What are the first-line treatment medications for an adult patient presenting with a severe case of recurrent aphthous stomatitis (canker sores), and is there a role for vitamin B12 and prebiotics/probiotics in management?

From the Research

For a severe case of aphthous ulcer in an adult patient, I would prescribe topical corticosteroids as first-line treatment, specifically triamcinolone acetonide dental paste (0.1%) applied directly to the ulcer 2-3 times daily after meals and before bedtime, as supported by the most recent study 1 which showed significant reduction in pain and erythema and improvement in ulcer healing. This approach helps reduce inflammation and pain, and is in line with the recommendations from other studies 2, 3, 4, 5. For pain management, I would recommend benzocaine 20% gel or lidocaine 2% viscous solution applied to the ulcer before meals to allow comfortable eating. A chlorhexidine 0.12% mouthwash used twice daily can help prevent secondary infection. For systemic therapy in severe cases, I might prescribe prednisone 40-60mg daily for 5-7 days with a tapering dose.

Regarding vitamin B12 and probiotics, there is some evidence supporting their use.

• Vitamin B12 deficiency has been associated with recurrent aphthous ulcers, so I would recommend checking B12 levels and supplementing with 1000mcg daily if deficient.
• Probiotics containing Lactobacillus species may help modulate the immune response and reduce recurrence, though evidence is still emerging. I would suggest a probiotic supplement containing at least 1 billion CFU daily. These treatments work because aphthous ulcers involve immune dysregulation and possibly nutritional deficiencies, with topical treatments providing symptomatic relief while addressing potential underlying factors may prevent recurrence, as discussed in the studies 2, 3, 5.

Key points to consider:

• The primary goals of therapy for aphthous ulcers are relief of pain, reduction of ulcer duration, and restoration of normal oral function, as stated in the study 2.
• Topical medications, such as antimicrobial mouthwashes and topical corticosteroids, can achieve the primary goals but have not been shown to alter recurrence or remission rates, as noted in the study 2.
• Systemic medications can be tried if topical therapy is ineffective, as recommended in the study 3.
• The treatment of chronic recurrent oral aphthous ulcers is symptomatic, mainly with topically applied agents, and is tailored to the severity of the problem in the individual case, as discussed in the study 3.