What are the treatment options for herpangina, recurrent aphthous (canker sore) ulcers, and jaw pain?

Treatment of Herpangina, Recurrent Aphthous Ulcers, and Jaw Pain

Herpangina Management

For herpangina (viral pharyngitis), treatment is supportive only, as this is a self-limiting viral infection that resolves without antiviral therapy. 1

• Provide pain control with topical anesthetics such as viscous lidocaine 2% applied before meals 2, 3
• Use benzydamine hydrochloride oral rinse or spray every 3 hours, particularly before eating 2, 3
• Maintain oral hygiene with warm saline mouthwashes daily 2, 3
• Ensure adequate hydration and avoid dehydration 1
• Counsel patients to avoid spicy, acidic, and hot foods/drinks 1

Important distinction: Herpangina is caused by coxsackievirus (not herpes simplex virus) and does not respond to antiviral medications like acyclovir. 1, 4, 5

Recurrent Aphthous Ulcers (Canker Sores)

First-Line Topical Therapy

Start with topical corticosteroids as primary therapy for accessible lesions. 2, 6, 7

• For localized ulcers: Apply clobetasol gel or ointment 0.05% directly to dried mucosa 2, 6
• For widespread ulcers: Use betamethasone sodium phosphate 0.5 mg in 10 mL water as a rinse-and-spit preparation four times daily 2, 3, 6
• Alternative: Dexamethasone mouth rinse 0.1 mg/mL for difficult-to-reach areas 2

Pain Management and Barrier Protection

• Apply viscous lidocaine 2% before meals for severe pain 2, 3
• Use benzydamine hydrochloride rinse or spray every 3 hours 2, 3, 6
• Apply mucoprotectant mouthwashes (Gelclair) three times daily to form protective coating 2, 3
• Use white soft paraffin ointment to lips every 2 hours if affected 2, 3

Oral Hygiene Measures

• Clean mouth daily with warm saline mouthwashes 2, 3, 6
• Use antiseptic oral rinses twice daily (0.2% chlorhexidine digluconate or 1.5% hydrogen peroxide) 2, 3, 6
• Avoid toothpastes containing sodium lauryl sulfate 7
• Avoid hard, acidic, salty foods, alcohol, and carbonated drinks 7

Second-Line Therapy for Refractory Cases

If topical therapy fails after 1-2 weeks, escalate to systemic treatment. 2, 7

• Colchicine is first-line systemic therapy for recurrent aphthous stomatitis, especially with erythema nodosum or genital ulcers 2, 8, 7
• Consider intralesional triamcinolone injections weekly (total dose 28 mg) for non-responsive ulcers 2, 3
• For highly symptomatic cases: Systemic corticosteroids (prednisone/prednisolone 30-60 mg or 1 mg/kg for 1 week, tapering over second week) 2, 6, 7
• Alternative systemic options: Pentoxifylline or, in severe refractory cases, azathioprine, TNF-alpha inhibitors, or apremilast 2, 7

When to Refer

Refer to a specialist for ulcers lasting more than 2 weeks or not responding to 1-2 weeks of treatment. 2

Jaw Pain Management

Initial Assessment and Treatment

Monitor for swelling of the jaw and/or jaw pain as these may indicate osteonecrosis, particularly in patients with history of head/neck cancer or radiation. 1

• For early stage lesions: Administer broad-spectrum antibiotics and daily saline or aqueous chlorhexidine gluconate irrigations 1
• If osteonecrosis is suspected: Refer immediately to an oral surgeon, maxillofacial surgeon, oral oncologist, or dentist 1
• Watch for appearance of exposed mandibular bone, which confirms osteonecrosis 1

Dental Evaluation

Refer to a dentist or periodontist for thorough evaluation of jaw pain to rule out periodontal disease, temporomandibular joint disorders, or dental infections. 1

Common Pitfalls to Avoid

• Do not confuse aphthous ulcers with recurrent herpes simplex virus infections - they require different treatments and aphthae do not respond to antivirals 4, 5
• Do not prematurely taper corticosteroids before disease control is established 2
• Do not delay biopsy for ulcers lasting over 2 weeks to rule out squamous cell carcinoma 2, 8
• Do not use topical antivirals for herpangina - they are ineffective for this viral condition 1