para>Common causes in the pediatric population (e.g., herpetic [primary], hand-foot-mouth disease, herpangina, traumatic ulcers)
Geriatric Considerations
Certain etiologies are more likely in the geriatric population (e.g., ill-fitting dentures, nutritional deficiencies).
COMMONLY ASSOCIATED CONDITIONS
- Pregnancy may bring on recurrent ulcerative stomatitis.
- AIDS: associated with multiple, severe oral lesions
- Aphthous ulcers may be associated with Crohn disease or celiac disease.
DIAGNOSIS
HISTORY
- Patient will complain of burning sensation, intolerance to temperature, and irritation with certain foods.
- Detailing the onset, progression, and duration of each lesion helps to diagnose localized versus systemic lesions.
PHYSICAL EXAM
The physical exam should include comprehensive oral examination. Examine and palpate the lips, tongue, cheeks, and hard and soft palate as well as cervical, submandibular, and submental lymph nodes. Erythema and edema are the usual oral manifestations, often with ulcerations. Some will have constitutional symptoms: low-grade fever, malaise, lymphadenopathy, and headache. Pain will vary. Below is a list of specific characteristics:
- Allergic stomatitis
- Intense shiny erythema
- Slight swelling
- Itching
- Dryness
- Burning
- Common allergens include nuts; shellfish; cinnamon; fruits; metals; dental materials; and ingredients in toothpaste, mouthwash, and gum.
- Herpetic stomatitis
- Same as allergic stomatitis; may have low-grade fever and easy bleeding
- RAS
- Same as allergic stomatitis; often multiple lesions
- Vincent infection: necrotic ulceration of interdental papillae and mucous membrane
- Pseudomembranous stomatitis: membrane-like exudate
- Mucous lesions accompanying systemic disease
- Mucous patches (syphilis)
- Strawberry tongue (Kawasaki disease, scarlet fever, staphylococcal toxic shock syndrome)
- Koplik spots (measles)
- Ulcers (erythema multiforme)
- Smooth, fire red, painful (pellagra)
- Varicella zoster
DIFFERENTIAL DIAGNOSIS
- Hand-foot-mouth disease, herpangina
- RAS (note: can be associated with colitis)
- Erythema multiforme/Stevens-Johnson syndrome
- Beh §et disease
- Angular stomatitis
- Noma (gangrenous stomatitis)
- Scarlatina (scarlet fever)
- Cancers of oral mucosa
- Uremic stomatitis
- Reactive arthritis
- Pemphigus/pemphigoid
- Squamous cell cancer
- Cyclic neutropenia
- Burning mouth syndrome
- PFAPA (periodic fever, aphthous ulcers, pharyngitis, and adenopathy)
DIAGNOSTIC TESTS & INTERPRETATION
- Diagnosis relies on clinical symptoms and history. Testing is not routinely performed.
- Usually none needed; consider the following for differential diagnosis:
- Tzanck test of historic interest only; herpes simplex virus (HSV) culture (from vesicles)
- Serologic test for syphilis
Initial Tests (lab, imaging)
Follow-Up Tests & Special Considerations
If not resolving in 7 to 14 days or getting worse, consider CBC; cultures to determine secondary infection
Diagnostic Procedures/Other
- Biopsy if persistent/recurrent/suspicious
- Direct fluorescent antibody testing is useful in the differential diagnosis between RAS and bullous skin diseases (5)[B].
Test Interpretation
Biopsy suspicious lesion or lesions that fail to heal or chronically recur to rule out oral granulomatosis, tuberculosis, hematologic cancer, or vasculitis.
TREATMENT
- To date, no strong evidence for broadly applicable efficacy of a single treatment. This likely reflects the poor methodologic rigor of trials and lack of studies rather than the true effect of the intervention. It is also recognized that, in clinical practice, individual drugs appear to work for individual patients (3)[A].
- Treatments target the causative factors. If cause is allergic, identification and removal of allergen is critical. For infectious causes, regimens include antibiotics or antifungals. Steroidal anti-inflammatory drugs used for systemic conditions with stomatitis manifestation. If the cause of stomatitis is due to medical treatment or cancer therapy, management needs to be more aggressive (5)[A].
GENERAL MEASURES
- In most cases, treatment of symptoms only, analgesics
- Severe cases may require parenteral fluids, particularly in children.
