What is the best treatment approach for a patient with recurrent aphthous stomatitis?

Treatment of Recurrent Aphthous Stomatitis

For recurrent aphthous stomatitis, initiate treatment with non-alcoholic sodium bicarbonate mouthwash 4-6 times daily as foundational care, then escalate to topical high-potency corticosteroids (betamethasone sodium phosphate 0.5 mg in 10 mL water as rinse-and-spit 1-4 times daily) for moderate symptoms, reserving systemic corticosteroids (prednisone 30-60 mg daily for 1 week with taper) only for severe or recalcitrant cases. 1, 2

Foundational Management for All Patients

• Establish basic oral care with non-alcoholic mouthwashes containing sodium bicarbonate used 4-6 times daily to maintain oral pH and reduce inflammation. 1, 3
• Maintain good oral hygiene with gentle brushing using mild toothpaste to prevent secondary infections and reduce symptom severity. 1, 3
• Use 0.9% saline or sodium bicarbonate rinses (1 teaspoon salt with three-quarter teaspoon baking soda in 500 mL water) for symptomatic relief. 1, 3
• Apply barrier preparations such as Gengigel mouth rinse/gel or Gelclair for pain control. 1

Severity-Based Treatment Algorithm

Mild RAS (Small ulcers, minimal functional impairment)

• Continue sodium bicarbonate rinses 4-6 times daily as primary therapy. 1, 2
• Add topical anesthetics such as viscous lidocaine 2% applied before meals for pain control. 1, 2, 3
• Use anti-inflammatory oral rinses containing benzydamine hydrochloride every 3 hours, particularly before eating. 1, 2

Moderate RAS (Larger ulcers, difficulty eating/drinking)

• Increase sodium bicarbonate mouthwash frequency up to hourly if necessary. 1, 3
• Initiate topical high-potency corticosteroids as first-line therapy: betamethasone sodium phosphate 0.5 mg dissolved in 10 mL water as rinse-and-spit 1-4 times daily. 1, 3
• Alternative topical corticosteroid options include fluticasone propionate nasules diluted in 10 mL water twice daily or dexamethasone mouth rinse (0.1 mg/mL, 10 mL swish for 2 minutes then spit, four times daily). 1, 3
• For localized lesions, apply clobetasol 0.05% ointment mixed in 50% Orabase twice daily or clobetasol gel/ointment 0.05% applied twice daily. 1, 3
• Monitor response to topical corticosteroids; if no improvement after 2 weeks, escalate to systemic therapy. 2

Severe or Recalcitrant RAS (Multiple large ulcers, severe pain, inability to eat)

• Administer systemic corticosteroids: prednisone or prednisolone 30-60 mg (or 1 mg/kg) daily for 1 week, then taper over the second week. 1, 2, 3
• Consider intralesional triamcinolone injections (total dose 28 mg weekly) in conjunction with topical clobetasol gel/ointment for ulcers that fail to resolve. 1, 3
• For recalcitrant cases unresponsive to corticosteroids, use tacrolimus 0.1% ointment applied twice daily for 4 weeks as second-line therapy. 1
• Hospitalization is required for Grade 3-4 stomatitis with inability to maintain oral intake. 3

Critical Diagnostic Considerations Before Treatment

You must distinguish RAS from herpes labialis before initiating therapy, as corticosteroids potentiate HSV infection and should never be used for herpes, while antivirals are ineffective for aphthous ulcers. 2

• Herpes presents with vesicles that rupture into ulcers, often with prodromal tingling and possible systemic symptoms, whereas RAS presents as recurrent round, clearly defined ulcers without vesicles. 2, 4, 5
• If HSV is suspected, initiate antiviral treatment immediately (acyclovir 200-400 mg five times daily, valacyclovir 500 mg 2-3 times daily, or famciclovir 250 mg twice daily) and avoid corticosteroids entirely. 2
• Assess for nutritional deficiencies (iron, B vitamins) and gastrointestinal diseases, as treating these "correctable causes" can result in remission or substantial lessening of disease activity. 3, 4
• Treat any concurrent candidal infection with nystatin oral suspension or miconazole oral gel before initiating corticosteroid therapy. 1

Supportive Measures Throughout Treatment

• Instruct patients to consume soft, moist, non-irritating foods that are easy to chew and swallow. 1, 3
• Recommend drinking plenty of water and using lip balm for dry lips. 1, 3
• Suggest using ice chips or ice pops as needed to numb the mouth for temporary relief. 1, 3
• Consider sugarless chewing gum, candy, or salivary substitutes for oral dryness. 1, 3

Important Clinical Pitfalls to Avoid

• Never use alcoholic mouthwashes, as they aggravate mucosal irritation and worsen symptoms. 3
• Avoid topical trifluridine beyond 2 weeks due to epithelial toxicity if HSV is being treated. 2
• Do not use topical corticosteroids for HSV infection, as they potentiate viral replication. 2
• Recognize that inadequate pain control can lead to poor oral intake and treatment discontinuation; consider alternative routes (transdermal, intranasal) for severe cases. 3
• Be aware that systemic immunomodulatory agents (colchicine, pentoxifylline, dapsone, levamisol, thalidomide, azathioprine, methotrexate, cyclosporin A) are reserved for resistant cases of major RAS or aphthosis with systemic involvement, but evidence remains insufficient to support routine use. 6, 7

Special Considerations for Complex Cases

• Consider PFAPA syndrome (periodic fever, aphthous stomatitis, pharyngitis, and adenitis) as a modifying factor that may favor more aggressive treatment. 8
• Evaluate for Behçet's disease if patient presents with the triad of uveitis, aphthous stomatitis, and genital ulcers. 8, 4
• Assess for HIV disease in patients with aphthous-like oral ulcerations, as this represents a challenging differential diagnosis requiring different management. 4