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13"BicnuK стоматологИ", № 4, 2017
L
НА ДОПОМОГУ ПРАКТИКУЮЧОМУ Л1КАРЕВ1
УДК 616.31-07-08:614.253.2-055
G. G. Boyko, CMS, V. I. Fesenko CMS
Dnipropetrovsk Medical Academy of the Ministry of Health of Ukraine
DIAGNOSIS AND TREATMENT OF DENTAL DISEASES, MOST COMMON IN THE PRACTICE OF A FAMILY DOCTOR
ABSTRACT
The multidisciplinary training of the family doctor includes extremely important issues of diagnosis and treatment of diseases of the mucous membranes of the oral cavity, especially those that may eventually transform into malignant neoplasms.
Due to the reforms in the health care system of Ukraine, diagnosis of diseases and medical and preventive measures at the stage of ambulatory and polyclinic care are important. In the primary care posts and especially in health facilities located in rural areas, the role of family doctor becomes more and more important for medical care improvement. The main goal of his work is to provide continuous and qualified primary health care to every person, regardless of age, gender, family status. These factors determine the need for multi-disciplinary family physician training, including on the diagnosis and tactics of treating patients who complains about the manifestations of the diseases in the oral cavity. However, it should be noted that in the training programs for family doctor preparation there is not enough time allocated for the study of diseases of oral mucous membrane and jaw-frontal area.
In our work, we focus on dental disease that is most common in the practice of family doctor. Key words: diseases, mucous membranes of the oral cavity, practice of family doctor.
Г. Г. Бойко, В. I. Фесенко
Дншропетровська медична академш Мшютерства охорони здоров'я Украши
Д1АГНОСТИКА ТА Л1КУВАННЯ СТОМАТОЛОГ1ЧНИХ ЗАХВОРЮВАНЬ, НАЙБ1ЛЬШ РОЗПОВСЮДЖЕНИХ В ПРАКТИЦ1 С1МЕЙНОГО Л1КАРЯ
Для багатопрофшьно'1 пiдготовки амейного лкаря надзвичайно важливим е питання diazHocmuKU та лi-кування захворювань слизово'1' оболонки рота, особливо mi, що можуть з часом трансформуватись в злоя-ксш новоутворення.
В зв'язку з реформуванням в cucmемi охорони здоров 'я Украти важливого значення набувають дiaгнo-стика захворювань та л^вально-профтактичш заходи на етат амбулаторно - пoлiклiнiчнoi допомоги. В умовах первинно'1' ланки та особливо в закладах охорони здоров 'я, розташованих у сшьськй мicцевocmi
для покращення медичног' допомоги зростае роль ci-мейного лкаря. Головною метою роботи якого е за-безпечення безперервно'1' та квалiфiковано'i первинно'1' медико-сантарноЧ допомоги кожнт людинi, незале-жно eid eiKy, cтаттi, амейного стану. Дат чинники обумовлюють необхiднicть багатопро-фiльноi пiдготовки амейного лкаря, в тому чиcm i з питань дiагноcтики та тактики ведення хворих, як звертаються 3i скаргами на прояви захворювань в ротовт порожнинi. Слiд зауважити, що в учбових программах по пiдготовцi Амейного лкаря недостат-ньо видшяеться годин для вивчення хвороб слизово'1' оболонки порожнини рота (СОПР) та передратв ще-лепно-лицево'1' дшянки.
В нашш роботi ми звертаемо увагу на cтоматологi-чнi захворювання, як найбшьш поширеш в практиц амейного лкаря.
Ключов1 слова: захворювання, слизова оболонка рота, амейний лжар.
Г. Г. Бойко, В. И. Фесенко
Днепропетровская медицинская академия
Министерства здравоохранения Украины
ДИАГНОСТИКА И ЛЕЧЕНИЕ СТОМАТОЛОГИЧЕСКИХ ЗАБОЛЕВАНИЙ, НАИБОЛЕЕ РАСПРОСТРАНЕННЫХ В ПРАКТИКЕ СЕМЕЙНОГО ДОКТОРА
Для многопрофильной подготовки семейного врача чрезвычайно важным является вопрос диагностики и лечения заболеваний слизистой оболочки рта, особенно те, которые могут со временем трансформироваться в злокачественные новообразования. В связи с реформированием в системе здравоохранения Украины, большое значение обретают диагностика заболеваний и лечебно-профилактические мероприятия на этапе амбулаторно-поликлинической помощи. В условиях первичного звена, особенно в учреждениях здравоохранения, расположенных в сельской местности, для улучшения медицинской помощи, возрастает роль семейного врача. Главной целью которого, является обеспечение непрерывной и квалифицированной первичной медико-санитарной помощи каждому человеку, не зависимо от возраста, пола, семейного положения.
