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UDC 616.311-002-07-08
THE STRUCTURE, DIAGNOSIS, CLINICAL FEATURES OF ORAL MUCOSA DISEASES AND MODERN TECHNOLOGIES OF COMBINATION THERAPY
Altai State Medical University, Barnaul S.N. Tokmakova, O.V. Bondarenko, T.N. Ulko
Altai Krai and Barnaul witness the diversity of the structure of the oral mucosal diseases. The growth of appealability of such patients is largely due to the increase of patients' and dentists' awareness of the new methods of diagnostics and treatment. The implementation of modern screening fluorescence allows to conduct prenosological diagnostics contributing to the prevention of the oral mucosal diseases, including precancerous ones. The effectiveness of the suggested methods of treatment is scientifically proved, the described methods are recommended for the implementation in common practice. Key words: dentistry, oral mucosal diseases, diagnostics, screening fluorescence.
The problem of early diagnosis and treatment of oral mucosa (OM) diseases is urgent today because of their high degree of incidence and the variety of clinical signs. The effectiveness of medical care depends on early and accurate diagnosis, followed by appropriate treatment. During medical examination the correct diagnosis is made only in one third of patients [1] and it happens because of complicated symptoms and potential paucisymptomatic course of the disease. Delayed and inadequate dental care can lead to complications including malignant transformation. Therapeutic approach depends on the type of pathological process, on its duration, on the immune state, on microbiocenosis, on the effectiveness of earlier provided conservative treatment.
In Barnaul and Altai Krai OM diseases patients seek treatment in various medical institutions where dentists perform diagnosis and provide treatment for this pathological process. However, complete examination and combination therapy of difficult patients are not always available in the workplace that is why when the diagnosis is complicated and the provided treatment is not effective these patients are sent to ASMU Department of Conservative Dentistry.
The aim of this study is to analyze the structure and clinical features of oral mucosa diseases in patients who sought medical help at the Department for the period from 1992 to 2016.
During our study we performed statistical analysis of archive materials of 2246 patients in Barnaul and Altai Krai. Due to medical consultations being computerized and OM pathological processes being photographed it became possible to create an outpatient medical records data base and to trace the course of those diseases before and after the course of treatment.
The patients underwent complete examination that included medical history intake, skin examination, palpation of the lymph nodes, the oral mucosa, the tongue and the lips according
to the WHO recommendations, examination of hard tooth tissues and the periodontium and also fluorescent screening test for premalignant lesions. When necessary, the patients underwent laboratory testing of the blood, immunoassay (serodiagnosis, EIA), mouth liquid analysis (amount, viscosity, pH-metry), microbiological analysis of oral smears with qualitative and quantitative assessment of oral microflora including Candida fungi and with antibiotic sensitivity assessment. In patients with metal dental prostheses we measured galvanic currents, assessed acceptability of dental materials by the Voll method and performed X-ray imaging. All patients went through the supervised oral hygiene instruction and tongue hygiene instruction (cleaning the tongue with a scraper), through the oral cavity sanation, through the removal of OM traumatic agents and got recommendations for the replacement of dissimiliar metal prostheses and for sustainable prosthetics. Detailed examination of patients with somatic pathology was performed together with physicians. During medical consultations doctors showed infectious and oncological alertness in order to prevent various serious complications.
Due to the results of our study received during the medical consultations we brought structure into the OM diseases group. It was found that the most common diseases included stomatodynia (32%) and oral candidiasis (21%). Lichen planus was diagnosed in 13% of cases, leukoplakia - in 11% of patients. Less often we registered different forms of cheilitis (4%) and glossitis (3%), chronic recurrent aphthous stomatitis (2%) and neoplasms (2%). In rare cases erythema multiforme, vesicular fever, herpes, permanent injury, haemangioma, syphilis, neurostomatological diseases, Sjorgen's syndrome and OM visual symptoms of haemopathy took place. It should be noted that the number of OM diseases patients increased by 3-4 times in recent years in comparison with the beginning of the study.
During the specified period we provided treatment to 753 stomatodynia patients (K14.6) at the age from 40 to 80 years old. The differential diagnosis of this pathological process included allergic and inflammatory disorders, tongue neoplasms and also some disorders with similar symptoms (trigeminal and glossopharyngeal neuropathy, trigeminal neuralgia, anaemia, Sjorgen's syndrome, Costen's syndrome, galvanic syndrome, oral candidiasis). 10 % of stomatodynia patients had a long-term medical history (more than 10-15 years). The major part of the patients (89%) lacked oral cavity sanation, chronic periodontitis was diagnosed in more than a half of all cases (59%), poor oral hygiene was present in 68% of stomatodynia patients. Besides, 72% of the patients had improper dental prosthetics (DMF index=23.4+0.05 with D=1.4+0.07; M=16.4+0.05; F=5.6+0.04) and temporomandibular joint dysfunction (9%). The primary disease was often complicated by oral candidiasis. As for visceral disorders, the following were diagnosed: chronic atrophic gastritis (86%), cardiovascular diseases (54%) and endocrine diseases (8%): thyroid pathology, diabetes mellitus. Nervous system disorders (69%) were represented by cerebrovascular pathology, osteochondrosis of the cervical spine, diabetic polyneuropathy, nervous system functional disorders (51%) with various psychopathological syndromes (asthenic syndrome, cancerophobia and Candida phobia). Disease recurrence (after 5-10 years) in partially and completely edentulous patients was usually associated with the prosthesis defunctionalization and the need for its remaking.
