Stomatitis overview

# Overview
Stomatitis is an inflammation of the mucous lining of any structure in the mouth, which may involve the cheeks, gums, tongue, lips, throat, and/or the roof or floor of the mouth.  The inflammation can be the result of conditions within the mouth itself, such as poor oral hygiene, poorly fitted dentures, or mouth burns from hot food or drinks. It may also be caused 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/or pipes, and is characterized by small red bumps on the roof of the mouth.
When stomatitis 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 common cause of angular stomatitis is repeated lip-licking; in adults, it may be a sign of underlying iron deficiency anemia, or vitamin B deficiencies (e.g., B2-riboflavin, B9-folate, or B12-cobalamins), which in turn may be evidence of poor dietary habits or malnutrition (e.g., celiac disease).

## Classification
There is no established classification system for stomatitis. Stomatitis can be classified on the basis of aetiology or on the basis of the pathogens involved. The infectious and non-infectious types of stomatitis may include:
- Infectious
Bacterial
Necrotizing ulcerative stomatitis or stomatitis gangrenosa (Noma)
Viral
Herpetic gingivostomatitis
Vincent's stomatitis (Trench Mouth)
Fungal
Candidal stomatitis
- Bacterial
Necrotizing ulcerative stomatitis or stomatitis gangrenosa (Noma)
- Necrotizing ulcerative stomatitis or stomatitis gangrenosa (Noma)
- Viral
Herpetic gingivostomatitis
Vincent's stomatitis (Trench Mouth)
- Herpetic gingivostomatitis
- Vincent's stomatitis (Trench Mouth)
- Fungal
Candidal stomatitis
- Candidal stomatitis
- Non-infectious
Autoimmune
Aphthous stomatitis
SLE
Pemphigus vulgaris
Bullous pemphigoid
SJS
Pyostomatitis vegetans
Drug-induced
Chemotherapy
Antibiotics
Antihistamine
Monoclonal antibodies
Antirheumatic agents
Irritant induced
Denture stomatitis
Contact stomatitis
Stomatitis nicotina
Other causes
Tumors
Black hairy tongue
Burning  mouth syndrome
Migratory stomatitis or geographic stomatitis
Ulcerative or chronic ulcerative stomatitis
- Autoimmune
Aphthous stomatitis
SLE
Pemphigus vulgaris
Bullous pemphigoid
SJS
Pyostomatitis vegetans
- Aphthous stomatitis
- SLE
- Pemphigus vulgaris
- Bullous pemphigoid
- SJS
- Pyostomatitis vegetans
- Drug-induced
Chemotherapy
Antibiotics
Antihistamine
Monoclonal antibodies
Antirheumatic agents
- Chemotherapy
- Antibiotics
- Antihistamine
- Monoclonal antibodies
- Antirheumatic agents
- Irritant induced
Denture stomatitis
Contact stomatitis
Stomatitis nicotina
- Denture stomatitis
- Contact stomatitis
- Stomatitis nicotina
- Other causes
Tumors
Black hairy tongue
Burning  mouth syndrome
Migratory stomatitis or geographic stomatitis
Ulcerative or chronic ulcerative stomatitis
- Tumors
- Black hairy tongue
- Burning  mouth syndrome
- Migratory stomatitis or geographic stomatitis
- Ulcerative or chronic ulcerative stomatitis

## Pathophysiology
Stomatitis is the inflammation of the mucosal surfaces in the mouth. Various factors can contribute to the pathogenesis of stomatitis depending on the type of stomatitis.
- A definitive pathogenesis for aphthous stomatitis is not known. The proposed mechanism involves immune system abnormalities and the presence of autoimmune antibodies. It is thought to be caused by some types of cytokine and T cell accumulation, manifesting as a defective cell-mediated arm of immunity. Recurrence is very common in aphthous ulcers.

## Causes
Various causes, including herpes virus, lack of oral hygiene, and nutritional deficiencies, can lead to the development of stomatitis.
The most common causes of stomatitis include:
- Aphthous stomatitis
- Dentures
- Folate deficiency
- Herpes
- Oropharyngeal candidiasis
- Vitamin B12 deficiency
- Chemotherapy

## Differential Diagnosis
Stomatitis should be differentiated from various subtypes of stomatitis, as well as from many other disease that can involve the oral cavity, such as agranulocystosis, Behcet's disease, immunodeficiency, and tumors of the oral cavity (e.g., leukoplakia).

