What is the treatment for stomatitis?

Treatment for Stomatitis

Begin treatment with sodium bicarbonate-containing mouthwash (1 teaspoon salt with three-quarter teaspoon baking soda in 500 mL water) 4-6 times daily, combined with basic oral hygiene using non-alcoholic mouthwashes, then escalate to topical corticosteroids based on severity. 1

Initial Management for All Types of Stomatitis

• Establish foundational oral care with non-alcoholic, sodium bicarbonate-containing mouthwashes used 4-6 times daily to maintain oral pH and reduce inflammation 2, 1, 3
• Avoid alcoholic mouthwashes entirely, as they aggravate mucosal irritation and worsen symptoms 1
• Maintain gentle oral hygiene with mild toothpaste and soft-bristled brushing 1

Severity-Based Treatment Algorithm

Mild Stomatitis (Grade 1-2)

• Continue sodium bicarbonate rinses 4-6 times daily for symptomatic relief 1, 3
• Apply topical anesthetics such as viscous lidocaine 2% before meals for pain control 2, 1, 3
• Consider barrier preparations like Gengigel or Gelclair for additional pain management 3
• Use ice chips or ice pops as needed to numb the mouth 1

Moderate Stomatitis

• Increase sodium bicarbonate mouthwash frequency up to hourly if necessary 2, 3
• Initiate topical high-potency corticosteroids as first-line therapy: 2, 1, 3
  • Dexamethasone mouth rinse (0.1 mg/mL): 10 mL swish for 2 minutes then spit, four times daily for multiple or difficult-to-reach ulcerations 2, 1
  • Clobetasol gel or ointment (0.05%): applied twice daily for limited, easily accessible ulcers 2, 3
  • Betamethasone sodium phosphate 0.5 mg dissolved in 10 mL water as rinse-and-spit 1-4 times daily 3
• Apply topical NSAIDs (amlexanox 5% oral paste) for moderate pain if NSAIDs are tolerated 2
• If NSAIDs are contraindicated, use acetaminophen as maintenance therapy combined with immediate-release oral opioids 2

Severe or Recalcitrant Stomatitis (Grade 3-4)

• Administer systemic corticosteroids: prednisone 30-60 mg or 1 mg/kg daily for 1 week, followed by dose tapering over the second week for highly symptomatic or recurrent ulcers 2, 1
• Consider intralesional steroid injection (triamcinolone weekly, total dose 28 mg) in conjunction with topical clobetasol for ulcers that fail to resolve 2, 3
• Use alternative administration routes (transdermal or intranasal) for analgesics when oral intake is compromised 2, 1
• Fast-acting fentanyl preparations (50 μg nasal spray) may be considered for short-term pain relief, particularly before meals, in patients already on opioid therapy 2
• Hospitalization is required for Grade 3-4 stomatitis with inability to maintain oral intake 1

Specific Stomatitis Subtypes

mTOR Inhibitor-Associated Stomatitis (mIAS)

• Start prophylactic dexamethasone mouthwash (0.5 mg/5 mL, 10 mL swish for 2 minutes then spit, four times daily) before initiating mTOR inhibitor therapy 1
• This represents the most effective prevention strategy for drug-induced stomatitis 1

Angular Stomatitis

• Apply topical antifungal agents as primary treatment: nystatin oral suspension or miconazole oral gel to affected corners of the mouth 4
• Evaluate and adjust dental appliances (dentures, braces) that may contribute to moisture accumulation 4
• Consider combination antifungal and antibacterial therapy if secondary bacterial infection is suspected 4
• Add 0.2% chlorhexidine digluconate mouthwash twice daily for moderate to severe cases 4

Denture Stomatitis

• Address poor oral hygiene and denture plaque biofilm, which are the primary causative factors 5
• Remove dentures overnight to reduce aspiration pneumonia risk 5
• Treat concurrent candidal infection with antifungal therapy 4, 3

Recurrent Aphthous Stomatitis (RAS)

• Assess for nutritional deficiencies (iron, folate, vitamin B12) before diagnosing idiopathic RAS, as correction may resolve symptoms 1, 6, 7
• For resistant cases, consider tacrolimus 0.1% ointment applied twice daily for 4 weeks 3
• Hydroxychloroquine may be effective for chronic ulcerative stomatitis that is refractory to standard treatments 8

Critical Diagnostic Pitfalls to Avoid

• Distinguish RAS from herpes simplex virus infection, which requires antiviral therapy rather than corticosteroids 1, 3
• Evaluate for herpes simplex virus before initiating corticosteroid therapy in immunocompromised patients 1
• Consider prophylactic antiviral therapy for immunocompromised patients with severe symptoms 1
• Treat any concurrent candidal infection before or during corticosteroid therapy 3

Supportive Care Measures

• Consume soft, moist, non-irritating foods that are easy to chew and swallow 2, 1, 3
• Maintain adequate hydration by drinking plenty of water 1
• Use sugarless chewing gum, candy, or salivary substitutes for oral dryness 2, 1, 3
• Apply lip balm regularly for dry lips 1

When to Reassess Treatment

• If symptoms do not improve within 7 days of topical therapy, escalate to more aggressive management 9
• If irritation, pain, or redness persists or worsens despite treatment, consider alternative diagnoses 9
• Inadequate pain control can lead to poor oral intake and treatment discontinuation, requiring prompt adjustment of analgesic strategy 1