dental disorders
Stomatitis
Evaluation of Stomatitis
History of present illnessshould ascertain the duration of symptoms and whether the patient ever had them previously. Presence and severity of pain should be noted. The relation of symptoms to food, drugs, oral hygiene materials (eg, toothpaste, mouth rinses), and other substances (particularly occupational exposure to chemicals, metals, fumes, or dust) is sought. seeks symptoms of possible causes, including chronic diarrhea and weakness ( Overview of Inflammatory Bowel Disease , should ascertain known conditions that cause oral lesions, including Overview of Herpesvirus Infections , Behçet disease, inflammatory bowel disease, and risk factors for oral lesions, including immunocompromised state (eg, cancer, diabetes, organ transplant, use of immunosuppressants, HIV infection). Whether chemotherapy or radiation therapy has ever been used to manage cancer needs to be determined. Medication history should note all recent medications used. History of tobacco use should be noted. Social history should include sexual contact, particularly oral sex, unprotected sex, and sex with multiple partners. Vital signs are reviewed for fever. The patient’s general appearance is noted for lethargy, discomfort, or other signs of significant systemic illness. The mouth is inspected for the location and nature of any lesions. The skin and other mucosal surfaces (including the genitals) are inspected for any lesions, rash, petechiae, or desquamation. Any bullous lesions may be tested for the Nikolsky sign (upper layers of epidermis move laterally with gentle lateral pressure or rubbing of skin adjacent to a blister). The following findings are of particular concern: Fever Cutaneous bullae Ocular inflammation Immunocompromise (Nikolsky sign) Occasionally, causes are obvious in the history (eg, cytotoxic chemotherapy; significant occupational exposure to chemicals, fumes, or dust). Recurrent episodes of oral lesions occur with Recurrent Aphthous Stomatitis (RAS), some of which suggest a cause. Recurrent gastrointestinal symptoms suggest inflammatory bowel disease or celiac disease. Ocular symptoms can occur with Behçet disease and SJS. Genital lesions may occur with Behçet disease and Syphilis . Some causes usually also haveextraoral, cutaneous findings. Bullous Pemphigoid None are typical with chickenpox or herpes zoster (see Overview of Herpesvirus Infections ). Unilateral lesions in a band along a dermatome suggest herpes zoster. Diffuse, scattered vesicular and pustular lesions in different stages suggest chickenpox. Kawasaki Disease None Other cutaneous lesions may implicate Erythema Multiforme , including RAS, most viral infections, Acute Necrotizing Ulcerative Gingivitis (ANUG) (ANUG), primary syphilis, Location of oral lesions may help identify the cause. Interdental ulcers occur with primary Herpes Simplex Virus (HSV) Infections or Primary Interpretation of findings None Acute Necrotizing Ulcerative Gingivitis (ANUG) None chancres may appear in the mouth. Tertiary syphilis may cause oral gummas or a generalized glossitis and mucosal atrophy. A common sign of Human Immunodeficiency Virus (HIV) Infection becoming AIDS is C. albicansand related species, which are normal oral flora, can overgrow in people who have taken antibiotics or corticosteroids or who have immunocompromise, such as patients with AIDS.C. albicanscan cause whitish, cheesy plaques that leave erosions when wiped off. Sometimes only flat, erythematous areas appear (erosive form ofCandida). Bacterial and viral culture Laboratory tests Biopsy Patients with acute stomatitis and no symptoms, signs, or risk factors for systemic illness probably require no testing. If stomatitis is recurrent, viral and bacterial cultures, complete blood count, serum iron, ferritin, vitamin B12, folate, zinc, and endomysial antibody (for Celiac Disease ) are done. Biopsy at the periphery of normal and abnormal tissue can be done for persistent lesions that do not have an obvious etiology. Systematically eliminating foods from the diet can be useful, as can changing brands of toothpaste, chewing gum, or mouthwash. 