opic 141: Traumatic lesions of the mucous membranes of the oral cavity

(mechanical, chemical, physical, electrical injury). Radiation injuries. The etiology,

pathogenesis, clinical features, diagnosis, treatment and prevention.

Control questiones:
1. Acute and chronic mechanical trauma, clinical differential diagnosis, treatment, prevention.
2. Dekubital ulcer, differential diagnosis, treatment.
3. Oral manifestations of acute and chronic chemical injury.
4. The concept of physical injury, causes, clinical manifestation.
5. manifestation in the oral cavity radiation injuries. The concept of the film radiomukozitah,
treatment, prevention.
6. Galvanism, causes species manifestation in the oral cavity, prophylaxis. The concept of
galvanosis.
7. Iatrogenic stomatitis. Diagnosis, differential diagnosis, emergency treatment, prevention.

1. Justification of topics:
Traumatic lesions of the oral mucosa of various etiologies are a frequent pathology in the
practice of dentistry and often the fault of the doctor. Therefore, their detection, differential
diagnosis, emergency care, adequate treatment and prevention are the subject of in-depth selfstudy students.
2. The purpose of the activity:
2.1 General:
Know the etiology and pathogenesis of primary traumatic stomatitis, methods of examination,
the basic diagnostic criteria, principles of emergency care, and further treatment, principles of
early detection of cancer, iatrogenic damage to the mucous membrane of oral cavity ().
2.2 Specific: a) know:
- Etiology and pathogenesis of injury mechanical, chemical, physical, electrical;
- Traumatic stomatitis clinical manifestation depending on the etiology, including iatrogenic;
- Clinical and laboratory methods of examination.
b) be able to:
- To carry out a clinical examination ;
- Distinguish the clinical manifestations of trauma on , depending on the cause;
- Conduct a survey of the patient, the differential diagnosis;
- Diagnosis
- Develop a plan of treatment;
- Perform medical procedures needed to treat;
- Substantiate preventive measures for different types of injuries;
- Prescription the necessary drug.
c) the practical skills:
- To carry out a clinical examination of the patient with trauma ;
- To issue patient card dental patient;
- Draw up a plan of examination and treatment;
- To take the material for cytological and bacteriological examination;
- To direct the clinical or biochemical analysis of blood, urine;
- To analyze the results of the analyzes;
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- Perform anesthesia;
- To carry out irrigation, instillation, applique drugs;
- Write out prescriptions medications: analgesics, antiseptics, enzymes, keratolytics and
keratoplastic;
- To determine the patient's prognosis and work capacity, prevention of complications;
- To issue accounting and reporting documentation.

3. Count of logical structure of the topics.

MECHANICAL TRAUMA
ACUTE
without violation
the MM (edema,
hyperemia,
hemorrhage)

CHRONIC

in violation of the
MM (erosion,
excoriation, ulcer)

Dekubital ulcer
CANCER

Papillomatosis
Fibrosis
Keratosis

leukoplakia
flat / verrucose / erosive and ulcerative

PHYSICAL TRAUMA

ELECTROCHEMICAL

Membranous
radiomukozit

Superficial, deep
necrosis

Galvanosis

Trophic ulcer

Lichen ruber planus

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4. Control questiones:
1. Acute and chronic mechanical trauma, clinical differential diagnosis, treatment, prevention.
2. Dekubital ulcer, differential diagnosis, treatment.
3. Oral manifestations of acute and chronic chemical injury.
4. The concept of physical injury, causes, clinical manifestation.
5. manifestation in the oral cavity radiation injuries. The concept of the film radiomukozitah,
treatment, prevention.
6. Galvanism, causes species manifestation in the oral cavity, prophylaxis. The concept of
galvanosis.
7. Iatrogenic stomatitis. Diagnosis, differential diagnosis, emergency treatment, prevention.

5. Contein of the topic.

Traumatic Lesions of the Oral Mucosa
Traumatic lesions of the oral mucosa occur as a result of different factors (mechanical,
physical, chemical), if the intensity of their influence surpasses the safety factor of the mucosa.
The degree of damage and clinical manifestations depend on the nature of a stimulus,
intensity of its impact, time, location, individual characteristics, general condition of the body
and age.
The mucous membrane of the oral cavity has high protective and regenerative abilities.
Traumatic injuries of the oral mucosa are immediately followed by its infection.

Mechanical Trauma
Acute mechanical injury (trauma mechanicum acutum).
Etiology: Acute mechanical trauma of the oral mucosa occurs by chance when biting, hitting, or
injuring by different objects. Mostly the mucous membrane of the tongue, lips and cheeks is
damaged along the line of dental closure.
Clinical features: First, in this case, pain appears, and a hematoma, excoriation, erosion or ulcer
can be formed at the site of injury. Often, the size, shape and location of manifestations
mentioned above coincide with those of a traumatic agent.

