stomatitis

Definition

Inflammation of the mucous lining of any of the structures in the mouth, which may involve the cheeks, gums, tongue, lips, and roof or floor of the mouth. The word "stomatitis" literally means inflammation of the mouth. The inflammation can be caused by conditions in the mouth itself, such as poor oral hygiene, poorly fitted dentures, or from mouth burns from hot food or drinks, or by conditions that affect the entire body, such as medications, allergic reactions, or infections.

Description

Stomatitis is an inflammation of the lining of any of the soft-tissue structures of the mouth. Stomatitis is usually a painful condition, associated with redness, swelling, and occasional bleeding from the affected area. Bad breath (halitosis) may also accompany the condition. Stomatitis affects all age groups, from the infant to the elderly.

— Joseph Knight, PA

Key Terms: Mucositis, Mucous membranes, Oral cavity.

Description

Stomatitis describes an inflammation of the mucous membranes of the mouth. This condition, frequently referred to as mucositis, can result from cancer treatments such as chemotherapy and radiation therapy. It is characterized by mouth ulcers or sores, and pain in the mouth. The first symptoms may be sensitivity to spicy foods and reddened mucous membranes. The patient with stomatitis may also experience a dry or swollen tongue, difficulty swallowing, and an inability to eat or drink. It is usually a short-term condition, lasting from just a few days to a few weeks. Reddened areas in the mouth may appear as early as three days after receiving chemotherapy, but normally it is within five to seven days. As time goes on, ulceration occurs. The inflammation can range from mild to severe. If such complications as infection do not occur, stomatitis usually heals completely within two to four weeks.

Although stomatitis is often a short-term problem, it is of concern to cancer patients and health care professionals because it can interfere with the patient's receiving adequate nutrition as well as cause pain and discomfort.

Causes

Stomatitis is most often caused by such cancer treatments as chemotherapy and radiation therapy. Chemotherapy medications work because they are attracted to rapidly growing cells like cancer cells. However, many of the body's normal cells also grow rapidly, and chemotherapy kills them as well. The mouth includes several structures that together are referred to as the oral cavity: the lips, teeth, gums, tongue, pharynx, and the salivary glands. Most of these structures are covered by mucous membranes, the shiny, pink moist lining of the mouth. The outer layer of mucous membranes grows very rapidly, and because of this characteristic they can easily be damaged by chemotherapy and radiation therapy. When these cells are damaged, they slough off, and the lining of the mouth is left vulnerable and without protection. This exposed lining may become inflamed, swollen, and dry, and will often develop ulcers or sores.

Stomatitis caused by radiation therapy normally develops in the area where the radiation is given. It generally begins seven to fourteen days after starting radiation. It will usually exhibit improvement about two to three weeks after the treatment stops.

Stomatitis may also develop as an indirect result of cancer treatment or the cancer itself. Chemotherapy can frequently cause the patient's infection-fighting white blood cells to drop down below normal levels. When this happens, the body may be unable to keep the normal organisms in the oral cavity in balance and stomatitis, as well as such infections as thrush (oral candidiasis), may result. The severity of the stomatitis is dependent on various factors, including the diagnosis, the patient's age, the patient's oral condition before cancer treatment, and the level of oral care during therapy. The duration and severity of the low white blood count is another factor.

Stomatitis may also be caused or worsened by wearing dentures, braces, or other dental appliances that irritate the tissues of the mouth. According to the American Dental Association, about 8.4% of all Americans over the age of 17 have denture stomatitis.

Treatments

Various measures can be taken by the cancer patient to help prevent the occurrence or severity of stomatitis. A carefully followed program of good oral care started before cancer treatment can reduce the severity of stomatitis. The primary preventative measures include good nutritional intake, good oral hygiene practices, and early detection of any oral lesions by either the patient or a health care professional.

