What is the recommended treatment for a typical adult patient with canker sores?

Treatment of Canker Sores (Aphthous Ulcers)

For typical adult patients with canker sores, start with topical corticosteroids as first-line therapy: betamethasone sodium phosphate 0.5 mg dissolved in 10 mL of water as a rinse-and-spit solution 1-4 times daily, or clobetasol 0.05% ointment mixed in 50% Orabase applied twice daily to localized lesions on dried mucosa. 1

First-Line Treatment Algorithm

Topical Corticosteroids (Primary Treatment)

• Betamethasone sodium phosphate 0.5 mg dissolved in 10 mL water, used as a 2-3 minute rinse-and-spit solution 1-4 times daily 1
• Clobetasol 0.05% ointment mixed in 50% Orabase, applied twice weekly to localized lesions on dried mucosa 1
• Fluticasone propionate nasules diluted in 10 mL water twice daily as an alternative 1
• Apply topical corticosteroids four times daily for inflammatory conditions 2, 3

Supportive Care (Concurrent with Corticosteroids)

• Apply white soft paraffin ointment to affected areas every 2 hours for protection and moisturization 2, 3
• Clean mouth daily with warm saline mouthwashes to reduce bacterial load 2, 3
• Use barrier preparations such as Gengigel mouth rinse/gel or Gelclair for additional pain control 1

Pain Management

• Use benzydamine hydrochloride anti-inflammatory oral rinse or spray every 2-4 hours, particularly before eating 2
• For inadequate pain control, consider topical anesthetic preparations such as viscous lidocaine 2% 2
• Benzocaine-containing products provide anesthetic relief, though duration varies by formulation 4
• Follow the WHO pain management ladder for more severe pain 1

Critical Pitfall: Avoid alcohol-containing mouthwashes, which cause additional pain and irritation 2, 3

Second-Line Treatments (If First-Line Fails After 2 Weeks)

For Recalcitrant Ulcers

• Tacrolimus 0.1% ointment applied twice daily for 4 weeks 1
• Weekly intralesional triamcinolone (total dose 28 mg) in conjunction with topical clobetasol gel or ointment (0.05%) for ulcers that don't resolve with topical treatment 1

Systemic Therapy for Severe/Recurrent Cases

• High-dose pulse corticosteroids: 30-60 mg or 1 mg/kg oral prednisone/prednisolone for 1 week, followed by dose tapering over the second week 1
• This is reserved for highly symptomatic or recurrent ulcers that fail topical therapy 1

Special Considerations

Concurrent Infections

• If candidal infection is present concurrently, treat with nystatin oral suspension or miconazole oral gel 2, 1
• For suspected bacterial infection, use 0.2% chlorhexidine digluconate mouthwash twice daily 2, 3

Immunocompromised Patients

• May require more aggressive and prolonged therapy than standard protocols 2, 3
• Consider earlier escalation to systemic corticosteroids if topical therapy inadequate 1

Treatment Response Evaluation

• Evaluate treatment response within 2 weeks 2
• If no improvement, reevaluate diagnosis or consider alternative treatments 2
• Pain and ulcer size should reduce considerably by day 3, with continued improvement through day 10 5

Alternative/Adjunctive Therapies

Low-Level Laser Therapy

• Single application on three alternate days shows significant reduction in pain and erythema by day 3 compared to triamcinolone alone 5
• Complete ulcer healing typically achieved by day 10 5

Mucoadhesive Tablets

• Tablets containing citrus oil and magnesium salts that adhere to mucosal tissue and gradually erode over 8 hours can reduce pain and decrease healing time 6

Prevention Strategies

• Avoid frequent washing with hot water 2
• Avoid skin irritants such as over-the-counter anti-acne medications, solvents, or disinfectants 2
• Use alcohol-free moisturizing creams or ointments twice daily 2

Important Note: The diagnosis of recurrent aphthous stomatitis is made on clinical grounds alone and must be differentiated from other causes of recurrent ulceration, particularly Behçet disease, which presents with aphthous-like ulcers associated with genital ulceration and eye disease 7