What is the treatment for a patient presenting with a sore on the tongue?

Treatment for Tongue Sores

For most tongue sores, start with topical corticosteroids (betamethasone sodium phosphate 0.5 mg in 10 mL water as a rinse-and-spit solution 1-4 times daily) combined with supportive care including white soft paraffin ointment applied every 2 hours and benzydamine hydrochloride spray every 3 hours for pain control. 1, 2

Initial Assessment and Supportive Care

Before initiating specific treatment, examine the tongue daily to monitor progression and identify any secondary infections 3. The foundation of treatment for all tongue sores includes:

• Apply white soft paraffin ointment every 2 hours to protect and moisturize affected areas 2, 4
• Clean the mouth daily with warm saline mouthwashes to reduce bacterial colonization 3, 2
• Use benzydamine hydrochloride oral rinse or spray every 2-4 hours, particularly before eating, for pain management 1, 2

First-Line Pharmacologic Treatment

Topical Corticosteroids (Primary Treatment)

Betamethasone sodium phosphate 0.5 mg dissolved in 10 mL water as a 2-3 minute rinse-and-spit solution 1-4 times daily is the recommended first-line treatment 1. This addresses the inflammatory component present in most tongue sores.

For localized lesions on dried mucosa, clobetasol 0.05% ointment mixed in 50% Orabase applied twice weekly provides more potent anti-inflammatory effects 1. Alternatively, clobetasol propionate 0.05% mixed in equal amounts with Orabase can be applied directly to affected areas daily 3.

Pain Management Algorithm

When benzydamine provides inadequate pain control:

• Viscous lidocaine 2%, 15 mL per application, can be used as needed 3, 2
• For severe discomfort, cocaine mouthwashes 2-5% three times daily may be considered 3, 4
• Barrier preparations such as Gelclair mouthwash three times daily protect ulcerated surfaces and provide additional pain relief 1, 4

Antiseptic Therapy

Use antiseptic oral rinse twice daily to reduce bacterial colonization 3, 2. Options include:

• 1.5% hydrogen peroxide mouthwash, 10 mL twice daily 3
• 0.2% chlorhexidine digluconate mouthwash, 10 mL twice daily (can be diluted by 50% to reduce soreness) 3

Treatment for Secondary Infections

If bacterial or candidal infection is suspected, obtain cultures and treat accordingly 3, 4:

Fungal Infections

• Nystatin oral suspension 100,000 units four times daily for 1 week 3, 1
• Miconazole oral gel 5-10 mL held in mouth after food four times daily for 1 week 3, 1

Second-Line Treatment for Recalcitrant Cases

When first-line therapy fails after 2 weeks 4:

• Tacrolimus 0.1% ointment applied twice daily for 4 weeks for treatment-resistant lesions 1, 4
• Weekly intralesional triamcinolone (total dose 28 mg) in conjunction with topical clobetasol gel or ointment (0.05%) for ulcers that don't resolve with topical treatment alone 1

Systemic Therapy for Severe or Highly Symptomatic Cases

Consider systemic corticosteroids (30-60 mg or 1 mg/kg oral prednisone/prednisolone for 1 week followed by dose tapering over the second week) for highly symptomatic or recurrent ulcers 1.

Critical Pitfalls to Avoid

• Never use alcohol-containing mouthwashes as they cause additional pain and irritation 2, 4
• Do not use topical anesthetics like benzocaine for more than 7 days unless directed by a healthcare provider 5
• Reevaluate diagnosis if no improvement after 7 days of appropriate treatment, as persistent sores may indicate underlying conditions requiring biopsy 5, 6
• Obtain cultures if secondary infection is suspected rather than empirically treating 3, 4

Special Populations

Immunocompromised patients require more aggressive and prolonged therapy 2, 4. Consider underlying systemic conditions (diabetes, nutritional deficiencies, inflammatory bowel disease) in persistent cases 6, 7.