What is the treatment for stomatitis?

Treatment of Stomatitis

Topical corticosteroid preparations, such as clobetasol 0.05% ointment, betamethasone sodium phosphate, or fluticasone propionate, are recommended as the most effective first-line treatment for stomatitis. 1

Diagnosis and Classification

Before initiating treatment, it's important to correctly identify the type of stomatitis:

• Aphthous stomatitis (canker sores): Most common form (80-85%), typically less than 1cm in size, healing within 7-14 days 1
• Denture stomatitis: Common in denture wearers, often associated with Candida infection 2
• Viral stomatitis: Caused by herpes simplex virus, Coxsackie virus (herpangina, hand-foot-mouth disease) 3
• Fungal stomatitis: Commonly oral candidiasis (thrush), especially in infants 3
• Other forms: Including chronic ulcerative stomatitis, which may mimic lichen planus 4

Treatment Algorithm

First-Line Treatments

1. Topical corticosteroids:

   • Clobetasol 0.05% ointment
   • Betamethasone sodium phosphate
   • Fluticasone propionate
   • Triamcinolone acetonide 0.1% 1

2. Alternative topical agents:

   • Tacrolimus 0.1% ointment (twice daily) - comparable efficacy to triamcinolone acetonide 0.1% 1
   • Amlexanox (anti-inflammatory) 5
   • Tetracyclines (antibiotics) 5

3. Pain management:

   • Lidocaine viscous 2% solution: Standard adult dose of 15 mL (300 mg) swished and expectorated every 3 hours as needed, not exceeding 8 doses in 24 hours 1
   • Barrier preparations (Gengigel or Gelclair) for pain control 1
   • Oral analgesics (paracetamol) 3

For Fungal Stomatitis

• Fluconazole: Effective for oropharyngeal candidiasis 6
  • Specimens for fungal culture should be obtained prior to therapy
  • Therapy may be initiated before culture results are available but adjusted once results are known

For Severe or Resistant Cases

1. Intralesional treatments:

   • Triamcinolone acetonide injections to reduce time to clinical remission 1

2. Systemic therapy (for constant and aggressive outbreaks):

   • Corticosteroids (prednisone)
   • Thalidomide (in selected cases) 5
   • Topical ciclosporin mouthwash (expensive and unpleasant tasting) 1

Supportive Care and Prevention

1. Oral hygiene:

   • Soft toothbrush and mild non-foaming toothpaste
   • Rinse with saline solution 4-6 times daily
   • Alcohol-free mouthwash at least four times daily 1

2. Dietary modifications:

   • Avoid spicy, acidic, or rough foods
   • Stay hydrated 1

3. Denture care (for denture stomatitis):

   • Remove dentures before applying treatments
   • Clean dentures with toothpaste and rinse with water
   • Soak dentures in antimicrobial solution for 10 minutes before reinsertion
   • Consider adhesives to improve fit and remove dentures at night 1, 2

4. Trigger avoidance:

   • Avoid toothpastes containing sodium lauryl sulfate
   • Avoid alcohol and carbonated drinks 1

Clinical Pearls and Pitfalls

• Differential diagnosis is crucial: Distinguish aphthous ulcers from herpes labialis, which requires antiviral therapy 1

• Investigate underlying causes in recurrent or severe cases:

  • Complete blood count
  • Vitamin B12, folate, iron, and ferritin levels
  • Celiac disease screening 1

• Monitor for complications: Dehydration is a common complication, especially in children 3

• Most cases are self-limiting: Reassurance and symptomatic treatment are often sufficient 3, 7

• Treatment goals: Alleviate pain, reduce ulcer duration, and prevent recurrence 7

• For resistant cases: Consider other microorganisms beyond Candida in denture stomatitis resistant to antifungal therapy 2