What is the treatment for aphthous ulcers (canker sores)?

Treatment for Canker Sores (Aphthous Ulcers)

Topical treatments should be the first line of therapy for canker sores, with benzocaine-containing products providing the most effective immediate pain relief and chlorhexidine rinses promoting healing. 1, 2

First-Line Treatment Options

Immediate Pain Relief

• Topical anesthetics:
  • Benzocaine-containing products (like Red Cross Canker Sore Medication, Maximum Strength Anbesol, and Orajel) provide effective pain relief 2, 3
  • Apply directly to the ulcer before eating or drinking to reduce discomfort

Promote Healing and Prevent Infection

• Chlorhexidine gluconate 0.2% (Corsodyl) rinse twice daily to prevent secondary infection and promote healing 1
• Non-alcoholic analgesic rinses such as benzydamine hydrochloride 0.15% (Difflam Oral Rinse) for pain relief, especially before eating 1
• Protective gels like Gengigel or Gelclair to form a barrier over the ulcer, helping with pain control and promoting healing 1

Second-Line Treatment Options

For larger ulcers or those present for more than one week:

• Topical corticosteroids to reduce inflammation 1, 4
• Sucralfate suspension has shown effectiveness for oral ulcers 5, 6

Management Algorithm Based on Severity

Minor Aphthous Ulcers (80-85% of cases, <1cm, healing within 7-14 days)

1. Topical anesthetics (benzocaine products)
2. Chlorhexidine rinse twice daily
3. Protective gels as needed for pain

Major Aphthous Ulcers (>1cm, may cause scarring)

1. All treatments for minor ulcers
2. Add topical corticosteroids
3. Consider sucralfate suspension
4. If no response after 2 weeks, evaluate for underlying conditions

Preventive Measures

• 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:
  • Hard, acidic, spicy, or salty foods 4
  • Toothpastes containing sodium lauryl sulfate 4
  • Alcohol and carbonated drinks 4

When to Consider Further Evaluation

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

• Nutritional deficiencies (iron, folates)
• Gastrointestinal disorders (celiac disease, inflammatory bowel disease)
• Immune disorders
• HIV infection

Special Considerations

• For denture wearers: Remove dentures at night, clean thoroughly daily, and consider adhesives to improve fit 1
• For recurrent aphthous stomatitis (RAS): Consider systemic evaluation if ulcers recur at least 4 times per year 6

The evidence supporting these recommendations varies in quality, with stronger evidence for topical treatments like benzocaine and chlorhexidine, and more limited evidence for systemic therapies. Treatment should focus first on pain relief and promoting healing, with consideration of underlying causes for persistent or recurrent cases.