STOMATITIS

OVERVIEW OF DISEASE

Stomatitis is a sore or inflammation in the mouth. This can be in the cheeks,

gums, inside of the lips, or on the tongue. There are two main forms of stomatitis: herpes

stomatitis and aphthous stomatitis. Both forms usually occur more often in children and

teens.

Herpes stomatitis is an infection, usually in young children between the ages of

six months and 5 years. It’s an infection of the Herpes Simplex 1 (HSV 1) virus, the

same virus that causes cold sores on the outside of the lips in adults. It is related to HSV

2, the virus that causes genital herpes, but it is not the same virus.

Aphthous stomatitis is also called canker sores. They are one or a cluster of small pits or

ulcers in the cheeks, gums, the inside of the lips, or on the tongue. This is also much more

common in young people, most often between 10 and 19 years old. (Krucik, 2013)

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STOMATITIS

CAUSES

 Herpes Stomatitis is caused by infection of the HSV1 virus in young children.

 Aphthous stomatitis is caused by a variety of problems with oral hygiene or

damage to mucous membranes.

Some potential causes include:

 dry tissues from breathing through the mouth due to clogged nasal passages

 Small injuries due to dental work, accidental cheek bite, etc.

 sharp tooth surfaces, dental braces, or retainers

 celiac disease (allergy to gluten)

 food sensitivities to strawberries, citrus fruits, coffee, chocolate, eggs, cheese, or

nuts

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STOMATITIS

 allergic response to certain bacteria in the mouth

 inflammatory bowel diseases

 autoimmune disease that attacks cells in the mouth

 HIV/AIDS

 weakened immune system

 deficiency in Vitamin B12, folic acid, iron, or zinc

 certain medications

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STOMATITIS

CLINICAL MANIFESTATION

Symptoms manifestations vary by type of stomatitis.

 Allergic

Shiny erythema with slight edema, itching, drying, burning

 Thrush

White, raised, milk curd patches; bleeding; dryness of the mouth; diminished

taste; pain; fever; lymphadenopathy

 Gingivitis

Redness, swelling, bleeding of gums; gum retraction from teeth

 Herpetic

It is usually indicated by multiple blisters that occur in the gums, palate, cheeks,

tongue, or lip border. Eating, drinking, and swallowing may be difficult.

Dehydration is a risk. The child can be very irritable. Ulcers may be 34 cm in

diameter scattered over mucous membranes; swollen, inflamed gums; enlarged

lymph nodes, drooling may occur.

A fever is a major marker of the HSV1 infection, which can get as high as 104

degrees Fahrenheit. The fever occurs a few days before the blisters appear. When

the blisters pop, ulcers can form in their place. Secondary infections of these

ulcers can occur. The entire infection lasts between 7-10 days.

 Canker sores

Small, yellowish, hardened, painful sores with red, raised margins that often

appear singly or in groups on the lips or in the corner of mouth

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STOMATITIS

 Necrotizing

Necrotic ulceration of mucous membranes with severe pain, increased salivation,

and inability to eat; fetid breath; bleeding gums; difficulty talking and

swallowing; pseudo membrane on ulcers. Complications include tissue sloughing

from necrosis may create craters and other altered tissue topography.

Medi-Info, 2015 retrieved from www.medi-info.com

ASSESSMENT AND DIAGNOSTICS

Diagnostic Tests

 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, CBC,

serum iron, ferritin, vitamin B 12 , folate, zinc, and endomysial antibody 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. (Merck manual 2015).

 Assess oral hygiene practices.

Provides information on possible causative factors, and provides guidance for

subsequent education.

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STOMATITIS

 Assess nutrition status

Malnutrition can be a contributing cause. Oral fluids needed for moisture to

membranes.

 Assess for ability to eat and drink.

Inability to chew and swallow may occur secondary to pain of inflamed or

ulcerated oral and/or oropharyngeal mucous membranes.

Inspection and Palpation

 Assess status of oral mucosa; include tongue, lips, mucous membranes, gums,

saliva, and teeth.

Home caregivers also need to be informed of the importance of these assessments.

 Use adequate source of light.

 Remove dental appliances.

o Lesions may be underlying and further irritated by the appliance.

 Use a moist, padded tongue blade to gently pull back the cheeks and

tongue.

o In order to expose all areas of oral cavity for inspection.

 Assess for extensiveness of ulcerations involving the intraoral soft tissues,

including palate, tongue, gums, and lips.

Sloughing of mucosal membrane can progress to ulceration.

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STOMATITIS

PATHOPHYSIOLOGY

The pathophysiology depends on the cause, but it involves a process that creates tissue

inflammation in the oral mucosa or gums. These inflammatory changes lead to redness,

ulceration, and fissures in the mouth.

MEDICAL MANAGEMENT

Diagnostic Tests

 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, CBC,

serum iron, ferritin, vitamin B 12 , folate, zinc, and endomysial antibody 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 (Merck manual, 2015).

