Evidence-based review and clinical practice recommendations for the diagnosis and management of common oral mucosal lesions

Table 4 Severity-based escalation protocol for common oral mucosal lesions in general dental practice

Severity level	Clinical indicators	First-Line management	Escalated treatment (if unresponsive)	Referral criteria	Ref.	Evidence level (GRADE)
Mild	Frictional keratosis, traumatic ulcer < 2 weeks, asymptomatic white patches	Oral hygiene, remove irritant, topical analgesics: Lidocaine hydrochloride 2% gel (Acuvisc®), Chlorhexidine gluconate 0.2% (Corsodyl®)	Betamethasone sodium phosphate 0.5 mg (Betnesol®) rinse, Benzydamine hydrochloride 0.15% (Difflam®) rinse	If symptoms persist > 2-3 weeks → reassess and consider biopsy	[1,2,12,19,25]	A
Moderate	Recurrent ulcers, symptomatic oral lichen planus, oral candidiasis	Clobetasol propionate 0.05% ointment (Dermovate®), Nystatin 100000 units/mL (Nystan®), Miconazole 2% oral gel (Daktarin®)	Fluconazole 50-100 mg OD, tacrolimus 0.03% ointment (Protopic®), Amitriptyline 10-25 mg nocte	Unresponsive after 2-4 weeks of compliant treatment → urgent review	[1,8,12,23,24]	A
Severe	Erythroplakia, non-healing ulcer > 3 weeks, severe pain, suspicious lesions	Urgent biopsy, clobetasol propionate (Dermovate®), systemic steroids as indicated	Multidisciplinary review, systemic immunomodulation	Urgent referral for any persistent red or red-white patch (erythroplakia/erythroleukoplakia), non-healing ulcer > 3 weeks, or unexplained lump on lip/oral cavity	[2,12,20,27,28]	A

Evidence level (GRADE): A: High; B: Moderate; C: Low. OD: Once a day; Nocte: At night.