From the Guidelines
As a first-line treatment for a severe case of aphthous ulcers in an adult patient, I would prescribe a high-potency topical corticosteroid such as dexamethasone mouth rinse (0.1 mg/ml) or clobetasol gel or ointment (0.05%) to be applied directly to the ulcers. This recommendation is based on expert opinion from the Annals of Oncology study 1, which suggests that topical high potency corticosteroids should be considered first for treating ulcers.
Key Considerations
- The patient should be advised to rinse their mouth with a bland non-alcoholic, sodium bicarbonate containing mouthwash four to six times a day to prevent further irritation and promote healing 1.
- For pain management, I would recommend using a topical anesthetic like viscous lidocaine 2% solution as needed before meals to reduce pain and allow comfortable eating, with instructions not to swallow and to avoid eating for 30 minutes after application 1.
- Additional pain relief can be achieved with over-the-counter analgesics such as acetaminophen or topical NSAIDs like amlexanox 5% oral paste, considering the patient's tolerance and medical history 1.
- To prevent secondary infection, a chlorhexidine 0.12% mouth rinse twice daily can be prescribed 1.
Treatment Duration and Follow-Up
The treatment should continue until the ulcers resolve, typically within 7-14 days. If no improvement occurs within a week, the patient should return for reassessment as more aggressive treatments or further investigation may be necessary.
Important Considerations
- The patient's medical history, current medications, and potential allergies should be considered when prescribing any medication.
- Patient education on proper oral hygiene, dietary adjustments to avoid irritants, and follow-up appointments are crucial for effective management and prevention of future episodes.
From the Research
First Line Treatment for Aphthous Ulcer
As a doctor, the first line treatment for an adult patient with a severe case of aphthous ulcer would involve the following medications:
- Topical antiseptic/anti-inflammatory agents such as triclosan and diclofenac 2
- Local anesthetics such as lidocaine 2
- Topical corticosteroids (dexamethasone, triamcinolone, fluocinonide, or clobetasol) 3
- Antimicrobial mouthwashes 3, 4
Treatment Approach
The treatment approach would involve:
- Avoiding hard, acidic, and salty foods and toothpastes containing sodium lauryl sulfate 2
- Avoiding alcohol and carbonated drinks 2
- Using topical medications as the primary treatment, with systemic medications reserved for severe cases or when topical therapy is ineffective 2, 3, 4
- Considering the frequency of ulcers, intensity of pain, and responsiveness of the lesions to treatment when selecting a treatment plan 2
Systemic Treatment
Systemic treatment may be considered in severe cases, including:
- Colchicine, pentoxifylline, or prednisolone 2
- Levamisole, which has shown variable efficacy in reducing ulcer frequency and duration in patients with minor RAU 4
- Oral corticosteroids, which should be reserved for severe cases of major RAU that do not respond to topical agents 4
- Thalidomide, which is effective but should be used only as an alternative to oral corticosteroids due to its toxicity and cost 4