What are effective topical treatments for mouth ulcers?

Effective Topical Treatments for Mouth Ulcers

Topical corticosteroid preparations are the most effective first-line treatment for mouth ulcers, with options including betamethasone sodium phosphate 0.5 mg dissolved in 10 mL water as a rinse-and-spit solution 1-4 times daily, fluticasone propionate nasules diluted in water twice daily, or clobetasol 0.05% ointment mixed in Orabase applied to localized lesions. 1

First-Line Topical Treatments

Topical Corticosteroids

• Betamethasone sodium phosphate 0.5 mg dissolved in 10 mL water (rinse for 2-3 minutes, 1-4 times daily) 1
• Fluticasone propionate nasules diluted in 10 mL water (twice daily) 1
• Clobetasol 0.05% ointment mixed in 50% Orabase applied to dried mucosa (twice weekly) 1
  • Can be mixed by the patient and stored in refrigerator

Topical Anesthetics

• Benzocaine-containing products for pain relief 2
• Lidocaine topical preparations (apply to affected area 3-4 times daily, not for children under 12 years without medical consultation) 3

Antimicrobial Rinses

• Chlorhexidine gluconate 0.2% rinse twice daily to prevent secondary infection and promote healing 2

Second-Line Topical Treatments

Protective Barriers

• Gengigel or Gelclair form a protective barrier over ulcers, helping with pain control 1, 2
• Sucralfate suspension, particularly effective for larger ulcers or those present for more than one week 2

Anti-inflammatory Options

• Non-alcoholic analgesic rinses such as Difflam Oral Rinse with benzydamine hydrochloride 0.15%, especially before eating or brushing teeth 2
• Tacrolimus 0.1% ointment (twice daily) has shown efficacy comparable to triamcinolone acetonide 0.1% paste in a split-mouth randomized trial 1

Alternative Options

• Topical ciclosporin (5 mL oral suspension three times daily) has shown effectiveness for recalcitrant oral lesions, though it tastes unpleasant and is relatively expensive 1
• Vitamin B12 ointment has demonstrated significant pain reduction in aphthous ulcers within 2 days compared to placebo 4
• Alchemilla vulgaris (Lady's Mantle) 3% extract in glycerine applied three times daily has shown promising results, with complete healing in 60.4% of patients within 2 days 5

Treatment Algorithm Based on Ulcer Severity

1. For mild ulcers:

   • Topical anesthetics (lidocaine or benzocaine) for pain relief 2, 3
   • Chlorhexidine rinse twice daily 2
   • Protective gels (Gengigel/Gelclair) as needed 1, 2

2. For moderate ulcers:

   • Topical corticosteroids (betamethasone rinse or fluticasone) 1
   • Pain management with topical anesthetics 2, 3
   • Protective barriers before eating 2

3. For severe or persistent ulcers:

   • Clobetasol 0.05% in Orabase 1
   • Consider tacrolimus 0.1% ointment 1
   • For recalcitrant cases, topical ciclosporin may be beneficial 1

Important Considerations and Pitfalls

• Dilution of mouthwashes (by 50%) may be necessary to reduce discomfort 1
• Persistent ulcers lasting >2 weeks should prompt further investigation for underlying systemic diseases 2
• Avoid common triggers such as hard, acidic, spicy foods, toothpastes containing sodium lauryl sulfate, and alcohol 2
• Maintain good oral hygiene with a soft toothbrush and mild fluoride-containing toothpaste 2
• For denture wearers, remove dentures at night and clean thoroughly daily to prevent ulcers 2
• Be aware that some medications, including antidepressants like sertraline, can cause oral ulceration 6

Remember that while topical treatments are often sufficient for most mouth ulcers, those with severe, recurrent, or persistent ulcers may require systemic therapy and further investigation for underlying causes.