Treatment of mouth ulcers at community pharmacy

Mouth ulcers

Mouth ulcers are extremely common, affecting as many as one in five of the population and they are a recurrent problem in some people. They are classified as aphthous (minor or major) or herpetiform ulcers. Most cases (more than three quarters) are minor aphthous ulcers, which are self-limiting. Ulcers may be due to a variety of causes including infection, trauma and drug allergy. However, occasionally mouth ulcers appear as a symptom of serious disease such as carcinoma. The pharmacist should be aware of the signs and characteristics that indicate more serious conditions. What you need to know Age Child, adult Nature of the ulcers Size, appearance, location, number Duration Previous history Other symptoms Medication

Significance of questions and answers

Age

Patients may describe a history of recurrent ulceration, which began in childhood and has continued ever since. Minor aphthous ulcers are more common in women and occur most often between the ages of 10 and 40.

 Nature of the ulcers 

Minor aphthous ulcers usually occur in crops of one to five. The lesions may be up to 5mm in diameter and appear as a white or yellowish centre with an inflamed red outer edge. Common sites are the tongue margin and inside the lips and cheeks. The ulcers tend to last from 5 to 14 days.
Other types of recurrent mouth ulcer include major aphthous and herpetiform. Major aphthous ulcers are uncommon, severe variants of the minor ones. The ulcers, which may be as large as 30mm in diameter, can occur in crops of up to ten. Sites involved are the lips, cheeks, tongue, pharynx and palate. They are more common in sufferers of ulcerative colitis. Herpetiform ulcers are more numerous, smaller and, in addition to the sites involved with aphthous ulcers, may affect the floor of the mouth and the gums. Table 1 summarises the features of the three main types of aphthous ulcers. Systemic conditions such as Behc¸et’s syndrome and erythema multiforme may produce mouth ulcers, but other symptoms would generally be present (see below).

Medication

The pharmacist should establish the identity of any current medication, since mouth ulcers may be produced as a side-effect of drug therapy. Drugs that have been reported to cause the problem include aspirin and other NSAIDs, cytotoxic drugs and sulfasalazine (sulphasalazine). Radiotherapy may also induce mouth ulcers. It is worth asking about herbal medicines because feverfew (used for migraine) can cause mouth ulcers. It would also be useful to ask the patient about any treatments tried either previously or on this occasion and the degree of relief obtained. The pharmacist can then recommend an alternative product where appropriate.

Treatment timescale

If there is no improvement after 1 week, the patient should see the

doctor

Management

Symptomatic treatment of minor aphthous ulcers can be recommended

by the pharmacist, and can relieve pain and reduce healing

time. Active ingredients include antiseptics, corticosteroids and local

anaesthetics. There is evidence from clinical trials to support use of

topical corticosteroids and chlorhexidine mouthwash. Gels and

liquids may be more accurately applied using a cotton bud or cotton

wool, providing the ulcer is readily accessible. Mouthwashes can be

useful where ulcers are difficult to reach.

Chlorhexidine gluconate mouthwash

There is some evidence that chlorhexidine mouthwash reduces duration

and severity of ulceration. The rationale for the use of antibacterial

agents in the treatment of mouth ulcers is that secondary

bacterial infection frequently occurs. Such infection can increase discomfort

and delay healing. Chlorhexidine helps to prevent secondary

bacterial infection but it does not prevent recurrence. It has a bitter

taste and is available in peppermint as well as standard flavour.

Regular use can stain teeth brown – an effect that is not usually

permanent. Advising the patient to brush the teeth before using the

mouthwash can reduce staining. The mouth should then be well rinsed

with water as chlorhexidine can be inactivated by some toothpaste

ingredients. The mouthwash should be used twice a day, rinsing 10 ml

in the mouth for 1 minute.

Topical corticosteroids

Hydrocortisone and triamcinolone act locally on the ulcer to reduce
inflammation and pain, and to shorten healing time. The former is
available as pellets, the latter in a protective paste. To exert its effect, a
pellet must be held in close proximity to the ulcer until dissolved. This
can be difficult when the ulcer is in an inaccessible spot. One pellet is
used four times a day. The pharmacist should explain that the pellets
should not be sucked, but dissolved in contact with the ulcer. These
treatments are best used as early as possible. Before an ulcer appears,
the affected area feels sensitive and tingling – the prodromal phase –
and treatment should start then. They should be applied 3–4 times
daily. They have no effect on recurrence but should be restarted at the
first signs of a new outbreak.

Local analgesics

Benzydamine mouthwash or spray and choline salicylate dental gel

are short-acting but can be useful in very painful major ulcers. The

mouthwash is used by rinsing 15 ml in the mouth three times a day.

Numbness, tingling and stinging can occur with benzydamine.

Diluting the mouthwash with the same amount of water before use

can reduce stinging. The mouthwash is not licensed for use in children

under 12. Benzydamine spray is used as four sprays onto the affected

area three times a day. Although aspirin is no longer recommended for

children under 16 years because of possible links with Reye’s syndrome,

choline salicylate dental gel produces low levels of salicylate

and can therefore be used in children.

Local anaesthetics (e.g. lidocaine (lignocaine), benzocaine)

Local anaesthetic gels are often requested by patients. Although they

are effective in producing temporary pain relief, maintenance of gels

and liquids in contact with the ulcer surface is difficult. Reapplication

of the preparation may be done when necessary. Tablets and pastilles

can be kept in contact with the ulcer by the tongue and can be of value

when just one or two ulcers are present. Any preparation containing a

local anaesthetic becomes difficult to use when the lesions are located

in inaccessible parts of the mouth.

Both lidocaine and benzocaine have been reported to produce sensitisation,

but cross-sensitivity seems to be rare, probably because the

two agents are from different chemical groupings. Thus, if a patient

has experienced a reaction to one agent in the past, the alternative

could be tried.