Stomatitis

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Sara Mehrsefat, M.D. [2], Usama Talib, BSc, MD [3]

Stomatitis is an inflammation of the mucous lining of any structure in the mouth, which may involve the cheeks, gums, tongue, lips, throat, and/or the roof or floor of the mouth. The inflammation can be the result of conditions within the mouth itself, such as poor oral hygiene, poorly fitted dentures, or mouth burns from hot food or drinks. It may also be caused by conditions that affect the entire body, such as medications, allergic reactions, or infections. A form of stomatitis known as stomatitis nicotina can be caused by smoking cigars, cigarettes, and/or pipes, and is characterized by small red bumps on the roof of the mouth.^[1]

When stomatitis also involves an inflammation of the gingiva, it is called gingivostomatitis. Irritation and fissuring in the corners of the lips is termed angular stomatits or angular cheilitis. In children, a common cause of angular stomatitis is repeated lip-licking; in adults, it may be a sign of underlying iron deficiency anemia, or vitamin B deficiencies (e.g., B2-riboflavin, B9-folate, or B12–cobalamins), which in turn may be evidence of poor dietary habits or malnutrition (e.g., celiac disease).

There is no established classification system for stomatitis. Stomatitis can be classified on the basis of aetiology or on the basis of the pathogens involved. The infectious and non-infectious types of stomatitis may include:^[2][3]

• Infectious
  • Bacterial
    • Necrotizing ulcerative stomatitis or stomatitis gangrenosa (Noma)^[4]
  • Viral
    • Herpetic gingivostomatitis
    • Vincent’s stomatitis (Trench Mouth)
  • Fungal
    • Candidal stomatitis^[5]
• Non-infectious
  • Autoimmune
    • Aphthous stomatitis
    • SLE
    • Pemphigus vulgaris
    • Bullous pemphigoid
    • SJS
    • Pyostomatitis vegetans
  • Drug-induced
    • Chemotherapy
    • Antibiotics
    • Antihistamine
    • Monoclonal antibodies
    • Antirheumatic agents
  • Irritant induced
    • Denture stomatitis
    • Contact stomatitis^[6]
    • Stomatitis nicotina
  • Other causes
    • Tumors
    • Black hairy tongue
    • Burning mouth syndrome
    • Migratory stomatitis or geographic stomatitis
    • Ulcerative or chronic ulcerative stomatitis^[7][8]

Stomatitis is the inflammation of the mucosal surfaces in the mouth. Various factors can contribute to the pathogenesis of stomatitis depending on the type of stomatitis.^[9]

• A definitive pathogenesis for aphthous stomatitis is not known. The proposed mechanism involves immune system abnormalities and the presence of autoimmune antibodies. It is thought to be caused by some types of cytokine and T cell accumulation, manifesting as a defective cell-mediated arm of immunity. Recurrence is very common in aphthous ulcers.^[10][11][2]

Various causes, including herpes virus, lack of oral hygiene, and nutritional deficiencies, can lead to the development of stomatitis. The most common causes of stomatitis include:^[12][13][9]

• Aphthous stomatitis
• Dentures
• Folate deficiency
• Herpes
• Oropharyngeal candidiasis
• Vitamin B12 deficiency
• Chemotherapy

Stomatitis should be differentiated from various subtypes of stomatitis, as well as from many other disease that can involve the oral cavity, such as agranulocystosis, Behcet’s disease, immunodeficiency, and tumors of the oral cavity (e.g., leukoplakia).^[3][14]

The epidemiology and demographics vary among different kinds of stomatitis.

