What treatment options are available for a patient presenting with mouth sores, potentially caused by viral or bacterial infections?

Treatment of Mouth Sores

For mouth sores, start with benzydamine hydrochloride oral rinse or spray every 2-4 hours for pain control, combined with topical corticosteroid mouthwashes (betamethasone sodium phosphate 0.5 mg in 10 mL water as a rinse-and-spit solution 1-4 times daily) for inflammatory lesions. 1, 2, 3

Immediate Pain Management

• Benzydamine hydrochloride is the first-line analgesic, providing both anti-inflammatory and pain-relieving effects; use every 2-4 hours, particularly before eating 1, 2
• If benzydamine provides inadequate relief, use viscous lidocaine 2% (15 mL per application) as a topical anesthetic alternative 1, 2
• For severe discomfort, cocaine mouthwashes 2-5% can be used three times daily, though this requires special prescribing 1
• Follow the WHO pain ladder for escalating systemic analgesia if topical measures fail 3

Topical Corticosteroids for Inflammatory Lesions

• Betamethasone sodium phosphate 0.5 mg dissolved in 10 mL water: use as a 2-3 minute rinse-and-spit solution 1-4 times daily for diffuse oral ulcers 1, 3
• For localized lesions, apply clobetasol propionate 0.05% mixed equally with Orabase directly to dried mucosa twice daily 1, 3
• These are particularly effective for aphthous ulcers and immune-mediated oral lesions 3

Oral Hygiene and Mucosal Protection

• Rinse with warm saline or sodium bicarbonate mouthwashes 4-6 times daily to reduce bacterial colonization and promote healing 1, 2
• Use antiseptic rinses twice daily: either 0.2% chlorhexidine digluconate (10 mL) or 1.5% hydrogen peroxide mouthwash to prevent secondary infection 1, 2
  • Dilute chlorhexidine by up to 50% if it causes additional soreness 1
• Apply mucoprotectant mouthwashes (e.g., Gelclair) three times daily to coat ulcerated surfaces and provide symptomatic relief 1, 2, 3
• Use white soft paraffin ointment on lips every 2 hours to prevent cracking and maintain moisture 1, 2

Treating Secondary Infections

• Take oral and lip swabs if bacterial or candidal infection is suspected 1
• For candidal infection, use 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, 3
• Note that slow healing may indicate HSV reactivation, which requires antiviral therapy 1
• Acyclovir is not effective for preventing aphthous stomatitis recurrences 4

Supportive Care Measures

• Use a soft toothbrush after meals and before sleep, replacing monthly 1
• Brush with mild fluoride-containing, non-foaming toothpaste twice daily 1
• Avoid smoking, alcohol, tomatoes, citrus fruits, hot drinks, and spicy/crusty foods 1
• Eat soft, moist, non-irritating food at room temperature; supplement with high-calorie/high-protein drinks if needed 1
• Drink ample fluids throughout the day to keep the mouth moist 1

Escalation for Severe or Refractory Cases

• For recalcitrant ulcers not responding to topical corticosteroids, use tacrolimus 0.1% ointment applied twice daily for 4 weeks 3
• Consider intralesional triamcinolone (total dose 28 mg weekly) combined with topical clobetasol for persistent ulcers 3
• For highly symptomatic or recurrent ulcers, use systemic corticosteroids: 30-60 mg or 1 mg/kg oral prednisone/prednisolone for 1 week, then taper over the second week 3

Critical Pitfalls to Avoid

• Do not use chlorhexidine for prevention in radiation-induced mucositis, though it remains useful for bacterial colonization in other mouth sore types 1, 2
• Avoid chronic use of petroleum jelly on lips as it promotes mucosal dehydration and increases infection risk 1
• Do not start interdental cleaning during active mouth sores if the patient wasn't using it previously, as it can break the epithelial barrier 1
• If symptoms don't improve in 7 days or worsen with swelling, rash, or fever, discontinue topical anesthetics and seek further evaluation 5