered to the skin and surrounding soft
tissue.
In some patients (14-25%), there are pustular rash on the face, chin, fingers (suppurative
paronychia), chest and back.
Defeat of the mucous membrane of the mouth accompanied by a violation of the general
condition of the body, which shows his toxicity. In most patients, the temperature rises, there is
tachycardia, disrupted the function of the gastrointestinal tract. Some disease may be complicated by the
development of necrotizing ulcerative stomatitis.
Period of fading of acute aphthous stomatitis is characterized by a decrease in toxicity,
normalization of temperature. Aphthas on the mucous membrane are reduced as a result of marginal
epithelization. The mucous membrane becomes pink, lymph nodes are reduced disappears bad breath, but
remains expressed catarrhal gingivitis.
Period of clinical recovery is accompanied by normalization of the general condition and the
mucous membranes of the mouth, and disappears catarrhal gingivitis, lymphatic nudes are not palpable.
Diagnosis. In cytology impression smears of the lesions there are mainly neutrophilic granulocytes in
various stages of necrobiosis, single and letters grouped lymphocytes, monocytes separate, in some places
- plasma cells of squamous epithelium. Mixed microfloramostly represented by streptococci and
staphylococci.
In the blood - leukocytosis, eosinophilia, wand-nuclear shift to the left, accelerated ESR.
Differential diagnosis should be carried out with diseases: chronic recurrent aphthous stomatitis,
acute herpetic stomatitis, erythema multiforme, pemphigus, allergic erosive stomatitis, syphilis (primary
and secondary), murrain, diphtheria.
Treatment of acute aphthous stomatitis depends on the severity of the disease and is divided by
the total and local.
Sometimes, in view of the etiologic role of streptococci-staphylococcal microflora in association
with the herpes virus, prescribes anti-bacterial and anti-viral drugs. There are: antibiotics, sulfa drugs,
antiseptics (ethonium, ekteritsid), nitro-furan preparations - furatsilin, furagin enzymes, and analgesics,
antimicrobial hlorfilipt in combination with enzymes trypsin, chymotrypsin, himopsina, which greatly
enhances the antibacterial effect of hlorofilipt. Recently are used drugs such as Stomatidin, ointments
"Levosin" "Levomikol" etc.

At the beginning of the period of epithelialization, prescribes appoint agents that stimulate the
regeneration of the mucous membranes of the mouth - karotolin, rosehip oil, Vinylinum, 5%
metatsilovaya ointment, aekol, carotene oil, oil solution of vitamin A.
In general treatment prescribes: to drink a lot of fluids (tea, broth hips, juices: carrot, carrotapple) and lightweight diet (vegetables, soups, low-fat meat stock, jelly of dried fruits, etc.). Recommend
a multivitamin "Geksavit" (1 tablet three times a day), askorutin (0, 5 - 3 times a day). If the disease is
accompanied by increase temperature - vitamins E 10% (15 drops 3 times a day, 2 weeks) and C as an
antioxidant therapy.
In order to reduce sensitization of the organism are used calcium gluconate, dimedrol,
diprazinum, fenkarol, suprastin and other immune-modulator: levamisole, timalin etc. Among
physiotherapy treatments prescribed ultraviolet and helium-neon laser.
2. Practical skills of the topic:
1) be able to work on the dental equipment;
2) be able to work with a dental tool, to know the rules of sterilization;
3) be able to make recording and reporting documents of therapist and to analyze performance;
4) be able to conduct the clinical examination of the patient with the pathology of the oral
mucosa, to make medical history, plan of examination and treatment of the patient;
5) be able to perform and assess the hygienic characteristics of oral cavity;
6) be able to take the material for bacteriological research, analyze the results.
7) be able to analyze the results of bacteriological tests of patient, blood count, urinalysis, blood
chemistry at the contents of glucose.
8) be able to carry out irrigation, instillation and application of drugs;
9) be able to write down the recipe, assign physical therapy;
10) be able to perform professional oral hygiene;
11) be able to give advice on the choice of means and objects of oral hygiene, prevention of
complications.
3. Terminology:stomatitis acuta herpes, stomatitis acuta aphtosa
4. Questions for control of knowledge:
1) Etiology and pathogenesis of acute herpetic stomatitis.
2) The clinic, diagnosis of acute herpetic stomatitis.
3) Differential diagnosis of acute herpetic stomatitis.
4) Treatment of acute herpetic stomatitis, prevention.
5) Etiology and pathogenesis of acute aphthous stomatitis.
6) The clinical manifestations of acute aphthous stomatitis.
7) Differential diagnosis of acute aphthous stomatitis.
8) Treatment of acute aphthous stomatitis, prevention.

