Infectious Disease and Microbiology – Stomatitis

Stomatitis is inflammation of the oral mucosa, which may be localized or widespread. It can result from infectious causes, trauma, allergy, nutritional deficiencies, medications, smoking, or systemic disease.

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Common forms include recurrent aphthous stomatitis, herpetic stomatitis, hand-foot-and-mouth disease, herpangina, oral candidiasis, acute necrotizing ulcerative gingivitis, and noma.

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Recurrent aphthous stomatitis, herpetic stomatitis, and hand-foot-and-mouth disease are common. Oral candidiasis is particularly frequent in immunocompromised patients, people receiving broad-spectrum antibiotics, diabetics, and patients treated with systemic or inhaled corticosteroids.

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Herpangina, hand-foot-and-mouth disease, and primary herpetic gingivostomatitis occur predominantly in children, whereas acute necrotizing ulcerative gingivitis is seen more often in adolescents and young adults.

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Noma, also called cancrum oris or gangrenous stomatitis, is a severe destructive disease involving oral soft tissue and bone. It occurs mainly in severely malnourished children, particularly in resource-limited settings.

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Important risk factors for stomatitis include smoking, alcohol use, antibiotic therapy, corticosteroid or other immunosuppressive treatment, HIV infection, malignancy, poor oral hygiene, and problematic dentures.

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General prevention includes smoking cessation, adequate oral hygiene, careful denture cleaning, and removal of complete dentures during sleep.

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Etiology

Oral candidiasis is caused by Candida species and commonly affects the tongue, buccal mucosa, palate, and gingiva.

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The exact cause of recurrent aphthous stomatitis is unknown. It is generally regarded as an inflammatory condition rather than a direct infection.

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Viruses are common causes of infectious stomatitis. Herpes simplex virus can cause primary and recurrent herpetic stomatitis, while enteroviruses such as coxsackieviruses cause herpangina and hand-foot-and-mouth disease.

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Acute necrotizing ulcerative gingivitis, historically called Vincent stomatitis or trench mouth, is associated with a polymicrobial anaerobic flora including Prevotella intermedia, Fusobacterium species, and oral spirochetes.

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Noma is also polymicrobial and is associated with anaerobic and fusospirochetal organisms such as Fusobacterium nucleatum and other oral bacteria.

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Noninfectious causes include drug or food allergy, contact reactions, vitamin deficiencies, trauma from dentures, smoking, anemia, uremia, Behçet disease, collagen vascular disorders, and other systemic illnesses.

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Riboflavin deficiency may cause angular stomatitis, while niacin deficiency can produce oral abnormalities as part of pellagra.

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Clinical Presentation

Symptoms depend on the underlying cause. Patients may complain of oral pain, gingival tenderness, difficulty eating, fever, or malaise.

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Oral Candidiasis

Pseudomembranous oral candidiasis produces creamy-white, curd-like plaques that can usually be wiped away, leaving an erythematous underlying surface.

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Erythematous candidiasis produces red, friable, tender plaques rather than the classic white coating.

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Aphthous Stomatitis

Recurrent aphthous stomatitis presents as small, round or oval, clearly demarcated painful ulcers within the oral cavity.

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These lesions usually heal spontaneously and typically do not leave scars.

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Herpetic Stomatitis

Primary herpetic gingivostomatitis occurs mainly in children and often begins with fever, malaise, and fatigue, followed by multiple painful vesicles.

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The vesicles rupture and become moist ulcers surrounded by an erythematous inflammatory border.

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Recurrent herpes can be precipitated by sun exposure, emotional stress, trauma, fever, or other systemic illness.

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Herpetic gingivostomatitis generally favors the anterior oral cavity, including the gingiva, lips, tongue, and hard palate.

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Herpangina

Herpangina usually begins with fever, sore throat, and painful swallowing.

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Small vesicles and ulcers surrounded by erythematous rings occur mainly on the soft palate, uvula, tonsillar pillars, and posterior pharyngeal wall.

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This posterior location helps distinguish herpangina from herpetic gingivostomatitis.

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Hand-Foot-and-Mouth Disease

Hand-foot-and-mouth disease generally causes oral ulcers accompanied by skin lesions on the hands and feet.

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Lesions can also appear on the buttocks and groin. The illness is usually mild and self-limited.

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Acute Necrotizing Ulcerative Gingivitis

Necrotizing ulcerative gingivitis produces painful gingival necrosis, especially involving the interdental papillae.

