Treatment of Mouth Ulcers in Adults
For simple mouth ulcers in adults without underlying conditions, start with topical corticosteroid rinses (betamethasone sodium phosphate 0.5 mg in 10 mL water as rinse-and-spit 2-4 times daily) combined with pain control measures, progressing to more potent topical agents or systemic therapy only if ulcers persist beyond 2 weeks or are highly symptomatic. 1, 2
First-Line Topical Therapy
Corticosteroid Options
- Betamethasone sodium phosphate 0.5 mg dissolved in 10 mL water used as a 2-3 minute rinse-and-spit solution 2-4 times daily is the primary recommendation for widespread or multiple ulcers 1, 3
- Fluticasone propionate nasules diluted in 10 mL water twice daily serves as an alternative corticosteroid rinse 1, 3
- Clobetasol 0.05% ointment mixed in 50% Orabase applied twice weekly to dried mucosa for localized lesions provides more potent topical therapy 1, 2, 3
Pain Management
- Benzydamine hydrochloride oral rinse or spray every 3 hours, particularly before eating, provides anti-inflammatory pain relief 4, 2, 3
- Viscous lidocaine 2% applied 3-4 times daily for more severe pain 2, 3
- Barrier preparations such as Gelclair or Gengigel mouth rinse/gel three times daily protect ulcerated surfaces and reduce pain 1, 2, 3
- Benzocaine topical can be applied up to 4 times daily using an applicator tip 5
Supportive Oral Hygiene
- Clean the mouth daily with warm saline mouthwashes to reduce bacterial colonization 4, 2, 3
- Antiseptic oral rinses twice daily using either 0.2% chlorhexidine digluconate or 1.5% hydrogen peroxide mouthwash 4, 2, 3
- White soft paraffin ointment to lips every 2 hours for lip involvement 4, 2
Second-Line Therapy for Refractory Ulcers
When ulcers persist beyond 1-2 weeks despite first-line therapy:
- Tacrolimus 0.1% ointment applied twice daily for 4 weeks for recalcitrant ulcers 1, 2, 3
- Intralesional triamcinolone injections weekly (total dose 28 mg) in conjunction with topical clobetasol for persistent localized ulcers 1, 2, 3
Systemic Therapy for Severe or Recurrent Cases
Reserve systemic therapy for highly symptomatic ulcers or recurrent aphthous stomatitis (≥4 episodes per year):
- Systemic corticosteroids: Prednisone/prednisolone 30-60 mg or 1 mg/kg for 1 week with tapering over the second week for highly symptomatic cases 1, 2, 3
- Colchicine as first-line systemic therapy for recurrent aphthous stomatitis, especially effective when associated with erythema nodosum or genital ulcers 2, 3
- Azathioprine, interferon-alpha, or TNF-alpha antagonists for resistant cases unresponsive to other measures 2, 3
Treatment of Secondary Infections
If candidal infection is suspected (slow healing, white patches):
- Nystatin oral suspension 100,000 units four times daily for 1 week 4, 3
- Miconazole oral gel 5-10 mL held in the mouth after food four times daily for 1 week as an alternative 4, 3
Critical Pitfalls to Avoid
- Do not taper corticosteroids prematurely before disease control is established 2, 3
- Refer to a specialist for ulcers lasting more than 2 weeks or not responding to 1-2 weeks of treatment, as biopsy may be needed to rule out malignancy 2
- Consider underlying systemic conditions (celiac disease, inflammatory bowel disease, nutritional deficiencies, Behçet's disease) in patients with recurrent ulcers 6, 7
- Review medication history as certain drugs (NSAIDs, ACE inhibitors, methotrexate, azathioprine) can cause oral ulceration 8
Treatment Algorithm Summary
- Start with topical corticosteroid rinses + pain control for all simple ulcers 1, 2
- Add oral hygiene measures (saline rinses, antiseptic mouthwashes) 2, 3
- Escalate to potent topical agents (clobetasol, tacrolimus) if no improvement in 1-2 weeks 1, 2
- Consider intralesional steroids for persistent localized ulcers 1, 2
- Use systemic therapy only for highly symptomatic or recurrent cases (≥4 episodes/year) 2, 3
- Refer for biopsy if ulcers persist beyond 2 weeks despite treatment 2