Patients with an unexplained mouth ulcer of more than 3 weeks' duration require urgent referral to hospital to exclude oral cancer.

NHS England (NHSE) has published new prescribing guidance for various common conditions for which over the counter (OTC) items should not be routinely prescribed in primary care (quick reference guide). These conditions include acute sore throats and mouth ulcers.

Many of these products are cheap to buy and are readily available OTC along with advice from pharmacies. Some self-care medicines are available from shops and supermarkets. Please click here for further information, exceptions, and a patient leaflet.

Benzydamine hydrochloride

• Mouthwash sugar free 0.15% (£4.58 = 300ml)
• Oromucosal spray sugar free 0.15% (£2.15 = 30ml)

Indications

• Painful inflammatory conditions of oropharynx

Dose

• 15ml every 1.5 to 3 hours (mouthwash)
• 4-8 sprays every 1.5 to 3 hours (spray)

Notes

1. Benzydamine is useful to treat discomfort in a variety of ulcerative conditions. It may cause stinging, often reduced by dilution with an equal volume of water.

Hydrocortisone

• Muco-adhesive buccal tablets sugar free 2.5mg (£8.94 = 20 tablets)

Indications

• Oral and perioral lesions

Dose

• One tablet dissolved against ulcer four times daily

Notes

1. Shortage of hydrocortisone 2.5mg muco-adhesive buccal tablets sugar free (June 2022):
   
   1. A Medicine Supply Notification (MSN/2022/054) for hydrocortisone 2.5mg muco-adhesive buccal tablets sugar free was issued on 06 June 2022 with resupply dates expected in September 2022. Anticipated resupply dates have been amended to 06 December 2024.
   2. Please refer to the SPS for advice on prescribing.
2. MHRA Drug Safety Update (December 2018): Hydrocortisone muco-adhesive buccal tablets: should not be used off-label for adrenal insufficiency in children due to serious risks.
   1. Hydrocortisone muco-adhesive buccal tablets are indicated only for local use in the mouth for aphthous ulceration and should not be used for treating adrenal insufficiency.
   2. Substitution of licensed oral formulations of hydrocortisone with muco-adhesive buccal tablets can result in insufficient cortisol absorption and, in stress situations, life-threatening adrenal crisis.
   3. Prescribers and pharmacists should only consider use of licensed hydrocortisone products for adrenal replacement therapy.

Choline salicylate

• Oromucosal gel sugar free 8.7% (£3.82 = 15g)

Indications

• Mild oral and perioral lesions

Dose

• Adult and child over 16 years, apply ½-inch of gel with gentle massage not more often than every 3 hours

Notes

1. Care should be taken using choline salicylate gel as it may itself cause ulceration (salicylate content).
2. Available for purchase over the counter (OTC).

Gelclair

(Polyvinylpyrrolidine and sodium hyaluronate)

• Concentrated oral gel sachets (£26.00 = 21 x 15ml sachets)

MuGard

(Carbomer, glycerin and polysorbate)

• Mucoadhesive oral rinse (£20.00 = 250ml)

Other preparations

Benzocaine and Codeine

• Mouthwash 1200mg benzocaine / 400mg codeine in 300ml (unlicensed preparation)

Notes

1. For use within University Hospitals Plymouth NHS Trust.

GelX Spray

(Zinc gluconate, polyvinylpyrrolidone, taurine)

• Oral spray (100ml)

Indications

• For the prevention and treatment of mucositis in patients receiving head and neck radiotherapy +/- chemotherapy.

Notes

1. For use in Torbay and South Devon NHS Foundation Trust.
1. To be used in accordance with the trust protocol for mucositis.
2. Prescribe by brand (to aid identification where products contain multiple ingredients, or to prevent confusion where multiple brands contain similar ingredients).