What is the management approach for oral aphthous ulcers?

Management of Oral Aphthous Ulcers

Topical corticosteroids are the first-line treatment for oral aphthous ulcers, followed by systemic therapies for refractory cases based on severity and underlying cause. 1

First-Line Management

Topical Treatments

• Apply high-potency topical corticosteroids as initial therapy for accessible lesions 1, 2:
  • For localized ulcers: Clobetasol 0.05% ointment/gel applied to dried mucosa twice daily 1, 2
  • For widespread or difficult-to-reach ulcers: Dexamethasone mouth rinse (0.1 mg/ml) 1
  • Betamethasone sodium phosphate 0.5 mg in 10 ml water as rinse-and-spit four times daily 1, 2
  • Fluticasone propionate nasules diluted in 10 ml water twice daily 2

Pain Management

• Use topical anesthetic mouthwashes (viscous lidocaine 2%) before meals to reduce pain 1
• Apply benzydamine hydrochloride rinse or spray every 3 hours, particularly before eating 1
• For severe pain, consider topical NSAIDs such as amlexanox 5% oral paste 1
• Use barrier preparations (Gengigel mouth rinse/gel or Gelclair) three times daily 1, 2

Oral Hygiene and Supportive Care

• Clean the mouth daily with warm saline mouthwashes 1
• Use antiseptic oral rinses twice daily (1.5% hydrogen peroxide or 0.2% chlorhexidine digluconate) 1
• Avoid hard, acidic, salty foods, alcohol, and carbonated drinks that may exacerbate pain 3
• Avoid toothpastes containing sodium lauryl sulfate 3

Second-Line Management for Refractory Cases

Intralesional and Topical Alternatives

• For ulcers not responding to topical therapy, consider intralesional steroid injections (triamcinolone weekly, total dose 28 mg) 1, 2
• Consider tacrolimus 0.1% ointment applied twice daily for 4 weeks for recalcitrant ulcers 2

Systemic Therapy

• For highly symptomatic or recurrent ulcers, consider systemic corticosteroids (prednisone/prednisolone 30-60 mg or 1 mg/kg for 1 week with tapering over the second week) 1, 2
• For recurrent aphthous stomatitis, try colchicine as first-line systemic therapy, especially for cases with erythema nodosum or genital ulcers 1, 3
• In severe cases, consider other immunosuppressives such as azathioprine, interferon-alpha, TNF-alpha inhibitors, or apremilast 1

Special Considerations

Differential Diagnosis

• Persistent ulcers (>2 weeks) may indicate underlying systemic conditions and require specialist referral 4, 5
• Consider potential causes including:
  • Traumatic factors (mechanical, physical, chemical) 4
  • Infectious causes (bacterial, viral, fungal) 4, 5
  • Systemic diseases (autoimmune disorders, inflammatory bowel disease) 4, 5
  • Malignancy (especially for solitary chronic ulcers) 4, 5

When to Refer to a Specialist

• Refer to an oral medicine specialist for ulcers persisting >2 weeks or not responding to 1-2 weeks of treatment 4
• Any solitary chronic ulcer should be biopsied to rule out squamous cell carcinoma 4, 5
• Consider referral if ulcers are associated with systemic symptoms like periodic fever (possible PFAPA syndrome) 6

Common Pitfalls to Avoid

• Treating concurrent candidal infection is essential - use nystatin oral suspension or miconazole oral gel when needed 2
• Relying solely on topical treatments without establishing a definitive diagnosis for persistent ulcers can lead to delayed diagnosis 4
• Premature tapering of corticosteroids before disease control is established is not recommended 7
• Overlooking systemic causes of oral ulcers can lead to delayed diagnosis and inappropriate management 4