What are the treatment options for a canker sore?

Canker Sore Treatment

For immediate pain relief and healing of canker sores, start with topical corticosteroids (betamethasone sodium phosphate 0.5 mg dissolved in 10 mL water as a rinse-and-spit solution four times daily) combined with benzydamine hydrochloride oral rinse every 3 hours, particularly before eating. 1, 2

First-Line Treatment Approach

Topical Corticosteroids (Primary Therapy)

• Betamethasone sodium phosphate 0.5 mg dissolved in 10 mL water used as a 3-minute rinse-and-spit preparation four times daily is the recommended first-line treatment 1, 2
• For localized ulcers, clobetasol propionate 0.05% mixed in equal amounts with Orabase can be applied directly to affected areas daily for more targeted therapy 1, 2
• Fluticasone propionate nasules diluted in 10 mL water twice daily serves as an alternative corticosteroid option 2

Pain Management

• Benzydamine hydrochloride oral rinse or spray every 3 hours, especially before eating, provides anti-inflammatory pain relief 1, 2
• Viscous lidocaine 2% (15 mL per application) can be applied 3-4 times daily for more severe pain 3, 1, 2
• Benzocaine topical products temporarily relieve pain associated with canker sores and are FDA-approved for this indication 4
• Gelclair mucoprotectant gel three times daily forms a protective coating over ulcerated surfaces, reducing pain and promoting healing 1

Essential Oral Hygiene Measures

• Clean the mouth daily with warm saline mouthwashes to reduce bacterial colonization 1, 2
• 0.2% chlorhexidine digluconate mouthwash twice daily is recommended for all patients with oral mucosa inflammation 3, 2
• Use a soft toothbrush or swab after meals and before sleep 3

Dietary and Lifestyle Modifications

• Avoid crunchy, spicy, acidic foods, citrus fruits, and hot beverages during active ulceration 3, 1
• Avoid smoking and alcohol, which can irritate lesions 3

Second-Line Treatments for Refractory Cases

When First-Line Therapy Fails After 7 Days

• Tacrolimus 0.1% ointment applied twice daily for 4 weeks for recalcitrant ulcers 1, 2
• Intralesional triamcinolone injections in conjunction with topical clobetasol for ulcers that don't respond to topical treatment alone 1, 2
• Amlexanox 5% paste reduces ulcer size, pain duration, and healing time and appears most effective overall in research studies 5

Systemic Therapy for Severe or Highly Recurrent Cases

• Prednisone/prednisolone 30-60 mg or 1 mg/kg for 1 week with tapering over the second week for highly symptomatic or recurrent ulcers 2
• Colchicine can be effective for recurrent aphthous stomatitis, especially when associated with erythema nodosum or genital ulcers 2
• Azathioprine, interferon-alpha, or TNF-alpha antagonists for resistant cases 2

Treatment of Secondary Infections

If Candidal Infection is Suspected

• Nystatin oral suspension 100,000 units four times daily for 1 week 3, 1, 2
• Miconazole oral gel 5-10 mL held in the mouth after food four times daily for 1 week as an alternative 3, 1, 2

Critical Pitfalls to Avoid

• Stop treatment and seek medical attention if symptoms do not improve in 7 days, or if irritation, pain, redness persists or worsens, or if swelling, rash, or fever develops 4
• Ensure proper diagnosis before initiating treatment, as other conditions can mimic canker sores 1, 2
• Do not prematurely taper corticosteroids before disease control is established 2
• Consider underlying systemic conditions (hematinic deficiency occurs in up to 20% of patients, celiac disease, immune defects) for patients with recurrent aphthous ulcers 2, 6

When to Refer

• Refer to dentistry for persistent symptoms despite appropriate first-line therapy 3
• Refer to dermatology if available for complex or refractory cases 3