TOPIC 161: Changes in the mucous membrane of oral cavity in hypovitaminosis and avitaminosis A, C. Tactics of dentists.

Questions for control of knowledge: 1. The causes of hypo-and vitamin A, C. 2. The main clinical manifestations of the symptoms of oral hypo- and avitaminosis A. 3. Differential diagnosis of oral manifestations of hypo- and avitaminosis A. 4. Treatment and prevention of hypo- and avitaminosis A. 5. Clinical manifestations of hypo- and avitaminosis C. 6. Differential diagnosis of oral manifestations of hypo- and avitaminosis C. 7. Management of patients and treatment of the manifestations of the principle of local bands in the oral cavity hypo- and avitaminosis C. 8. Prevention of hypo- and avitaminosis C. Homework: 1. To compose plan of treatment for the patient with hypovitaminosis C.

Graphology structure of topic

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Manifestations in the Differential diagnostics

oral cavity

Pathology of balance vitamin &

Avitaminosis
(scurvy, scorbutus) Necrotizing ulcerative gingivitis, tooth loss, petechiae in the mouth

Avitaminosis
Dry mucous membrane of the mouth, bubbles, erosion, ulcers

1. Avitaminosis A, PP, 2. Blood diseases, 3. Secondary syphilis.

1. Avitaminosis A, PP, 2. Erythema multiform, 3. The appearance of the mucous in endocrine disease.

Treatment

Total
To appoint vitamins, given the etiologic spectrum of violations of vitamin balance

Local
Symptomatic

Differential-diagnostic algorithm of hypovitaminosis

Gingivitis: catarrhal, hypertrophic, ulcerative.

Hypovitaminosis

Dryness in oral cavity Dermatitis

Hypovitaminosis

Cheilitis
Discoloration Diarrhoea of the skin

Hypovitaminosis

Glossitis Dementia

Hypovitaminosis 2

Paresthesia
Material and methodical providing of the topic: tables, pictures, videos, atlases, equipment of clinical hall, dental tools, color-tests to determine the index of oral hygiene, x-ray view box, the bank R-grams, forms reporting records, medical records of dental patients (f.043). Materials for practical lessons: Vitamin A (retinol) is essential in the growth and development of the body, regulates the maturation of the epithelium and keratinization, increases the resistance of the mucous membranes of the mouth to the action on it of various traumatic and irritating factors, ensure the normal function of the organ of vision, favors the normal function of the salivary and sweat glands. The human body gets retinol from food. Among the products of animal origin (milk, butter, eggs, liver, kidney, and fish oil) is the richest in vitamin A liver fat of marine animals and fish. In plant foods (tomato, pumpkin, carrots, spinach, broccoli, melon, peach, sea buckthorn), vitamin A is in the form of provitamin - carotene. In humans and animals (in the gut wall, liver, blood, etc.) involving karotinaza choline carotene is converted to vitamin A. The daily requirement for vitamin A in our country for adults is 750-800 mg. In the body of dietary beta-carotene is absorbed only in the third part, and converted to retinol provitamin assimilate, utilization efficiency of carotene is sixth. Carotene is absorbed better if the products are heat treated and prepared with fats. The physiological significance. 1. Takes part in the formation of the visual pigment of the retina rods - rhodopsin and cone visual pigment-iodopsin. 2. Is required for normal differentiation of epithelial tissue. 3. Specialty antagonist is a substance which causes the keratinization of the epithelial cells. 4. It has an impact on the regulation of cell division. At low retinol reduced number of mitoses. 5. Antagonist is thyroxine (thyroid hormone), reducing its action against increase metabolism. 6. An antagonist of the toxic effect of vitamin D (vitamin A delayed manifestations of scurvy, vitamin D and their speeds).

