Stomatitis refers to inflammation of the mucous membrane lining the mouth. This condition can affect any part of the oral cavity, including the lips, cheeks, gums, tongue, palate, and floor of the mouth. Stomatitis is not a single disease but rather a general term encompassing various inflammatory conditions of the oral mucosa, each with distinct causes, clinical presentations, and management strategies. It can range from mild, localized irritation to severe, widespread inflammation causing significant pain and discomfort, impacting eating, speaking, and overall quality of life.

Definition and Scope

Stomatitis is characterized by redness, swelling, and sometimes ulceration of the oral mucosa. The term is derived from the Greek words “stoma” (mouth) and “-itis” (inflammation). It can be acute or chronic and can be caused by a wide array of factors, including infections, allergic reactions, trauma, nutritional deficiencies, systemic diseases, and irritants. Understanding the specific type and underlying cause of stomatitis is crucial for effective diagnosis and management.

The scope of stomatitis is broad, encompassing conditions such as:

• Aphthous Stomatitis (Canker Sores): Recurrent, painful ulcers with a white or yellowish center and a red border.

• Herpetic Stomatitis: Caused by the Herpes Simplex Virus (HSV), typically presenting as multiple small vesicles that rupture to form painful ulcers.

• Denture Stomatitis: Inflammation of the oral mucosa beneath a denture, often associated with fungal infection (Candida).

• Angular Stomatitis (Angular Cheilitis): Inflammation and cracking at the corners of the mouth.

• Allergic Stomatitis: Inflammatory reaction to allergens in food, medications, or dental materials.

• Nutritional Deficiency Stomatitis: Oral manifestations of deficiencies in vitamins (e.g., B vitamins, vitamin C) or minerals (e.g., iron).

• Chemical Stomatitis: Inflammation caused by contact with irritant chemicals.

• Radiation Stomatitis: Oral inflammation resulting from radiation therapy to the head and neck region.

• Chemotherapy-Induced Stomatitis (Oral Mucositis): A common and often severe side effect of chemotherapy.

Etiology and Risk Factors

The causes of stomatitis are diverse and can be broadly categorized:

1. Infections:

• Viral: Herpes Simplex Virus (HSV) is the most common viral cause, leading to herpetic stomatitis. Other viruses, such as Varicella-Zoster Virus (causing chickenpox and shingles) and Coxsackievirus (causing Hand, Foot, and Mouth Disease), can also cause oral lesions.

• Fungal: Candida albicans is the most frequent fungal culprit, causing candidiasis (thrush), which often presents as white patches that can be wiped away, leaving a red, inflamed surface. Risk factors include antibiotic use, corticosteroid use (inhaled or systemic), immunosuppression (e.g., HIV/AIDS, chemotherapy), diabetes, and denture wear.

• Bacterial: While less common as a primary cause of widespread stomatitis, bacterial infections can complicate existing lesions or cause specific conditions like necrotizing ulcerative gingivitis and periodontitis, which involve inflammation of the gums and surrounding tissues.

2. Trauma and Irritation:

• Mechanical: Ill-fitting dentures, sharp teeth, orthodontic appliances, biting the cheek or tongue, and vigorous brushing can cause localized trauma and inflammation.

• Thermal: Burns from hot food or liquids.

• Chemical: Contact with irritant chemicals in toothpaste, mouthwash, food (e.g., acidic foods), or tobacco products.

• Radiation Therapy: Direct damage to oral mucosa cells and salivary glands from radiation.

• Chemotherapy: Cytotoxic effects on rapidly dividing cells in the oral mucosa.

3. Allergic Reactions:

• Contact Allergy: Reactions to ingredients in toothpaste, mouthwash, dental materials (e.g., metals, acrylics), or certain foods.

• Systemic Allergy: Reactions to ingested medications or foods.

4. Nutritional Deficiencies:

• Deficiencies in B vitamins (e.g., B1, B2, B6, B12, folate), vitamin C, and iron can lead to oral manifestations, including stomatitis, glossitis (inflammation of the tongue), and angular cheilitis.

5. Systemic Diseases:

• Autoimmune Diseases: Conditions like Sjögren’s syndrome (causing dry mouth), Behcet’s disease, and inflammatory bowel diseases (e.g., Crohn’s disease) can manifest with oral lesions.

