Management of Stomatitis and Cheilosis

Treatment Approach

The American College of Oncology recommends initiating treatment with steroid mouthwash (dexamethasone 0.5 mg/5 mL, 10 mL swish for 2 minutes then spit, four times daily) for prevention and early management of stomatitis, combined with good oral hygiene using non-alcoholic mouthwashes, escalating to topical or systemic corticosteroids based on severity 1, 2
For mild stomatitis (Grade 1-2), the European Society for Medical Oncology suggests using 0.9% saline or sodium bicarbonate rinses (1 teaspoon salt with three-quarter teaspoon baking soda in 500 mL water) 4-6 times daily to soothe the mouth, and applying topical anesthetics such as viscous lidocaine 2% for pain control 2, 3, 4
The American College of Oncology recommends maintaining gentle oral hygiene with mild toothpaste and non-alcoholic mouthwashes for mild stomatitis (Grade 1-2) 1, 2

The Multinational Association of Supportive Care in Cancer recommends consuming soft, moist, non-irritating foods that are easy to chew and swallow, drinking plenty of water, and using lip balm for dry lips 2, 4
The European Society for Medical Oncology suggests using ice chips or ice pops as needed to numb the mouth, and considering sugarless chewing gum, candy, or salivary substitutes for oral dryness 2, 4

The American College of Oncology recommends assessing for nutritional deficiencies (iron, B vitamins) before diagnosing idiopathic recurrent aphthous stomatitis 1
The European Society for Medical Oncology suggests evaluating for herpes simplex virus (requires antiviral therapy, not corticosteroids) before diagnosing viral stomatitis 4

The American College of Oncology recommends starting steroid mouthwash prophylactically (dexamethasone 0.5 mg/5 mL, 10 mL swish for 2 minutes then spit, four times daily) to prevent mTOR inhibitor-associated stomatitis (mIAS) 1
The European Society for Medical Oncology suggests considering prophylactic antiviral therapy for immunocompromised patients or those with severe symptoms of viral stomatitis 2

The American Society of Clinical Oncology recommends systemic corticosteroids (prednisone 30-60 mg or 1 mg/kg daily for 1 week, then taper) for highly symptomatic ulcers in severe stomatitis cases 5
The National Comprehensive Cancer Network suggests that prophylactic measures, such as non-alcoholic mouthwashes, soft foods, and adequate hydration, can benefit patients with both cheilitis and stomatitis 6
Hospitalization is required for Grade 3-4 stomatitis with inability to maintain oral intake, as recommended by the American College of Physicians 6
Inadequate pain control in stomatitis can lead to poor oral intake and treatment discontinuation, and alternative routes (transdermal, intranasal) should be considered for severe cases, according to the American Society of Clinical Oncology 5
Using alcoholic mouthwashes can aggravate both conditions through mucosal irritation, and non-alcoholic mouthwashes are recommended instead, as suggested by the American Dental Association 6

The American Society of Clinical Oncology recommends establishing foundational oral care with non-alcoholic, sodium bicarbonate-containing mouthwashes used 4-6 times daily to maintain oral pH and reduce inflammation 7
Topical anesthetics such as viscous lidocaine 2% can be applied before meals for pain control in patients with mild stomatitis 7
The Multinational Association of Supportive Care in Cancer suggests using sugarless chewing gum, candy, or salivary substitutes for oral dryness 7

For moderate stomatitis, the European Society for Medical Oncology recommends increasing sodium bicarbonate mouthwash frequency up to hourly if necessary, and initiating topical high-potency corticosteroids as first-line therapy 7
Dexamethasone mouth rinse (0.1 mg/mL) can be used for multiple or difficult-to-reach ulcerations, with a recommended dose of 10 mL swish for 2 minutes then spit, four times daily 8
Clobetasol gel or ointment (0.05%) can be applied twice daily for limited, easily accessible ulcers 8

The American Pain Society recommends using topical NSAIDs (amlexanox 5% oral paste) for moderate pain if NSAIDs are tolerated 7
If NSAIDs are contraindicated, acetaminophen can be used as maintenance therapy combined with immediate-release oral opioids 8
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 8

Systemic corticosteroids, such as prednisone 30-60 mg or 1 mg/kg daily, can be administered for 1 week, followed by dose tapering over the second week for highly symptomatic or recurrent ulcers 8
Intralesional steroid injection (triamcinolone weekly, total dose 28 mg) can be considered in conjunction with topical clobetasol for ulcers that fail to resolve 8

The American Academy of Allergy, Asthma, and Immunology recommends prophylactic dexamethasone mouthwash (0.5 mg/5 mL, 10 mL swish for 2 minutes then spit, four times daily) to be started before treatment initiation in patients undergoing cancer therapy, as most cases of stomatitis are mild but can be very painful and interfere with eating 9
The European Society for Medical Oncology suggests using saline-containing mouthwashes instead of plain water due to increased microbial burden with targeted agents 10
The American Academy of Allergy, Asthma, and Immunology recommends management of chemotherapy-associated stomatitis to include topical and systemic corticosteroids, with dose reduction or temporary discontinuation of the causative agent if severe 9