Treatment of Aphthous Ulcers
Start with high-potency topical corticosteroids as first-line therapy, specifically betamethasone sodium phosphate 0.5 mg dissolved in 10 mL of water as a rinse-and-spit solution one to four times daily, which is the primary recommended treatment for aphthous ulcers. 1
First-Line Topical Corticosteroid Options
The following high-potency topical corticosteroids are effective first-line treatments:
Betamethasone sodium phosphate 0.5 mg in 10 mL water: Use as a 2-3 minute rinse-and-spit solution one to four times daily for accessible lesions 1, 2
Dexamethasone mouth rinse (0.1 mg/ml): Particularly useful for multiple lesions or difficult-to-reach ulcerations 1, 3
Clobetasol 0.05% ointment: Mix in 50% Orabase and apply twice weekly to localized lesions on dried mucosa 1, 2
Fluticasone propionate nasules: Dilute in 10 mL of water twice daily as an alternative option 1
Pain Management Strategy
Pain control should be initiated alongside corticosteroid therapy, with intensity matched to symptom severity:
Mild pain: Bland non-alcoholic sodium bicarbonate mouthwash four to six times daily, increasing to hourly if needed 1
Moderate pain: Topical NSAIDs such as amlexanox 5% oral paste 1
Severe pain: Anesthetic mouthwashes like viscous lidocaine 2% or benzydamine hydrochloride rinse/spray 1, 2
Adjunctive measures: Coating agents (such as Gelclair) and systemic analgesics as needed 1, 2
Supportive Care
Avoid hard, acidic, salty foods, toothpastes containing sodium lauryl sulfate, alcohol, and carbonated drinks 4. For patients with oral dryness, use sugarless chewing gum or candy, salivary substitutes, or sialogogues 1.
Second-Line Treatments for Non-Responders
If ulcers do not improve after 1-2 weeks of topical corticosteroids:
Tacrolimus 0.1% ointment: Apply twice daily for 4 weeks for recalcitrant ulcers 1
Intralesional triamcinolone: Weekly injections (total dose 28 mg) combined with topical clobetasol gel or ointment (0.05%) for ulcers resistant to topical treatment alone 1, 2
Antiseptic rinses: 0.2% chlorhexidine digluconate to prevent secondary infection 2
Systemic Therapy for Severe or Recurrent Cases
For highly symptomatic, recurrent, or refractory ulcers:
Oral corticosteroids: High-dose pulse 30-60 mg or 1 mg/kg oral prednisone/prednisolone for 1 week, followed by dose tapering over the second week 1, 2
Colchicine: Appropriate for recurrent aphthous stomatitis (RAS) when combined with topical treatments 5, 4
Advanced immunosuppressives: Azathioprine, interferon-alpha, or TNF-alpha inhibitors reserved for severe refractory cases or Behçet's disease 2, 5
Thalidomide: Most effective for RAS but limited by frequent adverse effects 5
Critical Clinical Pitfalls
Any oral ulcer lasting more than 2 weeks or not responding to 1-2 weeks of treatment requires specialist referral and biopsy to rule out malignancy, particularly squamous cell carcinoma. 2, 5 This is especially important for solitary chronic ulcers.
Before initiating treatment, determine if underlying systemic conditions are contributing: celiac disease, inflammatory bowel disease, nutritional deficiencies (iron, folates), HIV infection, neutropenia, or Behçet's disease 5, 3. Correct these factors when identified.
Special Considerations
Concurrent candidal infection: Treat with nystatin oral suspension or miconazole oral gel 1
Nutritional support: Consider protein or amino acid supplementation to promote healing 2
Recurrent aphthous stomatitis (RAS): Defined as oral aphthous ulcers recurring at least 4 times per year, requiring investigation for underlying causes 5