Apthous ulcer treatment

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Aphthous Ulcer (Recurrent Aphthous Stomatitis) - Treatment

Classification (Guides Treatment Intensity)

Type	Size	Duration	Features
Minor (85% of cases)	<10 mm	7-10 days	Non-keratinized mucosa, heals without scarring
Major (10%)	>10 mm	Up to 3 months	Posterior oral cavity, may scar, can mimic malignancy
Herpetiform (least common)	<5 mm	Up to 2 weeks	Up to 100 small ulcers, coalesce, no vesicular phase

Step 1 - Identify and Correct Triggers

Before prescribing, screen for correctable causes:

Haematinic deficiencies: Check serum ferritin, folate, and vitamin B12 (a normal blood count does NOT exclude deficiency)
Coeliac disease: Screen concurrently
Dietary triggers: Sodium lauryl sulphate (SLS)-containing toothpastes, benzoates, chocolate, cinnamon - avoid these
Drug causes: NSAIDs, beta-blockers, potassium-channel blockers can cause aphthous-type ulcers - withdraw if possible
Stress and trauma are known triggers

Step 2 - Treatment (by modality and severity)

Key principle: Immunomodulatory drugs must be started at the onset of the first symptom (prodromal phase). Once the ulcer is visible, it is too late - only symptomatic relief is effective at that point.

Symptomatic Relief (for established ulcers)

Drug	How to Use
Benzydamine (Difflam) solution	Spray or rinse for 1 minute before meals to reduce sensitivity
Occlusive paste (e.g., Orabase)	Apply to ulcer before eating to protect and relieve discomfort
Lignocaine gel	Apply topically before meals for local anaesthesia

Topical Episodic Treatment (early onset - immunomodulatory)

Drug	How to Use
Betamethasone mouthwash	1 mg dissolved in 10 mL water, rinse 2 min twice daily from onset until healed
Beclomethasone inhaler (50-200 mcg/puff)	2 puffs three times daily directly onto ulcer from onset until healed
Triamcinolone acetonide paste	Apply directly to ulcer topically

Topical Preventative (for recurrent cases)

Drug	How to Use
Betamethasone mouthwash	1 mg in 10 mL water, once daily every day
Doxycycline mouthwash	100 mg soluble tablet in 10 mL water, rinse 2 min twice daily
These two can be combined into a single mouthrinse

Major or Non-healing Ulcers / HIV-related Cases

Intralesional or systemic corticosteroids: Effective for major aphthous ulcers
Thalidomide 200 mg/day: Shown effective for treatment in HIV-associated major aphthous ulcers (not for prevention of recurrence)
Liquid nutritional supplements: Essential given impact on caloric intake
Biopsy: Mandatory for major aphthous ulcers to exclude lymphoma and SCC, as they can be indistinguishable clinically

Systemic Preventative (specialist use only)

Colchicine
Azathioprine
Mycophenolate mofetil

Recent Evidence (2024-2025)

Two recent meta-analyses (PMID 39899066, PMID 40560435) confirm diode laser therapy as a safe and effective treatment for recurrent aphthous ulcers, reducing pain and promoting faster healing vs. placebo. This is a useful adjunct where available.

Key Points Summary

Treat the underlying cause first (iron/B12/folate deficiency, coeliac disease, drug causes)
Avoid SLS toothpastes and known dietary triggers
Minor ulcers: symptomatic relief (benzydamine, occlusive paste)
Early-onset use of topical steroids (betamethasone mouthwash) is the mainstay of episodic treatment
Recurrent cases: topical preventatives (betamethasone + doxycycline mouthwash)
Major ulcers: biopsy first to exclude malignancy, then systemic steroids or thalidomide (HIV patients)
Systemic immunosuppressants (colchicine, azathioprine) only under specialist supervision
Laser therapy is an effective adjunct for pain and healing

- Scott-Brown's Otorhinolaryngology, Table 42.10 | Cummings Otolaryngology, Ch. 87

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