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Aphthous Ulcers Treatment & Management

  • Author: Crispian Scully, MD, MRCS, PhD, MDS, CBE, FDSRCS(Eng), FDSRCPS, FFDRCSI, FDSRCSE, FRCPath, FMedSci, FHEA, FUCL, FSB, DSc, DChD, DMed(HC), Dr(HC); Chief Editor: Arlen D Meyers, MD, MBA  more...
 
Updated: May 10, 2016
 

Medical Care

Identify and correct predisposing factors for recurrent aphthous stomatitis (RAS). Ensure that patients brush atraumatically (eg, with a small-headed, soft toothbrush) and avoid eating particularly hard or sharp foods (eg, toast, potato crisps) and avoid other trauma to the oral mucosa.

SLS should be avoided if implicated as a predisposing factor. Any iron or vitamin deficiency should be corrected once the cause of that deficiency has been established. If an obvious relationship to certain foods is established, these should be excluded from the diet. Patch testing may be indicated to reveal allergies. The occasional patient who relates ulcers to her menstrual cycle or to use of an oral contraceptive may benefit from suppression of ovulation with a progestogen or a change in the oral contraceptive.

In most cases, the natural history of RAS is one of eventual remission. However, for some patients, remission occurs spontaneously several years later; thus, treatment is indicated in these patients if discomfort is significant. Relief of pain and reduction of ulcer duration are the main goals of therapy. There is a huge range of supposed or possible remedies available, but objective evidence shows the most efficacy from corticosteroids and antimicrobials used topically.[7, 8]

  • Vitamin B12 used orally may have some effect
  • Topical corticosteroids (TCs) remain the mainstays of treatment. A spectrum of different TCs can be used. At best, TCs reduce painful symptoms but not the rate of ulcer recurrence. The commonly used preparations are as follows:
    • Hydrocortisone hemisuccinate pellets (Corlan), 2.5 mg used 4 times daily
    • Triamcinolone acetonide in carboxymethyl cellulose paste (Adcortyl in orabase [withdrawn in some countries], Kenalog), administered 4 times daily
    • Betamethasone sodium phosphate as a 0.5-mg tablet dissolved in 15 mL of water to make a mouth rinse, used 4 times daily for 4 minutes each time
  • Hydrocortisone and triamcinolone preparations are popular because neither causes significant adrenal suppression; however, ulcers still recur.
  • Betamethasone, fluocinonide, fluocinolone, fluticasone, and clobetasol are more potent and effective than hydrocortisone and triamcinolone, but they carry the possibility of some adrenocortical suppression and a predisposition to candidiasis.
  • Topical tetracyclines may reduce the severity of ulceration, but they do not alter the recurrence rate. A doxycycline capsule of 100 mg in 10 mL of water administered as a mouth rinse for 3 minutes or tetracycline 500 mg plus nicotinamide 500 mg administered 4 times daily may provide relief and reduce ulcer duration. Avoid tetracyclines in children younger than 12 years who might ingest them and develop tooth staining.
  • Chlorhexidine gluconate and bioadhesive (Gelclair) mouth rinses reduce the severity and pain of ulceration but not the frequency.
  • Anti-inflammatory agents can help; a spectrum of topical agents such as benzydamine and amlexanox may help. Benzydamine hydrochloride mouthwash, though no more beneficial than a placebo, can produce transient pain relief.

If RAS fails to respond to local measures, systemic immunomodulators may be required. A wide spectrum of agents has been suggested as beneficial, but few studies have been performed to assess their efficacy (or their adverse effects are significant). Thalidomide 50-100 mg daily is effective against severe RAS, although ulcers tend to recur within 3 weeks. Teratogenicity, neuropathy, and other adverse effects dissuade most physicians from its use.

Few, if any, of the other medications used for RAS have undergone serious scientific evaluation. These include biologics, transfer factor, gamma-globulin therapy, sodium cromoglycate lozenges, dapsone, colchicine, pentoxifylline, levamisole, colchicine, azathioprine, prednisolone, azelastine, alpha 2-interferon, ciclosporin, deglycerinated liquorice, 5-aminosalicylic acid (5-ASA), prostaglandin E2 (PGE2), sucralfate, diclofenac, and aspirin.