Hematomas and superficial lesions (excoriation, erosion) disappear rather quickly (in 13 days).
In case of secondary infection, erosion can go to a persistent ulcer. The base of erosion during
palpation is painful and infiltrated.
Diagnosis: There are no any difficulties, the cause is easily specified after the anamnesis.
Treatment: Examine the wound, stop bleeding if necessary, using 0,51% hydrogen
peroxide, 5% solution of aminocaproic acid.
In case of severe pain an application, irrigation or rinsing with 0,51% solution of
novocaine, 0,51% solution of lidokaine should be carried out.
If deep wounds have been formed they should be stitched.
Lesions that are not deep should be treated with common, not irritative, warm antiseptics
(0,5% solution of chlorhexidine bigluconate, 0,2% furacilin solution, 0,5% solution of
Aethonium, 1% solution of Dimexidum, 1% solution of hydrogen peroxide, etc.), and the oral
rinsing by artificial lysozyme or the solution of potassium permanganate should be administered.
If erosions occur, add the application with keratoplastic agents (kalanchoe juice, ectericide,
solution of vitamin A, etc.).
When the wound is covered with some coat and infiltrated, such lesions persist for long.
Proteolytic enzymes within 810 min are used to treat them. Thereafter, necrotic tissues or
fibrous coat are removed mechanically, and the ulcer or erosion is treated with antiseptics. When
clean granulations appear, drugs improving reparative properties of tissues (Solcoseryl) and
keratoplastic agents are applied.
It is necessary to examine dentitions, and to prevent chronic injuries it is obligatory to
carry out the treatment of caries and its complications, restoring the anatomical shape of the
affected crown or polishing its sharp edge.
Chronic Mechanical Trauma (Trauma Mechanicum Chronicum)
Etiology and pathogenesis: It occurs rather often, especially among the elderly who use
plate dentures. (Plate prosthesis transmits chewing pressure to the mucous membrane and
impedes self-cleaning of the mouth disturbing the established balance between different types of
microorganisms, and changes the analyzing function of receptors of the mucosa. These changes
are often the starting point for the development of pathology and neurostomatological diseases or
exacerbations of chronic lesions, which are in the stage of remission).
It is also caused by sharp-edged teeth if they are affected by caries, pathological
abrasion, lack of teeth and malocclusion, defective or disabled orthopedic constructions,
orthodontic appliances, dental calculus, bad habits, etc.
More often chronic mechanical trauma occurs in aged people due to the lowering of the
vertical dimension, dysfunction of the temporomandibular joint, presence of terminal defects of
dentitions, IIIII degree of periodontitis, lowering of the turgor of the mucous membrane, or
slow process of regeneration of the epithelium.
Thus, prolonged traumatic factor triggers and maintains the chronic focus of
inflammation forming congestive hyperemia and edema; on this area erosion may appear and
later turn into ulcer called decubital or traumatic. If the course lasts for a long period of time, the
base and edges of the ulcer become denser, its depth varies up to the muscular layer, malignancy
is possible.
Clinical features: The presence of chronic traumatic lesions on the mucosa of the oral
cavity may not disturb the patient, but in case of ulcers, most of them complain of burning
sensations, swelling, discomfort, pain in the certain area, intensifying during ingestion and
conversation.
The clinical course in aged people is more severe than in the young.
More often such ulcers are located on the tongue, lips, cheeks, along the line of the
closure of teeth, as well as within the area of prosthetic localization. As a rule, it is single,
painful, surrounded by inflammatory infiltrate, with the floor covered by fibrous coat. Regional
lymph nodes are enlarged, painful on palpation. The inflammation may be focal or diffuse. It is

