What is the treatment for aphthous ulcers in the mouth?

Treatment for Aphthous Ulcers in the Mouth

Start with topical corticosteroid rinses as first-line therapy, specifically betamethasone sodium phosphate 0.5 mg dissolved in 10 mL water used as a rinse-and-spit solution 2-4 times daily, combined with pain control measures before meals. 1, 2

First-Line Topical Corticosteroid Options

Choose your topical steroid based on ulcer location and extent:

For multiple or widespread ulcers:

• Betamethasone sodium phosphate 0.5 mg in 10 mL water as rinse-and-spit 2-4 times daily 1, 2, 3
• Alternative: Dexamethasone mouth rinse (0.1 mg/ml) 1
• Alternative: Fluticasone propionate nasules diluted in 10 mL water twice daily 2, 3

For localized, accessible ulcers:

• Clobetasol 0.05% ointment mixed in 50% Orabase applied twice weekly to dried mucosa 1, 2, 3
• Alternative: Triamcinolone acetonide 0.1% paste applied directly to dried ulcer 2-4 times daily 1

Pain Management (Use Before Meals)

Combine corticosteroids with pain control for optimal symptom relief:

• Benzydamine hydrochloride rinse or spray every 3 hours, particularly before eating 1, 2
• Viscous lidocaine 2% applied 3-4 times daily for severe pain 1, 2
• Barrier preparations (Gelclair or Gengigel) three times daily for mucosal protection 1, 2, 3

Oral Hygiene Measures (Essential Adjunct)

• Warm saline mouthwashes daily to reduce bacterial colonization 1, 2
• Antiseptic rinses: 0.2% chlorhexidine digluconate mouthwash twice daily 1, 2

Second-Line Treatment for Non-Responsive Ulcers

If ulcers persist beyond 1-2 weeks or don't respond to topical therapy:

• Tacrolimus 0.1% ointment applied twice daily for 4 weeks 2, 3
• Intralesional triamcinolone injections weekly (total dose 28 mg) combined with topical clobetasol 1, 2, 3

Systemic Therapy for Severe or Recurrent Cases

For highly symptomatic ulcers or recurrent aphthous stomatitis (≥4 episodes per year):

• Prednisone/prednisolone 30-60 mg (or 1 mg/kg) for 1 week, then taper over the second week 1, 2, 3
• Colchicine as first-line systemic therapy for recurrent cases, especially effective if patient also has erythema nodosum or genital ulcers 1, 2, 4, 5

For refractory cases unresponsive to above measures:

• Consider azathioprine, interferon-alpha, or TNF-alpha antagonists 1, 2

When to Refer or Escalate

• Refer to specialist if ulcers last more than 2 weeks or don't respond to 1-2 weeks of treatment 1
• Biopsy any solitary chronic ulcer to rule out squamous cell carcinoma 4
• Perform blood tests (CBC, coagulation, fasting glucose, HIV, syphilis serology) before biopsy 1

Critical Pitfalls to Avoid

• Never taper corticosteroids prematurely before disease control is established 1, 2
• Avoid sodium lauryl sulfate-containing toothpastes, hard/acidic/salty foods, alcohol, and carbonated drinks 5
• Treat concurrent candidal infections with nystatin oral suspension 100,000 units four times daily for 1 week or miconazole oral gel 2, 3
• Consider underlying systemic conditions (celiac disease, inflammatory bowel disease, nutritional deficiencies, Behçet's disease) in patients with recurrent ulcers 1, 4

Special Consideration for Behçet's Disease

If Behçet's syndrome is suspected (recurrent oral and genital ulcers):

• Start with topical corticosteroids 1
• Add colchicine for recurrent mucocutaneous involvement 1
• Consider sucralfate suspension, which has demonstrated efficacy in RCT 1