What is the recommended treatment approach for a patient presenting with stomatitis?

Treatment of Stomatitis

The first critical step is distinguishing viral stomatitis (particularly HSV) from non-viral causes (aphthous, drug-induced), as this determines opposite treatment pathways: viral stomatitis requires immediate antivirals with supportive care only, while non-viral stomatitis is treated with topical corticosteroids escalating to systemic therapy based on severity. 1, 2

Critical Diagnostic Distinction

Never use corticosteroids for HSV infection—they potentiate viral replication and worsen outcomes. 1, 2

• Viral stomatitis (HSV) presents with vesicles that rupture into ulcers, often with prodromal tingling and possible systemic symptoms 2
• Aphthous stomatitis presents with recurrent painful ulcers without vesicles 1
• This distinction is essential because corticosteroids are contraindicated in HSV but are first-line for aphthous ulcers 2

Treatment Algorithm for Viral Stomatitis (HSV)

Initiate antiviral therapy immediately upon clinical suspicion: 2

• Oral antivirals: acyclovir 200-400 mg five times daily, valacyclovir 500 mg 2-3 times daily, or famciclovir 250 mg twice daily 1, 2
• Supportive care only: topical anesthetics (viscous lidocaine 2%) and soft foods 1
• Consider prophylactic antivirals for recurrent HSV 1, 2

Treatment Algorithm for Non-Viral Stomatitis

Grade 1 (Mild): Erythema of Mucosa

Start with foundational oral care: 3, 1

• Sodium bicarbonate mouthwash (1 teaspoon salt with three-quarter teaspoon baking soda in 500 mL water) 4-6 times daily 1, 4
• Topical anesthetics: viscous lidocaine 2% applied before meals for pain control 1, 4
• Non-alcoholic mouthwashes only—alcoholic mouthwashes aggravate mucosal irritation 3, 4
• Continue current medications if tolerated 3

Grade 2 (Moderate): Patchy Ulcerations or Pseudomembranes

Escalate to topical corticosteroids as first-line therapy: 1, 4

• Dexamethasone mouth rinse (0.1 mg/mL or 0.5 mg/5 mL): 10 mL swish for 2 minutes then spit, four times daily 1, 4
• Clobetasol gel or ointment (0.05%) applied twice daily for limited, easily accessible ulcers 1, 4
• Increase sodium bicarbonate mouthwash frequency up to hourly if necessary 4
• Consider dose interruption or reduction of causative medications if drug-induced 3

Grade 3 (Severe): Confluent Ulcerations; Bleeding with Minor Trauma

Discontinue causative medications and initiate systemic therapy: 3, 1

• Systemic corticosteroids: prednisone 30-60 mg (or 1 mg/kg) daily for 1 week, then taper over second week 1, 4
• Hospitalization usually indicated for appropriate pain relief and supportive care 3, 4
• Reinstate causative medications only when resolved to Grade 1 3

Grade 4 (Life-Threatening): Tissue Necrosis; Significant Spontaneous Bleeding

Refer for specialist assessment immediately—concern for Stevens-Johnson Syndrome 3

• Causative medications should already be discontinued 3
• Only reinstate after complete resolution and careful assessment 3

Prevention Strategies for High-Risk Patients

For immunocompromised patients or those receiving targeted therapy/chemotherapy: 1, 4

• Prophylactic steroid mouthwash: dexamethasone 0.5 mg/5 mL, 10 mL swish for 2 minutes then spit, four times daily 1, 4
• Basic oral care protocols: non-alcoholic, sodium bicarbonate-containing mouthwash 4-6 times daily 1, 4
• Patient education about risk and need to alert healthcare professional at first signs 3

Supportive Care Measures (All Grades)

Dietary and oral hygiene modifications: 3, 4

• Eat soft, moist, non-irritating food that is easy to chew and swallow; serve at room temperature or cold 3, 4
• Avoid acidic, spicy, salty, rough/coarse food 3
• Drink plenty of water; use lip balm for dry lips 3, 4
• Use ice chips or ice pops to numb mouth as needed 3, 4
• Practice good dental hygiene with gentle brushing and non-alcoholic mouthwash 3, 4
• Evaluate use of dental appliances (braces, dentures) before therapy begins, as they can aggravate oral mucositis 3

Infection Management

Consider prophylaxis against fungal, viral, and/or bacterial infections in Grade 1-2 stomatitis: 3

• Treat infections as necessary with topical or systemic antimicrobials per local guidelines 3

Follow-Up Monitoring

Reassess within 7 days if symptoms do not improve: 1

• Monitor for resolution of lesions and healing 1
• If no improvement after 2 weeks of topical corticosteroids, escalate to systemic therapy 2
• Assess for nutritional deficiencies (iron, B vitamins) in recurrent aphthous stomatitis 1, 4

Critical Pitfalls to Avoid

• Never use corticosteroids for HSV infection—this potentiates viral replication and can lead to severe complications 1, 2
• Never use alcoholic mouthwashes—they aggravate mucosal irritation 3, 4
• Never ignore inadequate pain control—this leads to poor oral intake and treatment discontinuation; consider alternative routes (transdermal, intranasal) for severe cases 4