What are the treatment options for oral ulcers?

Treatment Options for Oral Ulcers

Topical treatments should be used as first-line therapy for oral ulcers, with systemic therapies reserved for refractory cases based on the underlying cause and severity of the ulcers. 1

First-Line Topical Treatments

• Apply topical steroids directly to affected areas as primary treatment for oral ulcers 1, 2:

  • For localized ulcers: clobetasol gel/ointment (0.05%) 1
  • For widespread/difficult-to-reach ulcers: dexamethasone mouth rinse (0.1 mg/ml) 1
  • Alternative option: betamethasone sodium phosphate 0.5 mg in 10 ml water as rinse-and-spit preparation four times daily 1

• Pain management options:

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

• Protective agents:

  • White soft paraffin ointment to lips every 2 hours 1, 2
  • Mucoprotectant mouthwashes (e.g., Gelclair) three times daily 1, 2

Oral Hygiene and Supportive Care

• Clean mouth daily with warm saline mouthwashes 1, 2
• Use antiseptic oral rinses twice daily (e.g., 0.2% chlorhexidine digluconate) 1, 2
• For dry mouth: recommend sugarless chewing gum, candy, or salivary substitutes 1
• Avoid painful stimuli including smoking, alcohol, spicy foods, hot foods/drinks, and acidic foods 2

Second-Line Management for Refractory Cases

• For ulcers unresponsive to topical therapy, consider intralesional steroid injections (triamcinolone weekly, total dose 28 mg) 1, 2
• 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
• For recurrent aphthous stomatitis, try colchicine as first-line systemic therapy, especially for erythema nodosum or genital ulcers 3, 1, 4
• Consider azathioprine, interferon-alpha, TNF-alpha inhibitors, or apremilast in selected cases 1

Treatment for Secondary Infections

• If candidal infection is suspected, treat with Nystatin oral suspension 100,000 units four times daily for 1 week 2, 5
• Alternatively, miconazole oral gel 5-10 mL held in the mouth after food four times daily for 1 week 2

Special Considerations for Specific Conditions

• For Behçet's syndrome: start with topical steroids and colchicine 3, 1
• For Stevens-Johnson syndrome/toxic epidermal necrolysis with oral involvement: implement aggressive topical measures including steroids, anesthetics, and antiseptics 1

Common Pitfalls to Avoid

• Premature tapering of corticosteroids before disease control is established 1
• Failure to identify and treat underlying causes of oral ulcers 6, 4
• Neglecting to refer patients with ulcers lasting more than 2 weeks or not responding to 1-2 weeks of treatment to a specialist 1
• Not considering systemic conditions that may present with oral ulcers (e.g., inflammatory bowel disease, celiac disease, HIV infection) 4, 7, 8

Treatment Algorithm

1. Start with topical treatments (steroids, pain management, protective agents)
2. If no improvement after 1-2 weeks, consider:
   • Intralesional steroid injections
   • Systemic therapy based on underlying cause
   • Referral to specialist
3. For recurrent cases, investigate for underlying systemic conditions
4. Maintain oral hygiene throughout treatment