What is the best approach to manage a patient with mouth sores?

Management of Mouth Sores

Start with topical high-potency corticosteroids (betamethasone 0.5 mg in 10 mL water as rinse-and-spit four times daily, or clobetasol 0.05% ointment mixed with Orabase for localized lesions) combined with viscous lidocaine 2% for pain control, while maintaining rigorous oral hygiene with chlorhexidine rinses. 1, 2

Immediate First-Line Management

Topical Corticosteroids

• Betamethasone sodium phosphate 0.5 mg dissolved in 10 mL water used as a 2-3 minute rinse-and-spit solution four times daily is the preferred initial treatment. 2, 3
• For localized lesions on the buccal mucosa or tongue, apply clobetasol 0.05% ointment mixed in 50% Orabase twice weekly directly to dried mucosa. 2, 3
• Alternatively, fluticasone propionate nasules diluted in 10 mL water twice daily can be used. 2, 3

Pain Management

• Viscous lidocaine 2% (15 mL per application) should be used up to 3-4 times daily for severe pain, held in mouth for 1-2 minutes before spitting out. 1, 2
• Benzydamine hydrochloride oral rinse every 3 hours, particularly before eating, reduces pain effectively. 1, 2
• Gelclair mucoprotectant gel applied three times daily forms a protective barrier over ulcerated surfaces. 1, 2
• Avoid eating or drinking for 30 minutes after topical anesthetic use for maximum effectiveness. 1

Essential Oral Hygiene Measures

• Use 0.2% chlorhexidine digluconate mouthwash twice daily as an antiseptic rinse for all patients with oral mucosa inflammation. 1, 2
• Clean the mouth daily with warm saline mouthwashes to reduce bacterial colonization. 2
• Maintain good oral hygiene with twice-daily toothbrushing using a soft toothbrush; if toothbrushing is too painful, chlorhexidine rinses can substitute. 1
• Apply white soft paraffin ointment to lips every 2 hours throughout treatment. 1

Dietary Modifications

• Avoid crunchy, spicy, acidic foods, citrus fruits, and hot beverages during the healing period. 1, 2
• Avoid smoking and alcohol, which are potential irritants. 1

Second-Line Treatments for Refractory Cases

Advanced Topical Therapy

• Tacrolimus 0.1% ointment applied twice daily for 4 weeks for recalcitrant lesions that don't respond to corticosteroids. 2, 3
• Liquid dexamethasone 0.5 mg/5 mL elixir or fluocinonide 0.05% gel for moderate inflammation. 1
• Compounded budesonide 3 mg/10 mL solution for severe cases. 1

Intralesional Therapy

• For ulcers that don't resolve with topical treatment, intralesional triamcinolone (total dose 28 mg weekly) in conjunction with topical clobetasol 0.05% gel or ointment should be considered. 4, 2, 3

Systemic Therapy for Severe or Recurrent Cases

For highly symptomatic ulcers, recurrent ulcers, or esophageal lesions, systemic corticosteroids should be used: high-dose oral prednisone/prednisolone 30-60 mg or 1 mg/kg for 1 week, followed by dose tapering over the second week. 4, 2, 3

This aggressive approach is reserved for cases where topical therapy has failed and quality of life is significantly impacted. 2

Treatment of Secondary Infections

Candidal Infections

If candidal infection is suspected (common pitfall in patients with persistent mouth sores):

• Nystatin oral suspension 100,000 units four times daily for 1 week, or 4, 1, 2
• Miconazole oral gel 5-10 mL held in mouth after food four times daily for 1 week. 4, 1, 2

When to Investigate Further

Obtain blood work and consider biopsy if: 2

• Ulcers persist beyond 3 weeks despite appropriate treatment 2
• Multiple sites with different morphological characteristics are present 2
• Patient has systemic symptoms (fever, weight loss, malaise) 2

Recommended Laboratory Workup

• Full blood count to rule out hematologic disorders like leukemia or anemia 2
• Fasting blood glucose to identify diabetes as a predisposing factor for fungal infections 2
• HIV antibody and syphilis serology if risk factors present 2

Critical Pitfalls to Avoid

• Hyperglycemia is an important predisposing factor for invasive fungal infections presenting as oral ulcers—always check blood glucose in persistent cases. 2
• Oral ulcers may be the first manifestation of systemic diseases including Crohn's disease, Behçet's disease, or hematologic malignancies—maintain high index of suspicion. 2, 5
• Always perform regular oral examinations to monitor treatment effectiveness and detect secondary infections. 1, 2
• Do not use benzocaine-containing products for more than 7 days; if symptoms don't improve, escalate care. 6
• Acyclovir is not effective for prevention of recurrent aphthous stomatitis and should not be used for typical canker sores. 7

Referral Indications

• Refer to dentistry for persistent symptoms despite appropriate treatment. 1
• Refer to dermatology if available for complex or refractory cases. 1