What is the recommended treatment for an adult male diagnosed with stomatitis?

Treatment of Stomatitis in Adult Males

For an adult male with stomatitis, initiate treatment with non-alcoholic sodium bicarbonate mouthwash 4-6 times daily combined with topical high-potency corticosteroids (dexamethasone 0.5 mg/5 mL, 10 mL swish for 2 minutes then spit, four times daily) for mild-to-moderate disease, escalating to systemic corticosteroids (prednisone 30-60 mg daily for 1 week, then taper) for severe or recalcitrant cases. 1, 2, 3

Critical Diagnostic Distinction

Before initiating treatment, you must differentiate between aphthous stomatitis and oral herpes, as they require opposite therapeutic approaches:

• Aphthous stomatitis presents with painful ulcers without vesicles, no prodromal tingling, and no systemic symptoms—treat with corticosteroids 1
• Oral herpes presents with vesicles that rupture into ulcers, often with prodromal tingling and possible systemic symptoms—treat with antivirals, never corticosteroids 1

This distinction is critical because corticosteroids potentiate HSV infection and should be avoided in herpes, while antivirals are ineffective for aphthous ulcers. 1

Treatment Algorithm by Severity

Mild Stomatitis (Grade 1-2)

Foundational care:

• Non-alcoholic sodium bicarbonate mouthwash (1 teaspoon salt with three-quarter teaspoon baking soda in 500 mL water) 4-6 times daily 2, 3
• Topical anesthetics: viscous lidocaine 2% applied before meals for pain control 1, 2, 3
• Benzydamine hydrochloride rinse every 3 hours, particularly before eating 1, 3
• Maintain gentle oral hygiene with mild toothpaste and non-alcoholic mouthwashes 2

Supportive measures:

• Soft, moist, non-irritating foods that are easy to chew and swallow 2, 3
• Ice chips or ice pops as needed to numb the mouth 2, 3
• Adequate hydration and lip balm for dry lips 2, 3

Moderate Stomatitis

Escalate treatment intensity:

• Increase sodium bicarbonate mouthwash frequency up to hourly if necessary 2, 3
• Topical high-potency corticosteroids as first-line therapy: 2, 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
  • Betamethasone sodium phosphate 0.5 mg dissolved in 10 mL water as rinse-and-spit 1-4 times daily 3
  • Clobetasol 0.05% ointment mixed in 50% Orabase applied twice weekly for localized, easily accessible ulcers 2, 3
  • Fluticasone propionate nasules diluted in 10 mL water twice daily as alternative 3

Pain management:

• Topical NSAIDs: amlexanox 5% oral paste for moderate pain if NSAIDs tolerated 2
• If NSAIDs contraindicated, use acetaminophen combined with immediate-release oral opioids 2

Severe or Recalcitrant Stomatitis (Grade 3-4)

Systemic therapy required:

• Prednisone 30-60 mg or 1 mg/kg daily for 1 week, then taper over second week 2, 3
• Intralesional triamcinolone injections (total dose 28 mg weekly) in conjunction with topical clobetasol 0.05% for non-resolving ulcers 1, 2, 3
• Hospitalization required if unable to maintain oral intake 2

Second-line for resistant cases:

• Tacrolimus 0.1% ointment applied twice daily for 4 weeks 3

Special Context: Chemotherapy-Associated Stomatitis

If stomatitis is related to cancer therapy (TKIs, mTOR inhibitors, or chemotherapy):

• Prophylactic dexamethasone mouthwash (0.5 mg/5 mL, 10 mL swish for 2 minutes then spit, four times daily) should be started before treatment initiation 4, 2
• Use saline-containing mouthwashes instead of plain water due to increased microbial burden with targeted agents 4
• Most cases are mild but can be very painful and interfere with eating 4
• Management includes topical and systemic corticosteroids, with dose reduction or temporary discontinuation of the causative agent if severe 4

Critical Pitfalls to Avoid

• Never use alcoholic mouthwashes—they aggravate mucosal irritation 2
• Never use corticosteroids if herpes simplex is suspected—they potentiate HSV infection 1
• Assess for nutritional deficiencies (iron, B vitamins) before diagnosing idiopathic recurrent aphthous stomatitis 2
• Treat any concurrent candidal infection with nystatin oral suspension or miconazole oral gel 3
• Consider systemic conditions: evaluate for Behçet's disease if patient has triad of uveitis, aphthous stomatitis, and genital ulcers 3
• Monitor response to topical corticosteroids; if no improvement after 2 weeks, escalate to systemic therapy 1

Pain Control Considerations

For inadequate pain control that threatens oral intake or treatment adherence:

• Consider alternative routes: transdermal or intranasal delivery 2
• Fast-acting fentanyl preparations (50 μg nasal spray) may be used for short-term relief before meals in patients already on opioid therapy 2