What is the treatment for stomatitis or cheilosis?

Treatment of Stomatitis and Cheilosis

For stomatitis, initiate treatment with steroid mouthwash (dexamethasone 0.5 mg/5 mL, 10 mL swish for 2 minutes then spit, four times daily) for prevention and early management, combined with good oral hygiene using non-alcoholic mouthwashes, escalating to topical or systemic corticosteroids based on severity. 1, 2

Treatment Algorithm by Type and Severity

General Stomatitis Management

Mild Stomatitis (Grade 1-2):

• Use 0.9% saline or sodium bicarbonate rinses (1 teaspoon salt with three-quarter teaspoon baking soda in 500 mL water) 4-6 times daily to soothe the mouth 2, 3
• Apply topical anesthetics such as viscous lidocaine 2% for pain control 2, 4
• Consider benzydamine HCl rinses every 3 hours, particularly before eating 2, 4
• Maintain gentle oral hygiene with mild toothpaste and non-alcoholic mouthwashes 1, 2
• Prophylaxis against fungal, viral, and/or bacterial infections may be warranted 2

Moderate Stomatitis (Grade 2):

• Increase sodium bicarbonate mouthwash frequency up to hourly if necessary 2, 4
• Apply topical high-potency corticosteroids: betamethasone sodium phosphate 0.5 mg dissolved in 10 mL water as rinse-and-spit 1-4 times daily 4
• Alternative: fluticasone propionate nasules diluted in 10 mL water twice daily 4
• For localized lesions: clobetasol 0.05% ointment mixed in 50% Orabase applied twice weekly 4
• Consider mucosal coating agents or barrier preparations like Gengigel or Gelclair 4
• Delay treatment with causative agents until toxicity resolves and consider dose reduction 1

Severe Stomatitis (Grade 3-4):

• Administer systemic corticosteroids: high-dose pulse 30-60 mg or 1 mg/kg oral prednisone/prednisolone for 1 week, followed by tapering over the second week 2, 4
• For recalcitrant cases: intralesional triamcinolone injections (total dose 28 mg) in conjunction with topical clobetasol gel/ointment 4
• Consider tacrolimus 0.1% ointment applied twice daily for 4 weeks as second-line therapy 4
• Implement aggressive pain management with alternative administration routes (transdermal, intranasal) for persistent severe pain 2
• Hospitalization may be indicated for severe cases with dehydration risk 2

mTOR Inhibitor-Associated Stomatitis (mIAS)

This represents a distinct entity from conventional chemotherapy-induced mucositis and requires specific management: 1

• Prevention is key: Start steroid mouthwash prophylactically (dexamethasone 0.5 mg/5 mL, 10 mL swish for 2 minutes then spit, four times daily) 1
• Early intervention is critical to prevent progression 1
• Add steroid dental paste to treat developing ulcerations 1
• For grade 2 or higher toxicity, treatment interruption and dose reduction are generally effective 1
• Discontinue treatment for grade 4 toxicity 1

Angular Cheilitis (Angular Stomatitis)

Primary treatment targets the infectious component while addressing underlying factors: 3

• Apply topical antifungal agents as first-line: nystatin oral suspension or miconazole oral gel to affected corners of the mouth 3, 5
• Nystatin dosing: Adults use 4-6 mL (400,000-600,000 units) four times daily, retaining in mouth as long as possible before swallowing; continue for at least 48 hours after symptoms resolve and cultures confirm eradication 5
• Use sodium bicarbonate rinses 4-6 times daily to maintain oral pH and reduce microbial load 3
• Evaluate and adjust dental appliances (dentures, braces, retainers) that may trap moisture at oral commissures 3
• For moderate to severe cases with suspected bacterial superinfection: add combination antifungal and antibacterial therapy 3
• Consider 0.2% chlorhexidine digluconate mouthwash twice daily for moderate to severe cases 3
• Topical corticosteroids may be added if significant inflammation is present, but only after ensuring adequate antimicrobial coverage 3
• Critical pitfall: Iron deficiency is an often-overlooked predisposing factor, especially in women of childbearing age—consider checking iron studies 6

Viral Stomatitis

Management focuses on supportive care with consideration of antiviral therapy in specific populations: 2

• For immunocompromised patients or those with severe symptoms: consider prophylactic antiviral therapy 2
• Symptomatic treatment with lidocaine gel and analgesics provides good recovery in most cases 7
• Most viral stomatitis is self-limiting; reassurance and prevention of dehydration are paramount 7
• Critical distinction: Differentiate from Stevens-Johnson syndrome, which requires specialist assessment 2, 7

Supportive Care Measures (All Types)

• Consume soft, moist, non-irritating foods that are easy to chew and swallow 2, 4
• Drink plenty of water and use lip balm for dry lips 2, 4
• Use ice chips or ice pops as needed to numb the mouth 2, 4
• Consider sugarless chewing gum, candy, or salivary substitutes for oral dryness 2, 4
• Assess for xerostomia and consider salivary substitutes or sialogogues if contributing to symptoms 3

Critical Diagnostic Considerations

Before diagnosing idiopathic recurrent aphthous stomatitis, rule out: 8, 9

• Systemic inflammatory processes (inflammatory bowel disease, Behçet's disease, connective tissue disease)
• Inherited fever syndromes
• Hematologic disorders (leukemia, agranulocytosis, cyclic neutropenia)
• Nutritional deficiencies (iron, B vitamins)
• Herpes simplex virus (requires antiviral therapy, not corticosteroids) 4

For cheilitis, evaluate for: 10

• Irritants (climatic, mechanical, caustic agents)
• Allergic contact cheilitis (requires patch testing)
• Chronic actinic cheilitis (requires biopsy to exclude dysplasia or carcinoma)
• Systemic conditions (lichen planus, lupus, atopic dermatitis)
• Granulomatous macrocheilitis (requires biopsy confirmation)

Common Pitfalls to Avoid

• Treating angular cheilitis with antifungals alone without addressing underlying nutritional deficiencies or ill-fitting dental appliances 6, 3
• Using corticosteroids for viral stomatitis without ruling out herpes simplex infection first 4
• Failing to initiate prophylactic steroid mouthwash when starting mTOR inhibitors 1
• Not evaluating dental appliances before cancer treatment, which can aggravate mucositis 2
• Treating symptoms without identifying and addressing predisposing systemic conditions 8, 9