Test tasks:
1. What kind of microorganisms is caused acute herpetic stomatitis?
A. Actinomycetes
B. Yeast-like fungi
C. Herpes simplex virus
D. Spirochete of Vincent
E. Fuzobakterii
2. How many periods in the pathogenesis of the disease?
A.
4
B.
5
C.
1
D.
3
3. The incubation period for acute herpetic stomatitis lasts:
A. 6-8 days
B. 2-4 days

C. 1-3 days
D. 9-10 days
E. 1-5 days
4. What kind of grope of the elements of destruction refers the bubbles?
A. Primary
B. Secondary
5. What kind of grope of the elements of destruction refers erosion, aphthae?
A. Primary
B. Secondary
6. Erosions heal up:
A. With the formation of scar
B. Without scarring
7. In acute herpetic stomatitis regional lymph nodes:
A. Enlarged, painful
B. Not enlarged, painless
8. What is the method to detect multinucleated giant cells, neutrophils polymorphic?
A. Serologically
B. Fluorescent
C. Cytological
D. Immunofluorescence
E. Histological
9.Differential diagnosis of acute herpetic stomatitis is not carried out with:
A. Medication stomatitis
B. Diphtheria
C. Pemphigus
D. Acute aphthous stomatitis
E. Fungal infection
10. To antiviral drugs include:
A. Calcium gluconate, calcium glycerophosphate
B. Tavegil, Tsetrin
C. Rimantadine, acyclovir
D. Ascorbic acid, calcium lactate
E. Gamma globulin gistoglobulin
11. What kind of physiotherapeutic methods is prescribed in acute herpetic stomatitis?
A. Ultrahigh frequency, microwave therapy
B. Helium-neon laser, ultra-violet radiation
C. Ultrasound
D. Electrophoresis
E. Fluktorisation
12.The most common acute aphthous stomatitis occurs:
A. In children
B. In adults
C. Equally
13. In the clinic of acute aphthous stomatitis allocates such periods
A. Incubation, eruption, extinction and period of clinical recovery
B. Incubation, prodromal, extinction
C. Prodromal, eruption, extinction, clinical recovery

D. Period of rashes, extinction, clinical recovery

14. Aphthae in acute aphthous stomatitis has shape:
A. Round, oval, surrounded by a bright red tubercles
B. Oval without rim
15. Is aphthae painful in acute aphthous stomatitis?
A. Yes
B. No
16. What are the characteristic changes in the clinical analysis of blood during herpetic
stomatitis?
A. Leukopenia, eosinophilia
B. Leukocytosis, eosinophilia
C. Leukopenia, stab shift to the left
D. Leukocytosis, eosinophilia, accelerated ESR, wand-nuclear shift to the left
17. Is affected skin of the face, trunk in acute aphthous stomatitis?
A. Yes
B. No
18. What medications are prescribed in a period of epithelization of aphthas?
A. Enzymes
B. Keratoplasty
C. Keratolytics
D. Antibiotics
E. Sulfanilamides
19. A patient, 25 years, complains on fever up to 38,5 C, chills, sore throat and muscle pain,
pain in the mouth, bad breath. On examination of the mucous of lips, cheeks, tongue, palate, there
are multiple aphthas with rounded shape and bright red rim, covered with gray coating. There is
salivation. Regional lymph nodes are enlarged, painful on palpation.
A. Acute herpetic stomatitis
B. Severe ulcerative stomatitis
C. Acute aphthous stomatitis
D. Erythema multiforme
E. Gerpangina
20. What is necessary to treatment of a patient with acute aphthous stomatitis during
epithelialization of aphthas?
A. Antibiotics
B. Antiseptics
C. Proteolytic enzymes
D. Keratoplasty
E. Keratolytics
21. The patient, 27 years, complains on the appearance of blisters on the lips, which have
appeared two days ago. On examination: the red border of lips swollen, there are grouped vesicles
on the red border of lips and skin, around presents redness and pain on palpation, mucous
membrane of the mouth unchanged. The causative agent of this disease is:
A. Fusiform bacteria
B. Herpes simplex virus
C. Filterable virus
D. The influenza virus
E. Pale trepanema

