What is the treatment for aphthous ulcers?

Treatment of Aphthous Ulcers

For aphthous ulcers, treatment should focus on pain relief, reducing ulcer duration, and restoring normal oral function through topical treatments including sodium bicarbonate mouthwashes, topical corticosteroids, and analgesics as first-line therapy.

Classification and Assessment

Aphthous ulcers are among the most common oral lesions, affecting up to 25% of the general population with three-month recurrence rates as high as 50% 1. They are classified into three types:

• Minor aphthous ulcers: Most common, small (<1 cm), heal within 7-14 days without scarring
• Major aphthous ulcers: Larger (>1 cm), deeper, more painful, may take weeks to months to heal, often with scarring
• Herpetiform ulcers: Multiple small clustered ulcers that may coalesce

First-Line Treatment

Topical Treatments

1. Sodium bicarbonate mouthwash:

   • Expert opinion suggests using bland, non-alcoholic, sodium bicarbonate containing mouthwash 4-6 times daily 2
   • For active ulcers, increase frequency up to once per hour as needed 2

2. Pain management:

   • For mild pain: Topical anesthetic mouthwashes (2% viscous lidocaine) or coating agents 2
   • For moderate pain: Topical NSAIDs (e.g., amlexanox 5% oral paste) 2
   • For severe pain: Consider systemic analgesics following WHO pain management ladder 2
   • If mouthwash is painful, use anesthetic approaches before rinsing 2

3. Topical corticosteroids:

   • For ulcers, high-potency corticosteroids are recommended as first-line therapy 2:
     • Dexamethasone mouth rinse (0.1 mg/ml) for multiple or difficult-to-reach ulcers
     • Clobetasol gel or ointment (0.05%) for limited, accessible ulcers

Second-Line Treatment

For Persistent or Severe Ulcers

1. Intralesional steroid injection:

   • Consider triamcinolone weekly (total dose 28 mg) in conjunction with topical clobetasol gel/ointment (0.05%) for ulcers that don't resolve with topical therapy 2

2. Systemic corticosteroids:

   • For highly symptomatic or recurrent ulcers, consider high-dose pulse therapy (30-60 mg or 1 mg/kg oral prednisone/prednisolone) for 1 week followed by tapering over the second week 2
   • Should be reserved for severe cases that don't respond to topical agents 1

3. Other systemic medications:

   • Levamisole has shown variable efficacy in reducing ulcer frequency and duration 1
   • Thalidomide is effective but should only be used as an alternative to oral corticosteroids due to toxicity and cost concerns 1
   • Colchicine may be suitable for recurrent aphthous stomatitis 3

Supportive Measures

1. Oral hygiene and dietary modifications:

   • Maintain good oral hygiene
   • Avoid hard, acidic, salty foods, alcohol, and carbonated drinks 4
   • Avoid toothpastes containing sodium lauryl sulfate 4

2. For dry mouth:

   • Consider sugarless chewing gum, candy, salivary substitutes, or sialogogues 2

Treatment Algorithm

1. Initial approach: Start with sodium bicarbonate mouthwash and topical pain management
2. If inadequate response: Add topical high-potency corticosteroids
3. For persistent ulcers: Consider intralesional steroid injection
4. For severe or refractory cases: Consider short-course systemic corticosteroids
5. For frequent recurrences: Evaluate for underlying conditions (nutritional deficiencies, immune disorders, gastrointestinal diseases) 3

Important Considerations

• Underlying conditions: Recurrent aphthous stomatitis may be associated with systemic diseases (celiac disease, inflammatory bowel diseases), nutritional deficiencies (iron, folates), or immune disorders (HIV infection, neutropenia) 3
• Differential diagnosis: Rule out other conditions that can present with oral ulcers, including trauma, infections, systemic diseases, and malignancy 3
• Chronic solitary ulcers: Any oral solitary chronic ulcer should be biopsied to rule out squamous cell carcinoma 3

Monitoring and Follow-up

• Assess response to treatment within 1-2 weeks
• For recurrent aphthous stomatitis (defined as recurrence of oral aphthous ulcers at least 4 times per year), consider referral to specialist for evaluation of underlying causes 3
• Document frequency, duration, and severity of recurrences to guide long-term management