A randomized, single-blind, placebo-controlled trial by Albrektson et al indicated that low-level laser therapy can relieve RAS pain. The study, which involved 40 patients with RAS, also found that patients who received laser treatment found it easier to eat, drink, and brush their teeth than did the placebo patients.[9]

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Consultations

See the list below:

  • Gastroenterologist
  • Immunologist/allergologist
  • Hematologist
  • Rheumatologist
  • Dermatologist
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Diet

The patient should avoid consuming any foods that could lead to RAS.

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Contributor Information and Disclosures
Author

Crispian Scully, MD, MRCS, PhD, MDS, CBE, FDSRCS(Eng), FDSRCPS, FFDRCSI, FDSRCSE, FRCPath, FMedSci, FHEA, FUCL, FSB, DSc, DChD, DMed(HC), Dr(HC) Emeritus Professor, University College London; Visiting Professor, Universities of Athens, BPP, Edinburgh, Granada, Helsinki and Plymouth

Crispian Scully, MD, MRCS, PhD, MDS, CBE, FDSRCS(Eng), FDSRCPS, FFDRCSI, FDSRCSE, FRCPath, FMedSci, FHEA, FUCL, FSB, DSc, DChD, DMed(HC), Dr(HC) is a member of the following medical societies: Academy of Medical Sciences, British Society for Oral Medicine, European Association for Oral Medicine, International Academy of Oral Oncology, International Association for Dental Research, International Association for Oral and Maxillofacial Pathology

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Robert M Kellman, MD Professor and Chair, Department of Otolaryngology and Communication Sciences, State University of New York Upstate Medical University

Robert M Kellman, MD is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Head and Neck Society, American Rhinologic Society, Triological Society, American Neurotology Society, American Academy of Otolaryngology-Head and Neck Surgery, American College of Surgeons, American Medical Association, Medical Society of the State of New York

Disclosure: Nothing to disclose.

Chief Editor

Arlen D Meyers, MD, MBA Professor of Otolaryngology, Dentistry, and Engineering, University of Colorado School of Medicine

Arlen D Meyers, MD, MBA is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, American Head and Neck Society

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Cerescan;RxRevu;SymbiaAllergySolutions<br/>Received income in an amount equal to or greater than $250 from: Symbia<br/>Received from Allergy Solutions, Inc for board membership; Received honoraria from RxRevu for chief medical editor; Received salary from Medvoy for founder and president; Received consulting fee from Corvectra for senior medical advisor; Received ownership interest from Cerescan for consulting; Received consulting fee from Essiahealth for advisor; Received consulting fee from Carespan for advisor; Received consulting fee from Covidien for consulting.

Additional Contributors

Hassan H Ramadan, MD, MSc Professor and Vice-Chair, Department of Otolaryngology-Head and Neck Surgery, Professor, Department of Pediatrics, West Virginia University School of Medicine

Hassan H Ramadan, MD, MSc is a member of the following medical societies: American Academy of Otolaryngic Allergy, American Academy of Otolaryngology-Head and Neck Surgery, American College of Surgeons, American Rhinologic Society

Disclosure: Nothing to disclose.

References
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  2. Preeti L, Magesh K, Rajkumar K, Karthik R. Recurrent aphthous stomatitis. J Oral Maxillofac Pathol. 2011 Sep. 15(3):252-6. [Medline]. [Full Text].

  3. Shotts RH, Scully C, Avery CM, Porter SR. Nicorandil-induced severe oral ulceration: a newly recognized drug reaction. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 1999 Jun. 87(6):706-7. [Medline].

  4. Gülseren D, Karaduman A, Kutsal D, Nohutcu RM. The relationship between recurrent aphthous stomatitis, and periodontal disease and Helicobacter Pylori infection. Clin Oral Investig. 2016 Jan 6. [Medline].

  5. Hijazi K, Lowe T, Meharg C, et al. Mucosal Microbiome in Patients with Recurrent Aphthous Stomatitis. J Dent Res. 2014 Dec 24. [Medline].

  6. Kim YJ, Choi YS, Baek KJ, Yoon SH, Park HK, Choi Y. Mucosal and salivary microbiota associated with recurrent aphthous stomatitis. BMC Microbiol. 2016 Apr 1. 16 Suppl 1:57. [Medline]. [Full Text].