accompanied by edema and hyperemia of the mucous membrane on the background of which
hemorrhage, erosions and hyperplasia of the mucosa can occur in the form of grain.
In addition, at the site of injury of the mucosa caused by a prosthetic edge, a proliferative
process can develop and lobed fibroma may occur. It looks like several folds parallel to the
prosthetic edge.
If there is a habit to bite or suck the lips, tongue, cheeks, the mucous membrane (mainly
along the line of dental closure) takes on a peculiar view: swells and has a white macerated
surface in the form of spots or large, not clearly limited areas, or has fimbriated view (as if it has
been eaten up by the moth) because of many small patches bitten unevenly. The lesion is
asymptomatic but in case of deep biting, erosions are formed, and they are painful if there is a
contact with chemical stimuli. Synonyms: soft leukoplakia, cheek biting.
Differential diagnosis: Chronic trauma (if there is a habit to bite the mucosa) should be
differentiated from candidosis (no fungi in the cytology), white sponge nevus of Cannon
(become evident from the early childhood and progresses with age: buccal mucous membrane
looks thick, spongy, with deep folds). The termination of biting of mucosa leads to a
spontaneous recovery.
Traumatic ulcers of the oral mucosa should be distinguished from cancerous ulcers,
trophic ulcers, tuberculous ulcers and hard chancre. Traumatic ulcers are characterized by the
presence of a stimulating factor, painful infiltration, the absence of specific changes in cytology.
Usually the elimination of the traumatic factor leads to the healing of ulcers in 56 days.
If the ulcer exists for a long time, its edges and base can become denser (infiltrative
bank) due to a chronic inflammation; mucous tunic around the ulcer is edematous and
hyperemic, the floor of the ulcer becomes bossed, covered with the coat. Tenderness persists
when palpating the ulcer. Lymph nodes are enlarged and painful. Persistent ulcers can be
infected by fuso-spirochetes, Candida, as well as become malignant.
Cancerous ulcers differ from traumatic by the higher density of edges and base,
excrescences on the edges (resembling cauliflower) and sometimes their keratinization. After
eliminating the stimulus the healing does not occur. Cytological and histological studies of
cancerous ulcers reveal atypical cells. Lymph nodes are painless on palpation.
Tuberculous ulcers are characterized by pain, soft, disrupted, creeping edges; their
floor is granular (Trails grains microabscesses) and yellowish. They do not epithelize after
removing the irritant. Cytological studies reveal epithelioid cells and giant cells Pirogov
Langhans, and the bacterioscopic study shows Mycobacterium tuberculosis.
Hard chancre is different from traumatic ulcers by presence of dense cartilaginous
infiltrate surrounding the ulcer with even edges, smooth bottom of saturated scarlet colour, and
painless on palpation. The surrounding mucosa is without any changes. Regional lymph nodes
are enlarged, painless, indurated (scleradenitis). Diagnosis is specified after finding pale
treponema in ulcerous secretions. Wassermann test becomes positive within 3 weeks after the
onset of the chancre.
Trophic ulcerations differ from traumatic by longer occurrence, torpid course, ill-defined
signs of inflammation, the presence of common diseases in a patient (often in cardio-vascular
system). The elimination of a supposed traumatic factor does not heal the ulcer rapidly.
The treatment provides for the mandatory elimination of the traumatic factor, treatment
of oral ulcers with antiseptic solutions. If necrotic tissues are evident, they are removed
mechanically under anesthesia or by means of proteolytic enzymes. Simple erosions and ulcers
are treated with keratoplastic agents (RegeneCure, Dibunol, Sanguiritrinum, briar rose oil, seabuckthorn oil, oily solution of vitamin A, kalanchoe juice, Solcoseryl, Olasol, Hiposol-N
etc.). The lobed form is treated surgically.
Traumatic ulcers infiltrated in the bottom and not healing within 2 3 weeks after
removing the causative factor are the reason for the suspicion of their malignancy.
Prevention of traumatic injuries includes the elimination of irritants from the oral cavity,
and its timely sanation.
5

Chemical Trauma
Chemical trauma (trauma chymicum) occurs when the mucosa contacts with chemicals. It
can be both acute and chronic. Acute chemical trauma occurs if chemicals with rather high
concentration get on the mucous tunic. Usually it happens when using them wrongly in
household and in industry, attempting suicide or at the dentist's office. The burns of the mucosa
in the oral cavity can occur during a contact with acids, alkalis, application of arsenic paste,
phenol, formaldehyde, resorcinol- formalin mixture, argentic nitrate. The clinical picture of the
lesion (hyperemia, edema, erosion, necrosis, and ulcer) depends on the nature of the chemical, its
amount, concentration and time of action.
Acid burns lead to coagulatory necrosis the dense membrane of brown colour from
sulfuric acid, yellow colour from nitric acid, gray and white colour from other acids. The
phenomena of inflammation with edema and hyperemia are apparent around the membrane.
Alkaline burns result in colliquative necrosis of the mucosa without formation of the
dense membrane. Alkaline affection causes deeper injuries comparing with acidic one, and it can
cover all the layers of the mucous tunic. Painful erosive or ulcerative surfaces that heal very
slowly become bare after the rejection of necrotic tissues.
Treatment. It is demanded to remove quickly the damaging chemical and rinse the oral
cavity with a weak solution of some neutralizing agent. In case of acid burns soapsuds, 1% lime
water, burning magnesium, 0,1% solution of ammonium chloride (15 drops in a glass of water)
are used. Alkalis are neutralized by 0,5% solution of acetic or citric acid, and the solution of
hydrochloric acid (10 drops in a glass of water). So in this way the further penetration of the
chemical in tissues is stopped.
A solution of 23% sodium chloride or Lugols solution (Lugols iodine) is applied to
reduce the absorption of concentrated solutions of argentic nitrate. It causes the formation of
insoluble compounds of silver. If an injury is caused by phenol, the mucosa is treated with castor
oil and 50% ethanol. The further treatment of patients with chemical burns of the mucous tunic
in the oral cavity is similar to the treatment of acute non-specific inflammatory process:
painkillers, light solutions of antiseptics in the form of oral bathes, rinse, medicines accelerating
the process of epithelization (1% solution of citral with peach oil, Methyluracil ointment,
vitamins A and E , Cygerolum, Hiposol-N) are prescribed.
Physical Trauma
Physical injury (trauma physicum). The most common traumas of the mucous membrane
of the oral cavity caused by physical factors are: thermal lesions (the effect of high and low
temperatures), electric shock (burns, galvanosis) and radiation damage (in case of localized
effects of high doses of ionizing radiation).
Burns of the oral mucosa can be caused by hot food, steam, hot objects, fire and hot air.
Acute catarrhal stomatitis accompanied by pain develops under the effect of hot water or steam.
The oral mucosa is very hyperemic and the maceration of the epithelium becomes evident. If the
burn is severe, thick layers of the epithelium are exfoliated or vesicles appear, and later extensive
superficial ulcerations or erosions are formed at this area. Joining of a secondary infection and
the effect of local irritants complicate the course and slow down the epithelization of lesions.
Treatment. The area of burn should be analgized locally by the application of antiseptics;
coating and anti-inflammatory drugs should be administered together with antimicrobials.
Keratoplastic agents are used in phase of dehydration.
The impact of low and ultralow temperatures mainly is caused by cryotherapy of
different lesions and periodontium. In this case an acute catarrh occurs suddenly in the focus of
cryotherapy; and in 12 days it turns into necrosis. In the first few hours of the postoperative
period after cryodestruction an oral bath and antiseptic rinse are prescribed. If necrosis develops
they administer the therapy similar to that of necrotizing stomatitis.

