Stomatitis

Author Credentials 

Camille Huwyler, MD
Resident Physician
Head and Neck Surgery
Kaiser Permanente East Bay
Oakland, California

Benjamin D. Malkin, MD, FACS
Attending Physician
Head and Neck Surgery
Kaiser Permanente East Bay
Oakland, California

Module Summary

Stomatitis refers to a broad group of inflammatory and ulcerative lesions of the oral cavity. Clinical context and physical exam--often combined with pathologic testing--are key to diagnosis and effective treatment.

 

Module Learning Objectives 
  1. Review the anatomy, physiology, and histologic characteristics of the oral cavity.
  2. Diagnose the causes of stomatitis based on the clinical picture, physical exam findings and pathologic characteristics.
  3. Describe treatment strategies for common causes of stomatitis.

 

Embryology

Learning Objectives 
  1. Describe the embryology and development of the oral cavity.
References 
  1. Winning TA, Townsend GC. Oral mucosal embryology and histology. Clin Dermatol 2000;18(5):499-511.
  2. Chen J, Jacox LA, Saldanha F, Sive H. Mouth development. Wiley Interdiscip Rev Dev Biol 2017;6(5):e275. 

Anatomy

Learning Objectives 
  1. Describe the anatomy of the oral cavity subsites.
  • Lips
  • Buccal mucosa
  • Gingiva
  • Tongue
  • Hard palate
  • Floor of mouth
  • Retromolar trigone
  1. Compare the mucosal histology of different sites within the oral cavity.
  2. Describe the innervation of the various structures of the lips and oral cavity, giving rise to motor control, somatosensation and gustatory sensation.
References 
  1. Madani M, Berardi T, Stoopler ET. Anatomic and examination considerations of the oral cavity. Med Clin North Am. 2014;98(6):1225-38.
  2. Travers JB, Travers SP, and Christian JM. Physiology of the Oral Cavity. Cummings Otolaryngology, 88, 1281-1297.e5.
  3. Winning TA, Townsend GC. Oral mucosal embryology and histology. Clin Dermatol 2000;18(5):499-511. 

Pathogenesis

Learning Objectives 
  1. Describe the pathogenesis of common painful, ulcerative oral lesions.
  • Infectious
  • Viral - Herpes (labialis, gingivostomatitis), HIV
  • Fungal - Candidiasis
  • Iatrogenic
  • Erythema multiforme
  • Chemotherapy or radiation-induced mucositis
  • Metabolic
  • Autoimmune/Idiopathic
  • Recurrent aphthous stomatitis
  • Mucous membrane pemphigoid
  • Pemphigus vulgaris
  • Oral lichen planus
References 
  1. Porter SR, Scully C. Aphthous stomatitis—an overview of aetiopathogenesis and management. Clin Exp Dermatol 1991;16(4):235-43.
  2. Balasubramaniam R, Kuperstein AS, Stoopler ET. Update on oral herpes virus infections. Dent Clin North Am 2014;58(2):265-80.
  3. Sugerman PB, Savage NW, and Walsh LJ: The pathogenesis of oral lichen planus. Crit Rev Oral Biol Med 2002; 13:350-365.
  4. Ellepola AN, and Samaranayake LP: Inhalational and topical steroids and oral candidosis: a mini review. Oral Dis 2001; 7:211-216.
  5. Villa A, Sonis ST. Mucositis: pathobiology and management. Curr Opin Oncol 2015;27(3):159-64.
  6. Samim F, Auluck A, Zed C, Williams PM. Erythema multiforme: a review of epidemiology, pathogenesis, clinical features, and treatment. Dent Clin North Am 2013;57(4):583-96.

Incidence

Learning Objectives 
  1. Describe the prevalence of common oral mucosal lesions.
  2. Recognize the potential of oral lichen planus to undergo malignant transformation.