Данные факторы обуславливают необходимость многопрофильной подготовки семейного врача, в том числе и по вопросам диагностики и тактики ведения больных, которые обращаются с жалобами на проявления заболеваний в полости рта. Следует заметить, что в учебных программах по подготовке семейного врача недостаточно выделяется часов для изучения заболеваний слизистой оболочки полости рта (СОПР) и предраков челюстно-лицевой области. В нашей работе мы обращаем внимание на стоматологические заболевания, которые наиболее распространены в практике семейного врача.
© Boyko G.G., Fesenko V.I. ,2017.
"BicHUK стоматологи", № 4, 2017
Ключевые слова: заболевания, слизистая оболочка рта, семейный врач.
Precancer of maxillofacial area. An important part of modern medical science and practice is the disease of oral mucosa and lips. Under constant influence of external and internal factors, oral mucosa and red lining of the lips are the place of manifestations of various kinds of diseases, including oncological ones.
Diagnosis and treatment of oncological diseases in the early stages in patients presents some difficulties, since tumours of the maxillofacial area differ both in the large heterogeneity of the morphological structure and in clinical manifestations, and at present nobody has any doubts about the relationship between the majority of pathological processes in oral mucosa with diseases of various organs, violation of metabolic processes, activity of the nervous system, changes in immune status, etc.
Cancer development is a process that is prolonged and often is predisposed with precancerous conditions.
The study of precancerous diseases is one of the most urgent problems in medical prophylaxis.
And as often happens with diseases that are on the border of several specialties, the pathogenesis of oral mucosa is not always paid sufficient attention by both dentists and doctors of other specialties. The term "precancer" has been described for the first time in Dubreuilh's works, and he defines changes that may lead, but not necessarily lead to cancer.
In broad terms, the term "precancerous" implies all chronic processes, benign neoplasms, and others; in the narrow sense the notion "precancer" is a specific change in the epithelium: a violation of the processes of keratinization by the hyper type and dyskeratosis, atypical keratinization, loss of ties between adjacent cells and their nuclei, an atypical growth of the immature epithelium with an inclination to infiltration growth, but even without tissue destruction.
Factors that provoke the development of the precancer:
- heredity, age, mechanical trauma (substandard dentures, sharp edges of teeth, seals, dental deposits, etc.), thermal effects, tobacco, chronic alcoholism Vitamin A avitaminosis, radiation exposure, diseases of the gastrointestinal tract, accompanied with changes in oral mucosa.
There are two types of precancer: optional and obligatory
Optional precancerous lesions of the first group are those that can be treated conservatively:
- flat leukoplakia;
- chronic ulcers of oral mucosa;
- chronic cracked lips;
- erosive - ulcerative and hyperkeratotic forms of lupus erythematosus and lichen ruber planus;
Optional precancerous lesions of the second group are those that are more likely to malignancy and require immediate surgical intervention:
- The veracious and erosive forms of leu-koplakia;
- cutaneus horn;
- keratoacanthoma;
- papilloma and papillomatosis of the palate.
Obligatory precancerous lesions are those
forms of the precancer, which sooner or later turn into cancer and require radical intervention:
- pigmented dermatoxerasia;
- Bowen's disease;
- Manganotti's Cheilitis;
- wartlike (nodular) precancer;
- precancerous hyperkeratosis;
- chronic ulcers that do not heal after removing the irritant.
The main requirements for a family doctor - it is not necessary to accurately establish the diagnosis of the pathological process, but in due time pay attention to deviation from the norm and send the patient to a specialist for consultation, that is to show oncological alertness for this it is necessary to know the classification of precancerous processes, their clinical implications, as well to know the methods of objective examination.
