Stomatitis overview
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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]Usama Talib, BSc, MD [3]
Overview
Stomatitis is an inflammation of the mucous lining of any of the structures in the mouth, which may involve the cheeks, gums, tongue, lips, throat and roof or floor of the mouth. The inflammation can be caused by conditions in the mouth itself, such as poor oral hygiene, poorly fitted dentures, or from mouth burns from hot food or drinks, or by conditions that affect the entire body, such as medications, allergic reactions, or infections. A form of stomatitis known as stomatitis nicotina can be caused by smoking cigars, cigarettes, and pipes, and is characterized by small red bumps on the roof of the mouth.[1]
When it also involves an inflammation of the gingiva, it is called gingivostomatitis. Irritation and fissuring in the corners of the lips is termed angular stomatits or angular cheilitis. In children a frequent cause is repeated lip-licking and in adults it may be a sign of underlying iron deficiency anemia, or vitamin B deficiencis (e.g. B2-riboflavin, B9-folate or B12-cobalamins), which in turn may be evidence of poor dietary habits or malnutrition (e.g. celiac disease).
Classification
There is no known classification of stomatitis. Stomatitis can be classified on the basis of aetiology and on the basis of the pathogens involved. The infectious and non-infectious types of stomatitis may include:[2][3]
- Infectious
- Non-infectious
- Autoimmune
- Aphthous stomatitis
- SLE
- Pemphigus vulgaris
- Bullous pemphigoid
- SJS
- Pyostomatitis vegetans
- Drug induced
- Irritant induced
- Other causes
- Tumors
- Black hairy tongue
- Burning mouth syndrome
- Migratory stomatitis or geographic stomatitis
- Ulcerative or Chronic ulcerative stomatitis[7][8]
- Autoimmune
Pathophysiology
Stomatitis is the inflammation of the mucosal surfaces in the mouth. Various factors can contribute to the pathogenesis of stomatitis depending on the type of stomatitis.[9]
- A definitive pathogenesis for aphthous stomatitis is not known but the proposed mechanism involves immune system abnormalities and the presence of autoimmune antibodies. It is thought to be caused by some types of cytokine and T cell accumulation manifesting as a defective cell mediated arm of the immunity. Recurrence is very common in aphthous ulcers.[10][11][2]
Causes
Various pathogens including Herpes virus, lack of oral hygiene and nutritional deficiencies can cause stomatitis along with many other causes. A detailed insight on the various causes of stomatitis has been described. The common causes of stomatitis include:[12][13][9]
- Aphthous stomatitis
- Dentures
- Folate deficiency
- Herpes
- Oropharyngeal candidiasis
- Vitamin B12 deficiency
- Chemotherapy
Differential Diagnosis
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.[3][14]
Epidemiology and Demographics
The epidemiology and demographics vary for various kinds of stomatitis.
- Herpetic gingivostomatitis occurs mostly in children between 6 months to 5 years. It can also occur in other age groups[12]
- Noma or gangrenous stomatitis is more common in children[3]
- Pyostomatitis vegetans usually occurs between the age of 20 to 50 years[15]
Risk Factors
Many factors contribute the development of stomatitis in an individual. The risk factors for stomatitis include alcohol, smoking, trauma, stress, nutritional deficiency, immunocompromised status etc.[16] The following risk factors are believed to influence the development of stomatitis:[17][18]
- Smoking
- Alcohol
- Trauma
- Psychological stress
- H. pylori
- Sensitivity to food
- Nutritional abnormalities
- Immunologic deficiencies e.g HIV
- Genetic factors
- Chemotherapy or radiotherapy[19]
- Poor denture hygiene[20][21]
Screening
Screening for stomatitis is not recommended.[22]
Natural History, Complications, and Prognosis
Natural History
- If left untreated herpetic stomatitis resolves after the vesicles erupt and the ulcers heal. The HSV travels along the nerves and moves to the ganglions where it stays in latent form. When the host becomes immunocompromised after taking medications or due to some other illness, the virus assesses the opportunity and through the same nerves becomes active once again manifesting symptoms such as oral vesicles.[12]The viral shedding can continue for 2-12 days after primary infection.[23]
Complications
Some complications of stomatitis include[12][24]
- Meningoencephalitis
- Recurrent skin and mouth infections
- Dissemination of the infection
- Teeth loss
Prognosis
The prognosis of stomatitis is good.
