What is the best first‑line treatment for an oral ulcer in an elderly denture wearer?

Treatment of Oral Ulcers in Elderly Denture Wearers

The best first-line treatment for an oral ulcer in an elderly denture wearer is to remove the denture to eliminate mechanical trauma, followed by topical corticosteroid therapy (clobetasol 0.05% gel for localized ulcers or dexamethasone 0.1 mg/ml mouth rinse for widespread ulcers) combined with topical anesthetic mouthwashes (viscous lidocaine 2%) before meals. 1

Initial Assessment and Denture Management

The first critical step is identifying and eliminating the source of trauma:

• Remove ill-fitting dentures immediately and defer wearing them until the oral mucosa has healed completely 2
• Have a dental professional evaluate the dentures for sharp edges, overextension, or unbalanced occlusion that may be causing the ulceration 2, 3
• Traumatic ulcers from dentures occur in approximately 5% of denture wearers and are typically located where the ulcer shape corresponds to the stimulating factor 2, 3
• If the denture must be worn temporarily, soak it for 10 minutes in chlorhexidine 0.2% antimicrobial solution before insertion 2

Common pitfall: Elderly patients have age-induced changes in oral mucosa including progressive loss of sensitivity to mechanical stimuli, meaning they may not feel denture trauma until significant ulceration has occurred 4. This delayed awareness makes regular inspection crucial.

First-Line Topical Corticosteroid Therapy

Once mechanical trauma is eliminated, initiate topical steroids based on ulcer location and extent:

For localized, accessible ulcers:

• Apply clobetasol gel or ointment 0.05% directly to the dried ulcer 2-4 times daily 1
• Alternative: triamcinolone acetonide 0.1% paste applied to dried ulcer 2-4 times daily 1

For multiple or widespread ulcers:

• Use dexamethasone mouth rinse 0.1 mg/ml, swish and spit 1
• Alternative: betamethasone sodium phosphate 0.5 mg dissolved in 10 ml water as rinse-and-spit preparation four times daily 1

Pain Control Measures

Concurrent with corticosteroids, implement aggressive pain management:

• Topical anesthetic mouthwashes with viscous lidocaine 2% applied before meals 1
• Benzydamine hydrochloride rinse or spray every 3 hours, particularly before eating 1
• For severe pain, consider topical NSAIDs such as amlexanox 5% oral paste 1

Barrier Protection and Oral Hygiene

• Apply white soft paraffin ointment to lips every 2 hours to prevent drying and cracking 1
• Use mucoprotectant mouthwashes (e.g., Gelclair) three times daily to create a protective barrier over the ulcer 1
• Clean the mouth daily with warm saline mouthwashes 1
• Use antiseptic oral rinses twice daily (1.5% hydrogen peroxide or 0.2% chlorhexidine digluconate) to prevent secondary infection 1

Important consideration: Elderly patients often have reduced salivary flow; recommend sugarless chewing gum, candy, or salivary substitutes for dry mouth 1

When to Escalate Treatment

If the ulcer does not respond to 1-2 weeks of topical therapy:

• Consider intralesional steroid injections with triamcinolone weekly (total dose 28 mg) 1
• For highly symptomatic or recurrent ulcers, systemic corticosteroids may be necessary: prednisone/prednisolone 30-60 mg or 1 mg/kg for 1 week with tapering over the second week 1

Critical red flag: Any oral ulcer persisting beyond 2 weeks despite appropriate treatment requires biopsy to exclude squamous cell carcinoma, as chronic denture irritation can rarely predispose to malignancy 2, 1, 3, 5

Special Considerations in Elderly Denture Wearers

• Arteriosclerotic processes and progressive capillary obliteration in aging oral mucosa lead to chronic atrophic changes rather than acute inflammatory responses 4
• Denture stomatitis affects approximately 50% of complete or partial denture wearers and may coexist with traumatic ulcers 3
• Angular cheilitis (present in 15% of denture wearers) often accompanies oral ulceration and requires concurrent treatment 3
• Approximately 12% of denture wearers develop denture irritation hyperplasia from chronic tissue injury 3

Referral Criteria

Refer to oral medicine specialist or dermatologist for:

• Ulcers lasting more than 2 weeks 1
• Ulcers not responding to 1-2 weeks of appropriate treatment 1
• Recurrent ulcers (≥4 episodes per year) suggesting underlying systemic disease 1, 5
• Suspicion of malignancy based on indurated borders, fixation to underlying tissue, or atypical appearance 5