During the examination of patients, a physician should pay attention to any changes in the oral mucosa and the red border of the lips, to determine which diseases the patient experienced in his life, the state of his nervous system, the nature and working conditions. It is very important that a family doctor, in addition to complaints, carried out a complete overview of the skin, tissues of the oral cavity, tongue, with the obligatory palpation of soft tissues and lymph nodes. Pay attention to the deviation from normal color, the presence of hyperkeratosis, erosions, ulcers, the consistency of these changes, the painful areas of damage, relationship with adjacent tissues.
It is important to remember the signs of the transformation of precancerous changes in cancer: the appearance of areas of bleeding on the surface of the tumor, growth of scales, increased hyperkerato-sis, the appearance of ulcers, compaction of the site of injury, and others. It is necessary to pay attention to the condition of the lymph nodes, their density, shape, crests, cohesion with the surrounding tissues, mobility, pain, etc.
Such precancerous diseases as leukoplakia is the most commonly encountered in the practice: -keratinization site of oral mucosa, which occurs in response to mechanical stimulation, accompanied by
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inflammation of the stroma. The veracious form of this disease has a potential for malignancy: it is distinguished by more pronounced signs of keratiniza-tion and hyperplasia, the lesions are protruding above the surrounding tissues, dense in palpation, and have an intense grayish-white colour.
Sometimes there are ulcers, cracks or erosions on its surface, sometimes tight-bubbling that is localized on cheek mucosa, at the corner of the mouth, where it can be traumatized by the sharp edges of the teeth. Signs of malignancy: density of the edge of the lesion area, bleeding of its surface, papilla enlargement, after removing the irritator does not disappear. It is necessary to differentiate with such diseases as candidiasis, lichen ruber planus, lupus erythematosus, etc.
Cutaneus horn. An area of limited hyperplasia of the epithelium with significant hyperkeratosis in the form of a horny protuberance. It is localized on the face of the skin or in the area of the lower lip, etc. Dimensions from 0.5 cm to 4 cm, dirty gray colour, dense consistency, conjugate with subordinate tissues. In case of malignancy - induration with subordinate tissues, inflammation around the lesions. Treatment is surgical.
Keratoacanthoma. A globular nodule in the open part of face, of grayish-red colour, dense, having in the centre funnel-like depression, filled with easily removable horny masses, mobile, not condensed with subordinate tissues, can disappear by itself.
Wartlike or nodular precancer. It is localized more often on the mucosa of the lower lip, represents a limited area of hyperkeratosis, the surface of which is covered with densely located scales of grayish-white color. The foci can develop on the background of inflammation of the mucous membrane of the lips. Needs surgical treatment.
Pigmented dermatoxerasia is a type of disease, which includes congenital hereditary skin dystrophy - high sensitivity of the skin to sun exposure. In childhood - solar dermatitis (redness, peeling, dry skin), later there are atrophic spots - localized pigmentation, erythema, hyperkeratosis, cracks, wart growth. These changes have a tendency to transition to basal cell and squamous cell carcinoma, sometimes melanoma develops. Patients are observed and treated in an oncology dispensary.
Bowen's Disease. Localized, slowly enlarged, spotted nodal formation with a stagnant-red surface or covered with papillary enlargement, in case of fo-cis fusion a plaque is formed.
Clinic picture of the disease is sometimes not distinguished from leukoplakia or lichen ruber planus. At the beginning of the development of lesions on the skin - spotty-vulcanic focis, covered with scales or crust, with their fusion a plaque is
formed of yellowish-red colour or wart formation. Eczema-like type is characterized by a damp surface. Treatment is surgical.
Manganotti's Cheilitis. The disease, which is characterized by appearance on the red border of the lips of erosion oval with a smooth, like a polished surface of a rich red colour. On the surface of erosion, sometimes there are pebbles, which periodically disappear, then appear again, especially in spring. When removing the crust, the surface of erosion bleeds. The appearance of density in and around the centre of the cell, bleeding and enlargement of the papillae provides grounds for confirming the transformation into cancer.
For a family doctor, as well as for a dentist, it's important to keep in mind that any new tumour treatment should only be done depending on the results of the research: there is no need to use the anticipatory tactic (1-2 weeks) and conservative treatment, instead of surgical intervention.
Acute herpetic stomatitis. Acute herpetic stomatitis (AHS) holds a leading place among oral mucosa diseases. AHS is an acute infectious viral disease observed in children aged 1 to 3-5 years. Localization of the lesion is mucoa of the lips, tongue, cheeks, gums, red rim of the lips.
