What is the initial workup and management for a patient presenting with mouth sores?

Initial Workup and Management of Mouth Sores

The initial workup for mouth sores should include thorough oral examination, identification of potential causes, and implementation of appropriate topical treatments including antiseptic rinses, pain management, and protective measures to promote healing and prevent complications.

Initial Assessment and Diagnosis

• Perform a detailed examination of the oral cavity, including:

  • Location, size, number, and appearance of lesions
  • Presence of erythema, ulceration, or blistering
  • Involvement of lips, tongue, palate, and other oral structures 1
  • Signs of secondary infection (bacterial or fungal)

• Collect oral and lip swabs if bacterial or candidal infection is suspected 2

• Consider potential etiologies:

  • Aphthous ulcers (canker sores)
  • Infectious causes (viral, bacterial, fungal)
  • Traumatic injury
  • Medication side effects
  • Systemic conditions (e.g., Stevens-Johnson syndrome)
  • Nutritional deficiencies

Management Approach

1. Oral Hygiene Measures

• Clean the mouth daily with warm saline mouthwashes or gentle oral sponge 2, 1
• Use a soft toothbrush after meals and before sleep 2
• Clean teeth with mild fluoride-containing, non-foaming toothpaste 2
• Rinse mouth with alcohol-free mouthwash at least four times daily 2, 1
• For denture wearers:
  • Remove dentures before performing oral care
  • Defer wearing dental prostheses until tissues heal
  • Soak dentures in antimicrobial solution (e.g., chlorhexidine 0.2%) 2

2. Pain Management

• Apply topical anesthetics for pain relief:

  • Viscous lidocaine 2% (15 mL per application) for severe pain 2, 1
    • Caution: Monitor for toxicity with frequent use 3
    • Systemic absorption is typically minimal but may occur with extensive mucosal damage 4
  • Benzydamine hydrochloride rinse or spray every 3 hours, particularly before eating 2, 1

• For severe pain that is inadequately controlled with topical agents:

  • Consider systemic analgesics following WHO pain ladder 1

3. Anti-inflammatory and Protective Treatments

• Apply white soft paraffin ointment to lips every 2 hours 2
• Use mucoprotectant mouthwash (e.g., Gelclair) three times daily 2, 1
• Consider topical corticosteroids for inflammation reduction:
  • Betamethasone sodium phosphate 0.5 mg in 10 mL water as rinse-and-spit preparation four times daily 2, 1
  • Clobetasol propionate 0.05% mixed with equal amounts of Orabase applied directly to affected areas 2
  • Triamcinolone acetonide cream 0.1% applied to affected areas 2-3 times daily (for accessible lesions) 5

4. Infection Management

• Use antiseptic oral rinse twice daily:

  • 1.5% hydrogen peroxide mouthwash or
  • 0.2% chlorhexidine digluconate mouthwash (consider diluting by up to 50% to reduce soreness) 2

• For suspected or confirmed candidal infection:

  • Nystatin oral suspension 100,000 units four times daily for 1 week, or
  • Miconazole oral gel 5-10 mL held in mouth after food four times daily for 1 week 2, 1

5. Dietary and Lifestyle Modifications

• Avoid painful stimuli:

  • Smoking
  • Alcohol
  • Acidic foods (tomatoes, citrus fruits)
  • Hot, spicy, raw, or crusty foods 2, 1

• Maintain adequate hydration to keep mouth moist 2

• Consume soft, moist, and non-irritating foods 1

Special Considerations

• For Stevens-Johnson syndrome/toxic epidermal necrolysis:

  • More intensive management may be required
  • Daily oral review during acute illness
  • Monitor for complications including scarring and sicca syndrome 2

• For cancer therapy-related mucositis:

  • Consider specialized interventions like oral cryotherapy for patients receiving bolus 5-fluorouracil chemotherapy
  • Recombinant human keratinocyte growth factor-1 may be indicated for certain patients undergoing stem cell transplantation 2

• For persistent or recurrent lesions:

  • Follow-up every 3-6 months
  • Monitor for changes in appearance that could suggest malignant transformation 1

Common Pitfalls to Avoid

• Delaying treatment (early intervention is crucial for optimal outcomes) 1
• Using alcoholic mouthwashes that can irritate ulcers 1
• Overuse of topical lidocaine leading to potential toxicity 3
• Failing to identify underlying systemic diseases that may present with oral ulcers 1
• Neglecting nutritional deficiencies or psychological factors that may contribute to recurrent mouth sores 1