Oral Inflammation

Michael Medina and Miriam Lango

Stomatitis and mucositis may cause diffuse mouth discomfort. By definition, stomatitis refers to any inflammatory reaction affecting the oral mucosa, with or without ulceration, that may be caused or intensified by local factors. Mucositis refers to inflammation affecting the gastrointestinal (GI) system anywhere from the mouth to anus, most commonly in response to chemotherapeutic agents or ionizing radiation. Frequently, the terms stomatitis and mucositis are used interchangeably. There may be predominant involvement of the tongue (glossitis) or gums (gingivitis). Individuals with diminished immunity due to malignancy, human immunodeficiency virus (HIV), malnutrition, pregnancy, or infancy are subject to severe and potentially life-threatening stomatitis. The most common causes of stomatitis in this population are listed in Table 35.1.

Stomatitis in Immunodeficient Individuals

Candidiasis: The white plaques of pseudomembranous candidiasis are usually asymptomatic, although burning or a foul taste in the mouth may be reported. Individuals with erythematous or atrophic candidiasis may complain of a “scalded mouth.” Diffuse loss of filiform papillae yields a reddened “bald” tongue. In immunodeficient patients it may be refractory to usual measures. Hyperplastic candidiasis and chronic multifocal candidiasis are also encountered in this population.

Aphthous stomatitis: Frequent, extensive outbreaks that may lead to severe infection.

Viral infections: Including Herpes simplex virus, Varicella-zoster virus, and Epstein-Barr virus

Vitamin deficiency

Vitamin B deficiency (niacin, B6, B12): Can cause stomatitis and glossitis even in patients without symptomatic anemia or macrocytosis. There may be associated angular cheilitis. A red beefy tongue is characteristic. Infants and children demonstrate developmental and growth delays. Pregnant or lactating women, alcoholics, and patients with malignancies or malabsorption are also at high risk.

Iron-deficiency anemia, Plummer-Vinson syndrome, and folate deficiency anemia: presents with glossitis and recurrent aphthous ulcers

Vitamin C deficiency: Causes generalized gingival swelling with spontaneous hemorrhage, ulceration, tooth mobility (scorbutic gingivitis) associated with widespread petechial hemorrhages and ecchymoses.

**Table 35.1** Common Causes of Stomatitis/Mucositis
Immunodeficient patient	Any age	Candidiasis Aphthous stomatitis Viral Necrotizing ulcerative gingivitis/noma Drug/radiation treatment Leukemia/plasma cell gingival hyperplasia Graft versus host disease
Immunocompetent patient	Children/young adults	Viral Kawasaki disease Drug reaction Contact stomatitis Trauma Poisoning Emesis Diarrhea (Crohn/celiac disease) Malnutrition
	Middle-aged and older adults	Aphthous stomatitis Smoking Poor oral hygiene Trauma Emesis Malnutrition Candidal stomatitis Contact stomatitis Denture stomatitis Drug reaction Lichen planus Behçet syndrome Pemphigoid Systemic lupus erythematosus Mouth breathing Orthodontic work Geographic tongue Uremia Burning mouth/burning tongue syndrome

Noma (or cancrum oris, or necrotizing/gangrenous stomatitis): Occurs in individuals with immune suppression as a result of malignancy (leukemia) or HIV and is an opportunistic infection of the oral flora. Malnutrition, dehydration, poor oral hygiene, are other predisposing factors. The process frequently starts as an acute necrotizing ulcerative gingivitis. This condition primarily affects 2- to 10-year-olds, but is rare in the United States. HIV-related gingivitis and periodontitis are common.

Acute mucositis secondary to chemotherapy, radiotherapy, radioactive iodine ablation: is common. These treatments disrupt the mucosal cell cycle causing mucosal erythema and random, focal-to-diffuse, ulcerative lesions. Methotrexate, 5-fluorouracil (5-FU), and cytarabine in particular are associated with increased stomatotoxicity. The combination of radiation with chemotherapy increases the incidence and severity of mucositis in head and neck cancer patients. Mucosal breakdown and impaired wound healing promote infection and tissue loss.