Stomatitis

Stomatitis Microchapters
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Overview
Historical perspective
Classification
Pathophysiology
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Differentiating Stomatitis from other Diseases
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief:

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. Most physicians do not regularly examine the mouth of patients and so stomatitis or triggering conditions can remain undiagnosed unless they become symptomatic. The inflammation of the structures in the mouth can be caused by a condition limited just to the mouth, 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.

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 diets or malnutrition (e.g. celiac disease).

Historical Perspective

• Between 460-370 B.C., in relation to disorders of the mouth the term aphthae was first used by Hippocrates.
• In 1898, the first clinical description of the aphthous stomatitis was reported by Von Mikulicz and Kumme as a Mikuliez aphthea
• In 1911, stomatitis aphthae recurrens cicatricicans was first described by Sutton.
• In 1961, stomatitis aphthae recurrens herpetiformis was first described by Cooke.

Classification

According to the etiology, stomatitis may be classified into:

Infectious Stomatitis

• Aphthous stomatitis
  • Major aphthous stomatitis
  • Minor aphthous stomatitis
  • Recurrent Aphthous stomatitis
  • Herpetiform stomatitis
• Herpetic gingivostomatitis
• Necrotizing ulcerative stomatitis or stomatitis gangrenosa(NOMA)
• Vesicular stomatitis
• Diphtheritic stomatitis
• Vincent's stomatitis (Trench Mouth)
• Enteroviral vesicular stomatitis with exanthem
• Candida stomatitis

Other forms

• Angular stomatitis
• Denture stomatitis
• Ulcerative or Chronic ulcerative stomatitis
• Contact stomatitis
• Migratory stomatitis or geographic stomatitis
• Stomatitis nicotina
• Pyostomatitis vegetans
• Bovine papular stomatitis
• Feline stomatitis

Causes

Life Threatening Causes

Life-threatening causes include conditions which may result in death or permanent disability within 24 hours if left untreated.

• Ebola

Common Causes

The common causes of stomatitis include:

• Aphthous stomatitis
• Dentures
• Folate deficiency
• Herpes stomatitis
• Oropharyngeal candidiasis
• Vitamin B12 deficiency