• Herpetic gingivostomatitis commonly affects children between 6 months and 5 years of age. It occurs less frequently in other age groups.^[12]
• Noma or gangrenous stomatitis commonly affects children.^[3]
• Pyostomatitis vegetans commonly affects individuals between the age of 20 and 50 years.^[15]

Common risk factors in the development of stomatitis include alcohol, smoking, trauma, stress, nutritional deficiency, and immunocompromised status.^[16] The risk factors believed to influence the development of stomatitis include:^[17][18]

• Smoking
• Alcohol
• Trauma
• Psychological stress
• H. pylori
• Sensitivity to food
• Nutritional abnormalities
• Immunologic deficiencies (e.g., HIV)
• Genetic factors
• Chemotherapy or radiotherapy^[19]
• Poor denture hygiene^[20][21]

According to the the U.S. Preventive Service Task Force (USPSTF), there is insufficient evidence to recommend routine screening for stomatitis.^[22]

If left untreated, herpetic stomatitis resolves after the vesicles erupt and the ulcers heal. The HSV travels along the nerves and moves to the ganglions where it stays in latent form. When the host becomes immunocompromised after taking medications or due to some other illness, the virus assesses the opportunity and through the same nerves becomes active once again manifesting symptoms such as oral vesicles.^[12] The viral shedding can continue for 2-12 days after primary infection.^[23]

Some complications of stomatitis include:^[12][24]

• Meningoencephalitis
• Recurrent skin and mouth infections
• Dissemination of the infection
• Teeth loss

The prognosis of stomatitis is generally good.

It is necessary to collect a thorough history and understanding of the symptoms in order to arrive at a diagnosis of stomatitis. The diagnosis of stomatitis is mostly clinical. The location and features of the ulcers are also important findings for this purpose. Previous history of bad breath and refusal to eat or drink are common among patients presenting with an episode.^[12] Some general symptoms associated with herpetic stomatitis include:^[12]

• Fever
• Anorexia
• Irritability
• Drooling
• Malaise
• Headache

A thorough history and physical exam are a necessary for a detailed understanding and diagnosis of stomatitis. The diagnosis of stomatitis is mostly clinical. The location and features of the ulcers are also important findings in this regard. The exam findings may include:

• Oral pin-head vesicles
• Oral mucosal ulcers
• Submandibular lymphadenitis
• Halitosis

History and physical examination are the primary means of diagnosing stomatitis. If required, laboratory findings can play an important role in diagnosing and differentiating between different types of stomatitis. Viral culture, Tzanck smear for active lesions, serology, studies using immunofluorescent techniques, and PCR are a few techniques normally used to diagnoses herpetic stomatitis.

There are no X ray findings associated with stomatitis.

There are no CT findings associated with stomatitis.

There are no MRI findings associated with stomatitis.

There are no ultrasound findings associated with stomatitis.

Preventive measures and medical therapy are the mainstay of therapy for stomatitis. The medical therapy varies for various causes and types of stomatitis.The therapy for stomatitis is governed by following principles:^[25]

• Oral or IV hydration
• Pain control
• Application of a barrier cream or jelly
• Zilactin, a combination of lidocaine and hydroxypropyl cellulose, used to prevent trauma and irritation^[26]

Surgical intervention is not recommended for the management of most types of stomatitis. It is not preferred unless there is a suspicion for an oral tumor or a biopsy is required for the diagnosis of the exact type of stomatitis. Surgical debridement may be done for Noma or trench mouth. Surgery is sometimes performed for cosmetic reasons (e.g., in the case of noma/gangrenous stomatitis).

Effective measures for the primary prevention of stomatitis include:

• Adequate hydration
• Oral hygiene
• Denture hygiene
• Prevention of exposure to bovine papular stomatitis virus-infected cow

Effective measures for the secondary preventive measures for stomatitis include:

• Treatment of IBD prevents the development of pyostomatitis vegetans.^[27]
• Treatment of candidiasis

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Sara Mehrsefat, M.D. [2], Usama Talib, BSc, MD [3]

The term aphthae was first used by Hippocrates to describe disorders of the mouth between 460-370 B.C.^[1]

• Between 460-370 B.C., in relation to disorders of the mouth, the term aphthae was first used by Hippocrates.^[1]
• In 1898, the first clinical description of the aphthous stomatitis was reported by Von Mikulicz and Kumme as a Mikuliez aphthea.
• In 1911, stomatitis aphthae recurrens cicatricicans was first described by Sutton.
• In 1961, stomatitis aphthae recurrens herpetiformis was first described by Cooke.^[2]

