How should a bleeding oral ulcer be treated?

Treatment of Bleeding Oral Ulcers

For a bleeding mouth sore (oral ulcer), apply direct pressure with gauze, use topical anesthetics for pain control, and initiate topical corticosteroids if the ulcer is non-infectious; avoid acidic/salty foods and sodium lauryl sulfate-containing toothpastes. 1

Immediate Hemostasis

• Apply direct pressure with clean gauze or cotton to the bleeding site for 5-10 minutes to achieve mechanical hemostasis—this is the critical first step for any actively bleeding oral lesion 1
• Avoid disturbing the clot once formed, as premature disruption increases rebleeding risk 1

First-Line Topical Management

• Start with topical anesthetics (lidocaine gel or viscous lidocaine) for immediate pain relief, which should be applied 15-20 minutes before meals to enable eating 1
• Apply topical antiseptic agents (triclosan) or anti-inflammatory agents (diclofenac gel) directly to the ulcer 2-3 times daily after meals 1
• If antiseptics and local anesthetics are ineffective after 3-5 days, escalate to topical corticosteroids (triamcinolone acetonide 0.1% in orabase or betamethasone mouthwash) applied directly to the ulcer 2-4 times daily 1

Dietary and Environmental Modifications

• Immediately eliminate hard, acidic, salty foods, alcohol, and carbonated drinks as these mechanically irritate the ulcer and delay healing 1
• Switch to a toothpaste without sodium lauryl sulfate, as this detergent prolongs ulcer duration and increases recurrence frequency 1

When to Escalate Treatment

• For severe pain or large ulcers (>1 cm) not responding to topical therapy within 7-10 days, consider systemic treatment with colchicine (0.5-1.5 mg daily) or pentoxifylline 1
• Any solitary oral ulcer persisting beyond 2-3 weeks requires biopsy to rule out squamous cell carcinoma, particularly in patients over 40 years or with tobacco/alcohol use 2

Critical Pitfalls to Avoid

• Never assume all oral ulcers are benign aphthous ulcers—drug-induced ulcers (from NSAIDs, ACE inhibitors, methotrexate, nicorandil) present as solitary lesions that resist conventional treatment and only heal after stopping the offending medication 3
• Do not use systemic immunosuppressants (azathioprine, thalidomide) for simple recurrent aphthous ulcers—reserve these only for refractory cases or Behçet's disease due to significant adverse effects 1
• Oral ulcers with symptoms of burning mouth, metallic taste, or taste disturbances strongly suggest a pharmacological origin—review all medications, especially recent additions 3

Adjunctive Therapies for Recurrent Ulcers

• For patients with frequent recurrences (≥4 episodes per year), consider mecobalamin (vitamin B12) 500 mcg three times daily plus vitamin E 100 mg daily, which significantly reduces ulcer number, shortens healing time (mean 4.2 vs 6.8 days), and prolongs remission intervals 4
• Screen for underlying conditions: celiac disease (anti-tissue transglutaminase antibodies), inflammatory bowel disease, nutritional deficiencies (iron, folate, B12), and HIV infection in patients with recurrent aphthous stomatitis 2