Stomatitis

Stomatitis: Excerpt from The 5-Minute Pediatric Consult

Lee R. Atkinson-McEvoy, MD

Stomatitis - BASICS

Stomatitis - description

• Inflammation of the mucous membranes of the mouth
• Gingivostomatitis is when stomatitis is accompanied by inflammation of the gingiva.
• Recurrent aphthous stomatitis, known more commonly as canker sores, does not have an identified infectious agent.
• Herpangina is a disease caused by coxsackievirus group A and marked by stomatitis consisting of 1–2-mm oral vesicles and ulcers, and systemic symptoms, most notably fever.

Stomatitis - general prevention

• Hand washing can prevent spread of viral infections.
• Due to the long life of enteroviruses on surfaces, toys and other objects used by affected children should be sterilized before being used by other children.
• Contact isolation should be observed for children with viral stomatitis in the hospital setting.

Stomatitis - epidemiology

• Enteroviral infections occur commonly in summer and fall months.
• Recurrent aphthous stomatitis has a prevalence of 20–37% in children.
• Herpes simplex virus (HSV) type 1:
  • Up to 90% of the adult population has serologic evidence of previous infection.
• Age of child:
  • Herpangina and herpetic gingivostomatitis occur in infants, toddlers, and preschool-aged children.
  • Coxsackievirus (hand-foot-and-mouth disease) occurs most frequently in toddlers and young school-aged children.
  • Aphthous stomatitis occurs in older children and adults.

Stomatitis - pathophysiology

• Infection, inflammation, or trauma leads to interruption of the integrity of the mucosal epithelium.
• Ongoing inflammation leads to further denudation of the epithelium.
• Inflammatory cells and mediators can produce exudates and erythema of the ulceration.

Stomatitis - etiology

• Multiple etiologies, with viral infections (e.g., HSV type 1) and recurrent aphthous stomatitis being the most common in children
• Recurrent aphthous stomatitis is believed to be mediated by antibody-dependent cell-mediated cytotoxicity due to multifactorial insults, including trauma, stress, hormonal fluctuations, infections, vitamin or nutritional deficiencies, and allergens.There is also a familial tendency in 40% of cases.
• Herpangina is caused by coxsackievirus group A.
• Stomatitis:
  • Enteroviruses, including coxsackievirus
  • HSV, particularly type 1

Stomatitis - DIAGNOSIS

Stomatitis - signs & symptoms

• Inflammation
• Pain in the mouth
• Decreased intake
• Drooling
• Fever
• Malaise
• Diarrhea
• Constitutional symptoms

Stomatitis - history

• Ask about associated symptoms:
  • Fever, malaise, diarrhea, or other constitutional symptoms occur with coxsackievirus, herpangina, and primary herpetic gingivostomatitis.
• Ask about chronic medical problems:
  • Immunodeficiency states (e.g., HIV and neutropenia), poor nutritional status, and inflammatory bowel disease are associated with development of mucosal ulceration.
• Ask about medications and possible exposures to medications:
  • Medications, particularly penicillins, sulfa-containing drugs, and antiepileptics, have been associated with Stevens-Johnson syndrome, which has oral mucositis as part of its constellation of symptoms.