Causes by Organ System

Cardiovascular	Kawasaki disease
Chemical/Poisoning	Bismuthia, gold, mercury poisoning, nickel, thallium
Dental	Angular cheilitis, angular stomatitis, aphthous stomatitis, aphthous ulcer, burning mouth syndrome, dentures, desquamative gingivitis, dry mouth, herpetic gingivostomatitis, hypertrophic gums, nicotine stomatitis, oral lesions, oral submucous fibrosis, oral ulceration, trench mouth, ulcerative gingivitis, Vincent's angina
Dermatologic	Behcet's disease, bismuthia, erythema multiforme, gluten-sensitive enteropathy associated conditions, lip balm, pemphigoid, Stevens-Johnson syndrome, vesicular stomatitis with exanthem, warts
Drug Side Effect	Acmella oleracea, afatinib, aflibercept, alemtuzumab, aminopterin, aralen phosphate, auranofin, benzydamine, bleomycin, boceprevir, busulfan, cabozantinib, capecitabine, carboplatin, cerubidine, chemotherapy, chloramphenicol, chloroquine phosphate, clofibrate, cosmegen, cyclophosphamide, cytosine arabinoside, dacarbazine, dactinomycin, daptomycin, daunorubicin, docetaxel, epirubicin,eribulin, etoposide, everolimus, floxuridine, fluorouracil, gemcitabine, gemtuzumab ozogamicin, gentamicin, ginkgo biloba, hexetidine, ixabepilone, ketorolac tromethamine, lenvatinib, levoleucovorin, lincomycin hydrochloride, lomustine, loratadine, melphalan, methotrexate, metronidazole, mitomycin, mitoxantrone, nabumetone, nicotine polacrilex, oxaliplatin, oxaprozin, oxcarbazepine, palbociclib, panitumumab, paraplatin, penicillin G potassium, pentostatin, peplomycin, pertuzumab, phenylbutazone, pixantrone, pralatrexate, pramipexole, procainamide, sargramostim, sirolimus, sodium aurothiomalate, sorafenib, sulfasalazine, sulindac, sunitinib, temsirolimus, thioguanine, tiagabine, tolmetin, trametinib, ziv-aflibercept
Ear Nose Throat	Angular stomatitis, aphthous stomatitis, aphthous ulcer, glandular fever, oropharyngeal cancer, periodic fever, aphthous stomatitis, pharyngitis and adenitis, trench mouth, uvulitis, Vincent's angina
Endocrine	Glucagonoma
Environmental	No underlying causes
Gastroenterologic	Celiac disease, Crohn's disease, dysphagia, inflammatory bowel disease, odynophagia, oropharyngeal candidiasis, ulcerative colitis
Genetic	Chronic granulomatous disease
Hematologic	Agranulocytosis, anemia, cyclic neutropenia, iron deficiency anemia, leukemia, neutropenia
Iatrogenic	Irradiation
Infectious Disease	Aphthous stomatitis, aphthous ulcer, arbovirus, baculovirus, bovine papular stomatitis, candidiasis, coxsackie virus, diphtheritic stomatitis, ebola, esophageal candidiasis, feline calicivirus, feline immunodeficiency virus, gangrenous stomatitis, glandular fever, hand-foot-and-mouth disease, herpangina, herpes simplex virus, herpes zoster, herpes, herpetic gingivostomatitis, HIV, infectious stomatitis, lassa fever, lichen planus, Marburg virus, noma (disease), oncolytic virus, oropharyngeal candidiasis, parapoxvirus, periodic fever, aphthous stomatitis, pharyngitis and adenitis, syphilis, trench mouth, tuberculosis, typhlitis, vesicular stomatitis virus, vesicular stomatitis with exanthem, vesiculovirus, Vincent's angina, warts
Musculoskeletal/Orthopedic	Odynophagia
Neurologic	Parkinson's disease
Nutritional/Metabolic	Angular cheilitis, ariboflavinosis, folate deficiency, kwashiorkor, lingzhi, nutritional deficiency, pyrophosphate, vitamin B12 deficiency, vitamin B2 deficiency, vitamin B6 deficiency, vitamin C deficiency
Obstetric/Gynecologic	Warts
Oncologic	Cancer, glucagonoma, leukemia, oropharyngeal cancer
Ophthalmologic	No underlying causes
Overdose/Toxicity	No underlying causes
Psychiatric	Emotional stress
Pulmonary	No underlying causes
Renal/Electrolyte	No underlying causes
Rheumatology/Immunology/Allergy	Allergies, autoimmune diseases, Behcet's disease, chronic granulomatous disease, combined immunodeficiencies, drug hypersensitivity, gluten-sensitive enteropathy associated conditions, pemphigoid, periodic fever syndrome, systemic lupus erythematosus, TNF receptor associated periodic syndrome
Sexual	No underlying causes
Trauma	Trauma
Urologic	No underlying causes
Miscellaneous	Mucosa hemorrhage

Causes in Alphabetical Order

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Differentiating Stomatitis from other Diseases

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 Paltinus
    • It is a nodular mass on the hard palate, covered with normal mucosa
• Autoimmune diseases
• Aphthous ulcers
  • Apthous stomatitis
  • Behcet's syndrome
  • 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.

Risk Factors

The following risk factors are believed to influence the development of stomatitis:

• Smoking
• Alcohol
• Trauma
• H. pylori
• Sensitivity to food
• Nutritional abnormalities
• Immunologic deficiencies e.g HIV
• Genetic factors
• Chemotherapy or radiotherapy

Screening

Screening for stomatitis is not recommended.