How should bleeding oral aphthous ulcers be treated?

Treatment of Bleeding Oral Aphthous Ulcers

For bleeding mouth ulcers (aphthous ulcers), immediately apply topical corticosteroids such as clobetasol gel 0.05% directly to the dried ulcer 2-4 times daily, combined with topical anesthetic mouthwashes (viscous lidocaine 2%) before meals for pain control. 1

Immediate Management of Bleeding

• Apply direct pressure with gauze soaked in topical anesthetic to control active bleeding while providing pain relief 1
• Use barrier preparations such as Gelclair or white soft paraffin ointment applied three times daily to protect the ulcer surface and prevent further trauma 1
• Rinse with antiseptic solutions (0.2% chlorhexidine digluconate or 1.5% hydrogen peroxide) twice daily to prevent secondary infection 1

First-Line Topical Therapy

For Localized Ulcers:

• Clobetasol gel or ointment 0.05% applied directly to the dried ulcer 2-4 times daily is the most potent topical steroid option 1
• Triamcinolone acetonide 0.1% paste can be used as an alternative, applied 2-4 times daily to dried ulcer 1
• For more severe localized ulcers, clobetasol 0.05% ointment mixed in 50% Orabase applied twice weekly to dried mucosa 1

For Multiple or Widespread Ulcers:

• Dexamethasone mouth rinse (0.1 mg/ml) used as rinse-and-spit 1
• Betamethasone sodium phosphate 0.5 mg in 10 ml water as a rinse-and-spit preparation four times daily 1

Pain Control Strategy

• Viscous lidocaine 2% applied before meals to enable eating 1
• Benzydamine hydrochloride rinse or spray every 3 hours, particularly before eating 1
• Topical NSAIDs such as amlexanox 5% oral paste for severe pain 1

Oral Hygiene During Healing

• Clean the mouth daily with warm saline mouthwashes to promote healing 1
• Use antiseptic oral rinses twice daily (1.5% hydrogen peroxide or 0.2% chlorhexidine digluconate) 1
• Avoid sodium lauryl sulfate-containing toothpastes, hard, acidic, salty foods, alcohol, and carbonated drinks 2

Second-Line Management for Non-Healing Ulcers

If ulcers persist beyond 1-2 weeks or continue bleeding despite topical therapy:

• Intralesional steroid injections (triamcinolone weekly, total dose 28 mg) for persistent ulcers 1
• Systemic corticosteroids (prednisone/prednisolone 30-60 mg or 1 mg/kg for 1 week with tapering over the second week) for highly symptomatic cases 1
• Colchicine as first-line systemic therapy for recurrent aphthous stomatitis (≥4 episodes per year), especially if associated with erythema nodosum or genital ulcers 1, 3

Critical Red Flags Requiring Specialist Referral

• Ulcers lasting more than 2 weeks despite treatment require biopsy to exclude malignancy 1
• Solitary chronic ulcers must be biopsied to rule out squamous cell carcinoma 3
• Perform blood tests (full blood count, coagulation, fasting glucose, HIV antibody, syphilis serology) before biopsy to exclude contraindications and provide diagnostic clues 1

Common Pitfalls to Avoid

• Do not taper corticosteroids prematurely before disease control is established 1
• Do not ignore underlying systemic diseases: Check for celiac disease, inflammatory bowel disease, nutritional deficiencies (iron, folates), HIV infection, or Behçet's disease in recurrent cases 3, 2
• Do not use epinephrine injection alone if considering any injection therapy, as it provides suboptimal efficacy 4