• Immunodeficiency States: Conditions like HIV/AIDS and congenital immunodeficiencies increase susceptibility to opportunistic infections, including candidiasis and herpetic stomatitis.

• Hematological Disorders: Conditions like anemia and neutropenia can predispose individuals to oral infections and ulceration.

• Skin Conditions: Some dermatological conditions, such as lichen planus and pemphigus, can affect the oral mucosa.

6. Idiopathic:

• Aphthous stomatitis, the most common cause of recurrent oral ulcers, often has no identifiable underlying cause, although genetic predisposition, stress, hormonal changes, and certain foods are considered contributing factors.

Risk factors for developing stomatitis include poor oral hygiene, smoking, alcohol consumption, dry mouth (xerostomia), compromised immune system, use of certain medications, and ill-fitting dental prosthetics.

Clinical Manifestations

The clinical presentation of stomatitis varies widely depending on the underlying cause and severity. Common signs and symptoms include:

• Pain and Discomfort: Often the most prominent symptom, ranging from mild soreness to severe, debilitating pain that interferes with eating and speaking.

• Redness (Erythema): Inflammation of the oral mucosa.

• Swelling (Edema): Puffiness of the affected tissues.

• Ulceration: Open sores or lesions, which can be shallow or deep, single or multiple, and vary in size and shape.

• Vesicles or Bullae: Small fluid-filled blisters (vesicles) or larger blisters (bullae) that may rupture to form ulcers (commonly seen in herpetic stomatitis).

• White Patches: Can be present in fungal infections (thrush) or certain other conditions.

• Bleeding: Gums or other areas may bleed easily, particularly in cases of severe inflammation or infection.

• Dry Mouth (Xerostomia): Can be a contributing factor or a symptom of underlying conditions.

• Halitosis (Bad Breath): May be present, especially with infection or poor oral hygiene.

• Difficulty Eating and Swallowing (Dysphagia): Severe pain or extensive lesions can make it difficult to consume food and liquids.

• Fever and Malaise: May accompany infectious causes, particularly in primary herpetic stomatitis in children.

• Lymphadenopathy: Swollen lymph nodes in the neck may be present, especially with infectious or inflammatory causes.

Specific types of stomatitis have characteristic appearances:

• Aphthous Ulcers: Typically round or oval, well-demarcated ulcers with a gray or yellow base and an erythematous halo. They commonly occur on non-keratinized mucosa (inner lips, cheeks, floor of mouth, ventral tongue).

• Herpetic Stomatitis: Multiple small vesicles that quickly rupture to form painful, irregular ulcers, often on keratinized mucosa (gums, hard palate, dorsal tongue). May be preceded by a prodrome of fever and malaise.

• Denture Stomatitis: Erythema and edema of the palatal mucosa beneath a denture. May be asymptomatic or cause burning and discomfort.

• Angular Stomatitis: Redness, cracking, and fissuring at the corners of the mouth.

Diagnosis

Diagnosing stomatitis involves a thorough medical history, clinical examination, and sometimes laboratory investigations.

• Medical History: Obtain a detailed history of the onset, duration, location, and character of the oral lesions. Inquire about any associated symptoms (pain, fever), recent illnesses, medications (including antibiotics, corticosteroids, chemotherapy), allergies, dietary habits, smoking and alcohol use, use of dental prosthetics, and any underlying medical conditions.

• Clinical Examination: A careful visual inspection of the entire oral cavity is essential, noting the location, size, shape, color, and characteristics of the lesions (ulcers, vesicles, white patches, redness). Palpate the neck for swollen lymph nodes. Assess oral hygiene and the fit of any dental prosthetics.

• Laboratory Investigations: May be necessary to confirm the diagnosis or identify the underlying cause:

  • Microbiological Cultures: Swabs of lesions can be taken for viral (HSV), fungal (Candida), or bacterial cultures if infection is suspected.

  • Biopsy: In cases of persistent or atypical lesions, a biopsy may be necessary to rule out malignancy or identify specific inflammatory conditions.

  • Blood Tests: May be performed to check for nutritional deficiencies (e.g., complete blood count, serum iron, ferritin, vitamin B12, folate), markers of inflammation, or evidence of systemic diseases (e.g., autoimmune markers).