Electrical trauma of the oral mucosa is often associated with electrotherapy

(galvanization, electrophoresis) or the development of galvanism in the oral cavity. Galvanic
burns are formed when the mucosa contacts with the active electrode in case of wrong use of
electrophoretic techniques. Clinical features include a painful continuous erosion surrounded by
reactive inflammations of adjacent tissues and accompanied by painful reaction of regional
lymph nodes.
Galvanism is the occurrence of registered electric potentials in the mouth in the presence
of metal inclusions without the expressed objective and subjective symptoms. (It is a
phenomenon).
Galvanosis is the pathological changes in local and general character caused by the
electrochemical interaction between the metal inclusions in the oral cavity. (It is the complex of
symptoms).
Galvanosis induces the development of glossalgia, leukoplakia, lichen planus, and also is
an aggravating factor in the existing pathology of the oral mucosa. It can lead to microbial
imbalance and development of oral candidiasis.
The presence of different metal inclusions contributes to the electrochemical reactions,
accumulation of electromotive force at the margin of the metal and oral fluid, which provides the
appearance of galvanic couples. According to Nikitina T. E. the value of zeta potential (ZP/
microvolts) 120 -140 mV is the standard of electric current. If it is higher than 140 mV, the risk
of galvanosis development and its complications arises. High level of metal consenration in the
oral fluid results in the accumulation of metals in the mucous membrane, soft tissues of the
mouth, jaw bones. And as they get to the gastrointestinal tract constently, it leads to their spread
throughout the body and the appearance of sensitization to metals.
Clinical features: Clinical manifestations of galvanosis of the oral mucosa depends on the
intensity of current, time of its influence, individual sensitivity of tissues. Patients complain of:
metal taste in the mouth, gustatory perversion, burning or tingling, pain on the tongue and
cheeks, dryness or hypersalivation, easy irritability, headache and weakness.
Galvanic currents can cause burns or hyperkeratosis occurring at the tip of the tongue, its
side and lower surfaces, more rarly on cheeks, lips and palatal surfaces. Clinical picture is
catarrhal or erosive-ulcerative lesions. Catarrhal lesions are characterized by bright redness,
swelling and burning. Inflammatory foci are clearly dilimited from the changeless surface of the
oral mucosa. The erosive-ulcerative form is rare and characterized by the focal or diffuse
inflammation of the musous membrane. It is accompanied by the formation of single or multiple
erosions (sometimes ulcers or vesicles) covered with a whitish-gray coat.
Diagnostics. At least five criteria should be evident to diagnose galvanosis:
1) presence of metal taste in the oral cavity;
2) subjective symptoms, more severe in the morning and persisting during the day;
3) presence of two or more metal inclusions in the mouth;
4) determination of the difference of potentials between the metal inclusions
(registration);
5) improving general state after removing dentures from the oral cavity.
To detect galvanic phenomena in the oral cavity a device Lira100 is used.
Treatment. Etiotropic therapy of galvanosis of the mucosa consists of the removal of
dentures and fillings made from heterogeneous metals. In addition, if the catarrhal lesions of the
oral mucosa occur, protease inhibitors, anti-inflammatory and antiseptic agents are applied at an
early stage. The lesion focus is treated with 5% solution of unitiol.
Galvanic burns occurring with erosions, ulcers, vesicles and accompanied by soreness are
treated by antiseptics and topical anesthetics (410% oil solution of anesthesin, 10% alcoholic
solution of propolis with glycerol (1:1), 2040% solution of DMSO). It is advisable to apply
Nitacid at the first stage of the wound process because it has a high osmotic activity and a
wide spectrum of antimicrobial effect. The infusions of plantain, nettle leaves and green tea have
7

analgesic and anti-inflammatory effects. Hiposol-N, Solcoseryl (ointment, gel), Erbisol,

