What is the best treatment approach for a 19-year-old patient presenting to the Emergency Department (ED) with a painful and enlarging canker sore?

Treatment of Canker Sore in a 19-Year-Old ED Patient

For a 19-year-old patient presenting to the ED with a painful, enlarging canker sore, the recommended first-line treatment is topical corticosteroids combined with chlorhexidine oral rinse, as these are most effective for large ulcers present for more than a few days. 1

Initial Management in the ED

1. Pain Management:

   • Apply topical anesthetics (benzocaine-containing products) for immediate pain relief 1
   • Prescribe non-alcoholic analgesic rinses such as Difflam Oral Rinse with benzydamine hydrochloride 0.15% to provide pain relief, especially before eating 1
   • Consider oral analgesics (NSAIDs) for systemic pain control if pain is severe 1

2. Topical Treatments:

   • Primary treatment: Apply topical corticosteroids for this large, worsening ulcer 1, 2
   • Prescribe chlorhexidine gluconate 0.2% (Corsodyl) to prevent secondary infection and promote healing 1
   • Consider protective gels like Gengigel or Gelclair to form a protective barrier over the ulcer 1

3. Avoid Hydrogen Peroxide:

   • While hydrogen peroxide is sometimes used as an antiseptic, there is no evidence supporting its use for canker sores in the guidelines 1
   • Hydrogen peroxide can potentially cause tissue irritation and delay healing 3
   • Studies on hydrogen peroxide focus on other conditions like seborrheic keratosis at high concentrations (30-40%), not oral aphthous ulcers 4

Discharge Instructions

1. Home Care Recommendations:

   • Maintain good oral hygiene with a soft toothbrush 1
   • Avoid hard, acidic, salty foods, and carbonated drinks that may irritate the ulcer 5
   • Avoid toothpastes containing sodium lauryl sulfate 5
   • Stay hydrated to keep oral tissues moist 1
   • Apply medicated lip balm containing natural moisturizers regularly 1

2. Follow-up Guidance:

   • Schedule follow-up with dental provider within 1-2 weeks 1
   • Return to ED if ulcer persists beyond 2 weeks despite treatment, as this warrants evaluation for underlying conditions 1
   • Consider biopsy if ulcer does not heal to rule out malignancy 1

Important Considerations

• Red Flags: If the canker sore is part of multiple recurrent ulcers or associated with systemic symptoms, consider underlying conditions such as nutritional deficiencies, gastrointestinal disorders, immune disorders, or HIV infection 1, 5

• Treatment Efficacy: Most minor aphthous ulcers heal within 7-14 days with appropriate treatment 1, but topical treatments can significantly accelerate healing 6

• Pitfall to Avoid: Don't use alcohol-based mouth rinses as they can irritate inflamed tissues and worsen pain 1

• Alternative Treatments: For patients with treatment-resistant ulcers, systemic medications like colchicine, pentoxifylline, or prednisolone may be considered, but these are typically reserved for severe or recurrent cases 5