Management of Oral Ulceration
Begin treatment immediately with high-potency topical corticosteroids (clobetasol 0.05% gel for localized lesions or betamethasone sodium phosphate 0.5 mg in 10 mL water as rinse-and-spit four times daily for widespread ulcers), combined with topical anesthetics and barrier agents for pain control. 1, 2, 3
Immediate First-Line Therapy
Topical Corticosteroids (Primary Treatment)
- For localized, accessible ulcers: Apply clobetasol 0.05% ointment mixed in 50% Orabase directly to dried mucosa twice daily 1, 2, 3
- For multiple or widespread ulcers: Use betamethasone sodium phosphate 0.5 mg dissolved in 10 mL water as a 2-3 minute rinse-and-spit solution four times daily 1, 2, 3
- Alternative option: Fluticasone propionate nasules diluted in 10 mL water twice daily 2, 3
Pain Management (Essential Concurrent Therapy)
- Apply viscous lidocaine 2% (15 mL per application) up to 3-4 times daily before meals for severe pain 1, 3
- Use benzydamine hydrochloride rinse or spray every 3 hours, particularly before eating 1, 3
- Apply mucoprotectant gel (Gelclair) three times daily to form protective barrier over ulcerated surfaces 1, 2, 3
Oral Hygiene Protocol
- Perform daily warm saline mouthwashes to reduce bacterial colonization 1, 3
- Use 0.2% chlorhexidine digluconate mouthwash twice daily as antiseptic rinse 1, 3
- Avoid crunchy, spicy, acidic foods and hot beverages during healing 3
Second-Line Management for Non-Responsive Ulcers (After 1-2 Weeks)
Intralesional Therapy
- Administer intralesional triamcinolone injections weekly (total dose 28 mg) in conjunction with topical clobetasol for persistent ulcers 1, 2
Alternative Topical Agent
Systemic Corticosteroids (For 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
- Critical pitfall: Do not taper prematurely before disease control is established 1
Third-Line Therapy for Recurrent Ulcers (≥4 Episodes Per Year)
- Start colchicine as first-line systemic therapy, especially effective when erythema nodosum or genital ulcers are present 1
- Consider azathioprine, interferon-alpha, TNF-alpha inhibitors, or apremilast for resistant cases 1
Mandatory Investigations for Persistent Ulcers
Refer to specialist and perform biopsy for any ulcer lasting more than 2 weeks or not responding to 1-2 weeks of treatment. 1, 3, 4
Pre-Biopsy Blood Work
- Full blood count (rule out leukemia, anemia, neutropenia) 1, 3
- Fasting blood glucose (identify diabetes predisposing to fungal infections) 1, 3
- HIV antibody and syphilis serology if risk factors present 1, 3
- Coagulation studies to exclude contraindications to biopsy 1
Treatment of Secondary Infections
Candidal Infection (If Suspected)
- Nystatin oral suspension 100,000 units four times daily for 1 week 3
- OR miconazole oral gel 5-10 mL held in mouth after food four times daily for 1 week 3
- Critical consideration: Hyperglycemia is an important predisposing factor for invasive fungal infections presenting as oral ulcers 3
Critical Red Flags Requiring Immediate Specialist Referral
- Ulcer persists beyond 3 weeks despite appropriate treatment 3
- Multiple sites with different morphological characteristics 3
- Systemic symptoms present (fever, weight loss, malaise) 3
- Solitary chronic ulcer (must rule out squamous cell carcinoma) 5, 4
- Oral ulcers may be first manifestation of Crohn's disease, Behçet's disease, or hematologic malignancies 3
Diagnostic Framework Based on Duration
The 2022 International Journal of Oral Science consensus guideline emphasizes that oral ulceration complexity requires systematic evaluation based on detailed clinical history, histopathological examination when indicated, and screening for ulceration-related systemic diseases 6. The diversity ranges from simple traumatic ulcers (corresponding to sharp edges, thermal burns, chemical injury) to complex cases associated with autoimmune disease, inflammatory bowel disease, or malignancy 6.