What is the management and treatment for a canker sore (aphthous ulcer)?

Management and Treatment of Canker Sores (Aphthous Ulcers)

For canker sores (aphthous ulcers), topical triamcinolone acetonide 0.1% in Orabase adhesive paste applied to dried mucosa 2-4 times daily is the recommended first-line treatment, as it effectively reduces inflammation and promotes healing. 1

Treatment Options

First-Line Treatments

1. Topical Corticosteroids

   • Triamcinolone acetonide 0.1% in Orabase adhesive paste applied 2-4 times daily to dried mucosa 1
   • For severe or recurrent cases: Clobetasol 0.05% ointment mixed in 50% Orabase applied twice weekly 1

2. Pain Management

   • Topical anesthetics such as 2% viscous lidocaine for moderate pain 1
   • Benzocaine-containing products (Red Cross Canker Sore Medication showed longest duration and greatest intensity of anesthetic effect) 2
   • Oral acetaminophen for systemic pain relief 1

Second-Line Treatments

1. Low-Level Laser Therapy

   • Single application on three alternate days has shown significant reduction in pain and erythema by day 3 compared to triamcinolone acetonide 0.1% 3
   • Carbon dioxide laser therapy can reduce or eliminate pain and inflammation 4

2. Desiccating Agents

   • Concentrated mixture of sulfates that cauterizes affected epithelial tissue
   • May provide some pain relief, though evidence for significant improvement over natural healing is limited 5

Supportive Measures

Oral Hygiene

• Use soft toothbrush after meals and before sleep 1
• Use mild fluoride-containing toothpaste 1
• Use saline-containing mouthwashes instead of plain water 1
• Avoid alcohol-based mouth rinses as they can cause further irritation 1

Dietary Modifications

• Consume soft, moist, non-irritating foods 1
• Avoid:
  • Acidic foods and beverages
  • Spicy foods
  • Salty foods
  • Rough/coarse foods
  • Hot foods
  • Alcohol 1

Monitoring and Follow-up

• Assess pain daily using an appropriate pain scale 1
• Monitor for signs of secondary infection or worsening symptoms 1
• Follow up within 3-5 days if symptoms are not improving 1
• For persistent cases, follow-up every 3-6 months is recommended 1

Treatment Algorithm

1. Mild to Moderate Canker Sores:

   • Apply triamcinolone acetonide 0.1% in Orabase 2-4 times daily
   • Use topical anesthetics for pain relief as needed
   • Implement supportive oral hygiene and dietary measures

2. Severe or Recurrent Canker Sores:

   • Consider clobetasol 0.05% ointment in Orabase twice weekly
   • Consider low-level laser therapy if available
   • Evaluate for underlying systemic conditions if recurrence is frequent 6

Special Considerations

• Prolonged use of topical corticosteroids (>2 weeks) should be avoided to prevent mucosal atrophy 1
• Infants have more sensitive oral mucosa and require careful dosing of topical medications to avoid systemic absorption 1
• If canker sores are frequent, large, or persistent beyond 2 weeks, evaluation for underlying systemic conditions should be considered 6

Common Pitfalls to Avoid

• Confusing canker sores (aphthous ulcers) with herpetic stomatitis, which requires antiviral treatment rather than corticosteroids
• Using alcohol-based products that can exacerbate pain and delay healing
• Prolonged use of topical corticosteroids beyond recommended duration
• Failing to modify diet and oral hygiene practices during healing