Diagnosis
History and symptoms
A thorough history and understanding of the symptoms is necessary for a detailed understanding and diagnosis of stomatitis. The diagnosis of stomatitis is mostly clinical. The location and features of the ulcers are also important findings in this regard. Previous history of bad breath and refusal to eat or drink is common among patients presenting with an episode. [12] Some general symptoms associated with herpetic stomatitis include[12]
- Fever
- Anorexia
- Irritability
- Drooling
- Maliase
- Headache
Physical Examination
A thorough history and physical exam are a necessary for a detailed understanding and diagnosis of stomatitis. The diagnosis of stomatitis is mostly clinical. The location and features of the ulcers are also important findings in this regard. The exam findings may include[12]
- Oral pin-head vesicles
- Oral mucosal ulcers
- Submandibular lymphadenitis
- Halitosis
Laboratory Findings
History and physical examination are the mainstay of diagnosing stomatitis. If required laboratory findings can play an important role in diagnosing and differentiating the particular type of stomatitis. Viral culture, tzank smear for active lesions, serology, studies using immunofluorescent techniques and PCR are a few techniques normally used to diagnoses herpetic stomatitis.
X ray
X ray is not required for the diagnosis of stomatitis.
CT
CT is not required for the diagnosis of stomatitis.
MRI
MRI is not required for the diagnosis of stomatitis.
Ultrasound
Ultrasound is not required for the diagnosis of stomatitis.
Treatment
Medical Therapy
Preventive measures and medical therapy are the main stay of the therapy of stomatitis. The medical therapy varies for various causes and types of stomatitis.The therapy for stomatitis is governed by following principles:[25]
- Oral or IV hydration
- Pain control
- Application of a barrier cream or jelly
- Zilactin, a combination of lidocaine and hydroxypropyl cellulose can be used to prevent the ulcers from further trauma and irritation.[26]
Surgery
Surgery is not the treatment of choice in most types of stomatitis. It is not preferred unless there is a suspicion for an oral tumor or a biopsy is required for the diagnosis of the exact type of stomatitis. Surgical debridement may be done for Noma or Trench mouth. Surgery is sometimes done for cosmetic reasons e.g in the case of Noma i.e Gangrenous stomatitis.
Primary Prevention
Some techniques for Primary prevention of stomatitis include:
- Adequate hydration
- Oral hygiene
- Denture hygiene
- Prevention of exposure to bovine papular stomatitis virus infected cow
Secondary Prevention
Treatment of the underlying conditions like IBD or candidiasis which are a reason for causing stomatitis, are included in the secondary prevention of stomatitis. Some secondary preventive measures for stomatitis include:
- Treatment of IBD prevents the development of pyostomatitis vegetans.[27]
- Treatment of candidiasis
References
- ↑ "Smoking and Noncancerous Oral Disease" (PDF). The Reports of the Surgeon General. 1969. Retrieved 2006-06-23.
- ↑ 2.0 2.1 Murray LN, Amedee RG (2000). "Recurrent aphthous stomatitis". J La State Med Soc. 152 (1): 10–4. PMID 10668310.
- ↑ 3.0 3.1 3.2 Mandell; Gouglas, Gordon; Bennett, John. Principles and Practice of Infectious Diseases. Harvard Medical School: WILEY MEDICAL. p. 383. ISBN 0-471-87643-7. Unknown parameter
|firs1t=ignored (help) - ↑ Zwetyenga N, See LA, Szwebel J, Beuste M, Aragou M, Oeuvrard C; et al. (2015). "[Noma]". Rev Stomatol Chir Maxillofac Chir Orale. 116 (4): 261–79. doi:10.1016/j.revsto.2015.06.009. PMID 26235765.
- ↑ Zhou PR, Hua H, Liu XS (2017). "Quantity of Candida Colonies in Saliva: A Diagnostic Evaluation for Oral Candidiasis". Chin J Dent Res. 20 (1): 27–32. doi:10.3290/j.cjdr.a37739. PMID 28232964.
- ↑ A. Tosti, B. M. Piraccini & A. M. Peluso (1997). "Contact and irritant stomatitis". Seminars in cutaneous medicine and surgery. 16 (4): 314–319. PMID 9421224. Unknown parameter
|month=ignored (help) - ↑ Anderson JG, Peralta S, Kol A, Kass PH, Murphy B (2017). "Clinical and Histopathologic Characterization of Canine Chronic Ulcerative Stomatitis". Vet Pathol: 300985816688754. doi:10.1177/0300985816688754. PMID 28113036.
- ↑ Katsoulas N, Chrysomali E, Piperi E, Levidou G, Sklavounou-Andrikopoulou A (2016). "Atypical methotrexate ulcerative stomatitis with features of lymphoproliferative like disorder: Report of a rare ciprofloxacin-induced case and review of the literature". J Clin Exp Dent. 8 (5): e629–e633. doi:10.4317/jced.52909. PMC 5149103. PMID 27957282.
- ↑ 9.0 9.1 Sonis ST (2004). "The pathobiology of mucositis". Nat Rev Cancer. 4 (4): 277–84. doi:10.1038/nrc1318. PMID 15057287.
