What are the treatment options for a canker sore?

Treatment Options for Canker Sores

For canker sores (aphthous ulcers), a sodium bicarbonate containing mouthwash used up to hourly is the first-line treatment, followed by topical pain management and topical corticosteroids for persistent cases. 1

First-Line Treatment Options

Immediate Pain Relief

1. Topical anesthetics:
   • Benzocaine-containing products (e.g., Anbesol, Orajel) 2, 3
   • Viscous lidocaine 2% for more severe pain 1
   • Anti-inflammatory oral rinse containing benzydamine hydrochloride 1

Cleaning and Protection

1. Sodium bicarbonate mouthwash:

   • Use a bland, non-alcoholic sodium bicarbonate mouthwash
   • Start with 4-6 times daily
   • Increase frequency up to hourly for better symptom control 1

2. Protective measures:

   • Apply white soft paraffin ointment to affected areas 1
   • Use mucoprotectant mouthwashes (e.g., Gelclair) three times daily 1
   • Clean with warm saline mouthwashes daily 1

3. Antiseptic rinses:

   • 0.2% chlorhexidine digluconate mouthwash twice daily (can be diluted by 50% to reduce soreness) 1
   • 1.5% hydrogen peroxide mouthwash twice daily 1

Second-Line Treatment Options

For Persistent or Severe Canker Sores

1. Topical corticosteroids:

   • Dexamethasone mouth rinse (0.1 mg/ml) for multiple or difficult-to-reach ulcers 1
   • Clobetasol gel/ointment (0.05%) for limited, accessible ulcers 1
   • Betamethasone sodium phosphate (0.5 mg in 10 ml water as a 3-minute rinse-and-spit preparation) four times daily 1
   • Triamcinolone acetonide 0.1% applied four times daily 4

2. Topical NSAIDs:

   • Amlexanox 5% oral paste for moderate pain 1

3. Advanced pain management:

   • For severe pain, consider systemic analgesics following the WHO pain management ladder 1
   • Alternative administration routes (transdermal, intranasal) if oral intake is difficult 1

Treatment for Specific Complications

For Secondary Infections

• Monitor for bacterial or candidal infections with regular oral swabs 1
• For candidal infection: nystatin oral suspension 100,000 units four times daily for 1 week, or miconazole oral gel 5-10 ml four times daily after meals for 1 week 1

For Oral Dryness

• Sugarless chewing gum or candy
• Salivary substitutes or sialogogues 1

Advanced/Alternative Therapies

1. Low-level laser therapy:

   • Single application on three alternate days has shown significant reduction in pain and erythema by day 3 compared to topical corticosteroids 4

2. For highly resistant cases:

   • Intralesional steroid injection (triamcinolone weekly; total dose 28 mg) in conjunction with topical clobetasol 1
   • Systemic corticosteroids for highly symptomatic or recurrent ulcers (high-dose pulse 30-60 mg or 1 mg/kg oral prednisone/prednisolone for 1 week followed by tapering over the second week) 1

Important Clinical Considerations

• Timing of treatment: Begin treatment as soon as possible after onset for optimal therapeutic effect 1
• Duration of treatment: If symptoms do not improve within 7 days, consult a healthcare provider 2
• Warning signs: Seek medical attention if irritation, pain, or redness persists or worsens, or if swelling, rash, or fever develops 2

Common Pitfalls to Avoid

1. Delayed treatment: The natural healing process starts within the first 24 hours of onset, so early intervention is crucial 1
2. Inadequate pain management: Pain can significantly impact quality of life and ability to eat/drink; address it promptly and adequately
3. Overlooking secondary infections: Slow healing may reflect secondary infection that requires specific treatment 1
4. Ignoring persistent cases: Canker sores that don't resolve within 7 days may require professional evaluation 2

The treatment approach should progress from topical sodium bicarbonate mouthwash and pain management to topical corticosteroids if initial measures are insufficient, with consideration of more advanced therapies for resistant cases.