What are the treatment options for canker sores?

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
• Azathioprine, interferon-alpha, or TNF-alpha antagonists: Consider for resistant cases that fail other systemic therapies 1

Treatment of Secondary Infections

If candidal infection is suspected (white coating, burning sensation):

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

Critical Pitfalls to Avoid

• Do not prematurely taper corticosteroids before disease control is established, as this leads to recurrence 1
• Ensure proper diagnosis before initiating treatment—distinguish aphthous ulcers from herpes simplex, Behçet disease, or other systemic conditions 2, 4
• Screen for underlying systemic conditions in patients with recurrent aphthous ulcers, including nutritional deficiencies, inflammatory bowel disease, or immunodeficiency states 1, 5
• Apply white soft paraffin ointment to lips every 2 hours if lips are affected to prevent cracking and secondary infection 2