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Sara Mehrsefat, M.D. [2], Usama Talib, BSc, MD [3]

There is no established classification system for stomatitis. Stomatitis can be classified on the basis of etiology and on the basis of the pathogens involved.^[1][2]

According to the etiology, stomatitis may be classified into:^{[1][2][3][4][5][6][7][8][9]}

Stomatitis

Infectious

Non-infectious

Viral

Fungal

Bacterial

Autoimmune

Drug-induced

Irritant induced

Other causes

•HSV •VZV •HIV •Coxsackie virus •Bovine papular stomatitis virus •CMV •Trench mouth

•Candida stomatitis •Other fungi   •Cryptococcus    •Histoplasma capsulatum

•Noma    •Treponema    •Prevotella •Other bacteria    •Bartonella    •H. pylori    • Mycobacterium avium

• Aphthous stomatitis    • Major    • Minor    • Herpetiform • SLE • Pemphigus vulgaris •Bullous pemphigoid • SJS • Pyostomatitis vegetans

• Chemotherapy • Antibiotics • Antihistamine • Monoclonal antibodies •Antirheumatic agents • For detailed drug list click here

• Denture stomatitis    • Gold    • Fitting    • Hygiene • Contact stomatitis • Nicotinic stomatitis

• Oral tumors • Migratory stomatitis • Black hairy tongue •Burning mouth syndrome •Genetic    • Inherited epidermolysis bullosa

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Sara Mehrsefat, M.D. [2], Usama Talib, BSc, MD [3]

Stomatitis is the inflammation of the mucosal surfaces in the mouth. Various factors can contribute to the pathogenesis of stomatitis depending on the type of stomatitis.^[1]

Different mechanism are understood to cause different types of stomatitis:^[1]

• Herpetic stomatitis:
  • This type is causes by HSV-1 virus. It is caused by the destructive effect of the virus on the tissues in the form of break down of the infected cells. The infection may start as vesicles that are typically pin-head like and ultimately rupture, resulting ulceration. As a characteristic to the virus these ulcers are painful, irregular in appearance and often have a yellow-grey covering layer.
  • After the lesions resolve, the virus travels though the nerves to the nerve cells and goes into a latent stage. It can then reactivate when the person becomes immunocompromised and cause symptoms.^[2]
  • Encephalitis associated with herpetic stomatitis is due to the interaction of HSV-1 with Toll-like receptor 2 or TLR2.
• Zoster stomatitis or chicken pox:
  • Zoster stomatitis is caused by VZV.
  • The vesicles of zoster stomatitis are found in a cluster on one side of the hard palate. The vesicles can also be found the buccal mucosa, gingival tissue and the tongue.

• Noma or Gangrenous stomatitis:
  • Gangrenous stomatitis is also known as Noma or ‘cancrum doris’. Noma or gangrenous stomatitis is focal and destructive infection caused by Borrelia vincentii, Fusobacterium and Bacteroides. It is an acute infection of the tissues in the orofacial region. Immunocompromised individuals are predisposed to develop this condition. Noma or gangrenous stomatitis is more common in children. The infection can begin as a spot or vesicle on the gingival surface of the mandibular molars and premolars. This spot or vesicle is red initially and painful and develops into an ulcer. The lesion has cone shaped expansion with bone, teeth and tissue underneath being exposed after the soft tissue sloughs off.^[3]
• Bovine papular stomatitis:
  • Bovine papular stomatitis is a zoonotic disease. It is caused by bovine papular stomatitis virus, starting as a single lesion and becoming a nodular mass ultimately. The virus has chemokine binding proteins that prevent the neutrophils and monocytes from migrating to the site of the pathology.^[4][5]

• Trench mouth or Acute necrotizing ulcerative gingivitis:
  • Trench mouth also known as vincent’s angina, presents as ulceration and severe oral pain accompanied by gingival necrosis. It is characterised by acute onset of bad breath and the ulceration and destruction of the part of gum tissue present between the teeth. The scrapings from the necrotic ulcer contains fibrin, leukocytes, erythrocytes, bacteria and necrotic tissue. Fever and lymphadenopapthy may accompany.^[6][7]

