Definition
A.Stomatitis is tender, round, discrete, oval, shallow, 1- to 5-mm ulcers in the oral cavity. The ulcers are gray-white or yellow, on nonkeratinized skin, and surrounded by erythematous halos. They typically involve the labial and buccal mucosa and tongue, and adjacent tissue appears healthy.
B.Major recurrent aphthous stomatitis (RAS) has larger, deeper ulcers; lasts a longer period of time; usually recurs up to four times a year; and frequently leaves scars. It can cause significant dysphagia.
Incidence
A.Stomatitis affects 20% to 50% of the population. It is very common in North America.
Pathogenesis
A.Cause is poorly understood. Genetic, immunologic, viral, or nutritional causes are possible.
Predisposing Factors
A.Minor trauma.
B.History of RAS.
C.Possible nutritional deficiency of iron, B12 deficiency, folic acid, or zinc.
D.Hormonal changes.
Common Complaints
A.Painful sore in mouth.
Other Signs and Symptoms
A.Burning sensation in mouth for 24 to 48 hours before lesions appear.
Subjective Data
A.Elicit history of aphthous stomatitis.
B.Ask the patient about prodrome of burning or stinging in the mouth.
C.Elicit information regarding previous illness and trauma.
Physical Examination
A.Check temperature, pulse, respirations, and blood pressure.
B.Inspect:
1.Inspect mouth for ulcers.
2.Inspect ears, nose, and throat.
3.Inspect skin, especially palms and soles, for lesions; indicates hand-foot-and-mouth disease.
C.Auscultate: Auscultate heart and lungs.
Differential Diagnoses
A.Aphthous stomatitis.
B.Herpetic stomatitis.
C.Behçet’s disease.
D.Crohn’s disease.
E.HIV.
F.Kawasaki syndrome.
G.Hand-foot-and-mouth disease.
Plan
A.General interventions:
1.Avoid spicy, salty, or hot foods.
2.Encourage cold foods, such as fluids, ice pops, and so on to help with pain.
3.Avoid hard, sharp food that is difficult to chew.
4.Recommend using a soft bristle toothbrush when brushing teeth. Sodium lauryl sulfate found in toothpaste may delay healing time.
B. 
See Section III: Patient Teaching Guide Aphthous Stomatitis.
C.Pharmaceutical therapy:
1.Mouthwash made of diphenhydramine (Benadryl), with Kaopectate, or Maalox or sucralfate, and viscous lidocaine three to four times a day. Tell the patient not to swallow medication.
2.Sucralfate (Carafate) suspension one teaspoon four times a day may be used to swish in mouth and spit out for oral comfort.
3.Topical corticosteroids, such as dexamethasone, triamcinolone, fluocinonide, or clobetasol are highly recommended. For severe cases, systemic corticosteroids may be needed. Example: Glucocorticoid gel such as fluocinonide gel (Lidex) 0.05% two to four times a day, one of which is always at bedtime.
4.Orabase with or without triamcinolone acetonide (Kenalog) applied to ulcer two to four times a day until healed.
5.Immunomodulatory agents, antimicrobials, and anesthetic agents may also be used.
Follow-Up
A.Follow-up as needed for treatment of recurrences.
Consultation/Referral
A.Refer the patient to, or consult with, a physician/specialist if ulcers are deeper or larger than 1 to 5 mm, if Kawasaki disease is suspected, or if no improvement is seen with adequate treatment.
B.Any lesion lasting longer than 3 weeks should be evaluated by a dentist or oral surgeon to rule out cancer.
Individual Considerations
A.Pregnancy: Avoid use of fluocinonide and triamcinolone acetonide (Kenalog) in pregnant or nursing women.
B.Adults: Consider underlying immunological conditions for patients who have recurrent oral ulcers.
C.Geriatrics: See the following section Thrush.