What is the treatment for oral ulcers?

Treatment of Oral Ulcers

Start with topical corticosteroids as first-line therapy for oral ulcers, progressing to systemic treatments only for refractory or severe cases. 1, 2

First-Line Topical Therapy

Topical corticosteroids are the cornerstone of initial management and should be selected based on ulcer location and extent 3, 1:

For Localized, Accessible Ulcers

• Apply clobetasol gel or ointment 0.05% directly to dried ulcer 2-4 times daily 1, 2
• Alternatively, use triamcinolone acetonide 0.1% paste applied to dried ulcer 2-4 times daily 1
• For more severe localized ulcers, clobetasol 0.05% ointment mixed in 50% Orabase applied twice weekly to dried mucosa 1, 2

For Multiple or Widespread Ulcers

• Use dexamethasone mouth rinse (0.1 mg/ml) as rinse-and-spit solution 2-4 times daily 1
• Betamethasone sodium phosphate 0.5 mg dissolved in 10 ml water as rinse-and-spit preparation four times daily 1, 2
• Fluticasone propionate nasules diluted in 10 ml water twice daily as an alternative 2

Pain Management and Supportive Care

Combine topical anesthetics with corticosteroids for symptomatic relief 1, 2:

• Viscous lidocaine 2% applied before meals 3-4 times daily 1, 2
• Benzydamine hydrochloride rinse or spray every 3 hours, particularly before eating 1, 2
• Barrier preparations (Gelclair or Gengigel) applied three times daily for mucosal protection 1, 2
• White soft paraffin ointment to lips every 2 hours 1

Oral Hygiene Measures

Maintain meticulous oral hygiene to reduce bacterial colonization and secondary infection 1, 2:

• Clean mouth daily with warm saline mouthwashes 1, 2
• Use antiseptic oral rinses twice daily (0.2% chlorhexidine digluconate or 1.5% hydrogen peroxide) 1, 2
• For dry mouth, recommend sugarless chewing gum or salivary substitutes 1

Second-Line Therapy for Refractory Cases

When topical therapy fails after 1-2 weeks, escalate treatment systematically 1, 2:

Intralesional Steroids

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

Alternative Topical Immunosuppressants

• Tacrolimus 0.1% ointment applied twice daily for 4 weeks as an alternative to repeated steroid injections 1, 2

Systemic Corticosteroids

• Prednisone/prednisolone 30-60 mg (or 1 mg/kg) for 1 week with tapering over the second week for highly symptomatic or recurrent ulcers 1, 2
• Reserve systemic steroids for severe cases that don't respond to topical measures 1

Third-Line Therapy for Recurrent Aphthous Stomatitis

For patients with recurrent ulcers (≥4 episodes per year), consider disease-modifying agents 1, 2, 4:

• Colchicine as first-line systemic therapy, especially effective for erythema nodosum or genital ulcers 3, 1, 2
• Azathioprine, interferon-alpha, or TNF-alpha antagonists for resistant cases 3, 1, 2
• Apremilast in selected refractory cases 1

Special Considerations for Behçet's Disease

When oral ulcers are part of Behçet's syndrome, follow this treatment algorithm 3:

• Start with topical corticosteroids for isolated oral ulcers 3
• Add colchicine for recurrent mucocutaneous involvement 3
• Escalate to azathioprine, interferon-alpha, or TNF-alpha antagonists for refractory cases 3
• Sucralfate suspension has demonstrated efficacy in RCT for oral and genital ulcers 3

Critical Pitfalls to Avoid

Do not taper corticosteroids prematurely before disease control is established 1

Refer to specialist for ulcers lasting >2 weeks or not responding to 1-2 weeks of treatment 1

Perform biopsy for chronic ulcers >2 weeks to exclude squamous cell carcinoma, particularly for solitary palatal or lateral tongue ulcers 1, 4, 5

Screen for underlying systemic conditions in patients with recurrent aphthous ulcers, including celiac disease, inflammatory bowel disease, nutritional deficiencies (iron, folate, B12), HIV, and neutropenia 4

Avoid ciclosporine A in patients with neurological involvement due to neurotoxicity risk 3