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, celiac disease); genital lesions (Behçet disease, syphilis); 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, 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. Medication history should note all recent medications 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:

• Fever

• Cutaneous bullae

• Ocular inflammation

• Immunocompromise (Nikolsky sign)

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 (RAS), herpes simplex, and Behçet disease. History of diabetes, HIV infection or other immunocompromise, or recent antibiotic use should increase suspicion of Candida infection. Recent medication use (particularly sulfa medications, other antibiotics, and antiseizure medications) should increase suspicion of Stevens-Johnson syndrome (SJS).

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.

Some causes usually also have extraoral, cutaneous findings.

Cutaneous bullae suggest SJS, pemphigus vulgaris, or bullous pemphigoid. 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). Unilateral lesions in a band along a dermatome suggest herpes zoster. Diffuse, scattered vesicular and pustular lesions in different stages suggest chickenpox.

Kawasaki disease usually has a macular rash, desquamation of hands and feet, and conjunctivitis, but lesions can be present at different times; 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, hand-foot-and-mouth disease (resulting from coxsackievirus), or secondary syphilis.

Some causes have isolated oral findings, including RAS, most viral infections, acute necrotizing ulcerative gingivitis (ANUG), primary syphilis, gonorrhea, and Candida.

Primary Syphilis (Mouth Chancre)

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Image courtesy of the Public Health Image Library of the Centers for Disease Control and Prevention.

Location of oral lesions may help identify the cause. Interdental ulcers occur with primary herpes simplex or acute necrotizing ulcerative gingivitis. 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 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 patient with frailty or undernutrition. It begins as a gingival, buccal, or palatal (midline lethal granuloma) ulcer that becomes necrotic and spreads rapidly. Tissue sloughing may occur.

Noma (Gangrenous Stomatitis)

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This photo shows a child's face disfigured by severe gangrenous stomatitis or cancrum oris. This disease is an infective gangrene of the tissues of the cheek or mouth and occurs in undernourished children.

BSIP, MARIE BABEY/SCIENCE PHOTO LIBRARY

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 becoming AIDS is hairy leukoplakia (vertical white lines on the lateral border of the tongue).

Oral Hairy Leukoplakia

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Image courtesy of J.S. Greenspan, BDS, University of California, San Francisco and Sol Silverman, Jr., DDS via the Public Health Image Library of the Centers for Disease Control and Prevention.

C. albicans and related species, which are normal oral flora, can overgrow in people who have taken antibiotics or corticosteroids or who have immunocompromise, 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).

• 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) 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

• Anesthetics

• Protective coatings

• Corticosteroids

• Physical measures (eg, cautery)

To reduce discomfort that may interfere with eating and drinking, the following may be effective:

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

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