How to manage recurrent mouth ulcers?

Management of Recurrent Mouth Ulcers

Start with topical corticosteroids as first-line therapy, progressing to systemic treatments only for refractory cases, while simultaneously investigating underlying causes through targeted blood work and biopsy for ulcers persisting beyond 2 weeks. 1

Initial Topical Treatment Approach

First-Line Topical Therapies

• Apply clobetasol gel or ointment (0.05%) directly to localized, accessible ulcers 2-4 times daily after drying the lesion 1
• Use dexamethasone mouth rinse (0.1 mg/ml) for widespread or difficult-to-reach ulcers as a rinse-and-spit preparation 1
• Alternatively, dissolve betamethasone sodium phosphate 0.5 mg in 10 ml water and use as rinse-and-spit four times daily 1
• For children or localized lesions, triamcinolone acetonide 0.1% paste applied directly to dried ulcer 2-4 times daily is effective 1, 2

Pain Control Measures

• Apply viscous lidocaine 2% before meals to enable eating 1
• Use benzydamine hydrochloride rinse or spray every 3 hours, particularly before eating 1
• Consider amlexanox 5% oral paste for severe pain 1, 2

Mucosal Protection and Hygiene

• Apply mucoprotectant mouthwashes (Gelclair) three times daily to create a protective barrier 1
• Clean the mouth daily with warm saline mouthwashes 1
• Use antiseptic oral rinses twice daily (1.5% hydrogen peroxide or 0.2% chlorhexidine digluconate) 1
• Apply white soft paraffin ointment to lips every 2 hours if affected 1

Diagnostic Workup for Persistent or Recurrent Ulcers

When to Investigate

Proceed with comprehensive workup for any ulcer lasting more than 2 weeks or not responding to 1-2 weeks of topical treatment 1, 3

Essential Blood Tests

• Full blood count to detect anemia, leukemia, neutropenia, or other blood disorders 1, 3, 4
• Fasting blood glucose level to identify diabetes (predisposes to fungal infections) 1, 3
• HIV antibody testing 1, 3, 4
• Syphilis serology 1, 3, 4
• Nutritional markers: vitamin B1, B2, B6, B12, folate, and iron levels 1, 4, 5
• Coagulation studies before biopsy 1, 3
• Serum antibodies (Dsg1, Dsg3, BP180, BP230) if autoimmune bullous disease suspected 1, 3

Note: 28% of patients with recurrent aphthous ulceration have vitamin B1, B2, or B6 deficiency, and replacement therapy produces sustained clinical improvement only in deficient patients 5

Biopsy Indications

• Any solitary ulcer persisting beyond 2 weeks must be biopsied to exclude malignancy 3, 4
• Ulcers with atypical features (irregular borders, induration, lack of surrounding erythema) 3
• Recurrent ulcers not responding to standard therapy 1
• Include direct immunofluorescence for suspected autoimmune conditions 3

Systemic Therapy for Refractory Cases

Second-Line Options

• For ulcers unresponsive to topical therapy, administer intralesional triamcinolone injections weekly (total dose 28 mg) 1
• Prescribe systemic corticosteroids for highly symptomatic or severe recurrent ulcers: prednisone/prednisolone 30-60 mg (or 1 mg/kg) for 1 week, then taper over the second week 1, 6
• For pediatric patients, dose at 1-1.5 mg/kg/day up to maximum 60 mg 1

Third-Line Systemic Therapies

• Consider colchicine as first-line systemic therapy for recurrent aphthous stomatitis (≥4 episodes per year), especially effective when erythema nodosum or genital ulcers are present 1
• For resistant cases, consider azathioprine, interferon-alpha, or TNF-alpha inhibitors 1
• Thalidomide is effective but reserve only as alternative to oral corticosteroids due to toxicity and cost 6
• Apremilast may be considered in selected refractory cases 1

Disease-Specific Considerations

Behçet's Syndrome

• Start with topical corticosteroids for isolated oral ulcers 1
• Add colchicine for recurrent mucocutaneous involvement 1
• Progress to azathioprine, interferon-alpha, or TNF-alpha antagonists for refractory cases 1
• Sucralfate suspension has demonstrated RCT-proven efficacy for oral and genital ulcers 1

Inflammatory Bowel Disease

• Oral ulcers may indicate underlying Crohn's disease or ulcerative colitis 7, 4
• Investigate for abdominal pain, diarrhea, or other gastrointestinal symptoms 7
• Colonoscopy may be warranted if intestinal disease suspected 7
• Treatment of underlying IBD often resolves oral ulcers 7

Nutritional Deficiency

• Replace identified vitamin B1, B2, B6, B12, folate, or iron deficiencies 1, 4, 5
• Reassess after 1 month of replacement therapy and follow for 3 months 5

Critical Pitfalls to Avoid

• Never rely solely on topical treatments for persistent ulcers without establishing definitive diagnosis—this delays identification of malignancy or systemic disease 3, 4
• Do not taper corticosteroids prematurely before disease control is established 1
• Inadequate biopsy technique (too small or superficial) misses diagnostic features 3
• Overlooking medication history—NSAIDs commonly cause oral ulceration 4
• Failing to review dental appliances or identify mechanical trauma sources 3, 4, 8

Referral Criteria

Refer to oral medicine specialist for ulcers lasting more than 2 weeks, those not responding to 1-2 weeks of treatment, or cases with recurrent, severe, or atypical presentations 1, 3