Linimentum Spedianum, Vinylinum, anti-ambustial liquids and others are applied to improve
the epithelization of damaged areas.
Recommended Drugs (G.M. Barer)
Topical (superficial) anesthesia:
Benzocaine/glycerin 5/20g, top (topically), ac (before meals), until clinical improvement or
Lidocaine 2,55% ointment or 10% spray, top, ac, until clinical improvement.
To treat the oral cavity and elements of mucosal lesions and prevent their infection:
Hydrogen peroxide 1% solution, top, 12 times or
Potassium permanganate 0,02% solution, top, 12 times or
Chlorhexidine 0,06% solution, top, 12 times or
Ethacridine 0,05% solution, top, 12 times.
To clean the surface of erosions and ulcers:
Trypsin (in isotonic sodium chloride solution) 5 mg, top, 12 times per day or
Chymotrypsin (in isotonic sodium chloride solution) 5 mg, top, 12 times per day.
In case of necessary correction of psycho-emotional sphere (for example, buccal biting):
Vitamin B1 2030 mg daily or 12 ml of 6% solution, intramuscularly (im), once a day, for 10
days
Vitamin B12 12 ml, im, once a day, for 10 days
Extract of Valerian rhizome/root 1 pill by mouth (po per os), 12 times per day, for a long
time or
Glycine 0,1g sublingually (sl), 23 times per day, for a long period
Diazepam 515 mg, po, 12 times per day, for 4 weeks or
Medazepam 10 mg, po, 23 times per day, for 4 weeks
To promote healing of lesions:
Sea-buckthorn oil is topically applied on a cleaned area of the affected mucosa 13 times a day,
until the clinical improvement is seen or
Solcoseryl, ointment or dental adhesive paste, is topically applied on a cleaned area of the
affected mucosa 13 times a day, until the clinical improvement is seen or
Rosehip oil is topically applied on a cleaned area of the affected mucosa 13 times a day, until
the clinical improvement is seen
As anti-inflammatory, immune-stimulating agent that improves the histological trophism:
Retinol solution, top, on the affected areas 56 times a day, until clinical improvement
As an active antioxidant to stimulate protein synthesis and reduce capillary permeability:
Vitamin E, solution, top, on the affected areas 56 times per day, until clinical improvement
To regulate redox (oxidation-reduction) processes, stimulate histological regeneration,
activate phagocytosis and antibody synthesis:
Ascorbic acid 50100 mg, po, 35 times a day or 1 ml of 5% solution, im, once daily, for 20
40 days
To normalize the exchange of fatty acids, stimulate the formation of acetylcholine, steroid
hormones, utilize products of deamination of amino acids:
Calcium pantothenate 0,1g, po, 24 times per day or 5% solution, topically applied on
prolonged persistent erosions, 24 times per day or
2 ml of 10% solution, im, 12 times per day, for 2040 days
To enhance the processes of blood formation and maturation of red blood cells, and
histological regeneration:
Cyanocobalamin 0,00005 g, po, once every day, for 2040 days
Folic acid 0,0008 g, po, once every day, for 2040 days
To regulate the respiration of tissues, metabolism:
Riboflavin 0,0050,01g, po, once every day, for 2040 days
In order to normalize the metabolism and peripheral circulation:
8

Nicotinic acid 0,0250,05g, po, pc (after meals), tid (3 times a day), for 2040 days or 1 ml of
1% solution, im, iv (intravenously) or under the focus of lesion, once every day, for 1015 days.
Affection of the Oral Mucosa during Radiotherapy of Neoplasms of the Maxillofacial Area.
During radiotherapy of neoplasms of the maxillofacial area, unaffected sites of the oral
mucosa are exposed to radiation. The response of different areas of the mucosa to irradiation
varies and has some clinical particularities depending on the type of radiation therapy, single and
total dose, histological radioanaphylaxis and oral health prior to irradiation. The first clinical
signs of disturbance of the oral mucosa appear at the sites covered with non-keratinized
epithelium (redness, swelling). They are expanded with increasing dose of irradiation. The
mucous membrane (due to the enhanced keratinization) becomes roily, dense and folded losing
the glance. With further exposure to irradiation this keratinized epithelium is rejected in some
areas. It leads to the formation of erosions, covered with the adhesive necrotic plaque (focal
membranous radiomucositis). If necrosis extends to adjacent areas, erosions are merged and the
merged membranous radiomucositis occurs.
The soft palate is particularly sensitive to the irradiation of mucosa: radiomucositis
occurs immediately without the phase of keratinization. Focal epithelial desquamation or single
erosions occur at the sites of the oral mucosa that is normally covered by the keratinized
epithelium. The further development of the process is complicated by the affection of salivary
glands, because their epithelium is very sensitive to radiation. During the first 35 days
salivation can be increased, and thereafter, the fast development of permanent sialoschesis
becomes evident. In 1214 days xerostomia develops, which is accompanied by dysphagia,
dysgeusia and ageusia. Later the hyperemia of the tip and sides of the tongue and the atrophy of
its papillae become apparent.
Radiation changes in the oral cavity are reversible to a considerable extent. The oral
mucosa becomes relatively normal in 23 weeks after termination of exposure to radiation.
However, when the absorbed dose is high (50006000 rad), irreversible changes in the salivary
glands and mucous membrane of the oral cavity can occur (hyperemia, atrophy and radiation
ulcers).
To prevent radiation reactions it is of great importance to sanitize the oral cavity. It
should be performed in the following sequence:
1) to remove the mobile and damaged teeth having chronic periodontal foci and with
further suturing no later than 35 days before the start of radiation therapy;
2) to remove supra and subgingival dental plaque, curettage of periodontal pockets;
3) to fill all carious cavities. Metal prostheses and fillings made from amalgam should be
removed, or rubber or plastic protective mouthpieces with thickness of 23 mm should be made
and applied to dentitions immediately before a session of radiotherapy. Instead of mouthpieces
tampons saturated in liquid paraffin or novocaine. The dose of 0,20,8 g of radioprotective
cysteamine hydrochloride is administered 1030 min before irradiation or 0,05 g of mexamine
3040 min prior to irradiation. Directly before irradiation the mucous membrane is irrigated by
the solution of adrenaline in isotonic sodium chloride solution (2:100); or adrenaline is injected
under the skin, and the mucosa is washed with prednisolone. In case of initial manifestations of
the radiation reaction, the oral mucosa and gums are treated 45 times a day by weak antiseptic
solutions. At the moment when the radiation reaction is manifested most of all, to anesthetize the
mucosa they use1% solution of novocaine or trimecaine, 1% solution of dicain, 10% oil
emulsion of anesthesin; periodontal pockets are washed with a warm solution of antiseptics;
applications of enzymes with antibiotics are made, and thereafter, the mucosa is treated with
such drugs as Hiposol-N, Sanguiritrin, the oil of rosehip or sea-buckthorn. At this time,
extractions of teeth, removal of dental calculus and curettage of periodontal pockets are
contraindicated. The therapy of post-radiation effects and complications is aimed at
strengthening the resilience of the body, reducing the permeability of tissues, as well as
removing the factors affecting the oral mucous membrane. The next medications are prescribed:
9

