What is the treatment for stomatitis?

Treatment for Stomatitis

The treatment for stomatitis should begin with sodium bicarbonate-containing mouthwash used 4-6 times daily, with frequency increased up to hourly for symptomatic relief, followed by topical high-potency corticosteroids for ulcerative lesions, and appropriate pain management based on severity. 1, 2

First-Line Management

• Implement basic oral care protocols with non-alcoholic, sodium bicarbonate-containing mouthwash 4-6 times daily as preventive and initial treatment 1
• For mild stomatitis, use 0.9% saline or sodium bicarbonate rinses to soothe the mouth 2
• For moderate to severe stomatitis, increase mouthwash frequency up to hourly if necessary 1, 2
• For ulcerative lesions, apply topical high-potency corticosteroids as first-line therapy 1, 3:
  • Dexamethasone mouth rinse (0.1 mg/ml) for widespread or difficult-to-reach ulcerations 1, 3
  • Clobetasol gel or ointment (0.05%) for limited, accessible lesions 1, 3
  • Betamethasone sodium phosphate 0.5 mg dissolved in 10 mL of water as a rinse-and-spit solution 1-4 times daily 4, 3

Pain Management

• For mild to moderate pain, use topical anesthetics such as viscous lidocaine 2% 1, 2, 3
• For moderate pain, consider topical NSAIDs (e.g., amlexanox 5% oral paste) 1, 3
• When NSAIDs are not tolerated, use acetaminophen (paracetamol) as maintenance therapy 1
• For severe pain, follow the WHO pain management ladder with more aggressive pain management 1, 3
• Consider alternative administration routes (transdermal, intranasal) when oral administration is difficult 1

Supportive Measures

• Use sugarless chewing gum, candy, or salivary substitutes for oral dryness 1, 3
• Apply mucoprotectant mouthwashes or coating agents to protect ulcerated areas 2, 3
• Consume soft, moist, non-irritating foods that are easy to chew and swallow 2
• Use lip balm for dry lips and drink plenty of water 2
• Consider ice chips or ice pops to numb the mouth as needed 2

Second-Line Treatment for Refractory Cases

• For ulcers that don't respond to topical therapy, consider intralesional steroid injection (triamcinolone weekly, total dose 28 mg) in conjunction with topical clobetasol gel or ointment (0.05%) 1, 3
• For highly symptomatic or recurrent ulcers, consider systemic corticosteroids (prednisone/prednisolone 30-60 mg or 1 mg/kg for 1 week with tapering over the second week) 1, 3

Special Considerations

• Treat any secondary infections with appropriate topical or systemic antimicrobials 2
• Consider prophylaxis against fungal, viral, and/or bacterial infections, especially in immunocompromised patients 2
• For recurrent aphthous stomatitis specifically, colchicine can be considered as first-line systemic therapy 3, 5
• For chronic ulcerative stomatitis that is resistant to standard treatments, hydroxychloroquine may be effective 6

Important Pitfalls to Avoid

• Failure to distinguish between different types of stomatitis (e.g., viral, aphthous, medication-induced) can lead to ineffective treatment 2, 3
• Oral ulcers lasting more than 2 weeks or not responding to 1-2 weeks of treatment should be referred to a specialist 3
• Stop using benzocaine-containing products and consult a doctor if symptoms don't improve in 7 days, or if irritation, pain, redness persists or worsens 7
• Premature tapering of corticosteroids before disease control is established should be avoided 3