What is the treatment for recurrent aphthous ulcers?

Treatment for Recurrent Aphthous Ulcers

Topical treatments should be the first-line therapy for recurrent aphthous ulcers, with topical corticosteroids like 0.1% triamcinolone acetonide and 5% amlexanox being the most effective options for reducing pain, size, and healing time. 1, 2

Classification and Clinical Presentation

Aphthous ulcers are classified into three main types:

• Minor aphthous ulcers: Most common (80-85%), less than 1cm in size, healing within 7-14 days
• Major aphthous ulcers: Larger, deeper, may take weeks to heal
• Herpetiform ulcers: Multiple small clustered ulcers

Treatment Algorithm

First-Line Treatment Options:

1. Topical Treatments

   • Topical corticosteroids: 0.1% Triamcinolone acetonide applied 4 times daily 1, 3
   • 5% Amlexanox: Apply 4 times daily 2
   • Chlorhexidine gluconate 0.2% rinse: Use twice daily to prevent secondary infection 1
   • Topical anesthetics: Benzocaine-containing products for pain relief 1
   • Sucralfate suspension: Particularly effective for larger ulcers present for more than one week 1

2. Pain Management

   • Non-alcoholic analgesic rinses: Difflam Oral Rinse with benzydamine hydrochloride 0.15% 1
   • Protective gels: Gengigel or Gelclair to form a protective barrier 1

For Severe or Refractory Cases:

1. Systemic Medications
   • Colchicine: For recurrent aphthous stomatitis (RAS) 4
   • Pentoxifylline: For severe cases 4
   • Systemic corticosteroids: Short course of prednisolone for severe outbreaks 4
   • Thalidomide: Most effective for RAS but limited by adverse effects 5

Preventive Measures

1. Dietary Modifications

   • Avoid hard, acidic, spicy, or salty foods 1, 4
   • Avoid toothpastes containing sodium lauryl sulfate 1, 4
   • Avoid alcohol and carbonated drinks 1, 4
   • Eat soft, moist, non-irritating foods during outbreaks 1

2. Oral Hygiene

   • Use a soft toothbrush 1
   • Apply medicated lip balm regularly 1
   • Stay hydrated to keep oral tissues moist 1
   • Replace toothbrush monthly to prevent bacterial accumulation 1

Special Considerations

1. Recurrent Aphthous Stomatitis (RAS)

   • Defined as recurrence of oral aphthous ulcers at least 4 times per year 5
   • Consider systemic evaluation for underlying causes 1
   • Potential associations:
     • Gastrointestinal diseases (celiac disease, inflammatory bowel disease)
     • Nutritional deficiencies (iron, folates)
     • Immune disorders (HIV infection, neutropenia)
     • Behçet's disease 5

2. Monitoring

   • Regular follow-up every 3-6 months for persistent symptomatic cases 1
   • Monitor for signs of systemic disease 1

Comparative Efficacy

Recent research shows that 0.1% triamcinolone acetonide and 5% amlexanox are more effective than benzocaine gel, doxycycline hyclate, or placebo in reducing ulcer size, number, pain, erythema, and exudate levels by day 8 of treatment 2.

Low-level laser therapy has also shown promising results with significant reductions in pain and erythema by day 3 compared to triamcinolone acetonide, though both treatments achieve complete reduction in ulcer size by day 10 3.

Important Caveats

• Always rule out systemic causes in cases of severe or persistent aphthous ulcers
• Every oral solitary chronic ulcer should be biopsied to rule out squamous cell carcinoma 5
• Avoid alcohol-based mouth rinses as they can irritate inflamed tissues 1
• The treatment approach should be tailored based on the frequency of ulcers, intensity of pain, and responsiveness to treatment 4