Management of Aphthous Ulcers
Apply high-potency topical corticosteroids as first-line treatment, specifically betamethasone sodium phosphate 0.5 mg dissolved in 10 mL of water as a rinse-and-spit solution one to four times daily, combined with appropriate pain management based on symptom severity. 1
First-Line Topical Corticosteroid Options
The primary treatment approach centers on topical corticosteroids, with several evidence-based options:
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 diffuse or multiple lesions 1
Clobetasol 0.05% ointment mixed in 50% Orabase: Apply twice daily to localized lesions on dried mucosa when ulcers are few and easily accessible 1
Dexamethasone mouth rinse (0.1 mg/mL): Recommended for multiple lesions or difficult-to-reach ulcerations 2, 1
Fluticasone propionate nasules diluted in 10 mL water: Use twice daily as an alternative corticosteroid option 1
These topical corticosteroids reduce pain and improve healing time, though they do not prevent recurrence 3, 4
Pain Management Algorithm
Pain control should be initiated simultaneously with corticosteroid therapy:
For mild pain:
- Bland non-alcoholic, sodium bicarbonate containing mouthwash four to six times daily, increasing frequency up to once per hour if needed 2, 1
For moderate pain:
For severe pain:
- Anesthetic mouthwashes such as viscous lidocaine 2% applied before meals or as needed 2, 1
- Systemic analgesics following the WHO pain ladder if topical measures are insufficient 2, 1
Supportive Measures
- Recommend sugarless chewing gum or candy, salivary substitutes, or sialogogues for patients experiencing oral dryness 1
- Advise avoiding hard, acidic, salty foods, toothpastes containing sodium lauryl sulfate, alcohol, and carbonated drinks 4
Second-Line Treatments for Refractory Ulcers
If no improvement occurs after 1-2 weeks of topical corticosteroids:
Tacrolimus 0.1% ointment: Apply twice daily for 4 weeks for recalcitrant ulcers 1
Intralesional corticosteroids: Weekly intralesional triamcinolone (total dose 28 mg) combined with topical clobetasol gel or ointment (0.05%) for ulcers that don't resolve with topical treatment alone 2, 1
Systemic Therapy for Severe or Recurrent Cases
For highly symptomatic ulcers, recurrent ulcers (≥4 episodes per year), or major aphthous ulcers:
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 2, 1
Colchicine: Consider for recurrent aphthous stomatitis when associated with systemic conditions 5
Thalidomide: Most effective for severe recurrent aphthous stomatitis but use is limited by frequent adverse effects and requires strict monitoring 5
Important Clinical Considerations
Rule out underlying systemic disease in patients with recurrent aphthous stomatitis (≥4 episodes per year), as this can be associated with:
- Gastrointestinal diseases (celiac disease, inflammatory bowel disease) 5
- Nutritional deficiencies (iron, folate, vitamin B12) 5, 3
- Immune disorders (HIV infection, neutropenia) 5
- Behçet's disease (characterized by recurrent bipolar aphthosis) 5
Biopsy any solitary chronic oral ulcer that persists beyond 2-3 weeks to rule out squamous cell carcinoma 5
Treat concurrent candidal infection with nystatin oral suspension or miconazole oral gel if present 1
Common Pitfalls to Avoid
- Do not confuse aphthous ulcers with oral herpes simplex—aphthous ulcers occur on unattached oral mucosa (buccal mucosa, soft palate, tongue) while herpes affects attached mucosa (hard palate, gingiva) 6
- Avoid using antimicrobial dressings or agents solely to accelerate healing, as evidence does not support this approach 2
- Do not prescribe systemic immunosuppressive agents (beyond corticosteroids) unless dealing with refractory disease or Behçet's disease 4
- Antiseptic agents and local anesthetics should be tried before escalating to topical corticosteroids 4