Oral ulceration

Prescribing Notes:

• It is important to consider any possible underlying diagnosis. Please see Lothian RefHelp, and local guidance in Borders and Fife for information to support referral procedure.
• There is some evidence that chlorhexidine gluconate may reduce the duration and severity of each episode of ulceration. Benzydamine mouthwash can be used 10 minutes before meals to relieve pain in patients suffering from aphthous ulcers.
• Oral ulceration can be due to a variety of underlying causes. It is important to establish the diagnosis in each case as the majority of these lesions require specific management in addition to local treatment.
• Patients with an unexplained mouth ulcer of more than 3 weeks’ duration require urgent referral to hospital to exclude oral cancer.
• Local treatment aims to protect the ulcerated area, to relieve pain, to reduce inflammation, or to control secondary infection.
• Benzydamine relieves the pain of inflammatory conditions and is also effective in reducing the discomfort of post-irradiation mucositis. Some patients find that the full-strength mouthwash causes stinging and in these cases it can be diluted with an equal volume of water.
• Benzydamine oral rinse may be used 10 minutes before meals to relieve pain due to aphthous ulcers.
• Choline salicylate oral gel is recommended as an analgesic for the pain from mouth ulcers.
• Choline salicylate gel is not recommended for children under the age of 16 due to the risk of Reye’s syndrome.
• Hydrocortisone oromucosal tablets can be placed on the ulcer and allowed to dissolve four times daily.
• A saline mouthwash made up with warm water may relieve the pain of traumatic ulceration and radiotherapy mucositis.

Prescribing Notes:

• Current practice is to encourage self-care. Local treatment aims to:
  • Protect ulcerated area.
  • Relieve pain.
  • Reduce inflammation.
  • Control secondary infection.
• There is some evidence that chlorhexidine gluconate may reduce the duration and severity of each episode of ulceration. Rinse mouth well after brushing teeth as some ingredients in toothpaste can inactivate chlorhexidine.
• Chlorhexidine can stain teeth if used regularly.
• Benzydamine mouthwash can be used 10 minutes before meals to relieve pain in patients suffering from mouth ulcers.
• Stopping smoking can increase the incidence of mouth ulcers.
• Advise patients to use a softer toothbrush, reduce stress and avoid obvious food causes.
• For the management of sore throats, simple oral analgesics e.g. paracetamol or ibuprofen should be considered in preference to specific sore throat products.
• Products containing choline salicylate are no longer recommended in patients aged under 16.
• Hydrocortisone pellets are useful in the treatment of mouth ulcers.

When to advise patient to contact GP or Dental Practitioner
Duration of longer than 3 weeks.
Associated weight loss.
Involvement of other mucous membranes.
Rash.
Suspected adverse drug reaction.
Diarrhoea.
Recurrent bouts of infection.
Difficulty in swallowing (dysphagia).
Failed medication (no improvement in symptoms after 7 days).