10 Treatment of mucosal diseases

10.1 General rules for treatment of mucosal diseases

Systemic and local therapy of mucosal diseases

Systemic therapy

  • analgetics, antipyretics
  • antibiotics, antivirotics, antimycotics
  • corticoids, immunosuppressants, immunomodulators

Local therapy

  • antiseptics (chlorhexidine, octenidine, cetylpyridine, hexetidine, hydrogen peroxide)
  • antimycotics (nystatin, natrium tetraboricum); antiseptics with antimycotic effects (chlorhexidine, octenidine, cetylpyridine, hexetidine)
  • virostatics (acyclovir, zincum sulfuricum)
  • anaesthetics
    • amid - lidocaine, trimecaine
    • ester - tetracaine, benzocaine
  • antiflogistics (benzydamine, choline salicylate)
  • corticoids (dexamethasone, triamcinolone)
  • epitelisant (dexpanthenol)

General rules of mucosal disease treatment and lifestyle measures

Local therapy

  • always
  • form
    • solutions (mouthwashes, sprays), gels, mucoadhesive pastes (orabases)
    • ointment (lip red)

Systemic therapy

  • infectious diseases (serious infectious, severious course of the disease)
  • skin disease with manifestation in the mouth (dermatologist designs and guids treatment)
  • allergic reactions
  • changes in the oral cavity in patient with systemic disease (treatment of the underlying disease helps to improve mucosal disease)

Causal therapy – targeted to the cause of the disease (infections, lack of minerals/vitamins)

Symptomatic therapy – targeted to minimizing symptoms (pain, inflammation)

Prophylactic therapy – with the aim to avoid frequent recedives or prevent the infectious complications in susceptible individuals

Elimination of local irritation and possible solutions

sharp and abraded edges of teeth, fillings, dentures, sharp parts of orthodontic apparatuses
  • smoothing sharp tooth cusps, sharp edges of fillings
  • smoothing the dentures, adjusting orthodontis apparatuses
chronic lip/cheek biting
  • protecting occlusal splint
chronic irritation of stand-alone teeth, inclinated teeth, supraocluded teeth and teeth with traumatic bite
  • dentures/crowns and bridges
  • extraction

Lifestyle measures

  • avoid spicy and irritant food, in acute state eat food of soft consistency
oral hygiene
  • soft, one-headed toothbrush, soft toothpastes, mouthwashes without alcohol
  • in case of suspected allergic reaction and in extensive erosion do not use mouthwash

In most mucosal diseases we routinely encounter in the dental practice, local treatment is sufficient. Systemic therapy (antibiotics, antimycotics, antivirotics) is usually indicated in a serious course of infectious diseases; such drugs should always be administered if the infection is found in an immunodeficient person or in patients otherwise susceptible to a rapid disease progression.

Systemic therapy is also relevant where an immunopathological disease is concerned. If we suspect an allergic reaction, antihistamines and corticoids are indicated, which should be followed by a complex allergological examination. In blistering and autoimmune epithelial diseases (especially pemphigus, systemic lupus erythematosus, scarring pemphigoid, etc.), systemic corticoids, often combined with immunosuppressants, are administered, the therapy is however always to be prescribed and managed by a dermatologist. Similar situation (treatment shall be managed by a dermatologist) applies to other cutaneous diseases that can manifest in the oral cavity (e.g. a more serious course of erosive and bullous forms of oral lichen planus).

Causal treatment is focused on the true cause of the disease (e.g. antivirotics in herpes zoster facialis). The situation when we have to make do with just symptomatic treatment is however far more common (analgesia, antipyretic or anti-inflammatory medication).

Preventive administration of some drugs (mostly antibiotics, antimycotics, antivirotics) is reasonable in some individuals to prevent infectious complications or recurrences. Patients who may benefit from such prophylactic treatment include individuals with recurrent oral candidosis and serious predisposing factors, in HIV-positive patients with recurrent infections or in people in whom a herpetic infection often provokes an acute manifestation of erythema multiforme.

