What is the best course of treatment for painful sores on the inside of the cheeks and sides of the tongue?

Treatment of Painful Oral Sores on Cheeks and Tongue

Start with betamethasone sodium phosphate 0.5 mg dissolved in 10 mL of water as a 2-3 minute rinse-and-spit solution four times daily, which is the first-line treatment recommended for oral aphthous ulcers. 1

Initial Management Approach

First-Line Topical Corticosteroids

• Betamethasone sodium phosphate 0.5 mg in 10 mL water used as a rinse-and-spit solution 1-4 times daily provides effective anti-inflammatory control 1
• For localized lesions on the buccal mucosa or tongue, apply clobetasol 0.05% ointment mixed in 50% Orabase twice weekly directly to dried mucosa 1
• Alternatively, fluticasone propionate nasules diluted in 10 mL water twice daily can be used 1

Pain Control Measures

• Benzydamine hydrochloride oral rinse should be used every 3 hours, particularly before eating, to reduce pain 2
• Viscous lidocaine 2% (15 mL per application) can be applied up to 3-4 times daily for severe pain 3, 2
• Gelclair mucoprotectant gel applied three times daily forms a protective barrier over ulcerated surfaces, reducing pain and promoting healing 2

Essential Supportive Care

• Clean the mouth daily with warm saline mouthwashes to reduce bacterial colonization 2
• Use 0.2% chlorhexidine digluconate mouthwash twice daily as an antiseptic rinse 3, 2
• Avoid crunchy, spicy, acidic foods and hot beverages during the healing period 3

Treatment for Secondary Infections

If candidal infection is suspected (particularly with white pseudomembrane or in patients with risk factors), treat immediately with antifungals:

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

Second-Line Treatments for Refractory Cases

If ulcers persist beyond 2 weeks despite first-line therapy:

• Tacrolimus 0.1% ointment applied twice daily for 4 weeks for recalcitrant lesions 1, 2
• Intralesional triamcinolone (total dose 28 mg weekly) in conjunction with topical clobetasol for non-healing ulcers 1, 2

Systemic Therapy for Severe or Recurrent Cases

For highly symptomatic or recurrent ulcers that don't respond to topical treatment:

• High-dose oral prednisone/prednisolone 30-60 mg or 1 mg/kg for 1 week, followed by dose tapering over the second week 1, 2
• This should be reserved for cases where topical therapy has failed and quality of life is significantly impacted 1

When to Investigate Further

Obtain blood work and consider biopsy if:

• Ulcers persist beyond 3 weeks despite appropriate treatment 4
• Multiple sites with different morphological characteristics are present 4
• Patient has systemic symptoms (fever, weight loss, malaise) 4
• Full blood count to rule out hematologic disorders like leukemia or anemia 4
• Fasting blood glucose to identify diabetes as a predisposing factor for fungal infections 4
• HIV antibody and syphilis serology if risk factors present 4

Critical Pitfalls to Avoid

• Do not assume all oral ulcers are benign aphthous ulcers; neoplastic lesions (squamous cell carcinoma, lymphoma) can mimic benign ulcers and require biopsy for definitive diagnosis 5
• Hyperglycemia is an important predisposing factor for invasive fungal infections presenting as oral ulcers 4
• Oral ulcers may be the first manifestation of systemic diseases including Crohn's disease, Behçet's disease, or hematologic malignancies 4
• Always perform regular oral examinations to monitor treatment effectiveness and detect secondary infections 3