Stomatitis

Stomatitis is inflammation of the mucous membranes lining the mouth or lips, causing pain, redness, and sometimes sores that can make eating, drinking, and talking difficult.

Table of contents

• What is stomatitis?
• Types of stomatitis
• Areas affected
• Symptoms
• Causes
• Diagnosis
• Treatment
• Prevention
• Outlook

What is stomatitis?

Stomatitis, or oral mucositis (inflammation of the mouth’s mucous membranes), refers to inflammation in the tissue lining the mouth or lips^[1]. This is a type of mucositis, which includes inflammation involving the oral mucosa or any of the mucous membranes lining the gastrointestinal tract^[1].

Inflammation is the body’s natural response to injury, which means that most anything that damages the mucosa in the mouth can lead to stomatitis^[1]. The condition may be mild and localized or severe and widespread. It is invariably painful^[3]. Many causes of the inflammation are not serious and heal on their own, but others require prescriptions or other treatments^[1].

• Gums
• Tongue
• Lips
• Cheeks (inside)
• Roof of the mouth (palate)
• Floor of the mouth
• Throat

Types of stomatitis

The two most common types of stomatitis are canker sores and cold sores^[1].

Canker sores (aphthous stomatitis) appear inside the mouth, in places like the inner lip. They are single pale or yellow ulcers with a red outer ring or a cluster of such ulcers in the mouth, usually on the cheeks, tongue, or inside the lip^[2]. Canker sores can be painful and usually last 5 to 10 days^[2]. They tend to come back but are generally not associated with fever^[2]. Canker sores are not contagious^[2].

Cold sores (herpetic stomatitis) are fluid-filled blisters that appear alone or in clusters on the lip or around the mouth^[1]. They rarely form on the gums or the roof of the mouth^[2]. Cold sores later crust over with a scab and are usually associated with tingling, tenderness, or burning before the actual sores appear^[2]. They are usually painful and are usually gone in 7 to 10 days^[2]. Cold sores are contagious^[2].

Less common types of stomatitis include^[1]:

• Angular cheilitis (angular stomatitis): Involves irritation, cracks, and sores in the corners (“angles”) of the mouth.
• Thrush (candidal stomatitis): Involves an overgrowth of candida fungi in the mouth.
• Contact stomatitis: Involves inflammation that happens inside the mouth because of an allergic reaction.
• Denture stomatitis: Involves irritation in the mouth that often happens alongside candidal stomatitis. It mostly affects people who wear dentures.
• Gingivostomatitis: A viral or bacterial infection that leads to inflammation of the mouth or gums.
• Nicotine stomatitis: Affects people who smoke or use tobacco. Signs include white, cobblestone-like patches of tissue in the roof of the mouth.

Areas affected

Stomatitis can occur anywhere in the mouth, including the inside of the cheeks, gums, tongue, lips, and palate^[2]. The inflammation may be localized in a precise point of the oral mucosa or involve the oral mucosa in a diffuse and generalized manner^[6].

Depending on the area of occurrence, it may be associated with secondary disorders such as gingivitis (gums), glossitis (tongue), or cheilitis (lips)^[6].

Symptoms

Signs and symptoms of stomatitis include^[1]:

• Redness and swelling inside the mouth
• A tiny blister (or cluster of blisters) that appears on or around the lips
• One or more sores inside the mouth that are usually white, gray, or yellow, with a red border
• White or gray patches on the tongue, the roof of the mouth, or inside the cheeks
• The sensation that the tongue and the roof of the mouth are burning
• Mild to severe pain or discomfort that may make it difficult to eat, swallow, or talk

The blisters may make it difficult or painful to eat, drink, or swallow. Dehydration is a risk if drinking is uncomfortable^[7]. Drooling, pain, and swollen gums can also occur^[7]. If extremely painful, the lesions can make food intake problematic, leading to dehydration and malnutrition^[6]. In some cases, general symptoms such as fever and enlarged lymph nodes also appear^[6].

Causes

Stomatitis can have many causes, including viral infections, mouth injuries, and immune system conditions^[1]. Stomatitis may be caused by local infection, systemic disease, a physical or chemical irritant, or an allergic reaction; many cases are idiopathic (without known cause)^[3].

