Stomatitis
John G. Spangler
Stomatitis represents a broad category of oral mucosal infections and inflammatory lesions that are more common in the adult population than tension headaches, phlebitis, or arthralgias. In one large survey, the 30 most common lesions accounted for 93% of all oral lesions (1).
Approach
A. Stomatitis categories include the following: (a) premalignant or malignant lesions; (b) human immunodeficiency virus (HIV)-related lesions (e.g., Kaposi’s sarcoma, oral hairy leukoplakia); (c) infections that may be bacterial (e.g, necrotizing ulcerative gingivitis), viral [e.g., herpes simplex virus (HSV), hand-foot-mouth disease], or fungal (e.g., thrush, angular cheilitis); (d) ulcerative and erosive conditions (e.g., Behçet’s disease, autoimmune disorders); (e) traumatic and irritant lesions; and (f) drug-related eruptions (Stevens–Johnson syndrome, chemotherapy-associated mucositis).
B. Special concerns. Treatable infections such as thrush should be recognized promptly and in certain clinical situations may raise the suspicion of underlying immunosuppression. Premalignant and malignant disorders need prompt diagnosis and treatment to optimize survival. Oral signs of some systemic diseases, such a Behçet’s disease or drug-related Stevens–Johnson syndrome, may be life threatening and require urgent attention. In general, any oral ulceration, patch, or plaque that does not heal within 2 weeks needs referral for definitive diagnosis and treatment (2).
History
A. Characteristics of the oral lesion. Describe the onset: Was it abrupt, suggesting infection; or insidious, suggesting inflammatory or neoplastic origin? Are there associated signs and symptoms? Many oral infections are associated with pain, malaise, and fever. Behçet’s disease has associated ocular and genital lesions, whereas other autoimmune diseases such as systemic lupus erythematosus (SLE) or ulcerative colitis may have systemic symptoms (3). Describe the lesions: Are they painful or painless? Infections? Inflammatory lesions and aphthous ulcers are usually painful (3), whereas premalignant and malignant lesions may be painless (2,4). Are there vesicles or bullae? Pemphigoid and pemphigus can cause bullae or ulcers. HSV starts as vesicular lesions, then ulcerates. Varicella zoster lesions can occur in the mouth (3,5). Did vesicles precede the lesions, suggesting HSV, or was there ulceration without vesicles, suggesting aphthous ulcers (3)? Are the lesions white and will they not wipe off of the mucosa? Leukoplakia, a premalignant lesion, is white and will not wipe off. Any coexisting red component, called erythroplakia, greatly increases the malignant potential of the lesion (2,4). Lichen planus also produces a striated white lesion, usually on the buccal mucosa (3). Where are the lesions? HSV tends to occur on periosteally bound mucosa (gingiva, hard palate), whereas recurrent aphthous ulcers occur on nonperiosteally bound mucosa (buccal, lip, or tongue mucosa) (3). The floor of the mouth under the tongue, the lateral aspects of the tongue, the retromolar regions, and the soft palate are worrisome areas for malignancy to develop (4), but malignancy can occur anywhere.
B. Past medical history. Does the patient have systemic inflammatory conditions such as SLE or lichen planus? Has the patient had the lesions previously? Aphthous ulcers and HSV tend to recur. Does the patient wear dentures making him or her more susceptible to denture stomatitis or angular cheilitis, both caused by Candida species (5)? Are HIV-risk factors present, making oral hairy leukoplakia, Kaposi’s sarcoma, and severe oral candidiasis more likely (5)? Do family members or other close associates have similar symptoms, suggesting enteroviral infections (e.g., herpangina and hand-foot-mouth disease) (Chapter 13.3)? Is the patient on any medications known to cause oral drug-related eruptions? Sulfonamides and many other drugs can cause Stevens–Johnson syndrome, whereas recent cancer chemotherapy can produce severe mucosal inflammation.
C. Social history. Does the patient use alcohol or tobacco, thus increasing the risk for premalignancy or malignancy (2,4)? Has there been exposure to known oral irritants such as foods or spices or potential irritants such as chemicals or new mouth care products? Is the patient sexually active and has there been oral–genital contact? Syphilis and gonorrhea can both occur in the oropharynx.
