Vincent’s Ulcerative Necrotic Stomatitis

What is Vincent’s Ulcerative Necrotic Stomatitis?

Vincent’s ulcerative necrotic stomatitis (stomatitis ulceronecroticans Vincenti) is an infectious disease caused by spindle-shaped bacillus and spirochete (Borrelia) Vincent. In the world literature it is described under the following names: ulcerative stomatitis, ulcerative necrotic stomatitis, ulcerative-membranous stomatitis, fusospirochetous stomatitis, “trench mouth”, Botkin – Simanovsky – Plaut – Vincent and others.

When gums are affected, the disease is defined as Vincent’s gingivitis, while gums and other parts of the mucous membrane are affected — stomatitis, and Vincent’s tonsillitis is involved in the process of palatine tonsils.

Causes of Vincent’s Necrotic Stomatitis

The causative agents of Vincent’s ulcerative necrotic gingivostomatitis belong to the resident flora of the oral cavity and are found in small quantities in the norm in all people who have teeth, especially in the gingival groove. With poor care and a non-sanitized oral cavity, especially with periodontitis, their number increases dramatically.

Fusobacteria and Vincent’s Borrelia belong to opportunistic microorganisms. The decisive role in the occurrence of the disease plays, as a rule, a decrease in the body’s resistance to infections. It occurs especially often with general cooling due to a general illness, overwork, stress, malnutrition (for example, in wartime).

A predisposing factor is also a violation of the integrity of the mucous membrane, which creates the conditions for the invasion of microorganisms. This happens with injuries, more often chronic, for example, sharp edges of the teeth, with difficult eruption of third molars. Breakthrough of the epithelial barrier also occurs with periodontitis. Vincent’s ulcerative necrotic stomatitis occurs more often with careless hygienic care of the oral cavity against the background of previously existing inflammatory processes of the gums, with the deposition of supra- and subgingival stones, which interferes with the normal process of desquamation of the epithelium, irritates the gums and, closing the entrance to periodontal pockets, creates favorable conditions for the development of anaerobic infection.

Vincent’s ulcerative necrotic stomatitis can occur as a complication of viral infections (influenza, herpetic stomatitis), erosive allergic stomatitis, erythema multiforme exudative, some serious common diseases – leukemia, agranulocytosis, infectious mononucleosis, is attached to poisoning with heavy metal salts, mourning. Cancer ulcers and syphilis in the mouth are sometimes also complicated by fusospirochetosis.

Symptoms of Vincent’s Necrotic Stomatitis

By the nature of the course of the disease, acute, subacute, chronic ulcerative necrotic stomatitis and relapse are distinguished.

The severity of the course is mild, moderate and severe.

At the beginning of the disease appears weakness, headache, fever, aches in the joints. Concerned about bleeding gums, a burning sensation and dry mucous membrane. This period can last from several hours to several days, depending on the form of the disease.

As stomatitis progresses, general weakness intensifies, body temperature rises, headache intensifies, and work capacity decreases.

The pain in the oral cavity sharply intensifies from the slightest touch, the tongue during a conversation is inactive. Eating and brushing your teeth becomes almost impossible. Salivation increases, a strong putrid breath appears. When the inflammatory process is localized in the area of ​​the wisdom tooth, a limited opening of the mouth (trismus) occurs.

Most often, ulceration of the mucous membrane begins with the gums, from areas where local irritating factors are present: tartar, damaged teeth, dental crowns, traumatic gums. Gradually, ulceration spreads to neighboring areas of the mucous membrane.

With ulcerative necrotic stomatitis, the gums are swollen, loosened, reddened, sharply painful, bleeding from a light touch. At first, necrosis affects the tops of the interdental papillae, and then spreads to the entire gum. Over time, the gum is covered with necrotic masses of white-gray, gray-brown or gray.

For a mild form of ulcerative necrotic stomatitis, a limited distribution of the process is characteristic. Most often, only the tops of the interdental papillae in a certain group of teeth are necrotic. General well-being does not change significantly. Disability, as a rule, is not broken.

In severe Vincent stomatitis, body temperature rises to 38.5-40 ° C. The general state of health sharply worsens.
The ulceration spreads over a significant area of ​​the mucous membrane; deep into the ulcer, it can reach muscle tissue, tendons, and bones. With this course of the disease, osteomyelitis (bone melting) of the affected area of ​​the jaw bone develops.

When a ulcerative necrotic lesion spreads to the palate and tonsils, stomatitis is called the sore throat of Simanovsky-Plaut-Vincent.

Acute ulcerative necrotic stomatitis with inadequate treatment can recur and become chronic. This transition is more often observed against a background of chronic somatic pathology, as well as with an unorganized oral cavity.

Mostly young people (17-30 years old), mostly men, are affected. The disease begins more often in the fall and spring, with a maximum of new cases occurring in October – December.

There are pains in the oral cavity, especially when eating, bleeding gums, increased salivation, putrid breath, general weakness. The patient is usually pale due to severe intoxication. Regional lymph nodes are enlarged, compacted and painful on palpation, retain mobility.

