Treatment of mouth ulcer
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Treatment of Mouth Ulcers (Oral Ulcers / Aphthous Stomatitis)
Overview
Mouth ulcers, most commonly recurrent aphthous stomatitis (RAS), are shallow, painful mucosal lesions. They can also be caused by trauma, infections, systemic diseases (Behçet's syndrome, Crohn's disease, celiac disease, lupus, HIV/AIDS), or medications.
Types of Aphthous Ulcers
| Type | Size | Healing Time | Scarring |
|---|---|---|---|
| Minor (most common) | < 1 cm | 7–14 days | No |
| Major (Sutton's disease) | > 1 cm | Weeks–months | Yes |
| Herpetiform | 1–3 mm, multiple | 7–14 days | No |
Treatment Approaches
1. General Measures
- Identify and eliminate triggers: stress, trauma, certain foods (nuts, chocolate, spicy/acidic foods), SLS-containing toothpastes
- Maintain good oral hygiene
- Ensure adequate nutrition — deficiencies in B12, folate, iron, zinc can predispose to recurrence; supplementation if deficient
- Avoid trauma to the mucosa (orthodontic wax if needed)
2. Topical Therapies (First-Line)
Analgesics / Protective Agents
- Benzydamine hydrochloride (oral rinse/spray) — anti-inflammatory and local anaesthetic; reduces pain
- Lidocaine gel / benzocaine gel — topical anaesthetics for symptomatic relief before eating
- Carmellose sodium (Orabase) — forms a protective film over the ulcer
Topical Corticosteroids (mainstay of treatment)
- Triamcinolone acetonide 0.1% in Orabase — applied 2–4 times daily
- Fluocinonide 0.05% gel — applied 3–4 times daily
- Betamethasone sodium phosphate — dissolved in water as a mouthwash
- Hydrocortisone hemisuccinate pellets — 2.5 mg dissolved in mouth 4 times daily
- Goal: reduce inflammation, pain, and duration of ulcers
Tetracycline Mouthwash
- Doxycycline or tetracycline suspension (250 mg in 5 mL water) — swished for 2–3 minutes, 4 times daily
- Reduces secondary infection, pain, and healing time
- Avoid in children < 12 years and pregnant women
Antimicrobials / Antiseptics
- Chlorhexidine gluconate 0.2% mouthwash — reduces secondary bacterial colonisation and ulcer duration
- Hydrogen peroxide diluted rinse — cleansing effect
Cauterizing Agents
- Trichloroacetic acid (TCA) or silver nitrate sticks — chemical cauterization; immediate pain relief but does not speed healing
- Debacterol (sulphonated phenolics) — topical cauterizing agent
3. Systemic Therapies (For Severe/Recurrent Cases)
| Drug | Dose | Notes |
|---|---|---|
| Prednisolone | 25–40 mg/day, tapering | Short courses for major aphthae |
| Colchicine | 0.5–1.5 mg/day | For recurrent minor aphthae |
| Dapsone | 50–150 mg/day | Useful in refractory RAS |
| Pentoxifylline | 400 mg 3×/day | TNF-α inhibitor |
| Thalidomide | 50–200 mg/day | Very effective for HIV-related and major aphthae; teratogenic — use with strict precautions |
| Levamisole | 150 mg/day for 3 days every 2 weeks | Immunomodulatory |
4. Laser Therapy
- Low-level laser therapy (LLLT) — significantly reduces pain and healing time; well-tolerated; used in clinical settings
5. Treatment of Underlying Causes
If ulcers are secondary to a systemic condition, treating the underlying disease is critical:
- Celiac disease: gluten-free diet can resolve aphthae (Harrison's, p. 1094)
- HIV/AIDS: antiretroviral therapy reduces frequency of deep aphthous ulcers
- Behçet's syndrome: colchicine, azathioprine, biologic agents (e.g., infliximab)
- Nutritional deficiencies: replace iron, B12, folate, zinc
Practical Step-Up Algorithm
Mild ulcer
└─> Topical analgesic (lidocaine/benzocaine)
+ Chlorhexidine mouthwash
+ Topical corticosteroid (triamcinolone/Orabase)
Moderate ulcer / not responding
└─> Tetracycline mouthwash
+ Stronger topical steroid (fluocinonide / betamethasone rinse)
+ Address nutritional deficiencies
Severe / Major / Refractory
└─> Short course systemic prednisolone
+ Colchicine or dapsone for recurrence prevention
+ Thalidomide (HIV-related / very refractory)
+ Specialist referral
When to Refer / Investigate Further
- Ulcers persisting > 3 weeks (biopsy to exclude malignancy)
- Large, deep, or multiple simultaneous ulcers
- Associated systemic symptoms (fever, joint pain, genital ulcers, eye inflammation) — consider Behçet's
- Recurrence > monthly despite treatment
- Any suspicion of oral squamous cell carcinoma (indurated, non-healing, painless lesion)
Sources: Harrison's Principles of Internal Medicine, 21st Ed. (p. 1094); Managing People with Behçet's (p. 13); supplemented with standard clinical guidelines.
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