What is the initial treatment for stomatitis?

Initial Treatment for Stomatitis

The initial treatment for stomatitis should begin with basic oral hygiene using non-alcoholic mouthwashes containing sodium bicarbonate or 0.9% saline rinses 4-6 times daily, combined with topical anesthetics for pain control and topical corticosteroids for moderate-to-severe cases. 1

Foundational Management for All Patients

Basic oral care forms the cornerstone of initial stomatitis management:

• Maintain good oral hygiene with non-alcoholic mouthwashes to prevent secondary infections and reduce symptom severity 1, 2
• Use sodium bicarbonate rinses or 0.9% saline rinses 4-6 times daily to soothe the oral mucosa 1, 2
• Avoid alcoholic mouthwashes as they can irritate inflamed tissues 3, 1

Dietary modifications should be implemented immediately:

• Consume soft, moist, non-irritating foods that are easy to chew and swallow 3, 2
• Avoid acidic, spicy, salty, or rough/coarse foods that can aggravate lesions 3
• Drink plenty of water and use lip balm for dry lips 3, 2
• Use ice chips or ice pops to numb the mouth as needed 3, 2

Pain Management Algorithm

For mild pain (Grade 1 - erythema only):

• Continue with sodium bicarbonate or saline rinses 1, 2
• Add topical anesthetics such as viscous lidocaine 2% for symptomatic relief 1, 4
• Consider benzydamine hydrochloride oral rinses every 3 hours, particularly before eating 1, 5
• Barrier preparations such as Gengigel mouth rinse/gel or Gelclair can provide additional pain control 1

For moderate pain (Grade 2 - patchy ulcerations):

• Increase sodium bicarbonate mouthwash frequency up to hourly if necessary 1
• Apply topical high-potency corticosteroids as first-line therapy: dexamethasone mouth rinse (0.1 mg/ml) for multiple or difficult-to-reach locations, or clobetasol gel/ointment (0.05%) for limited, easily accessible ulcers 3, 1
• Alternative topical corticosteroid: betamethasone sodium phosphate 0.5 mg dissolved in 10 mL water as rinse-and-spit 1-4 times daily 1
• Add topical NSAIDs such as amlexanox 5% oral paste for moderate pain 2, 6
• When NSAIDs are not tolerated, use acetaminophen (paracetamol) as maintenance therapy 3, 2

For severe pain (Grade 3 - confluent ulcerations):

• Initiate systemic corticosteroids: high-dose pulse 30-60 mg or 1 mg/kg oral prednisone/prednisolone for 1 week, followed by dose tapering over the second week 3, 1, 2
• Consider more aggressive pain management with alternative administration routes (transdermal or intranasal) since oral administration may be complicated 3
• Hospitalization is usually indicated for Grade 3 stomatitis 3

Infection Prophylaxis and Treatment

Preventing and treating secondary infections is critical:

• Consider prophylaxis against fungal, viral, and/or bacterial infections in all patients 3, 2
• Treat any concurrent candidal infection with nystatin oral suspension or miconazole oral gel 1, 5
• Use antiseptic oral rinses such as 0.2% chlorhexidine digluconate mouthwash or 1.5% hydrogen peroxide mouthwash twice daily 5
• Treat infections as necessary with appropriate topical or systemic antimicrobials per local guidelines 3, 2

Important Clinical Pitfalls

Critical distinctions must be made to avoid treatment errors:

• Distinguish stomatitis from herpes labialis, which requires antiviral therapy rather than corticosteroids 1
• Evaluate dental appliances (braces, dentures, retainers) before treatment as they can aggravate oral mucositis 3, 2
• For Grade 4 toxicity (tissue necrosis, spontaneous bleeding), refer for specialist assessment due to concern for Stevens-Johnson Syndrome 3, 2
• In immunocompromised patients with severe symptoms, consider prophylactic antiviral therapy 2

Context-Specific Considerations

The evidence provided primarily addresses stomatitis in the context of cancer therapy (chemotherapy, radiation, EGFR-TKI, mTOR inhibitors) 3, but the treatment principles apply broadly to recurrent aphthous stomatitis and other etiologies 1, 7, 6. The ESMO guidelines 3 and UK expert consensus 3 provide the most comprehensive algorithmic approach, though much of the evidence is based on expert opinion rather than high-level randomized trials.