What is the treatment for stomatitis in children?

Treatment of Stomatitis in Children

For pediatric stomatitis, initiate treatment with supportive care including non-alcoholic sodium bicarbonate mouthwash 4-6 times daily, topical anesthetics for pain control, and escalate to topical corticosteroids for moderate cases or systemic therapy for severe presentations, while carefully distinguishing viral causes (requiring antivirals, not steroids) from aphthous stomatitis (requiring corticosteroids, not antivirals). 1, 2

Critical First Step: Distinguish Viral from Non-Viral Etiology

The most important clinical decision is differentiating viral stomatitis (particularly HSV) from aphthous stomatitis, as these require opposite therapeutic approaches. 2

• Viral stomatitis (HSV) presents with vesicles that rupture into ulcers, often with prodromal tingling and possible systemic symptoms like fever 2, 3
• Aphthous stomatitis presents with recurrent painful ulcers without vesicles, no prodrome, and typically no systemic symptoms 2, 4
• Never use corticosteroids for HSV infection as they potentiate viral replication and worsen outcomes 2
• Conversely, antivirals are ineffective for aphthous ulcers 2

Treatment Algorithm by Severity and Type

For Viral Stomatitis (HSV)

Initiate antiviral therapy immediately upon clinical suspicion: 2

• Oral antivirals (preferred for systemic coverage): acyclovir 200-400 mg five times daily, valacyclovir 500 mg 2-3 times daily, or famciclovir 250 mg twice daily 2
• Topical antivirals can be added: ganciclovir 0.15% gel 3-5 times daily (less toxic) or trifluridine 1% solution 5-8 times daily (do not use beyond 2 weeks due to epithelial toxicity) 2
• Supportive care: topical anesthetics (viscous lidocaine 2%) for pain, soft foods, adequate hydration 1, 3
• Consider prophylactic antivirals for recurrent HSV 2

For Non-Viral Stomatitis (Aphthous, Drug-Induced, or Idiopathic)

Mild Stomatitis (Grade 1-2)

Start with foundational oral care and topical measures: 1, 5

• Sodium bicarbonate mouthwash (1 teaspoon salt with three-quarter teaspoon baking soda in 500 mL water) 4-6 times daily 1, 5
• Topical anesthetics: viscous lidocaine 2% applied before meals for pain control 1, 5, 6
• Benzocaine topical can be used up to 4 times daily in children ≥2 years (requires supervision in children <12 years) 7
• Benzydamine HCl rinse every 3 hours for pain relief 1, 2
• Maintain gentle oral hygiene with non-alcoholic mouthwashes 5
• Soft, moist, non-irritating foods and adequate hydration 1, 5

Moderate Stomatitis

Escalate to topical corticosteroids as first-line therapy: 1, 5

• Increase sodium bicarbonate mouthwash frequency up to hourly if necessary 1, 5
• Topical high-potency corticosteroids:
  • Dexamethasone mouth rinse (0.1 mg/mL or 0.5 mg/5 mL): 10 mL swish for 2 minutes then spit, four times daily for multiple or difficult-to-reach ulcerations 5
  • Clobetasol gel or ointment (0.05%) applied twice daily for limited, easily accessible ulcers 5
  • Betamethasone sodium phosphate 0.5 mg in 10 mL water 2
• Topical NSAIDs: amlexanox 5% oral paste for moderate pain 1, 2
• If NSAIDs not tolerated, use acetaminophen as maintenance therapy 1
• Sugarless chewing gum, candy, or salivary substitutes for oral dryness 1, 5

Severe or Recalcitrant Stomatitis

Initiate systemic corticosteroids for highly symptomatic ulcers: 1, 5

• Prednisone 30-60 mg (or 1 mg/kg) daily for 1 week, then taper over the second week 1, 2, 5
• Intralesional triamcinolone injections (weekly, total dose 28 mg) combined with topical clobetasol 0.05% for non-resolving ulcers 2, 5
• Aggressive pain management with alternative routes (transdermal, intranasal) for persistent severe pain 1, 5
• Fast-acting fentanyl preparations (50 μg nasal spray) for short-term relief before meals in patients already on opioids 5
• Hospitalization indicated for Grade 3-4 stomatitis with inability to maintain oral intake 5

Prevention Strategies

For high-risk patients (immunocompromised, receiving targeted therapy or chemotherapy): 8, 1

• Start prophylactic steroid mouthwash (dexamethasone 0.5 mg/5 mL, 10 mL swish for 2 minutes then spit, four times daily) 5
• Basic oral care protocols with non-alcoholic, sodium bicarbonate-containing mouthwash 4-6 times daily 8, 1
• Consider prophylactic antiviral therapy for immunocompromised patients at risk for viral stomatitis 1, 5

Critical Pitfalls to Avoid

Common errors that worsen outcomes: 2, 5

• Using corticosteroids for HSV infection - this potentiates viral replication and can lead to severe complications 2
• Using alcoholic mouthwashes - these aggravate mucosal irritation 5
• Inadequate pain control leading to dehydration - this is the most common complication requiring hospitalization in children 3
• Failing to distinguish Stevens-Johnson syndrome from simple stomatitis - this requires immediate specialist assessment 1
• Using topical trifluridine beyond 2 weeks - causes epithelial toxicity 2

Follow-Up Monitoring

Reassess within 7 days if symptoms do not improve: 7

• Stop topical agents and consult if irritation, pain, or redness persists or worsens 7
• Monitor for resolution of lesions and healing 1
• If no improvement after 2 weeks of topical corticosteroids, escalate to systemic therapy 2
• Continue preventive oral hygiene measures even after resolution 1
• Assess for nutritional deficiencies (iron, B vitamins) in recurrent aphthous stomatitis 5