Treatment of Pediatric Mouth Sores
For pediatric mouth sores, start with benzydamine hydrochloride oral rinse every 2-4 hours for pain control, combined with daily warm saline mouthwashes for oral hygiene, and add topical benzocaine for breakthrough pain in children over 2 years of age.
Pain Management Approach
First-Line Topical Anti-inflammatory Treatment
- Benzydamine hydrochloride oral rinse or spray should be applied every 2-4 hours, particularly before eating, as this provides anti-inflammatory and analgesic effects for oral mucosal lesions 1, 2.
- This agent is specifically recommended in pediatric guidelines for managing painful oral lesions 1.
Topical Anesthetic for Breakthrough Pain
- Benzocaine topical preparations can be used up to 4 times daily in children 2 years and older for additional pain relief when anti-inflammatory rinses are insufficient 3.
- Children under 12 years should be supervised during use 3.
- Do not use benzocaine for more than 7 days unless directed by a dentist or doctor 3.
- Stop use if symptoms do not improve in 7 days or if irritation worsens 3.
Alternative Topical Anesthetic Option
- Viscous lidocaine 2% can be considered when benzydamine provides inadequate pain control 2.
Oral Hygiene and Supportive Care
Daily Mouth Cleaning
- Clean the mouth daily with warm saline mouthwashes to reduce bacterial colonization and promote healing 1, 2.
- This simple intervention is emphasized across multiple pediatric guidelines as foundational care 1.
Antiseptic Rinses
- Consider antiseptic oral rinses twice daily, such as 0.2% chlorhexidine digluconate mouthwash or 1.5% hydrogen peroxide mouthwash, to prevent secondary infection 2.
Lip Protection
- Apply white soft paraffin ointment to the lips every 2 hours if they are affected to prevent cracking and provide a protective barrier 1, 2.
Topical Corticosteroid Mouthwashes for Severe Cases
When to Consider
- For severe or persistent mouth sores not responding to initial measures, consider potent topical corticosteroid mouthwashes such as betamethasone sodium phosphate (0.5 mg dissolved in 10 mL water) used as a rinse-and-spit solution 1-4 times daily 1.
- In infants, clobetasol propionate 0.05% cream or ointment can be applied topically to affected areas 1.
Important Caveat
- Evidence for additional benefit of topical corticosteroids beyond supportive care is limited, as most data comes from adult autoimmune conditions rather than common pediatric mouth sores 1.
Mucosal Protection
- Mucoprotectant mouthwashes such as Gelclair can be used three times daily to protect ulcerated surfaces and provide symptomatic relief 2.
- Barrier preparations like Gengigel mouth rinse or gel are also helpful for pain control 1.
Treatment of Secondary Infections
- If candidal infection develops (white patches, increased pain), treat with nystatin oral suspension or miconazole oral gel 2.
- This is particularly important in children with prolonged mouth sores or those on corticosteroid therapy 2.
When to Escalate Care
Red Flags Requiring Specialist Referral
- Oral lesions that do not respond to therapeutic protocols within 7 days should be referred to appropriate specialists 4.
- Consider underlying systemic conditions if ulcers are recurrent, unusually severe, or associated with systemic symptoms 5.
- The differential diagnosis for pediatric oral ulcers is broad, ranging from viral infections to autoimmune conditions, nutritional deficiencies, and medication reactions 5.
Common Pitfalls to Avoid
- Do not use chlorhexidine mouthwash for prevention in radiation-induced mucositis, as guidelines recommend against this approach 1; however, it may still have a role in managing bacterial colonization in other types of pediatric mouth sores 2.
- Avoid prolonged use of topical anesthetics beyond 7 days without medical supervision 3.
- Do not use benzocaine in children with a history of allergy to local anesthetics 3.
- Ensure adequate hydration, as painful mouth sores can decrease oral intake and lead to dehydration 6.