What is the first line of treatment for stomatitis?

First-Line Treatment for Stomatitis

Oral acyclovir is the first-line treatment for herpetic stomatitis, showing significant benefit by reducing healing time. 1

Types of Stomatitis and Initial Assessment

Stomatitis refers to inflammation of the oral mucosa, which can have various causes:

• Herpetic stomatitis: Caused by herpes simplex virus
• Aphthous stomatitis: Recurrent oral ulcers of unclear etiology
• Candidal stomatitis: Fungal infection (oral thrush)
• Drug-induced stomatitis: Common with EGFR tyrosine kinase inhibitors

The appropriate first-line treatment depends on the specific type of stomatitis:

Treatment Algorithm by Type

1. Herpetic Stomatitis

• First-line: Oral acyclovir (200-400 mg five times daily for 7-10 days) 1
• Alternatives:
  • Valacyclovir (500 mg twice daily or 1 g twice daily)
  • Famciclovir (250 mg three times daily)
• Timing: Must be started within first 3 days of symptoms for maximum effectiveness 1
• Pain management: Acetaminophen orally and topical 2.5% lidocaine ointment 1

2. Aphthous Stomatitis

• First-line topical options:
  • Triamcinolone acetonide 0.1% in Orabase adhesive paste (2-4 times daily) 1
  • Topical corticosteroids like dexamethasone mouth rinse (0.1 mg/ml) 1
• For severe cases: Clobetasol 0.05% ointment mixed in 50% Orabase (twice weekly) 1
• For recurrent cases: Consider laser therapy for short-term relief and probiotics for long-term management 2

3. Candidal Stomatitis (Thrush)

• First-line: Nystatin oral suspension
  • Children and adults: 400,000 to 600,000 units four times daily
  • Infants: 200,000 units four times daily
  • Continue treatment for at least 48 hours after symptoms resolve 3

4. Drug-induced Stomatitis (e.g., from EGFR-TKIs)

• Grade 1 (erythema): Continue medication, use saline or sodium bicarbonate rinses 4
• Grade 2 (patchy ulcerations): Consider dose interruption or reduction 4
• Grade 3-4 (severe): Discontinue medication, provide supportive care, restart at lower dose when improved to grade ≤1 4

Supportive Care for All Types

1. Oral hygiene:

   • Regular brushing with soft toothbrush
   • Non-alcoholic mouthwashes
   • Saline rinses (0.9%) or sodium bicarbonate rinses 4, 1

2. Pain management:

   • Topical anesthetics (2% viscous lidocaine)
   • Oral analgesics (acetaminophen)
   • For severe pain: Follow WHO pain management ladder 1

3. Dietary modifications:

   • Soft, moist, non-irritating foods
   • Avoid acidic, spicy, salty, rough foods
   • Maintain adequate hydration 4, 1

Important Considerations and Pitfalls

• Timing matters: Antiviral therapy for herpetic stomatitis must be started within 72 hours of symptom onset; delaying beyond this window significantly reduces efficacy 1

• Topical vs. systemic: Topical antivirals alone are not effective for herpetic stomatitis; oral antiviral therapy is required 1

• Corticosteroid caution: Avoid prolonged use of topical corticosteroids (>2 weeks) to prevent mucosal atrophy 1

• Monitoring: Assess pain daily, examine for color changes, swelling, and specific patterns that might indicate systemic disease 1

• Follow-up: Monitor for 3-5 days if symptoms aren't improving; consider follow-up every 3-6 months for persistent cases 1

• Special populations: Use minimal amounts of topical anesthetics in infants to avoid systemic absorption and potential toxicity 1

By identifying the specific type of stomatitis and following the appropriate treatment algorithm, most cases can be effectively managed with significant improvement in symptoms and healing time.