Topic 149: Oral mucosal changes associated with flu, infectious mononucleosis, foot-and-mouth

disease. Clinical picture, diagnostics, treatment, prevention.

1. Questions for knowledge control:
1. Oral mucosal changes associated with flu.
2. Oral mucosal changes associated with infectious mononucleosis.
3. Oral mucosal changes associated with foot-and-mouth disease.
4. Tactics of dentist to patients with acute infections.
Hand, foot, and mouth disease
Hand, foot, and-mouth disease (not the same as foot and mouth disease) is caused by a
Coxsackie A virus, usually type 16 but less commonly types 5 and 10. A number of minor epidemics of
this condition have occurred and been described in detail, one involving students and staff at a dental
hospital. The oral lesions in this outbreak consisted of small ulcers, resembling minor aphthous ulcers,
relatively few in number and distributed over the oral mucosa. However, oral lesions, observed by one
of the authors, also in dental hospital personnel, and confirmed by a full range of investigations, have, in
fact, consisted of bullae that later ruptured to produce transiently painful erosions of the mucosa. The
lesions of the hands and feet consist of a red macular rash, each macule apparently surrounding a deepseated vesicle. The constitutional symptoms experienced are of a mild nature, a slight malaise with
minimal pain and discomfort. The symptoms resolve in about a week.
Clinical features of Coxsackie virus infections
Hand, foot, and mouth diseaseCoxsackie A16 (others: A5, A10)
Intraoral vesicles/ulcers
Macular rash with vesiculation on
palmar surface of hands
plantar surace of feet
Malaise
Duration: 7 days
Mini-epidemics
Herpangina Coxsackie A (most types)
Sore throat and malaise
Vesicles/ulcers on palate and pharynx
Duration: 3-5 days
Herpangina
Herpangina is predominantly caused by Coxsackie A viruses. It is a mild infection, seen
predominantly (but not entirely) in children, that tends to occur in minor epidemics. The patient
complains of a moderate degree of malaise and of a sore throat, while occasionally there is also a minor
degree of muscle weakness and pain. Small vesicular lesions appear in the posterior part of the mouth,
in particular, on the soft palate. These lesions are not particularly characteristic of the condition, but
resemble other virus-induced lesions and are recognizable only by their typical distribution. This is a
self-limiting condition. The lesions fade after some 3-5 days and complications are extremely rare.
Infectious mononucleosis (monocytic angina, Pfeiffers disease)
It is caused by EBV (Epstein-Barr virus) or cytomegalovirus (CMV), with prevalence in younger
people (adolescents). Infection is transmitted by saliva from an infected individuals or clinically healthy
carriers. After the incubation period, the disease presents initially as unspecific general symptoms
(fever, loss of appetite, tiredness), followed by gingivostomatitis with ulcerations (however, some forms
cannot be distinguished from the herpetic form), with petechiae on the soft palate (Holzers sign) that
may disappear quickly, or by temporary facial edema (Bass symptom). This results in
pseudomembranous angina with coatings that may spread from tonsils into the surroundings. In some
cases, only acute pharyngitis will develop, being accompanied with painful swallowing and the edema
of the pharynx and larynx, and inspiratory stridor. Submandibular and painless cervical

lymphadenopathy is always diagnosed. Some individuals also show enlarged lymph nodes in other parts
of the body; hepatosplenomegalia is sometimes present. Neurological complications such as meningitis,
meningoencephalitis, polyradiculoneuritis or organ-specific complications (hepatopathy, pancreatitis,
nephritis) can also occur. The disease shows a prolonged progression and tends to chronicity in some
patients.
Dg: Blood count examination shows lymphocytosis with the finding of atypical lymphoid cells; the high
count of monocytes is a typical finding (up to 50%), together with the positive Paul-Bunnel test and
laboratory signs of hepatopathy. Virological examination is performed to detect antibodies against viral
antigens VCA, EBNA, sometimes IgG and IgM antibodies against CMV-infection.
Th: General therapy is provided by infectologists, bed rest is important as well as liver diet +
hepatoprotective products, gradual recovery. When acute gingivostomatitis occurs, local symptomatic
therapy is recommended (anesthetics, antiseptic washes)
Dif. dg: Streptococcal angina (angina lacunaris) will resolve during ATB therapy in 2-3 days; enlarged
lymph nodes are painful. Herpetic gingivostomatitis has a typical two-phase progression (general
symptoms disappear with the development of the intraoral disease) and pseudomembraneous angina is
absent. Herpangina is not accompanied with lymphadenopathy, the affliction is usually mild.
Particularly in children, it is necessary to distinguish initial acute hemoblastosis from the symptoms of
acute pharyngitis or tonsilitis with great general alteration (blood count!).
The practical skills on the topic:
1) to be able to work on the dental equipment;
2) to be able to work with dental instruments, to know of the rules of sterilization;
3) to be able to make recording and reporting documentation for therapeutic dentist and to make
analysis of performance;
4) to be able to conduct the clinical examination of the patient with oral mucosa pathology in
the mouth, to make correctly of the medical history, to make plan of examination and
treatment of patient;
5) to be able to perform and assess condition of hygiene in the mouth;
6) to be able to take the material for bacteriological tests, to analyze the results;
7) to be able to analyze the results bacteriological tests of the bacteriological tests of patient,
clinical analysis of blood, urine, biochemical analysis of blood on the glucose;
8) to be able to perform application and non-infiltration nerve block anesthesia;
9) to be able to perform application, irrigation and instillation medical drugs;
10) to be able to write down the recipe, to appoint physiotherapy treatment;
11) to be able to perform professional hygiene of oral cavity;
12) to be able to make recommendations about choice of means and objects of the hygiene of
oral cavity, prevention of complications.
3. Terminology: influenza, Epstein-Barr virus, Coxsackie A viruses.
4. Questions for knowledge control:
1. Oral mucosal changes associated with flu.
2. Oral mucosal changes associated with infectious mononucleosis.
3. Oral mucosal changes associated with foot-and-mouth disease.
4. Tactics of dentist to patients with acute infections.
2.