Splenin, sodium nucleinate, Batilol, rutin, niacin, vitamin B6, B12, Aevit, calcium supplements,
Galascorbinum. The relative normalization of the oral mucosa occurs within 23 months.
Radiation Sickness
Radiation sickness is a disease appearing due to the exposure of an organism to ionizing
radiation. There are acute and chronic forms of X-ray sickness. Acute radiation syndrome
(ARS) develops if a body is exposed to rays and neutron flux at doses higher than 1 Gy (gray)
for a short time (from few minutes to 13 days). It is characterized by a staging course and
polymorphism of clinical picture. The clinical features of ARS include several forms: bonemarrow (110 Gy), intestinal (1020 Gy), toxical (2080 Gy), cerebral (80 Gy).
According to the severity the bone-marrow form is divided into I (mild) 12 Gy, II
(medium) 24 Gy, III (severe) 48 Gy, IV (fatal) more than 10 Gy. The X-ray trauma
occurs after exposure to less than 1 Gy of radiation.
Ionizing radiation causes metabolic changes in stem cells, lymphocytes, in the epithelium
of the small intestine, etc.
There are five stages in the course of the disease:
1) the period of primary reaction to irradiation;
2) the latent period, or period of imaginary wellbeing;
3) the period of clinical manifestations or the high point;
4) the period of resolution;
5) the period of late complications and consequences of injury.
Clinical features. The first period: general malaise, dizziness, headache, drowsiness,
nausea, vomiting, diarrhea, bleeding nose, fever, loss of consciousness, hyperemia of the skin,
injection of the sclera. Dryness, metal taste and reduced sensitivity of the mucosa appear in the
oral cavity. Edema and hyperemia become evident, petechial hemorrhages occur. Visible clinical
changes in teeth are not observed, but the inhibition of calcium-phosphorus metabolism comes
during this stage. Later, in the IIIrd period, it turns into structural and morphological changes.
Neutrophilic leukocytosis, reticulocytosis, lymphopenia are found in the blood. The period of
primary reaction lasts for 2 days.
The second period begins in the third day after exposure to radiation and lasts for 24
weeks. It is characterized by a relative improvement in general condition. There are no changes
in the mouth, but the number of leukocytes and lymphocytes continues to decrease, the inhibition
of hematopoiesis becomes evident.
The third period is observed in the 7th 12th day after exposure and lasts for 34 weeks. It
is characterized by severe general condition due to hematologic, gastrointestinal disorders,
increased hemophilia, fever and other multiple complications. The inhibition of hematopoiesis
progresses. There is an apparent hemorrhagic syndrome in the oral cavity. Necrotizing ulcerative
gingivitis and stomatitis develop gradually. The mucosa of lips, cheeks and tongue is covered
with whitish, viscous mucus. In severe cases necrosis can be spread from the mucous tunic to
subjacent soft tissues and bone that leads to the sequestration and possible jaw fractures. Tonsils
are covered with dirty gray coat that is hard to be removed. Under this coat there is a bleeding
surface. Deglutition of food is almost impossible because of the sharp pain. A putrid smell
comes out from the mouth. Regional lymph nodes are enlarged and painful on palpation.
The fourth period is observed in the 4th week after exposure and lasts for 13 months. It
is characterized by a slow regression of symptoms.
The fifth period begins in the 5th6th week of exposure and lasts for 3 months or more. It
is characterized by residual effects of ARS in the form of long-term inhibition of hematopoiesis
(leukopenia, thrombocytopenia, erythropenia). The transitions into leukemia (myelosis,
reticuloendotheliosis) and other somatic pathology are possible. Changes of hard tissues of teeth
are apparent: they become spalled as the edges of enamel are eroded; abnormal abrasion appears
too. All these moments are accompanied with a great number of carious cavities mainly
localized in the cervical region in approximal surfaces. Circular caries, enamel opacity and the
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appearance of dark spots on the last one are evident. The areas of enamel demineralization are
found; dentin is easily removed by layers with an excavator. Generalized periodontitis of the I
III degree and oral dysbiosis develop. Xerostomia, partial hyperkeratosis and cyanosis are
observed in the oral cavity. The tongue is enlarged in size. Neurostomatological symptoms
occur: occasional tingling and prickling, burning or pain in the mouth, resembling attacks of
trigeminal neuralgia.
Chronic radiation sickness (CRS) occurs in case of prolonged external exposure to lowdose ionizing radiation; usually it develops in people facing nuclear radiation (radiologists, etc.)
by the nature of their work and breaching safety regulations. Mild (I), medium (II) and severe
(III) degrees are defined.
Clinical picture: the initial manifestation of CRS is characterized by changes of the
nervous system in the form of neurosis with autonomic disorders. Hereinafter, disorders of the