- Good oral hygiene
- Topical anesthesia
- Oral rinses such as half-strength hydrogen peroxide, chlorhexidine gluconate. Avoid oral rinses containing alcohol.
- Smoking cessation
- Refit dentures; daytime wear only
- Avoid specific allergens.
- Replace vitamin deficiencies.
- Treat malnutrition, if present.
MEDICATION
- Acetaminophen or ibuprofen for analgesia
- Steroids, colchicine, and cytotoxic drugs for Beh §et disease
- 2% viscous lidocaine (Xylocaine) swish and spit for local discomfort; max of 8 doses/day
- Precautions: Toxic dose of topical lidocaine is uncertain, but likely only 25 " 33% of dose may have significant absorption from open ulcers or mucous membrane.
- Liquid diphenhydramine (Benadryl) by mouth or swish and spit, for allergic reactions
- "Miracle mouth rinses " : various combinations of the following in equal parts; use swish and spit QID
- Maalox or Mylanta, diphenhydramine, lidocaine
- Maalox or Mylanta, diphenhydramine, Carafate
- Duke 's: nystatin, diphenhydramine, hydrocortisone
- Steroid oral rinses or topical preparations for aphthous ulcers (Kenalog in Orabase) or steroids injected into lesions for severe cases
- Antibiotics for gangrenous stomatitis (penicillin and metronidazole are reasonable first-line agents; often start with IV)
- Acyclovir 200 to 800 mg 5 times per day for 7 to 14 days for herpetic stomatitis
- Sucralfate (Carafate) suspension 1 tsp swish in mouth or place on ulcers QID (helpful)
- Topical 0.2% hyaluronic acid for recurrent aphthous ulcers
- Chemical cauterization with silver nitrate for aphthous stomatitis (treatment can cause burning sensation)
- Thalidomide 200 mg 1 to 2 times per day for 3 to 8 weeks in HIV-positive patients with nonhealing aphthous ulcers (extreme caution for birth defects)
- For candidiasis: nystatin PO suspension 400,000 U (4 mL) QID for 10 days; swish and swallow (1 mL QID for infants)
- Antifungal ointment (e.g., nystatin [Mycostatin]) for candidiasis-complicating angular stomatitis
- For prevention or reducing severity of mucositis with cancer treatments, these agents have some evidence of benefit: allopurinol, Aloe vera, amifostine, cryotherapy, glutamine (IV), honey, keratinocyte growth factor, laser, and polymyxin/tobramycin/amphotericin (PTA) antibiotic pastille/paste (6)[A].
- Contraindications: allergy to specific medication
COMPLEMENTARY & ALTERNATIVE MEDICINE
- Avoiding toothpaste with sodium lauryl sulfate reduces duration of RAS (7)[B].
- Replenish vitamin deficiencies.
INPATIENT CONSIDERATIONS
IV Fluids
In severe cases involving dehydration owing to oral ulcerations
Nursing
For infants with painful stomatitis, feeding can be particularly challenging. Topical analgesic agents should be used prior to bottlefeeding. Nasogastric feeds or parenteral, as needed
ONGOING CARE
FOLLOW-UP RECOMMENDATIONS
Patient Monitoring
Lesions need to be followed until resolved. Biopsy if they fail to resolve, continuously recur, or appear suspicious.
DIET
Avoid spicy, acidic, sharp, hard, and dry foods. Keep well hydrated.
PATIENT EDUCATION
Patient handouts
- Aphthous ulcers (English and Spanish): www.aafp.org/afp/2000/0701/p149.html
- Mouth sores (English and Spanish): http://www.nlm.nih.gov/medlineplus/mouthdisorders.html
- Mouth problems in infants and children: http://familydoctor.org/familydoctor/en/health-tools/search-by-symptom/mouth-problems-infants-children.html
PROGNOSIS
- Herpetic/hand-foot-mouth disease/erythema multiforme: self-limited " 1 to 3 weeks
- RAS: 7- to 14-day course per episode
- Vincent: may progress to fascial space infection with airway compromise or sepsis
- Nicotinic: resolves with smoking cessation
- Denture: resolves with proper fitting, careful oral hygiene, and daytime-only denture wear
- Stevens-Johnson: resolution in ~6 weeks with adequate supportive care
- Recurrent ulcerative: recurs over time, but overall prognosis is good
- Recurrent scarifying: Occasional patients suffer continuous ulcers; others have recurrence with eventual scarring. Prognosis is otherwise good.
