Management of Common Oral Sores

Mea A. Weinberg, DMD, MSD, RPh; Stuart L. Segelnick, DDS, MS

US Pharmacist. 2013;38(6):43-48.

Abstract and Introduction

Abstract

Oral sores can occur anywhere in the oral cavity and oropharyngeal region. Since not all oral sores are benign, a careful differential diagnosis is important. The two most common types are canker sores (recurrent aphthous stomatitis) and cold sores (herpetic lesions). Early intervention is important with both. The pharmacist will most likely be the primary source for recommending medications (e.g., topical corticosteroids, oral and topical antivirals) for the treatment of these conditions.

Introduction

Oral sores can occur anywhere in the oral cavity and oropharyngeal region, including the lips, oral mucosa (movable tissue inside the lips, vestibule, and cheeks), gingivae or gums (nonmovable tissue immediately surrounding the teeth), tongue, soft and hard palate, and throat. Most oral sores are painful and annoying and, in severe cases, can cause significant morbidity. The two most common oral sores are canker sores and cold sores. The pharmacist will most likely be the primary source for recommending medications for the treatment of these conditions.

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Abstract and Introduction
Canker Sores
Herpetic Lesions
Recurrent Herpetic Infections (Cold Sores)
Conclusion
References

Table 1. Common Risk Factors for RAS and Aphthous-like Lesions
Hematinic (e.g., vitamin B¹², iron, folic acid) deficiency Gastrointestinal malabsorption conditions (e.g., celiac disease [gluten], Crohn's disease, pernicious anemia) Pharyngitis Smoking Stress Hormonal state Traumatic injury (e.g., biting mucosa or irritation from a dental appliance such as braces or ill-fitting denture) Food allergies (e.g., chocolate, peanuts, strawberries, tomatoes, wheat flour) Immunodeficiency (e.g., HIV/AIDS, cyclic neutropenia) Medications (e.g., NSAIDs, alendronate, nicorandil) Ingredients in toothpaste (e.g., sodium lauryl sulfate) Illicit use of cocaine

NSAIDs: nonsteroidal anti-inflammatory drugs; RAS: recurrent aphthous stomatitis.
Source: References 1, 4, 7–9.

Table 2. Treatment Goals of RAS
1) Reduce the painful symptoms
2) Reduce the severity of the condition
3) Reduce the duration of the lesion(s)
4) Reduce the size of the lesion(s)
5) Increase the time interval between recurrences
6) Use medications that have the fewest adverse effects

RAS: recurrent aphthous stomatitis. Source: References 1, 4, 8, 9.

Table 3. Medications Used in the Management of RAS Lesions
TOPICAL AGENTS (BRAND)	DOSING
Corticosteroids
Dexamethasone 0.5 mg/5 mL elixir (Dexasone)	Rinse and expectorate 5 mL every 15 h
Triamcinolone 0.1% dental paste (Adcortyl or Kenalog)	Dab on ulcer 2 to 4 times daily until healed
Analgesics
Viscous lidocaine 2% rinse (Xylocaine)^a	Rinse with 5–10 mL and expectorate or apply directly to lesion; 6 doses in 24 h
Orabase with benzocaine 20%	Using a finger cot or gauze, dab on paste up to 4 times daily
Benzocaine 20%, compound benzoin tincture (Kank-A)	Apply to ulcer up to 4 times daily
Benzocaine 10% (Zilactin-B)	Apply to ulcer up to 4 times daily; allow 30–60 sec to dry
Benzocaine 20% (Orajel)	Apply to ulcer up to 4 times daily; allow 30–60 sec to dry
Benzocaine 10% (Anbesol)	Apply to ulcer up to 4 times daily
Antibiotics
Tetracycline suspension USP 250 mg^a	Dissolve 1 capsule in 180 mL of water and then rinse and expectorate up to 4 times daily for 4–5 days
Tetracycline syrup 250 mg/5 mL (Sumycin)^a	Use 5 mL to rinse and expectorate 4 times daily for 4–5 days
Other Anti-inflammatory Agents
Amlexanox 5% (Aphthasol)^a	As soon as prodromal symptoms appear, dab on paste up to 4 times daily
Other Agents^b
Magnesium hydroxide (Milk of Magnesia)	Rinse and swish with 5 mL in mouth and expectorate
50% Milk of Magnesia and 50% liquid diphenhydramine (Benadryl)	Rinse and swish with 5 mL in mouth and expectorate

^aAvailable by prescription only. ^bFor a soothing effect.
RAS: recurrent aphthous stomatitis; sec: seconds. Source: References 1, 2.

Table 4. Management of Recurrent Herpes Labialis
Agent (Brand)	Dosing
Acyclovir (Zovirax)	Caps: 200 mg 5 times a day; 400 mg twice a day for prevention Cream/ointment 5%: Apply every 3 h up to 6 times a day for 7 days
Valacyclovir (Valtrex)	Tabs: 2 g twice a day for 1 day
Famciclovir (Famvir)	Tabs: 1,500 mg once for 1 day; 500 mg once a day for prevention
Penciclovir 1% cream (Denavir)	Apply every 2 h while awake
Docosanol 10% cream (Abreva)^a	Apply 5 times a day at first sign of cold sore; use until lesion is healed
Benzalkonium chloride 0.13% + benzocaine 7.5% (Viroxyn)^a	Apply in a single application using the provided applicator