Stomatitis refers to inflammation of the mouth. It appears as either a red and swollen appearance of the mouth, with pain, or as discrete ulcers. Rarely, there are no ulcers, but only a burning sensation inside the mouth.

Aphthous ulcers are the most common cause of stomatitis. These are acute painful ulcers on the tongue, or the inside of the lips or cheeks. They are also called canker sores, and have a reddish base, with a yellowish covering. They are not associated with other symptoms, and heal in a week or two. They usually appear first after the age of 10 years, and may reappear on and off over the next few years.

Causes of stomatitis

Stomatitis in general has several possible causes, which may overlap or interact with each other.

Local causes of stomatitis include factors such as:

• Trauma, as by ill-fitting dentures or other dental appliances.
• Infections, either bacterial,  such as in syphilis, or viral, such as in herpes simplex and herpes zoster, ulcers caused by hand-foot-and-mouth disease due to the Coxsackie virus, or yeast infections.
• Weakened or deficient immunity.
• Chemical irritation by strong chemicals.
• Recurrent aphthous ulcers, or stomatitis (RAS).
• Medications such as sulfa drugs, antiepileptics and certain antibiotics.

Systemic causes include:

• Stress
• Diseases such as Behcet’s disease, celiac disease, lupus and other vasculitic illnesses.
• Nutritional deficiencies, such as riboflavin deficiency.
• Chemotherapy for cancer.
• Allergic reactions.
• Any condition which is associated with xerostomia.
• Sexually transmitted diseases such as syphilis, gonorrhea.
• Other infections such as acute necrotizing ulcerative gingivitis.

Diagnosis and treatment

Diagnosis depends on a careful history and examination. A lot of information can be obtained by carefully noting the type and distribution of the ulcers, what their appearance is related to, other symptoms which may indicate the presence of systemic disease, a history of sexual contact with multiple partners, the medications the patient is on, or has taken in the past, and a history of tobacco use.

Certain diseases cause recurrent oral ulcers, such as RAS, herpes simplex and Behcet’s disease. On the other hand, yeast infection as a cause of stomatitis should be suspected in the presence of diabetes, HIV infection, or any other condition which causes weakened immunity.

Some diseases have associated findings, such as:

• Gastrointestinal symptoms with celiac disease, or inflammatory bowel disease
• Skin bullae with pemphigus
• Fever, conjunctival redness and skin rashes with Steven-Johnson syndrome
• Erythema and palmar skin scaling with Kawasaki disease

Conditions which present with both skin and oral ulceration include:

• Steven-Johnson syndrome
• Erythema multiforme
• Pemphigus
• Bullous pemphigoid
• Kawasaki disease
• Hand-foot-and-mouth disease
• Varicella or herpes zoster
• Secondary syphilis

Conditions which manifest with oral ulcers alone include:

• RAS
• Herpes simplex
• Behcet’s disease
• Yeast infections
• Acute necrotizing ulcerative gingivitis
• STDs such as primary syphilis and gonorrhea
• Most viral causes

In the absence of systemic symptoms, diagnosis of primary ulceration is easy, and no testing is required. If such symptoms are present, or ulcers persist without obvious cause, testing and sometimes, biopsy, should be done.

Treatment includes eliminating or treating any obvious local or systemic causes, good oral hygiene, salt-water rinses, use of a soft toothbrush, and the use of mouthwashes which, preferably, do not contain alcohol. Topical treatments include the use of anesthetics, substances which coat the ulcer, steroids or cauterization.

References

• http://www.msdmanuals.com/professional/dental-disorders/symptoms-of-dental-and-oral-disorders/stomatitis
• https://www.urmc.rochester.edu/encyclopedia/content.aspx?ContentTypeID=90&ContentID=P01843