Pediatric Aphthous Ulcers Medication

Updated: Feb 25, 2019
  • Author: Michael C Plewa, MD; Chief Editor: Russell W Steele, MD  more...
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Medication

Medication Summary

Local and systemic medications are used. As a general rule, topical therapy should be initiated first to avoid the adverse effects associated with systemic treatment. Many treatments are controversial, and the clinical data for many treatments are limited. Many treatment modalities are not discussed in this article.

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Topical anesthetics

Class Summary

These drugs are used to relieve localized pain.

Benzocaine (Anbesol, Hurricaine Gel, Kank-A, Orabase, Orajel)

PABA derivative ester-type local anesthetic; minimally absorbed. Inhibits neuronal membrane depolarization, blocking nerve impulses. Used to control pain.

Lidocaine (Xylocaine)

Available as gel or viscous PO solution. Decreases permeability of neuronal membranes to sodium ions, inhibiting depolarization and blocking transmission of nerve impulses. Initial treatment of choice for small, sparse ulcers. Does not shorten healing time but may help patient to tolerate eating and drinking. Pain relief may be short, and frequent applications may be necessary.

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Antihistamines

Class Summary

These drugs act by competitively inhibiting histamine at the H1 receptor. They prevent histamine responses in sensory nerve endings to relieve symptoms (eg, localized irritation, pain).

Diphenhydramine elixir (Benadryl)

First-line antihistamine for topical treatment of localized skin and mucus-membrane irritation. May be applied directly to ulcerated submucosal tissue. Relieves PO pain in some patients.

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Topical corticosteroids

Class Summary

These drugs decrease inflammation by suppressing migration of polymorphonuclear (PMN) leukocytes and reversing capillary permeability. Many factors, including the vehicle, the integrity of the mucosal barrier, the amount of friction from adjacent structures, and the amount of salivation determine the extent of mucocutaneous absorption. The medical profile for triamcinolone is outlined below; other medications with the same or similar profiles include betamethasone valerate 0.1% (Valisone), clobetasol propionate 0.05% cream or ointment (Temovate), dexamethasone (Decadron), halobetasol propionate 0.05% ointment (Ultravate), and fluocinonide 0.05% gel (Lidex).

A benzocaine preparation (Orabase B) is sometimes added to the corticosteroid, but the practice remains controversial. Data suggest that the benzocaine preparation helps keep the steroid in prolonged contact with the mucosal surface; however, its addition dilutes the mixture, lessening steroid potency. To add the benzocaine preparation to any of these topical steroid prescriptions, simply mix the steroid preparation 1:1 with Orabase.

Triamcinolone topical (Kenalog in Orabase, Oralone Dental)

Moderate-potency steroid; reduces pain and inflammation at ulcer sites. Close follow-up required to monitor for candidiasis and other secondary infections and adverse effects. Available as dental paste 0.1%.

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Local corticosteroid injections

Class Summary

These drugs decrease inflammation by suppressing migration of PMN leukocytes and by reversing capillary permeability.

Triamcinolone diacetate 25 mg/mL (Aristocort-Intralesional) or betamethasone sodium phosphate 3 mg/mL and betamethasone acetate 3 mg/mL (Celestone Soluspan)

Local submucosal injections may substantially reduce pain and inflammation; premedication with topical anesthetic may reduce discomfort.

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Topical corticosteroid elixirs

Class Summary

These drugs decrease inflammation by suppressing migration of PMN leukocytes and reversing capillary permeability. Many factors, including the vehicle, the integrity of the mucosal barrier, the amount of friction from adjacent structures, and the amount of salivation determine the extent of mucocutaneous absorption. This type of corticosteroid delivery is indicated when topical or local steroids are not effective, when the lesions are too numerous for practical application, or when the lesions are too difficult to reach with the cotton applicator.

Dexamethasone elixir (Decadron)

Liquid increases delivery of steroid dose to local area when lesions severe or numerous; typical concentration 0.5 mg/5 mL. Close follow-up required to monitor for candidiasis and other secondary infections and adverse effects.

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Miscellaneous throat and mouth products

Class Summary

These drugs accelerate aphthous ulcer (canker sore) healing.

Amlexanox oral paste (Aphthasol)

Mechanism of action is unknown, but elicits antiallergic and anti-inflammatory activity. Inhibits inflammatory mediators (ie, histamine, leukotrienes) from mast cells, neutrophils, and mononuclear cells. Available in 5 g tubes. One-fourth inch (about 0.5 cm) is approximately 100 mg of paste and contains 5 mg amlexanox.

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Systemic corticosteroids

Class Summary

The drugs decrease inflammation by suppressing migration of PMN leukocytes and reversing capillary permeability.

Prednisone (Deltasone)

Systemic corticosteroid for severe aphthae; inactive and must be metabolized to the active metabolite prednisolone. Close follow-up care and monitoring for candidiasis and other secondary infections and adverse reactions required. Available as elixir 5 mg/5 mL.

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Controversial therapies

Class Summary

Controversial therapies include 5-aminosalicylic acid, levamisole, colchicine, [36] gamma-globulin, dapsone, [66] estrogen replacement, thalidomide, clofazimine, [67] MAOIs, topical penicillin, [86] topical quercetin, [87] lactic acid mouthwash, topical hyaluronic acid (0.2%), bee propolis, [88] Alchemilla vulgaris [19] (Lady's Mantle) extract in glycerine (Aphtarine), pentoxifylline, [89] botulinum toxin A injection, [90] silver nitrate sticks, tincture of benzoin, and tetracycline. A small study suggested topical therapy with 5-aminosalicylic acid diminished symptoms and hastened resolution in recurrent aphthous ulcers (canker sores). [91] Of these, only silver nitrate sticks, tincture of benzoin and tetracycline are used with enough frequency and efficacy to be mentioned here.

Silver nitrite sticks cause chemical cauterization. Research findings are split on whether this treatment, which changes the lesion from an ulcer to a burn injury, shortens or prolongs healing. All lesions must be anesthetized before cauterization. This treatment is particularly effective at relieving the pain associated with ulcers. [78]

Similarly, tincture of benzoin applied after use of local anesthesia has been used to coat the surface of the ulcer. Few studies have addressed this method, [58] and although it may diminish pain, it may have little effect of ulcer resolution.

Some evidence supports treatment with tetracycline, either as mouthwash or subantimicrobial dose (20 mg orally twice daily). Minocycline 0.2% is more effective than tetracycline 0.25% oral mouth rinse (ie, swish orally and swallow) in decreasing healing time and pain severity and duration. [45, 43] Benefit is likely due to inhibitory effects on leukocyte function rather than due to a direct antimicrobial effect because effective doses are below those that effect bacterial flora.

Tetracycline syrup (Sumycin)

Decreases healing time and level and duration of discomfort from aphthae; mechanism of action unknown, but attributed to direct antimicrobial effect or inhibitory effect on chemotaxis and chemotoxicity.

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Oral Rinses

Class Summary

Mucoadhesive action reduces pain by adhering to the mucosal surface of the mouth.

Bioadherent oral (Gelclair)

This agent adheres to the mucosal surface of mouth and forms a protective coating that shields exposed and overstimulated nerve endings. Ingredients include water, maltodextrin, propylene glycol, polyvinylpyrrolidone (PVP), sodium hyaluronate, potassium sorbate, sodium benzoate, hydroxy ethylcellulose, polyethylene glycol (PEG)–40, hydrogenated castor oil, disodium edetate, benzalkonium chloride, flavoring, saccharin sodium, and glycyrrhetinic acid.

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