Stomatitis - physical exam

• Recurrent aphthous stomatitis lesions are usually round to oval and have a white-yellow fibrinous pseudomembranous cap.
• Enteroviral infections are associated with small shallow ulcerations with smooth borders on the posterior oral cavity structures such as the tonsils, soft palate, and pharynx. In addition, vesicular lesions may be present on the palms and soles.
• Hand-foot-and-mouth disease, due to coxsackievirus (a type of enterovirus) consists of lesions in the mouth as well as the palms and soles.
• Herpangina consists of oral vesicles and ulcers, typically around the fauces, near the tonsillar pillars.
• HSV infections are shallow ulcers with irregular, erythematous borders that coalesce; they are found on the lips, tongue, and gingiva.
• Gingivitis in association with stomatitis is usually present in drug-induced causes of stomatitis, as well as with HSV.
• Herpetic whitlow is the transmission of herpes virus and development of lesions on the extremities, notably the fingers, due to direct contact with lesions in the mouth.
• Varicella presents with grouped vesicles or erosions on the tongue, gingival, buccal mucosa and lips. The lesions are shallow ulcers with erythematous borders that usually do not coalesce. In addition, diffuse vesicles in varying stages of healing can be found on the skin, particularly the trunk and extremities. In severe cases, there may be lesions in the oral cavity particularly on the soft palate.
• Smallpox may also present with small red spots on the tongue and in the oral mucosa following a prodromal period with fever. These then can become ulcerated. This is followed by the development of a diffuse erythematous rash that becomes papular over the entire body, including the palms and soles. The rash becomes pustular, then crusted.
• Stevens-Johnson syndrome presents with large irregular ulcers, which may occasionally be deep. There is occasionally a hemorrhagic component to these ulcers. Ulcers are also sometimes present on other mucosal surfaces. Target lesions, bullae, and urticarial lesions may also be present.
• Behçet syndrome and Reiter syndrome may have painless ulceration of the oral mucous membranes.
• Oral lichen planus is a chronic inflammatory disease usually seen in adults but can occur in children. It causes bilateral white striations, papules, or plaques on the buccal mucosa, tongue, and gingivae. Erythema, erosions, and blisters may or may not be present.
• Familial Mediterranean fever syndrome is an autosomal recessive disease that presents with painful febrile episodes. Unassociated with these episodes are recurrent oral aphthae.

Stomatitis - tests

Usually there is no need for laboratory testing for simple stomatitis. If there are other systemic signs of illness (e.g., diarrhea or arthritis), a more thorough workup for more severe illnesses such as Crohn disease, Reiter syndrome, or cyclic neutropenia should be done.

Stomatitis - lab

• HSV can be diagnosed with direct fluorescent antibody staining, rapid enzyme immunoassay, or viral culture of the lesion.
• Enteroviruses can be cultured from stool, nasopharyngeal, throat, CSF, and blood specimens.
• Polymerase chain reaction of CSF fluid also can diagnose an enteroviral infection.

Stomatitis - differencial diagnosis

• Infection:
  • Enteroviruses, including coxsackievirus
  • HSV
  • Varicella
  • Smallpox (variola)
  • Candidal infection
  • HIV-associated aphthous ulcers
• Hemologic:
  • Cyclic neutropenia
• Trauma
• Medications (e.g., chemotherapeutic agents)
• Miscellaneous:
  • Stevens-Johnson syndrome
  • Oral lichen planus
  • Reiter syndrome or disease (reactive arthritis, rash, conjunctivitis, urethritis, diarrhea, and stomatitis with painless erosive ulcers)
  • Behçet syndrome (associated with ulcerations of the oral and genital mucous membranes)
  • Crohn’s disease
  • PFAPA syndrome: Periodic fever, aphthous stomatitis, pharyngitis, and adenitis

Stomatitis - TREATMENT

Stomatitis - general measures

Rinses:

• Salt-water rinses (normal saline or 1 tsp of table salt mixed with 16 oz of tepid water or 1 tsp of baking soda with 32 oz of water) q1–2 h while ulcers are present may aid in reducing pain and shortening the duration of the ulceration.
• Magic mouthwash: Equal parts of diphenhydramine and Maalox^TM or Kaopectate^TM. In severe cases, 2% viscous lidocaine can be added in an equal amount, but care must be taken to limit the application of lidocaine on ulcerated mucosa, as it may be absorbed and possibly result in arrhythmias. In addition, when applied to the posterior pharynx, lidocaine can decrease the gag reflex, increasing the risk of aspiration.

Stomatitis - medication

• Analgesics:
  • Acetaminophen or ibuprofen
  • Acetaminophen with codeine may be used in severe cases, when intake of fluids is greatly affected by pain. Codeine should be used cautiously, as it may cause constipation and CNS depression.
  • Viscous lidocaine 2% (but see “General Measures”)
  • Silver nitrate in a single application for recurrent aphthous stomatitis has been shown to reduce the severity of pain without altering healing time.
  • Topical nonsteroidal anti-inflammatory agents or corticosteroids may be required for severe recurrent aphthous ulcers may require.
• Acyclovir can be given orally for herpes simplex infections to decrease the length of infection, but in order to be effective it needs to be given within the 1st 48 hours of development of oral lesions. Acyclovir usually is more beneficial when used for household contacts who begin to exhibit symptoms, and when treatment can be initiated early. Topical acyclovir has not been shown to be effective.