AHS has five developmental stages: prodromal, catarrhal, period of rash of lesion elements, period of extinction and clinical recovery.
There are three stages of its severity: light, medium and grave form.
The incubation period of the AHS lasts about 67 days. The disease begins acutely: body temperature from 37.5 to 39-40°C; phenomena of intoxication (the child refuses to eat, sleeps poorly, dyspepsia phenomena are possible); regional lymph nodes are enlarged and painful (their reaction precedes rash in the oral cavity). The symptoms during the 24-48 hours are supplemented with pain in the oral cavity, which increases during the conversation and intake of food. During the examination, multiple sclerosis bubbles filled with a clear liquid appear on the oral mucosa, which subsequently burst and erosions of round or ovoid form to 1 - 5 mm in diameter are formed in their place. Erosion is extremely painful, covered with yellowish-gray bloom. On the red border of the lips and skin there are multiple bubbles (may merge) with clear or hemorrhagic (in severe form) contents, burst with the formation of erosions covered with a crust.
Radical treatment of AHS is aimed at epitheli-zation of the elements oral mucosa lesion and normalization of indicators of body defences.
General treatment includes:
1. Antiviral therapy (drugs of choice): prescribed in the first 5-7 days of the disease - acyclovir (virolex) - to 0.2-0.8 g 4-5 times a day, zovi-
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rax-1 tablet 5 times a day, remantadine - 0.05 3 times a day for 5-10 days, arbidol -200 mg 4 times a day, valtrex (valciclovir) 500 mg twice a day, flavazid according to age-related doses of the basic treatment scheme, vifron-feron in the form of a suppository in the age-old dose 1 time per day, gency-clovir, famciclovir 250 mg 2 times a day, etc.
2. Disinfection therapy - the use of a significant amount of liquid (mineral water, juices, dogrose decoction) and enterosorbents).
3. Hyposensitizers - tavegil (syrup): for children from 3 to 6 years - 5 ml 2 times a day, supras-tin - in the age-old dose 2-3 times a day, fencholol -for children from 3 to 7 years - 0.01 g 2 times a day (after meal), tsetrin - 1 tablet 1 time per day, di-medrol - 0.05 to 1 tablet 2 times a day, calcium gluconate - 0.5 g 3 times a day.
4. Vitamin therapy - ascorutin 0.05 g 3-4 times a day, ascorbic acid 0.05-0.1 g 2-3 times a day, mul-titabs, etc.
5. To correct the state of the immune system -imudon - tabl. for resorption up to 8 times a day, sodium nucleate, metacillum, pentoxyl 0.25 - 3 times daily, immunal 5-25 drops 3 times a day for 3 weeks, isoprinosine - 2 tab. 3-4 times a day, amixin, gosipol, and others.
6. Pain reliever, antipyretic and anti-inflammatory drugs - paracetamol for children aged 2-5 years by 0.1-1.15 g 2-3 times a day, children's panadol - suspension, mephenamic acid in 3-4 tables per day, sodium salicylate by 1 pill 4 times a day.
7. Diet. Fermented milk products (cheese, kefir), boiled eggs, fresh vegetable broths, meat and fish broths, mashed vegetables and fruits are recommended.
Local therapy includes:
1. Anaesthetics - Applying 1-2 % solution of trimecaine, pyromycin, lidocaine, 0.1-0.5 % ethony, cholizal for 15-20 min. etc.
2. Antiseptics for irrigation of the oral cavity -1% solution of potassium permanganate - 1 %, 5 % anesthetic emulsion, furatsilin (dilution 1: 5000), 1% solution of copper sulfate (diluted to 0.25 % solution), hydroalcohol according to instructions, 1 % solution of sanguviritrin, 0.5 % mefenamin acid and others.
3. Enzyme preparations - 1-2 % solution of chymotrypsin, trypsin for cleaning erosions from ne-crotic tissues, lysozyme, lysobakt.
4. Antiviral agents are prescribed in the first 5-7 days in the form of application of solutions or ointments for 20 minutes 3-7 times a day, leukocyte interferon (solution, or 30-50 % ointment), aqueous solution of human leukocyte interferon for digestion in the nasal or oral cavity 3-5 drops a day after meals. Interferon ointment can be prepared "ex tempore" (for 100.0 anaesthetic 3 % ointment add pow-
der of 4 ampoules of interferon, ointment of choice -5% acyclovir, 3% zovirax, 0.5% florenalum, 3% gossipol, 1% bonaphton, 0.25% oxolin and 0.250.5% rhododendron ointments.