4 7. Participates in the mineral metabolism of phosphorus and cholesterol formation. Clinical manifestations of vitamin deficiencies due to reduced barrier properties of the skin and mucous membranes of the mouth, disruption of normal differentiation of epithelial tissue. In hypovitaminosis A oral mucosa pale, cloudy, dry, loses its characteristic luster. On the mucous membrane of the cheeks, hard and soft palate appear whitish layers, reminiscent of a softer form of leukoplakia. There is a epidermidalization ducts of salivary glands. This leads to a decrease in the secretion of saliva - sialoschesis. Keratinization detected in the secretory cells of salivary glands which leads to the delay in the secretion glands sialoadenity developed. Along with dry mouth and dry throat notes. The mucous membrane of the lips becomes bluish color, it is epidermizatsium increased, especially at the border with a red border. On the mucous membrane of the mouth eroziron process can be complicated and ulceration. In case of insufficiency of vitamin A in the body during the period of tooth development disorders occur in solid tissues of the tooth, in particular enamel. There have defects in the formation, as well as change the color of the enamel, it loses its luster and transparency, the teeth become melopodobnymi, there is atrophy of the odontoblasts of the pulp. At the same time revealed eye disease (gemeralopatiya, xerophthalmia), weight loss, pallor, and peeling of the skin, the hair becomes liquid, lose luster, brittle nails, and slow wound healing due to inhibition of the formation of granulation tissue. Diagnosis. A diagnosis of hypovitaminosis put together on the basis of clinical data: dryness of mucous membranes of the mouth, the emergence of goose skin, lack of appetite, general weakness, disorders of the gastrointestinal tract (diarrhea, Akhil). A deficiency disease - a common disease in children in India, Indonesia, North Africa, Central and South America. Treatment - prescribe foods rich in vitamin A (butter, milk, egg yolk, cream, liver), or carotene is converted into vitamin A (carrots, apricots, peach, black currant). Prescribe fish oil (3 table spoons a day for an adult, 3 teaspoons - for a child). Inside prescribers vitamin A in the form of an oily solution or dragees (3300 ME 1 dragees, - to 50,000-100,000 IU per day). In diseases of the gastrointestinal tract retinol is administered parenteral. Highlights the role of vitamin A in the treatment of a dental practice hyperkeratosis, erosive and ulcerative processes. Prevention of vitamin A deficiency. One of the preventive measures is the fortification of food products of mass consumption. This is the first milk, cooking oils, margarine, vegetable oil. Safety of vitamin A in these products is quite high. A person with incomplete turned vitamin C from food, in cases of increased demand for its body, malabsorption, and (or) the assimilation of developing hypovitaminosis C. Lack of vitamin C (ascorbic acid) leads to disruption of metabolic processes in the body, reducing its reactivity (decrease phagocytic activity, breach of AT education, etc.), a disorder of collagen synthesis processes of growth and development, sharp disturbance processes permeability of capillaries and connective tissue structures. The daily intake of vitamin C should be: for men - from 70 to 100 mg (depending on physical activity) for women - from 70 to 80, pregnant women - 90-100, nursing - 110-120, for people aged and elderly - 80 mg for children from 40 to 70 mg (depending on age). The daily requirement for vitamin C in different groups of the population on average is 30 to 120 mg / day. The need for vitamin C increased in pregnant women, nursing mothers, with enhanced mental and physical work, people who live and work in the Far North, in patients with a number of other infectious diseases. Factors that increase the need for this vitamin include: smoking (increased need for vitamin C in a 1.5-fold), work in a cold climate in hazardous environments, heavy exercise, neuro-emotional stress, pregnancy, breast-feeding, rehabilitation after serious illnesses, operations, the need to strengthen the immune system. By the development of endogenous C-vitamin deficiencies can cause the following diseases: - diseases of the digestive system - liver disease (hepatitis, cirrhosis) - Infectious diseases industrial and medicinal intoxication - kidney disease (acute and chronic nephritis) - disorders of the endocrine system (eg, hyperthyroidism).

