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Stomatitis

(Oral Mucositis)

By

Bernard J. Hennessy

, DDS, Texas A&M University, College of Dentistry

Last full review/revision May 2020| Content last modified May 2020
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Oral inflammation and ulcers, known as stomatitis, may be mild and localized or severe and widespread. They are invariably painful.

Stomatitis may involve swelling and redness of the oral mucosa or discrete, painful ulcers (single or multiple). Less commonly, whitish lesions form, and, rarely, the mouth appears normal (burning mouth syndrome Burning Mouth Syndrome Burning mouth syndrome is intraoral pain, usually involving the tongue, in the absence of intraoral physical signs. There are no specific diagnostic tests, and treatment is symptomatic. Burning... read more ) despite significant symptoms. Symptoms hinder eating, sometimes leading to dehydration and malnutrition. Secondary infection occasionally occurs, especially in immunocompromised patients. Some conditions are recurrent.

Etiology of Stomatitis

The most common specific causes overall include

Table
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Evaluation of Stomatitis

History

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.

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.

Physical examination

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 are rubbed for the Nikolsky sign (upper layers of epidermis move laterally with slight pressure or rubbing of skin adjacent to a blister).

Red flags

The following findings are of particular concern:

  • Fever

  • Cutaneous bullae

  • Ocular inflammation

  • Immunocompromise

Interpretation of findings

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 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 and... read more Recurrent Aphthous Stomatitis (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 Herpes Simplex Virus (HSV) Infections , 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 Behçet Disease . 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 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 Stevens-Johnson Syndrome (SJS) and Toxic Epidermal Necrolysis (TEN) .

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 clinical, symptomatic stages separated by periods of asymptomatic latent infection. Common manifestations... read more Syphilis .

Some causes usually also have extraoral, cutaneous findings.

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 Kawasaki Disease 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.

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 Herpes Simplex Virus (HSV) Infections 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 Acute Necrotizing Ulcerative Gingivitis (ANUG) . Lesions on keratinized surfaces suggest herpes simplex, RAS, 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 Acute Necrotizing Ulcerative Gingivitis (ANUG) 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 Human Immunodeficiency Virus (HIV) Infection 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).

Testing

  • Bacterial and viral culture

  • Laboratory tests

  • Biopsy

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 Celiac Disease ) 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.

Treatment of Stomatitis

  • Cause treated

  • Oral hygiene

  • Topical agents and rinses

  • Chemical or physical cautery

Specific disorders are treated, and any causative substances or drugs are avoided. Mouth rinses that contain ethanol can cause stomatitis and should not be used.

Meticulous oral hygiene (using a soft toothbrush and salt-water rinses) may help prevent secondary infection. A soft diet that does not include acidic or salty foods is followed.

Topical measures

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

  • Anesthetics

  • Protective coatings

  • Corticosteroids

  • Physical measures (eg, cautery)

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

  • Lidocaine rinse

  • Sucralfate plus aluminum-magnesium antacid rinse

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

  • Rinse and expectorate after meals with dexamethasone elixir 0.5 mg/5 mL (1 tsp)

  • Apply a paste of 0.1% triamcinolone in an oral emollient

  • Wipe amlexanox over the ulcerated area with the tip of a finger

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.

Key Points

  • Isolated stomatitis in patients with no other symptoms and signs or risk factors for systemic illness is usually caused by a viral infection or recurrent aphthous stomatitis (RAS).

  • Extraoral symptoms, rash, or both suggest more immediate need for diagnosis.

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