Stomatitis

History of present illness should ascertain the duration of symptoms and whether the patient ever had them previously. Presence and severity of pain should be noted. The relation of symptoms to food, drugs, oral hygiene materials (eg, toothpaste, mouth rinses), and other substances (particularly occupational exposure to chemicals, metals, fumes, or dust) is sought.

Review of systems seeks symptoms of possible causes, including chronic diarrhea and weakness (inflammatory bowel disease Overview of Inflammatory Bowel Disease Inflammatory bowel disease (IBD), which includes Crohn disease and ulcerative colitis, is a relapsing and remitting condition characterized by chronic inflammation at various sites in the gastrointestinal... read more , celiac disease Celiac Disease Celiac disease is an immunologically mediated disease in genetically susceptible people caused by intolerance to gluten, resulting in mucosal inflammation and villous atrophy, which causes malabsorption... read more ); genital lesions (Behçet disease Behçet Disease Behçet disease is a multisystem, relapsing, chronic vasculitic disorder with mucosal inflammation. Common manifestations include recurrent oral ulcers, ocular inflammation, genital ulcers, and... read more , syphilis Syphilis Syphilis is caused by the spirochete Treponema pallidum and is characterized by 3 sequential symptomatic stages separated by periods of asymptomatic latent infection. Common manifestations... read more ); eye irritation (Behçet disease); and weight loss, malaise, and fever (nonspecific chronic illness).

Past medical history should ascertain known conditions that cause oral lesions, including herpes simplex Overview of Herpesvirus Infections Eight types of herpesviruses infect humans ( see Table: Herpesviruses That Infect Humans). After initial infection, all herpesviruses remain latent within specific host cells and may subsequently... read more , Behçet disease, inflammatory bowel disease, and risk factors for oral lesions, including immunocompromised state (eg, cancer, diabetes, organ transplant, use of immunosuppressants, HIV infection). Whether chemotherapy or radiation therapy has ever been used to manage cancer needs to be determined. Drug history should note all recent drugs used. History of tobacco use should be noted. Social history should include sexual contact, particularly oral sex, unprotected sex, and sex with multiple partners.

Vital signs are reviewed for fever. The patient’s general appearance is noted for lethargy, discomfort, or other signs of significant systemic illness.

The mouth is inspected for the location and nature of any lesions.

The skin and other mucosal surfaces (including the genitals) are inspected for any lesions, rash, petechiae, or desquamation. Any bullous lesions may be tested for the Nikolsky sign (upper layers of epidermis move laterally with gentle lateral pressure or rubbing of skin adjacent to a blister).

The following findings are of particular concern:

Occasionally, causes are obvious in the history (eg, cytotoxic chemotherapy; significant occupational exposure to chemicals, fumes, or dust). Recurrent episodes of oral lesions occur with recurrent aphthous stomatitis Recurrent Aphthous Stomatitis Recurrent aphthous stomatitis (RAS) is a common condition in which round or ovoid painful ulcers recur on the oral mucosa. Etiology is unclear. Diagnosis is clinical. Treatment is symptomatic... read more (RAS), herpes simplex Herpes Simplex Virus (HSV) Infections Herpes simplex viruses (human herpesviruses types 1 and 2) commonly cause recurrent infection affecting the skin, mouth, lips, eyes, and genitals. Common severe infections include encephalitis... read more , and Behçet disease Behçet Disease Behçet disease is a multisystem, relapsing, chronic vasculitic disorder with mucosal inflammation. Common manifestations include recurrent oral ulcers, ocular inflammation, genital ulcers, and... read more . History of diabetes, HIV infection or other immunocompromise, or recent antibiotic use should increase suspicion of Candida infection. Recent drug use (particularly sulfa drugs, other antibiotics, and antiseizure drugs) should increase suspicion of Stevens-Johnson syndrome (SJS) Stevens-Johnson Syndrome (SJS) and Toxic Epidermal Necrolysis (TEN) Stevens-Johnson syndrome and toxic epidermal necrolysis are severe cutaneous hypersensitivity reactions. Drugs, especially sulfa drugs, antiseizure drugs, and antibiotics, are the most common... read more .