## Epidemiology and Demographics
The epidemiology and demographics vary among different kinds of stomatitis.
- Herpetic gingivostomatitis commonly affects children between 6 months and 5 years of age. It occurs less frequently in other age groups.
- Noma or gangrenous stomatitis commonly affects children.
- Pyostomatitis vegetans commonly affects individuals between the age of 20 and 50 years.

## Risk Factors
Common risk factors in the development of stomatitis include alcohol, smoking, trauma, stress, nutritional deficiency, and immunocompromised status.
The risk factors believed to influence the development of stomatitis include:
- Smoking
- Alcohol
- Trauma
- Psychological stress
- H. pylori
- Sensitivity to food
- Nutritional abnormalities
- Immunologic deficiencies (e.g., HIV)
- Genetic factors
- Chemotherapy or radiotherapy
- Poor denture hygiene

## Screening
According to the the U.S. Preventive Service Task Force (USPSTF), there is insufficient evidence to recommend routine screening for stomatitis.

## Natural History, Complications, and Prognosis

### Natural History
If left untreated, herpetic stomatitis resolves after the vesicles erupt and the ulcers heal. The HSV travels along the nerves and moves to the ganglions where it stays in latent form. When the host becomes immunocompromised after taking medications or due to some other illness, the virus assesses the opportunity and through the same nerves becomes active once again manifesting symptoms such as oral vesicles. The viral shedding can continue for 2-12 days after primary infection.

### Complications
Some complications of stomatitis include:
- Meningoencephalitis
- Recurrent skin and mouth infections
- Dissemination of the infection
- Teeth loss

### Prognosis
The prognosis of stomatitis is generally good.

# Diagnosis

## History and Symptoms
It is necessary to collect a thorough history and understanding of the symptoms in order to arrive at a diagnosis of stomatitis. The diagnosis of stomatitis is mostly clinical. The location and features of the ulcers are also important findings for this purpose.
Previous history of bad breath and refusal to eat or drink are common among patients presenting with an episode.
Some general symptoms associated with herpetic stomatitis include:
- Fever
- Anorexia
- Irritability
- Drooling
- Malaise
- Headache

## Physical Examination
A thorough history and physical exam are a necessary for a detailed understanding and diagnosis of stomatitis. The diagnosis of stomatitis is mostly clinical. The location and features of the ulcers are also important findings in this regard. The exam findings may include:
- Oral pin-head vesicles
- Oral mucosal ulcers
- Submandibular lymphadenitis
- Halitosis

## Laboratory Findings
History and physical examination are the primary means of diagnosing stomatitis. If required, laboratory findings can play an important role in diagnosing and differentiating between different types of stomatitis.
Viral culture, Tzanck smear for active lesions, serology, studies using immunofluorescent techniques, and PCR are a few techniques normally used to diagnoses herpetic stomatitis.

## X ray
There are no X ray findings associated with stomatitis.

## CT
There are no CT findings associated with stomatitis.

## MRI
There are no MRI findings associated with stomatitis.

## Ultrasound
There are no ultrasound findings associated with stomatitis.

# Treatment

## Medical Therapy
Preventive measures and medical therapy are the mainstay of therapy for stomatitis. The medical therapy varies for various causes and types of stomatitis.The therapy for stomatitis is governed by following principles:
- Oral or IV hydration
- Pain control
- Application of a barrier cream or jelly
- Zilactin, a combination of lidocaine and hydroxypropyl cellulose, used to prevent trauma and irritation

## Surgery
Surgical intervention is not recommended for the management of most types of stomatitis. It is not preferred unless there is a suspicion for an oral tumor or a biopsy is required for the diagnosis of the exact type of stomatitis. Surgical debridement may be done for Noma or trench mouth. Surgery is sometimes performed for cosmetic reasons (e.g., in the case of noma/gangrenous stomatitis).

## Primary Prevention
Effective measures for the primary prevention of stomatitis include:
- Adequate hydration
- Oral hygiene
- Denture hygiene
- Prevention of exposure to bovine papular stomatitis virus-infected cow

## Secondary Prevention
Effective measures for the secondary preventive measures for stomatitis include:
- Treatment of IBD prevents the development of pyostomatitis vegetans.
- Treatment of candidiasis