Stomatitis

Charles M. Myer IV and Allen M. Seiden

History

A 58-year-old white man presented with complaints of burning oral pain, dry mouth, and loss of taste. Five months ago, the patient was diagnosed with a right tonsillar carcinoma and subsequently had undergone a right lateral pharyngectomy and neck dissection, followed by 6 weeks of radiotherapy, completed 2 months before the current presentation. The patient received a total of 60 Gray (Gy) of radiation and did develop difficulties with sore throat after the third week. He also noted a loss of taste at that time, which had yet to show much improvement. In addition, his mouth had become quite dry, and this too had not improved following completion of radiation. The soreness seemed to resolve until around 2 weeks before presentation when the burning pain began.

He was tolerating a soft diet but described a particular sensitivity to hot and warm liquids, complaining that they produced a scorched feeling. He denied smoking or using any tobacco products since surgery. His appetite was diminished, and he had lost roughly 15 pounds from his preoperative weight. He relied on a rather old pair of dentures but noted acceptable fit.

Other medical problems included hypertension, which was well-controlled with a diuretic. No history of diabetes, heart disease, or other systemic illness was present.

Physical examination revealed a patient in no acute distress, sitting comfortably and able to handle his secretions. He appeared thin but not emaciated. At his side was a water bottle, and he was able to swallow without aspiration.

Examination of the mouth revealed parched lips and a small amount of cracking at the oral commissure bilaterally. Intraoral examination did not reveal significant edema, ulceration, or exudate. The dorsal surface of the tongue, however, had a dusky red, smooth appearance. The mucosa overlying the hard palate also appeared quite erythematous, with a sharply demarcated border that coincided with the patient’s denture. The buccal mucosa was very dry but otherwise displayed normal pink coloration. The oropharynx, though dry, showed well-healed postoperative changes and was normal in color.

Differential Diagnosis—Key Points

2. Xerostomia, or dry mouth, is an almost universal effect of radiation therapy in the head and neck in patients receiving more than 60 Gy. Radiation effects on the salivary glands begin after only 15 Gy of radiation and are somewhat reversible at the lower levels (<30 Gy). Not only is salivary flow rate diminished, but the composition of produced saliva changes as well. Adequate presence of saliva allows for healthy mucosa both through antimicrobial effects as well as protecting the integrity of the mucosal surface. Without an appropriate amount of saliva, the mucosa is at risk for irritation and infection.

3. Dysgeusia is a common occurrence during radiation therapy, with most patients experiencing a partial or complete loss of taste. Radiation results in direct damage to the taste buds, beginning at about 10 Gy, and reduces the amount and composition of saliva, which also alters taste perception. Bitter and sour flavors are more susceptible than salt and sweet sensitivity. Maximum loss generally occurs at a level of 30 Gy. Regeneration of the taste bud receptors occurs, and taste will generally return to near-normal levels by 1 year.

4.