Oral ulceration

If a patient presenting with oral ulceration is severely dehydrated, advise the parent/carer to seek emergency medical care. 

If there are signs of dehydration (dizziness/lightheaded, tiredness, dry mouth, lips, eyes) advise the patient or parent/carer to seek urgent medical care. 

Do not examine with ungloved hands because of potential infection risk with viral ulcers. 

Determine how long the ulceration has been present. 

If ulceration has been present 3 weeks or more, refer the patient for urgent care via the local rapid access pathway (oral surgery) to investigate potential dysplasia or malignancy. 

When ulceration has been present for less than 3 weeks:  

• If ulceration is recurrent and self-limiting, advise the patient to use 0.2% chlorhexidine mouthwash* and to seek non-urgent dental care. For children, recommend optimal analgesia, soft diet and advise that ulcers are likely to resolve within 1-2 weeks. 
• If the patient is receiving drug treatment or has an underlying medical condition that might be the cause of the ulcer(s), advise them to seek urgent medical care (see Table 1 and Appendix 3). 
• If there are multiple ulcers present, advise the patient to seek non-urgent dental care. However, if the patient is also systemically unwell, advise them to seek urgent medical care.  
• If ulceration is due to ill-fitting dentures, advise the patient to use 0.2% chlorhexidine mouthwash*, to keep dentures out where possible and to seek non-urgent dental care (also refer to Section 4.10). 
• If there has been trauma from an adjacent tooth or orthodontic appliance, advise the patient to seek non-urgent dental care (also refer to Section 4.11). 
• If ulceration is likely to be due to trauma to anaesthetised tissue following recent treatment using local anaesthesia, advise the patient to avoid smoking, drinking hot liquids and biting the cheek or lip, and to see a dentist only if symptoms persist or worsen.  
• If a single ulcer appears not to have been caused by trauma, advise the patient to use 0.2% chlorhexidine mouthwash* until symptoms resolve or if the ulcer fails to heal within a week, to see a dentist within 7 days. 
• Do not prescribe antibiotics unless there are signs of spreading infection, systemic infection, or for an immunocompromised patient.  

In all of the above cases, recommend optimal analgesia, including prescription of topical analgesics (e.g. benzydamine oromucosal spray, see Appendix 2).  

* Chlorhexidine mouthwash is not suitable for children under 7 years old.  

Consider: 

• Fixing ill-fitting dentures if appropriate. 
• Prescribing a topical steroid. 
• Referring to the local rapid access pathway to investigate potential dysplasia or malignancy if symptoms persist.  
• Referral to a dermatologist or an oral medicine specialist if vesiculobullous disorder is suspected. 

In cases of primary herpetic gingivostomatitis or herpes zoster infection, if the symptoms are severe or the patient is immunocompromised, consider prescribing antiviral agents (aciclovir or penciclovir, see SDCEP ‘Drug Prescribing for Dentistry’ guidance for doses), ideally in the early stages. 

Refer to a general medical practitioner if the patient has an underlying medical condition and is receiving a drug that may be the cause of ulceration.