- Beh §et disease may recur for several years. Overall prognosis is related to other aspects of the disease.
- Angular: After correction of mechanical problems, allergic disorders, and nutritional deficiencies, the prognosis is good.
- Gangrenous: most serious stomatitis, requiring aggressive treatment with IV antibiotics and debridement to avoid death
- Scarlatina: Prognosis is related to other manifestations of the disease.
- Uremic: depends on the underlying renal disease
COMPLICATIONS
- Recurrent scarifying stomatitis may result in intraoral scarring with restriction of oral mobility.
- Beh §et disease may result in visual loss, pneumonia, colitis, vasculitis, large-artery aneurysms, thrombophlebitis, or encephalitis.
- Gangrenous stomatitis may lead to facial disfigurement and even death.
- Scarlet fever may result in cardiac disease.
- Herpetic stomatitis may be complicated by ocular or CNS involvement.
REFERENCES
11 Guimar £es AL, Correia-Silva Jde F, S ‘ AR, et al. Investigation of functional gene polymorphisms IL-1 beta, IL-6, IL-10 and TNF-alpha in individuals with recurrent aphthous stomatitis. Arch Oral Biol. 2007;52(3):268 " 272.22 Liang MW, Neoh CY. Oral aphthosis: management gaps and recent advances. Ann Acad Med Singapore. 2012;41(10):463 " 470.33 Belenguer-Guallar I, Jimenez-Soriano Y, Claramunt-Lozano A. Treatment of recurrent aphthous stomatitis. A literature review. J Clin Exp Dent. 2014;6(2):e168 " e174.44 Lalla RV, Choquette LE, Feinn RS, et al. Multivitamin therapy for recurrent aphthous stomatitis: a randomized, double-masked, placebo-controlled trial. J Am Dent Assoc. 2012;143(4):370 " 376.55 Usatine RP, Tinitigan R. Nongenital herpes simplex virus. Am Fam Physician. 2010;82(9):1075 " 1082.66 Worthington HV, Clarkson JE, Bryan G, et al. Interventions for preventing oral mucositis for patients with cancer receiving treatment. Cochrane Database Syst Rev. 2010;(12):CD000978.77 Shim YJ, Choi JH, Ahn HJ, et al. Effect of sodium lauryl sulfate on recurrent aphthous stomatitis: a randomized controlled clinical trial. Oral Dis. 2012;18(7):655 " 660.
ADDITIONAL READING
- Brocklehurst P, Tickle M, Glenny AM, et al. Systemic interventions for recurrent aphthous stomatitis (mouth ulcers). Cochrane Database Syst Rev. 2012;(9):CD005411. doi:10.1002/14651858.CD005411.pub2.
- Le Doare K, Hullah E, Challacombe S, et al. Fifteen-minute consultation: a structured approach to the management of recurrent oral ulceration in a child. Arch Dis Child Educ Pract Ed. 2014;99(3):82 " 86.
- S 'lebioda Z, Szponar E, Kowalska A. Recurrent aphthous stomatitis: genetic aspects of etiology. Postepy Dermatol Alergo. 2013;30(2):96 " 102.
CODES
ICD10
- K12.1 Other forms of stomatitis
- B00.2 Herpesviral gingivostomatitis and pharyngotonsillitis
- B08.4 Enteroviral vesicular stomatitis with exanthem
- K12.0 Recurrent oral aphthae
- B08.5 Enteroviral vesicular pharyngitis
- A69.1 Other Vincent 's infections
- K05.10 Chronic gingivitis, plaque induced
ICD9
- 528.00 Stomatitis and mucositis, unspecified
- 054.2 Herpetic gingivostomatitis
- 074.3 Hand, foot, and mouth disease
- 528.2 Oral aphthae
- 074.0 Herpangina
- 101 Vincent 's angina
- 523.10 Chronic gingivitis, plaque induced
SNOMED
- stomatitis (disorder)
- herpetic gingivostomatitis (disorder)
- hand foot and mouth disease (disorder)
- aphthous ulcer of mouth (disorder)
- Vincent 's angina
- Herpangina
CLINICAL PEARLS
- Stomatitis is often self-limiting and requires only pain relief treatment and supportive care.
- Consider broad differential diagnosis to determine etiology.
- Treat all underlying conditions.
- Depending on geographic location, age of patient, and comorbidities, be prepared to treat worsening or severe causes aggressively.