Once cancer treatment has started, the patient should carefully observe the mouth daily. The patient should inform their health care professional if any symptoms such as reddened areas, swelling, blisters, sores, white patches, or bleeding are noted. Meticulous oral hygiene and comfort measures are the focus of care. Sometimes, no matter what the patient does, stomatitis occurs. However, if good oral care is performed, the severity of symptoms is usually lessened. The following measures may be recommended to treat stomatitis:

• Rinsing the oral cavity after meals and before bedtime with a mild salt-water or baking soda and water solution will help keep the mouth clean and free of debris.
• A soft-bristled toothbrush or soft foam tooth-cleaning device should be used to keep the mouth and teeth very clean.
• Maintaining a good nutritional intake and drinking adequate amounts of fluids helps the body heal the stomatitis.
• The use of any tobacco products and alcohol should be avoided, as they can irritate the lining of the mouth.
• Avoid spicy or acidic foods, or very hot foods.
• Patients who wear dentures should remove them at night rather than leaving them in the mouth overnight, and should clean them carefully with an antiseptic solution.

Sometimes stomatitis develops in spite of the patient's best efforts. If the mouth sores are painful enough to prohibit eating and drinking, pain medications, including numbing medicines and both non-narcotic and narcotic pain medicines, may be prescribed.

Alternative and Complementary Therapies

Some preliminary studies have shown glutamine, an amino acid, to be effective in shortening the duration of stomatitis. Topical Vitamin E has also been studied and it shows some suggestions of being an effective therapy in patients with stomatitis. Other small studies suggest that using ice chips or a chamomile mouthwash will decrease the severity of symptoms. However, most of these studies have been small in scope, and cannot definitively claim the effectiveness of the varying treatments. As with anyone undergoing cancer treatment, the patient with stomatitis should consult with their physician or other health care professional regarding the usage of these alternative approaches.

More recently, a group of researchers in Brazil have reported that an extract made from the leaves of Trichilia glabra, a plant found in South America, is effective in killing several viruses that cause stomatitis.

Resources

Books

Beers, Mark H., MD, and Robert Berkow, MD, editors. "Disorders of the Oral Region." Section 9, Chapter 105 In The Merck Manual of Diagnosis and Therapy. Whitehouse Station, NJ: Merck Research Laboratories, 2002.

Sonis, Stephen T. "Oral Complications of Cancer Chemotherapy." In Cancer Medicine. 5th ed. Hamilton: B.C. Decker, 2000.

Periodicals

Cella, M., D. A. Riva, F. C. Coulombie, and S. E. Mersich. "Virucidal Activity Presence in Trichilia glabra Leaves." Revista Argentina de microbiologia 36 (July-September 2004): 136–138.

Sciubba, James J., DMD, PhD. "Denture Stomatitis." eMedicine June 11, 2002. .

Shulman, J.D., M.M. Beach, and F. Rivera-Hidalgo. "The Prevalence of Oral Mucosal Lesions in U.S. Adults: Data from the Third National Health and Nutrition Examination Survey, 1988–1994." Journal of the American Dental Association 135 (September 2004): 1279–1286.

Wohlschlaeger, A. "Prevention and Treatment of Mucositis: A Guide for Nurses." Journal of Pediatric Oncology Nursing 21 (September-October 2004): 281–287.

Wojtaszek, Cynthia. "Management of Chemotherapy-induced Stomatitis." Clinical Journal of Oncology Nursing 4 (November-December 2000).

Other

"Oral Complications of Chemotherapy and Head/Neck Radiation: Supportive Care." National Cancer Institute. [cited July 3, 2001]. .

—Deanna Swartout-Corbeil, R.N.; Rebecca J. Frey, PhD

Inflammation of the soft tissues of the mouth occurring as a result of mechanical, chemical, thermal, bacterial, viral, electrical, or radiation injury or reactions to allergens or as secondary manifestations of systemic disease.

Definition

Stomatitis is an inflammation of the mucous lining of the mouth, which may involve the cheeks, gums, tongue, lips, and roof or floor of the mouth. The word "stomatitis" literally means inflammation of the mouth.

