What is the treatment for oral aphthous ulcers?

Treatment for Oral Aphthous Ulcers

Topical corticosteroids should be the first-line treatment for oral aphthous ulcers, with high-potency options like clobetasol 0.05% ointment or dexamethasone rinse providing the most effective symptom relief and healing. 1, 2, 3

First-Line Treatment Options

Topical Corticosteroids

• High-potency options:
  • Betamethasone sodium phosphate 0.5 mg dissolved in 10 mL of water as a 2-3 minute rinse-and-spit solution 1-4 times daily 1
  • Clobetasol 0.05% ointment mixed in 50% Orabase applied to dried mucosa for localized lesions 1, 2
  • Dexamethasone ointment applied three times daily after meals (shown to significantly reduce ulcer size, pain, and improve healing rates compared to placebo) 3

Topical Pain Management

• Topical anesthetics (2% viscous lidocaine) for immediate pain relief 1
• Barrier preparations such as Gengigel mouth rinse or gel for pain control 1, 2
• Mucoprotectant mouthwash (e.g., Gelclair) three times daily 2

Other Topical Agents

• White soft paraffin ointment (petroleum jelly) applied every 2 hours during acute phase 2
• Antiseptic mouthwashes (1.5% hydrogen peroxide or 0.2% chlorhexidine digluconate) twice daily, especially if secondary infection is suspected 2

Second-Line Treatment Options

Alternative Topical Agents

• Tacrolimus 0.1% ointment applied twice daily for up to 4 weeks (effective alternative to corticosteroids) 1, 2
• Topical NSAIDs (e.g., amlexanox 5% oral paste) for moderate pain 1
• Sucralfate suspension (shown effective for oral ulcers in randomized controlled trials) 1

Systemic Treatments for Resistant Cases

For recurrent or severe aphthous ulcers that don't respond to topical therapy:

• Colchicine (first choice for recurrent aphthous stomatitis) 1, 4
• Oral tetracyclines (500 mg twice daily for 4-6 weeks) 2
• Short course of systemic corticosteroids for severe cases (prednisone/prednisolone 30-60 mg or 1 mg/kg for 1 week with tapering over second week) 1, 4
• For extremely resistant cases: consider azathioprine, interferon-alpha, or TNF-alpha antagonists 1

Treatment Algorithm Based on Severity

Mild Aphthous Ulcers (1-5 small ulcers)

1. Topical corticosteroid (clobetasol 0.05% ointment or dexamethasone)
2. Pain management with topical anesthetics as needed
3. Maintain good oral hygiene

Moderate Aphthous Ulcers (multiple or larger ulcers)

1. Corticosteroid rinse (betamethasone sodium phosphate)
2. Pain management (lidocaine, barrier preparations)
3. Consider tacrolimus 0.1% if not responding to corticosteroids

Severe or Recurrent Aphthous Ulcers

1. Combination of topical treatments
2. Consider systemic therapy with colchicine
3. For highly resistant cases, short course of systemic corticosteroids
4. Evaluate for underlying conditions (Behçet's disease, inflammatory bowel disease, nutritional deficiencies, immune disorders)

Important Considerations

• Aphthous ulcers are often self-limiting but can cause significant pain and functional impairment 5, 4
• Treatment goals are pain relief, reduction of ulcer duration, and restoration of normal oral function 6
• Avoid hard, acidic, salty foods, alcohol, and carbonated drinks during active ulceration 4
• Toothpastes containing sodium lauryl sulfate should be avoided 4
• Dexamethasone ointment has been proven safe with no detectable serum levels after topical application 3
• Triamcinolone acetonide ointment (0.1%) has shown superior efficacy (86.7% positive response) compared to other treatments in patients with Behçet's syndrome 7

Treatment Pitfalls to Avoid

• Delaying treatment can prolong pain and healing time
• Inadequate dosing or frequency of topical corticosteroids may reduce effectiveness
• Overuse of topical corticosteroids can lead to mucosal atrophy
• Failing to identify and address underlying systemic conditions in recurrent cases
• Using thalidomide without considering its serious adverse effects (peripheral neuropathy, teratogenicity) 1, 6