Physical examination
A. Head, eyes, ears, nose, and throat (HEENT). Based on the history, a focused physical examination of the HEENT is necessary. Look for signs of trauma. Examine the conjunctiva and nasal mucosa for inflammatory changes or ulcerations. Evaluate the patient for coexisting upper respiratory signs and symptoms such as rhinorrhea, sinus tenderness to palpation, and otitis media. Inspect facial skin for vesicles from HSV or varicella-zoster or other lesions such as echymoses, malar rash, or viral exantham. Look for facial asymmetry. Varicella-zoster can cause facial nerve paralysis, called the “Ramsay Hunt syndrome.” Evaluate preauricular, postauricular, and cervical lymph node chains. Finally, evaluate the oral cavity, documenting the size, location, and appearance of the lesion.
B. Additional physical examination. Based on findings from the HEENT examination, additional physical examination might include (a) pulmonary examination for viral pneumonitis or pulmonary findings in autoimmune diseases; (b) abdominal and rectal examination for Crohn’s disease or ulcerative colitis; (c) genitourinary examination for mucosal ulcers in Behçet’s disease and Stevens–Johnson syndrome, and for signs of syphilis or gonorrhea; (d) a general skin examination looking for viral exanthemas, drug eruptions, lichen planus, pemphigus, pemphigoid, and SLE; and (e) a musculoskeletal examination for signs of SLE, Reiter’s syndrome, or other autoimmune diseases (3).
Testing
A. Clinical laboratory testing should be guided by history and physical findings. A potassium hydroxide wet mount is useful in the diagnosis of candidiasis. Viral and bacterial cultures can be obtained from swabs of oral lesions, but viral cultures are usually more helpful than bacterial cultures. Darkfield microscopy can be performed from swabs of syphilis chancres or plaques. Cytologic scrapings of premalignant or malignant lesions, prepared in a manner similar to a Pap smear, are not a substitute for biopsy of suspected oral neoplasia (2,4).
B. Diagnostic imaging is indicated only in selected cases such as coexisting sinus disease [“mini” sinus computed tomogram (CT)], coexisting neck mass or lymphadenopathy suggestive of malignant disease (head and neck CT), suspected metastatic disease (chest x-ray study; CT of the head, abdomen, and chest), or trauma (cervical spine series; cranial CT; dental Panorex films). If HSV is suspected, cranial magnetic resonance imaging (MRI) may be useful to evaluate the temporal lobes. A chest x-ray study is also indicated in suspected lower respiratory tract disease such as viral or autoimmune pneumonitis or secondary bacterial pneumonia. If a severe lip laceration has occurred, plain films can help to rule out mandibular condylar fractures or tooth fractures.
Diagnostic assessment
The diagnosis of stomatitis depends on synthesis of the aforementioned key historical, physical examination, laboratory, and imaging elements. All oral ulcers that do not heal, as well as white or reddish-white lesions that do not resolve in 2 weeks, need biopsy to rule out malignancy (2,4).
References
1. Yeatts D, Burns JC. Common oral mucosal lesions in adults. Am Fam Physician 1991;44:2043–2050.
2. Silverman S. Oral cancer, 4th ed. Hamilton, Ontario: BC Decker, 1998.
3. Salisbury PL, Jorizzo JL. Oral ulcers and erosions. Adv Dermatol 1993;8:31–79.
4. Mashberg A, Samit A. Early diagnosis of asymptomatic oral and oropharyngeal squamous cell cancer. CA Cancer J Clin 1995;45:328–351.
5. Laskaris G. Oral manifestations of infectious diseases. Dent Clin N Am 1996;40:
395–423.
Book Source Details
- Book Title: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter
- Author(s): Robert B. Taylor (editor)
- Year of Publication: 2000
- Copyright Details: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter, Copyright © 2000 Lippincott Williams & Wilkins.
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Copyright Details: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter, Copyright © 2008 Williams & Wilkins.
More About Causes of Tongue symptoms
» Next page: Stomatitis and other oral infections (Handbook of Diseases)
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