Description

Stomatitis is an inflammation of the lining of any of the soft-tissue structures of the mouth. It is usually a painful condition, associated with redness, swelling, and occasional bleeding from the affected area. The inflammation may be caused by conditions in the mouth itself, such as poor hygiene, from burns from hot food or drinks, or by conditions that affect the entire body, such as medications, allergic reactions, or infections. Children may develop stomatitis at any point in their development, from infancy to adolescence. The two most common types seen in children are herpes stomatitis, which is caused by the herpes simplex virus, and aphthous stomatitis, more often referred to as canker sores.

Transmission

Depending upon its cause, stomatitis may or may not be contagious. Herpes stomatitis is considered contagious. Children may be exposed through kissing, sharing food, or playing in close contact with others who have an active herpes infection, such as a cold sore. Aphthous stomatitis is not contagious.

Demographics

Though stomatitis may occur at any time during a child's growth, different types affect children at different times. Herpes stomatitis can occur anywhere between six months and five years of age but is most common in children one to two years old who have not been exposed to the herpes virus before. Aphthous stomatitis begins in childhood or adolescence, with peak onset in those aged ten to 19 years. Aphthous ulcers may be more common in females than males. Children of higher socioeconomic status may be more affected than those who are from lower socioeconomic groups.

Causes and Symptoms

Causes

A number of factors can cause stomatitis. Cheek biting, braces, or jagged teeth may persistently irritate the oral structures. Chronic mouth breathing due to plugged nasal airways may cause dryness of the mouth tissues, which in turn leads to irritation. The cause of herpes stomatitis is the herpes virus type 1 (not to be confused with genital herpes, which is caused by the herpes virus type 2 and is a sexually transmitted disease). The cause of aphthous stomatitis is unknown, although several factors are suspected. There may be an inherited tendency to develop canker sores and there may also be an immune system link. In addition, they may be triggered by emotional stress; nutritional deficiencies of iron, folic acid, or vitamin B12; menstrual periods; food allergies; or viral infections. They may occur with no identifiable cause.

Symptoms

Stomatitis is characterized by pain or discomfort in the mouth and the presence of open sores or ulcers in the mouth. Herpes stomatitis may cause the following symptoms:

• fever, sometimes as high as 101–104°F (38.3–40°C), which may precede the appearance of blisters and ulcers by one or two days
• irritability and restlessness
• blisters in the mouth, often on the tongue or cheeks or roof of the mouth, which then pop and form ulcers (These ulcers are usually small [about one to five millimeters in diameter], grayish white in the middle, and red around the edges.)
• swollen gums, which may be irritated and bleed
• pain in the mouth
• drooling
• difficulty swallowing
• foul-smelling breath

Aphthous stomatitis may cause the following symptoms:

• burning or tingling sensation in the mouth prior to the onset of other symptoms
• skin lesions on the mucous membranes of the mouth, which begin as a red spot or bump, then develop into an open ulcer, which is usually small (one to two millimeters to one centimeter in diameter) (The ulcers can be single or break out in clusters. The ulcers are painful, and the center appears white or yellow with a fibrous texture. The border of the sore may be bright red.)

When to Call the Doctor

Parents should call the doctor if any of the following occur:

• inability to drink or swallow
• high temperature
• fussiness and inability to settle down
• symptoms not improved after three days

If the child appears dehydrated, parents should seek immediate medical attention. Signs include dry lips, the absence of tears when crying, a sinking soft spot on an infant's head, and no urination in eight hours or very dark urine. Parents should also seek care if the child is very weak, tired, or difficult to waken.

Diagnosis

Stomatitis is diagnosed by the doctor based primarily upon the appearance of the mouth sores. Both herpes and aphthous stomatitis have lesions that are unique in appearance. Although laboratory studies are seldom performed, the physician may order further blood tests or cultures of the lesions in order to confirm the diagnosis and rule out other causes.

Treatment

The treatment of stomatitis is based upon the problem causing it. For all types, local cleansing and good oral hygiene is fundamental. Sharp-edged foods such as peanuts, tacos, and potato chips should be avoided. A soft-bristled toothbrush should be used, and the teeth and gums should be brushed carefully. If toothbrushing is too painful, the child should rinse out his mouth with plain water after each meal. Local factors, such as sharp teeth or braces, can be addressed by a dentist or orthodontist.

