What is the appropriate treatment for glossitis and stomatitis?

Treatment for Glossitis vs Stomatitis

Glossitis and stomatitis require fundamentally different treatment approaches: glossitis typically responds to correction of nutritional deficiencies (particularly B vitamins and iron), while stomatitis requires topical corticosteroids as first-line therapy, with the critical exception that viral stomatitis (herpes) must never receive corticosteroids and instead requires antiviral therapy. 1, 2

Critical Diagnostic Distinction

Before initiating treatment, you must differentiate between these conditions:

• Glossitis presents as smooth, atrophic tongue with loss of papillae, often associated with burning sensation 3, 4
• Aphthous stomatitis presents as round/oval ulcers with gray-white fibrin layer and erythematous ring 5
• Herpes stomatitis presents with vesicles that rupture into ulcers, often with prodromal tingling and possible systemic symptoms 1

The distinction between herpes and aphthous stomatitis is absolutely essential because corticosteroids potentiate HSV infection and should never be used for herpes, while antivirals are ineffective for aphthous ulcers. 1

Treatment Algorithm for Glossitis

Initial Workup

Check complete blood count, serum iron, vitamin B12, folic acid, homocysteine, and consider gastric parietal cell antibody, thyroglobulin antibody, and thyroid microsomal antibody 4

Primary Treatment

• Correct identified nutritional deficiencies: Vitamin B12 supplementation for deficiency (found in 5.3% of glossitis patients), folic acid for deficiency (found in 2.3%), and iron for deficiency (found in 16.9%) 4
• Vitamin BC capsules plus corresponding deficient hematinics can achieve complete remission of oral symptoms and glossitis 4
• Atrophic glossitis linked to nutritional deficiency resolves with treatment of the underlying condition 3

Special Considerations

• Median rhomboid glossitis: If symptomatic and associated with candidal infection, treat with antifungals (nystatin oral suspension or miconazole oral gel) 3, 6
• Folate deficiency is present in 44-56% of patients with glossitis even without anemia or macrocytosis; daily folic acid supplements should be given when suspected 7
• Patients with positive gastric parietal cell antibody have higher frequencies of hemoglobin, iron, and vitamin B12 deficiencies 4

Treatment Algorithm for Stomatitis

Aphthous Stomatitis (Non-Viral)

Foundational Care (All Severity Levels)

• Non-alcoholic sodium bicarbonate mouthwash 4-6 times daily 2
• Good oral hygiene with gentle brushing 2
• Soft, moist, non-irritating foods; avoid acidic, spicy, salty, or rough foods 8
• Drink plenty of water and use lip balm for dry lips 2

Mild Aphthous Stomatitis (Erythema Only)

• Continue sodium bicarbonate rinses 4-6 times daily 2
• Topical anesthetics: Viscous lidocaine 2% for pain control 1, 2
• Benzydamine hydrochloride rinse every 3 hours, particularly before eating 2
• Barrier preparations such as Gengigel mouth rinse/gel or Gelclair for pain control 2

Moderate Aphthous Stomatitis (Visible Ulceration <7 Days)

• Increase sodium bicarbonate mouthwash frequency up to hourly if necessary 2
• Topical high-potency corticosteroids: Betamethasone sodium phosphate 0.5 mg dissolved in 10 mL water as rinse-and-spit 1-4 times daily 2
• Alternative: Fluticasone propionate nasules diluted in 10 mL water twice daily 2
• For localized lesions: Clobetasol 0.05% ointment mixed in 50% Orabase applied twice weekly 2
• Topical NSAIDs: Amlexanox 5% oral paste 1

Severe or Recalcitrant Aphthous Stomatitis (Ulceration ≥7 Days)

• Systemic corticosteroids: Prednisone 30-60 mg (or 1 mg/kg) daily for 1 week, then taper over second week 1, 2
• Intralesional triamcinolone injections (total dose 28 mg) in conjunction with topical clobetasol 0.05% gel/ointment for non-resolving ulcers 1, 2
• If no improvement after 2 weeks of topical corticosteroids, escalate to systemic therapy 1
• Second-line for resistant cases: Tacrolimus 0.1% ointment applied twice daily for 4 weeks 2

Herpes Stomatitis (Viral)

Never use topical corticosteroids for HSV as they potentiate infection. 1

Immediate Treatment Upon Clinical Suspicion

• Topical antivirals: Ganciclovir 0.15% gel 3-5 times daily (less toxic to oral mucosa) OR trifluridine 1% solution 5-8 times daily (do not use beyond 2 weeks due to epithelial toxicity) 1
• Oral antivirals for systemic coverage: Acyclovir 200-400 mg five times daily, valacyclovir 500 mg 2-3 times daily, OR famciclovir 250 mg twice daily 1
• Combination therapy is more effective: Oral antivirals alone may not prevent progression; adding topical antiviral is recommended 1

Follow-Up

Re-evaluate within 1 week with visual acuity measurement and examination 1

Chemotherapy/Radiation-Induced Stomatitis (Mucositis)

Prevention

• Benzydamine oral rinse for prevention of radiation-induced mucositis in head and neck cancer patients receiving moderate-dose radiation 8
• Oral cryotherapy for prevention in patients receiving bolus 5-FU chemotherapy 8
• Frequent use of non-medicated oral rinses (saline mouth rinses 4-6 times daily) 8
• Avoid alcohol-based mouth rinses 8

Treatment

• Patient-controlled analgesia with morphine is the treatment of choice for oral mucositis pain in patients undergoing hematopoietic stem cell transplantation 8
• Topical anesthetics can provide short-term pain relief 8
• Screen all patients for nutritional risk and initiate early enteral nutrition if swallowing problems develop 8

Drug-Induced Stomatitis (EGFR-TKI, mTOR Inhibitors)

Grade 1 (Erythema Only)

• Continue medication at current dose 8
• 0.9% saline or sodium bicarbonate rinses 8
• Use non-alcoholic mouthwash only 8
• Consider prophylaxis against fungal, viral, and/or bacterial infections 8

Grade 2 (Moderate Symptoms)

• Interrupt medication temporarily 8
• Increase supportive care measures 8
• Treat any concurrent infections appropriately 8

Grade 3 (Severe)

• Discontinue medication 8
• Hospitalize for supportive care 8
• Administer appropriate pain relief and antimicrobials 8
• Restart at lower dose once toxicity resolves to grade ≤1 8

Common Pitfalls and Caveats

• Never use corticosteroids for herpes stomatitis - this is the most critical error to avoid 1
• Chlorhexidine is not recommended for prevention of oral mucositis in head and neck cancer patients undergoing radiotherapy 8
• Treat any concurrent candidal infection with nystatin oral suspension or miconazole oral gel before or during stomatitis treatment 2, 6
• Evaluate and adjust dental appliances (dentures, braces, retainers) that may aggravate oral lesions 8
• Consider systemic diseases: Celiac disease is associated with 3.79-fold higher incidence of recurrent aphthous stomatitis 5
• Evaluate for Behçet's disease if patient presents with triad of uveitis, aphthous stomatitis, and genital ulcers 2
• Glossitis may occur in vitamin B12 deficiency even without symptomatic anemia or macrocytosis 9