Tests:
1. What is the average duration of the incubative period of flu?
A. 2-7 days;
B. 7-10 days;
C. 9-17 days;
D. 20-23 days;
E. 25-30 days.

2. What is the average duration of the incubative period of infectious mononucleosis?

A. 2-5 days;
B. 7-10 days;
C. 47 weeks;
D. 20-23 days;
E. 25-30 days.
3. What is the average duration of the incubative period of foot-and-mouth disease?
A. 3-7 days;
B. 8-21 days;
C. 9-17 days;
D. 20-23 days;
E. 25-30 days.
4. A bacterial disease with oral manifestation is:
A. Herpes
B. Measles
C. Diphtheria
D. Leishmaniasis
E. Infectious mononucleosis
Tasks for self-monitoring and self-correction initial level of knowledge:
1. According to the mother, a 5-year-old child complains about pain during swallowing, weakness,
body temperature rise up to 39,5oC, swelling of submental lymph nodes. Objectively: the child's
condition is grave, body temperature is 38,8oC. Mucous membrane of oral cavity is brightly
hyperemic and edematic with haemorrhages and ulcerations. Pharynx is brightly hyperemic,
lacunae are enlarged and have necrosis areas. Regional, cervical, occipital lymph nodes are
painful, enlarged and dense. What is the most likely diagnosis?
A. Necrotizing ulcerative gingivostomatitis
B. Infectious mononucleosis
C. Acute herpetic stomatitis
D. Herpetic angina
E. Lacunar tonsillitis
2. A 4,5-year-old child presents with eruptions on skin and in the mouth which appeared on the
previous day. Objectively: the child isin medium severe condition, body temperature is 38,3oC.
Scalp, trunk skin and extremities are covered with multiple vesicles with transparent content.
Mucous membrane of cheeks, tongue, hard and soft palate exhibits roundish erosion covered with
fibrinous film. Gums remain unchanged. Submandibular lymph nodes are slightly enlarged. What
diagnosis can be assumed?
A. Scarlet fever-induced stomatitis
B. Chicken pox-induced stomatitis
C. Acute herpetic stomatitis
D. Exudative erythema multiforme
E. Measles-induced stomatitis
3. A 12-year-old child complains of body temperature rise up to 39,8 oC, weakness, headache and
pain in throat getting worse when swallowing. Objectively: mucous membrane of gums is
edematic, hyperemic. Tonsils are bright red, hypertrophic, covered with yellow-gray deposit
which does not extend beyond the lymphoid tissue and can be easily removed. Submandibular,
occipital lymph nodes are significantly enlarged, slightly painful on palpation.
Hepatosplenomegaly is present. Identify the causative agent of this disease:

A. Bordet-Gengou bacillus
B. Coxsackie virus
C. Loeffler's Bacillus
D. Herpes virus
E. Epstein-Barr virus
4. A 19-year-old patient complains of pain in throat, weakness, and headache, and fever 38, 0 .
He is sick the second day. Visually intraoral: there are 11 aphtaes (size 2-5 mm) on the hyperemic
soft palate, tonsills, and posterior oropharingeal wall. The other oral mucosa is normal, moderate
lymphoadenopaty is palpated. Select ethiologic factor responsible for occurring that pathology:
A. Anaerobic microflora
B. Herpes simplex virus
C. Gram-negative bacterium
D. Candida albicans
E. Coxsackie A, B viruses