What is the treatment for oral ulcers?

Treatment of Oral Ulcers

Start with topical corticosteroids as first-line therapy for oral ulcers, combined with pain control measures and oral hygiene, escalating to systemic therapies only for refractory or severe cases. 1

Initial Topical Management

Corticosteroid Options

• For localized, accessible ulcers: Apply clobetasol gel or ointment 0.05% directly to dried ulcer 2-4 times daily 1, 2
• For widespread or difficult-to-reach ulcers: Use dexamethasone mouth rinse (0.1 mg/ml) or betamethasone sodium phosphate 0.5 mg dissolved in 10 mL water as rinse-and-spit solution four times daily 1, 2
• Alternative option: Triamcinolone acetonide 0.1% paste applied directly to dried ulcer 2-4 times daily 1

Pain Control Measures

• Apply viscous lidocaine 2% before meals for immediate pain relief 1
• Use benzydamine hydrochloride rinse or spray every 3 hours, particularly before eating 1, 2
• Consider amlexanox 5% oral paste (topical NSAID) for severe pain 1
• Apply mucoprotectant mouthwashes (Gelclair or Gengigel) three times daily to create a protective barrier 1, 2

Oral Hygiene Protocol

• Clean mouth daily with warm saline mouthwashes to reduce bacterial colonization 1, 2
• Use antiseptic oral rinses twice daily: either 0.2% chlorhexidine digluconate or 1.5% hydrogen peroxide 1, 2
• Apply white soft paraffin ointment to lips every 2 hours if lip involvement present 1
• Avoid sodium lauryl sulfate-containing toothpastes, as well as hard, acidic, salty foods, alcohol, and carbonated drinks 3

Second-Line Management for Non-Responsive Ulcers

When to Escalate

If ulcers persist beyond 1-2 weeks of topical therapy or cause severe symptoms, escalate treatment 1

Intralesional Therapy

• Inject triamcinolone weekly (total dose 28 mg) for persistent localized ulcers 1, 2

Systemic Corticosteroids

• Prescribe prednisone/prednisolone 30-60 mg (or 1 mg/kg) for 1 week, then taper over the second week for highly symptomatic or recurrent ulcers 1, 2
• Critical pitfall: Do not taper corticosteroids prematurely before disease control is established 1

Alternative Systemic Agents

• Colchicine is the preferred first-line systemic therapy for recurrent aphthous stomatitis, particularly effective when erythema nodosum or genital ulcers are present 4, 1, 2
• For refractory cases: Consider azathioprine, interferon-alpha, TNF-alpha antagonists, or apremilast in selected cases 4, 1, 2
• Tacrolimus 0.1% ointment applied twice daily for 4 weeks can be used as an alternative to systemic corticosteroids 1, 2

Special Considerations by Underlying Condition

Behçet's Disease

• Begin with topical corticosteroids plus colchicine 4, 1
• Sucralfate suspension is effective for both oral and genital ulcers (proven in RCT) 4
• Progress to azathioprine 2.5 mg/kg/day for resistant mucocutaneous lesions 4
• Reserve thalidomide, interferon-alpha, or TNF-alpha antagonists for most resistant cases, weighing serious adverse effects (teratogenicity, peripheral neuropathy) against benefits 4

Recurrent Aphthous Stomatitis

• Colchicine is first-line systemic therapy 1, 2, 3
• Minocycline can reduce frequency of oral ulcers in open studies 4

When to Refer or Biopsy

• Refer to specialist if ulcers last more than 2 weeks or don't respond to 1-2 weeks of treatment 1
• Biopsy any solitary chronic ulcer to rule out squamous cell carcinoma 1, 5
• Perform blood tests before biopsy: full blood count, coagulation studies, fasting glucose, HIV antibody, and syphilis serology 1

Key Clinical Distinctions

The evidence distinguishes between acute ulcers (trauma, infections, aphthous stomatitis) and chronic ulcers (lichen planus, pemphigoid, pemphigus, malignancy) 5, 6, 7. Location helps differentiate herpes simplex ("cold sores" on keratinized mucosa) from aphthous ulcers ("canker sores" on non-keratinized mucosa) 8. This distinction matters because treatment approaches differ fundamentally—infectious causes require antimicrobials while inflammatory causes respond to immunosuppression.

Duration of Topical Anesthetic Use

FDA guidance indicates stopping benzocaine if symptoms don't improve in 7 days or if irritation, pain, or redness persists or worsens 9, which aligns with the general principle of escalating therapy for non-responsive ulcers.