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The gingiva develops a characteristic punched-out, eroded appearance, often covered by a gray pseudomembrane.

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Halitosis and gingival bleeding are common.

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Noma

Noma is substantially more aggressive than ordinary necrotizing gingivitis.

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It can rapidly progress from oral ulceration to extensive destruction of the cheek, lips, gingiva, jaw, and facial soft tissues.

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Diagnosis

Diagnosis is primarily based on the clinical appearance and distribution of the oral lesions.

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Cultures, stains, and molecular tests may be useful when the diagnosis is uncertain or the patient is immunocompromised.

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In oral candidiasis, microscopy may demonstrate budding yeast with or without pseudohyphae.

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For suspected herpes infection, PCR is generally the most useful confirmatory test. Viral culture or direct antigen testing may also be performed.

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Historically, a Tzanck smear may demonstrate multinucleated giant cells, although it is neither highly specific nor the preferred modern diagnostic method.

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Any persistent, chronically recurrent, atypical, indurated, or nonhealing oral lesion should be biopsied to exclude malignancy or another serious disorder.

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Differential Diagnosis

The principal differential diagnoses include herpetic stomatitis, herpangina, hand-foot-and-mouth disease, recurrent aphthous stomatitis, oral candidiasis, necrotizing ulcerative gingivitis, and noma.

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Treatment

Most forms require supportive and cause-specific treatment.

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Oral Candidiasis

Mild oral candidiasis may be treated with topical agents such as nystatin or clotrimazole.

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Moderate-to-severe disease is commonly treated with oral fluconazole.

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Predisposing factors such as unnecessary antibiotics, poorly controlled diabetes, improper denture hygiene, or corticosteroid exposure should be corrected when possible.

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Aphthous Stomatitis

Treatment is mainly symptomatic.

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Topical anesthetics, antiseptic mouth rinses, and topical corticosteroids may reduce pain and inflammation.

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Systemic therapy is reserved for severe or refractory disease and should generally be directed by a clinician experienced in recurrent oral ulceration.

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Herpetic Stomatitis

Significant primary herpetic stomatitis may be treated with acyclovir or valacyclovir, particularly when therapy is started early.

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Severely immunocompromised patients may require intravenous acyclovir.

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Acyclovir-resistant HSV infection may require foscarnet, particularly in advanced immunosuppression.

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Coxsackievirus Disease

Herpangina and hand-foot-and-mouth disease usually require no specific antiviral treatment.

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Management consists of hydration, analgesia, and supportive care.

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Necrotizing Ulcerative Gingivitis

Treatment includes professional oral cleaning or debridement, meticulous oral hygiene, pain control, and antibiotics when systemic or extensive disease is present.

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Metronidazole or penicillin-class antibiotics may be used according to the clinical situation.

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Noma

Noma requires urgent and comprehensive management, including antibiotic therapy, nutritional rehabilitation, wound care, treatment of dehydration or systemic illness, and removal of loose teeth or necrotic tissue when indicated.

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Major facial deformities may later require reconstructive surgery.

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Additional Care

Smoking should be discontinued, problematic dentures should be corrected, and oral hygiene should be optimized.

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Topical anesthetics and systemic analgesics can help control oral pain.

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Patients who cannot maintain adequate oral intake because of severe pain may require liquid nutrition, oral rehydration, intravenous fluids, or hospitalization.

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Spicy, acidic, or otherwise irritating foods may worsen symptoms and can be temporarily avoided.

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Follow-Up

Most viral stomatitis and uncomplicated aphthous episodes resolve within approximately 7–14 days.

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Persistent, recurrent, unusual, or nonhealing lesions require reassessment and often biopsy.

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Complications

Severe herpes infection can occasionally involve the eye or central nervous system, particularly in immunocompromised patients.

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Severe stomatitis can cause dehydration, malnutrition, and inability to maintain oral intake.

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Noma can result in severe facial destruction, functional disability, sepsis, and death.

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High-Yield Pattern

White removable plaques → oral candidiasis

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Small recurrent painful ulcers → aphthous stomatitis

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Anterior oral vesicles/ulcers + gingivitis → herpetic gingivostomatitis

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Posterior oral vesicles/ulcers → herpangina

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Oral ulcers + hand and foot lesions → hand-foot-and-mouth disease

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Painful punched-out necrotic gingiva + halitosis → acute necrotizing ulcerative gingivitis

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Rapidly destructive oral/facial necrosis in a malnourished child → noma