What is the management and treatment for canker sores (also known as aphthous ulcers)?

Management of Canker Sores (Aphthous Ulcers)

Start with topical corticosteroids as first-line therapy, specifically betamethasone sodium phosphate 0.5 mg dissolved in 10 mL water as a rinse-and-spit solution 2-4 times daily, combined with topical anesthetics for pain control. 1, 2, 3

First-Line Topical Therapy

Corticosteroids (Primary Treatment)

• Apply betamethasone sodium phosphate 0.5 mg in 10 mL water as a 3-minute rinse-and-spit preparation 2-4 times daily for multiple or widespread ulcers 1, 2, 3
• For localized ulcers on accessible areas (like the tongue), use clobetasol 0.05% ointment mixed in equal amounts with Orabase, applied twice weekly to dried mucosa 1, 2, 3
• Alternative option: fluticasone propionate nasules diluted in 10 mL water twice daily 2, 3

Pain Management (Essential Adjunct)

• Use benzydamine hydrochloride oral rinse or spray every 3 hours, particularly before eating 1, 2
• For inadequate pain control with benzydamine, apply viscous lidocaine 2% (15 mL per application) 3-4 times daily before meals 1, 2
• Apply barrier preparations like Gelclair or Gengigel three times daily for mucosal protection and additional pain relief 1, 2, 3

Supportive Oral Hygiene

• Clean the mouth daily with warm saline mouthwashes 1, 2
• Use antiseptic oral rinses twice daily: either 1.5% hydrogen peroxide mouthwash (10 mL) or 0.2% chlorhexidine digluconate mouthwash (10 mL), diluted by up to 50% if it causes soreness 1, 2
• Apply white soft paraffin ointment to lips every 2 hours if lips are affected 1

Second-Line Therapy for Refractory Cases

When Topical Steroids Fail After 1-2 Weeks

• Consider intralesional triamcinolone injections weekly (total dose 28 mg) in conjunction with topical clobetasol gel or ointment 0.05% 1, 3
• Alternative: tacrolimus 0.1% ointment applied twice daily for 4 weeks 2, 3

Systemic Therapy for Severe or Highly Symptomatic Cases

• Prescribe prednisone/prednisolone 30-60 mg (or 1 mg/kg) for 1 week, followed by tapering over the second week 1, 2, 3
• For recurrent aphthous stomatitis (≥4 episodes per year), colchicine is the preferred first-line systemic therapy, especially effective if the patient also has erythema nodosum or genital ulcers 1, 2
• For resistant cases not responding to colchicine, consider azathioprine, interferon-alpha, TNF-alpha inhibitors, or apremilast 1, 2

Critical Pitfalls to Avoid

• Do not taper corticosteroids prematurely before disease control is established 1
• Refer patients to a specialist if ulcers last more than 2 weeks or don't respond to 1-2 weeks of treatment 1
• Check for secondary infections: take oral swabs if bacterial or candidal infection is suspected 1
  • Treat candidal infections with nystatin oral suspension 100,000 units four times daily for 1 week, or miconazole oral gel 5-10 mL held in the mouth after food four times daily for 1 week 1, 2, 3
• Consider underlying systemic conditions (nutritional deficiencies, inflammatory bowel disease, Behçet's disease) in patients with recurrent ulcers 2, 4

Treatment Algorithm Summary

1. Start immediately: Topical corticosteroid (betamethasone rinse or clobetasol ointment) + topical anesthetic (benzydamine or lidocaine) + oral hygiene measures 1, 2, 3
2. If no improvement in 1-2 weeks: Add intralesional triamcinolone or switch to tacrolimus ointment 1, 2, 3
3. If highly symptomatic or recurrent (≥4 episodes/year): Systemic corticosteroids for acute flares, then colchicine for prevention 1, 2
4. If refractory to above: Consider immunosuppressive agents (azathioprine, biologics) 1, 2