22. A patient, 20 years, complains on the pain in the mouth, the appearance of ulcers, fever up to
38 C, and headache. OBJECTIVE: there is hyperemia, swelling of the mucous membrane of the
mouth, mucous on the palate, gums, lips, and presents multiple rounded erosion, which fuse
together and covered with gray-white coating. What is the most probable diagnosis:
A. Acute herpetic stomatitis
B. Erythema multiforme
C. Pemphigus vulgaris
D. Murrain
E. Allergic stomatitis
23. The patient, 24, complains on general malaise, pain in the left side on the palate. Been sick for
2 days. OBJECTIVE: regional lymph nodes are enlarged, painful, moving, body temperature
38,2 C. On the mucosa of the palate - limited hyperemia, a group of vesicles filled with a clear
liquid, painful erosion with scalloped edges. Choose etiotropic drug of local therapy:
A. Antibiotics
B. Antisepsis
C. Sulfonamides
D. Antivirals
E. Antifungals
24. Girl, 19 years, is sick during 2 days: Temperature 37,8 C, cough, runny nose, pain during
meal. OBJECTIVE: hyperemia of the mucous membrane of gums, swollen, bleeding when
touched, submandibular lymph nodes are enlarged, mobile, painful, there is single round-shape
erosion on the mucous membrane of the cheeks. What is the most credible diagnosis?
A. Erythema multiforme
B. Ulcerative gingivitis
C. Hypertrophic gingivitis
D. Oral candidiasis
E. Acute herpetic stomatitis
25. The patient, 59 years, complains on pain in the mouth during the meal. OBJECTIVE: on the
gingival edge of the upper jaw on the right and on the buccal mucosa there are erosions of
bright red color, the periphery of erosions are preserved with fragments of bubbles. If you try to
remove them - to exfoliate the epithelium on intact mucosa. What method of a special study is
critical to the diagnosis?
A. Biochemical
B. Luminescent
C. Microbiological
D. Allergic
E. Cytological
26. Patient, 27 years, nurse, complains on general weakness, fever, the appearance of bilateral
regional lymphadenitis. At the 2-3 days of illness appeared blisters on the mucous membrane of
the mouth. On examination of the oral cavity - painful erosion, along the periphery of erosion
there are scraps of epithelium. In scraping the bottom of the bubble - giant ballooning cells. What
is the most credible diagnosis?
A. Aphthous stomatitis
B. Murrain
C. Acute herpetic stomatitis
D. Erosive stomatitis
E. Herpes zoster
27. Patient, 35 years, complains on headache, fever up to 39 C, the appearance of painful
"wounds" on the lip. In the anamnesis: recurrences. OBJECTIVE: on the red border of the lower
lip and border of the skin - grouped vesicles of 1-3 mm in diameter with a serous exudates.
Mucosa is edematous, erythematous. Regional lymph nodes are enlarged. Cytology detected
macrophages, multinucleated giant cells. What kind of drug with etiotropic actions do you need

to assign a patient to a local treatment?

A. Clotrimazole
B. Phenylbutazone
C. Solkoseril
D. A Lorinden
E. Zovirax

28. Girl, 18 years, works on the chemical factory, after hypothermia observed malaise, fever, pain
at food intake. The patient is suffering on enter colitis. OBJECTIVE: hyperemia, edema of
mucous membrane of the mouth, there are numerous blisters and erosions which are formed after
the open of bubbles. HI = 3,0 points, multiple caries cavities. What was the most likely cause of
the disease?
A. Harmful working conditions.
B. Virus.
C. Pathology of the gastrointestinal tract.
D. Oral hygiene.
E. Bacterial allergy.
29. Farmer, 27 years, after hypothermia complains on general weakness, fever up to 38,5 C,
cough, runny nose, pain at a swallowing. OBJECTIVE: edema and hyperemia of mucous
membrane of the mouth, increased vascular pattern, hemorrhage, plaque and desquamation of the
epithelium on the tongue, numerous vesicles containing clear exudates. What is etiotropic
treatment need to use?
A. Antivirals
B. Analgesics
C. Antihistamines
D. Antibiotics
E. Sulfa drugs
30. Patient, 20 years, complains on the pain in the mouth, the presence of ulcers, fever up to 38
C, headache. OBJECTIVE: oral mucosa is hyperemic, edematous. On the hard palate, gums, lips
there are many fused erosions with polycyclic contours, which covered with grayish-white
coating. What is the primary diagnosis?
A. Pemphigus vulgaris
B. Murrain
C. Erythema multiforme
D. Acute herpetic stomatitis
E. Allergic stomatitis