What is the treatment for mouth ulcers?

Treatment of Mouth Ulcers

Start with topical corticosteroids as first-line therapy: betamethasone sodium phosphate 0.5 mg dissolved in 10 mL water used as a rinse-and-spit solution four times daily. 1, 2, 3

Algorithmic Treatment Approach

Step 1: First-Line Topical Therapy

For widespread or multiple ulcers:

• Betamethasone sodium phosphate 0.5 mg in 10 mL water, rinse for 2-3 minutes and spit, four times daily 1, 2, 3
• Alternative: Fluticasone propionate nasules diluted in 10 mL water twice daily 2, 3

For localized, easily accessible ulcers:

• Clobetasol propionate 0.05% ointment mixed in equal amounts with Orabase, applied directly to dried mucosa twice weekly 1, 2, 3

Step 2: Pain Management (Use Concurrently)

Immediate pain relief:

• Benzydamine hydrochloride oral rinse or spray every 3 hours, especially before eating 1, 2, 3
• For severe pain: Viscous lidocaine 2% applied 3-4 times daily (15 mL per application) 2, 3

Protective barrier formation:

• Gelclair mucoprotectant gel applied three times daily to coat ulcerated surfaces and reduce pain 1, 3
• White soft paraffin ointment to lips every 2 hours if affected 1

Step 3: Oral Hygiene Measures (Essential for All Cases)

• Warm saline mouthwashes daily to reduce bacterial colonization 1, 2, 3
• Chlorhexidine digluconate 0.2% mouthwash twice daily as antiseptic rinse 1, 2, 3
• Alternatively: Hydrogen peroxide 1.5% mouthwash 1
• Avoid crunchy, spicy, acidic foods and hot beverages during healing 3

Step 4: Treat Secondary Infections if Present

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

• Nystatin oral suspension 100,000 units four times daily for 1 week 1, 2, 3
• OR Miconazole oral gel 5-10 mL held in mouth after food four times daily for 1 week 1, 2, 3

Note: Hyperglycemia predisposes to invasive fungal infections presenting as oral ulcers, so check fasting glucose if recurrent candidal infections occur 3

Step 5: Second-Line Treatments for Refractory Cases (No Response After 2 Weeks)

Escalate topical therapy:

• Tacrolimus 0.1% ointment applied twice daily for 4 weeks 1, 2, 3
• Intralesional triamcinolone injections (28 mg total dose weekly) combined with topical clobetasol 4, 1, 2

Step 6: Systemic Therapy for Severe or Highly Symptomatic Cases

When topical therapy fails and quality of life is significantly impacted:

• Oral prednisone/prednisolone 30-60 mg (or 1 mg/kg) for 1 week, then taper over the second week 4, 2, 3
• For recurrent aphthous stomatitis with erythema nodosum or genital ulcers: Colchicine 2, 5
• Alternative systemic options: Pentoxifylline 5
• For resistant cases: Consider azathioprine, interferon-alpha, or TNF-alpha antagonists 2

Critical Red Flags Requiring Further Investigation

Obtain blood work and consider biopsy if:

• Ulcers persist beyond 3 weeks despite appropriate treatment 3
• Multiple sites with different morphological characteristics 3
• Systemic symptoms present (fever, weight loss, malaise) 3

Essential investigations:

• Full blood count to rule out leukemia or anemia 3
• Fasting blood glucose for diabetes screening 3
• HIV antibody and syphilis serology if risk factors present 3

Common Pitfalls to Avoid

• Don't assume all mouth ulcers are benign aphthous ulcers - solitary ulcers may represent squamous cell carcinoma and require biopsy if persistent 6
• Don't prematurely taper corticosteroids before disease control is established 2
• Don't overlook systemic diseases - oral ulcers may be the first manifestation of Crohn's disease, Behçet's disease, or hematologic malignancies 3, 6
• Don't forget that both viral (herpes simplex) and fungal (Candida) infections can contribute to oral ulceration, especially in immunocompromised patients 7
• Avoid sodium lauryl sulfate-containing toothpastes, alcohol, and carbonated drinks as these can exacerbate ulcers 5