Sections

Treatment

Approach Considerations

Many therapeutic options, with varying degrees of supporting evidence, are recommended for the treatment of aphthous stomatitis. The choice should be guided by disease severity, level of evidence, cost, and adverse effect profile. Treatment for recurrent aphthous ulcers is directed at palliation of symptoms, shortening of healing time,^{[83, 84]}and prophylaxis against future episodes.

Of note, many of the treatments are used without research demonstrating therapeutic results specific to aphthous stomatitis. A 2012 Cochrane review of systemic treatments for aphthous stomatitis found that data from four major trials lacked methodological rigor and concluded that no single therapy could be recommended given the data currently available.^[85]

Medical Care

Please refer to medications section for specific information regarding recommended dosage and mechanism of action.

Topical regimens may include the following:

Topical corticosteroids, including dexamethasone,^[86]triamcinolone, fluocinonide, and clobetasol^[66]
Immunomodulatory agents, including retinoids, cyclosporine, and amlexanox^{[87, 88]}: Cyclosporine has been tested as a systemic agent and a topical paste with mixed reports of efficacy, but it is now most often used effectively as an oral rinse.^{[89, 90, 91]}Isotretinoin (0.1% gel), tretinoin in an adhesive base (0.1%), and retinoic acid in an oral base (0.05%) have been used in the treatment of oral lichen planus with reported efficacy, and they may also be useful in the treatment of recurrent aphthous ulcers.^{[92, 93]}Researchers have also found systemic isotretinoin to be an effective therapy for recurrent aphthous ulcers.^[94]
Antimicrobials, including tetracycline,^[95]chlorhexidine gluconate,^[96]and dilute hydrogen peroxide
Anesthetics such as topical lidocaine or benzocaine^[97]
Occlusive and bioadherents agents such as oral bioadherent (Gelclair),^[98]sucralfate, bismuth subsalicylate, and 2-octyl cyanoacrylate^[99]: Some studies have reported improvement in symptomology and duration of ulcers,^[100]while other studies have found that sucralfate is not effective in the treatment of recurrent aphthous ulcers.^[101] Some clinicians advise patients to include bismuth subsalicylate in mouthwash recipes along with other ingredients, such as liquid diphenhydramine.^{[102, 103]}

Systemic agents may include the following:

Systemic steroids such as prednisone and dexamethasone^[104]
Immunomodulatory agents such as colchicine,^{[80, 105, 106]}azathioprine,^[107]montelukast,^[104]clofazimine,^[108]sulodexide,^[109]and thalidomide^[80]: Close follow-up, including nerve conduction studies and electromyography every 6 months, is recommended in patients using thalidomide.^[110] Montelukast is reported to have equal efficacy as prednisone in the treatment of recurrent aphthous stomatitis, with fewer adverse effects.^{[104, 109]}

Miscellaneous medical treatments are as follows:

Pentoxifylline: Hemorheologic agents may be beneficial in patients who do not respond to other therapies; they are not first-line treatment. ^[111]
Quercetin ^{[112, 113]}
Secretagogues such as cevimeline (Evoxac) or pilocarpine (Salagen) ^[32]
Curcumin: This agent has been suggested as promising for recurrent aphthous stomatitis, with good efficacy reported for relieving pain and reducing ulcer size. ^[114]Further study with good-quality clinical trials was highly recommended.
Probiotic lozenges: Studies have suggested that probiotic lozenges, specifically one containing Lactobacillus reuteri, may be helpful for pain relief and ulcer healing in recurrent aphthous stomatitis, with further research warranted. ^{[115, 116]}
Doxycycline: A single application of topical doxycycline showed efficacy in reducing the signs and symptoms of recurrent aphthous stomatitis; however, well-designed clinical trials with adequate sample sizes are required. ^[117]

Laser therapy has been reported to provide pain relief and lesion resolution for isolated lesions, but it does not affect episodic recurrence.^{[118, 119]}

Surgical Care

No surgical treatment has been used effectively because of the recurrent nature of recurrent aphthous ulcers.^[120]

Diet

An elimination diet may help control outbreaks by revealing suspected allergic stimuli that initiate oral lesions. If food exposure is thought to be the culprit, a food diary can be helpful.^{[121, 122, 123]}Advise avoidance of salt and hot spices to prevent pain from unnecessary aphthae irritation. Some patients report aphthae after exposure to figs, pineapple, cheese, and sodium lauryl sulfate, which is found in certain toothpastes and oral rinses. In such cases, remission may be achieved by avoiding the inciting agent.

A gluten-free diet helps patients with gluten-sensitive enteropathy (celiac disease) control outbreaks of aphthae.^[31]

Patients with oral lesions should avoid hard or sharp foods that may gouge existing ulcers or create new ones (Koebnerization).