Herpes Stomatitis Treatment

In herpes stomatitis, the most important part of treatment is for parents to keep their child drinking as normally as possible. Bland fluids such as apple juice, liquid flavored gelatin, or lukewarm broth are easiest to drink. Sucking on a Popsicle or sherbet may be soothing. Citrus juices and spicy or salty foods should be avoided. In the event of severe disease, the doctor may use intravenous fluids to prevent dehydration. Acetaminophen may be used for temperatures over 101°F (38.3°C) and to address pain. Medicines that numb the mouth, like viscous lidocaine or topical anesthetics only last for a brief time and, by numbing the mouth, may cause your child to further injure damaged tissues without knowing it. Antibiotics are of no help in treating herpes stomatitis. However, if the case is particularly severe, the doctor may prescribe an antiviral medication such as acyclovir which, if given at the beginning of the outbreak, may help clear things up faster.

Aphthous Stomatitis Treatment

Medical treatment is usually not necessary for aphthous stomatitis, unless the ulcers are severe (larger than one centimeter or lasting longer than two weeks). In this case medical evaluation and treatment may be indicated, and topical or oral tetracycline may be given. However, tetracycline is usually not prescribed for children until after all of their permanent teeth have erupted, as it can permanently discolor teeth that are still forming. Avoid hot or spicy foods to minimize discomfort. Mild mouth washes such as salt water or over-the-counter mouthwashes may help. Over-the-counter topical medications applied to the ulcerated area may reduce discomfort and sooth the area. To prevent bacterial infections from developing, parents should encourage their child to brush and floss teeth regularly.

Alternative Treatment

Placing a spent tea bag on a canker sore may provide comfort. Sodium lauryl sulfate (SLS), a component of some toothpastes, is a potential cause of canker sores. In one study, most recurrent canker sores were eliminated just by avoiding SLS-containing toothpaste for three months.

Nutritional Concerns

Some physicians may recommend a variety of dietary measures to treat stomatitis. These may include eating cottage cheese, buttermilk, and yogurt, as well as foods high in B vitamins. Some doctors may recommend supplementation with folic acid, iron, or vitamin B12.

Prognosis

The prognosis for the resolution of stomatitis is based upon the cause of the problem. Many mouth ulcers are benign and resolve without specific treatment. In the case of herpes stomatitis, complete recovery is expected within ten days without any medical intervention. Oral acyclovir may speed up recovery. Most children are minimally inconvenienced by aphthous stomatitis, because attacks are usually infrequent and only last a few days.

Prevention

Stomatitis caused by irritants can be prevented by good oral hygiene, regular dental checkups, and good dietary habits. Because so many adults and children carry the herpes virus, and because they can pass it on even if they have no symptoms, there is no practical way to prevent herpes stomatitis. Parents can, however, discourage their child from kissing, sharing food, or playing in close contact with people who have an active herpes infection.

Canker sores may be minimized by teaching children to avoid trauma, even minor trauma, to the mouth, such as hard toothbrushes and rough foods. If the doctor has determined that the child has a nutritional deficiency, parents can insure that the child is taking the appropriate supplements and eating the recommended foods. Avoiding stressful situations may also be beneficial.

Parental Concerns

Most cases of stomatitis in children are benign and resolve within a relatively short period of time. Children with herpes stomatitis may return to school or day care when their fever is gone and the mouth sores are healed. Since aphthous stomatitis is not contagious, there is no need to curtail a child's activities unless they have developed signs of complications, such as infection.

See also Canker sores.

Resources

Periodicals

Vander Schaaf, Rachelle. "Cool Relief for Canker Sores." Parenting 17, no. 6 (August 1, 2003): 38.

Organizations

American Dental Association. 211 E. Chicago Ave., Chicago, IL 60612. Web site: www.ada.org.

Web Sites

"Medical Encyclopedia: Herpetic Stomatitis." Medline Plus January 16, 2004. Available online at www.nlm.nih.gov/medlineplus/print/ency/article/001383.htm (accessed October 14, 2004).