5 Changes related to the lack of vitamin C, are manifestations of the syndrome and hemorrhagic complications caused by a secondary infection. Hypovitaminosis is accompanied by weakness, weakness, loss of appetite, fatigue, pain in the limbs. The skin becomes dark due to the accumulation of melanin in it, dry, easy to peel off. Lack of Vitamin C is always manifested by changes in the oral cavity. One of the earliest and most frequent symptoms is a scorbutic stomatitis. C-deficiency disease, scurvy (scurvy) develops in the absence or insufficient content of vitamin C in the diet for defective monotonous diet carbohydrate diet. There are three stages scorbutic stomatitis: 1) scurvied stomatopatiya - the initial stage; 2) scurvied reparative stomatitis - a developed stage; 3) scurvied ulcerative stomatitis - complicated stage. The initial stage is characterized by a pronounced gingivitis against the anemic pale mucous membranes of the mouth, gums looks infiltrated, gingival margin becomes dark red, bleeds easily. Sometimes there is sporadic, scattered petechiae in the gums and oral mucosa. Simultaneously, petechiae, and can be found on the legs, in the shins. Patients complain of general weakness, drowsiness, rheumatic pains in the limbs, headache, fatigue. The initial stage is often accompanied by iron deficiency anemia. The advanced stage of the disease is characterized by significant inflammation of the gums. Sharp swollen gums, overgrown, loose, covers a significant portion of tooth crowns. Especially grow and slides over the crowns of the teeth interdental papillae. Gingival margin becomes cyanotic hue, much bleeding when touched. At the edge of the interdental papillae often appear blood clots. At the oral mucosa observed multiple petechiae, ecchymosis. Tongue coated, Sharp swells, it can be seen on the edges of the prints of the teeth. The teeth become loose. Petechiae, ecchymosis, and massive hemorrhage observed in the mucosa of the cheek, palate, and in different parts of the body. The general condition of the patients deteriorate, they become adynamic, his face pale with an earthy hue. Due to the bleeding in the lungs can occur hemoptysis, develop pneumonia. Third, complicated stage of the disease arises due to the connection of the secondary (fuzospiril) infection, resulting in growing scurvies ulcerative stomatitis. Overgrown by gingival edge of the granulation reach the cutting edge or the chewing surfaces of the teeth, the gums appear areas of necrosis and ulceration. The gums are bleeding heavily, covered necrotic plaque, with fetid odor. Ulcerative process extends to the language, cheeks, lips, hard and soft palate. The teeth become loose and fall out. The general condition of the patients is extremely difficult. Without treatment, the disease can result in lethal. Diagnosis is performed by determining the content of ascorbic acid in the blood and its daily urinary excretion. After heavy exercise, with infectious diseases, with generalized periodontitis need for ascorbic acid increases two to three times. Treatment. Prescribe vitamin C in the form of fruit juice or ascorbic acid. Of the most effective lemon juice, orange, black currant juice, tomato. Ascorbic acid is administered in the early days of the disease in large doses (at 0.250.35 g 3 times a day). Then reduce the dose (0.1 grams 3 times per day). The drug should be taken not only in the period expressed manifestations of the disease, but also the disappearance of hemorrhagic phenomena. Recover within 1-1,5 months. In the initial stage of the disease with proper treatment in

