What is the appropriate treatment for a patient with oral sores?

Treatment for Oral Sores

Topical corticosteroids, such as 0.1% triamcinolone acetonide in orabase applied 2-4 times daily until healing, are the first-line treatment for most types of oral ulcers. 1

Diagnosis and Assessment

Before initiating treatment, proper assessment is crucial:

• Examine the entire oral cavity, noting:

  • Shape and appearance (well-defined, round/oval with white/yellow pseudomembrane and red halo for canker sores)
  • Location (helps differentiate herpes from aphthous ulcers)
  • Duration (any ulcer persisting >2 weeks requires further investigation)
  • Cervical lymph node examination

• Key differential diagnoses to consider:

  • Canker sores (aphthous ulcers)
  • Traumatic ulceration
  • Herpes simplex virus infection
  • Autoimmune conditions (pemphigus, pemphigoid)
  • Infectious causes (tuberculosis, fungal)
  • Inflammatory bowel disease (Crohn's)
  • Squamous cell carcinoma 1, 2

Treatment Algorithm

First-line Treatment

• Topical corticosteroids:
  • 0.1% triamcinolone acetonide in orabase, 2-4 times daily until healing (typically 7-14 days) 1
  • Alternative options: clobetasol 0.05% ointment, betamethasone sodium phosphate, fluticasone propionate 1

Pain Management

• Topical anesthetics
• Oral analgesics as needed
• For severe cases: patient-controlled analgesia with morphine 1

Supportive Care

• Good oral hygiene:

  • Soft toothbrush and mild non-foaming toothpaste
  • Saline solution rinses 4-6 times daily
  • Alcohol-free mouthwash 1

• Dietary modifications:

  • Avoid spicy, acidic, and rough foods
  • Stay hydrated 1

For Refractory Cases

• Consider 3% citric acid as a topical agent applied three times daily (shown to heal refractory ulcers by day 10 in case studies) 3
• Systemic steroids may be necessary for severe, widespread, or persistent lesions 4

Special Considerations

When to Refer or Investigate Further

• Any oral ulcer persisting beyond 2 weeks despite treatment
• Red sores on the tongue persisting beyond 2 weeks
• Multiple, recurrent, or unusually painful ulcers
• Accompanying systemic symptoms 1

Follow-up and Monitoring

• Regular monitoring for persistent cases
• Follow-up every 3-6 months for persistent symptomatic cases
• Daily pain assessment 1

Prevention Strategies

• Avoid known triggers:
  • Hard, acidic, spicy, or salty foods
  • Toothpastes containing sodium lauryl sulfate
  • Alcohol and carbonated drinks
• Address chronic irritation (ill-fitting dentures, sharp teeth edges)
• Tobacco cessation and alcohol moderation 1

Clinical Pearls

• Most common oral ulcers are benign and self-limiting 5
• Recurrent aphthous stomatitis (canker sores) and herpes labialis (cold sores) can be differentiated primarily by location 6
• Persistent ulceration, especially in high-risk individuals, should raise suspicion for oral cancer 1
• Immunodeficiency should be considered in patients with severe recurrent herpes simplex or chronic oral candidiasis 6