The first step after establishing diagnosis or preliminary diagnosis of the mucosal disease is to remove all mechanical irritation that could cause injuries to the mucosa (sharp edges of the teeth, of dentures, orthodontic apparatuses). Next come the lifestyle measures. The patients must be advised to avoid spicy and irritant food (note that citruses, paprika, tomatoes, onion, garlic, etc. frequently also act as irritants) and to mind the suitable consistency of the food. The oral hygiene is to be performed thoroughly but with care using a soft toothbrush (use of a single tuft toothbrush and interdental toothbrushes is recommended). Depending on the diagnosis, we may or may not recommend the use of mouthwashes; those containing ethanol and other irritant substances (propylene glycol, menthol, etc.) are always to be avoided. In extensive lesions, washing the mouth with herbal infusions (using herbs with antiseptic and epithelialization effects such as sage) is preferred; potential allergic reactions must always be taken into account.

Local therapy is indicated in most oral mucosal diseases. Mostly, this includes mouthwashes, mucoadhesive pastes with antiseptic, antiflogistic, epithelialization, anaesthetic or adstringent effects. There is only a limited number of preparations intended for the local therapy of the oral cavity in the form of mucoadhesive pastes/gels and it is therefore sometimes useful to prescribe custom-made preparations (magistral prescriptions). The dentist should be aware of the active substances and their effects in the widespread mouthwashes and gels to be able to choose a product suitable for the patient. The principal antimicrobial agent is chlorhexidine with its antibacterial, antifungal and antiviral effects. The main indication for its use are therefore bacterial infections and prevention from secondary infection, especially in diseases causing erosions and ulcerations on the oral mucosa (recurrent aphthae, traumatic ulcers, etc.), viral infections (especially herpetic or enteroviral), and oral candidosis. The recommended chlorhexidine concentration for the use in the oral cavity is 0.12-0.2 %, it should always be administered only for a short term (0.2 % no more than two weeks). Hexetitidine and benzydamine have somewhat weaker antiseptic effects and are used predominantly for their anti inflammatory and mild anaesthetic effects. In treatment of acute necrotising ulcerative gingivitis, hydrogen peroxide in appropriate concentrations (different for home care and clinical care) remains the prescription of the first choice. In oral candidosis, we at present use a magistral prescription for a nystatin suspension. If the patient’s diagnosis is prosthetic stomatitis, the hygiene of the dentures is also of utmost importance. In case of immunopathological diseases (recurrent major aphthae, pemphigus, pemphigoid, erosive and bullous forms of the oral lichen planus), a short-term local corticosteroid treatment is usually indicated (at present, it is also a magistral prescription).

In local treatment of extensive erosions, consideration must be given to the possibly rapid resorption of the active substances through the eroded mucosa. In such cases, rinsing the mouth with herbal infusions possessing antiseptic and epithelialization effects (e.g. sage) is preferred.

The local treatment must be modified in children. If they are of age when they are unable to spit out the mouthwash, it is necessary to instruct the parents to gently apply a mild antiseptic preparation (e.g. hexetidine in oral candidosis in infant age) using a pad or swab.

For treating changes on the lip red, many other local preparations with antibacterial, antimycotic, epithelialization and anti-inflammatory effects are available. It is necessary to heed the manufacturer-recommended maximum duration of the therapy.

If the lesion does not react to the local treatment within one to two weeks, the patient should be referred to a specialized department.

10.2 New trends in the treatment of oral mucosal diseases

Like in other diseases, the research in the field of therapy of oral mucosal diseases keeps bringing novel treatment protocols and approaches.

10.2.1 Ozone therapy

Ozone for the use in dentistry is produced by so-called “plasma lamps”; the amount of the ozone produced is minimal. Germicidal properties of ozone are associated with its high oxidation potential. Its action can eliminate bacteria, viruses, protozoans and yeasts as well as their products and necrotic remnants (Domb, 2014). The action of ozone stimulates the immune response and microcirculation in the gingiva.