6 an outpatient setting scorbutic gingivitis disappears in 5-7 days. With advanced and complicated stage of the disease patients are hospitalized. When combined with the effects of hypovitaminosis anemia should be injected ascorbate iron. Ascorbic acid is best given with vitamin P or rutin. These drugs increase the effect of vitamin C. In severe hemophilia furthermore designate calcium chloride, vitamin K. Local: shows oral hygiene, careful hygienic care of her, removing tartar and plaque on the teeth, mouth watering with a weak solution of potassium permarganata, citral solution, 1% sodium galaskorbin. Assign gums irrigation water saturated with carbon dioxide, electrophoresis with vitamins C and E or galaskorbin. Scurvied ulcerative stomatitis is treated as necrotic stomatitis Vincent. At the height of the disease is contraindicated removal of granulation, extraction of teeth. At C-hypovitaminosis the content of ascorbic acid in the urine is reduced, and further delayed introduction of acid in the tissues and not excreted in the urine until saturation of the body (0,8-1 mg of ascorbic acid in the blood). Prevention of vitamin C deficiency. The main activities for the prevention of hypovitaminosis C are in the regular consumption of fresh fruits and vegetables that are rich in this vitamin (4-5 servings daily, or about 500 g daily), proper storage of food-vitaminonositeley, their sound processed. The important preventive measures include the regular use of vitamin supplements containing ascorbic acid, and the inclusion in the diet of foods rich in vitamins, especially vitaminfortified drinks and juices. According to the content of vitamin C foods are divided into three groups: first group of foods containing more than 100 mg% of vitamin C: rose, black currant, red pepper, Siberian sea buckthorn berries, Brussels sprouts, second group of products with vitamin C from 50 to 100 mg%: red cabbage and cauliflower, strawberries, berries of mountain ash, third group of products with vitamin C content of 50 to 10 mg%, and the average activity vitamin including: cabbage, green onions, all citrus fruits, apples, green peas, tomatoes, raspberries, cranberries, and animal products (mare's milk, liver). Sources of vitamin C weak activity (up to 10 mg%) include: potatoes, onions, carrots, cucumbers, beets. Distribution of ascorbic acid in various parts of plants varies. Vitamin C is found more in the skin than in the flesh, is more in the leaves than in the petiole or stem. Even in a type of plant leaves, cabbage example can be a different amount of ascorbic acid (in the outer leaves than in the interior). Practical skills for the topic: 1. Working dental equipment and tools to be able to sterilize them. 2. Make a report and accounting records dentist to analyze quantitative and qualitative measures of the dentist to receive the therapy. 3. Conduct the clinical examination of the patient with pathology of the oral mucosa, the right to make medical history, plan examination and treatment of the patient. 4. Identify and assess the hygienic indices of the oral cavity and appreciate them. 5. Analyze the results of bacteriological tests patient blood count, urinalysis, and blood chemistry. 6. Conduct irrigation, instillation and applique drugs. 7. Write out prescriptions of drugs and prescribe physical therapy. 8. Conduct a professional oral hygiene. 9. Give advice on oral hygiene.

7 The list of terms, concepts, characteristics that a student must learn in preparation for the class: Term Vitamin C (ascorbic acid) Meaning of the term Ascorbic acid is a vitamin has metabolic effects, not formed in the body and fed with food alone. Participates in the regulation of oxidation-reduction processes, carbohydrate metabolism, blood coagulation, tissue regeneration, increases the body's resistance to infection, reduces vascular permeability, reduces the need of vitamins B1, B2, A, E, folic acid, pantothenic acid. Vitamin A (retinol) - fat-soluble vitamin, an antioxidant essential for vision and bone, as well as the health of the skin, hair and the immune system. Vitamin A is involved in oxidation-reduction processes, regulation of protein synthesis, promotes normal metabolism, the function of cellular and subcellular membranes, plays an important role in the formation of bones and teeth, as well as body fat, essential for the growth of new cells, slows the aging process. Lack of vitamin C Lack of vitamin C Develops in the absence or insufficient content of vitamin C in the diet for defective monotonous diet carbohydrate diet. kind of exudative inflammation that develops in the mucous and characterized by copious mucus and any exudate (serous, purulent, hemorrhagic). Inflammation of the mucous membrane of the mouth

Vitamin A (retinol)

Hypovitaminosis Hypovitaminosis Scurvied ulcerative stomatitis Catarrhalis Stomatitis

