What is the recommended treatment for a patient presenting with a canker sore?

Treatment for Canker Sores (Aphthous Ulcers)

For canker sores, start with topical corticosteroids (betamethasone sodium phosphate 0.5 mg dissolved in 10 mL water as a rinse-and-spit four times daily) combined with benzydamine hydrochloride oral rinse every 3 hours for pain relief. 1

First-Line Topical Therapy

Corticosteroid treatment:

• Betamethasone sodium phosphate 0.5 mg dissolved in 10 mL water used as a 3-minute rinse-and-spit preparation four times daily is the primary treatment 1
• For localized ulcers, apply clobetasol propionate 0.05% mixed in equal amounts with Orabase directly to affected areas daily 1
• Topical corticosteroids reduce severity but do not prevent recurrence 2

Mucoprotectant barrier:

• Apply Gelclair mucoprotectant gel three times daily to form a protective coating over ulcerated surfaces, reducing pain and promoting healing 1

Pain Management

Anti-inflammatory rinse:

• Benzydamine hydrochloride oral rinse or spray every 3 hours, particularly before eating 1

Topical anesthetics:

• Viscous lidocaine 2% applied up to 3-4 times daily for severe pain 1, 3
• Benzocaine-containing products (such as those FDA-approved for canker sores) temporarily relieve pain associated with mouth and gum irritations 4

Essential Supportive Measures

Oral hygiene:

• Clean the mouth daily with warm saline mouthwashes 1
• Use antiseptic oral rinses twice daily: either 1.5% hydrogen peroxide mouthwash or 0.2% chlorhexidine digluconate mouthwash 1, 3

Dietary modifications:

• Avoid hard, acidic, salty foods and toothpastes containing sodium lauryl sulfate 5
• Avoid alcohol and carbonated drinks 5

Treatment for Secondary Infections

If candidal infection is suspected (white coating, burning sensation):

• Nystatin oral suspension 100,000 units four times daily for 1 week 1, 3
• Alternatively, miconazole oral gel 5-10 mL held in mouth after food four times daily for 1 week 1, 3

Second-Line Treatments for Refractory Cases

When first-line topical treatments fail after 2 weeks:

• Tacrolimus 0.1% ointment applied twice daily for 4 weeks 1
• Intralesional triamcinolone injections in conjunction with topical clobetasol 1
• Systemic corticosteroids for highly symptomatic or recurrent ulcers (systemic corticosteroids completely suppress lesions) 1, 6
• Consider systemic colchicine, pentoxifylline, or prednisolone in severe cases 5

Treatment Algorithm Based on Severity

Mild (1-5 small ulcers, minimal pain):

• Start with mucoprotectant gel and benzydamine rinse 1
• Add topical anesthetic as needed 4

Moderate (multiple ulcers, significant pain affecting eating):

• Betamethasone rinse four times daily 1
• Benzydamine rinse every 3 hours 1
• Antiseptic mouthwash twice daily 1

Severe (large ulcers, severe pain, frequent recurrence):

• Clobetasol 0.05% with Orabase to individual lesions 1
• Consider systemic corticosteroids 5
• Evaluate for underlying systemic conditions (Behçet disease, celiac disease, nutritional deficiencies) 2, 5

Common Pitfalls to Avoid

• Do not use caustic agents like silver nitrate or phenol as first-line treatment, though they can stop lesion growth and pain 6
• Ensure proper diagnosis before treatment—differentiate from Behçet disease (which includes genital ulcers and eye disease) 2
• For recurrent cases, investigate underlying systemic conditions including gluten sensitivity, nutritional deficiencies, and immunologic disorders 2, 5
• Topical treatments only reduce severity; they do not cure or prevent recurrence 2