Stomatitis differential diagnosis

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Sara Mehrsefat, M.D. [2]

Overview

Stomatitis should be differentiated from various subtypes of stomatitis and from many other disease that can involve the oral cavity such as agranulocystosis, Behcet's disease, immunodeficiency and tutors of the oral cavity like leukoplakia etc.

Differential diagnosis

Stomatitis must be differentiated from its different kinds and from various other disease that can mimic stomatitis or have accompanying features involving other organs.

Disease	Presentation	Risk Factors	Diagnosis	Systemic Involvement	Important features	Picture
Diseases predominantly affecting the oral cavity
Squamous cell carcinoma	Ulcer, nodule, or indurated plaque May involve skin, lips, inside the mouth, throat or esophagus	Chronic sun or UV exposure Fair skin Elderly age (>45 yrs) Male sex Smoking	Physical exam	Oral Cavity Floor of mouth Lateral tongue Throat Esophagus	Malignant Can spread to TMJ Some times associated with leukoplakia
Leukoplakia	White leathery spots on the mucous membranes of the tongue and inside of the mouth Lateral borders of tongue	Tobacco use Chronic irritation Immunodeficiency Bloodroot (sanguinaria)	Physical exam Diagnosis of exclusion	Vulvar lesions occur independent of oral lesions	Associated with HIV Persistant white spots
Melanoma	A lesion with ABCD Asymmetry Border irregularity Color variation Diameter changes Bleeding from the lesion	UV radiations Genetic predisposition Old age Male gender Family or personal history of melanoma Multiple benign or atypical nevi	ABCD characteristics Bleeding or ulceration may show malignancy Serum LDH may be elevated in case of malignancy	Can metastasize All UV radiation or sun exposed areas can be effected independently 1-2 to hundreds of granules	Neural crest cell derivative development begins with disruption of nevus growth control Progression involves MAPK/ERK pathway N-RAS or BRAF oncogene also involved
Fordyce spots	Rice-like granules or spots Small, painless, raised, pale, red or white 1 to 3 mm in diameter	Greasy skin types Some rheumatic disorders Hereditary nonpolyposis colorectal cancer Lower gingiva (gums) Vestibular mucosa	Physical exam Small keratin-filled pseudocysts May be seen on incidental mucosal biopsy Biopsy not done for them primarily	Oral cavity Vermilion border of the lips Oral mucosa of the upper lip Buccal mucosa in the commissural region often bilaterally Genitals	Visible sebaceous glands No surrounding mucosal change Several adjacent glands may coalesce into a larger cauliflower-like cluster
Torus palatinus	Bony growth on midline of the hard palate	Genetic predisposition Autosomal Dominant	Physical exam Types Flat tori Spindle tori Nodular tori Lobular tori	None	More common in Asian and Inuit populations Twice more common in females Repeated trauma can cause bleeding Surgery may be required in symptomatic
Diseases involving oral cavity and other organ systems
Behcet's disease	Painful mouth sores Acne like skin lesions Headache, fever, poor balance, disorientation Abdominal pain, diarrhea or bleeding Uveitis Joint swelling and joint pain Genital sores wit pain and scaring Aneurysms	Over active immune system	Physical examination	Mouth Genitals GIT Eye Joints Skin Vascular system Brain	Outbreaks of exaggerated inflammation Affects smaller blood vessels
Crohn's disease	Chronic, episodic diarrhea or constipation Abdominal pain Vomiting Weight loss or weight gain.	Smoking Whites and European Jews Hormonal contraception Diets high in microparticles, sweet, fatty or refined foods Industrialized country	Typical history and symptoms Skip lesions on biopsy Anti-Saccharomyces cerevisiae antibodies (ASCA) Anti-neutrophil cytoplasmic antibodies (ANCA)		May lead to Obstructions Abscesses Free perforation Hemorrhage
Agranulocytosis			Neutropenia <100 cells per micro litre Eosinopenia Basopenia
Burning mouth syndrome
Syphilis
Coxsackie virus
Chicken pox
Measles

Stomatitis should be differentiated from other disease as well as from possible underlying conditions causing stomatitis including:

• Tumors of the tongue
  • Squamous cell carcinoma
    • It can prevent as a non healing ulcer or as a mass and is mostly caused by smoking or alcohol utilization.
  • Leukoplakia
    • It is benign but can progress to carcinoma after almost 10 years. It is common in atypical users of tobacco, other than smoking.
    • Oral proliferative verrucous leukoplakia is an aggressive sub type that has multiple lesions and has higher conversion to warts or carcinoma.
  • Melanoma
    • It has the typical abcde characteristics including asymmetry, irregular borders, color change, increase in diameter and evolution and is usually diagnosed in its later stages.
  • Fordyce spots
    • These are benign neoplasms with sebaceous features
  • Torrus Palatinus
    • It is a nodular mass on the hard palate, covered with normal mucosa
• Autoimmune diseases
  • Behcet's syndrome
  • Crohn's disease
• Agranulocytosis
• Nicorandil induced ulcers
  • It is a drug use in angina pectoris
• Burning mouth syndrome
  • It is characterized by constant sensation of burning in the mouth in post menopausal women.
  • There is no particular cause for it and no specific treatment is done.
• Syphilis
• Coxsackie virus accompanies involvement of the hands and the mouth
• HIV
• VZV or Chicken pox

References

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