Basics
Description
- Inflammation of the mucous membranes of the mouth including the buccal mucosa, gingiva, tongue, lips, hard palate, and soft palate
- Also called gingivostomatitis when the gums are specifically involved
- Enteroviruses (causing herpangina and hand-foot-and-mouth disease) and herpes simplex virus type 1 are the most common infectious causes of stomatitis.
- Recurrent aphthous stomatitis (or canker sores) is also common in children. Etiology is unknown.
Epidemiology
- Enteroviruses (including coxsackie viruses)
- More common in the summer and fall months in temperate climates but occur year-round in the tropics
- Herpangina and hand-foot-and-mouth disease are most common in infants, toddlers, and young children.
- Herpes simplex virus type 1 (HSV-1)
- Infections occur throughout the year.
- Most primary HSV infections in childhood after the neonatal period are asymptomatic.
- Primary herpetic gingivostomatitis is most common in infants, toddlers, and young children.
- Recurrent HSV-1 infections can occur any time after the primary infection.
- Seroprevalence of HSV-1 in the United States: more than 25% by age 7 years; more than 40% by age 21 years
- Recurrent aphthous stomatitis is most common in older children and adolescents.
General Prevention
- Wash hands after contact with infected individuals to help prevent spread of viral stomatitis.
- Disinfect surfaces, toys, and other objects used by an infected child to decrease spread. Enteroviruses can survive on surfaces long enough to allow transmission of infection.
- Use contact precautions for hospitalized patients with viral stomatitis.
Pathophysiology
- Enteroviral infections
- Spread by fecal " oral and respiratory routes. Can also be passed from mother to infant prenatally, in the peripartum period, and possibly via breast milk
- Result in viremia which spreads virus to target organs
- HSV-1 infections
- Spread via contact with mucous membranes or open skin
- Travel from the skin to the trigeminal sensory ganglion where infection persists for life. Reactivation causes recurrent symptoms.
Etiology
- Herpangina: most often coxsackie A viruses; also caused by other enteroviruses
- Hand-foot-and-mouth disease: most often coxsackie A viruses; also coxsackie B, enterovirus 71, and echoviruses
- Primary herpetic gingivostomatitis: typically HSV-1; can also be caused by HSV-2
- Recurrent aphthous stomatitis: possible causative factors: physical and chemical trauma, foods, nutrient deficiencies, immunodeficiency, systemic illness, infections, genetic predisposition, smoking, stress, medications
Diagnosis
History
- History of present illness
- Onset and duration
- Mouth pain or sores in mouth
- Drooling
- Fever
- Intake of liquids and food
- Urine output
- Activity level
- Close contact with similar symptoms
- Review of systems
- Vomiting, diarrhea, abdominal pain
- Rash on body
- Headache, mental status changes
- Respiratory symptoms
- Previous history of oral lesions
- Chronic health issues and family history: immunodeficiency (including HIV infection), inflammatory bowel disease, gluten enteropathy, anemia, neutropenia, rheumatologic disease
- Include recent medication history to assess risk for Stevens-Johnson syndrome.
Physical Exam
- Exam of lips and oral cavity
- Mucous membranes: Moist? Erythematous? Swollen? Friable?
- Oral lesions: Color? Location? Number? Ulceration?
- Additional physical exam
- General appearance
- Hydration status
- Respiratory, cardiovascular, and abdominal exam
- Skin exam for additional rash
- Lymphadenopathy
- Typical physical findings
- Herpangina: vesicles and ulcers surrounded by erythematous ring on tonsillar pillars, soft palate, uvula, tonsils, and/or posterior pharynx
- Hand-foot-and-mouth: inflamed oropharynx with scattered vesicles and ulcers with an erythematous ring on buccal mucosa, tongue, gingiva, hard and soft palate, and/or posterior pharynx. Maculopapular, vesicular, and/or pustular lesions on hands and fingers, feet, and buttocks. Hand and foot lesions most commonly on dorsal surface but can also be on palms and soles.