 If signs of mild stomatitis occur (sensation of dryness and burning; mild

erythema and edema along the mucocutaneous junction):

 Increase frequency of oral hygiene by rinsing with one of the suggested

solutions between brushings and once during the night.

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STOMATITIS

 Discontinue flossing if it causes pain.

 Provide systemic or topical analgesics as ordered.

o Increased sensitivity to pain is a result of thinning of oral mucosal

lining.

 Instruct patient that topical analgesics can be administered as "swished

and swallow" or "swish and spit" 15 to 20 minutes before meals, or

painted on each lesion immediately before mealtime.

Topical analgesics include the following:

1. Dyclone 1%

2. Viscous lidocaine (10 ml per dose up to 120 ml in 24 hours)

These provide a "numbing" feeling.

o Xylocaine (viscous 2%)

o Benadryl elixir (12.5 mg per 5 ml) and an antacid mixed in equal

proportions.

o Instruct patient to hold solution for several minutes before

expectorating, and not to use solution if mucosa is severely

ulcerated or if drug sensitivity exists.

o Caution client to chew or swallow after each dose

As numbness of throat may be experienced.

o Explain use of topical protective agent

To coat the lesions and promote healing as prescribed

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STOMATITIS

Zilactin or Zilactin-B

Has benzocaine for pain and is painted on lesion and allowed to dry to

form a protective seal.

Substrate of an antacid and Kaolin preparations.

This substance is prepared by allowing antacid to settle. The pasty residue

is swabbed onto the inflamed areas and, after 15 to 20 minutes, rinsed with

saline or water. The residue remains as a protectant on the lesion.

 Refer patient to dietitian for instructions on maintenance of a well-balanced

diet. (NANDA, 2013)

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STOMATITIS

NURSING DIAGNOSIS

 Altered Oral Mucous Membrane related to dehydration, trauma: chemical (e.g.,

acidic foods, drugs, noxious agents, alcohol); mechanical (e.g., ill-fitting dentures,

braces, tubes [endotracheal or nasogastric]), surgery in oral cavity, nothing by

mouth for more than 24 hours, ineffective oral hygiene, mouth breathing,

malnutrition, lack of or decreased salivation.

 Altered nutrition: less than body requirements related to inability to ingest

adequate nutrients because of oral pain, gingival disease, ill-fitting dentures.

 Body image disturbance related to difficulty with eating or halitosis.

 Noncompliance related to lack of finances and lack of motivation.

NURSING MANAGEMENT

 Implement meticulous mouth care regimen after each meal and every 4

hours while awake.

To prevent buildup of oral plaque and bacteria. Patients with oral catheters and

oxygen may require additional care.

For eating problems:

 Encourage diet high in protein and vitamins

o To promote healing and new tissue growth.

 Serve foods and fluids lukewarm or cold

o As this may feel soothing to the oral mucosa.

 Serve frequent small meals or snacks spaced throughout the day

o To maintain fluid balance and nutrition.

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STOMATITIS

 Encourage soft foods (mashed potatoes, puddings, custards, creamy cereals)

o To avoid tissue trauma and pain.

 Encourage use of a straw

o To make swallowing easier.

 Encourage peach, pear, or apricot nectars and fruit drinks instead of citrus juices

o As these are not irritating and are easier to swallow.

 Brush with a nonirritating dentrifice such as baking soda.

 Remove and brush dentures thoroughly during and after meals and as needed.

To reduce risk of infection and improve appetite.

 Rinse the mouth thoroughly during and after brushing.

Removing food particles decreases risk of infection related to trapped decaying

food.

 Avoid alcohol-containing mouthwashes.

As these may dry oral mucous membranes, increasing risk for disruption of

mucous membrane.

 Use recommended mouth rinses:

 Hydrogen peroxide and saline or water (1:2 or 1:4). Peroxide solutions

should be mixed immediately before use and held in mouth for 1 to 1.5

minutes. Follow with a rinse of water or saline.

o To maintain oxydizing property

 Baking soda and water (1 tsp in 500 ml).

 Salt (.5 tsp), baking soda (1 tsp), and water (100 ml).

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STOMATITIS

 Keep lips moist.

To prevent drying and cracking.

 Use a lip product or a water-soluble lubricant

(K-Y jelly, Aquaphor Cream)

To minimize risk of aspirating non-water-soluble agent.

 Include food items with each meal that require chewing.

As this stimulates gingival tissue and promotes circulation.

 Minimize trauma to mucous membranes. Avoid use of tobacco and alcohol.

As these are irritating and drying to the mucosa.

 Avoid extremely hot or cold foods. Avoid acidic or highly spiced foods.

 Have loose-fitting dentures adjusted.

Rubbing and irritation from ill-fitting dentures promotes disruption of the oral

mucous membrane. (NANDA, 2013)

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