What is the initial workup and treatment for a patient presenting with sore gums and canker sores?

Initial Workup and Treatment for Sore Gums and Canker Sores

For patients presenting with sore gums and canker sores, begin with thorough oral examination to identify trauma sources and assess ulcer characteristics, initiate basic oral hygiene measures with twice-daily brushing using soft toothbrush and fluoride toothpaste plus warm saline rinses, and consider biopsy if ulcers persist beyond 2 weeks or fail to respond to initial treatment. 1, 2

Initial Clinical Assessment

History and Examination Focus

• Document the duration of symptoms, as ulcers persisting beyond 2 weeks require more aggressive workup 1
• Perform systematic visual inspection of the entire oral cavity including teeth, gingiva, tongue, floor of mouth, and oropharynx to identify all affected areas 3
• Identify and document sources of mechanical trauma such as ill-fitting dentures, fractured teeth, or sharp dental restorations that may be contributing to gingival irritation 2, 4
• Assess ulcer morphology: recurrent aphthous ulcers typically present as well-demarcated, oval or round ulcers with white or yellow pseudomembrane and surrounding erythematous halo 1

When to Obtain Laboratory Testing

Blood tests should be obtained before biopsy for ulcers that do not respond to 1-2 weeks of treatment or have duration exceeding 2 weeks. 1

Required blood work includes:

• Complete blood count to detect blood system diseases, anemia, or leukemia 1
• Coagulation studies and fasting blood glucose to exclude biopsy contraindications 1
• HIV antibody and syphilis serology to rule out infectious causes 1
• If anemia is suspected, add serum iron, folate, and vitamin B12 levels 1
• For suspected bullous diseases, obtain serum specific antibodies (Dsg1, Dsg3, BP180, BP230) before biopsy 1

First-Line Treatment Measures

Basic Oral Hygiene Protocol

• Brush teeth twice daily using a small, ultra-soft-headed, rounded-end bristle toothbrush with prescription-strength fluoride toothpaste 1, 2
• Spit out foam after brushing but do not rinse mouth to maximize fluoride contact 1
• Rinse toothbrush in hot water to soften bristles before use 1
• Brush within 30 minutes after eating and before bed, ensuring the gingival portion of tooth and periodontal sulcus are included 1

Oral Rinsing Regimen

• Rinse vigorously with bland rinse (1 teaspoon salt, 1 teaspoon baking soda in 4 cups water) at least 4 times daily 1, 2
• Each rinse should last approximately 1 minute 4
• Avoid commercial mouthwashes with alcohol base as they cause additional pain, irritation, and impair healing 1, 2

Interdental Cleaning

• Floss at least once daily using waxed floss to minimize gingival trauma 1
• If flossing causes bleeding that persists beyond 2 minutes, consult the treating team 1
• For adults with gingivitis, once-daily interdental cleaning provides additional benefit 5

Dietary and Lifestyle Modifications

• Eliminate irritating foods including tomatoes, citrus fruits, hot drinks, and spicy, hot, raw, or crusty foods 2
• Avoid smoking and alcohol, which significantly impair healing 2
• Maintain adequate hydration by drinking ample fluids to keep the mouth moist 2, 4

Topical Symptomatic Relief

FDA-Approved Topical Anesthetics

• Benzocaine topical products temporarily relieve pain associated with canker sores, sore gums, and minor dental procedures 6
• Discontinue use and seek evaluation if symptoms do not improve within 7 days, or if irritation, pain, redness persists or worsens 6

Lip Care

• Use only animal or plant-based oils such as beeswax, cocoa butter, and lanolin for lip lubrication 1
• Avoid petroleum-based products as they promote mucosal dehydration and create an occlusive environment increasing secondary infection risk 1, 2

Elimination of Trauma Sources

• Have dental team eliminate sources of mechanical trauma including ill-fitting dentures or fractured teeth 2, 4
• Remove dentures before performing oral care 2
• Defer wearing dental prostheses until oral tissues are healed 2
• Counsel patients to avoid conscious cheek biting or tongue thrusting against oral mucosa 4

Follow-Up and Escalation Criteria

Monitoring Timeline

• Evaluate treatment response within 2 weeks 2
• If no improvement is seen after 1-2 weeks of treatment, reevaluate for correct diagnosis and consider biopsy 1, 2
• Remain vigilant for signs of secondary infection or complications 2

Indications for Biopsy

Biopsy should be strongly considered for:

• Oral ulceration with course exceeding 2 weeks 1
• Cases that do not respond to 1-2 weeks of appropriate treatment 1
• Any solitary chronic ulcer to rule out squamous cell carcinoma 7

Common Clinical Pitfalls

• Do not rely solely on clinical appearance for diagnosis, as many conditions can mimic aphthous ulcers including bullous diseases, infections, drug reactions, and malignancies 1, 7
• Inadequate pain management can impact nutrition and hydration, though topical anesthetics provide first-line relief 2, 6
• Chronic use of petroleum-based lip products creates an occlusive environment that increases infection risk 1, 2
• Glycerin or lemon-glycerin swabs dry the mouth and should be avoided 1

Additional Considerations for Recurrent Cases

For recurrent aphthous stomatitis (RAS) defined as oral aphthous ulcers occurring at least 4 times per year:

• Investigate for associated conditions including celiac disease, inflammatory bowel diseases, nutritional deficiencies (iron, folates), HIV infection, or neutropenia 7
• Colchicine associated with topical treatments constitutes suitable treatment for most RAS cases 7
• Thalidomide is the most effective treatment but use is limited by frequent adverse effects 7