What are the treatment options for oral ulcers?

Treatment of Oral Ulcers

Start with topical corticosteroids as first-line therapy for all oral ulcers, selecting the formulation based on ulcer location and extent, combined with pain control measures and oral hygiene, escalating to systemic therapy only for refractory or severe recurrent cases. 1, 2

First-Line Topical Corticosteroid Therapy

The choice of corticosteroid formulation depends on ulcer location and distribution:

For localized, accessible ulcers:

• Apply clobetasol 0.05% gel or ointment directly to the dried ulcer 2-4 times daily 1, 2
• Alternatively, use triamcinolone acetonide 0.1% paste applied to dried ulcer 2-4 times daily 1, 2

For multiple or widespread ulcers:

• Use betamethasone sodium phosphate 0.5 mg dissolved in 10 mL water as a rinse-and-spit solution 4 times daily 1, 2, 3
• Dexamethasone mouth rinse (0.1 mg/mL) serves as an alternative 1, 2

Pain Management (Essential Adjunct)

Pain control should be initiated simultaneously with corticosteroids:

• Apply viscous lidocaine 2% topically 3-4 times daily, particularly before meals 1, 2, 3
• Use benzydamine hydrochloride rinse or spray every 3 hours, especially before eating 1, 2, 3
• Consider amlexanox 5% oral paste (topical NSAID) for severe pain 1, 2

Barrier Protection and Oral Hygiene

These measures reduce bacterial colonization and protect ulcerated mucosa:

• Apply mucoprotectant mouthwashes (Gelclair or Gengigel) 3 times daily 1, 2, 3
• Rinse with warm saline mouthwashes daily 1, 2, 3
• Use 0.2% chlorhexidine digluconate mouthwash twice daily as antiseptic rinse 1, 2, 3

Second-Line Therapy for Refractory Cases (After 1-2 Weeks)

If topical therapy fails after 1-2 weeks of treatment:

• Inject intralesional triamcinolone weekly (total dose up to 28 mg) for persistent localized ulcers 1, 2, 3
• Consider tacrolimus 0.1% ointment applied twice daily for 4 weeks for recalcitrant ulcers 1, 2, 3

Systemic Therapy for Severe or Recurrent Cases

For recurrent aphthous stomatitis (≥4 episodes per year):

• Colchicine is the preferred first-line systemic therapy, particularly effective for patients with erythema nodosum or genital ulcers 1, 2, 3, 4

For highly symptomatic or severe cases:

• Use prednisone/prednisolone 30-60 mg (or 1 mg/kg) for 1 week, then taper over the second week 1, 2, 3
• In pediatric patients, dose at 1-1.5 mg/kg/day up to maximum 60 mg 1

For resistant cases:

• Consider azathioprine, interferon-alpha, or TNF-alpha antagonists 1, 2, 3

Critical Pitfalls to Avoid

• Never taper corticosteroids prematurely before disease control is established 1
• Avoid ciclosporine A in patients with neurological involvement due to neurotoxicity risk 1
• Stop benzocaine use if symptoms do not improve in 7 days or if irritation, pain, or redness persists or worsens 5

When to Refer or Investigate Further

Mandatory referral and biopsy indications:

• Any ulcer persisting >2 weeks despite treatment requires specialist referral 1, 2
• Biopsy is mandatory for ulcers lasting >2 weeks to rule out malignancy 1, 2

Workup for recurrent ulcers:

• Obtain complete blood count, coagulation studies, fasting blood glucose 1
• Check nutritional studies (iron, folate, B12) and celiac serology 2
• Consider HIV antibody and syphilis serology 1

Special Considerations for Behçet's Disease

If Behçet's syndrome is diagnosed:

• Start with topical corticosteroids for isolated oral ulcers 1
• Add colchicine for recurrent mucocutaneous involvement 1, 3
• Progress to azathioprine, interferon-alpha, or TNF-alpha antagonists for refractory cases 1, 3
• Sucralfate suspension has demonstrated efficacy in randomized controlled trials 1

Dietary and Lifestyle Modifications

• Avoid hard, acidic, salty foods and toothpastes containing sodium lauryl sulfate 4
• Avoid alcohol and carbonated drinks 4