Treatment of Minor Aphthous Oral Ulcers in Adults
For minor aphthous oral ulcers, begin with topical corticosteroids 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 barrier agents and topical analgesics for symptom control. 1, 2
First-Line Topical Therapy
Topical Corticosteroids (Primary Treatment)
- Betamethasone sodium phosphate 0.5 mg in 10 mL water: Use as a 2-3 minute rinse-and-spit preparation 1-4 times daily 1, 2, 3
- Fluticasone propionate nasules: Dilute in 10 mL water and use twice daily 1
- Clobetasol 0.05% ointment: For localized ulcers, mix in 50% Orabase and apply directly to dried mucosa twice daily 1, 2, 3
- Triamcinolone acetonide 0.1% paste: Apply directly to dried ulcer 2-4 times daily for localized lesions 3
Barrier Agents for Mucosal Protection
- Gelclair mucoprotectant gel: Apply three times daily to form a protective coating over ulcerated surfaces, reducing pain and promoting healing 1, 2, 3
- Gengigel mouth rinse/gel: Alternative barrier preparation for pain control 1
Topical Analgesics
- Benzydamine hydrochloride oral rinse or spray: Use every 3 hours, particularly before eating 2, 3
- Viscous lidocaine 2%: Apply 15 mL per application up to 3-4 times daily for more severe pain 2, 3
Oral Hygiene and Antiseptic Measures
- Warm saline mouthwashes: Clean the mouth daily to reduce bacterial colonization 2, 3
- Antiseptic oral rinses twice daily: Use either 1.5% hydrogen peroxide mouthwash (10 mL) or 0.2% chlorhexidine digluconate mouthwash (10 mL); dilute chlorhexidine by up to 50% to reduce soreness 4, 2, 3
Treatment of Secondary Infections
If candidal infection is suspected based on clinical appearance or culture:
- Nystatin oral suspension: 100,000 units four times daily for 1 week 1, 2
- Miconazole oral gel: 5-10 mL held in the mouth after food four times daily for 1 week 2
Second-Line Therapy for Refractory Ulcers
If ulcers persist beyond 2 weeks or fail to respond to first-line topical therapy:
- Tacrolimus 0.1% ointment: Apply twice daily for 4 weeks 1, 2, 3
- Intralesional triamcinolone: Weekly injections (total dose 28 mg) in conjunction with topical clobetasol gel or ointment 1, 2, 3
Systemic Therapy for Severe or Highly Symptomatic Cases
Reserve for patients with severe pain interfering with eating/speaking or multiple recurrent ulcers:
- Oral corticosteroids: Prednisone/prednisolone 30-60 mg or 1 mg/kg daily for 1 week, followed by dose tapering over the second week 1, 3
- Colchicine: Particularly effective for recurrent aphthous stomatitis (≥4 episodes per year), especially when associated with Behçet disease 1, 3, 5
Treatment Algorithm Based on Severity
Mild ulcers (1-3 small ulcers, minimal pain):
- Start with barrier agents (Gelclair) + benzydamine hydrochloride rinse 1, 2
- Add betamethasone rinse if no improvement in 3-5 days 1, 2
Moderate ulcers (multiple ulcers or significant pain):
- Begin immediately with betamethasone rinse + barrier agents + topical analgesics 1, 2
- For localized ulcers, use clobetasol ointment in Orabase 1, 3
Severe ulcers (interfering with eating/speaking):
- High-potency topical corticosteroids (clobetasol) + barrier agents + viscous lidocaine 1, 2
- Consider systemic corticosteroids if no improvement within 1 week 1, 3
Critical Pitfalls to Avoid
- Do not taper corticosteroids prematurely before disease control is established 3
- Avoid sodium lauryl sulfate-containing toothpastes, as well as hard, acidic, and salty foods that may trigger ulcers 6
- Refer for biopsy any ulcer lasting more than 2 weeks or not responding to 1-2 weeks of treatment to exclude malignancy 3
- Screen for underlying systemic conditions in patients with recurrent aphthous stomatitis, including celiac disease, inflammatory bowel disease, nutritional deficiencies (iron, folate, B12), and HIV infection 5, 6
Pain Management Ladder
For inadequate pain control with topical measures, follow the WHO pain management ladder: