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

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.

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.

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 1.95-20.78; 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).

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 exposure-a 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.