What are the management options for oral ulcers?

Management of 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

First-Line Management

Topical Treatments

• Apply topical steroids as first-line therapy for oral ulcers, especially for accessible lesions 1
  • For localized ulcers: clobetasol gel or ointment (0.05%) 1
  • 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 a rinse-and-spit preparation four times daily 1

Pain Management

• Use topical anesthetic mouthwashes (viscous lidocaine 2%) before meals 1, 2
  • Apply no more than 3-4 times daily 2
  • Avoid contact with eyes and mucous membranes 2
  • Do not use on large areas or irritated skin 2
• 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

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

Second-Line Management for Refractory Cases

For Ulcers Not Responding 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, 3
• For recurrent aphthous stomatitis, try colchicine as first-line systemic therapy, especially for erythema nodosum or genital ulcers 4, 1, 5
• Consider azathioprine, interferon-alpha, TNF-alpha antagonists, or apremilast in selected cases 4, 1

Management Based on Specific Causes

Behçet's Disease

• Topical measures (local corticosteroids) should be the first line of treatment for isolated oral and genital ulcers 4
• Colchicine should be preferred when the dominant lesion is erythema nodosum 4
• Azathioprine, interferon-alpha, and TNF-alpha antagonists may be considered in resistant cases 4, 1

Ulcerated Infantile Hemangiomas

• Manage with barrier dressings, pain control (acetaminophen and cautious use of topical 2.5% lidocaine), and control of hemangioma growth 4, 1
• Consider propranolol therapy for ulcerated hemangiomas 4, 1

When to Refer to a Specialist

• For oral ulcers lasting more than 2 weeks 4, 6
• For ulcers that do not respond to 1-2 weeks of treatments 4, 6
• If benzocaine-treated sore mouth symptoms do not improve in 7 days 7
• If irritation, pain, or redness persists or worsens 7, 2
• If swelling, rash, or fever develops 7

Diagnostic Approach for Persistent Ulcers

• Blood tests should be performed before biopsy to exclude contraindications and provide diagnostic clues 4
  • Include full blood count, coagulation, fasting blood glucose level, HIV antibody, and syphilis serology examination 4
• Biopsy is indicated for ulcers lasting over 2 weeks or not responding to treatment 4, 6
• Special tests may include direct immunofluorescence, serum antibody tests, and microbiological cultures 6

Common Pitfalls to Avoid

• Premature tapering of corticosteroids before disease control is established 1
• Relying solely on topical treatments without establishing a definitive diagnosis for persistent ulcers 6
• Overlooking systemic causes of oral ulcers leading to delayed diagnosis 6
• Using lidocaine on large areas of the body or on cut, irritated, or swollen skin 2
• Bandaging or applying local heat to the area treated with topical anesthetics 2

Classification of Oral Ulcers

• Acute ulcers: sudden onset and short lasting (traumatic ulcer, recurrent aphthous stomatitis, viral/bacterial infections) 8, 9
• Chronic ulcers: insidious onset and long lasting (oral lichen planus, oral cancer, pemphigoid, pemphigus, drug-induced ulcers) 8, 9
• Recurrent aphthous ulcers classified as minor, major, and herpetiform based on size and number 3, 10