Ozone therapy is painless, quick and has no side effects. It can be used as a supplementary therapy in gingivitis, herpetic diseases, stomatitis, recurrent aphthae, crevices, alveolitis, yeasts infections and other diseases of the oral cavity. In OLP, a corticoid therapy combined with ozone therapy was found more effective than laser therapy (Kazancioglu a Erisen, 2015). Thanks to the antibacterial effects of ozone, it can be a useful tool in treatment of halitosis. A topical ozone therapy combined with antivirotic and laser therapy helped reduce pain, shorten the course of the disease and improve patients’ condition in patients with herpes zoster; it was statistically significantly more efficient than antiviral treatment without the use of ozone (Huang et al., 2018). If ozone is used early, while the patient only complains of burning and itching, the blisters may be completely prevented.

Ozone therapy however still requires establishing safe, well-defined parameters and guidelines based on randomized controlled trials that would provide indications of ozone therapy for treatment of various pathological conditions (Nogales et al., 2008).

10.2.2 Laser therapy


In the treatment of oral mucosal diseases, it is also possible to employ biostimulation lasers supporting tissue regeneration and healing. These so-called LLLT lasers (low-level laser therapy) emit energy as a beam of electromagnetic radiation. In oral mucositis, laser therapy was shown to reduce the extent and intensity of the disease as well as to shorten its overall duration (Carvalho et al., 2011). As many pilot studies demonstrated, treatment of recurrent aphthae using LLLT provides satisfactory results including pain reduction and shortening of the time needed for ulcer healing, no standardized protocol is however in place yet (Valo et al., 2015). The laser therapy can also serve as an auxiliary treatment to corticosteroid administration in individuals with mucosal pemphigoid (Yilmaz et al., 2010). It can be used in treatment of herpes simplex as well (Ferreira et al., 2011), even in children (Stona et al., 2014).

10.2.3 Biological treatment

Biological treatment based in particular on monoclonal antibodies is used in the treatment of squamous cell carcinoma of the oral mucosa, autoimmune diseases affecting salivary glands (Sjögren syndrome) and oral mucosa (pemphigus vulgaris, benign mucosal pemphigoid), as well as in some other diseases of the oral mucosa with uncertain etiological participation of immunopathology (OLP, recurrent major aphthae, Behçet disease). The action of the biological treatment in particular indications is based on the inhibition of the proliferation activity of the tumour cells and angiogenesis (cytostatics) or on suppression of effects of pro-inflammatory cytokines, particularly TNFα, IL-1 and IL-6. Most commonly, biological treatment agents such as rituximab, cetuximab and erlotinib are indicated in treatment of the above-described diseases (Slezák et al., 2013). Biological treatment shall be always prescribed by a specialist.

10.2.4 Other substances potentially useful in treatment of mucosal diseases

Prevention of the mucosal diseases includes maintaining oral hygiene, healthy lifestyle (diet, non-smoking, physical activity), avoiding potentially dangerous influences (especially excessive use of xenobiotics), etc. In treatment of oral mucosal diseases, many other substances can be used; they can be locally administered in the form of solutions, mucoadhesive pills, etc.

Levamizol, originally an antihelmintic veterinary drug, was used in patients with serious recurrent aphthae, OLP and pemphigus vulgaris with promising results.

Vitamin D belongs to a group of lipid-soluble steroids; in humans, the vitamin D3 and D2 are the most important forms, the primary function of which is the regulation of the homeostasis of Ca2+ and phosphorus in the organism. It plays also a role in the process of carcinogenesis and has immune modulation effects. It also influences the condition of the oral mucosa. Its reduced serum concentrations are a common finding in patients with autoimmune diseases, recurrent aphthae, Behçet disease, Sjögren syndrome and neoplastic lesions. Supplementing vitamin D has a great potential in treatment of patients with oral mucosal diseases in whom hypovitaminosis is clinically confirmed by lab tests and kidney disease is excluded. It can also have a preventive function (Anand et al., 2017).

Resveratrol is a phytoalexin synthetized by many plants; it is present in relatively large quantities in the red/blue grapes and it is reported to have antioxidative, anti-inflammatory, cardioprotective, neuroprotective and immunomodulation effects (Perrone et al., 2017).

Other substances that can be used for supplementary therapy of oral diseases include e.g. ginger (Zingiber officinale), quercetine (plant flavonoid present in many species of fruit and vegetable), aloe vera and many other natural materials and substances.