Management of oral infections

The most common types are candidiasis, denture stomatitis and angular cheilitis (soreness, redness and fissures at corners of mouth). Risk factors include wearing dentures, concomitant antibiotic or steroid use and xerostomia.

• Maintain oral hygiene.
• Systemic treatments are likely to be more effective than topical treatments. In many cases, a systemic antifungal such as fluconazole (capsules or suspension) 50mg daily for 7 days will be indicated with review and extension as necessary. Higher doses may be necessary in immunocompromised patients. Doses may need to be reduced in renal impairment. Topical miconazole oral gel 2% may also be used. Apply 2.5ml topically four times daily, retained near lesions before swallowing. Continue use for at least a week after lesions have healed. Topical miconazole should be considered for treating angular cheilitis.
• In patients where this treatment is contra-indicated, or for mild oral candidiasis in non‑immunocompromised patients, nystatin oral suspension 100,000 units/ml can be considered. Prescribe 1ml four times daily after food, usually for 7 days. Rinse around mouth and hold in contact with affected areas as long as possible. Continue use for 48 hours after lesions have healed. Some patients may be unable to comply with the administration instructions for nystatin and require a systemic antifungal.
• Always check the BNF or seek advice from a pharmacist before prescription of antifungal medication as there is a risk of serious drug interactions. Fluconazole and miconazole (including topical route) should be avoided in patients prescribed warfarin and statins.
• Swab angles, tongue and nostrils to investigate possible Staphylococcal infection. If present, adjust treatment accordingly.
  • If a fungal infection is present, dentures must be cleaned thoroughly – soak in chlorhexidine 0.2% mouthwash (if dentures have metal components) or dilute sodium hypochlorite for 20 minutes twice a day. Toothbrushes should also be replaced.
  • If symptoms persist, consider referral to a dentist with consent or a palliative care specialist.

Herpes simplex is the most common viral infection.

• Treat infections inside the mouth with oral aciclovir: 200mg five times a day for at least 5 days (or until healing is complete). Soluble preparations are available.
• The dose of aciclovir may be doubled or intravenous treatment considered if the patient is immunocompromised or if absorption is impaired. In this case seek advice. Doses may need to be reduced in renal impairment.
• The use of antimicrobial mouthwashes (either chlorhexidine 0.2% mouthwash or hydrogen peroxide mouthwash, 6%) controls plaque accumulation if toothbrushing is painful and also helps to control secondary infection in general.
• Immunocompetent patients in the early stages of an uncomplicated herpes simplex infection in the lips (cold sore) should receive a topical antiviral preparation, for example acyclovir 5% cream applied 5 times a day for 5 days.
• Provide supportive therapy: encourage fluid intake, keep mouth moist, apply water-based lubricant, antipyretic medication and analgesia.
• Viral infections are highly contagious. Strict adherence to infection control measures is essential.

• The mouth may become infected and malodorous particularly if there is an oral cancer infected with anaerobic organisms. Poor dental hygiene may also encourage infection. Oral metronidazole (400mg every 8 hours for 3 to 7 days or longer if necessary) is recommended to control anaerobic infection and the associated odour.