What is the management and treatment of canker sores?

Management and Treatment of Canker Sores

First-line management of canker sores should begin with topical treatments including steroids, barrier agents, and pain control measures, followed by systemic therapies for refractory cases based on the severity of the ulcers. 1

First-Line Topical Treatments

Topical Steroids

• Apply topical steroids as first-line therapy for accessible canker sores 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, 2

Pain Management

• Apply topical anesthetic mouthwashes (viscous lidocaine 2%) before meals to reduce pain 1, 2
• Use benzydamine hydrochloride rinse or spray every 3 hours, particularly before eating 1, 3
• Consider topical NSAIDs (e.g., amlexanox 5% oral paste) for moderate pain 1, 3
• Benzocaine-containing products provide effective anesthetic relief, with some formulations (like Red Cross Canker Sore Medication) showing longer duration and greater intensity of effect 4

Protective Barriers

• Apply white soft paraffin ointment to lips every 2 hours if affected 1, 3
• Use mucoprotectant mouthwashes (e.g., Gelclair) three times daily to protect ulcerated surfaces 1, 3
• Consider adhesive tablets that gradually erode over time, releasing active ingredients that can reduce pain and promote healing 5

Oral Hygiene and Supportive Care

• Clean the mouth daily with warm saline mouthwashes to reduce bacterial colonization 1, 3
• Use antiseptic oral rinses twice daily (e.g., 1.5% hydrogen peroxide or 0.2% chlorhexidine digluconate) 1, 3
• For dry mouth, recommend sugarless chewing gum, candy, or salivary substitutes 1

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, 2
• Consider 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 1, 6
• Caustics, such as silver nitrate, can stop the growth and pain of lesions in persistent cases 7

Special Considerations

• Identify and avoid potential trigger foods in individual cases 7, 6
• Consider testing for gluten sensitivity in patients with persistent or recurrent canker sores, as gluten has been implicated in some cases 7
• For patients with candidal infection complicating canker sores, treatment with nystatin oral suspension or miconazole oral gel may be necessary 3
• Recognize that canker sores often occur at sites of trauma, and increased viscosity of oral submucosal extracellular matrix may play a role in their development 7

Treatment Pitfalls and Caveats

• Avoid delaying treatment as early intervention provides better outcomes; the natural healing process starts within the first 24 hours of onset 2
• Do not use honey or bee-related products for wound healing of oral ulcers as evidence does not support their efficacy 2
• Avoid using collagen or alginate dressings for oral ulcers as they have not shown benefit 2
• Do not use topical antiseptic or antimicrobial dressings as primary treatment for wound healing of oral ulcers 2
• Recognize that recurrent aphthous stomatitis affects over 50% of the population and may require individualized management strategies based on frequency and severity 6