- Primary herpetic gingivostomatitis (herpes labialis): inflamed gingiva with mucosal hemorrhages. Clusters of vesicles throughout the mouth including the lip 's mucocutaneous margin and perioral skin
- Recurrent herpes labialis: cluster of vesicles on lip or mucocutaneous margin
- Aphthous stomatitis: shallow round or ovoid ulcers with gray base and surrounding erythema
- Also consider the following:
- Varicella: grouped vesicles or ulcers on hard palate, buccal mucosa, tongue, or gingiva. Diffuse vesicles in various stages of healing on skin of body
- Stevens-Johnson syndrome: erythema and edema of lips. Painful intraoral bullae that rupture, leaving erosions. Rash on body includes urticaria, target lesions, and bullae.
- Beh §et syndrome: oral ulcers accompanied by genital ulcers, uveitis, rash, and other systemic symptoms
- Periodic fever with aphthous stomatitis, pharyngitis, and adenitis (PFAPA syndrome): prodrome of systemic symptoms, sore throat, and aphthous ulcers on lips or buccal mucosa followed by abrupt onset of fever and chills
Diagnostic Tests & Interpretation
Lab
- Diagnosis of stomatitis is typically made by history, location and characteristics of oral lesions, and additional physical findings.
- Confirmatory lab tests are available if needed:
- Enterovirus can be identified by polymerase chain reaction (PCR) assay or culture of stool, throat, blood, urine, tracheal aspirate, or conjunctiva or by tissue biopsy.
- HSV can be detected by viral culture, PCR, direct fluorescent antibody (DFA) staining, or enzyme immunoassay (EIA).
- For HSV culture: Unroof a vesicle with scalpel or sterile needle, and use swab to soak up fluid and scrape the base. Use appropriate viral transport media.
Differential Diagnosis
- Infectious
- Enteroviruses (coxsackievirus and others)
- HSV
- Varicella
- HIV infection
- Syphilis
- Candida
- Recurrent aphthous stomatitis
- Trauma
- Burn
- Other
- Chemotherapy-associated stomatitis
- Stevens-Johnson syndrome
- Beh §et syndrome
- Reiter syndrome
- PFAPA syndrome
- Geographic tongue
Treatment
Medication
- Pain control
- Acetaminophen or ibuprofen
- Acetaminophen with codeine in severe cases. Use caution due to risk of sedation and constipation. Do not use in combination with regular acetaminophen.
- Use codeine with caution due to variability in metabolism by cytochrome P450 CYP2D6. Patients who are "ultra-rapid metabolizers " of codeine convert up to 15% (vs. 3%) of the drug to morphine, which can lead to toxicity.
- Antivirals
- Oral acyclovir can be used for immunocompetent children with herpetic gingivostomatitis if started within the first 72 " 96 hours of illness. May shorten the duration of symptoms and viral shedding
- Topical acyclovir is not recommended for primary herpetic gingivostomatitis.
- Topical therapy: "magic mouthwash "
- 1:1 mixture of diphenhydramine and calcium carbonate or bismuth subsalicylate (plus viscous lidocaine in severe cases)
- Use with caution. Many young children cannot "swish and spit " and will swallow the medication. Applying magic mouthwash to ulcers with a swab may cause additional irritation to friable mucosa. Use of viscous lidocaine can result in systemic toxicity (e.g., arrhythmias), anesthesia of the oral mucosa leading to mechanical trauma, and anesthesia of the posterior pharynx leading to choking or aspiration.
Additional Therapies
General Measures
- Maintain hydration. Offer small amounts of cool, nonacidic liquids frequently. Use a syringe to continue giving liquids when children are refusing to drink. Try popsicles as another source of liquids.
- Offer soft, cool foods such as ice cream, yogurt, and Jell-O. Avoid foods that are salty, spicy, hard, or acidic, as they are likely to irritate the mouth sores and cause more pain.
- Apply petroleum jelly or other barrier ointment to the lips to limit cracking and prevent adhesions in herpetic gingivostomatitis.
Ongoing Care
Follow-up Recommendations
Patient Monitoring
- Most children with stomatitis can be cared for at home with pain control and maintenance of hydration.
- Providers should ensure that parents and caregivers are familiar with signs and symptoms of dehydration.
- Children with poor oral intake due to pain may be unable to maintain hydration at home and require admission for intravenous fluids.