 

References 
  1. Shulman JD, Beach MM, Rivera-Hidalgo F. The prevalence of oral mucosal lesions in US adults: data from the Third National Health and Nutrition Examination Survey, 1988–1994. J Am Dent Assoc 2004;135(9):1279-86.
  2. Miller MF, and Ship II: A retrospective study of the prevalence and incidence of recurrent aphthous ulcers in a professional population, 1958-1971. Oral Surg Oral Med Oral Pathol 1977; 43:532-537.
  3. Aghbari SMH at al. Malignant transformation of oral lichen planus and oral lichenoid lesions: A meta-analysis of 20095 patient data. Oral Oncol 2017;68:92-102.

Patient Evaluation

Learning Objectives 
  1. Distinguish between and characterize the physical exam findings of various causes of stomatitis.

 

References 
  1. Leão JC, Gomes VB, Porter S. Ulcerative lesions of the mouth: an update for the general medical practitioner. Clinics (Sao Paulo) 2007;62(6):769-80.
  2. Hargitai IA. Painful Oral Lesions. Dent Clin North Am 2018;62(4):597-609.
  3. AAO-HNSF The ENT Exam Episode 2: The Oral Cavity and Neck Exam. 

Pathology

Learning Objectives 
  1. Describe the pathologic findings associated with stomatitis diseases.

 

References 
  1. Woo S. Diseases of the oral mucosa. McKee's Pathology of the Skin. 2012, 362-436.
  2. Magliocca KR, Fitzpatrick SG. Autoimmune Disease Manifestations in the Oral Cavity. Surg Pathol Clin 2017;10(1):57-88.

Medical Therapies

Learning Objectives 
  1. Describe the treatment for common infectious and inflammatory causes of stomatitis including aphthous ulcers, herpes stomatitis, Candidiasis, erythema multiforme, lichen planus.
  2. Review the treatment of chemo(radio)therapy-associated mucositis.
References 
  1. Lalla RV et al. MASCC/ISOO clinical practice guidelines for the management of mucositis secondary to cancer therapy. Cancer 2014;120(10):1453-61.
  2. Ellepola AN, and Samaranayake LP. Oral candida infections and antimycotics. Crit Rev Oral Biol Med 2002;11:172-198.
  3. Samim F, Auluck A, Zed C, Williams PM. Erythema multiforme: a review of epidemiology, pathogenesis, clinical features, and treatment. Dent Clin North Am 2013;57(4):583-96.
  4. Stoopler E, and Balasubramaniam R. Topical and systemic therapies for oral and perioral herpes simplex virus infections. J Calif Dent Assoc 2013;41:259-262.
  5. Scully C, Gorsky M, and Lozada-Nur F: The diagnosis and management of recurrent aphthous stomatitis: a consensus approach. J Am Dent Assoc 2003;1143:200-202.

Staging

Learning Objectives 
  1. Review the available staging systems for oral mucositis.
References 

Sonis ST et al. Perspectives on cancer therapy-induced mucosal injury: pathogenesis, measurement, epidemiology, and consequences for patients. Cancer 2004;100(9 Suppl):1995-2025.

Review

Review Questions 
  1. What proportion of patients with longstanding lichen planus develop oral SCC? 1% (Aghbari)
  2. What component of the adaptive immune response contributes to the pathogenesis of erythema multiforme? Autoreactive T-cells (Samim)
  3. What treatments can be used to prevent chemo(radio)therapy-associated mucositis? Palifermin, benzydamine mouthwash, oral cryotherapy (Lalla 2014)
  4. T/F Intraoral pemphigus vulgaris often precedes cutaneous manifestations. T (Hargitai)
References 
  1. Aghbari SMH at al. Malignant transformation of oral lichen planus and oral lichenoid lesions: A meta-analysis of 20095 patient data. Oral Oncol 2017;68:92-102.
  2. Samim F, Auluck A, Zed C, Williams PM. Erythema multiforme: a review of epidemiology, pathogenesis, clinical features, and treatment. Dent Clin North Am 2013 Oct 1;57(4):583-96.
  3. Lalla RV et al. MASCC/ISOO clinical practice guidelines for the management of mucositis secondary to cancer therapy. Cancer 2014;120(10):1453-61.
  4. Hargitai IA. Painful Oral Lesions. Dent Clin North Am 2018;62(4):597-609.
Resources 

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  1. Annual Meeting Webcast (AMW):