  • Allergy Testing: If an allergic reaction is suspected, patch testing or other allergy tests may be indicated.

Differentiating between the various causes of stomatitis based solely on clinical appearance can be challenging, making a thorough history and appropriate investigations crucial.

Management

Management of stomatitis is directed at treating the underlying cause, relieving symptoms, and preventing complications.

General Measures:

• Oral Hygiene: Maintain meticulous oral hygiene, but use a soft toothbrush and non-irritating toothpaste. Gentle rinsing with warm salt water or a mild antiseptic mouthwash can be soothing.

• Dietary Modifications: Avoid hot, spicy, acidic, or rough foods that can irritate the lesions. A soft, bland diet may be necessary during acute phases. Ensure adequate hydration and nutrition.

• Pain Relief: Over-the-counter or prescription pain relievers (e.g., acetaminophen, ibuprofen) can help manage pain. Topical anesthetics (e.g., lidocaine rinse or gel) can provide localized relief before eating.

• Avoid Irritants: Refrain from smoking, alcohol consumption, and using irritating mouthwashes.

Specific Treatment Based on Cause:

• Infectious Stomatitis:

  • Herpetic Stomatitis: Antiviral medications (e.g., acyclovir, valacyclovir, famciclovir) are effective, especially if started early in the course of the infection.

  • Candidiasis (Thrush): Antifungal medications, such as topical nystatin suspension or clotrimazole troches, or systemic antifungals (e.g., fluconazole) for more severe or widespread infections.

  • Bacterial Infections: Antibiotics as indicated by culture and sensitivity testing.

• Aphthous Stomatitis: Treatment is primarily aimed at symptom relief and reducing inflammation. Topical corticosteroids (e.g., triamcinolone acetonide in Orabase, clobetasol gel) can reduce inflammation and pain. Other topical agents like sucralfate suspension or protective pastes can provide a barrier. In severe, recurrent cases, systemic medications may be considered under specialist guidance.

• Denture Stomatitis: Treatment involves improving denture hygiene (cleaning dentures thoroughly and soaking them in an antiseptic solution), leaving dentures out at night, and antifungal treatment (topical or systemic) if Candida infection is present.

• Allergic Stomatitis: Identifying and eliminating the causative allergen is essential. Topical or systemic antihistamines or corticosteroids may be used to manage the allergic reaction.

• Nutritional Deficiency Stomatitis: Supplementation with the deficient vitamin or mineral is the primary treatment.

• Chemotherapy-Induced Stomatitis (Oral Mucositis): Management focuses on pain control, maintaining oral hygiene, preventing secondary infections, and supportive care. Various agents, including mouth rinses (e.g., saline, bicarbonate, chlorhexidine), topical anesthetics, and sometimes systemic pain medication, are used. Palifermin, a recombinant human keratinocyte growth factor, can reduce the incidence and duration of severe oral mucositis in certain patient populations.

• Radiation Stomatitis: Similar management principles to chemotherapy-induced mucositis, with emphasis on pain control and preventing infection.

Addressing Underlying Systemic Diseases: Managing the underlying systemic condition is crucial for resolving stomatitis associated with these diseases.

Prevention

Preventing stomatitis involves addressing risk factors and maintaining good oral health.

• Maintain Good Oral Hygiene: Regular brushing with a soft toothbrush and fluoride toothpaste, flossing daily, and using an antimicrobial mouthwash if recommended by a dental professional.

• Regular Dental Check-ups: Routine visits to the dentist allow for early detection and management of oral issues.

• Proper Denture Care: Clean dentures daily, remove them at night, and ensure they fit properly.

• Avoid Irritants: Limit or avoid smoking, excessive alcohol consumption, and irritating foods or chemicals.

• Balanced Diet: Ensure adequate intake of vitamins and minerals, especially B vitamins, vitamin C, and iron.

• Identify and Avoid Allergens: If allergies are suspected, work with a healthcare professional to identify and avoid triggers.

• Manage Underlying Systemic Diseases: Effective management of conditions like diabetes, autoimmune diseases, and immunodeficiencies can reduce the risk of associated stomatitis.

• Prophylactic Measures: For patients undergoing chemotherapy or radiation therapy, prophylactic strategies (e.g., oral cryotherapy, specific mouth rinses, palifermin) may be used to reduce the severity of oral mucositis.