Stomatitis

Stomatitis is a general term referring to inflammation of the mucous membranes of the mouth, which may include sores. Stomatitis can be caused by infections, autoimmune disorders, allergic reactions, or exposure to irritants. The typical presentation may be either solitary or a group of painful oral lesions. The etiology of the lesion is diagnosed based on appearance and associated symptoms. Treatment involves symptomatic relief, but infectious causes may require antivirals/antibiotics and autoimmune etiologies may require steroid therapy.

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Overview

Definition

Stomatitis, sometimes called mucositis, is a broad term referring to inflammatory lesions of the oral mucosa of varied etiologies.

Etiology

  • Infectious:
    • Viral:
      • Herpes simplex virus (HSV)
      • Herpes zoster
      • Coxsackievirus
    • Fungal: Candida
    • Bacteria:
      • Mycoplasma
      • Syphilis
      • Gonorrhea
  • Chemotherapy related:
    • Cytotoxic chemotherapeutic agents: 
      • Methotrexate
      • Cytarabine
      • Doxorubicin
      • Etoposide
      • Fluorouracil
    • Radiation
  • Autoimmune:
    • Irritable bowel disease (IBD)
    • Celiac disease 
    • Lupus
    • Stevens-Johnson syndrome (SJS)
  •  Vascular:
    • Behcet’s disease
    • Kawasaki disease
  • Mechanical irritation:
    • Ill-fitting dentures or braces
    • Irregular fillings
  • Irritant exposure:
    • Oral hygiene products
    • Tobacco
    • Spicy, hot, or acidic food
  • Nutritional:
    • Iron deficiency
    • Zinc deficiency
  • Idiopathic: aphthous ulcers

Diagnosis

Given the varied etiology, a careful history and physical exam are essential to narrow the diagnosis. Laboratory testing can then confirm findings and clinical suspicion.

History

  • Timing of appearance of lesions: Recurrence suggests systemic illness.
  • Duration of symptoms
  • Presence of other family members currently with similar symptoms: Household outbreak suggests viral infection.
  • Immunization status
  • Associated factors:
    • Pain (lupus has painless oral ulcers)
    • Appearance of rash in other locations
    • New medication
    • Fever
    • Weight loss
    • Diarrhea
    • Specific food intolerance
    • Other systemic symptoms

Physical exam

  • Description of lesions:
    • Appearance:
      • Solitary and discrete vs. multiple and widespread
      • Blistering (suggests HSV or zoster)
      • Whitish (suggests Candida)
    • Location:
      • Inside cheeks
      • Gums
      • Tongue
      • Lips
      • Palate
  • Examination of other surfaces:
    • Mucosal:
      • Genital (Behcet’s disease, HSV)
      • Gastrointestinal (IBD)
    • Cutaneous:
      • Palms and soles (coxsackievirus, Kawasaki disease)
      • Face (malar rash seen with lupus)

Laboratory testing

  • Bacterial/viral culture
  • Blood work: complete blood count (CBC), iron, or vitamin levels
  • Biopsy of lesion if recurrent to rule out malignancy
Oral mucositis

Oral mucositis in a patient who has undergone radiotherapy

Image: “Radiation induced oral mucositis” by Ps SK, Balan A, Sankar A, Bose T. License: CC BY 2.0

Management

Management is focused on supportive care, pain reduction, and prevention of secondary infection of the exposed oral mucosa while the underlying cause is treated.

  • Supportive care: Ensure appropriate nutrition and hydration (intravenous (IV) therapy may be necessary).
  • Pain reduction:
    • Oral anesthetics (lidocaine rinse)
    • Risks and benefits of opioid use must be carefully weighed.
  • Infection prevention:
    • Protective coatings of the oral mucosa
    • Prophylactic antibiotics
  • Treatment of underlying etiology:
    • Antivirals (acyclovir) for herpetic lesions
    • Nystatin “swish and swallow” liquid for Candida infections
    • Treatment of underlying autoimmune disease
    • Correct nutritional imbalances.
  • If ulcers persist for > 6 weeks, investigation (e.g., biopsy) should be conducted to rule out malignancy.

