What medications are used to treat aphthous ulcers in the mouth?

Medications for Aphthous Ulcers in the Mouth

Start with topical corticosteroid mouthwashes as first-line treatment: betamethasone sodium phosphate 0.5 mg dissolved in 10 mL of water used as a rinse-and-spit solution 1-4 times daily. 1

First-Line Topical Corticosteroids

The most effective initial approach uses potent topical corticosteroids applied directly to the ulcers:

• Betamethasone sodium phosphate mouthwash (0.5 mg in 10 mL water) as a 2-3 minute rinse-and-spit solution 1-4 times daily is the primary recommendation 1
• Fluticasone propionate nasules diluted in 10 mL of water twice daily serves as an alternative 1
• Clobetasol 0.05% ointment mixed in 50% Orabase applied twice weekly to localized lesions on dried mucosa for isolated ulcers 1
• Dexamethasone ointment applied 3 times daily after meals for 5 days has proven efficacy with 83% healing rates versus 55% with placebo 2

These topical corticosteroids should be tried before systemic medications due to minimal side effects and proven effectiveness. 3, 4

Pain Management

For symptomatic relief while the ulcers heal:

• Benzydamine hydrochloride oral rinse or spray every 2-4 hours provides anti-inflammatory and analgesic effects 5
• Barrier preparations such as Gengigel mouth rinse/gel or Gelclair protect ulcerated surfaces and control pain 1, 5
• Viscous lidocaine 2% can be used as a topical anesthetic when other measures provide inadequate pain control 5
• Follow the WHO pain management ladder for more severe pain 1

Supportive Care Measures

Essential adjunctive treatments include:

• Warm saline mouthwashes daily to reduce bacterial colonization and promote healing 5
• Chlorhexidine 0.2% mouthwash twice daily as an antiseptic to prevent secondary infection 5
• White soft paraffin ointment to the lips every 2 hours to prevent cracking 5
• Avoid sodium lauryl sulfate-containing toothpastes, hard/acidic/salty foods, alcohol, and carbonated drinks 3

Second-Line Treatments for Resistant Cases

When topical corticosteroids fail after appropriate trial:

• Tacrolimus 0.1% ointment applied twice daily for 4 weeks for recalcitrant ulcers 1
• Intralesional triamcinolone (total dose 28 mg weekly) combined with topical clobetasol gel 0.05% for persistent ulcers 1
• Colchicine is particularly effective for recurrent aphthous stomatitis, especially when associated with Behçet disease 6, 7

Systemic Therapy for Severe or Recurrent Disease

Reserve systemic medications for highly symptomatic or frequently recurrent ulcers:

• Systemic corticosteroids: High-dose pulse 30-60 mg or 1 mg/kg oral prednisone/prednisolone for 1 week, followed by dose tapering over the second week 1
• Colchicine combined with topical treatments for recurrent aphthous stomatitis 6, 7
• Azathioprine 2.5 mg/kg/day for severe cases with frequent recurrences 6
• Thalidomide is the most effective treatment for recurrent aphthous stomatitis but use is limited by teratogenicity and peripheral neuropathy risks 6, 7

Critical Pitfall to Avoid

Always treat concurrent candidal infections with nystatin oral suspension or miconazole oral gel, as fungal superinfection commonly develops with prolonged ulceration or corticosteroid use. 1, 5 Failure to address candidiasis will result in treatment failure and prolonged symptoms.

Treatment Algorithm

1. Mild, isolated ulcers: Start with topical corticosteroid mouthwash (betamethasone) + pain control (benzydamine) + supportive care 1, 5
2. Moderate or localized ulcers: Add clobetasol ointment to specific lesions 1
3. Resistant ulcers after 2 weeks: Switch to tacrolimus 0.1% ointment or add intralesional triamcinolone 1
4. Severe or highly symptomatic: Add systemic corticosteroids (prednisone 30-60 mg) 1
5. Recurrent aphthous stomatitis (≥4 episodes/year): Add colchicine or azathioprine for prophylaxis 6, 7