Although some patients may have demonstrable hematinic deficiencies, daily multivitamin therapy does not appear to prevent recurrent aphthous stomatitis episodes.^[124]

Prevention

An association between smoking and reducing the occurrence of recurrent aphthous ulcer has been reported. In one epidemiologic study, the incidence of recurrent aphthous ulcer was lower in all groups using any form of tobacco than in people not using tobacco.^{[125, 126]}This may be dose-dependent, and the reduced incidence may be limited to heavy smokers.^[127] Tobacco may increase keratinization of the mucosa, which, in turn, may decrease the susceptibility to ulceration. Nicotine, a locally absorbed substance, may play a role in preventing aphthae. Research subjects lose the protective effect when they stop smoking and they may experience rebound ulceration. Despite this, these findings do not justify recommending the use of tobacco or nicotine to control this condition. Other, less harmful treatments are available. Nicotine replacement therapy may help ameliorate lesions that have resulted from cessation of a tobacco habit.^[128]

It has been suggested that various foods and environmental triggers have a role in causing or exacerbating recurrent aphthous ulcers. As such, avoidance of these potential triggers (including pineapple, tomato, figs, cheese, and sodium lauryl sulfate) may prevent or reduce the severity of episodes.^{[62, 63, 64]}

Although many patients with recurrent aphthous ulcers have hematinic deficiencies, multivitamins with iron have not been shown to reduce the severity of aphthae or the frequency of ulcer development.^[124]

Medication

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Media Gallery

Minor aphthous ulcer: Small superficial oval erosions with yellow pseudomembrane and an erythematous border are evident on the labial aspect of the left lower lip.
Major aphthous ulcer: Large oval ulcer with white pseudomembrane and raised red border located on the right upper labial mucosa adjacent to the buccal commissure. Note the irregular margin so typical in major aphthae.
Herpetiform aphthous ulcer: Grouped and single tiny white to yellow ulcers scattered on the labial mucosa and on the ventral aspect of the tongue.

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Author

Ginat W Mirowski, MD, DMD Adjunct Associate Professor, Departments of Oral Pathology, Medicine, and Radiology, Indiana University School Medicine

Ginat W Mirowski, MD, DMD is a member of the following medical societies: American Academy of Dermatology, American Medical Women's Association

Disclosure: Nothing to disclose.

Coauthor(s)

Heather C Rosengard, MPH Johns Hopkins University School of Medicine

Disclosure: Nothing to disclose.

Diana V Messadi, DDS, MMSc, DMSc Professor of Dentistry, Associate Dean for Education and Faculty Development, Chair, Section of Oral Medicine and Orofacial Pain, University of California, Los Angeles, School of Dentistry

Diana V Messadi, DDS, MMSc, DMSc is a member of the following medical societies: American Academy of Oral and Maxillofacial Pathology, American Academy of Oral Medicine, American Association for Cancer Research, American Association for Cancer Research, Women in Cancer Research, American Association for Dental Research, American Association of University Women, American Dental Association, American Dental Education Association, Arab American Dental Society, Association of Egyptian-American Scholars, California Dental Association, Egyptian Dental Association, International Association for Dental Research, Southern California Academy of Oral Pathology, West Los Angeles Dental Society

Disclosure: Nothing to disclose.

Specialty Editor Board

Richard P Vinson, MD Assistant Clinical Professor, Department of Dermatology, Texas Tech University Health Sciences Center, Paul L Foster School of Medicine; Consulting Staff, Mountain View Dermatology, PA

Richard P Vinson, MD is a member of the following medical societies: American Academy of Dermatology, Texas Medical Association, Association of Military Dermatologists, Texas Dermatological Society

Disclosure: Nothing to disclose.

Warren R Heymann, MD Head, Division of Dermatology, Professor, Department of Internal Medicine, Rutgers New Jersey Medical School

Warren R Heymann, MD is a member of the following medical societies: American Academy of Dermatology, American Society of Dermatopathology, Society for Investigative Dermatology

Disclosure: Nothing to disclose.

Chief Editor

William D James, MD Paul R Gross Professor of Dermatology, Vice-Chairman, Residency Program Director, Department of Dermatology, University of Pennsylvania School of Medicine

William D James, MD is a member of the following medical societies: American Academy of Dermatology, Society for Investigative Dermatology

Disclosure: Received income in an amount equal to or greater than $250 from: Elsevier; WebMD<br/>Served as a speaker for various universities, dermatology societies, and dermatology departments.

Additional Contributors

David P Fivenson, MD Associate Director, St Joseph Mercy Hospital Dermatology Program, Ann Arbor, Michigan

David P Fivenson, MD is a member of the following medical societies: American Academy of Dermatology, Michigan State Medical Society, Society for Investigative Dermatology, Photomedicine Society, Wound Healing Society, Michigan Dermatological Society, Medical Dermatology Society

Disclosure: Nothing to disclose.

Christy L Nebesio, MD Dermatologist

Christy L Nebesio, MD is a member of the following medical societies: Alpha Omega Alpha

Disclosure: Nothing to disclose.

Jeffrey M Casiglia, DMD, DMSc Lecturer, Harvard School of Dental Medicine; Private Practice, Salem, Massachusetts

Jeffrey M Casiglia, DMD, DMSc is a member of the following medical societies: American Academy of Oral Medicine, American Dental Association

Disclosure: Nothing to disclose.

Aphthous Stomatitis Treatment & Management

Approach Considerations

Medical Care

Surgical Care

Diet

Prevention

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