Prognosis
- Primary herpetic gingivostomatitis results in permanent HSV infection. Recurrent infection can be triggered by stress, fever, trauma, sun exposure, immunosuppression, or extremes in temperature. Children may have tingling, pain, itching, or paresthesias before the appearance of recurrent lesions.
- Recurrent aphthous stomatitis causes significant morbidity due to recurrences of painful oral lesions.
Complications
- Enteroviral infection
- Respiratory: bronchiolitis, pneumonia, pleurodynia
- Neurologic: viral meningitis, encephalitis, motor paralysis
- Gastrointestinal: vomiting, diarrhea, abdominal pain, pancreatitis, hepatitis
- Genitourinary: orchitis
- Ophthalmologic: uveitis, acute hemorrhagic conjunctivitis
- Cardiac: myocarditis, pericarditis
- Muscular: myositis
- HSV infection
- Herpetic keratitis: herpetic eye infection due to autoinoculation from mouth lesions
- Herpetic whitlow: development of herpetic lesions on the extremities (typically fingers) due to direct contact with mouth lesions
- Eczema herpeticum: extensive herpes infection of the skin in children with atopic dermatitis or other chronic skin disease
- HSV encephalitis
Alert
Enterovirus 71 (EV71) can cause both hand-foot-and-mouth disease and herpangina and can also cause children to develop severe neurologic disease (including brainstem encephalomyelitis and acute paralysis) followed by secondary pulmonary edema/hemorrhage and cardiopulmonary collapse.
Additional Reading
- Chattopadhyay A, Shetty K. Recurrent aphthous stomatitis. Otolaryngol Clin North Am. 2011;44(1):79 " 88. [View Abstract]
- Faden H. Management of primary herpetic gingivostomatitis in young children. Pediatr Emerg Care. 2006;22(4):268 " 269. [View Abstract]
- Gibson AM, Sommerkamp SK. Evaluation and management of oral lesions in the emergency department. Emerg Med Clin North Am. 2013;31(2):455 " 463. [View Abstract]
- Madadi P, Koren G. Pharmacogenetic insights into codeine analgesia: implications to pediatric codeine use. Pharmacogenomics. 2008;9(9):1267 " 1284. [View Abstract]
- Usatine RP, Tinitigan R. Nongenital herpes simplex virus. Am Fam Physician. 2010;82(9):1075 " 1082. [View Abstract]
Codes
ICD09
- 528.00 Stomatitis and mucositis, unspecified
- 054.2 Herpetic gingivostomatitis
- 074.3 Hand, foot, and mouth disease
- 528.2 Oral aphthae
- 523.10 Chronic gingivitis, plaque induced
- 074.0 Herpangina
- 101 Vincent 's angina
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
- K05.10 Chronic gingivitis, plaque induced
- A69.1 Other Vincent 's infections
SNOMED
- 61170000 stomatitis (disorder)
- 57920007 herpetic gingivostomatitis (disorder)
- 266108008 hand foot and mouth disease (disorder)
- 426965005 aphthous ulcer of mouth (disorder)
- 186963008 Vincent 'ss angina
- 186659004 Herpangina
FAQ
- Q: My child is refusing to drink any liquids. How can I keep her hydrated?
- A: Mouth sores can be very painful. Even if your child is not having fever, give regularly scheduled doses of ibuprofen or acetaminophen around the clock for pain control. Offer cool, nonacidic liquids and foods, which will be less likely to irritate the mouth sores. Use a syringe to put small amounts of liquids in her mouth every few minutes if she refuses to drink anything.
- Q: What should I do at home to prevent spread of the infection?
- A: Frequent hand washing is the most important way to prevent the spread of infection. Avoid sharing contaminated toys, utensils, and other objects until they have been cleaned, and wipe down surfaces to disinfect. For enteroviral infections, it is particularly important to do careful hand washing after diaper changes because the virus is shed in the stool.
- Q: When can my child return to school or daycare?
- A: Viral stomatitis is contagious. Children who drool are the most contagious and should not return to school until the mouth sores heal. Children with aphthous ulcers or recurrent herpes labialis should not be excluded from school.