What are the treatments for mouth ulcers?

Treatment of Mouth Ulcers

The management of mouth ulcers should follow a stepwise approach starting with white soft paraffin ointment applied every 2-4 hours, warm saline mouthwashes 4-6 times daily, and topical pain management with benzydamine hydrochloride rinse before meals. 1

Initial Treatment and Wound Care

• Apply white soft paraffin ointment to affected areas every 2-4 hours to promote healing and reduce discomfort 1
• Use warm saline mouthwashes 4-6 times daily or clean gently with an oral sponge 1
• Consider mucoprotectant mouthwash three times daily 1
• Avoid alcohol-based mouth rinses as they can cause further irritation 1

Pain Management

First-line options:

• Oral acetaminophen for systemic pain relief 1
• Anti-inflammatory oral rinse/spray containing benzydamine hydrochloride every 3 hours, particularly before eating 1

For moderate to severe pain:

• Topical 2.5% lidocaine ointment (use cautiously) 1
• Viscous lidocaine 2%, 15 mL per application for moderate pain 1
  • Note: Evidence suggests that while topical 1% lidocaine cream significantly reduces pain intensity compared to placebo 2, viscous lidocaine may not improve oral intake in children despite providing some pain relief 3
• For severe pain, follow WHO pain management ladder with consideration of transdermal or intranasal routes when oral medications are difficult 1

Infection Prevention and Treatment

• Use antiseptic oral rinse twice daily with either:
  • 1.5% hydrogen peroxide mouthwash, or
  • 0.2% chlorhexidine digluconate mouthwash (can be diluted by up to 50% to reduce soreness) 1
• Take oral swabs if bacterial or candidal secondary infection is suspected 1
• For confirmed candidal infection, treat with nystatin oral suspension or miconazole oral gel 1
• For HIV-infected patients with candidal angular cheilitis, use topical antifungal treatment with clotrimazole troches (10 mg) dissolved 5 times daily or miconazole mucoadhesive tablets 1

Dietary and Lifestyle Modifications

• Maintain adequate hydration to keep the mouth moist 1
• Modify diet to include soft, moist, non-irritating foods 1
• Avoid acidic, spicy, salty, rough/coarse food that may cause further irritation 1
• Stay hydrated by drinking ample fluids 1

Monitoring and Follow-up

• Inspect oral mucosa daily for signs of healing or worsening 1
• Assess pain at least once daily using an age-appropriate pain scale 1
• Monitor oral intake to prevent dehydration 1
• Follow up within 3-5 days if symptoms are not improving 1
• For persistent symptomatic cases, follow-up every 3-6 months is recommended 1

Special Considerations

• For recurrent aphthous stomatitis (RAS), systematic review evidence suggests that no single systemic intervention has been conclusively proven effective, highlighting the need to focus on topical treatments first 4
• Alternative treatments like Alchemilla vulgaris (Lady's Mantle) in glycerine have shown promising results in an open-label study, with 75% of patients experiencing complete healing within 3 days 5
• For isolated, persistent ulcerations that don't heal, consider biopsy to exclude squamous cell carcinoma or other malignancies 6

Diagnostic Approach for Persistent Ulcers

• Examine for color changes, surface changes, swelling, and specific patterns 1
• Check for dental factors that might cause trauma 1
• Assess for signs of systemic disease 1
• For persistent ulcers, consider biopsy to rule out malignancy 6
• Collect appropriate swabs for bacterial, candidal, or viral culture from affected areas 1