What are the treatment options for oral ulcers?

Treatment Options for Oral Ulcers

Topical treatments should be the first-line therapy for oral ulcers, with systemic therapies reserved for refractory or severe cases. 1, 2, 3

First-Line Management

• Apply topical corticosteroids as primary therapy for accessible oral ulcers:

  • For localized ulcers: clobetasol 0.05% gel or ointment applied to dried mucosa 1, 2
  • For widespread ulcers: betamethasone sodium phosphate 0.5 mg in 10 ml water as a rinse-and-spit preparation four times daily 1, 3
  • Alternative option: dexamethasone mouth rinse (0.1 mg/ml) 1

• Manage pain with:

  • Topical anesthetic mouthwashes (viscous lidocaine 2%) before meals 1, 2
  • Benzydamine hydrochloride rinse or spray every 3 hours, particularly before eating 1, 2
  • For severe pain, consider topical NSAIDs (e.g., amlexanox 5% oral paste) 1, 4

• Implement oral hygiene measures:

  • Clean mouth daily with warm saline mouthwashes 1, 2
  • Use antiseptic oral rinses twice daily (0.2% chlorhexidine digluconate) 1, 2
  • Apply barrier preparations (e.g., Gelclair, white soft paraffin ointment) 1, 3

Second-Line Management for Refractory Cases

• For ulcers not responding to topical therapy, consider:

  • Intralesional steroid injections (triamcinolone weekly, total dose 28 mg) 1, 3
  • Tacrolimus 0.1% ointment applied twice daily for 4 weeks 2, 3

• Systemic therapy options:

  • 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
  • Colchicine as first-line systemic therapy for recurrent aphthous stomatitis, especially effective for erythema nodosum or genital ulcers 1, 5
  • For resistant cases: azathioprine, interferon-alpha, TNF-alpha inhibitors 6, 1
  • Thalidomide can be effective but has serious adverse effects including teratogenicity and peripheral neuropathy 6, 7

Treatment Based on Ulcer Type

• For recurrent aphthous stomatitis (RAS):

  • Begin with topical corticosteroids 1, 4
  • Progress to colchicine for recurrent cases 1, 5
  • Consider systemic immunomodulators for severe cases 4, 7

• For Behçet's disease with oral ulcers:

  • Start with topical steroids for isolated oral ulcers 6, 1
  • Use colchicine for erythema nodosum and genital ulcers 6, 1
  • For resistant cases, consider azathioprine, IFNa, or TNFa antagonists 6
  • Avoid ciclosporine A in patients with neurological involvement due to potential neurotoxicity 6

Common Pitfalls and Considerations

• Proper diagnosis is essential as oral ulcers can be acute (sudden onset, short duration) or chronic (insidious onset, long lasting) 8, 9
• Treat any concurrent candidal infection with nystatin oral suspension or miconazole oral gel 3
• Premature tapering of corticosteroids before disease control is established should be avoided 1
• Consider underlying systemic conditions (celiac disease, inflammatory bowel diseases, nutritional deficiencies) in recurrent cases 5
• Any solitary chronic ulcer should be biopsied to rule out squamous cell carcinoma 5
• Refer patients to specialists for oral ulcers lasting more than 2 weeks or not responding to 1-2 weeks of treatment 1