What are the treatment options for aphthous ulcers?

Management of Aphthous Ulcers

Topical corticosteroids are the first-line treatment for aphthous ulcers, with triamcinolone acetonide 0.1% being the most recommended option applied 2-4 times daily until healing occurs. 1

Diagnosis and Assessment

• Aphthous ulcers (canker sores) are characterized by:

  • Solitary or multiple recurrent small ulcers
  • Erythematous haloes and yellow/gray floors
  • Typically located on non-keratinized oral mucosa
  • Painful lesions that may interfere with eating, speaking, and swallowing

• Three clinical forms:

  • Minor aphthous ulcers (most common)
  • Herpetiform aphthous ulcers
  • Major aphthous ulcers

• Red flags requiring biopsy:

  • Persistence beyond 2 weeks despite treatment
  • Induration or fixation
  • Unexplained bleeding
  • Cervical lymphadenopathy
  • Growth despite treatment
  • History of tobacco/alcohol use with persistent lesion 1

Treatment Algorithm Based on Severity

First-Line Treatment (All Aphthous Ulcers)

1. Topical Corticosteroids 1, 2

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

2. Pain Management 1, 3

   • Topical anesthetics (lidocaine viscous 2% solution)
   • Barrier preparations (Gengigel or Gelclair)

3. Antiseptic Measures 2, 4

   • Chlorhexidine or fluoride oral rinse
   • Saline solution rinses 4-6 times daily

Second-Line Treatment (Moderate to Severe Cases)

1. Anti-inflammatory Medications 2

   • Amlexanox paste
   • Topical antibiotics (doxycycline)

2. Barrier Agents 1, 4

   • Sucralfate suspension (rinse and spit)
   • Tacrolimus 0.1% ointment

Third-Line Treatment (Severe or Refractory Cases)

1. Systemic Medications 2, 5, 4
   • Colchicine (for recurrent aphthous stomatitis)
   • Prednisone (short course for severe outbreaks)
   • Pentoxifylline
   • Thalidomide (most effective but limited by adverse effects)

Preventive Measures

1. Oral Hygiene 1

   • Use soft toothbrush
   • Mild non-foaming toothpaste
   • Avoid toothpastes containing sodium lauryl sulfate

2. Dietary Modifications 1, 4

   • Avoid hard, acidic, spicy, or salty foods
   • Avoid alcohol and carbonated drinks
   • Stay well-hydrated

3. Identify and Address Triggers 5, 4

   • Stress management
   • Avoid local trauma to oral mucosa
   • Consider evaluation for nutritional deficiencies (iron, folates, B12)
   • Rule out associated conditions (celiac disease, inflammatory bowel diseases, immune disorders)

Follow-up and Monitoring

• Regular monitoring for persistent cases 1
• Follow-up every 3-6 months for persistent symptomatic cases
• Consider biopsy if ulcer persists beyond 2 weeks despite treatment

Common Pitfalls and Caveats

1. Failure to distinguish aphthous ulcers from other oral ulcerative conditions that may require different management approaches 5

2. Overlooking potential systemic causes of recurrent aphthous stomatitis, including:

   • Inflammatory bowel disease
   • Celiac disease
   • Nutritional deficiencies
   • Behçet's disease
   • HIV infection 5, 3

3. Prolonged use of topical corticosteroids without supervision, which may lead to oral candidiasis 1

4. Inadequate pain management, which can significantly impact quality of life and nutrition 1, 3

5. Using systemic immunosuppressive medications without proper consideration of benefit-risk ratio 2, 4