neurogenic regulation and cardiovascular system, and the development of hemorrhagic
syndrome are associated. Moreover, the dysfunction of gastrointestinal tract, liver, metabolism
and the endocrine system occurs. In the oral cavity CRS appears at the IIIrd degree in the form of
persistent gingivitis, bleeding gums, glossalgia and glossitis.
It is rather difficult to diagnose CRS. It is based on a study of peripheral blood and bone
marrow.
Treatment. In case of ARS the following factors are necessary: physical and mental rest,
high-calorie food, large amount of fluid, sedatives, anti-emetics, remedies for detoxification,
antihemorrhagic drugs and plasma expanders. Milk and sour milk products are recommended.
The prevention of inflammations of the oral mucosa is aimed at increasing the body resistance
and eliminating the factors that influence the mucous membrane negatively (traumatic factors,
infection). It is contraindicated to remove teeth and dental calculus, carry out the curettage of
periodontal pockets and use cauters. It is advisable to prescribe ascorutin, nicotinic acid, Aevit,
vitamin B6, B12, calcium supplements. It is recommended to treat the oral cavity with weak
antiseptic solutions. To enhance the local immunity in the mouth, rinsing with the solution of
artificial lysozyme and Imudon is prescribed. 1% solution of trimecaine, 2% solution of
lidocaine, 10% suspension of oily anesthezine, propolis oil solution and 1% solution of sodium
mephenaminate are used to anesthetize. The enzymatic applications are indicated trypsin,
chymotrypsin (10 ml of 0,25% novocaine + 10 mg of enzyme) as well as chonsuridum. The
applications with anti-inflammatory and keratoplastic agents are made on treated surfaces.
Various pastes and periodontal dressings with antibiotics, glucocorticoids, sodium
mephenaminate, made from rosehip and sea-buckthorn oil and vitamins A, E, are applied. A
complete sanation of the mouth is performed during the period of long-term effects. It is better to
use the glass-ionomer cement. Mobile and damaged teeth with chronic inflectional foci at the
apex are extracted, and the socket is sutured. The suturing is needed due to increased bleeding
and poor blood clotting. This aspect should be taken into consideration while removing dental
plaque, especially subgingival dental calculus, and in case of a surgical procedure on the
periodontium.
6. Situational tasks.
1. Male 57 years old complains of pain, difficulty opening the mouth. Was diagnosed
leukoplakia, ulcerative form. 12 days after the course of treatment observed increased of
bleeding and processes of keratinization around the periphery of ulcer. What is the study of the
following must take place in the first place?
A. Cytology.
B. Stomatoskopy.
C. Bacteriological.
D. Fluorescent.
E. Bacterioscopic.
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2. A patient 55 years complains of feeling of roughness on the buccal mucosa, dryness in the
mouth for several months. Not treated. Smokes. Objectively: for buccal mucosa, to the line
between the teeth in the anterior parts of whitish color in the form of triangles, painless.
Submandibular lymph nodes were not enlarged. What is the primary treatment strategy?
A. Antibacterial drugs locally.
B. Elimination of harmful habits.
C. Applications of oil solution of vitamin A.
D. Antifungal drugs locally.
E. Surgical removal of the lesion
3. A patient 33 years complains of pain in right side tongue, increasing during the meal and
conversation. Objectively: lateral surface of the tongue closer to the root is painful ulcer 0.6 cm
in diameter. Bottom is covered with gray coating. The crown 47 is destroyed. What is the most
likely diagnosis?
A. The chancre
B. Trophic ulcer
C. Tuberculous ulcer
D. A cancerous ulcer
E. Dekubital ulcer
4. The patient is 53 years old diagnosed leukoplakia of smokers (Tappeynera). What
pathological process prevails in the histology of the disease?
A. Hyperkeratosis
B. Dyskeratosis
C. Acanthosis
D. Parakeratosis
E. Papillomatosis
5. A patient of 54 years complains of burning tongue, increased salivation, glossalgia
phenomenon. Five days ago orthodontic treatment with metal bridges. Objectively: mucosa
hyperemia, swelling, blood eritropeniya, leukocytosis, elevated erythrocyte sedimentation rate.
What is the most likely diagnosis?
A. Kosten syndrome.
B. Toxic-chemical stomatitis.
C. Sjogren's syndrome.
D. Allergic stomatitis.
E. Mechanical stimulation of the dentures.
6. A patient 65 years old complains of pain in the mucosa of the hard palate on the left,
increasing after the meal, use of complete dentures during. Is sick 1.5 months. Objective: redness
and swelling of the mucous membrane of the hard palate on the left, on the border of the distal
edge of the prosthesis - ulcer with thick edges and the bottom, surrounding tissues are infiltrated.
The ulcer bottom hilly, covered with fibrinous coating; palpation painful ulcers. What method of
the survey should be used first?
A. Allergic contact test for plastics
B. Bacterioscopy
C. Biopsy
D. Serological
E. Cytology