  7. Baccaglini L, Lalla RV, Bruce AJ, Sartori-Valinotti JC, Latortue MC, Carrozzo M, et al. Urban legends: recurrent aphthous stomatitis. Oral Dis. 2011 Nov. 17(8):755-70. [Medline]. [Full Text].

  8. Brocklehurst P, Tickle M, Glenny AM, Lewis MA, Pemberton MN, Taylor J, et al. Systemic interventions for recurrent aphthous stomatitis (mouth ulcers). Cochrane Database Syst Rev. 2012 Sep 12. 9:CD005411. [Medline].

  9. Albrektson M, Hedström L, Bergh H. Recurrent aphthous stomatitis and pain management with low-level laser therapy: a randomized controlled trial. Oral Surg Oral Med Oral Pathol Oral Radiol. 2014 May. 117(5):590-4. [Medline].

  10. Liu C, Zhou Z, Liu G, Wang Q, Chen J, Wang L, et al. Efficacy and safety of dexamethasone ointment on recurrent aphthous ulceration. Am J Med. 2012 Mar. 125(3):292-301. [Medline].

  11. Akintoye SO, Greenberg MS. Recurrent aphthous stomatitis. Dent Clin North Am. 2005 Jan. 49(1):31-47, vii-viii. [Medline].

  12. Albanidou-Farmaki E, Deligiannidis A, Markopoulos AK, Katsares V, Farmakis K, Parapanissiou E. HLA haplotypes in recurrent aphthous stomatitis: a mode of inheritance?. Int J Immunogenet. 2008 Dec. 35(6):427-32. [Medline].

  13. Borra RC, de Mesquita Barros F, de Andrade Lotufo M, Villanova FE, Andrade PM. Toll-like receptor activity in recurrent aphthous ulceration. J Oral Pathol Med. 2009 Mar. 38(3):289-98. [Medline].

  14. Calderon PE, Valenzuela FA, Carreno LE, Madrid AM. A possible link between cow milk and recurrent aphtous stomatitis. J Eur Acad Dermatol Venereol. 2008 Jul. 22(7):898-9. [Medline].

  15. de Abreu MA, Hirata CH, Pimentel DR, Weckx LL. Treatment of recurrent aphthous stomatitis with clofazimine. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2009 Nov. 108(5):714-21. [Medline].

  16. Gallo Cde B, Mimura MA, Sugaya NN. Psychological stress and recurrent aphthous stomatitis. Clinics (Sao Paulo). 2009. 64(7):645-8. [Medline]. [Full Text].

  17. Gulcan E, Toker S, Hatipoğlu H, Gulcan A, Toker A. Cyanocobalamin may bebeneficial in the treatment of recurrent aphthous ulcers even when vitamin B12levels are normal. Am J Med Sci. 2008. 336:379-82.

  18. Marakoglu K, Sezer RE, Toker HC, Marakoglu I. The recurrent aphthous stomatitis frequency in the smoking cessation people. Clin Oral Investig. 2007 Jun. 11(2):149-53. [Medline].

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  20. Meng W, Dong Y, Liu J, et al. A clinical evaluation of amlexanox oral adhesive pellicles in the treatment of recurrent aphthous stomatitis and comparison with amlexanox oral tablets: a randomized, placebo controlled, blinded, multicenter clinical trial. Trials. 2009 May 6. 10:30. [Medline]. [Full Text].

  21. Piskin S, Sayan C, Durukan N, Senol M. Serum iron, ferritin, folic acid, and vitamin B12 levels in recurrent aphthous stomatitis. J Eur Acad Dermatol Venereol. 2002 Jan. 16(1):66-7. [Medline].

  22. Porter S, Scully C. Aphthous ulcers (recurrent). Clin Evid. 2004. 12:360-361.

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  27. Volkov I, Rudoy I, Freud T, Sardal G, Naimer S, Peleg R, et al. Effectiveness of vitamin B12 in treating recurrent aphthous stomatitis: arandomized, double-blind, placebo-controlled trial. J Am Board Fam Med. 2009. 22:9-16.

 
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Traumatic ulcer on ventrum/lateral margin of tongue; these must be differentiated from aphthae.
Recurrent aphthae in floor of mouth, showing ovoid ulcer with inflammatory halo.
Typical aphthous ulcer in a common site, showing inflammatory halo surrounding a yellowish round ulcer.
 
 
 
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