What is the management approach for oral ulcers?

Management of Oral Ulcers

Begin with topical corticosteroids as first-line therapy for oral ulcers, selecting the formulation based on ulcer location and extent, followed by systemic therapies only for refractory cases. 1

First-Line Topical Therapy

For Localized, Accessible Ulcers

• Apply clobetasol gel or ointment 0.05% directly to dried ulcer 2-4 times daily 1
• Alternatively, use triamcinolone acetonide 0.1% paste applied directly to dried ulcer 2-4 times daily 1
• For more severe localized ulcers, apply clobetasol 0.05% ointment mixed in 50% Orabase twice weekly to dried mucosa 1

For Multiple or Widespread Ulcers

• Use dexamethasone mouth rinse 0.1 mg/ml as rinse-and-spit solution 2-4 times daily 1
• Alternatively, dissolve betamethasone sodium phosphate 0.5 mg in 10 ml water and use as rinse-and-spit preparation four times daily 1

Pain Control Measures (Essential Adjuncts)

• Apply viscous lidocaine 2% topical anesthetic mouthwash before meals 1
• Use benzydamine hydrochloride rinse or spray every 3 hours, particularly before eating 1
• For severe pain, apply amlexanox 5% oral paste (topical NSAID) 1
• Apply white soft paraffin ointment to lips every 2 hours 1

Mucoprotection and Oral Hygiene

• Apply mucoprotectant mouthwashes (e.g., Gelclair or Gengigel) three times daily 1
• Clean mouth daily with warm saline mouthwashes 1
• Use antiseptic oral rinses twice daily (1.5% hydrogen peroxide or 0.2% chlorhexidine digluconate) 1
• For dry mouth, recommend sugarless chewing gum, candy, or salivary substitutes 1

Second-Line Therapy for Refractory Cases

Intralesional Steroids

• Administer intralesional triamcinolone injections weekly (total dose 28 mg) for persistent ulcers not responding to topical therapy 1

Systemic Corticosteroids

• Prescribe prednisone/prednisolone 30-60 mg (or 1 mg/kg) for 1 week with tapering over the second week for highly symptomatic or recurrent ulcers 1
• For children, dose at 1-1.5 mg/kg/day up to maximum 60 mg for severe cases 1
• Critical pitfall to avoid: Never taper corticosteroids prematurely before disease control is established 1

Alternative Second-Line Agent

• Consider tacrolimus 0.1% ointment applied twice daily for 4 weeks as an alternative to triamcinolone 1

Management of Recurrent Aphthous Stomatitis (≥4 Episodes Per Year)

• Use colchicine as first-line systemic therapy, especially effective when erythema nodosum or genital ulcers are present 1
• For resistant cases, consider azathioprine, interferon-alpha, TNF-alpha inhibitors, or apremilast 1

Special 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 efficacy in randomized controlled trials for oral and genital ulcers 1

Stevens-Johnson Syndrome/Toxic Epidermal Necrolysis

• Implement aggressive topical measures including steroids, anesthetics, and antiseptics 1
• Consider systemic therapy for severe cases 1

Ulcerated Infantile Hemangiomas

• Manage with barrier dressings, pain control (acetaminophen and cautious use of topical 2.5% lidocaine), and control of hemangioma growth 1
• Consider propranolol therapy 1

When to Escalate Care

Mandatory Specialist Referral Criteria

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

Pre-Biopsy Workup (Before Referral)

• Obtain full blood count to detect anemia, leukemia, or other blood disorders 2, 3
• Check coagulation studies and fasting blood glucose 2, 3
• Order HIV antibody and syphilis serology 2, 3
• Test serum antibodies (Dsg1, Dsg3, BP180, BP230) if bullous disease suspected 2, 3

Critical Pitfalls to Avoid

• Never rely solely on topical treatments for persistent ulcers without establishing definitive diagnosis, as this delays identification of malignancy or systemic disease that directly impacts mortality and morbidity 3
• Avoid ciclosporine A in patients with neurological involvement due to neurotoxicity risk 1
• Do not perform inadequate biopsy technique (too small or superficial) as this misses diagnostic features 2
• Do not overlook systemic causes, which leads to delayed diagnosis and inappropriate management 2