What is the best management approach for a patient with aphthous stomatitis?

Management of Aphthous Stomatitis

Start all patients with non-alcoholic sodium bicarbonate mouthwash 4-6 times daily as foundational therapy, then escalate treatment based on severity using topical corticosteroids for moderate disease and systemic corticosteroids for severe or recalcitrant cases. 1

Initial Assessment and Foundational Care

Before initiating any treatment, you must distinguish aphthous stomatitis from oral herpes, as this distinction is critical—corticosteroids will potentiate HSV infection and should never be used for herpes, while antivirals are ineffective for aphthous ulcers. 2 Oral herpes presents with vesicles that rupture into ulcers, often with prodromal tingling and possible systemic symptoms, whereas aphthous ulcers appear as round, clearly defined painful ulcers without vesicles. 2, 3

Additionally, assess for correctable causes before diagnosing idiopathic RAS:

• Nutritional deficiencies (iron, folate, B vitamins) 4, 5
• Gastrointestinal diseases (celiac disease, inflammatory bowel disease) 5, 6
• Behçet's disease (triad of uveitis, aphthous stomatitis, and genital ulcers) 1
• PFAPA syndrome in recurrent cases 1

All patients should begin with:

• Non-alcoholic sodium bicarbonate mouthwash 4-6 times daily 1, 2
• Good oral hygiene with gentle brushing 2
• Soft, moist, non-irritating foods that are easy to chew and swallow 1, 4
• Adequate hydration and lip balm for dry lips 1, 4

Severity-Based Treatment Algorithm

Mild Aphthous Stomatitis

For mild symptoms with small ulcers (<5mm) that typically heal in 10-14 days: 3

• Continue sodium bicarbonate rinses 4-6 times daily 1, 2
• Add topical anesthetics: viscous lidocaine 2% applied before meals for pain control 1, 2
• Consider benzydamine hydrochloride rinse every 3 hours, particularly before eating 1, 2
• Barrier preparations such as Gengigel mouth rinse/gel or Gelclair can help with pain control 1
• Ice chips or ice pops as needed to numb the mouth 1, 4

Moderate Aphthous Stomatitis

For larger ulcers (>5mm) or multiple lesions causing significant pain:

• Increase sodium bicarbonate mouthwash frequency up to hourly if necessary 1, 2
• Initiate topical high-potency corticosteroids as first-line therapy: 1, 2
  • Betamethasone sodium phosphate 0.5 mg dissolved in 10 mL water as rinse-and-spit 1-4 times daily 1
  • OR fluticasone propionate nasules diluted in 10 mL water twice daily 1
  • OR clobetasol 0.05% ointment mixed in 50% Orabase applied twice daily to localized lesions 1
  • OR dexamethasone mouth rinse (0.1 mg/mL), 10 mL swish for 2 minutes then spit, four times daily 4
• Add topical NSAIDs: amlexanox 5% oral paste if NSAIDs are tolerated 4
• Monitor response after 2 weeks; if no improvement, escalate to systemic therapy 2

Severe or Recalcitrant Aphthous Stomatitis

For major aphthous ulcers (>5mm) lasting 6 weeks or longer, scarring lesions, or failure of topical therapy: 3

• Systemic corticosteroids are necessary: prednisone 30-60 mg or 1 mg/kg daily for 1 week, then taper over the second week 1, 2, 4
• For non-resolving ulcers: intralesional triamcinolone injections (total dose 28 mg weekly) in conjunction with topical clobetasol 0.05% gel/ointment 1, 2
• Second-line for resistant cases: tacrolimus 0.1% ointment applied twice daily for 4 weeks 1
• Hospitalization is required for Grade 3-4 stomatitis with inability to maintain oral intake 4

Critical Pitfalls to Avoid

Never use topical corticosteroids if there is any suspicion of HSV infection, as they will potentiate the viral infection. 2 If uncertain, treat as HSV with antivirals (acyclovir 200-400 mg five times daily, valacyclovir 500 mg 2-3 times daily, or famciclovir 250 mg twice daily) until diagnosis is confirmed. 2

Avoid alcoholic mouthwashes, as they aggravate mucosal irritation and worsen symptoms. 4 Always use non-alcoholic formulations. 1, 2

Treat any concurrent candidal infection with nystatin oral suspension or miconazole oral gel, as fungal superinfection can complicate aphthous stomatitis. 1

For inadequate pain control, consider alternative routes (transdermal, intranasal) such as fentanyl 50 μg nasal spray for short-term relief before meals in patients already on opioid therapy. 4

Special Considerations

Topical corticosteroids reduce pain and improve healing time but do not improve recurrence or remission rates—this is palliative therapy, not curative. 7 For patients with frequent recurrences (≥4 times per year), colchicine associated with topical treatments constitutes suitable long-term management. 6 Thalidomide is the most effective treatment for recurrent aphthous stomatitis but its use is limited by frequent adverse effects. 6