From the Guidelines
Management of stomatitis involves a combination of symptomatic relief and treating the underlying cause, with the most recent guidelines recommending the use of steroid mouthwash for prevention of stomatitis induced by mTOR inhibitors 1. The management approach should prioritize good oral hygiene using gentle brushing and alcohol-free mouthwashes. For pain relief, topical anesthetics like lidocaine 2% viscous solution or benzocaine gel can be applied to affected areas before meals. Anti-inflammatory rinses such as 0.12% chlorhexidine gluconate or salt water (1/2 teaspoon salt in 8 ounces warm water) used 3-4 times daily help reduce inflammation. Some key points to consider in the management of stomatitis include:
- Preventive measures such as eliminating sources of trauma and avoiding painful stimuli like hot foods and drinks, and hard, sharp, or spicy foods 1
- The use of oral care protocols to prevent oral mucositis in all age groups and across all cancer treatment modalities 1
- Dietary modifications to avoid irritating the mucosa, opting for soft, bland foods, and staying hydrated
- Consideration of nutritional supplements if eating is difficult
- Targeted treatments for specific types of stomatitis, such as antifungal medications for candidal stomatitis, antivirals for herpetic stomatitis, and medication adjustments for drug-induced cases
- The potential role of systemic analgesics like acetaminophen or NSAIDs for significant pain, and the use of topical corticosteroids like triamcinolone acetonide 0.1% dental paste for moderate to severe cases 1. Given the most recent evidence, the use of steroid mouthwash, such as 0.5 mg/5 ml dexamethasone, is recommended for the prevention of stomatitis induced by mTOR inhibitors 1. Early intervention is also recommended, and for grade >2 stomatitis, delaying treatment until the toxicity resolves and considering lowering the dose of the targeted agent are also suggested 1.
From the FDA Drug Label
INDICATIONS AND USAGE Nystatin Oral Suspension, USP, is indicated for the treatment of candidiasis in the oral cavity. DOSAGE AND ADMINISTRATION Infants: 2 mL (200,000 units) four times daily (in infants and young children, use dropper to place one-half of dose in each side of mouth and avoid feeding for 5 to 10 minutes). The management for stomatitis caused by candidiasis includes the use of nystatin oral suspension. The dosage is as follows:
- Infants: 2 mL (200,000 units) four times daily
- Children and Adults: 4 to 6 mL (400,000 to 600,000 units) four times daily Treatment should be continued for at least 48 hours after perioral symptoms have disappeared and cultures demonstrate eradication of Candida albicans 2 2
From the Research
Management of Stomatitis
The management of stomatitis can be achieved through various treatment options, including:
- Topical medications such as corticosteroids (triamcinolone acetonide), anti-inflammatory drugs (amlexanox), antibiotics (doxycycline), and antiseptics (lidocaine) 3
- Systemic drugs such as corticosteroids (prednisone), immunomodulatory drugs (thalidomide), and antibiotics/antimicrobials (clofazimine) for more severe cases 3
- Dexamethasone mouthwash formulation, which has been shown to be effective in managing stomatitis in cancer patients 4, 5
Treatment Options for Specific Types of Stomatitis
- For denture stomatitis, nystatin and disinfecting agents have been found to be effective in reducing clinical signs of stomatitis and mycological assessment 6
- For oral candidiasis, nystatin pastille has been shown to be significantly superior to placebo in treating denture stomatitis, while nystatin suspension was not superior to fluconazole in treating oral candidiasis in infants, children, or HIV/AIDS patients 7