What are the best treatments for mouth ulcers?

Best Treatments for Mouth Ulcers

For most mouth ulcers, chlorhexidine gluconate 0.2% rinse, non-alcoholic analgesic rinses containing benzydamine hydrochloride 0.15%, and protective gels are the most effective first-line treatments to promote healing and provide pain relief. 1

First-Line Treatment Options

Pain Relief and Healing Promotion

• Topical treatments:
  • Chlorhexidine gluconate 0.2% (Corsodyl) - helps prevent secondary infection and promotes healing 1
  • Benzydamine hydrochloride 0.15% (Difflam Oral Rinse) - provides pain relief, especially before eating or brushing teeth 1
  • Protective gels (Gengigel, Gelclair) - form a protective barrier over the ulcer, helping with pain control and promoting healing 1
  • Topical anesthetics (benzocaine-containing products) - provide temporary pain relief 1, 2
  • 1% lidocaine cream - significantly reduces pain intensity compared to placebo (29.4mm reduction on VAS pain scale) 3

Specific Approaches Based on Cause

For Radiation-Induced Mucositis

• Prevention:
  • Use midline radiation blocks and 3D radiation treatment to reduce mucosal injury 4
  • Benzydamine oral rinse for prevention in head and neck cancer patients receiving moderate-dose radiation therapy 4
  • Avoid: Chlorhexidine and antimicrobial lozenges (not recommended for prevention) 4

For Chemotherapy-Induced Mucositis

• Prevention:
  • Oral cryotherapy (30 min) for patients receiving bolus 5-FU chemotherapy 4
  • Oral cryotherapy (20-30 min) for patients treated with bolus doses of edatrexate 4
  • Avoid: Acyclovir and its analogues (not recommended) 4

Second-Line and Adjunctive Treatments

Systemic Treatments

• Vitamin B12 ointment - effective for pain relief in aphthous ulcers (significant reduction in pain after 2 days compared to placebo) 5
• For severe cases or high-dose chemotherapy with HSCT:
  • Palifermin (60 μg/kg/day for 3 days before conditioning and 3 days post-transplant) 4

Oral Hygiene and Prevention

• Maintain good oral hygiene with a soft toothbrush 1
• Apply medicated lip balm regularly 1
• Stay hydrated to keep oral tissues moist 1
• Avoid known triggers (certain foods, stress) 1
• For denture wearers:
  • Remove dentures at night 1
  • Clean dentures thoroughly daily 1
  • Consider denture adhesives to improve fit 1

Treatment Algorithm

1. Initial assessment:

   • Determine size, location, and duration of ulcers
   • Rule out systemic causes if ulcers persist beyond 2 weeks

2. For minor aphthous ulcers (most common, <1cm):

   • Start with chlorhexidine 0.2% rinse and benzydamine hydrochloride 0.15% for pain relief
   • Apply protective gel to form a barrier
   • Consider topical anesthetics before meals

3. For persistent or severe ulcers:

   • Add topical corticosteroids for large ulcers present for more than one week 1
   • Consider vitamin B12 ointment as adjunctive therapy 5
   • Evaluate for underlying conditions if ulcers persist beyond 2 weeks

4. For special populations:

   • Radiation patients: Use benzydamine rinse preventively
   • Chemotherapy patients: Consider oral cryotherapy when appropriate
   • HSCT patients: Consider palifermin when indicated

Important Considerations and Pitfalls

• Monitoring: If an aphthous ulcer persists beyond 2 weeks or is particularly severe, evaluation for underlying conditions is warranted 1

• Biopsy: Consider if an ulcer persists beyond 2 weeks despite treatment to rule out malignancy 1

• Avoid:

  • Alcohol-based mouth rinses that can irritate inflamed tissues 1
  • Chlorhexidine for prevention of radiation-induced mucositis in head and neck cancer patients 4
  • Sucralfate for treatment of radiation-induced oral mucositis 4

• Evidence limitations: The Cochrane review on systemic interventions for recurrent aphthous stomatitis found insufficient evidence to support or refute the use of any particular systemic intervention, highlighting the need for more rigorous research 6

By following this evidence-based approach, most mouth ulcers should resolve within 7-14 days with appropriate symptomatic management.