Some causes typically have extraoral, noncutaneous findings, some of which suggest a cause. Recurrent gastrointestinal symptoms suggest inflammatory bowel disease or celiac disease. Ocular symptoms can occur with Behçet disease and SJS. Genital lesions may occur with Behçet disease and primary syphilis Syphilis Syphilis is caused by the spirochete Treponema pallidum and is characterized by 3 sequential symptomatic stages separated by periods of asymptomatic latent infection. Common manifestations... read more .

Some causes usually also have extraoral, cutaneous findings.

Cutaneous bullae Bullous Pemphigoid Bullous pemphigoid is a chronic autoimmune skin disorder resulting in generalized, pruritic, bullous lesions in older patients. Mucous membrane involvement is rare. Diagnosis is by skin biopsy... read more suggest SJS, pemphigus vulgaris Pemphigus Vulgaris Pemphigus vulgaris is an uncommon, potentially fatal, autoimmune disorder characterized by intraepidermal blisters and extensive erosions on apparently healthy skin and mucous membranes. Diagnosis... read more , or bullous pemphigoid Bullous Pemphigoid Bullous pemphigoid is a chronic autoimmune skin disorder resulting in generalized, pruritic, bullous lesions in older patients. Mucous membrane involvement is rare. Diagnosis is by skin biopsy... read more . Prodrome of malaise, fever, conjunctivitis, and generalized macular target lesions suggests SJS. Pemphigus vulgaris starts with oral lesions, then progresses to flaccid cutaneous bullae. Bullous pemphigoid has tense bullae on normal-appearing skin. The Nikolsky sign is usually positive in SJS and pemphigus vulgaris.

Cutaneous vesicles are typical with chickenpox or herpes zoster (see Herpesviruses Overview of Herpesvirus Infections Eight types of herpesviruses infect humans ( see Table: Herpesviruses That Infect Humans). After initial infection, all herpesviruses remain latent within specific host cells and may subsequently... read more ). Unilateral lesions in a band along a dermatome suggest herpes zoster. Diffuse, scattered vesicular and pustular lesions in different stages suggest chickenpox.

Kawasaki disease Kawasaki Disease Kawasaki disease is a vasculitis, sometimes involving the coronary arteries, that tends to occur in infants and children between the ages of 1 year and 8 years. It is characterized by prolonged... read more usually has a macular rash, desquamation of hands and feet, and conjunctivitis; it occurs in children, usually those < 5 years. Oral findings include erythema of the lips and oral mucosa.

Other cutaneous lesions may implicate erythema multiforme Erythema Multiforme Erythema multiforme is an inflammatory reaction, characterized by target or iris skin lesions. Oral mucosa may be involved. Diagnosis is clinical. Lesions spontaneously resolve but frequently... read more , hand-foot-and-mouth disease Hand-Foot-and-Mouth Disease (HFMD) Hand-foot-and-mouth disease (HFMD) is a febrile disorder usually caused by coxsackievirus A16, enterovirus 71, or other enteroviruses. Infection causes a vesicular eruption on the hands, feet... read more (resulting from coxsackievirus), or secondary syphilis Secondary syphilis Syphilis is caused by the spirochete Treponema pallidum and is characterized by 3 sequential symptomatic stages separated by periods of asymptomatic latent infection. Common manifestations... read more .

Some causes have isolated oral findings, including RAS, most viral infections, acute necrotizing ulcerative gingivitis Acute Necrotizing Ulcerative Gingivitis (ANUG) Acute necrotizing ulcerative gingivitis is a painful infection of the gums. Symptoms are acute pain, bleeding, and foul breath. Diagnosis is based on clinical findings. Treatment is gentle debridement... read more (ANUG), primary syphilis, gonorrhea Gonorrhea Gonorrhea is caused by the bacterium Neisseria gonorrhoeae. It typically infects epithelia of the urethra, cervix, rectum, pharynx, or conjunctivae, causing irritation or pain and purulent... read more , and Candida.