• Hand Foot and Mouth disease:
  • It is also called enteroviral vesicular stomatitis with exanthem. It is caused by coxsackie virus group A and involves maculopapular rash on the skin of the hands , the feet and the mouth including vesicles and ulcers on the tongue, gums, buccal mucosa and the soft palate.^[8]

• Candidal Stomatitis:
  • Candidal stomatitis is also known as oral candidiasis. It can occur exclusively or as part of systemic candidiasis in immunocompromised individuals. It can be can present a hyperplastic or erythematous pictures due to the invasion by the virus. Glossitis has also been noticed.^[9]

• HIV:
  • Ulcers in the mouth are very common presentation for HIV-1 infected individuals. The ulcers are superficial and have a clear demarcation. Autoimmune deficiency is thought to be the pathogenic factor behind the oral ulcers and stomatitis related to HIV.^[10][11][12]

• Aphthous stomatitis:
  • It is the most common cause of oral ulcers. A definitive pathogenesis does not exist for aphthous stomatitis, but the proposed mechanism involves immune system abnormalities and the presence of autoimmune antibodies. It is thought to be caused by some types of cytokine and T cell accumulation manifesting as a defective cell mediated arm of the immunity. It presents as round ulcers with a grey base. Recurrence is very common in aphthous ulcers.^[13][14][15]
  • It may take the following forms:
    • Major aphthous stomatitis
      • This type can last up to a few months and involves tonsils and the soft palate as well. It can subside for long intervals and then reappear.
    • Minor aphthous stomatitis
      • This is the characteristic form of aphthous stomatitis; it is characterized by yellow-grey, painful minute ulcers in the anterior oral cavity in the buccal and oral mucosa with raised margins. They can last from a few days up to 2 weeks.
    • Herpetiform stomatitis
      • These are multiple in number and effect the tongue at the lateral part and the tip. Ulcers are grey and very painful and are often accompanied by inability to eat. Intra nuclear inclusions can be found in the ulcers.

• Chemotherapy-associated stomatitis:
  • The chemotherapy causes RNA and DNA damage by the reactive oxygen species leading to an excessive production of inflammatory cytokines. These cytokines cause inflammation thus causing breaks in the epithelium.

• Denture stomatitis:
  • Denture stomatitis effects upto 67% of denture wearers. It moct commonly affects the palatal mucosa.^[16] The material used in fillings and dentures are porous because of the chemicals used and to give it a better grip. Pathogens like candida albicans can colonize such suitable sites, leading to an inflammatory response and thus denture stomatitis. The irritating effect of the foreign denture material can also contribute to the pathogenesis.^[17][18]

• Pyostomatitis vegetans:
  • Pyostomatitis vegetans is characterized by numerous painless, yellow, superficial pinpoint pustules with edema of the mucosa of the mouth. It is found in patients with ulcerative colitis. The vesicles can combine and involve the vermillion border of the upper as well as the lower lips. Snail track ulcerations are characteristic of pyostomatitis vegetans.^[19][20]
  • The involvement of skin along with the oral mucosa is characteristic of an entity called pyodermatitis pyostomatitis vegetans.^[21]

• Nicotinic stomatitis:
  • As the name indicates, nicotinic stomatitis is caused by use of nicotine in cigarette or pipe smokers. It normally occurs on the hard palate of individuals who use pipes to smoke. The pathogenesis is explained by the heat and not the tobacco, and thus there is no malignant potential. The condition improves within 1 to 2 weeks of smoking cessation.^[22][23][24]
• Contact stomatitis:
  • Allergic substances present in products used for oral hygiene can lead to contact stomatitis. The pathogenesis of contact stomatitis involves an allergic response to the aromatic substances in the oral, cosmetic, or hygiene products.^[25]

Though the genetics of stomatitis have not been studied extensively, it is understood that genetic polymorphisms are associated with the occurrence of stomatitis. Inherited epidermolysis bullosa is a known inherited disease and is associated with weak epithelium. ^[26]