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17. A patient of 24 years for 2 weeks, complaining of pain in the tongue when eating and
speaking. Objectively: the mucous membrane of the tongue on the right side of ulcer irregularly
shaped covered with necrotic plaque. The edges of the ulcer hyperemic, painful on palpation.
46.47 crowns destroyed. What are the priority actions of the dentist?
A. Use keratoplastyc medications
B. Use of anti-inflammatory medications
C. Elimination of traumatic factors
D. Surgical treatment
E. Pain control of the lesion
8. A woman 65 years old, which made full denture on the lower jaw, complained of a burning
sensation, swelling of the mucous membrane. Previously, the patient used plate denture
prosthesis made of plastic. Objectively: the mucous membrane of the alveolar process of the
lower jaw, lips, cheeks, tongue-plated hyperemia. There is edema of the lower lip. What is the
most likely diagnosis?
A. Stevens-Johnson syndrome
B. Traumatic prosthetic stomatitis
C. Reactions mucosal prosthesis
D. Allergic prosthetic stomatitis
E. Angioedema
9. Student 19 years complains about the roughness and dryness of the oral mucosa. Constantly,
without controlling yourself, biting on the line between the mucosa of the teeth. He suffers from
chronic cholecystitis, smokes. IH-2.3. Objectively: the mucous on the line between the teeth
loose, edematous, a whitish color. Which of the following is the leading event of the disease?
A. Xerostomia
B. Habitual biting of the oral mucosa
C. Poor oral hygiene
D. Somatic pathology
E. Smoking
10. The dentist for the painless holding a closed curettage instead of application of 10%
lidocaine mistakenly used a 10% solution of silver nitrate. Gums immediately became white,
swollen, painful. Which solution a doctor use for emergency care?
A. 50% ethyl alcohol
B. 0.5% acetic acid solution
C. 3% potassium iodide solution
D. 2% citric acid solution
E. 0.1% solution of ammonia
11. A patient 38 years old undergoing radiation therapy for cancer of the tongue. At the moment
complains of dry mouth, pain and inability to ingestion. Objectively: swelling, redness of the
mucous membrane of the mouth. On the lateral surfaces of tongue tooth imprints, on buccal and
retromolar mucosa significant erosive areas covered necrotic coating surface. What is the
pathological condition has evolved?
A. Necrotizing ulcerative stomatitis
B. Vincent's disease
C. Oral candidiasis
D. Membranous radiomukozit
E. Agranulocytosis

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12. Patient 55 y.o. complains of pain in the mouth associated with mucosal burns ammonia.
What is the solution neutralizes ammonia solution?
A. 0.5% solution of acetic acid or citric acid
B. Oil of rose hips
C. A solution of sodium chloride 3%
D. 50% ethyl alcohol
E. Lugol's solution
13. During impregnation of the root canal of the tooth 46 as a result of inaccurate actions doctor
silver nitrate solution came to the mucosa in the region of said teeth. Which solution should be
applied to reduce the suction and prevent burns?
A. 0.5% hydrochloric acid solution
B. 0.1% citric acid
C. 1% solution of ammonia
D. 50% ethyl alcohol
E. 2-3% sodium chloride solution
14. The patient is 58 years old complained of a metallic taste in the mouth and burning tongue.
Objectively: dental defects observed in both jaws. On the defects found are made soldered
bridges. What additional research is needed to for clarification of diagnosis?
A. Oklyuziografiya
B. Galvanometiya
S. Gnathodynamometiya
D. Electromyographiya
E. Mastikaciografiya

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