Medication Summary
NSAIDs or topical anesthetics (eg, viscous lidocaine, benzocaine, dyclonine) may be used to provide temporary pain relief and comfort while the patient eats.
Some clinicians suggest that the use of corticosteroids may delay healing; however, a mixture of Orabase with a topical corticosteroid ointment (eg, clobetasol, fluocinonide, triamcinolone) often is effective.
Although unnecessary, treatment with systemic prednisone or intralesional injections of triamcinolone has been successful in some patients.
Dexamethasone elixir and magic mouthwash may also provide relief.
Magic mouthwash provides symptomatic relief of stomatitis. Variations of this formulation may be available through a pharmacy or may be personally specified. A standard recipe may include 30 mL diphenhydramine (Benadryl) elixir, 60 mL calcium carbonate and magnesium hydroxide (Mylanta), and 4 g sucralfate (Carafate). Preparations may also include tetracycline (avoid tetracycline if < 9 yr), attapulgite (Kaopectate), lidocaine, cherry syrup (for children), or hydrocortisone.
Topical anesthetics
Class Summary
These agents may provide temporary symptomatic relief of pain. They also may improve the patient's comfort while eating.
Viscous lidocaine 2% (Xylocaine)
Viscous lidocaine 2% is an anesthetic liquid prescribed to treat painful lesions of the oral mucosa or lips. It inhibits neuronal membrane depolarization, blocking nerve impulses.
For small lesions, apply to the ulcer with a cotton-tipped applicator. It is generally not recommended for use in children because therapeutic doses usually approach potentially toxic levels. If necessary, use the lowest effective dose and supervise children.
Benzocaine (Americaine, Benzocol, Cylex)
Benzocaine inhibits neuronal membrane depolarization, blocking nerve impulses. In pediatric patients, this is a safe alternative to lidocaine.
Dyclonine (Dyclone)
Dyclonine is a ketone local anesthetic agent administered topically. It affects cell membrane permeability and blocks impulses at peripheral nerve endings in mucosa.
Analgesics
Class Summary
Analgesics are used for the relief of mild to moderate pain.
Ibuprofen (Motrin, Advil, Pediaprofen)
Ibuprofen is the drug of choice for patients with mild to moderate pain. It inhibits inflammatory reactions and pain by decreasing prostaglandin synthesis.
Acetaminophen (Tylenol, Tempra, FeverAll, Aspirin-Free Anacin)
Acetaminophen is the drug of choice for pain relief in patients with documented hypersensitivity to aspirin or NSAIDs, those with upper GI tract disease, or those who are taking oral anticoagulants.
Dental aids and preparations
Class Summary
These are topical corticosteroids that share anti-inflammatory, antipruritic, and vasoconstrictive properties. However, they should be mixed with a carrier such as Orabase to ensure adherence of the drug to the mucosal surface. Otherwise, saliva quickly washes away the medication.
Clobetasol (Temovate in Orabase)
Clobetasol is a class I superpotent topical steroid; it suppresses mitosis and increases the synthesis of proteins that decrease inflammation and cause vasoconstriction. Ointment is recommended for intraoral use. Most pharmacists mix 15 g of clobetasol with 15 g of Orabase; this should be indicated on the prescription.
Fluocinonide (Lidex in Orabase)
Fluocinonide is a class II high-potency topical corticosteroid that inhibits cell proliferation; it is immunosuppressive and anti-inflammatory. Ointment is recommended for intraoral use. Most pharmacists mix 15 g of fluocinonide with 15 g of Orabase; this should be indicated on the prescription.
Triamcinolone topical (Kenalog in Orabase)
Triamcinolone topical is of group III and of intermediate potency. It is used to treat inflammatory mucosal lesions that are responsive to steroids. It decreases inflammation by suppressing the migration of polymorphonuclear leukocytes and reversing capillary permeability. Ointment is recommended for intraoral use. Most pharmacists mix 15 g of triamcinolone with 15 g of Orabase; this should be indicated on the prescription.
Corticosteroids
Class Summary
These agents have anti-inflammatory properties and cause profound and varied metabolic effects. They modify the body's immune response to diverse stimuli.
Dexamethasone (Decadron, Dexone, Hexadrol, Methasone)
Dexamethasone is an elixir for various allergic and inflammatory diseases. It decreases inflammation by suppressing the migration of polymorphonuclear leukocytes and reducing capillary permeability. Supervise pediatric patients during administration.
Prednisone (Orasone, Deltasone, Meticorten)
Prednisone may decrease inflammation by reversing increased capillary permeability and suppressing PMN activity. In most cases, systemic corticosteroids are unnecessary in the management of eosinophilic ulcers. Dividing the dose may increase efficacy, but it also increases the risk of adrenal suppression/adverse effects.
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A 47-year-old African American woman with an eosinophilic ulcer on the lateral surface of the tongue. The anterior border of the lesion is raised. Courtesy of Dr Paul D. Freedman.
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Raised, indurated, nonhealing ulcer on the lateral surface of the tongue. The lesion was related to an adjacent fractured tooth. Courtesy of Dr Paul D. Freedman.
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Ulcer on the ventrolateral surface of the tongue. The differential diagnosis should include squamous cell carcinoma or an infectious etiology. Courtesy of Dr Paul D. Freedman.
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Lesion on the lateral surface of the tongue. Courtesy of Dr Paul D. Freedman.
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Low-power view showing an ulcerated surface epithelium with a dense cellular inflammatory infiltrate underlying the mucosal surface (original magnification X40). Courtesy of Dr Paul D. Freedman.
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Cellular infiltrate composed mainly of large mononuclear cells, including histiocytes and submucosal dendrocytes, eosinophils, and scattered T lymphocytes (original magnification X400). Courtesy of Dr Paul D. Freedman.
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Inflammatory infiltrate extending through and between muscle bundles (original magnification X400). Courtesy of Dr Paul D. Freedman.