The following conditions can be associated with stomatitis.^[2][27][1]

• Dentures
• Folate deficiency
• Herpes
• Oropharyngeal candidiasis
• Vitamin B12 deficiency
• Chemotherapy
• Immunodeficiency
• Diabetes
• HIV
• Hand, foot and mouth disease
• Candidiasis
• Syphilis
• Chicken pox

The gross pathology of stomatitis can vary from redness and inflammation to presence of vesicles or pustules. Oral candidiasis for example may present a hyperplastic picture, erythematous picture or whitish pseudomembrane (thrush).

The microscopic pathology helps to confirm the diagnosis and to differentiate different types of stomatitis.^[30]

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Sara Mehrsefat, M.D. [2], Usama Talib, BSc, MD [3]

Various pathogens including herpes virus, Ebola, HIV, lack of oral hygiene and nutritional deficiencies can cause stomatitis along with many other causes.^[1][2]

Life-threatening causes include conditions which may result in death or permanent disability within 24 hours if left untreated.

• Ebola

The common causes of stomatitis include:^[3][4][5]

• Dehydration
• Dentures
• Folate deficiency
• Herpes
• Oropharyngeal candidiasis
• Vitamin B12 deficiency
• Chemotherapy and radiotherapy
• Drugs

Some causative factors for the infectious subtypes of stomatitis include:

The following pathogens can cause stomatitis in HIV:^[6]

• Mycobacterium avium intracellulare
• Helicobacter pylori
• Leishmania
• Amoeba
• HSV
• CMV
• Interferon
• Foscarnet
• Histoplasma
• Cryptococcus

Causes of gangrenous stomatitis include:^[7][8]

• Borrelia
• Fusobacterium
• Bacteroides
• Borrelia vincentii
• Porphyromonas gingivalis
• Tannerella forsynthesis
• Staphylococcus aureus
• Nonhemolytic Streptococcus spp

• Spirochetes^[9]
  • Borrelia
  • Treponema spp
• Prevotella intermedia^[10]
• Fusobacterium necrophorum
• Bacteroides

• Bovine papular stomatitis virus^[11][12]

• Coxsackie Virus Group A^[10]

• Candida sp^[13]

• Smoking with a pipe^[14]

• Aromatic substances in products used for oral hygiene^[15][16]

