What is the initial treatment for stomatitis?

Initial Treatment for Stomatitis

Begin with basic oral hygiene using non-alcoholic mouthwashes containing sodium bicarbonate or 0.9% saline rinses 4-6 times daily, which serves as the foundation for all stomatitis management regardless of etiology. 1

Immediate First-Line Approach

Basic Oral Care (All Patients)

• Start with sodium bicarbonate rinses (1 teaspoon table salt mixed with three-quarter teaspoon baking soda in 500 ml water) 4-6 times daily as this maintains oral pH and provides symptomatic relief 1, 2
• Use only non-alcoholic mouthwashes to avoid further mucosal irritation 3, 1
• Evaluate and adjust dental appliances (dentures, braces, retainers) immediately as these can aggravate lesions 3, 2

Pain Management for Mild Symptoms

• Apply topical anesthetics such as viscous lidocaine 2% for immediate pain control 1, 4
• Consider dyclonine hydrochloride 1.0% (Dyclone) which provides superior pain relief lasting approximately 50 minutes compared to other topical agents 5
• Use benzydamine hydrochloride rinses every 3 hours, particularly before eating, for anti-inflammatory effects 1

Etiology-Specific Initial Treatment

For Recurrent Aphthous Stomatitis (RAS)

• Apply topical high-potency corticosteroids as first-line therapy: betamethasone sodium phosphate 0.5 mg dissolved in 10 mL water as rinse-and-spit 1-4 times daily 1
• Alternative: clobetasol 0.05% ointment mixed in 50% Orabase applied twice weekly to localized lesions 1
• Barrier preparations such as Gengigel mouth rinse/gel or Gelclair can supplement pain control 1

For Angular Stomatitis

• Apply topical antifungal agents immediately: nystatin oral suspension or miconazole oral gel to affected corners of the mouth 2
• This addresses the most common fungal etiology while sodium bicarbonate rinses reduce microbial load 2

For Drug-Induced Stomatitis (Chemotherapy/EGFR-TKI)

• Continue the same basic oral care with sodium bicarbonate or saline rinses 3, 4
• Consider prophylaxis against fungal, viral, and bacterial infections from the outset 3, 4
• Treat any identified infections immediately with appropriate topical or systemic antimicrobials 3

Supportive Dietary Measures (Initiate Immediately)

• Instruct patients to consume soft, moist, non-irritating foods that are easy to chew and swallow, served at room temperature or cold 3, 1
• Avoid acidic, spicy, salty, or rough/coarse foods 3
• Encourage drinking plenty of water and using lip balm for dry lips 3, 1
• Use ice chips or ice pops to numb the mouth as needed 1, 4

Critical Pitfalls to Avoid

Do not delay distinguishing RAS from herpes labialis, as the latter requires antiviral therapy rather than the treatments outlined above 1. Viral stomatitis may require prophylactic antiviral therapy, especially in immunocompromised patients 4.

Always treat concurrent candidal infections with nystatin oral suspension or miconazole oral gel, as fungal superinfection commonly complicates stomatitis 1.

Avoid alcoholic mouthwashes entirely as they cause further mucosal damage and pain 3, 1.

When to Escalate Beyond Initial Treatment

If symptoms persist or worsen after 7-10 days of initial treatment:

• For RAS: escalate to intralesional triamcinolone injections (28 mg total dose weekly) combined with topical clobetasol 1
• For severe ulceration: consider systemic corticosteroids (30-60 mg or 1 mg/kg oral prednisone/prednisolone for 1 week, then taper) 3, 1
• For refractory cases: tacrolimus 0.1% ointment applied twice daily for 4 weeks 1

The key principle is that initial treatment should always begin conservatively with topical measures and basic oral hygiene, reserving systemic therapies for cases that fail to respond or present with severe symptoms from the outset 1, 6, 7.