Stine, Annie. "Gingivostomatitis (herpes mouth sores)." Babycenter.com 2004. Available online at www.babycenter.com/refcap/toddler/toddlerills/todthroatprobs/1201460.htm (accessed October 14, 2004).

[Article by: Deanna M. Swartout-Corbeil, RN Joseph Knight, PA]

Inflammation of the mucosa of the mouth. It may be caused by one of many diseases of the mouth or it may accompany another disease. Both gingivitis (inflammation of the gums) and glossitis (inflammation of the tongue) are forms of stomatitis as are palatitis (or lampas in horses) and cheilitis (inflammation of lips). The specific identification of stomatitis is an important part of a clinical examination in a food animal because of the need to identify the highly infectious vesicular diseases and bluetongue.

• angular s. — superficial erosions and fissuring at the angles (commissures) of the mouth.
• catarrhal s. — diffuse erythema of lips, tongue, cheeks; causes some discomfort and unwillingness to eat.
• contagious pustular s. — see horsepox.
• erosive s. — see erosive stomatitis.
• erosive–ulcerative s. — advanced stage of stomatitis characterized by multiple erosions and deeper ulcers; complete anorexia results.
• mycotic s. — see mycotic stomatitis.
• necrotic s. of calves — see oral necrobacillosis.
• papular s. — see bovine papular stomatitis.
• s.–pneumoenteritis complex — see peste des petits ruminants.
• proliferative s. — a very rare disease of cattle said to be caused by a filterable agent and recorded only in association with such conditions as chlorinated naphthalene poisoning. The lesions are papular and may also occur on the teats.
• vesicular s. — stomatitis characterized by vesicular lesions which soon rupture to leave denuded areas which become infected, necrotic, even ulcerative. See also vesicular stomatitis, vesicular exanthema of swine, swine vesicular disease, foot-and-mouth disease.

Stomatitis
Classification and external resources
Kwashiorkor sufferers show signs of thinning hair, edema, inadequate growth, and weight loss. The stomatitis on the pictured infant indicates an accompanying Vitamin B deficiency
ICD-10	K12.
ICD-9	528.0
DiseasesDB	27158
MeSH	[1]

Stomatitis is an inflammation of the mucous lining of any of the structures in the mouth, which may involve the cheeks, gums, tongue, lips, throat, and roof or floor of the mouth. The inflammation can be caused by conditions in the mouth itself, such as poor oral hygiene, poorly fitted dentures, or from mouth burns from hot food or drinks, or by conditions that affect the entire body, such as medications, allergic reactions, radiation therapy, or infections. ^[1]

Contents 1 Pathophysiology 2 Angular stomatitis 3 See also 4 References 5 External links

Pathophysiology

Severe iron deficiency anemia can lead to stomatitis. Iron is necessary for the upregulation of transcriptional elements for cell replication and repair. Lack of iron can cause the genetic downregulation of these elements, leading to ineffective repair and regeneration of epithelial cells, especially in the mouth and lips.

When it also involves an inflammation of the gingiva, it is called gingivostomatitis.

Angular stomatitis

Main article: Angular cheilitis

Irritation and fissuring in the corners of the lips is termed angular stomatitis or angular cheilitis. In children a frequent cause is repeated lip-licking and in adults it may be a sign of underlying iron deficiency anemia, or vitamin B deficiencies (e.g. B2-riboflavin, B9-folate or B12-cobalamin, which in turn may be evidence of poor diets or malnutrition (e.g. celiac disease).

See also

• Cheilitis
• Pyostomatitis vegetans
• Aphthous ulcer
• Bovine papular stomatitis

References

1. ^ "Effects of Smoking on Pregnancy" (PDF). The Reports of the Surgeon General. 1969. http://profiles.nlm.nih.gov/NN/B/B/L/N/_/nnbbln.pdf. Retrieved 2006-06-23. 

