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. 1

Diagnosis and Assessment

Before initiating treatment, proper diagnosis is essential:

• Determine the type of ulcer based on clinical appearance, location, and history
• Assess duration (acute: <2 weeks; chronic: >2 weeks)
• Identify potential traumatic stimuli that may correspond to the shape and location of the ulcer
• Consider differential diagnoses including:
  • Recurrent aphthous stomatitis (canker sores)
  • Traumatic ulcers
  • Infectious causes (viral, bacterial, fungal)
  • Autoimmune conditions
  • Medication-related ulcers
  • Systemic diseases

Treatment Algorithm

First-Line Therapy

1. Topical Corticosteroids

   • 0.1% triamcinolone acetonide in orabase, 2-4 times daily until healing (typically 7-14 days) 1
   • Alternative options: clobetasol 0.05% ointment, betamethasone sodium phosphate, fluticasone propionate 1

2. Pain Management

   • Topical anesthetics: Lidocaine viscous 2% solution (15 mL swished and expectorated every 3 hours as needed, not exceeding 8 doses in 24 hours) 1
   • Barrier preparations: Gengigel or Gelclair 1

Alternative or Adjunctive Therapies

• Tacrolimus 0.1% ointment twice daily (comparable efficacy to triamcinolone) 1
• Intralesional triamcinolone acetonide injections for persistent lesions 1
• Topical ciclosporin mouthwash (though expensive and unpleasant tasting) 1

Supportive Measures

• Oral Hygiene

  • Use soft toothbrush and mild non-foaming toothpaste
  • Rinse with saline solution 4-6 times daily
  • Use alcohol-free mouthwash 1

• Dietary Modifications

  • Avoid spicy, acidic, rough foods
  • Stay hydrated to promote healing 1

• For Denture Wearers

  • Remove dentures before applying medications
  • Clean gums thoroughly
  • Consider adhesives to improve fit
  • Remove dentures at night 1

Follow-up and Further Investigation

If the ulcer persists beyond 2 weeks despite treatment:

1. Consider biopsy to rule out malignancy or other pathology
2. Perform blood tests:
   • Full blood count
   • Coagulation studies
   • Fasting blood glucose
   • HIV antibody
   • Syphilis serology 1

Special Considerations

Recurrent Aphthous Stomatitis (Canker Sores)

• Follow first-line therapy as above
• Consider vitamin supplements (B12, folate, iron) if deficiencies are suspected
• Avoid known triggers (SLS-containing toothpastes, certain foods) 1

Traumatic Ulcers

• Identify and eliminate the source of trauma (sharp tooth edges, ill-fitting dentures)
• Apply topical corticosteroids as above
• Monitor for healing within 2 weeks 1

Medication-Induced Ulcers

• If a medication is suspected as the cause, consult with the prescribing physician about possible alternatives
• Provide symptomatic relief with topical treatments until resolution 1

Common Pitfalls to Avoid

• Delayed diagnosis: Failure to investigate ulcers that don't respond to treatment within 2 weeks can lead to delayed diagnosis of serious conditions 1
• Inadequate follow-up: Regular monitoring is essential, especially for persistent cases
• Missing systemic causes: Oral ulcers can be manifestations of systemic diseases requiring comprehensive evaluation
• Overuse of topical anesthetics: Can mask symptoms and delay proper diagnosis and treatment

Remember that while most oral ulcers are benign and self-limiting, persistent ulceration requires thorough investigation to rule out malignancy and systemic diseases 2, 1.