What is the management for oral ulcers?

Management of Oral Ulcers

Topical corticosteroids, such as 0.1% triamcinolone acetonide in orabase applied 2-4 times daily after meals and before bedtime, are the most effective first-line treatment for most types of oral ulcers until healing is complete (typically 7-14 days). 1

Diagnostic Approach

Before initiating treatment, proper diagnosis is essential:

1. Identify ulcer characteristics:

   • Duration (acute: <2 weeks; chronic: >2 weeks)
   • Shape and location (may correspond to traumatic stimulus)
   • Number (solitary vs. multiple)
   • Appearance (well-demarcated, undermined edges, etc.)

2. Rule out serious causes:

   • If an ulcer persists beyond 2 weeks despite treatment, consider:
     • Biopsy to rule out malignancy
     • Blood tests (full blood count, coagulation, fasting blood glucose, HIV antibody, syphilis serology) 2, 1

Treatment Algorithm

First-Line Treatments

1. Topical corticosteroids:

   • 0.1% triamcinolone acetonide in orabase (2-4 times daily)
   • Alternative options: clobetasol 0.05% ointment, betamethasone sodium phosphate, fluticasone propionate 1

2. Pain management:

   • Lidocaine viscous 2% solution (15 mL swished and expectorated every 3 hours as needed, max 8 doses/24 hours) 1
   • Barrier preparations (Gengigel or Gelclair) 1

3. Supportive care:

   • Saline rinses 4-6 times daily
   • Soft toothbrush and mild non-foaming toothpaste
   • Alcohol-free mouthwash 1

Second-Line Treatments

1. Tacrolimus 0.1% ointment twice daily (comparable efficacy to triamcinolone) 1

2. Intralesional triamcinolone acetonide injections for persistent lesions 1

3. Topical ciclosporin mouthwash (though expensive and unpleasant tasting) 1

Management Based on Ulcer Type

Traumatic Ulcers

• Remove causative agent (sharp tooth edge, ill-fitting denture)
• Apply topical corticosteroids
• If denture-related: remove dentures before applying medications, clean gums thoroughly, consider adhesives to improve fit, and remove dentures at night 1

Recurrent Aphthous Stomatitis (Canker Sores)

• Topical corticosteroids as first-line therapy
• Avoid triggers: hard, acidic, spicy foods, toothpastes with sodium lauryl sulfate 1
• Consider vitamin supplementation if deficiency suspected

Infectious Ulcers

• Antiviral medications for herpes simplex virus (cold sores)
• Antifungal medications for candidiasis
• Appropriate antibiotics for bacterial infections 3

Prevention and Patient Education

1. Oral hygiene:

   • Use soft toothbrush
   • Mild non-foaming toothpaste
   • Regular saline rinses 1

2. Dietary modifications:

   • Avoid spicy, acidic, rough foods
   • Stay well hydrated
   • Avoid alcohol and carbonated drinks 1

3. Follow-up:

   • Regular monitoring every 3-6 months for persistent cases
   • Immediate follow-up if ulcers don't resolve within 2 weeks of treatment 1

Common Pitfalls and Caveats

1. Failure to investigate persistent ulcers: Any ulcer not responding to treatment within 2 weeks requires further investigation to rule out malignancy or systemic disease 2, 1

2. Missing systemic causes: Oral ulcers can be manifestations of systemic conditions such as Behçet's disease, inflammatory bowel disease, or autoimmune disorders 4, 5

3. Medication-induced ulcers: Some medications (including antidepressants) can cause oral ulcerations; consider medication review in persistent cases 6

4. Inadequate pain control: Pain from oral ulcers can significantly impact quality of life and nutrition; ensure adequate analgesia 1

5. Overlooking differential diagnoses: Conditions such as pemphigus vulgaris, bullous pemphigoid, and lichen planus can present with oral ulcerations and require specific management 3, 7