Cardiovascular	Kawasaki disease
Chemical/Poisoning	Bismuthia, gold, mercury poisoning, nickel, thallium
Dental	Angular cheilitis, angular stomatitis, aphthous stomatitis, aphthous ulcer, burning mouth syndrome, dentures, desquamative gingivitis, dry mouth, herpetic gingivostomatitis, hypertrophic gums, nicotine stomatitis, oral lesions, oral submucous fibrosis, oral ulceration, trench mouth, ulcerative gingivitis, Vincent’s angina
Dermatologic	Behcet’s disease, bismuthia, erythema multiforme, gluten-sensitive enteropathy associated conditions, lip balm, pemphigoid, Stevens-Johnson syndrome, vesicular stomatitis with exanthem, warts
Drug Side Effect	Acmella oleracea, afatinib, aflibercept, alemtuzumab, aminopterin, aralen phosphate, auranofin, benzydamine, bleomycin, boceprevir, busulfan, cabozantinib, capecitabine, carboplatin, cerubidine, chemotherapy, chloramphenicol, chloroquine phosphate, clofibrate, cosmegen, cyclophosphamide, cytosine arabinoside, dacarbazine, dactinomycin, daptomycin, daunorubicin, docetaxel, epirubicin,eribulin, etoposide, everolimus, floxuridine, fluorouracil, gemcitabine, gemtuzumab ozogamicin, gentamicin, ginkgo biloba, hexetidine, ixabepilone, ketorolac tromethamine, lenvatinib, levoleucovorin, lincomycin hydrochloride, lomustine, loratadine, melphalan, methotrexate, metronidazole, mitomycin, mitoxantrone, nabumetone, nicotine polacrilex, oxaliplatin, oxaprozin, oxcarbazepine, palbociclib, panitumumab, paraplatin, penicillin G potassium, pentostatin, peplomycin, pertuzumab, phenylbutazone, pixantrone, pralatrexate, pramipexole, procainamide, sargramostim, sirolimus, sodium aurothiomalate, sorafenib, sulfasalazine, sulindac, sunitinib, temsirolimus, thioguanine, tiagabine, tolmetin, trametinib, ziv-aflibercept
Ear Nose Throat	Angular stomatitis, aphthous stomatitis, aphthous ulcer, glandular fever, oropharyngeal cancer, periodic fever, aphthous stomatitis, pharyngitis and adenitis, trench mouth, uvulitis, Vincent’s angina
Endocrine	Glucagonoma
Environmental	No underlying causes
Gastroenterologic	Celiac disease, Crohn’s disease, dysphagia, inflammatory bowel disease, odynophagia, oropharyngeal candidiasis, ulcerative colitis
Genetic	Chronic granulomatous disease
Hematologic	Agranulocytosis, anemia, cyclic neutropenia, iron deficiency anemia, leukemia, neutropenia
Iatrogenic	Irradiation
Infectious Disease	Aphthous stomatitis, aphthous ulcer, arbovirus, baculovirus, bovine papular stomatitis, candidiasis, coxsackie virus, diphtheritic stomatitis, ebola, esophageal candidiasis, feline calicivirus, feline immunodeficiency virus, gangrenous stomatitis, glandular fever, hand-foot-and-mouth disease, herpangina, herpes simplex virus, herpes zoster, herpes, herpetic gingivostomatitis, HIV, infectious stomatitis, lassa fever, lichen planus, Marburg virus, noma (disease), oncolytic virus, oropharyngeal candidiasis, parapoxvirus, periodic fever, aphthous stomatitis, pharyngitis and adenitis, syphilis, trench mouth, tuberculosis, typhlitis, vesicular stomatitis virus, vesicular stomatitis with exanthem, vesiculovirus, Vincent’s angina, warts
Musculoskeletal/Orthopedic	Odynophagia
Neurologic	Parkinson’s disease
Nutritional/Metabolic	Angular cheilitis, ariboflavinosis, folate deficiency, kwashiorkor, lingzhi, nutritional deficiency, pyrophosphate, vitamin B12 deficiency, vitamin B2 deficiency, vitamin B6 deficiency, vitamin C deficiency
Obstetric/Gynecologic	Warts
Oncologic	Cancer, glucagonoma, leukemia, oropharyngeal cancer
Ophthalmologic	No underlying causes
Overdose/Toxicity	No underlying causes
Psychiatric	Emotional stress
Pulmonary	No underlying causes
Renal/Electrolyte	No underlying causes
Rheumatology/Immunology/Allergy	Allergies, autoimmune diseases, Behcet’s disease, chronic granulomatous disease, combined immunodeficiencies, drug hypersensitivity, gluten-sensitive enteropathy associated conditions, pemphigoid, periodic fever syndrome, systemic lupus erythematosus, TNF receptor associated periodic syndrome
Sexual	No underlying causes
Trauma	Trauma
Urologic	No underlying causes
Miscellaneous	Mucosa hemorrhage

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Sara Mehrsefat, M.D. [2], Usama Talib, BSc, MD [3]

Every type of stomatitis should be differentiated from various other subtypes and from many other disease that can involve the oral cavity such as agranulocystosis, behcet’s disease, immunodeficiency and tumors of the oral cavity like leukoplakia.^[1][2]

Stomatitis must be differentiated from its different kinds and from various other diseases that can mimic stomatitis or have accompanying features involving other organs:^[1][2]

• Tumors of the tongue
  • Squamous cell carcinoma ^[3]
  • Leukoplakia^[4]
  • Melanoma^[5]
  • Torus Palatinus^[6]
• Autoimmune diseases^[7]
  • Behcet’s syndrome^[8]
  • Crohn’s disease
• Agranulocytosis
• Fordyce’s spots
• Drug induced
• Burning mouth syndrome
• Syphilis
• Coxsackie virus accompanies involvement of the hands and the mouth
• HIV
• VZV or Chicken pox

Stomatitis must be differentiated from other diseases causing oral lesions such as leukoplakia and herpes simplex virus infection.