Location of oral lesions may help identify the cause. Interdental ulcers occur with primary herpes simplex Herpes Simplex Virus (HSV) Infections Herpes simplex viruses (human herpesviruses types 1 and 2) commonly cause recurrent infection affecting the skin, mouth, lips, eyes, and genitals. Common severe infections include encephalitis... read more or acute necrotizing ulcerative gingivitis Acute Necrotizing Ulcerative Gingivitis (ANUG) Acute necrotizing ulcerative gingivitis is a painful infection of the gums. Symptoms are acute pain, bleeding, and foul breath. Diagnosis is based on clinical findings. Treatment is gentle debridement... read more . Lesions on keratinized surfaces suggest herpes simplex or physical injury. Physical injury typically has an irregular appearance and occurs near projections of teeth, dental appliances, or where biting or an errant toothbrush can injure the mucosa. An aspirin burn next to a tooth and pizza burn on the palate are common.

Primary herpes simplex infection causes multiple vesicular lesions on the intraoral mucosa on both keratinized and nonkeratinized surfaces and always includes the gingiva. These lesions rapidly ulcerate. Clinical manifestation occurs most often in children. Subsequent reactivations (secondary herpes simplex, cold sore) usually appear starting in puberty on the lip at the vermilion border and, rarely, on the hard palate.

Acute necrotizing ulcerative gingivitis Acute Necrotizing Ulcerative Gingivitis (ANUG) Acute necrotizing ulcerative gingivitis is a painful infection of the gums. Symptoms are acute pain, bleeding, and foul breath. Diagnosis is based on clinical findings. Treatment is gentle debridement... read more causes severe inflammation and punched-out ulcers on the dental papillae and marginal gingivae. A severe variant called noma (gangrenous stomatitis) can cause full-thickness tissue destruction (sometimes involving the lips or cheek), typically in a debilitated or malnourished patient. It begins as a gingival, buccal, or palatal (midline lethal granuloma) ulcer that becomes necrotic and spreads rapidly. Tissue sloughing may occur.

Isolated oral gonorrhea very rarely causes burning ulcers and erythema of the gingiva and tongue, as well as the more common pharyngitis. Primary syphilis chancres may appear in the mouth. Tertiary syphilis may cause oral gummas or a generalized glossitis and mucosal atrophy. A common sign of HIV Human Immunodeficiency Virus (HIV) Infection Human immunodeficiency virus (HIV) infection results from 1 of 2 similar retroviruses (HIV-1 and HIV-2) that destroy CD4+ lymphocytes and impair cell-mediated immunity, increasing risk of certain... read more becoming AIDS is hairy leukoplakia (vertical white lines on the lateral border of the tongue).

C. albicans and related species, which are normal oral flora, can overgrow in people who have taken antibiotics or corticosteroids or who are immunocompromised, such as patients with AIDS. C. albicans can cause whitish, cheesy plaques that leave erosions when wiped off. Sometimes only flat, erythematous areas appear (erosive form of Candida).

Patients with acute stomatitis and no symptoms, signs, or risk factors for systemic illness probably require no testing.

If stomatitis is recurrent, viral and bacterial cultures, complete blood count, serum iron, ferritin, vitamin B12, folate, zinc, and endomysial antibody (for celiac disease Celiac Disease Celiac disease is an immunologically mediated disease in genetically susceptible people caused by intolerance to gluten, resulting in mucosal inflammation and villous atrophy, which causes malabsorption... read more ) are done. Biopsy at the periphery of normal and abnormal tissue can be done for persistent lesions that do not have an obvious etiology.

Systematically eliminating foods from the diet can be useful, as can changing brands of toothpaste, chewing gum, or mouthwash.

Numerous topical treatments, alone or in combination, are used to ease symptoms. These treatments include

For topical anesthesia of discomfort that may interfere with eating and drinking, the following may be effective:

A 2-minute rinse is done with 15 mL 2% viscous lidocaine every 3 hours as needed; patient expectorates when done (no rinsing with water and no swallowing unless the pharynx is involved). A soothing coating may be prepared with sucralfate (1-g pill dissolved in 15 mL water) plus 30 mL of aluminum-magnesium liquid antacid; the patient should rinse with or without swallowing. Many institutions and pharmacies have their own variation of this formulation (magic mouthwash), which sometimes also contains an antihistamine.

If the physician is certain the inflammation is not caused by an infectious organism, the patient can

Chemical or physical cautery can ease the pain of localized lesions. Silver nitrate sticks are not as effective as low-power (2- to 3-watt), defocused, pulsed-mode carbon dioxide laser treatments, after which pain relief is immediate and lesions tend not to recur locally.