External links

• Health A-Z
• DrHull

v • d • e Oral pathology: Stomatognathic disease (K06-K14, 526-529) Hard, soft, and periapical tissues gingival disease (Gingivitis, Pericoronitis, Necrotizing ulcerative gingivitis, Noma) · Periodontitis  · Ulcer Dentofacial anomalies Gnathitis · jaw abnormality (Micrognathism, Prognathism, Retrognathism) Temporomandibular joint disorder Maxillomandibular anomalies Cherubism · Congenital epulis · Keratocystic odontogenic tumour · Torus mandibularis · Torus palatinus Salivary glands Sialadenitis (Parotitis) · Benign lymphoepithelial lesion · Necrotizing sialometaplasia · Ranula · Sialolithiasis saliva: Drooling/sialorrhea · Xerostomia Lip and oral mucosa lip: Cheilitis (Angular, Actinic) · Herpes labialis oral mucosa: Erythroplakia · Leukoplakia (Hairy leukoplakia) · White sponge nevus Tongue Glossitis (Geographic tongue) · Fissured tongue · Glossodynia · Black hairy tongue · Strawberry tongue Other Stomatitis (Aphthous ulcer, Herpetic stomatitis) Velopharyngeal inadequacy mouth navs: anat/dev, noncongen/congen face/congen GI/neoplasia, symptoms, proc

v • d • e Inflammation Acute Plasma derived mediators Bradykinin · complement (C3, C5a, MAC) · coagulation (Factor XII, Plasmin, Thrombin) Cell derived mediators preformed: Lysosome granules · vasoactive amines (Histamine, Serotonin) synthesized on demand: cytokines (IFN-γ, IL-8, TNF-α, IL-1) · eicosanoids (Leukotriene B4, Prostaglandins) · Nitric oxide · Kinins Chronic Macrophage · Epithelioid cell · Giant cell · Granuloma Processes Traditional: Rubor · Calor · Tumor · Dolor (pain) · Functio laesa Modern: Acute-phase reaction/Fever · Vasodilation · Increased vascular permeability · Exudate · Leukocyte extravasation · Chemotaxis Specific types Nervous CNS (Encephalitis, Myelitis) · Meningitis (Arachnoiditis) · PNS (Neuritis) · eye (Dacryoadenitis, Scleritis, Keratitis, Choroiditis, Retinitis, Chorioretinitis, Blepharitis, Conjunctivitis, Iritis, Uveitis) · ear (Otitis, Labyrinthitis, Mastoiditis) Cardiovascular Carditis (Endocarditis, Myocarditis, Pericarditis) · Vasculitis (Arteritis, Phlebitis, Capillaritis) Respiratory upper (Sinusitis, Rhinitis, Pharyngitis, Laryngitis) · lower (Tracheitis, Bronchitis, Bronchiolitis, Pneumonitis, Pleuritis) · Mediastinitis Digestive mouth (Stomatitis, Gingivitis, Gingivostomatitis, Glossitis, Tonsillitis, Sialadenitis/Parotitis, Cheilitis, Pulpitis, Gnathitis) · tract (Esophagitis, Gastritis, Gastroenteritis, Enteritis, Colitis, Enterocolitis, Duodenitis, Ileitis, Caecitis, Appendicitis, Proctitis) · accessory (Hepatitis, Cholangitis, Cholecystitis, Pancreatitis) · Peritonitis Integumentary Dermatitis (Folliculitis) · Cellulitis · Hidradenitis Musculoskeletal Arthritis · Dermatomyositis · soft tissue (Myositis, Synovitis/Tenosynovitis, Bursitis, Enthesitis, Fasciitis, Capsulitis, Epicondylitis, Tendinitis, Panniculitis) Osteochondritis: Osteitis (Spondylitis, Periostitis) · Chondritis Urinary Nephritis (Glomerulonephritis, Pyelonephritis) · Ureteritis · Cystitis · Urethritis Reproductive female: Oophoritis · Salpingitis · Endometritis · Parametritis · Cervicitis · Vaginitis · Vulvitis · Mastitis male: Orchitis · Epididymitis · Prostatitis · Balanitis · Balanoposthitis pregnancy/newborn: Chorioamnionitis · Omphalitis Endocrine Insulitis · Hypophysitis · Thyroiditis · Parathyroiditis · Adrenalitis Lymphatic Lymphangitis · Lymphadenitis

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