What topical medications can be used to treat a sore in the mouth?

Topical Medications for Mouth Sores

For mouth sores, start with viscous lidocaine 2% (15 mL per application) for pain relief, combined with a mucoprotectant like Gelclair applied three times daily, and add topical corticosteroids such as dexamethasone ointment or clobetasol 0.05% for inflammation. 1, 2

First-Line Pain Management

Topical anesthetics provide immediate symptomatic relief:

• Viscous lidocaine 2% should be applied up to 3-4 times daily (15 mL per application) 3, 1, 2
• Benzocaine-containing products can be used, but should not exceed 7 days of continuous use 4
• Benzydamine hydrochloride oral rinse or spray should be used every 3 hours, particularly before eating 3, 1, 2
• For severe pain unresponsive to standard anesthetics, cocaine mouthwashes 2-5% can be used three times daily 3, 1

Mucosal Protection

Protective barriers reduce pain and promote healing:

• Gelclair mucoprotectant gel applied three times daily forms a protective coating over ulcerated surfaces 3, 1, 2
• White soft paraffin ointment should be applied to affected lips every 2 hours 3, 1, 2

Anti-Inflammatory Treatment

Topical corticosteroids are the cornerstone for reducing inflammation:

• Dexamethasone ointment applied 3 times daily after meals for 5 days is highly effective, with 83% healing rates versus 55% with placebo 5
• Betamethasone sodium phosphate 0.5 mg dissolved in 10 mL water as a 3-minute rinse-and-spit preparation four times daily 2
• For localized ulcers, clobetasol propionate 0.05% mixed in equal amounts with Orabase can be applied directly to affected areas daily 3, 2
• Triamcinolone acetonide can be used topically for resistant cases 6, 7

The British Journal of Dermatology guidelines emphasize that while topical corticosteroids are widely prescribed, their use is largely empirical, though one uncontrolled series showed reduction in oral inflammation 3. However, a 2012 randomized controlled trial demonstrated clear efficacy of dexamethasone ointment with significant improvements in ulcer size, pain levels, and healing ratios 5.

Antiseptic Oral Rinses

Reducing bacterial colonization prevents secondary infection:

• 0.2% chlorhexidine digluconate mouthwash (10 mL twice daily) is recommended for all patients 3, 1
• Diluting chlorhexidine by up to 50% reduces soreness while maintaining effectiveness 3
• 1.5% hydrogen peroxide mouthwash (10 mL twice daily) serves as an alternative 3, 1
• Warm saline mouthwashes should be used daily for gentle cleansing 3, 2

Treatment of Secondary Infections

Candidal superinfection requires specific antifungal therapy:

• Nystatin oral suspension 100,000 units four times daily for 1 week 3, 1, 2
• Miconazole oral gel 5-10 mL held in mouth after food four times daily for 1 week 3, 2
• Oral and lip swabs should be taken if bacterial or candidal infection is suspected 3

Practical Application Algorithm

Follow this stepwise approach:

1. Immediate relief (all patients): Apply viscous lidocaine 2% before meals and Gelclair three times daily 1, 2

2. Add anti-inflammatory: Start dexamethasone ointment 3 times daily after meals for 5 days 5

3. Oral hygiene: Use chlorhexidine 0.2% mouthwash twice daily 3, 1

4. Escalate if needed: Switch to clobetasol 0.05% for severe or non-responsive cases 2

5. Monitor for infection: If candidal infection develops, add nystatin or miconazole 3, 2

Important Caveats

Avoid these common pitfalls:

• Benzocaine products should not be used for more than 7 days without medical supervision 4
• Chlorhexidine is NOT recommended for treating established mucositis in cancer patients receiving radiotherapy, though it helps with oral hygiene 3
• Patients should avoid eating or drinking for 30 minutes after applying topical medications for maximum effectiveness 1
• Avoid alcohol-containing formulations as they cause additional irritation 1
• Patients should avoid crunchy, spicy, acidic foods and hot beverages during treatment 1, 2

Second-Line Options for Refractory Cases

When first-line treatments fail:

• Tacrolimus 0.1% ointment applied twice daily for 4 weeks 2
• Intralesional triamcinolone injections combined with topical clobetasol 2
• Systemic corticosteroids for highly symptomatic or recurrent ulcers 2