What is the best treatment for oral aphthous ulcers?

Management of Oral Aphthous Ulcers

Topical corticosteroids are the first-line treatment for oral aphthous ulcers, providing effective symptom relief and promoting healing. 1

First-Line Treatment Options

Topical Corticosteroids

• High-potency options:
  • Clobetasol 0.05% ointment mixed in 50% Orabase applied to dried mucosa for localized lesions 1
  • Dexamethasone mouth rinse (0.1 mg/ml) for multiple ulcers or difficult-to-reach areas 2
  • Betamethasone sodium phosphate 0.5 mg dissolved in 10 mL water as a rinse-and-spit solution 1-4 times daily 1

Pain Management

• Topical anesthetics (2% viscous lidocaine) for immediate pain relief 1
• Barrier preparations like Gengigel mouth rinse or gel 1
• Topical NSAIDs such as amlexanox 5% oral paste for moderate pain 1

Treatment Algorithm Based on Severity

For Mild to Moderate Ulcers:

1. Initial approach: Topical anesthetics + antiseptic mouthwashes

   • Benzydamine hydrochloride 0.15% (Difflam Oral Rinse) for pain relief 2
   • Chlorhexidine gluconate 0.2% or hexetidine 0.1% as antiseptic mouthwashes 2

2. If inadequate response: Add topical corticosteroids

   • Triamcinolone acetonide 0.1% in adhesive paste for isolated lesions 2
   • Dexamethasone ointment has shown 83.33% healing rate compared to 54.70% with placebo 3

For Severe or Recurrent Ulcers:

1. Intensify topical therapy:

   • High-potency corticosteroids like clobetasol 0.05% ointment 1
   • Tacrolimus 0.1% ointment twice daily for up to 4 weeks as an alternative to corticosteroids 1

2. Consider systemic therapy:

   • Colchicine as first-choice for recurrent aphthous stomatitis 1, 4
   • Short course of systemic corticosteroids (prednisone/prednisolone 30-60 mg or 1 mg/kg for 1 week with tapering over the second week) for severe cases 2, 1
   • Pentoxifylline for refractory cases 4

Supportive Measures

• Avoid hard, acidic, salty foods, toothpastes containing sodium lauryl sulfate, alcohol, and carbonated drinks 4
• Use soft diets and soft toothbrushes to minimize trauma 2
• Maintain good oral hygiene to prevent secondary infection 2
• Monitor for and treat oral candidiasis if present 2

Important Considerations and Pitfalls

• Triamcinolone acetonide ointment has shown greater effectiveness (86.7%) compared to phenytoin (53.3%) for aphthous ulcers in Behçet's syndrome 5
• Dexamethasone ointment is both effective and safe with no detectable serum levels after topical application 3
• Recurrent aphthous stomatitis may be associated with systemic conditions (celiac disease, inflammatory bowel diseases, nutritional deficiencies, immune disorders) that should be investigated in persistent cases 6
• Refer to a specialist if ulcers fail to respond to appropriate first-line treatment, recur despite preventive measures, or if diagnosis is uncertain 1
• Avoid overuse of topical corticosteroids as this can lead to mucosal atrophy and systemic absorption 1