What is the treatment for recurrent aphthous stomatitis?

Treatment for Recurrent Aphthous Stomatitis (RAS)

The first-line treatment for recurrent aphthous stomatitis should be topical high-potency corticosteroids such as betamethasone sodium phosphate 0.5 mg dissolved in 10 mL of water as a rinse-and-spit solution 1-4 times daily, or clobetasol 0.05% ointment applied to localized lesions. 1

Initial Management Approach

• Basic oral care with non-alcoholic mouthwashes containing sodium bicarbonate should be used as foundational management for all patients with RAS 2
• Maintaining good oral hygiene helps prevent secondary infections and reduces symptom severity 2
• For mild symptoms, 0.9% saline or sodium bicarbonate rinses can provide symptomatic relief 2
• Barrier preparations such as Gengigel mouth rinse/gel or Gelclair can help with pain control 1

Treatment Algorithm Based on Severity

Mild RAS

• Use sodium bicarbonate rinses 4-6 times daily 2
• Consider topical anesthetics such as viscous lidocaine 2% for pain management 2, 3
• Anti-inflammatory oral rinses containing benzydamine hydrochloride can be used every 3 hours, particularly before eating 3

Moderate RAS

• Increase frequency of sodium bicarbonate mouthwash up to hourly if necessary 2
• Apply topical high-potency corticosteroids:
  • Betamethasone sodium phosphate 0.5 mg dissolved in 10 mL water as a rinse-and-spit 1-4 times daily 1
  • Fluticasone propionate nasules diluted in 10 mL water twice daily 1
  • Clobetasol 0.05% ointment mixed in 50% Orabase applied twice weekly to localized lesions 1
• Consider topical NSAIDs such as amlexanox 5% oral paste for moderate pain 2, 4

Severe or Recalcitrant RAS

• For highly symptomatic ulcers, use high-potency topical corticosteroids as first-line therapy 1
• If topical treatments fail, consider intralesional triamcinolone injections (total dose 28 mg) in conjunction with topical clobetasol gel/ointment 1
• For persistent severe cases, systemic corticosteroids may be necessary (high-dose pulse 30-60 mg or 1 mg/kg oral prednisone/prednisolone for 1 week followed by tapering over the second week) 2, 1

Second-Line Treatments for Resistant Cases

• Tacrolimus 0.1% ointment applied twice daily for 4 weeks can be effective for recalcitrant cases 1
• For patients with constant and aggressive outbreaks where topical treatments are insufficient, systemic immunomodulatory therapy may be indicated 5
• Options for systemic therapy in severe cases include:
  • Colchicine 6, 7
  • Pentoxifylline 6, 7
  • Dapsone 6, 4
  • Thalidomide (for extremely resistant cases, with careful monitoring due to side effects) 6, 4

Important Considerations and Pitfalls

• Distinguish RAS from other conditions like herpes labialis, which requires antiviral therapy 8
• Treat any concurrent candidal infection with nystatin oral suspension or miconazole oral gel 1
• Systemic treatments should be reserved for severe cases unresponsive to topical therapy due to potential side effects 9, 4
• No treatment provides permanent remission; therapy is primarily aimed at symptom relief and reducing frequency/severity of recurrences 4
• Most patients with RAS can be managed effectively with topical agents alone 4

Supportive Measures

• Consuming soft, moist, non-irritating foods that are easy to chew and swallow 2
• Using sugarless chewing gum, candy, or salivary substitutes for oral dryness 2
• Drinking plenty of water and using lip balm for dry lips 2
• Using ice chips or ice pops as needed to numb the mouth can provide temporary relief 2