What is the appropriate management for a patient with oral sores and swelling?

Management of Oral Sores and Swelling

For oral sores and swelling, initiate treatment with betamethasone sodium phosphate 0.5 mg dissolved in 10 mL water as a rinse-and-spit solution four times daily, combined with benzydamine hydrochloride oral rinse every 3 hours for pain control. 1, 2

Immediate First-Line Management

Topical Corticosteroids

• Betamethasone sodium phosphate 0.5 mg in 10 mL water used as a 2-3 minute rinse-and-spit solution four times daily is the primary treatment 1
• For localized lesions on the buccal mucosa or tongue, apply clobetasol 0.05% ointment mixed in 50% Orabase twice daily directly to dried mucosa 1, 2
• Alternatively, fluticasone propionate nasules diluted in 10 mL water twice daily can be used 1

Pain Management

• Benzydamine hydrochloride oral rinse should be used every 3 hours, particularly before eating 1, 3, 2
• For severe pain, viscous lidocaine 2% (15 mL per application) can be applied up to 3-4 times daily 1, 3
• Gelclair mucoprotectant gel applied three times daily forms a protective barrier over ulcerated surfaces, reducing pain and promoting healing 1, 2

Essential Oral Hygiene Measures

• Clean the mouth daily with warm saline mouthwashes to reduce bacterial colonization 1, 2
• Use 0.2% chlorhexidine digluconate mouthwash twice daily as an antiseptic rinse 1, 3
• Maintain good oral hygiene with soft toothbrush or swab after meals and before sleep 3
• Avoid crunchy, spicy, acidic foods and hot beverages during the healing period 1, 3

Treatment for Secondary Infections

Candidal Infection Management

• If candidal infection is suspected (look for white patches, burning sensation, or in patients with hyperglycemia), treat immediately with antifungals 1, 2
• Nystatin oral suspension 100,000 units four times daily for 1 week 1, 3, 2
• Or miconazole oral gel 5-10 mL held in mouth after food four times daily for 1 week 1, 3, 2

Critical pitfall: Hyperglycemia is an important predisposing factor for invasive fungal infections presenting as oral ulcers—check fasting blood glucose 1

Second-Line Treatments for Refractory Cases

If symptoms persist after 7 days of first-line therapy 4:

• Tacrolimus 0.1% ointment applied twice daily for 4 weeks for recalcitrant lesions 1, 2
• Intralesional triamcinolone (total dose 28 mg weekly) in conjunction with topical clobetasol for non-healing ulcers 1, 2

Systemic Therapy for Severe Cases

For severe cases where topical therapy has failed and quality of life is significantly impacted, use 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

When to Investigate Further

Obtain blood work and consider biopsy if 1:

• Ulcers persist beyond 3 weeks despite appropriate treatment
• Multiple sites with different morphological characteristics are present
• Patient has systemic symptoms (fever, weight loss, malaise)

Specific Investigations to Order

• Full blood count to rule out hematologic disorders like leukemia or anemia 1
• Fasting blood glucose to identify diabetes as a predisposing factor for fungal infections 1
• HIV antibody and syphilis serology if risk factors present 1

Critical Pitfalls to Avoid

• Oral ulcers may be the first manifestation of systemic diseases including Crohn's disease, Behçet's disease, or hematologic malignancies—maintain high index of suspicion 1, 5
• Always perform regular oral examinations to monitor treatment effectiveness and detect secondary infections 1, 3
• Eliminate sources of trauma such as sharp edges and ill-fitting prostheses before initiating treatment 6
• Screen all patients for nutritional risk, as malnutrition can contribute to severity and delayed healing 6
• Patients who develop salivary hypofunction/xerostomia due to anti-emetic or other anti-cholinergic drugs may experience increased discomfort 6