What is the treatment for large aphthous ulcers?

Treatment of Large Aphthous Ulcers

For large aphthous ulcers, topical high-potency corticosteroids should be considered as first-line treatment, with dexamethasone mouth rinse (0.1 mg/ml) for multiple or difficult-to-reach ulcerations, or clobetasol gel/ointment (0.05%) for limited, accessible ulcers. 1

Step-by-Step Treatment Algorithm

First-Line Treatment

1. Topical Corticosteroids

   • For multiple/difficult-to-reach ulcers: Dexamethasone mouth rinse (0.1 mg/ml)
   • For limited/accessible ulcers: Clobetasol gel or ointment (0.05%)
   • Application: 3-4 times daily until resolution

2. Pain Management

   • Topical anesthetics: Viscous lidocaine 2% before meals
   • Topical NSAIDs: Amlexanox 5% oral paste for moderate pain
   • For severe pain: Consider systemic analgesics following WHO pain ladder

3. Basic Oral Care

   • Bland, non-alcoholic sodium bicarbonate mouthwash (frequency up to hourly)
   • Avoid irritants: hard, acidic, salty foods, alcohol, carbonated drinks
   • Avoid toothpastes containing sodium lauryl sulfate 2

Second-Line Treatment (If No Resolution)

1. Intralesional Steroid Injection
   • Triamcinolone weekly (total dose 28 mg) in conjunction with topical clobetasol 1

Third-Line Treatment (For Highly Symptomatic or Recurrent Ulcers)

1. Systemic Corticosteroids
   • High-dose pulse therapy: Prednisone/prednisolone 30-60 mg or 1 mg/kg daily for 1 week
   • Taper over the second week 1

Special Considerations

For Severe or Refractory Cases

• Consider systemic medications such as colchicine or pentoxifylline 2
• Thalidomide is highly effective but should be reserved for severe cases due to significant adverse effects 3

For Recurrent Aphthous Stomatitis (RAS)

• Investigate for underlying causes:
  • Gastrointestinal diseases (celiac disease, inflammatory bowel diseases)
  • Nutritional deficiencies (iron, folates)
  • Immune disorders (HIV infection, neutropenia)
  • Behçet's disease 4

Efficacy of Treatments

• Triamcinolone acetonide ointment has shown 86.7% positive response in patients with Behçet's syndrome compared to 53.3% with phenytoin 5
• Topical treatments achieve the primary goals of pain relief and reduction of ulcer duration but may not alter recurrence rates 3

Common Pitfalls to Avoid

• Delaying treatment of large aphthous ulcers can lead to increased pain, difficulty eating, and prolonged healing time
• Failing to rule out systemic diseases in cases of recurrent aphthous ulcers
• Using antimicrobial mouthwashes alone without addressing pain management
• Not considering intralesional or systemic steroids for severe or refractory cases

Remember that large aphthous ulcers can significantly impact quality of life through pain and interference with eating, speaking, and swallowing. Prompt and aggressive treatment is essential to reduce morbidity and improve patient outcomes.