The process usually begins on the gum and manifests itself in the form of foci of necrosis of the gingival margin and gingival papillae. Then necrosis can go to other parts of the mucous membrane. The region in the lower third molars is most often and severely affected, where necrosis quickly spreads to the mucous membrane of the cheek and the retromolar region, often causing trismus and pain when swallowing. In some cases, inflammation leads to pronounced asymmetry of the face due to edema of the surrounding tissues. In more severe cases, necrotic lesions occur on the lateral surfaces and back of the tongue, on a hard and soft palate. They have soft uneven edges, a thick fetid necrotic deposit of a grayish-green color, after the removal of which a friable, bleeding bottom is visible. The surrounding tissue is swollen, sharply hyperemic. There are no seals in the base and around the ulcers.

On a hard palate, the process quickly leads to necrosis of all layers of the mucous membrane and exposure of the bone. Isolated lesions of the pharynx (Vincent’s sore throat), as a rule, are one-sided and are rare in dentistry practice.

The general condition of the patient during the acute process, as a rule, worsens: the body temperature rises to 37.5 – 38 ° C in the first 2 to 3 days, but it can remain normal, headache is disturbing. Bad sleep, difficulty eating, intoxication weakens the patient. There is a tendency to fainting. In the hemogram, marked changes may be absent, but often there is a slight leukocytosis, a shift of the formula to the left, a moderate increase in ESR; in severe cases, toxigenic granularity of neutrophils.

The chronic form of this disease usually develops with careless treatment or its absence, but it can also occur primarily, without a previous acute process.

Diagnosis of Vincent’s Ulcerative Necrotic Stomatitis

The diagnosis of Vincent’s sore throat is based on the clinical picture and the detection of fusospirillar symbiosis.

Examination of biopsy samples from the edges of ulcers reveals two zones: superficial – necrotic and deep – inflammatory. In the surface layers of necrosis, the flora is plentiful and diverse (cocci, rods, fusobacteria, spirochetes, etc.), in the deeper layer adjacent to living tissues, fusospirochetes sharply prevail. The underlying tissues are in a state of acute inflammation. Inside the living tissue, only spirochetes are found.

The cytological picture of scrapings from ulcers with Vincent’s ulcerative necrotic stomatitis corresponds to a non-specific inflammatory process.

Differential diagnosis. First of all, it is necessary to exclude HIV infection. In addition, Vincent’s ulcerative necrotic stomatitis is differentiated from ulcerative lesions in blood diseases (leukemia, agranulocytosis, infectious mononucleosis), mercury poisoning, and mourning. In necrotic ulcers with these diseases, fusospirochetes in large quantities are also found. Rashes with secondary syphilis in the oral cavity can be secondary complicated by Vincent’s stomatitis. In order to avoid possible errors, in all cases of ulcerative gingivitis and stomatitis, an anamnesis should be carefully collected, taking into account not only local, but also general clinical manifestations, a general clinical blood test, analysis for HIV infection, Wasserman reaction, and if contact with mercury is detected – urine analysis for mercury. As mentioned above, fusospirochetosis can complicate the course of other ulcers (for example, decaying cancer of the oral mucosa). Therefore, the cytological method of research is of great importance in differential diagnosis.

Treatment of Vincent’s Necrotic Stomatitis

An important condition for successful treatment is a thorough sanitation of the oral cavity. After anesthesia, the decay of necrotic tissues, dental deposits are removed. The use of broad-spectrum antibiotics contributes to a quick cure. Frequent (4 – 5 times a day) rinsing with antiseptic solutions (0.05 – 0.1% chlorhexidine solution, 1 – 2% hydrogen peroxide solution) is necessary. A good effect is achieved by the use of Trichopolum 0.5 g 2 times a day for 5 to 7 days. To suppress microbial sensitization, antihistamine therapy (phencarol, tavegil or suprastin) is performed. Vitamin C is also prescribed (up to 1.5 g per day). Locally used enzyme preparations for the lysis of necrotic plaque, and then keratoplastic ointments (solcoseryl, methyluracil). When the process is localized, a solution of interferon is instilled in the pharynx. The prognosis for timely and adequate treatment is favorable. In the acute stage associated with difficult eruption of the third molars, surgical manipulations are not recommended. With proper treatment, epithelialization occurs in the acute process after 3 to 6 days, in the chronic – somewhat slower. Severe cases of Vincent’s ulcerative necrotic stomatitis, especially recurring when the treatment is carried out untimely or incorrectly, lead to irreversible changes: bone resorption, gum subsidence (retraction), severe periodontitis. After treatment, the gingival papillae may disappear, conditions are created for food retention, the progression of periodontitis. In other areas of the mucous membrane, in addition to the gums, the tissue is usually restored when the cure is complete, only after deep and extensive ulcers scars remain.

The treatment of symptomatic ulcerative necrotic stomatitis with blood diseases, mourning, mercury poisoning consists mainly in the general effect on the body.

Persons who have undergone Vincent’s stomatitis should be under medical observation for at least 1 year, and the first examination is carried out after 1 – 2 months.

The prognosis of angina and Vincent’s stomatitis is favorable, although in some cases, in the absence of rational therapy, the disease is delayed and can last several months. Relapses are possible.

Prevention of Vincent’s Necrotic Stomatitis

To prevent fusospirillosis, it is recommended to regularly reorganize the oral cavity, follow the rules of oral hygiene, especially during infectious diseases that reduce immunity, as well as in the treatment of bismuth preparations.