From the Guidelines
For severe aphthous ulcers in an adult patient, I would prescribe a combination of topical and systemic treatments, prioritizing corticosteroids as the first line of treatment, as suggested by expert opinion 1. The first-line prescription would include dexamethasone mouth rinse (0.1 mg/ml) to be used four to six times a day, as it is a high potency corticosteroid that can help reduce inflammation and pain by suppressing the local immune response.
- Additionally, I would prescribe sodium bicarbonate containing mouthwash to be used four to six times a day to help neutralize acid and reduce discomfort.
- For pain management, I would recommend viscous lidocaine 2% to be applied to ulcers as needed for pain relief, up to 4 times daily.
- If the ulcers are particularly severe or numerous, a short course of systemic therapy with prednisone 40mg daily for 5 days, tapering by 5mg every day until completion, may be appropriate, as suggested by expert opinion 1.
- I would also advise the patient to avoid spicy, acidic, or rough-textured foods that could exacerbate the ulcers, and to maintain good oral hygiene using a soft-bristled toothbrush.
- The patient should return for follow-up in two weeks if symptoms don't improve, as persistent or recurrent aphthous ulcers may indicate an underlying systemic condition requiring further investigation.
- Other treatments, such as coating agents, topical analgesic or anti-inflammatory agents, topical anesthetics, and alternative mouthwashes may be considered to treat stomatitis, as suggested by expert opinion 1.
From the Research
First Line Treatment for Severe Aphthous Ulcer
As a doctor, the first line treatment for 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 2, 3
Prescription Details
The prescription would include:
- Triclosan mouthwash (0.2%) to be used 2-3 times a day for 1-2 weeks
- Diclofenac gel (3%) to be applied topically 3-4 times a day for 1-2 weeks
- Lidocaine gel (2%) to be applied topically 3-4 times a day for 1-2 weeks
- Topical corticosteroid (e.g. triamcinolone acetonide) to be applied 3-4 times a day for 1-2 weeks
Additional Measures
In addition to the medications, the patient would be advised to:
- Avoid hard, acidic, and salty foods and toothpastes containing sodium lauryl sulfate 2
- Avoid alcohol and carbonated drinks 2
- Use a soft-bristled toothbrush and gentle toothpaste to minimize trauma to the oral mucosa
Systemic Treatment
If the patient's condition does not improve with topical treatment, systemic medications such as colchicine, pentoxifylline, or prednisolone may be considered 2, 3. However, the efficacy of systemic treatment is debated and should be used with caution.