During the course of combination therapy patients were provided with pharmacological therapy (antidepressants, benzodiazepines, antihistamines, vitamins, analgesics, vasoactive drugs and vegetotropic drugs), physiotherapy (acupuncture therapy, laser therapy, psychotherapy) and hirudotherapy. Taking into consideration intractable pain syndrome in these patients, frequent disease recurrence and possibility of restrictions for pharmacological therapy and physiotherapy we developed and successfully put into practice the method of including cryoanesthesia into stomatodynia combination therapy (patent No 2202329) [3]. Cryotherapy was performed with autonomous porous applicators made from titanium nickelide and considered applying liquid nitrogen in nondestructive dose on OM and biologically active zones of the head, neck and upper limbs 6-8 times during the course [3].
Oral candidiasis ^37.0) was diagnosed in 563 patients. General treatment was prescribed according to antifungal susceptibility (nystatin, amphotericin, clotrimazole, fluconazole, intraconazole, ketoconazole). In the majority
of cases two weeks after the course of therapy microbiological testing confirmed that Candida fungi were absent or their concentration became less than 101 CFU. In the case of dysbacteriosis probiotics stimulating normal microflora were additionally prescribed (Bifiform, Linex, Biovestin-lacto, Hylak forte and others). To correct tissue immunity and to prevent disease recurrence Imudon or Licopid were prescribed.
OM leukoplakia (03.2) and OM lichen planus (L43) were mainly represented by erosive-ulcerative forms and were treated by Diprospan injections under erosive defects, by application of multicomponent ointment consisting of anesthetics, antiseptics and keratoplastic drugs that was developed in Moscow State University of Medicine and Dentistry. When conservative treatment of lichen planus erosive-ulcerative and hyperkeratotic forms and leukoplakia verrucous and erosive-ulcerative forms (which are potential precancerous conditions) was not effective we used the method of liquid nitrogen cryodestruction with autonomous porous applicators made from titanium nickelide which were adapted for OM (we used this method after medical consultation with an oncologist). In order to freeze the tissues more deeply and to increase the cryogenic effect we injected 0.5 ml of nicotinic acid solution under the oral mucosa 30 minutes before the procedure of cryodestruction [2]. To reduce inflammation, to prevent secondary infections and to stimulate post-procedural regeneration we applied standardized ozonized oil on the cryotherapy spot [5].
We used combination therapy in chronic recurrent aphthous stomatitis (M2.0) patients. Alongside with the prescription of desensitizing, sedating, immunocorrecting drugs and vitamins in order to provide quick and persistent anaesthesia of aphthae and to hasten recovery we used the method of one-shot aphthae cryodestruction for 10-20 seconds (patent No 2340305) which was developed at our Depatment [4].
In herpetic stomatitis ^00.2) patients we applied cryotherapy on affected area of the OM, lips, face skin with porous titanium nickelide applicators of different configurations depending on the rash area with the following application of antiviral drugs on erosions. Cryotherapy was especially effective during the prodromal period of herpetic stomatitis because it prevented the formation of blisters.
In the course of combination therapy of OM inflammatory diseases we widely used physiotherapeutic methods: helium-neon laser therapy (laser Optodan), Piler light therapy (Bioptron) and others.
Thus, there is a multifarious structure of oral mucosa diseases in Barnaul and Altai Krai. The growth of incidence of patient visits can be explained by patients' and dentists' awareness
of new diagnostic and therapeutic methods provided by our Department. Modern fluorescent screening test allows us to perform prenosological diagnostics contributing to the prevention of oral mucosa diseases including precancerous conditions. The effectiveness of the suggested methods of therapy is scientifically based and the methods are recommended to be introduced into clinical practice.
References:
1. Anisimova I.V., Nedoseko V.B., Lomiashvili L.M. Klinika, diagnostika i lecheniye zabolevany SOPR i KKG. M., Med. Kniga; 2008.
2. Bondarenko O.V., Sysoeva O.V., Tokmakova S.I., Lepilov A.V., Popov V.A., Belousov Yu.N., Marakulina I.L. Morphological Changes in Tissues of the Oral Mucosa with Cryodestruction in Conjunction with the Angioprotectic and Haemostatic Medication. Meditsinskaya nauka i obrasovaniye Ural. 2013; 2 (74): 56-60.
3. Ulko T.N., Tokmakova S.I., Tibekina L.M. Glossodynia Treatment Method. Patent US 2202329. April, 2003.
4. Starokozheva L.Yu., Tokmakova S.I., Ulko T.N., Gyunter V.E., Ivanov A.N. Chronic Recurrent Aphthous Stomatitis Treatment Method. Patent US 2340305. December 10, 2008.
5. Tokmakova S.I., Bondarenko O.V., Zyablitskaya K.V. Comparative Evaluation of Efficacy of Cryosurgery and Local Ozone Therapy in the Treatment of Patients with Leukoplakia of the Oral Mucous Membrane. Zhurnal nauchnykh statei Zdorovie i obrazovaniye v XXI veke. 2016; 18 (8): 26-30.
Contacts:
656038, Barnaul, Lenina Prospect, 40.
Altai State Medical University.
Tel.: (3852) 471695.
Email: agmuterst@mail.ru
