What is the treatment for severe aphthous ulcers?

Treatment of Severe Aphthous Ulcers

Topical corticosteroids are the first-line treatment for severe aphthous ulcers, with 0.1% triamcinolone acetonide in orabase applied 2-4 times daily until healing occurs, typically within 7-14 days. 1

Classification and Diagnosis

Aphthous ulcers (canker sores) are painful ulcerations of the oral mucosa and come in three clinical forms:

• Minor aphthous ulcers: Most common (80-90%), small (<1cm), shallow, heal within 7-14 days without scarring 2
• Major aphthous ulcers: Larger (>1cm), deeper, more painful, heal slowly (weeks to months), may leave scars
• Herpetiform aphthous ulcers: Multiple small clustered ulcers that may coalesce

Diagnosis is primarily clinical, based on appearance and history. Any ulcer persisting beyond 2 weeks requires further investigation to rule out malignancy or systemic disease 1.

Treatment Algorithm for Severe Aphthous Ulcers

First-Line Therapy: Topical Treatments

1. Topical corticosteroids 1, 3, 2

   • 0.1% triamcinolone acetonide in orabase: Apply 2-4 times daily
   • Alternative options: clobetasol 0.05% ointment, betamethasone sodium phosphate, fluticasone propionate
   • Mechanism: Suppresses local immune response and inflammation
   • Evidence: Randomized controlled trials show significant reduction in pain and faster healing 3

2. Topical anesthetics for pain relief 1, 4

   • Lidocaine 2% gel
   • Benzocaine preparations
   • Apply before meals to reduce pain during eating

3. Antiseptic agents 5

   • Triclosan-containing preparations
   • Chlorhexidine mouthwash (0.2%)
   • Use 2-3 times daily

Second-Line Therapy: For Refractory Cases

1. Conversion to wound treatment 4

   • Chemical cautery (silver nitrate)
   • Debridement of ulcer base
   • Consider when topical treatments fail

2. Systemic medications 4, 5

   • Colchicine: 0.6mg twice daily
   • Pentoxifylline
   • Systemic corticosteroids (prednisolone): Reserved for severe cases
   • Thalidomide: Most effective but limited by adverse effects

Supportive Measures

1. Oral hygiene 1

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

2. Dietary modifications 1, 5

   • Avoid triggers: hard, acidic, spicy, or salty foods
   • Avoid toothpastes containing sodium lauryl sulfate
   • Limit alcohol and carbonated drinks
   • Stay well-hydrated

Special Considerations

• Underlying conditions: Investigate and treat associated systemic diseases (celiac disease, inflammatory bowel disease, vitamin deficiencies, immune disorders) 6, 4
• Recurrent aphthous stomatitis (RAS): For patients with ≥4 episodes per year, consider maintenance therapy and more thorough investigation for underlying causes 6
• Behçet's disease: Consider in patients with genital ulcers and other systemic manifestations; may require immunosuppressive therapy 6

Follow-Up and Monitoring

• Any ulcer not responding to treatment within 2 weeks requires biopsy to rule out malignancy 1
• Regular follow-up every 3-6 months for persistent or recurrent cases
• Monitor for systemic disease manifestations
• Assess pain control and quality of life impact

Pitfalls to Avoid

• Delaying biopsy for persistent ulcers (>2 weeks)
• Overlooking systemic diseases associated with aphthous ulcers
• Prolonged use of topical corticosteroids without monitoring
• Neglecting pain management, which can significantly impact quality of life
• Using alcohol-containing mouthwashes that may exacerbate symptoms

By following this treatment approach, most severe aphthous ulcers will show significant improvement within 7-14 days, with reduced pain and accelerated healing.