What is the appropriate treatment for an adult patient with no significant medical history presenting with oral sores?

Treatment of Oral Sores in Adults

For simple oral aphthous ulcers, start with topical corticosteroid rinses—specifically betamethasone sodium phosphate 0.5 mg dissolved in 10 mL of water as a 2-3 minute rinse-and-spit solution four times daily—combined with pain management using viscous lidocaine 2% and barrier preparations. 1, 2

Initial Assessment and Red Flags

Before initiating treatment, determine if the oral sores warrant immediate investigation:

• Ulcers persisting beyond 2-3 weeks despite treatment require biopsy and blood work 3, 2
• Multiple ulcers with different morphological characteristics suggest systemic disease 2
• Systemic symptoms (fever, weight loss, malaise) mandate immediate workup 2
• Blood tests should include: full blood count, fasting glucose, HIV antibody, and syphilis serology 3, 2

The rationale: hyperglycemia predisposes to invasive fungal infections presenting as oral ulcers, and oral ulcers may be the first manifestation of hematologic malignancies, Crohn's disease, or Behçet's disease 3, 2.

First-Line Topical Corticosteroid Treatment

For typical recurrent aphthous ulcers (well-demarcated, oval/round with white/yellow pseudomembrane and erythematous halo):

• Betamethasone sodium phosphate 0.5 mg in 10 mL water, rinse-and-spit for 2-3 minutes, 1-4 times daily 1, 2
• Alternative: Fluticasone propionate nasules diluted in 10 mL water twice daily 1, 2
• For localized lesions: Clobetasol 0.05% ointment mixed in 50% Orabase, applied twice weekly to dried mucosa 1, 2

These topical corticosteroids are recommended by the British Journal of Dermatology and represent the standard first-line approach 3, 1.

Pain Management Strategy

Pain control is essential for maintaining nutrition and quality of life:

• Viscous lidocaine 2% (15 mL per application), up to 3-4 times daily for severe pain 1, 4, 2
• Barrier preparations: Gengigel mouth rinse/gel or Gelclair applied three times daily 3, 1, 2
• Benzydamine hydrochloride oral rinse every 3 hours, particularly before eating 4, 2
• For severe pain: Follow WHO pain management ladder, escalating to systemic analgesics if needed 1

Patients should avoid eating or drinking for 30 minutes after application for maximum effectiveness 4.

Supportive Care and Infection Prevention

Essential adjunctive measures that improve outcomes:

• 0.2% chlorhexidine digluconate mouthwash twice daily as antiseptic rinse 4, 2
• Warm saline mouthwashes daily to reduce bacterial colonization 2
• Avoid crunchy, spicy, acidic foods and hot beverages 4, 2
• Good oral hygiene with soft toothbrush twice daily 4

Treatment of Secondary Candidal Infection

Critical pitfall: Concurrent candidal infection is common and must be treated:

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

This is particularly important in patients with hyperglycemia, which predisposes to fungal superinfection 3, 2.

Second-Line Treatment for Refractory Ulcers

If ulcers don't respond to topical corticosteroids within 1-2 weeks:

• Tacrolimus 0.1% ointment applied twice daily for 4 weeks 3, 1, 2
• Intralesional triamcinolone (total dose 28 mg weekly) combined with topical clobetasol gel 0.05% 1, 2

A split-mouth randomized trial (n=15) showed triamcinolone acetonide 0.1% paste and tacrolimus 0.1% ointment were equally effective, with both significantly reducing mucosal involvement and pain scores compared to baseline 3.

Systemic Therapy for Severe or Recurrent Cases

Reserved for highly symptomatic ulcers or frequent recurrences affecting quality of life:

• High-dose oral prednisone/prednisolone 30-60 mg (or 1 mg/kg) for 1 week, followed by dose tapering over the second week 1, 2
• For recurrent aphthous stomatitis with frequent recurrences: Colchicine, particularly effective when associated with Behçet disease 1
• For severe cases with frequent recurrences: Azathioprine 2.5 mg/kg/day 1

The Annals of the Rheumatic Diseases notes that thalidomide is the most effective treatment for recurrent aphthous stomatitis, but its use is severely limited by teratogenicity and peripheral neuropathy risks 1.

Special Consideration: Herpes Labialis (Cold Sores)

If the oral sores are vesicular and consistent with herpes simplex virus:

• Valacyclovir is FDA-approved for cold sores in adults and adolescents ≥12 years 5
• Dosing: 2 grams twice daily on Day 1, which shortened cold sore duration by approximately 1 day in clinical trials (n=1,856) 5
• Treatment must be self-initiated at earliest symptoms, prior to any visible lesion 5

However, the efficacy of valacyclovir initiated after development of clinical signs (papule, vesicle, or ulcer) has not been established 5.

Common Pitfalls to Avoid

• Don't assume all oral ulcers are benign aphthous ulcers—traumatic ulceration corresponds to location of irritant, tuberculosis ulcers are stellate with undermined edges, and malignancy must be excluded in persistent cases 3
• Don't overlook systemic disease—oral ulcers may herald Crohn's disease, Behçet's disease, or hematologic malignancies 2
• Don't forget to check for candidal superinfection, especially in diabetic patients or those on corticosteroids 3, 1, 2
• Don't delay biopsy for ulcers persisting beyond 2-3 weeks or those unresponsive to initial treatment 3, 2

When to Refer

• Refer to oral medicine specialist or dermatology if ulcers persist despite appropriate treatment, multiple morphologically distinct ulcers are present, or systemic disease is suspected 4, 2
• Consider dentistry referral for persistent symptoms that may be related to dental trauma 4