What is the initial approach to managing oral ulcers?

Initial Approach to Managing Oral Ulcers

The initial approach to oral ulcers should begin with topical treatments including steroids, barrier agents, and pain control measures, followed by systemic therapies for refractory cases based on the underlying cause and severity of the ulcers. 1

Assessment and Classification

• Oral ulcers may be classified as acute, recurrent, or chronic based on their presentation and duration 2
• Evaluate for potential causes including trauma, infections, immune disorders, nutritional deficiencies, and malignancies 3, 4
• Consider the distribution pattern (single vs. multiple), appearance, pain level, and associated symptoms to guide diagnosis 4
• Any solitary chronic ulcer that doesn't resolve within 2 weeks should be biopsied to rule out squamous cell carcinoma 3

First-Line Management

Topical Treatments

• Apply topical steroids as first-line therapy for oral ulcers, especially for accessible lesions 1

  • For localized ulcers: Use clobetasol gel or ointment (0.05%) 1
  • For widespread or difficult-to-reach ulcers: Use dexamethasone mouth rinse (0.1 mg/ml) 1
  • Consider betamethasone sodium phosphate 0.5 mg in 10 ml water as a rinse-and-spit preparation four times daily 1

• Implement pain control measures:

  • Use topical anesthetic mouthwashes (viscous lidocaine 2%) before meals 1
  • Apply benzydamine hydrochloride rinse or spray every 3 hours, particularly before eating 1
  • For severe pain, consider topical NSAIDs (e.g., amlexanox 5% oral paste) 1

• Use protective barrier agents:

  • Apply white soft paraffin ointment to lips every 2 hours 1
  • Use mucoprotectant mouthwashes (e.g., Gelclair) three times daily 1

Oral Hygiene and Supportive Care

• Clean the mouth daily with warm saline mouthwashes 1
• Use antiseptic oral rinses twice daily (e.g., 1.5% hydrogen peroxide or 0.2% chlorhexidine digluconate) 1
• For dry mouth, recommend sugarless chewing gum, candy, or salivary substitutes 1
• Avoid hard, acidic, salty foods, alcohol, and carbonated drinks that may exacerbate pain 5

Second-Line Management for Refractory Cases

• For ulcers that don't respond to topical therapy, consider:

  • Intralesional steroid injections (triamcinolone weekly, total dose 28 mg) 1
  • Systemic corticosteroids for highly symptomatic or recurrent ulcers (prednisone/prednisolone 30-60 mg or 1 mg/kg for 1 week with tapering over the second week) 1

• For recurrent aphthous stomatitis:

  • Try colchicine as first-line systemic therapy, especially for erythema nodosum or genital ulcers 1
  • Consider azathioprine, interferon-alpha, TNF-alpha inhibitors, or apremilast in selected cases 1

Special Considerations

• For ulcerated infantile hemangiomas:

  • Manage with barrier dressings, pain control (acetaminophen and cautious use of topical 2.5% lidocaine), and control of hemangioma growth 1
  • Consider propranolol therapy for ulcerated hemangiomas 1

• For Stevens-Johnson syndrome/toxic epidermal necrolysis with oral involvement:

  • Implement aggressive topical measures including steroids, anesthetics, and antiseptics 1
  • Consider systemic therapy for severe cases 1

• For Behçet's syndrome:

  • Start with topical steroids and colchicine 1
  • Progress to immunosuppressives for refractory cases 1

When to Refer or Consider Additional Testing

• Refer to a specialist if ulcers persist beyond 7 days despite appropriate treatment 6
• Consider biopsy for ulcers that:
  • Are solitary and persist for more than 2 weeks 3, 4
  • Have atypical features suggesting malignancy 4
  • Don't respond to conventional therapy 4
• Evaluate for systemic diseases in cases of recurrent or multiple ulcers, especially when accompanied by extraoral manifestations 5, 7