Canker Sore Treatment
Start with topical corticosteroids as first-line therapy, specifically betamethasone sodium phosphate 0.5 mg dissolved in 10 mL water used as a rinse-and-spit solution four times daily, which is the primary recommendation from the American College of Physicians. 1
First-Line Treatment Approach
Topical Corticosteroids (Primary Therapy)
- Betamethasone sodium phosphate 0.5 mg in 10 mL water: Use as a 3-minute rinse-and-spit preparation four times daily 1, 2
- Fluticasone propionate: Dilute nasules in 10 mL water and use twice daily as an alternative 1
- Clobetasol 0.05% ointment: For localized ulcers, mix in equal amounts with Orabase and apply directly to dried mucosa twice weekly 1, 2
Pain Management (Use Concurrently)
- Benzydamine hydrochloride oral rinse or spray: Apply every 3 hours, particularly before eating 1, 2
- Viscous lidocaine 2%: Apply 3-4 times daily for more severe pain 1, 3
- Barrier preparations: Use Gelclair mucoprotectant gel three times daily to form a protective coating over ulcerated surfaces 2
Oral Hygiene Measures (Essential Adjunct)
- Warm saline mouthwashes: Clean the mouth daily to reduce bacterial colonization 1, 2
- Chlorhexidine digluconate 0.2% mouthwash: Use twice daily as an antiseptic rinse 1, 2
Second-Line Treatments for Refractory Cases
When first-line therapy fails after 1-2 weeks:
- Tacrolimus 0.1% ointment: Apply twice daily for 4 weeks 1, 2
- Intralesional triamcinolone injections: Combine with topical clobetasol for ulcers unresponsive to topical treatment alone 1, 2
Systemic Therapy for Severe or Recurrent Cases
Reserve for highly symptomatic or frequently recurring ulcers:
- Prednisone/prednisolone: Start with 30-60 mg (or 1 mg/kg) for 1 week, then taper over the second week 1
- Colchicine: Particularly effective for recurrent aphthous stomatitis, especially when associated with erythema nodosum or genital ulcers 1
- Immunosuppressive agents: Consider azathioprine, interferon-alpha, or TNF-alpha antagonists for resistant cases 1
Treatment of Secondary Infections
If candidal infection is suspected (white coating, burning sensation):
- 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
Critical Pitfalls to Avoid
- Do not prematurely taper corticosteroids before disease control is established 1
- Ensure proper diagnosis before initiating treatment, as other conditions (Behçet disease, herpes simplex, pemphigus) can mimic canker sores 1, 4
- Investigate underlying systemic conditions in patients with recurrent aphthous ulcers, including nutritional deficiencies (B12, folate, iron), celiac disease, or inflammatory bowel disease 1, 2