Tasks for self-monitoring and self-correction initial level of knowledge: Task 1. A woman 40 years old complains on dryness of the lips, cracks in the corners of the mouth. The woman has hypo acid gastritis. Objective: lips are bright red, swollen, on the surface cracks and erosion. Tongue is sleek, shiny, covered with cracked sharply painful. What condition is characterized by such changes? A. Pellagra B. Hypovitaminosis B2 C. Hypovitaminosis A D. Beri-beri E. Candidosis Task 2. A woman 35 years old complains on burning sensation and pain in the tongue and red border of the lips, especially the pain gets worse when eating. Objectively: skin in the nasolabial folds, nose wings hyperemia and scaly. In the corners of the mouth is dry crusty crack. The red border of lips dry, scaly, cracked and bleeding covered many, dorsum of tongue is bright red, dry, papillae are atrophied. Manifestation of what vitamin deficiency may be given the clinical picture? A. Hypovitaminosis PP B. Hypovitaminosis B1 C. Hypovitaminosis B2 D. Hypovitaminosis C E. Hypovitaminosis A

8 Task 3. A woman 42 years old complains on of dryness of the oral mucosa, because of this complicated meal, apatite, bad mood and sleep. Objectively: the skin of the face, hands, dry, scaly, red border of lips bright red color with the manifestations of peeling, the mucous membrane of the mouth is dry, sometimes lined with white fur, which can be removed without much effort, without erosions. Which vitamin is necessary to assign to the patient to improve it? A Vitamin A. B. Vitamin B12 C.Vitamin PP D. Vitamin B6 E. Vitamin B1 Task 4. Woman 20 years old complains ont dryness of the lips, cracks in the corners of the mouth, pain when eating. The patient is suffering from gastritis with low acidity. OBJECTIVE: lips bloodshot, swollen, on the surface there are cracks and erosion. In the corners of the mouth are binding. Tongue is smooth, shining, covered with furrows. What condition is characterized by these changes? A. Hypovitaminosis B2 B. Pellagroid tongue C. Hypovitaminosis A D. Beri-beri E. Candida glossitis Task 5. A man 48 years old complain on malaise, weakness, burning of the mucous membranes of the mouth, dryness and peeling of the skin, memory loss, apathy. Sick for a long time had been treated by a physician and cardiologist. Objectively: skin especially in the neck, face, hands hyperemia, dry. Tongue is increased in volume, swollen, bright red, shiny, painful. Select the most likely diagnosis? A. Hypovitaminosis A B. hypovitaminosis C C. Hypovitaminosis B12 D. Manifestation of hypovitaminosis C E. The manifestation of diseases of the endocrine system Task 6. During the medical examination of industrial workers at the metal held in the month of March, 30% of surveyed individuals fill a complaint to the increased bleeding gums. On examination: swollen gums and loosened. After a little massaging the gums with your finger on the mucosa appears red blood. When measuring blood pressure cuff on the spot marked petechiae. Which lack of vitamin can give such symptoms? A. Hypovitaminosis A B. hypovitaminosis C C. Hypovitaminosis B12 D. Manifestation of hypovitaminosis C E. Manifestation of diseases of the endocrine system. Control test: 1. The most are rich in in vitamin A there are products: A. meat B. liver sea animals and fish C. tomatoes D. potatoes E. lemon

9 2. The daily requirement for vitamin A in our country for adults is A. 100-250 mcg. B. 250-350 mcg. C. 750-800 mcg D. 850-1000 mcg. E. 1500-2000 mcg. 3. When vitamin A deficiency in the human body may be observed: A. enamel discoloration B. eye disease C. hypo salivation D. paleness skin peeling E. all of the above 4. The daily requirement for vitamin "C" for different groups of the population on average is A. from 200 to 350 mg / day. B. from 1000 to 1200 mg / day. C. from 1 to 10 mg / day. D. from 15 to 20 mg / day. E. from 30 to 120 mg / day. 5. Factors that increase the need for vitamin C include: A. rehabilitation after serious illness B. heavy exercise, C. neuro-emotional stress D. pregnancy E. all of the above