What are the management options for canker sores?

Management of Canker Sores (Aphthous Ulcers)

For first-line treatment of canker sores, use topical corticosteroids—specifically betamethasone sodium phosphate 0.5 mg dissolved in 10 mL of water as a 2-3 minute rinse-and-spit solution one to four times daily. 1

First-Line Topical Corticosteroid Options

The most effective initial approach involves high-potency topical corticosteroids applied directly to the ulcers:

• Betamethasone sodium phosphate 0.5 mg in 10 mL water: Use as a rinse-and-spit solution for 2-3 minutes, one to four times daily 1
• Fluticasone propionate nasules: Dilute in 10 mL of water and use twice daily 1
• Clobetasol 0.05% ointment: Mix in 50% Orabase and apply twice weekly to localized lesions on dried mucosa 1
• Clobetasol propionate 0.05%: Mix in equal amounts with Orabase and apply directly to affected areas daily for localized ulcers 2

For highly symptomatic ulcers, prioritize high-potency topical corticosteroids first before considering other options 1

Pain Management

Effective pain control is essential and should be implemented alongside corticosteroid therapy:

• Benzydamine hydrochloride oral rinse or spray: Use every 3 hours, particularly before eating 2
• Barrier preparations: Apply Gelclair mucoprotectant gel three times daily to form a protective coating over ulcerated surfaces 2
• Topical anesthetics: For severe pain, use viscous lidocaine 2% up to 3-4 times daily 2, or benzocaine-containing products 3, 4
• WHO pain ladder: Follow this approach for more severe pain 1

Supportive Oral Hygiene Measures

Maintain proper oral hygiene to prevent secondary infection and promote healing:

• Warm saline mouthwashes: Clean the mouth daily to reduce bacterial colonization 2
• Antiseptic oral rinses: Use 0.2% chlorhexidine digluconate mouthwash or 1.5% hydrogen peroxide mouthwash twice daily 2
• Lip protection: Apply white soft paraffin ointment to affected lips every 2 hours 2

Treatment of Secondary Candidal Infection

If concurrent candidal infection is present (common with corticosteroid use):

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

Second-Line Treatments for Refractory Cases

If first-line topical corticosteroids fail after 7 days 3:

• Tacrolimus 0.1% ointment: Apply twice daily for 4 weeks for recalcitrant ulcers 1, 2
• Intralesional triamcinolone: Weekly injections (total dose 28 mg) in conjunction with topical clobetasol gel or ointment (0.05%) 1, 2
• Amlexanox 5% paste: Reduces ulcer size, pain duration, and healing time (most effective overall in research studies) 5

Systemic Therapy for Severe or Recurrent Cases

For highly symptomatic or recurrent ulcers that don't respond to topical treatment:

• High-dose pulse corticosteroids: 30-60 mg or 1 mg/kg oral prednisone/prednisolone for 1 week, followed by dose tapering over the second week 1, 2

Common Pitfalls and Caveats

• Duration of treatment: If symptoms do not improve in 7 days, or if irritation, pain, or redness persists or worsens, stop topical anesthetics and reassess 3
• Candidal superinfection: Always monitor for and treat concurrent candidal infection when using topical corticosteroids 1
• Proper diagnosis: Ensure accurate diagnosis before initiating treatment, as other conditions may mimic canker sores 2
• Immunodeficiency screening: Consider underlying immunodeficiency states in patients with severe recurrent lesions, major aphthous ulcers, or chronic presentations 6
• Application technique: For localized ulcers, apply corticosteroid ointments to dried mucosa for better adherence 1