What are the treatment options for canker sores?

Treatment of Canker Sores

For canker sores (aphthous ulcers), start with topical corticosteroids as first-line therapy—specifically betamethasone sodium phosphate 0.5 mg dissolved in 10 mL water used as a rinse-and-spit preparation four times daily. 1, 2, 3

First-Line Topical Corticosteroid Options

The most effective initial approach uses topical corticosteroids in the following hierarchy:

• Betamethasone sodium phosphate 0.5 mg in 10 mL water: Use as a 2-3 minute rinse-and-spit preparation four times daily for generalized oral ulcers 1, 2, 3
• Clobetasol propionate 0.05% mixed equally with Orabase: Apply directly to localized ulcers on dried mucosa twice weekly 1, 2, 3
• Fluticasone propionate nasules diluted in 10 mL water: Alternative option used twice daily 2, 3

These recommendations come from the British Journal of Dermatology and American College of Physicians guidelines, representing the strongest evidence for canker sore management.

Mucoprotective and Barrier Agents

Combine corticosteroids with protective coatings to enhance healing:

• Gelclair mucoprotectant gel: Apply three times daily to form a protective coating over ulcerated surfaces, reducing pain and promoting healing 1
• White soft paraffin ointment: Apply to affected lips every 2 hours if lips are involved 4, 1
• Gengigel mouth rinse/gel: Use for additional pain control 2, 3

Pain Management Strategy

Use a stepwise approach for pain control:

• Benzydamine hydrochloride oral rinse or spray: First-line analgesic used every 3 hours, particularly before eating 4, 1, 2
• Viscous lidocaine 2%: For more severe pain, apply 3-4 times daily 2, 5
• Benzocaine products: FDA-approved for temporary pain relief from canker sores, with some formulations providing longer duration of anesthetic effect 5, 6

Essential Oral Hygiene Measures

Maintain oral cleanliness to prevent secondary infection:

• Warm saline mouthwashes: Clean the mouth daily to reduce bacterial colonization 4, 1, 2
• Antiseptic rinses: Use 0.2% chlorhexidine digluconate mouthwash or 1.5% hydrogen peroxide mouthwash twice daily 4, 1, 2

Treatment of Secondary Infections

If candidal infection develops (indicated by white coating or slow healing):

• Nystatin oral suspension 100,000 units: Use four times daily for 1 week 4, 1, 3
• Miconazole oral gel 5-10 mL: Hold in mouth after food four times daily for 1 week as alternative 4, 1, 3

Second-Line Treatments for Refractory Ulcers

When first-line topical corticosteroids fail after 1-2 weeks:

• Tacrolimus 0.1% ointment: Apply twice daily for 4 weeks for recalcitrant ulcers 1, 2, 3
• Intralesional triamcinolone injections (28 mg total weekly): Use in conjunction with topical clobetasol for ulcers unresponsive to topical treatment alone 1, 2, 3

Systemic Therapy for Severe or Recurrent Cases

Reserve for highly symptomatic or frequently recurring ulcers:

• Prednisone/prednisolone 30-60 mg (or 1 mg/kg): Give for 1 week, then taper over the second week 2, 3
• Colchicine: Effective for recurrent aphthous stomatitis, particularly when associated with erythema nodosum 4, 2
• Azathioprine, interferon-alpha, or TNF-alpha antagonists: Consider only for resistant cases that fail all other treatments 4, 2

Critical Pitfalls to Avoid

• Do not use ciclosporine A if there is any suspicion of neurological involvement, as it carries significant neurotoxicity risk 4
• Ensure proper diagnosis before initiating treatment—persistent ulcers lasting >3 weeks require biopsy to exclude malignancy 1, 2
• Avoid premature tapering of corticosteroids before disease control is established 2
• Screen for underlying systemic conditions in patients with recurrent aphthous ulcers, including celiac disease, inflammatory bowel disease, Behçet's disease, or immunodeficiency states 1, 2, 7