What is the treatment for an aphthous ulcer on the tongue?

Treatment for Aphthous Ulcers on the Tongue

The first-line treatment for aphthous ulcers on the tongue should be topical corticosteroids, such as betamethasone sodium phosphate 0.5 mg in 10 ml water as a rinse-and-spit preparation four times daily. 1, 2

First-Line Topical Treatments

• Apply topical steroids as primary therapy for accessible aphthous ulcers on the tongue 1, 2
• For localized ulcers, use clobetasol gel or ointment (0.05%) mixed in 50% Orabase applied twice weekly to dried mucosa 1, 2
• For widespread or difficult-to-reach ulcers, use dexamethasone mouth rinse (0.1 mg/ml) 1
• Consider fluticasone propionate nasules diluted in 10 mL of water twice daily as an alternative treatment option 2

Pain Management

• Use topical anesthetic mouthwashes (viscous lidocaine 2%) before meals to reduce pain and facilitate eating 1, 2
• Apply 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
• Use mucoprotectant mouthwashes (e.g., Gelclair, Gengigel) three times daily to create a protective barrier 1, 2

Oral Hygiene and Supportive Care

• Clean the mouth daily with warm saline mouthwashes to reduce bacterial colonization 1, 2
• Use antiseptic oral rinses twice daily (e.g., 0.2% chlorhexidine digluconate) 1, 2
• Avoid hard, acidic, salty foods, alcohol, and carbonated drinks that may exacerbate symptoms 3
• Avoid toothpastes containing sodium lauryl sulfate which may trigger or worsen ulcers 3

Second-Line Treatments for Refractory Cases

• For ulcers that don't respond to topical therapy within 1-2 weeks, consider intralesional steroid injections (triamcinolone weekly, total dose 28 mg) 1, 2
• Tacrolimus 0.1% ointment applied twice daily for 4 weeks can be used for recalcitrant ulcers 2
• Consider 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, 2

Systemic Therapy for Severe or Recurrent Cases

• For recurrent aphthous stomatitis, try colchicine as first-line systemic therapy, especially if associated with erythema nodosum or genital ulcers 1, 2
• Consider azathioprine, interferon-alpha, TNF-alpha inhibitors, or apremilast in selected resistant cases 1, 2
• Thalidomide is effective but should be reserved for severe cases that don't respond to other treatments due to its toxicity and cost 4, 5

Common Pitfalls and Considerations

• Aphthous ulcers lasting more than 2 weeks or not responding to 1-2 weeks of treatment should be referred to a specialist for further evaluation 1
• Premature tapering of corticosteroids before disease control is established should be avoided 1
• Consider underlying systemic conditions (celiac disease, inflammatory bowel diseases, nutritional deficiencies, immune disorders) in patients with recurrent aphthous ulcers 5, 3
• Blood tests including full blood count, coagulation, fasting blood glucose level, HIV antibody, and syphilis serology examination may be necessary to exclude underlying causes 1
• Every oral solitary chronic ulcer should be biopsied to rule out squamous cell carcinoma 5

Treatment Algorithm Based on Severity

1. For minor aphthous ulcers (most common): Start with topical corticosteroids and pain management 4, 3
2. For major aphthous ulcers (>1cm, deeper, longer healing time): More aggressive topical treatment plus consider systemic therapy if not responding 6, 7
3. For herpetiform aphthous ulcers (clusters of small ulcers): Topical treatment plus antiseptic rinses 5