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Sara Mehrsefat, M.D. [2], Usama Talib, BSc, MD [3]

Epidemiology and demographics vary for various sub types of stomatitis. Herpetic gingivostomatitis occurs mostly in children between 6 months to 5 years. It can also occur in other age groups.^[1]

• Herpetic gingivostomatitis occurs mostly in children between 6 months to 5 years.^[1]
• Noma or gangrenous stomatitis is more common in children.^[2]
• Pyostomatitis vegetans usually occurs between the age of 20 to 50 years.^[3]
• Trench mouth is more common in roughly 5 years before and after age twenty in north America and Europe. In underdeveloped countries trench mouth is more common in children.

• Denture stomatitis is more common in females.^[4]
• Pyostomatitis vegetnas is more common in men^[5]

• Herpetic gingivostomatitis has no seasonal preference.^[6]

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Sara Mehrsefat, M.D. [2], Usama Talib, BSc, MD [3]

Many factors contribute the development of stomatitis in an individual. Risk factors for stomatitis include alcohol, smoking, trauma, stress, nutritional deficiency, and immunocompromised status.^[1]

The following risk factors are believed to influence the development of stomatitis:^{[2][3][4][5][6]}

Common risk factors for stomatitis include:

• Poor oral hygiene
• Smoking
• Alcohol
• Trauma
• Psychological stress
• H. pylori
• Sensitivity to food
• Nutritional abnormalities
• Immunologic deficiencies (e.g., HIV)
• Genetic factors
• Chemotherapy or radiotherapy

Risk factors for denture stomatitis include:^[7][8]

• Poor denture hygiene
• Wearing dentures overnight
• pH of oral mucosal surfaces < 6.5
• Nutritional deficiencies
• Hematological diseases

• HIV
• Inhaled glucocorticoid treatment for asthma
• Antibiotic use
• Diabetes
• Denture use
• Radiation or chemotherapy

• Exposure to infected cow

• IBD (especially ulcerative colitis)^[9]

• HIV^[10]
• Existing gingivitis^[4]
• Malnutrition

Risk factors for hand foot and mouth disease include:^[11]

• Fatigue
• Dehydrant drugs
• Maculopapular rash

• Hot beverages^[12]
• Pipe smokers^[13]

• Food allergens
• Allergic ingredients in cosmetics

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Sara Mehrsefat, M.D. [2], Usama Talib, BSc, MD [3]

Screening for stomatitis is not recommended.^[1]

Screening for stomatitis is not recommended.^[1]

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Sara Mehrsefat, M.D. [2], Usama Talib, BSc, MD [3]

The natural history and complications vary among different types of stomatitis. Meningoencephalitis, recurrent skin and mouth infections, dissemination of the infection, and teeth loss are a few known complications of stomatitis. The prognosis for most types of stomatitis is good.

If left untreated herpetic stomatitis resolves after the vesicles erupt and the ulcers heal. The HSV travels along the length of the nerves and moves to the ganglions where it stays in latent form. When the host becomes immunocompromised after taking medications or due to some other illness, the virus assesses the opportunity and through the same nerves becomes active once again manifesting symptoms such as oral vesicles.^[1] The viral shedding can continue for 2-12 days after the onset of primary infection.^[2]

Some complications of stomatitis include:^[1][3]

• Meningoencephalitis

• Recurrent skin and mouth infections
• Dissemination of the infection

• Teeth loss

• Pyostomatitis vegetans has no malignant potential and treatment of underlying IBD is very effective to eradicate the disease completely. The prognosis is good with treatment.^[4]
• Contact stomatitis is cured completely by avoiding allergens responsible for causing the stomatitis.^[5]
• Nicotinic stomatitis is cured completely by avoidance of smoking.

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