Infections: The most common infectious disease that causes stomatitis is HSV-1, the herpes virus that causes cold sores^[1]. Cold sores are caused by a virus called herpes simplex type 1. The initial infection often occurs before adulthood and may be confused with a cold or the flu^[2]. Once a person is infected with the virus, it stays in the body, becoming dormant and reactivated by such conditions as stress, fever, trauma, hormonal changes, and exposure to sunlight^[2]. Other viral infections, as well as bacterial and fungal infections, can also cause stomatitis^[1].

Mouth injuries: Most anything that damages the delicate mucous membrane inside the mouth triggers the body’s healing response, causing inflammation^[1]. Causes range from ill-fitting dentures that scrape the inside of the mouth to heat damage from smoking cigarettes^[1]. Mouth irritation can be caused by biting the cheek, tongue, or lip, wearing braces or another type of dental apparatus, having a sharp broken tooth, chewing tobacco, or burning the mouth from hot food or drinks^[2].

Allergic reactions or mouth irritation: Substances that you are allergic to or that irritate the mouth can cause oral mucositis. Causes may include ingredients in dental products (like mouthwash), cosmetics (like lipstick), or spicy foods^[1].

Cancer treatments: Oral mucositis is a common cancer treatment side effect. Treatments like chemotherapy and radiation therapy kill cancer cells, but they can damage healthy cells in the process^[1]. The cells in the mucous membranes lining the mouth are particularly vulnerable^[1]. Stomatitis occurs in approximately 20 to 40 percent of patients receiving chemotherapy and cancer treatments, such as radiation to the head and neck^[16]. Patients receiving a bone marrow transplant have an over 70 percent chance of developing stomatitis^[16].

Nutritional deficiencies: Deficiencies of iron, vitamin B2 (riboflavin), vitamin B3 (niacin), vitamin B6 (pyridoxine), vitamin B9 (folic acid), or vitamin B12 (cobalamin) may all manifest as stomatitis^[5]. Canker sores may also be related to low levels of vitamin B12 or folate^[2].

Other contributing factors: Other causes include poor oral hygiene, certain medications (trauma to the mouth), poor nutrition, stress, bacteria or viruses, lack of sleep, sudden weight loss, and certain foods such as potatoes, citrus fruits, coffee, chocolate, cheese, and nuts^[2]. Canker sores may also be related to a temporarily reduced immune system because of a cold or flu, hormonal changes, or from a genetic predisposition^[2]. Having certain autoimmune diseases affecting the mucosal lining of the mouth, such as lupus, Crohn’s disease, or Behçet’s disease can also cause stomatitis^[2].

Diagnosis

Stomatitis can be diagnosed by a careful examination of the patient’s mouth, tongue, and lips^[16]. Doctors or dentists make the diagnosis based on the pain and the appearance of the canker sores or cold sores^[9].

History of present illness should ascertain the duration of symptoms and whether the patient ever had them previously. The presence and severity of pain should be noted. The relation of symptoms to food, drugs, oral hygiene materials, and other substances is sought^[3].

In some cases, additional tests may be ordered. A blood test may be done to detect infection^[16]. Sometimes a scraping of the lining of the mouth may be sent to the laboratory to identify a specific organism causing the infection^[16]. In addition, blood tests, cultures of the lesions, or a biopsy (taking a small piece of tissue from the lesion and examining it microscopically) may be performed to help confirm the diagnosis and rule out other causes for the ulcers^[8].

Treatment

Treatment is based on the cause of stomatitis^[6]. Treatment usually is not necessary for minor canker sores, which tend to clear on their own in a week or two^[15]. But large, persistent, or unusually painful sores often need medical care^[15]. Many causes of inflammation are not serious and heal on their own, but others require prescriptions or other treatments that involve seeing a healthcare provider^[1].

The most important part of treatment is to keep the mouth and teeth clean^[16]. Treating the underlying condition clears the inflammation. In the meantime, medications can ease symptoms^[1].

Mouth rinses: If you have several canker sores, your doctor may prescribe a mouth rinse containing the steroid dexamethasone to reduce pain and inflammation or lidocaine to reduce pain^[15]. Chlorhexidine mouth rinses are often recommended^[9].

