What are the best treatments for mouth pain?

Treatment of Mouth Pain

For acute mouth pain, start with topical anesthetics (viscous lidocaine 2%, 15 mL per application) combined with regular saline rinses 4-6 times daily, escalating to systemic analgesics following the WHO pain ladder if topical measures are insufficient. 1, 2

Immediate First-Line Management

Topical Anesthetics

• Viscous lidocaine 2% (15 mL per application) provides rapid pain relief and should be held in the mouth for 1-2 minutes before spitting out 2
• Avoid eating or drinking for 30 minutes after application to maximize effectiveness 2
• Benzocaine topical preparations temporarily relieve pain from toothache, sore gums, canker sores, and minor dental procedures 3
• If symptoms do not improve in 7 days or if irritation, pain, or redness worsens, discontinue and seek professional evaluation 3

Anti-inflammatory Rinses

• Benzydamine hydrochloride oral rinses or sprays should be used every 3 hours, particularly before eating, for pain management 1
• This provides both analgesic and anti-inflammatory effects for oral mucosal pain 1

Basic Oral Care Protocol

• Rinse with warm saline (or sodium bicarbonate solution: 1 teaspoon salt + ¾ teaspoon baking soda in 500 mL water) 4-6 times daily to maintain oral hygiene and reduce bacterial colonization 4, 5
• Use a soft toothbrush replaced regularly, or switch to chlorhexidine rinses if brushing is too painful 4, 2
• Avoid alcohol-based mouth rinses as they cause additional irritation 4, 2

Second-Line Interventions for Moderate to Severe Pain

Antiseptic and Protective Measures

• Apply 0.2% chlorhexidine digluconate mouthwash twice daily to reduce bacterial colonization and prevent secondary infection 1, 2
• Consider mucoprotectant mouthwashes (e.g., Gelclair) three times daily to protect ulcerated surfaces 1, 2
• Apply white soft paraffin ointment to affected lips every 2 hours if involved 1, 2

Systemic Analgesics

• When topical measures provide inadequate relief, escalate to systemic analgesics following the WHO pain management ladder 1
• For severe pain interfering with oral intake (Grade 3 mucositis), patient-controlled analgesia with morphine is the treatment of choice, particularly in hematopoietic stem cell transplant patients 4
• Topical NSAIDs (amlexanox 5% oral paste) may be considered for moderate pain 1

Treatment of Underlying Infections

Fungal Infections

• If candidal infection is suspected (white patches, angular cheilitis), treat with nystatin oral suspension (100,000 units) four times daily for 1 week or miconazole oral gel 5-10 mL held in mouth after food four times daily for 1 week 1, 2, 5
• For angular stomatitis specifically, apply topical antifungal agents directly to the corners of the mouth 5

Combination Therapy for Severe Cases

• If secondary bacterial infection is suspected, consider combination antifungal and antibacterial therapy 5
• Topical corticosteroids (clobetasol propionate 0.05% mixed with Orabase applied daily, or liquid dexamethasone 0.5 mg/5 mL elixir) may be added for severe inflammation, but only after ensuring adequate antimicrobial coverage 1, 2

Context-Specific Considerations

Chemotherapy or Radiation-Induced Mucositis

• Oral cryotherapy (ice chips) is specifically recommended for prevention of mucositis in patients receiving bolus 5-FU chemotherapy 4
• Benzydamine oral rinse prevents radiation-induced mucositis in head and neck cancer patients receiving moderate-dose radiation therapy 4
• For radiation therapy, use midline radiation blocks and three-dimensional treatment planning to reduce mucosal injury 4
• Chlorhexidine is NOT recommended for prevention in head and neck cancer patients undergoing radiotherapy 4

Dietary and Lifestyle Modifications

• Avoid crunchy, spicy, acidic foods, citrus fruits, hot beverages, smoking, and alcohol 2
• Consider cold foods to diminish burning sensations 6
• Screen all patients receiving high-dose chemoradiotherapy for nutritional risk and start early enteral nutrition if swallowing problems develop 4

Important Clinical Pitfalls

• Regular oral pain assessment using validated self-reporting instruments is essential to guide treatment escalation 4
• Perform regular oral examinations to monitor treatment effectiveness and detect secondary infections 2
• Evaluate and adjust dental appliances (dentures, braces, retainers) that may contribute to moisture accumulation and tissue trauma 5
• Consider referral to dentistry for persistent symptoms or dermatology if available 2
• Antivirals are not recommended for mucositis prevention but may be indicated if a new or recurrent oral viral infection co-exists with mucositis 4