Stomatitis - FOLLOW UP

Stomatitis - prognosis

• Most cases of stomatitis are mild and resolve within 1–2 weeks.
• HSV stomatitis is most severe during the initial infection; however, it tends to recur in response to stress or trauma, as the virus has a long latent period within the nerves of the face, particularly the trigeminal nerve.
• Recurrent aphthous stomatitis also recurs in response to stress or trauma.

Stomatitis - complications

• Infectious:
  • Cellulitis
  • Lymphadenitis
• Miscellaneous:
  • Dehydration, particularly in young children
  • Pain

Stomatitis - patient monitoring

Young children should be followed closely. If dehydration occurs due to poor oral intake, IV rehydration should be considered.

Stomatitis - bibliography

American Academy of Pediatrics. Summaries of infectious diseases. In: Pickering LK, ed. 2006 Red Book: Report of the Committee on Infectious Diseases. 27th ed. Elk Grove Village, IL: American Academy of Pediatrics; 2006:284–285, 361–371, 591–595, 711–725.
1. Bruce AJ, Rogers RS. Acute oral ulcers. Dermatol Clin. 2003;21:1–15.
2. Padeh S. Period fever syndromes. Pediatr Clin North Am. 2005;52:577–609.
3. Pichichero ME, McLinn S, Rotbart HA, et al. Clinical and economic impact of enterovirus illness in private pediatric practice. Pediatrics. 1998;102:1126–1134.
4. Scott DA, Coulter WA, Lamey P-J. Oral shedding of herpes simplex virus type 1: A review. J Oral Pathol Med. 1997;26:441–447.
5. Siegel MA. Strategies for management of commonly encountered oral mucosal disorders. J Calif Dent Assoc. 1999;27:210–227.
6. Witman PM, Rogers RS. Pediatric oral medicine. Dermatol Clin. 2003;21:157–170.
7. Zunt SL. Recurrent aphthous stomatitis. Dermatol Clin. 2003;21:33–39.

Stomatitis - CODES

Stomatitis - icd9

528.0 Stomatitis

Stomatitis - FAQ

• Q: Is stomatitis contagious?
• A: Yes, this is a contagious infection. To avoid spreading the illness, careful hand washing should be done. In cases of suspected enteroviral infections, careful sterilization of toys and surfaces with which the affected child has contact should be done before use by unaffected children.
• Q: How can I get my child to take food and liquids if stomatitis is painful?
• A: The inability to stay hydrated is one of the complications of stomatitis. Children will not have their regular intake of solids due to mechanical effects of these on painful ulcers. Using regular analgesics, such as acetaminophen or ibuprofen, can help decrease pain. Topical administration of magic mouthwash (see “General Measures”) before offering fluids may be helpful. Small amounts of nonacidic, cool liquids (and popsicles) frequently may be better tolerated than large amounts given all at once. If your child has decreased urine output or altered mental status, seek medical attention.
• Q: When should I take my child to see medical care?
• A: Children with stomatitis are at high risk for dehydration if they have many lesions. If your child won’t take even sips of liquids, has marked decreased urine output, or is lethargic and difficult to arouse, bring him in to be evaluated. If the lesions do not heal in 7–10 days, bring your child in to be evaluated.
• Q: When can my child return to school/day care?
• A: Young children with herpes or enteroviral stomatitis can infect others via oral secretions. In cases of young children who drool frequently or place toys in their mouths, there is a high risk for transmitting the illness. Children become less contagious when the lesions heal. In the case of varicella, children are contagious until all vesicles are crusted over.

Book Source Details

• Book Title: The 5-Minute Pediatric Consult
• Author(s): M. William Schwartz MD; et al.
• Year of Publication: 2008
• Copyright Details: The 5-Minute Pediatric Consult, Copyright © 2008 Lippincott Williams & Wilkins.

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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.

More About This Book: Title: The 5-Minute Pediatric Consult Authors: M. William Schwartz MD; et al. Publisher: Lippincott Williams & Wilkins Copyright: 2008 ISBN: 0-7817-7577-9

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