Aphthous Ulcers Treatment & Management

  • Author: Crispian Scully, MD, PhD, MDS, CBE, MRCS, FDSRCS, FDSRCPS, FFDRCSI, FDSRCSE, FRCPath, FMedSci, FHEA, FUCL, DSc, DChD, DMed(HC), Dr(HC), ; Chief Editor: Arlen D Meyers, MD, MBA   more...
 
Updated: Apr 10, 2012
 

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. Causal drugs should be excluded.

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. Objective evidence shows the most efficacy from corticosteroids and antimicrobials used topically.

  • 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    • Triamcinolone acetonide in carboxymethyl cellulose paste (Adcortyl in orabase [withdrawn in some countries], Kenalog), administered 4 times daily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 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 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.
Next

Consultations

  • Gastroenterologist
  • Immunologist/allergologist
  • Hematologist
  • Rheumatologist
Previous
Next

Diet

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

Previous
Proceed to Medication
 
 
Contributor Information and Disclosures
Author

Crispian Scully, MD, PhD, MDS, CBE, MRCS, FDSRCS, FDSRCPS, FFDRCSI, FDSRCSE, FRCPath, FMedSci, FHEA, FUCL, DSc, DChD, DMed(HC), Dr(HC),  Professor of Oral Medicine, Bristol University; Co-Director of World Health Organization Collaborating Centre for Oral Health-General Health; Emeritus Professor of Oral Medicine and Special Care Dentistry, University College London; Professor, Oral Medicine, Pathology, and Microbiology, University of London; Visiting Professor at Universities of Athens,Edinburgh, Granada, Helsinki and Plymouth

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

Disclosure: Nothing to disclose.

Specialty Editor Board

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, and American Rhinologic Society

Disclosure: Nothing to disclose.

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

Disclosure: Medscape Salary Employment

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 Academy of Otolaryngology-Head and Neck Surgery, American College of Surgeons, American Medical Association, American Neurotology Society, American Rhinologic Society, American Society for Head and Neck Surgery, Medical Society of the State of New York, and Triological Society

Disclosure: Revent Medical Honoraria Review panel membership; Synthes Nursing Education Honoraria Other

Christopher L Slack, MD  Private Practice in Otolaryngology and Facial Plastic Surgery, Associated Coastal ENT; Medical Director, Treasure Coast Sleep Disorders

Christopher L Slack, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, and American Medical Association

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, and American Head and Neck Society

Disclosure: Covidien Corp Consulting fee Consulting; US Tobacco Corporation Unrestricted gift Unknown; Axis Three Corporation Ownership interest Consulting; Omni Biosciences Ownership interest Consulting; Sentegra Ownership interest Board membership; Medvoy Ownership interest Management position; Cerescan Imaging Consulting; Headwatersmb Consulting fee Consulting; Venturequest Royalty Consulting

References

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

  2. 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. Jun 1999;87(6):706-7. [Medline].

  3. 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. Mar 2012;125(3):292-301. [Medline].

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

  5. 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. Dec 2008;35(6):427-32. [Medline].

  6. Barrons RW. Treatment strategies for recurrent oral aphthous ulcers. Am J Health Syst Pharm. Jan 1 2001;58(1):41-50; quiz 51-3. [Medline].

  7. 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. Mar 2009;38(3):289-98. [Medline].

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

  9. 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. Nov 2009;108(5):714-21. [Medline].

  10. Edres MA, Scully C, Gelbier M. Use of proprietary agents to relieve recurrent aphthous stomatitis. Br Dent J. Feb 22 1997;182(4):144-6. [Medline].

  11. Eisen D, Lynch DP. Selecting topical and systemic agents for recurrent aphthous stomatitis. Cutis. Sep 2001;68(3):201-6. [Medline].

  12. Femiano F, Gombos F, Scully C. Recurrent aphthous stomatitis unresponsive to topical corticosteroids: a study of the comparative therapeutic effects of systemic prednisone and systemic sulodexide. Int J Dermatol. May 2003;42(5):394-7. [Medline].

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

  14. 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.

  15. Lo Muzio L, della Valle A, Mignogna MD, et al. The treatment of oral aphthous ulceration or erosive lichen planus with topical clobetasol propionate in three preparations: a clinical and pilot study on 54 patients. J Oral Pathol Med. Nov 2001;30(10):611-7. [Medline].

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

  17. McCullough MJ, Abdel-Hafeth S, Scully C. Recurrent aphthous stomatitis revisited; clinical features, associations, and new association with infant feeding practices?. J Oral Pathol Med. Nov 2007;36(10):615-20. [Medline].

  18. 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. May 6 2009;10:30. [Medline].

  19. 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. Jan 2002;16(1):66-7. [Medline].

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

  21. Porter SR, Hegarty A, Kaliakatsou F, Hodgson TA, Scully C. Recurrent aphthous stomatitis. Clin Dermatol. Sep-Oct 2000;18(5):569-78. [Medline].

  22. Porter SR, Scully C, Pedersen A. Recurrent aphthous stomatitis. Crit Rev Oral Biol Med. 1998;9(3):306-21. [Medline].

  23. Scully C. Clinical practice. Aphthous ulceration. N Engl J Med. Jul 13 2006;355(2):165-72. [Medline].

  24. Scully C, Gorsky M, Lozada-Nur F. The diagnosis and management of recurrent aphthous stomatitis: a consensus approach. J Am Dent Assoc. Feb 2003;134(2):200-7. [Medline].

  25. Scully C, Hodgson T. Recurrent oral ulceration: aphthous-like ulcers in periodic syndromes. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. Dec 2008;106(6):845-52. [Medline].

  26. Scully C, Hodgson T, Lachmann H. Auto-inflammatory syndromes and oral health. Oral Dis. Nov 2008;14(8):690-9. [Medline].

  27. Ship JA, Chavez EM, Doerr PA, Henson BS, Sarmadi M. Recurrent aphthous stomatitis. Quintessence Int. Feb 2000;31(2):95-112. [Medline].

  28. 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.

 
Previous
Next
 
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.
 
 
 
All material on this website is protected by copyright, Copyright © 1994-2012 by WebMD LLC.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.