Topical products: Over-the-counter and prescription products (pastes, creams, gels, or liquids) may help relieve pain and speed healing if applied to individual sores as soon as they appear^[15]. Some products have active ingredients such as benzocaine, fluocinonide, or hydrogen peroxide^[15]. If there are fewer canker sores, doctors recommend other corticosteroids such as fluocinonide or clobetasol applied as an ointment or mixed in a protective carboxymethylcellulose paste^[9].

Oral medications: Oral medications may be used when canker sores are severe or do not respond to topical treatments. If the corticosteroids that are applied directly to the affected area do not work, prednisone tablets may be taken by mouth^[9]. These may include medications not intended specifically for canker sore treatment, such as the intestinal ulcer treatment sucralfate used as a coating agent and colchicine, which is normally used to treat gout^[15].

Pain relief: Pain medicine in the form of a topical anesthetic such as lidocaine gel, systemic inflammatory or narcotic pain medications, or both may be used^[16]. Acetaminophen can be used for fever or pain^[8].

For cold sores: Antiviral medications may be prescribed for cold sores since they are caused by the herpes virus^[7].

For fungal infections: If your doctor gave you mouthwash or lozenges to treat a yeast infection (thrush), use them as directed^[14].

For antibiotics or other medications: If prescribed by your doctor, take them as directed^[14].

Prevention

Taking proactive steps can help prevent stomatitis^[1]:

Good oral hygiene: Regular brushing, flossing, and using antiseptic mouthwash can keep infections at bay^[1]. Practice good oral hygiene. Use a very soft toothbrush to brush your teeth at least two times a day^[14].

Regular dental checkups: Visiting a dentist regularly ensures early detection and treatment of oral issues^[1]. One way to prevent or lessen the severity of stomatitis is to find and treat oral problems before cancer treatment begins^[16].

Healthy diet: A balanced diet rich in vitamins and minerals supports overall oral health^[1]. Eating a well-balanced diet can help the body tolerate the stress of treatment and fight infection^[16].

Avoid irritants: Avoid consuming hot foods and beverages, as well as spicy, salty, and citrus-based foods^[14]. Avoid drinking high-acid juices such as orange, grapefruit, and cranberry juices^[14]. Do not use a mouthwash or other over-the-counter rinse with alcohol, as these can dry out your mouth or cause more pain^[14].

Eat soft foods: Eat soft foods such as mashed potatoes and other cooked vegetables, noodles, applesauce, clear broth soups, yogurt, and cottage cheese^[14]. Avoid eating spicy or crunchy foods^[14]. Try eating cold foods such as ice cream or yogurt^[14].

Stay hydrated: Drink plenty of fluids to prevent dehydration. Drinking through a straw may help with pain^[14].

Rinse your mouth: Make a rinse to keep your mouth from getting dry. Add 1 teaspoon of baking soda and ½ teaspoon salt to 4 cups of water. Use it to rinse your mouth 4 to 6 times each day. Spit out the rinse. Do not swallow it^[14].

Outlook

Many causes of inflammation are not serious and heal on their own^[1]. Mouth sores usually do not last very long. Even without treatment, you will be free of them in two weeks^[14]. It can take up to 2 weeks for the sores to heal^[14].

Canker sores usually last 5 to 10 days and tend to come back^[2]. In minor cases, which are the most usual, the ulcers heal within 4 to 14 days. In more severe cases, which account for about 1 in 10 of all cases of stomatitis, the sores can last up to 6 weeks^[4].

Cold sores are usually gone in 7 to 10 days^[2]. They tend to last for around 5 to 7 days and can keep coming back^[4]. When sores reappear, they tend to form in the same location^[2].

Follow-up care is a key part of your treatment and safety. Be sure to make and go to all appointments, and call your doctor if you are having problems^[14]. Watch closely for changes in your health, and be sure to contact your doctor if you do not get better as expected^[14].

Stomatitis can affect a patient’s cancer treatment and quality of life^[16]. Symptoms hinder eating, sometimes leading to dehydration and undernutrition. Secondary infection occasionally occurs, especially in patients with immunocompromise^[3].