What is the treatment for aphthous (canker) ulcers?

Treatment for Aphthous (Canker) Ulcers

Topical treatments should be the first-line therapy for aphthous ulcers, including high-potency topical corticosteroids, topical anesthetics, and coating agents to reduce pain and promote healing. 1

First-Line Treatments

Topical Medications

• Apply topical high-potency corticosteroids as first-line treatment: dexamethasone mouth rinse (0.1 mg/ml) for multiple or difficult-to-reach ulcers, or clobetasol gel/ointment (0.05%) for limited, accessible ulcers 1
• Use topical anesthetics such as viscous lidocaine 2% or benzocaine for pain relief 1, 2
• Consider topical NSAIDs like amlexanox 5% oral paste for moderate pain 1
• Apply coating agents such as sucralfate suspension to protect ulcers and promote healing 1, 3

Oral Hygiene and Supportive Care

• Maintain good oral hygiene with twice-daily toothbrushing and chlorhexidine or fluoride oral rinse if brushing is too painful 1
• Avoid triggering foods and drinks: crunchy, spicy, acidic foods and hot beverages 1, 3
• Consider sugarless chewing gum, candy, or salivary substitutes for patients with oral dryness 1

Second-Line Treatments

Systemic Medications

• For persistent severe pain, consider more aggressive pain management with systemic analgesics following the WHO pain management ladder 1
• For highly symptomatic or recurrent ulcers, consider systemic corticosteroids: high-dose pulse therapy (30-60 mg or 1 mg/kg oral prednisone/prednisolone) for 1 week followed by tapering over the second week 1
• For recurrent aphthous stomatitis, colchicine is recommended as an effective treatment 1, 3

Advanced Therapies

• For resistant cases, consider intralesional steroid injection (triamcinolone weekly; total dose 28 mg) in conjunction with topical clobetasol gel/ointment (0.05%) 1
• For severe recurrent cases that don't respond to other therapies, thalidomide may be considered, though its use is limited by potential adverse effects 3, 4

Special Considerations

Differential Diagnosis

• Rule out systemic conditions associated with recurrent aphthous stomatitis, including:
  • Gastrointestinal diseases (celiac disease, inflammatory bowel diseases) 3, 5
  • Nutritional deficiencies (iron, folates) 3, 6
  • Immune disorders (HIV infection, neutropenia) 3, 7
  • Behçet's disease (characterized by recurrent bipolar aphthosis) 1, 3

Treatment Based on Ulcer Type

• Minor aphthous ulcers (most common): Typically heal within 7-14 days with topical treatments 6, 7
• Major aphthous ulcers: May require more aggressive therapy including systemic medications 5, 7
• Herpetiform ulcers: Often respond to topical treatments but may need systemic therapy if severe 3, 5

Common Pitfalls

• Failure to distinguish aphthous ulcers from other oral lesions that may require different treatment approaches 3, 6
• Inadequate pain management leading to decreased oral intake and quality of life 1, 4
• Overuse of systemic corticosteroids for minor aphthous ulcers that would respond to topical therapy 1, 5
• Not addressing underlying systemic conditions that may contribute to recurrent ulcers 3, 7