5. From the 4th day, epithelizing preparations are used as an application for erosion - an oilseed solution of vitamins A and E, rosehip oil, 1% citral solution, retinol, caratolin, solcozeryl (gel, ointment, dental adhesive paste), aloe juice and kalanchoe juice and others.
6. For treatment of the lesions elements on the skin and the red border of the lips aniline dyes are used - 1-2 % alcoholic solution of brilliant green, 12 % aqueous solution of methylene blue.
In the treatment of AHS, pediatricians, immu-nologists, neuropathologists and other specialists should take an active part together with a dentist.
Chronic recurrent aphthous stomatitis. The most common oral mucosa disease (up to 20 %) is chronic recurrent aphthous stomatitis (CRAS). The disease is characterized by a recurrent rash of aph-taes (aphta in Greek - an ulcer), a prolonged period with periodic exacerbation which occurs in the age of 20-40 years. It's etiological factors are as follows: infectious allergy (mainly to the herpes simplex virus or cytomegalovirus, bacterial antigens); diseases of the digestion system organs and blood (in particular, in case of neutropenia, the so-called neutropenic aphtaes are developed); immune and neurotoxic disorders; genetic conditionality and the impact of various harmful factors, including industrial ones; idio-pathic nature of the disease. It should be noted that aphthous lesions of oral mucosa, which often occur and have a long run, may be associated with HIV infection.
Manifestations of the disease are noted more often in the anterior sections of the oral cavity (on the lips mucosa, transient fold, under the tongue, on the bridle).
Depending on the number of relapses during the year and the level of violations of the general condition, there are three stages: an easy one - single affects occur 1-2 times in 2-3 years; moderate severity - aphtaes occur several times a year; severe form -continuous relapse. Remixes can last from a few months, even years to several days.
Complaints of patients of the presence of one -two sharply painful ulcers on oral mucosa. The general condition is practically not changed, sometimes the appearance of aphtaes is accompanied by lymphadenitis, an increase in body temperature. Objectively, one can observe aphtaes sized 5-10 mm, of round-oval shape, surrounded by a narrow rim of hyperemia of a bright red colour, covered with a grayish-white fibrinous bloom. Aphtaes are sharply painful at touch, soft when palpated. Sometimes, a few days before aphta appearance, patients experi-
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ence heartburn or pain at the site of future changes.
The disease is diagnosed on the basis of: anamnesis data; clinical manifestations, the result of cyto-logical study of the material taken from the aphtaes surface (manifestation of non-specific inflammation); detection of high antibody titre for herpes simplex virus and cytomegalovirus.
Treatment. When herpes simplex virus or cy-tomegalovirus are found in the saliva, the following drugs are prescribed: antiviral drugs - acyclovir or valtrex 1 g per day from 5-8 days to several months; anti-herpetic immunoglobulin 3 ml / m 2 times a week - 5 injections; inductors of interferon - po-ludan, cycloferon, dibazole; immunomodulators - T - activin, ergosol, decaris, lycopod; antihistamines.
Local treatment includes: Solcaseril dental adhesive paste; applying analgesics (before eating, sleeping) - lidocaine, trimecain, holisal; antiseptic drugs; proteolytic enzymes (trypsin, chemopsin) -for clearing the surface of aphtaes from necrotic plaque; stimulators of local immunity - imudon (2 tablets 3 times a day (for resorption under the tongue) - for 20 days; vitamin therapy - vitamins of group B, ascorbic and nicotinic acid (in therapeutic doses); ionophoresis with heparin (3-5 procedures) ; far ultraviolet irradiation of lesions (5-6 sessions); laser therapy - a helium-neon laser (with torpidity to epithelial therapy), enterosorbents are prescribed, enterosorption, hemosorption, plasmapheresis are carried out. To accelerate the epithelization, lizot-sium trays are used. Pay attention to compliance with the appropriate diet with the exception of spicy foods. Treatment of patients with CRAS should include an expanded clinical and immunological study to identify the associated common diseases of the internal organs and systems, foci of chronic infection and its sanation.
