Doctors Revision

Oral & Dental Health

Stomatitis

General term for inflammation of the mucous lining of any structures in the mouth (oral mucosa), which may involve the cheeks, gums, tongue, lips, palate.

Also known as: Mouth Sores, Oral Mucositis

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Referral and warning signs

When to refer

Refer to Dentist/Physician/Specialist if: Diagnosis uncertain. Severe symptoms. Lesions persist >2-3 weeks despite initial treatment. Suspected systemic cause or malignancy. Recurrent severe episodes.

Red flags

  • Lesions persisting > 3 weeks.
  • Indurated (hardened) base or rolled borders of an ulcer (suspicious for malignancy).
  • Associated systemic symptoms (fever, weight loss, skin rash).
  • Difficulty breathing or swallowing.
  • Signs suggesting severe systemic illness (e.g., Stevens-Johnson syndrome, Pemphigus).

Signs and symptoms

  • Redness, swelling, soreness, or burning sensation of the oral mucosa.
  • Pain, especially when eating or drinking.
  • Presence of ulcers, blisters, or erosions.
  • Bleeding gums.
  • Dry mouth or increased salivation.
  • Difficulty swallowing or speaking.
  • Bad breath (halitosis).
  • Specific appearance depends on cause (e.g., white patches in thrush, vesicles in herpes, ulcers in aphthous stomatitis).

Risk factors

  • Infections (Viral: Herpes Simplex, Varicella Zoster, Coxsackie; Bacterial: ANUG; Fungal: Candida/Thrush).
  • Nutritional deficiencies (Iron, B vitamins - B12, folate, B6; Vitamin C, Zinc).
  • Trauma (ill-fitting dentures, sharp teeth, accidental bites, hot food burns).
  • Allergic reactions (to foods, medications, dental materials).
  • Irritants (tobacco, alcohol, harsh mouthwashes).
  • Medications (chemotherapy, radiation therapy, certain drugs causing dry mouth or hypersensitivity).
  • Systemic diseases (Autoimmune: Lichen planus, Pemphigus, Pemphigoid, Behcet's; Inflammatory bowel disease; HIV/Immunosuppression).
  • Aphthous stomatitis (recurrent canker sores - cause often unknown).
  • Poor oral hygiene.

Diagnosis

Clinical assessment

Based on history and clinical examination of the oral cavity, identifying the location, appearance, and pattern of inflammation/lesions. History should explore potential causes (diet, meds, habits, systemic illness).

Differential diagnosis

Wide, depends on presentation. Includes specific infections (Herpes, Candida, ANUG), Aphthous ulcers, Lichen planus, Pemphigus/Pemphigoid, Erythema multiforme, Allergic reaction, Nutritional deficiency glossitis/stomatitis, Geographic tongue, Trauma, Malignancy (Squamous cell carcinoma).

Investigations

  • Often clinical diagnosis.
  • Swab for fungal smear (KOH), bacterial culture, viral PCR (if specific infection suspected).
  • Blood tests (FBC, Iron studies, Vit B12/Folate, HIV test, RPR/VDRL) if nutritional deficiency or systemic cause suspected.
  • Biopsy of lesion (if persistent, atypical, or malignancy suspected).

Diagnostic criteria

Clinical evidence of inflammation of the oral mucosa.

Management

Non-pharmacological management

  • Identify and Address Underlying Cause: (e.g., treat infection, correct deficiency, adjust medication, improve denture fit, avoid irritants).
  • Maintain Good Oral Hygiene: Gentle brushing with soft toothbrush, saline rinses.
  • Dietary Modification: Avoid spicy, acidic, hard, or hot foods that irritate.
  • Hydration: Maintain adequate fluid intake.

Pharmacological treatment

  • Symptomatic Relief:
  • - Topical Analgesics/Anaesthetics: Lidocaine viscous solution or gel applied before meals. Benzydamine spray/mouthwash. (LOC: HC2+)
  • - Antiseptic Mouthwashes: Chlorhexidine 0.12%/0.2% or Warm Salt Water rinses TID (helps prevent secondary infection). (LOC: HC2)
  • - Systemic Analgesia: Paracetamol or NSAIDs.
  • Specific Treatment (based on cause):
  • - Oral Candidiasis (Thrush): Nystatin suspension/tablets or Fluconazole (See ODH019).
  • - Herpetic Stomatitis: Acyclovir (See ODH020).
  • - ANUG: Metronidazole +/- Amoxicillin (See ODH014).
  • - Aphthous Ulcers: Topical steroids (Triamcinolone paste), Chlorhexidine rinse (See ODH018).
  • - Nutritional Deficiencies: Appropriate supplements (Iron, B vitamins, etc.).

Monitoring

Monitor resolution of symptoms and lesions. Follow up based on underlying cause.

Complications

  • Pain, difficulty eating/drinking leading to dehydration/malnutrition.
  • Secondary infection of ulcers/erosions.
  • Chronic pain.
  • Scarring (in some conditions like major aphthae).

Prevention

  • Maintain good oral hygiene.
  • Balanced diet.
  • Avoid tobacco and excessive alcohol.
  • Manage systemic diseases.
  • Regular dental check-ups.

Patient education

  • Explanation of the likely cause.
  • Oral hygiene instructions.
  • Dietary advice.
  • How to use prescribed medications (mouthwashes, topicals).
  • Avoidance of irritants.
  • When to seek follow-up.

Uganda-specific notes

Common causes include infections (Candida, Herpes, ANUG associated with HIV), nutritional deficiencies, and trauma. Differentiate from specific conditions.

References

  • Uganda Clinical Guidelines (UCG) 2023

    Chapter 23, Section 23.2.9

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