Stomatitis generally refers to the inflammation of mouth and lips. Stomatitis can occur with or without oral ulceration. When stomatitis occurs along with gingival inflammation then the condition is known as gingivostomatitis. There are many causes of stomatitis of which common are infections, nutritional deficiencies and radiotherapy.
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Photographic Comparison of a Canker Sore, Herpes, Angular Cheilitis and Chapped Lips

Image: “Photographic Comparison of a Canker Sore, Herpes, Angular Cheilitis and Chapped Lips.” by Jeffrey Dorfman – http://www.nycdentist.com/dental-photo-detail/2471/215/Oral-Pathology-chapped-lips-herpes-canker-sore-angular-cheilitis-cyst. License: CC BY-SA 3.0


Causes of Stomatitis in Children

Nutritional deficiency

Poor absorption or inadequate dietary intake of iron, vitamin B2 (riboflavin), vitamin B3 (niacin), vitamin B6 (pyridoxine), vitamin B9 (folic acid) or vitamin B12 (cobalamine) can all manifest in the form of stomatitis.

Iron is an important element in cell repair and function, and deficiency of iron can lead to genetic downregulation and defective repair and replication of cells. Tropical sprue and kwashiorkor are examples of nutritional deficiencies.

Apthous stomatitis

Apthous ulcers also known as canker sores can occur in otherwise healthy individuals. The ulcers are recurrent and the cause is still not known but it is thought to be T cell mediated immune response.

Apthous ulcers occur in about 20 % of population. They can occur after a certain period of time and heal completely without any intervention. The symptoms range from minor discomfort to severe forms where one is not able to eat.

The treatment of apthous ulcers ranges from relieving the pain by giving local application ointments and promoting healing but none of the treatments has proved to be efficient yet.

Angular stomatitis

Angular stomatitis is the inflammation of corners of the mouth. In children it is usually caused by licking of lips repeatedly or by the deficiency of vitamins like riboflavin, folate, cobalamine or iron. A

ngular chelitis can also be caused by any condition that causes the jaw to tightly close rather than normal which causes the angles to be moist always which favors the growth of candida albicans or similar species.

Treatment includes administration of oral nystatin or if the occlusion is defective then adjusting the cause can be helpful in treatment.

Denture related stomatitis

As the name suggests the condition occurs in people wearing dentures. The patient usually presents with reddened mucosa generally without ulceration and in 90 % of the cases the cause is candida albicans. The treatment usually involves antifungals. Good oral hygiene and instructing the patients to avoid dentures during sleep can also be helpful.

Allergic contact stomatitis

Also known as allergic gingivostomatitis is an example of delayed type IV hypersentivity reaction that occurs in atopic individuals. Allergens are usually different for different individuals.

The allergens combine with epithelial derived proteins which leads to the formation of haptens which then binds with Langerhans cells in the mucosa which then presents the antigens to T lymphocytes which in turn produce specific clones for that specific antigen. If the same antigen is encountered the second time, then inflammatory response is triggered.

Allergic contact dermatitis is more common than angular stomatitis because the mouth is continuously being washed by saliva which washes away antigens. Secondly, oral mucosa is more vascular which means it has better supply which in turn leads to antigens being carried away more readily. Lastly it has less keratin than skin which means there is a decreased number of chances that the haptens will form.

patch test

Image: “Patch test.” by Jan Polák – Own work. License: CC BY-SA 3.0

Lichenoid lesion can occur in chronic patients. Some of the most common allergens include peppermint, zinc citrate, cinnamaldehyde, nickel and fluoride. Some allergens may originate from chewing gums, toothpastes, mouthwash, dental fillings, orthodontic bands and wires and from certain other foods. Patch test can be of diagnostic value and management includes avoidance of allergen.

Migratory stomatitis

This is an atypical presentation of tongue termed as geographic tongue. It presents as areas of depapillation that migrate over time. It can occur anywhere in the mouth. The condition is also known as stomatitis areata migrans.

Herpetic gingivostomatitis

This is caused by herpes simplex virus type 1. Prodromal symptoms include anorexia, fever, malaise and headache. The usual presentation is the appearance of numerous pin head vesicles which rapidly progresses to ulceration covered by yellow membrane.

Necrotizing ulcerative gingivostomatitis

This is acute infection of the gums and is non-contagious. The common symptoms include painful bleeding of gums, ulceration and necrosis of interdental papillae. Treatment includes antibiotics such as metronidazole and debridement.

Ulcerative necrotizing gingivitis

Image: “Ulcerative necrotizing gingivitis.” by dr.Mohamed HAMZE – personal practice in dental cabinet. License: Public Domain

Stomatitis nicotina

It is also known as smoker’s palatal keratosis and usually occurs in pipe smokers. The palate appears dry and cracked. The salivary glands become atrophic and the condition is reversible.

Chronic ulcerative stomatitis

This is a recently discovered condition which has an immunopathological basis. The condition is associated with erosions and the condition resembles oral lichen planus. Immunoflourescence techniques are used for diagnosis and treatment includes hydroxychloroquine.

Evaluation of Stomatitis

History

Duration of symptoms should be asked and whether the patient had those symptoms previously or not. Questions should be asked about pain and severity and duration and any other associated symptoms should be noted. History should be taken about association of ulcers with certain kind of foods or drugs.

Review of symptoms

Every system should be examined separately. History of weight loss due to ulcers, chronic diarrhea, any genital lesions or generalized weakness should also be taken into account.

Past medical history

Past history of any illness or oral lesions, organ transplant, use of immunosuppresants, chemotherapy or radiation therapy. Drug history is also very important in this aspect as many drugs can cause oral lesions.

Physical examination

Note down the vital signs and general appearance of the patient. The mouth should be inspected thoroughly for the presence of lesions. The skin and genital area should be examined thoroughly for the presence of any lesions, desquamation or rash.

Testing for Stomatitis

Bacterial and viral culture, biopsy if the lesion is recurrent, CBC, serum iron studies and testing the deficiency of any vitamins.

Treatment of Stomatitis

Topical treatments include anesthetics like lidocaine rinse, protective coatings, corticosteroids and sucralfate plus aluminium-magnesium antacid rinse. Cautery can ease the pain of lesions. For herpetic lesions, antiviral like acyclovir can be given.

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