What are the treatment options for oral aphthous ulcers?

Treatment Options for Oral Aphthous Ulcers

Topical corticosteroid preparations are the first-line treatment for oral aphthous ulcers, with options including betamethasone sodium phosphate mouthwash, fluticasone propionate nasules diluted in water, or clobetasol ointment mixed with Orabase for localized lesions. 1

First-Line Treatments

Topical Corticosteroids

• Betamethasone sodium phosphate 0.5 mg dissolved in 10 mL of water as a 2-3 minute rinse-and-spit solution one to four times daily 1
• Fluticasone propionate nasules diluted in 10 mL of water twice daily 1
• Clobetasol 0.05% ointment mixed in 50% Orabase applied twice weekly to localized lesions on dried mucosa 1
• For highly symptomatic ulcers, high-potency topical corticosteroids should be considered first 1

Pain Management

• Anti-inflammatory oral rinses containing benzydamine hydrochloride every 3 hours, particularly before eating 2
• Topical anesthetic preparations such as viscous lidocaine 2% for inadequate pain control 2
• Systemic analgesics following the WHO pain management ladder for more severe pain 1, 2
• Barrier preparations such as Gengigel mouth rinse/gel or Gelclair for pain control 1

Oral Care

• Daily cleaning with warm saline mouthwashes to reduce bacterial colonization 2
• Antiseptic oral rinse twice daily (0.2% chlorhexidine digluconate or 1.5% hydrogen peroxide) 2
• Mucoprotectant mouthwash three times daily 2
• White soft paraffin ointment for affected lips 2

Second-Line Treatments

Topical Tacrolimus

• Tacrolimus 0.1% ointment applied twice daily for 4 weeks has shown benefit in recalcitrant cases 1
• In a split-mouth randomized trial, tacrolimus 0.1% ointment was as effective as triamcinolone acetonide 0.1% paste in reducing mucosal involvement and pain scores 1

Intralesional Steroids

• Perilesional/intralesional triamcinolone acetonide injections can be effective when added to conventional therapy 1
• Weekly intralesional triamcinolone (total dose 28 mg) in conjunction with topical clobetasol gel or ointment (0.05%) for ulcers that don't resolve with topical treatment 1

Topical Cyclosporine

• Cyclosporine mouthwash (100 mg/mL, 5 mL three times daily) has shown effectiveness for recalcitrant oral lesions 1
• A 5-mL (500-mg) oral suspension used three times daily for 2 months has resulted in significant improvement in symptoms and signs 1
• Note: Topical cyclosporine tastes unpleasant and is relatively expensive 1

Systemic Therapy for Severe Cases

• For highly symptomatic or recurrent ulcers, systemic corticosteroids may be considered (high-dose pulse 30-60 mg or 1 mg/kg oral prednisone/prednisolone for 1 week followed by dose tapering over the second week) 1
• In severe cases, systemic drugs such as colchicine, pentoxifylline, or prednisolone can be combined with local measures 3
• Other immunosuppressive agents should be reserved for refractory or particularly severe cases 3

Lifestyle and Dietary Modifications

• Avoid hard, acidic, and salty foods 3
• Avoid toothpastes containing sodium lauryl sulfate 3
• Limit alcohol and carbonated drinks 3

Treatment Algorithm Based on Severity

1. Mild cases:

   • Topical corticosteroid preparations
   • Pain management with topical agents
   • Proper oral hygiene

2. Moderate cases:

   • Combination of topical corticosteroids with tacrolimus
   • Consider intralesional steroid injections for persistent lesions
   • More aggressive pain management

3. Severe/recurrent cases:

   • Consider systemic corticosteroids
   • Evaluate for underlying systemic conditions
   • Consider other systemic medications like colchicine or pentoxifylline 3

Common Pitfalls and Caveats

• Treatment is primarily symptomatic and palliative as there is no definitive cure for recurrent aphthous ulcers 4, 3
• Always consider that oral aphthous-like ulcers may be a manifestation of systemic diseases such as celiac disease, inflammatory bowel diseases, Behçet's disease, or nutritional deficiencies 4, 5
• Any solitary chronic ulcer that doesn't heal should be biopsied to rule out squamous cell carcinoma 4
• For patients with concurrent candidal infection, treatment with nystatin oral suspension or miconazole oral gel may be necessary 2