- ↑ Ship JA (1996). "Recurrent aphthous stomatitis. An update". Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 81 (2): 141–7. PMID 8665304.
- ↑ Dalghous AM, Freysdottir J, Fortune F (2006). "Expression of cytokines, chemokines, and chemokine receptors in oral ulcers of patients with Behcet's disease (BD) and recurrent aphthous stomatitis is Th1-associated, although Th2-association is also observed in patients with BD". Scand J Rheumatol. 35 (6): 472–5. PMID 17343257.
- ↑ 12.0 12.1 12.2 12.3 12.4 12.5 12.6 Kolokotronis A, Doumas S (2006). "Herpes simplex virus infection, with particular reference to the progression and complications of primary herpetic gingivostomatitis". Clin Microbiol Infect. 12 (3): 202–11. doi:10.1111/j.1469-0691.2005.01336.x. PMID 16451405.
- ↑ R. Morgan, J. Tsang, N. Harrington & L. Fook (2001). "Survey of hospital doctors' attitudes and knowledge of oral conditions in older patients". Postgraduate medical journal. 77 (908): 392–394. PMID 11375454. Unknown parameter
|month=ignored (help) - ↑ Scully C (1999). "A review of common mucocutaneous disorders affecting the mouth and lips". Ann Acad Med Singapore. 28 (5): 704–7. PMID 10597357.
- ↑ Hansen L.S., Silverman S., and Daniels T.E.: The differential diagnosis of pyostomatitis vegetans and its relation to bowel disease. Oral Surg Oral Med Oral Pathol 1983; 55: pp. 363-373
- ↑ R. Morgan, J. Tsang, N. Harrington & L. Fook (2001). "Survey of hospital doctors' attitudes and knowledge of oral conditions in older patients". Postgraduate medical journal. 77 (908): 392–394. PMID 11375454. Unknown parameter
|month=ignored (help) - ↑ R. Morgan, J. Tsang, N. Harrington & L. Fook (2001). "Survey of hospital doctors' attitudes and knowledge of oral conditions in older patients". Postgraduate medical journal. 77 (908): 392–394. PMID 11375454. Unknown parameter
|month=ignored (help) - ↑ Carolina-Cavalieri Gomes, Ricardo-Santiago Gomez, Livia-Guimaraes Zina & Fabricio-Rezende Amaral (2016). "Recurrent aphthous stomatitis and Helicobacter pylori". Medicina oral, patologia oral y cirugia bucal. 21 (2): e187–e191. PMID 26827061. Unknown parameter
|month=ignored (help) - ↑ Kenji Momo (2015). "[Indomethacin Spray Preparation for the Control of Pain Associated with Stomatitis Caused by Chemotherapy and Radiotherapy in Cancer Patients]". Yakugaku zasshi : Journal of the Pharmaceutical Society of Japan. 135 (8): 931–935. doi:10.1248/yakushi.15-00112-1. PMID 26234349.
- ↑ Arendorf TM, Walker DM (1987). "Denture stomatitis: a review". J Oral Rehabil. 14 (3): 217–27. PMID 3298586.
- ↑ Marinoski J, Bokor-Bratić M, Čanković M (2014). "Is denture stomatitis always related with candida infection? A case control study". Med Glas (Zenica). 11 (2): 379–84. PMID 25082257.
- ↑ U.S. Preventive Services Task Force http://www.uspreventiveservicestaskforce.org/BrowseRec/Search?s=stomatitis Accessed on August 31, 2016
- ↑ Amir J, Harel L, Smetana Z, Varsano I (1999). "The natural history of primary herpes simplex type 1 gingivostomatitis in children". Pediatr Dermatol. 16 (4): 259–63. PMID 10469407.
- ↑ Kurt-Jones, Evelyn A., et al. "Herpes simplex virus 1 interaction with Toll-like receptor 2 contributes to lethal encephalitis." Proceedings of the National Academy of Sciences of the United States of America 101.5 (2004): 1315-1320.
- ↑ Wade JC, Newton B, McLaren C, Flournoy N, Keeney RE, Meyers JD (1982). "Intravenous acyclovir to treat mucocutaneous herpes simplex virus infection after marrow transplantation: a double-blind trial". Ann Intern Med. 96 (3): 265–9. PMID 7036816.
- ↑ Rodu B, Mattingly G (1992). "Oral mucosal ulcers: diagnosis and management". J Am Dent Assoc. 123 (10): 83–6. PMID 1401597.
- ↑ Hegarty AM, Barrett AW, Scully C (2004). "Pyostomatitis vegetans". Clin Exp Dermatol. 29 (1): 1–7. PMID 14723710.