What are the treatment options for recurrent aphthous ulcers (canker sores)?

Treatment Options for Recurrent Aphthous Ulcers (Canker Sores)

For recurrent aphthous ulcers (canker sores), topical treatments including corticosteroids, anesthetics, and antiseptic agents are the first-line therapy, with systemic medications reserved for severe or refractory cases. 1

Classification and Clinical Presentation

Aphthous ulcers are classified into three main types:

• Minor aphthous ulcers: Most common (80-90%), less than 10mm in diameter, heal within 7-10 days without scarring 2
• Major aphthous ulcers: Larger than 10mm, can cause scarring, affect 10% of sufferers 3
• Herpetiform aphthous ulcers: Multiple small clustered ulcers 4

First-Line Treatment Options

Topical Treatments

1. Topical corticosteroids:

   • Most effective first-line therapy for pain reduction and accelerated healing 1, 5
   • Should be limited to <2 weeks of use to prevent adverse effects 1
   • Apply directly to ulcers 2-4 times daily

2. Topical anesthetics:

   • Provide immediate pain relief 1, 6
   • Options include lidocaine and benzocaine preparations
   • Apply before meals to facilitate eating and reduce discomfort

3. Antiseptic mouthwashes:

   • Chlorhexidine rinses can reduce severity and pain 3
   • Use 2-3 times daily, holding in mouth for 1 minute

4. Sucralfate suspension:

   • Forms protective coating over ulcers 4
   • Apply 4 times daily after meals and before bedtime

Second-Line and Adjunctive Treatments

1. Tetracycline mouthwash:

   • Can reduce ulcer duration and pain 3
   • Dissolve 250mg capsule in water and rinse for 2-3 minutes, 4 times daily

2. Bland mouth rinses:

   • Sodium bicarbonate solution can provide symptomatic relief 1
   • Mix 1 teaspoon in 8oz warm water and rinse several times daily

Management of Severe or Recurrent Cases

For patients with severe, frequent, or refractory ulcers:

1. Systemic medications:

   • Colchicine: Effective for reducing frequency and severity of recurrences 1, 5
   • Pentoxifylline: May reduce inflammation and promote healing 5
   • Systemic corticosteroids: Reserved for severe cases unresponsive to topical therapy 6, 5
   • Thalidomide: Most effective but limited by toxicity and cost; use only when other treatments fail 4, 6

2. Investigation of underlying factors:

   • Evaluate for nutritional deficiencies (iron, folates, B12) 4
   • Consider gastrointestinal diseases (celiac disease, inflammatory bowel disease) 4
   • Assess for immune disorders 1, 4

Preventive Measures

1. Avoid triggers:

   • Hard, acidic, salty foods 5
   • Toothpastes containing sodium lauryl sulfate 5
   • Alcohol and carbonated drinks 5
   • Local trauma to oral mucosa 6

2. Oral hygiene recommendations:

   • Use soft toothbrush and mild fluoride toothpaste 1
   • Replace toothbrush monthly 1
   • Daily inspection of oral mucosa 1

Important Considerations

• Treatment should focus on:

  1. Relief of pain
  2. Reduction of ulcer duration
  3. Restoration of normal oral function
  4. Reduction in frequency and severity of recurrences 6

• Most treatments are palliative and symptomatic, as the exact cause of recurrent aphthous ulcers is often idiopathic 4, 5

• For persistent or unusually severe cases, consider referral to evaluate for systemic conditions like Behçet's disease or other immune disorders 4

• Regular follow-up every 3-6 months is recommended for persistent symptomatic cases 1