What is the first line of treatment for stomatitis?

First-Line Treatment for Stomatitis

The first-line treatment for stomatitis consists of oral rinses with 0.9% saline or sodium bicarbonate solution, which can soothe the mouth and promote healing. 1

Assessment and Classification

Before initiating treatment, determine the type and severity of stomatitis:

• Grade 1 (mild): Erythema of the mucosa
• Grade 2 (moderate): Patchy ulcerations or pseudomembranes
• Grade 3 (severe): Confluent ulcerations or pseudomembranes; bleeding with minor trauma
• Grade 4 (life-threatening): Tissue necrosis; significant spontaneous bleeding; life-threatening consequences

Treatment Algorithm

Step 1: Initial Management for Mild to Moderate Stomatitis

• Oral rinses: Use 0.9% saline or sodium bicarbonate solution 4-6 times daily 1
• Apply white soft paraffin ointment to affected areas every 2-4 hours 1
• Avoid irritants: No alcohol-based mouthwashes, spicy foods, acidic foods, or rough/coarse foods 1
• Maintain hydration: Encourage adequate fluid intake 1
• Pain management:
  • Topical 2.5% lidocaine ointment applied to affected areas (not more than 3-4 times daily) 2
  • Oral acetaminophen for systemic pain relief 1

Step 2: For Persistent or Moderate Stomatitis

• Anti-inflammatory oral rinse: Benzydamine hydrochloride every 3 hours, particularly before eating 1
• Mucoprotectant mouthwash: Three times daily 1
• Antiseptic oral rinse: 1.5% hydrogen peroxide or 0.2% chlorhexidine digluconate twice daily 1

Step 3: For Severe Stomatitis or Suspected Infection

• Take oral swabs if bacterial or candidal infection is suspected 1
• For candidal infection: Nystatin oral suspension 4-6 mL (400,000-600,000 units) four times daily for adults, retained in mouth as long as possible 3
• For severe pain: Consider viscous lidocaine 2%, 15 mL per application 1
• Systemic analgesics following WHO pain management ladder for severe pain 1

Special Considerations

For Recurrent Aphthous Stomatitis (Canker Sores)

• Topical treatments have shown better efficacy than systemic interventions 4
• Consider sucralfate suspension for resistant cases 1
• Laser therapy has shown promise for immediate pain relief and accelerated healing 5

For EGFR-TKI Related Stomatitis

• Grade 1: Continue EGFR-TKI at current dose with supportive care 6
• Grade 3: Discontinue EGFR-TKI, provide supportive care, consider hospitalization 6
• Grade 4: Seek specialist dermatology assessment, especially if Stevens-Johnson Syndrome is suspected 6

Monitoring and Follow-up

• Assess pain at least once daily using an appropriate pain scale 1
• Monitor oral intake to prevent dehydration 1
• Follow up within 3-5 days if symptoms are not improving 1
• If sore mouth symptoms do not improve in 7 days, or if irritation, pain, redness persists or worsens, or if swelling, rash or fever develops, seek medical attention 7

Prevention Strategies

• Maintain good oral hygiene
• Use non-alcoholic mouthwashes
• Evaluate dental appliances that may aggravate oral mucositis
• Choose soft, moist, non-irritating foods
• Stay well-hydrated
• Use lip balms to reduce mouth dryness 6, 1

For most cases of stomatitis, the combination of saline/sodium bicarbonate rinses, topical pain relief, and appropriate oral hygiene measures will provide significant relief and promote healing.