What is the treatment for aphthous stomatitis (canker sores) versus oral ulcers?

Treatment for Aphthous Stomatitis vs Oral Ulcers

For aphthous stomatitis (canker sores), treatment should follow a severity-based approach starting with topical agents for mild cases and progressing to systemic therapy for severe or recalcitrant cases, while oral ulcers require identification of the underlying cause before specific treatment can be initiated. 1, 2

Aphthous Stomatitis Treatment Algorithm

Initial Management for Mild Aphthous Stomatitis

• Use sodium bicarbonate rinses 4-6 times daily for symptomatic relief 1
• Apply topical anesthetics such as benzocaine or viscous lidocaine 2% for pain control 1, 3
• Consider anti-inflammatory oral rinses containing benzydamine hydrochloride every 3 hours, particularly before meals 1
• Maintain good oral hygiene with non-alcoholic mouthwashes to prevent secondary infections 1
• Use barrier preparations such as Gengigel mouth rinse/gel or Gelclair to protect ulcerated surfaces 1

Moderate Aphthous Stomatitis

• Increase frequency of sodium bicarbonate mouthwash up to hourly if necessary 1
• Apply topical high-potency corticosteroids such as:
  • 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 daily to localized lesions 1
• Consider topical NSAIDs such as amlexanox 5% oral paste for pain and inflammation 4

Severe or Recalcitrant Aphthous Stomatitis

• Use high-potency topical corticosteroids as first-line therapy for highly symptomatic ulcers 5, 1
• For non-resolving ulcers, consider intralesional steroid injection (triamcinolone weekly; total dose 28 mg) in conjunction with topical clobetasol gel/ointment 5, 1
• For highly symptomatic or recurrent ulcers, systemic corticosteroids may be necessary (high-dose pulse 30–60 mg or 1 mg/kg oral prednisone/prednisolone for 1 week followed by dose tapering over the second week) 5, 1
• For persistent severe pain, consider more aggressive pain management with alternative administration routes (transdermal, intranasal) 5

Second-Line Treatments for Resistant Cases

• Tacrolimus 0.1% ointment applied twice daily for 4 weeks 1
• Systemic immunomodulatory agents for resistant cases:
  • Colchicine 6, 7
  • Pentoxifylline 6, 7
  • Dapsone for severe cases 6, 4
  • Thalidomide (limited by adverse effects) 2, 6

Oral Ulcers (Non-Aphthous) Treatment

Diagnostic Approach

• Differentiate between acute ulcers (abrupt onset, short duration), recurrent ulcers, and chronic ulcers (slow onset, insidious progression) 2
• Biopsy any solitary chronic ulcer to rule out squamous cell carcinoma 2
• Identify potential underlying causes:
  • Trauma
  • Infections (bacterial, fungal, viral)
  • Systemic diseases (inflammatory bowel disease, celiac disease)
  • Immune disorders (HIV, neutropenia)
  • Medications
  • Malignancy 2

Treatment Based on Underlying Cause

• For viral stomatitis:
  • Maintain good oral hygiene with non-alcoholic mouthwashes 8
  • Consider prophylactic antiviral therapy in immunocompromised patients 8
  • Use topical anesthetics for pain management 8
• For bacterial infections (including acute necrotizing ulcerative gingivitis):
  • Appropriate antibiotics based on culture results 2
  • Antiseptic oral rinses such as 0.2% chlorhexidine digluconate mouthwash 9
• For fungal infections:
  • Treat with nystatin oral suspension or miconazole oral gel 9

Supportive Measures for Both Conditions

• Consume soft, moist, non-irritating foods that are easy to chew and swallow 1, 8
• Use sugarless chewing gum, candy, or salivary substitutes for oral dryness 1, 8
• Drink plenty of water and use lip balm for dry lips 1, 8
• Use ice chips or ice pops as needed to numb the mouth for temporary relief 1, 8
• Avoid hard, acidic, salty foods, toothpastes containing sodium lauryl sulfate, alcohol, and carbonated drinks 7

Important Considerations and Pitfalls

• Stop treatment and consult a doctor if sore mouth symptoms do not improve in 7 days, irritation/pain persists or worsens, or swelling/rash/fever develops 3
• Distinguish aphthous ulcers from herpes labialis, which requires antiviral therapy 1
• For recurrent aphthous stomatitis, investigate potential underlying systemic conditions (celiac disease, inflammatory bowel disease, nutritional deficiencies, immune disorders) 2
• Solitary palatal ulcers may be related to necrotizing sialometaplasia and require different management 2