What is the medical management for oral sores, including the use of antibiotics or other medications?

Medical Management for Oral Sores

The first-line treatment for oral sores should include topical corticosteroids, pain management with benzydamine hydrochloride, and protective agents like mucoprotectant gel, while antibiotics should be reserved only for cases with confirmed bacterial infection. 1, 2

Initial Assessment and Diagnosis

• Proper diagnosis of the type of oral sore is essential before initiating treatment, as different types require specific management approaches 2, 3
• Common causes of oral sores include recurrent aphthous stomatitis (canker sores), herpes simplex virus, trauma, medication side effects, and fungal infections 4
• Examine the entire oral cavity, noting the number, size, location, and appearance of lesions 1

First-Line Treatments

Topical Corticosteroids

• Apply betamethasone sodium phosphate 0.5 mg dissolved in 10 mL water as a 3-minute rinse-and-spit preparation four times daily for widespread oral ulcers 1, 2
• For localized ulcers, use clobetasol propionate 0.05% mixed in equal amounts with Orabase applied directly to the affected areas daily 1, 2
• For highly symptomatic ulcers, consider high-potency topical corticosteroids as first-line therapy 1, 5

Protective Agents

• Apply white soft paraffin ointment to the lips every 2 hours if they are affected 1, 2
• Protect ulcerated mucosal surfaces with a mucoprotectant mouthwash (e.g., Gelclair) three times daily 1, 2
• Clean the mouth daily with warm saline mouthwashes to reduce bacterial colonization and promote healing 1, 2

Pain Management

• Use benzydamine hydrochloride oral rinse or spray every 3 hours, particularly before eating 1, 2
• For moderate pain, consider topical NSAIDs (e.g., amlexanox 5% oral paste) 1
• For more severe pain, use topical anesthetic preparations such as viscous lidocaine 2% applied up to 3-4 times daily 1, 2
• When NSAIDs are not tolerated, use acetaminophen (paracetamol) as maintenance therapy 1

Oral Hygiene Measures

• Use antiseptic oral rinses twice daily to reduce bacterial colonization, such as 1.5% hydrogen peroxide mouthwash or 0.2% chlorhexidine digluconate mouthwash 1, 2
• For patients with oral dryness, consider sugarless chewing gum, candy, salivary substitutes, or sialogogues 1
• Diluting 0.2% chlorhexidine mouthwash by up to 50% will reduce the soreness that can accompany this treatment 1

Treatment for Secondary Infections

Fungal Infections

• If candidal infection is suspected, treat with nystatin oral suspension 100,000 units four times daily for 1 week 1, 2
• Alternatively, use miconazole oral gel 5-10 mL held in the mouth after food four times daily for 1 week 1, 2

Bacterial Infections

• Antibiotics should not be used routinely for oral sores unless there is clear evidence of bacterial infection 1
• Most guidelines recommend use of antimicrobial dressings, antiseptics, and antibiotics only for patients with infected wounds to prevent bacterial resistance 6
• There is insufficient evidence to conclude that antiseptics or topical antibiotics improve or heal ulcers more effectively than nonmedicated dressings 6

Second-Line Treatments for Refractory Cases

• For ulcers that don't respond to topical treatment, consider intralesional triamcinolone injections (weekly; total dose 28 mg) in conjunction with topical clobetasol 1, 3
• Tacrolimus 0.1% ointment applied twice daily for 4 weeks can be effective for recalcitrant ulcers 3, 5
• For highly symptomatic or recurrent ulcers, consider systemic corticosteroids (high-dose pulse 30-60 mg or 1 mg/kg oral prednisone/prednisolone for 1 week followed by dose tapering over the second week) 1, 5

Special Considerations

• Certain medications can cause oral ulcerations, including NSAIDs, methotrexate, azathioprine, ACE inhibitors, and some antidepressants 7
• If oral ulcers persist despite appropriate treatment, consider medication-induced causes and potential underlying systemic conditions 7, 4
• Slow healing of the oral mucosa may reflect secondary infection by, or reactivation of, herpes simplex virus 1

Common Pitfalls to Avoid

• Premature discontinuation of treatment before healing is complete 3
• Overuse of antibiotics for non-infected oral sores, which can lead to resistance and disruption of oral microbiome 1, 6
• Failure to address underlying causes of recurrent oral ulcers 4
• Inadequate pain management, which can affect nutrition and quality of life 1