Clinical Relevance

  • Nutritional deficiency: deficiency of iron, zinc, vitamin B2, B3, B6, B9, or B12 due to dietary deficits or other pathologies resulting in malabsorption and causing painful oral lesions. Treatment is supplementation of the deficient nutrient.
  • Aphthous stomatitis (most common): painful ulcers that are round or oval, crater-like in appearance, and on a yellow-gray base with erythematous margins. Mucosal ulcers are on non-keratinized mucosal surfaces (lesions on the perioral area exclude diagnosis of aphthous ulcer). The recurrence of ulcers is common and does not involve systemic symptoms. Aphthous stomatitis occurs after minimal trauma (e.g., tongue biting) and treatment is supportive.
  • Angular stomatitis: Saliva collects in corners of the mouth causing a buildup of microorganisms, such as Candida, Streptococcus, or Staphylococcus, creating painful, ulcerative lesions. Risk factors include the use of a pacifier, dentures, or a face mask. Treatment includes antifungal or antibacterial topical agents and the prevention of chapped lips.
  • Oral candidiasis (or thrush): presents as white plaques on oral mucosa that can be scraped off using a tongue depressor. Predisposing conditions include ill-fitting dentures, immunosuppression, and corticosteroid inhaler use. Oral candidiasis is common in pediatrics, particularly in small children, and 90% of cases are due to Candida. Treatment is antifungal mouthwash.
  • Allergic or contact stomatitis: a Type IV hypersensitivity reaction presenting as ulcerations on the mouth or tongue due to contact with an allergen. Common causes are flavorings, metals, or other components in oral hygiene products, foods, dental restorations, and medications. Treatment is the removal of the offending product and supportive care.
  • Autoimmune conditions: Stevens-Johnson syndrome (SJS) is a serious disorder of the skin and oral mucosa, usually from medication. And, Behcet’s disease is a rare disorder due to blood vessel inflammation, causing sores on oral and urogenital mucosa. Various autoimmune disorders can involve oral mucosa but are usually associated with other systemic symptoms of disease.
  • Herpetic gingivostomatitis: presents with painful perioral vesicular lesions (clusters of small vesicles) caused by herpes simplex virus type 1 (HSV1). Herpetic gingivostomatitis is more common in children and usually occurs after the 1st exposure to the herpes virus, which is also responsible for cold sores and fever blisters. Treatment is supportive, but antivirals can be used.
  • Herpangina: common childhood illness often caused by a group A coxsackievirus. Oral lesions usually have a white base with a red border and may be very painful; lesions typically involve the posterior pharynx. Herpangina presents as a prodrome of fever, anorexia, irritability, malaise, sleeplessness, and headache. Treatment is supportive.

References

  1. Peterson DE, Schubert MM. Oral toxicity. In: The Chemotherapy Source Book, 3rd ed, Perry MC (Ed), Williams and Wilkins, Baltimore 2001.
  2. O’Duffy JD. Behcet’s syndrome. In: Primer on the Rheumatic Diseases, 10th, Arthritis Foundation, Atlanta 1993. Vol 29, p.206.
  3. Edgar NR, Saleh D, Miller RA. Recurrent Aphthous Stomatitis: A Review. J Clin Aesthet Dermatol. 2017 Mar;10(3):26-36. Epub 2017 Mar 1. PMID: 28360966; PMCID: PMC5367879. Retrieved from https://pubmed.ncbi.nlm.nih.gov/28360966/.
  4. Canavan TN, Mathes EF, Frieden I, Shinkai K. Mycoplasma pneumoniae-induced rash and mucositis as a syndrome distinct from Stevens-Johnson syndrome and erythema multiforme: a systematic review. J Am Acad Dermatol. 2015 Feb;72(2):239-45. doi: 10.1016/j.jaad.2014.06.026. PMID: 25592340. Retrieved from https://pubmed.ncbi.nlm.nih.gov/25592340/.
  5. Cifuentes M, Davari P, Rogers RS 3rd. Contact stomatitis. Clin Dermatol. 2017 Sep-Oct;35(5):435-440. doi: 10.1016/j.clindermatol.2017.06.007. Epub 2017 Jun 24. PMID: 28916024. Retrieved from https://pubmed.ncbi.nlm.nih.gov/28916024/.

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