Candidiasis. Fungal lesions of oral mucosa is a disease that is caused by saprophyte fungi of the oral cavity. Depending on the name of the causative fungus, the diseases caused by them, received the corresponding names: candidiasis, actinomycosis, etc. Among the mycoses in the cavity of the mouth, can-didiasis is most commonly encountered - a disease caused by Candida fungi on the background of an immunodeficiency.
In practice, domestic dentists use the classification of oral mucosa candidiasis, which distinguishes the clinical forms - acute course: pseudomembra-nous candidiasis (thrush), atrophic candidiasis; -chronic course: hyperplastic and atrophic (more often under removable plate prostheses) candidiasis.
Among the symptoms of oral candidiasis the following should be distinguished: heartburn and dryness of mucosa, pain when consuming irritating food, appearance of cracks in the corners of the mouth.
The main clinical feature common to all forms of candidiasis is the sore-like plaque of grayish-white or brown colour, which is scattered throughout the oral cavity in the form of individual areas, or is lumped in the folds of the transfused mucosa (atro-phic forms) or in the form of white plaques, over its surface (hyperplastic candidiasis).
The diagnosis is based on the detected fungal cultures, with microscopic examination of the plaque content taken on an empty stomach: in the field of view of the drug, there is a large number of cells or pseudomycelium of the Candida fungus. It should be noted that when clinics of acute candidiasis are found in young people who consider themselves healthy, an examination must be conducted to exclude HIV infection (candidiasis is an "indicator" disease in HIV-infected patients) and to exclude diabetes mellitus (often oral candidiasis is the first symptom of this disease).
Integrated therapy of oral mucosa candidiasis provides for the elimination of clinical and bacteriological signs of the disease and prevention of relapse of the disease.
General treatment includes: - treatment simultaneously with doctors of other specialties:
- prescription of antimycotics: azole group, anti-fungal antibiotics. In the medical complex, taking into account the sensitivity of the microbial flora of the oral cavity, antifungal drugs of systemic and local action shall be prescribed. In the absence of the possibility of obtaining sensitivity data in a specialized laboratory tank, ntimycotics of systemic action may serve as a preparation of choice. Such are nystatin and levorin in therapeutic doses for 10-14 days, as well as 7 days after the disappearance of clinical manifestations, pimafucin 1-2 tablets 2-4 times a day-10 days, itraconazole 100 - 200 mg per day, ke-toxone 200 mg 2 times a day from 1 to 4 weeks, flu-conazole 100 mg daily for 1-2 weeks, diflucan 50, 100 or 150 mg daily depending on the severity of fungal damage, for 10 -14 days.
- use of immunotropic drugs: in combined and generalized forms, as well as in immunodeficiency states (imudon, cycloferon, sodium nukiinat, poly-oxidonium, etc.);
- Correction of intestinal flora composition (bio-sporin, chilak, lactobacterin, biform); -giposensibilizing therapy (suprastin, fenkarol, lora-todin, etc.);
- hepatoprotectors on indications and general restorative preparations (vitamins of groups B and C in medical doses).
- Diet.
Local treatment involves: - strict adherence to the rules of oral hygiene, normalization of pH of the oral liquid - the use of alkaline compounds for the rinsing and treatment of oral mucosa: 2-4 % aqueous
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solution of borax, soda, 2 % boric acid solution, borax in glycerol (1:5), 20% sodium tetraborate; Aniline dyes - 1-2 % alcoholic solution of brilliant green (for angular chilitis processing), 1-2 % aqueous solution of methylene blue; iodine preparations -0.1 % aqueous iodinol solution, Lugol solution; drugs with antifungal effects - stomatite, myram-istin, fungicone, sporanox, mycosatin, antifungal ointment 0.25-0.5 % riodoksol, miramistin, 0.5-1 % decaminol, 1% clotrimazolum and nystatin, 5 % levorin, 0.15 % mikoheptin, gels - miconazole, pan-soral and creams - pemafucin, lamizyl, nizoral, kanesthen - gel or ointment 2-3 times a day within 1-2 weeks; antiseptics - 0.02-0.05 % solution of chlorhexidine, corsodil, givelux according to instructions, complex preparation - traxysan, which also shows analgesic effect, septyfril, 0.5 % etonium solution, buccal gel dactarin (2 %), decatylene, preparations of plant origin - sanguviritrin, stomatophyte, stomatophyte A, ephysole; immunomodulators (imudon, lysobakt).
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The article was received 28.11.17
