Paraquat associated stomatitis: A forensic marker of exposure intent and prognosis

Title

Paraquat associated stomatitis: A forensic marker of exposure intent and prognosis

Creator

Mohandoss, Anusa Arunachalam; Thavarajah, Rooban

Description

Introduction: Paraquat-associated stomatitis (PAS) is a hallmark of paraquat poisoning but its potential as an intent-specific or prognostic marker remains unexplored. This study investigated whether PAS patterns differ between accidental and suicidal exposures. Methods: A pooled, individual case analysis of 170 paraquat poisoning cases from 122 publications was conducted following PRISMA guidelines. Data on demographics, exposure intent, and detailed oral lesion characteristics (morphology, pattern, severity) were extracted. Statistical analyses identified predictors of intent and prognosis. Results: Oral lesions were present in 78.8% of cases. While the overall prevalence of PAS did not differ between accidental (85.1%) and suicidal (83.9%) intents, lesion morphology was a key differentiator. Widespread ulcers were strongly associated with suicidal ingestion (aOR=6.37; 95% CI 1.9520.78; P=0.002), independent of lesion severity or WHO grade. Conversely, focal but objectively more severe ulcers characterized accidental exposures. Lesion morphology, not severity, distinguishes intent. Other independent predictors of suicidal intent included female sex (aOR=3.40; P=0.031), oliguria (aOR=4.21; P=0.006), and delayed treatment (aOR=8.39; P=0.023). Paradoxically, accidental exposures were associated with significantly higher mortality (68.9%) compared to suicidal cases (39.8%) (P=0.001). The absence of PAS reliably indicated a non-oral exposure route (P<0.001). Discussion: This work introduces the novel concept of intent-specific PAS morphology, establishing ulcer pattern as a forensic marker. It is demonstrated, for the first time, that widespread lesions objectively indicate suicide, while focal, severe ulcers signify accidental exposurea finding linked to a paradoxical mortality risk. This intent-specific signature could provide clinicians with a rapid, objective tool for stratification. For medicolegal investigations, it qualifies PAS as crucial physical evidence to clarify disputed histories, advocating for its systematic documentation in clinical and autopsy practice as a new standard in forensic toxicology. 2026 Elsevier Ltd and Faculty of Forensic and Legal Medicine. All rights are reserved, including those for text and data mining, AI training, and similar technologies.

Source

Journal of Forensic and Legal Medicine;Volume;119;Issue;;Article No.;103113;

Date

01-01-2026

Publisher

Churchill Livingstone

Subject

Forensic toxicology; Oral mucositis; Paraquat; Poisoning; Stomatitis

Coverage

Mohandoss A.A., Department of Psychiatry, Shri Sathya Sai Medical College and Research Institute, Affiliated to Sri Balaji Vidyapeeth, Deemed to be University, SBV Nagar, Chennai Campus, Tamil Nadu, 603108, India; Thavarajah R., Marundeeswara Oral Pathology Services and Analytics, B-1, Mistral Apartments, Wipro Street (Off Rajiv Gandhi IT Highway), Shollinganallur, Chennai, 600119, India, Department of Oral and Maxillofacial Pathology, Ragas Dental College & Hospital, (Affiliated to the Tamil Nadu Dr. MGR Medical University, Chennai) 2/102 East Coast Road, Uthandi, Chennai, 600119, India

Rights

Restricted Access; Hardcopy may be available in the library

Relation

ISSN: 1752928X;

Format

online

Language

English

Type

Article

Identifier

https://doi.org/10.1016/j.jflm.2026.103113

https://www.scopus.com/pages/publications/105035119169?origin=resultslist