Pediatric Aphthous Ulcers Treatment & Management

Updated: Jan 31, 2017
  • Author: Michael C Plewa, MD; Chief Editor: Russell W Steele, MD  more...
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Treatment

Medical Care

The primary goals of medical therapy in patients with aphthous ulcers (canker sores) are pain relief, maintenance of fluid and nutrition intake, early resolution, and prevention of recurrence. Most patients with minor or herpetiform aphthae should be treated empirically before extensive and costly studies are initiated. Treatment of recurrent aphthous ulcers (canker sores) typically includes anti-inflammatory and/or symptomatic therapy, whereas immunomodulators are rarely used, except in severe, refractory cases. Many, if not all, of the therapies listed below have not specifically been studied in children.

Anti-inflammatory agents include corticosteroids, amlexanox and metalloprotease inhibitors. Treatment at onset may reduce symptoms or eliminate ulcer development.

  • High-potency corticosteroids applied locally 2-4 times daily may be successful in promoting healing and shortening the course of recurrent aphthous ulcers (canker sores), especially if applied early in the development of the lesions. [22, 23] Topical preparations such as mouthwash,  [24]  mucoadhesive paste, [89]  or gels are preferred because they limit the amount of medication delivered and thus reduce systemic adverse effects. Remember that corticosteroids increase the risk of candidiasis and other secondary infections.

    • Corticosteroid gels adhere better than creams or ointments, but any of these may be mixed with adhesive bases such as an emollient paste (eg, Orabase) for prolonged contact. The effects of these preparations are limited when lesions are numerous or difficult to reach with the cotton applicator.

    • Isolated severe ulcers may be treated with a one-time local injection of steroid (eg, triamcinolone) in the submucosal tissue after application of a topical anesthetic.

    • When lesions are severe or numerous, local steroid delivery can be achieved with liquid or spray-based (eg, beclomethasone spray) preparations. The liquid is swished around the oral cavity for 2 minutes, then expectorated. This is repeated 2-4 times a day, with one application always occurring at bedtime, until lesions subside.

    • A short course of pulsed oral prednisone should only be considered for persistent or severe cases. [25] Patients who arrive at this point in the treatment algorithm may require further screening to exclude additional diagnoses. If the patient's condition does not respond to a short burst of corticosteroids, oral prednisone should be continued until the lesions subside and then tapered.

  • Amlexanox paste 5% (available as an oral adhesive tablet in some countries) has been shown to diminish pain as well as hasten resolution of ulcers. [26, 27, 28, 29] In patients with recurrent aphthous ulcers (canker sores) who have a good understanding and recognition of their disease, early application at the onset of burning or pricking mucosal sensation 1-2 days before the ulcer appears may significantly reduce the effects of the disease. [30]

  • Metalloproteinase inhibitors include tetracycline, doxycycline and minocycline. These agents, such as doxycycline in a hydrogel or minocycline 0.2% oral rinse solution, [31] demonstrate significant improvement in ulcer healing as well as pain reduction, all at low doses without likelihood of systemic effects or alteration in oral flora. [32, 33, 31] This class of agents should not be used in women who are pregnant or in children.

Symptomatic therapy includes anesthetic and occlusive agents. These agents are commonly used when the ulcers are small and few, to minimize pain and improve oral intake, although some have been found to hasten ulcer healing.

  • Benzocaine is the most commonly used anesthetic agent, applied for temporary relief with cotton-tipped applicator on an as needed basis (usually before meals). Numerous preparations of between 6.4% and 20% benzocaine are available for use over-the-counter, including Anbesol, Hurricaine Liquid and Gel, Kank-A, Orabase B, Oralief, Senso-gard, Tanac, and Zilactin B. Benzocaine has not been studied in clinical trials or shown to improve healing. Excess use can lead to neurotoxicity.

  • Lidocaine 2% gel (by prescription only) can also be used, but can also cause toxicity in children.

  • The antihistamine diphenhydramine used as a swish-and-spit mouth rinse, or applied locally, may provide some pain relief. Diphenhydramine syrup is commonly mixed in a 50:50 dilution with magnesium containing antacid.

  • Local injectable anesthetics (lidocaine, bupivacaine) are discouraged because duration of pain relief is brief.

  • Sucralfate suspension (off-label use) may diminish pain without change in ulcer healing. [34]

  • Paste preparations, such as Orabase alone or in combination with 20% benzocaine (Orabase-B) can be temporarily effective for pain relief.

  • Bioadhesive "super-glues", such as 2-octyl cyanoacrylate or isobutyl cyanoacrylate (Iso-Dent) have been studied in children, [35] and significantly improves ulcer pain, without measurable difference in ulcer healing. [36, 37] Orabase Sooth-N-Seal is a cyanoacrylate product available over-the-counter.

  • Debacterol Canker Sore Pain Relief (available by prescription only in the United States) or HybenX (over-the-counter in Europe) as a single application to the ulcer, significantly diminishes pain. [40] This agent works by disruption (desiccation, denaturation, and coagulation) of the microbial biofilm matrix. [41]

  • Over-the-counter glycyrrhiza (licorice) bioadhesive hydrogel patch (CankerMelts GX patches) enhances ulcer healing in addition to reducing pain. [42, 43, 44]

  • An oral bioadherent containing polyvinylpyrrolidone and sodium hyaluronate gel (Gelclair) is used primarily for relief of oral mucositis associated with cancer chemotherapy or irradiation and is also indicated for pain control in severe, refractory, recurrent aphthous ulcers (canker sores). [45] Available by prescription only, Gelclair is mixed with 15 mL of water, stirred, rinsed around the mouth, gargled, and expectorated. At least 30-60 minutes must elapse after use before eating.

Many natural therapies have been suggested in the treatment of aphthous ulcers. El-Haddad et al noted reductions in ulcer pain, size and erythema with topical honey in a Saudi cohort of 94 subjects with minor aphthous ulcers. [54]  Adhesive patches with 7% alum used three times daily significantly decreased aphthous ulcer size and pain, hastening recovery in subjects with recurrent aphthous ulcers. [98]  A mucoadhesive patch which releases citrus oil and magnesium salt (Canker Cover) has been effective in reducing pain and decreasing healing time without adverse effects. [38, 39]  Ozone in air and ozonated oil have also been shown to be effective in relieving recurrent aphthous ulcer pain and size. [102]   [94]  Additional studies are needed to confirm these promising results.

Immunomodulators, including colchicine, [46, 25] dapsone, [47] clofazimine, [48] cyclosporine, interferon, tumor necrosis factor antagonists (infliximab, etanercept, adalimumab, pentoxifylline), [47, 101] T-cell modulator modifiers (efalizumab, alefacept), antimetabolites (methotrexate), alkylating agents (cyclophosphamide) and thalidomide [49] are used in severe, refractory cases, such as in patients with human immunodeficiency virus (HIV) or acquired immunodeficiency syndrome (AIDS) [50, 51] or Behçet syndrome. [52, 53] However, the indications and uses of such therapy are beyond the scope of this article, and adverse effects can be both problematic and clinically significant. The patient must be closely observed; therefore, use of this therapy stretches beyond the scope of practice of most primary care providers.

 

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Surgical Care

Few patients are unresponsive to the local or systemic therapies described above; however, several other invasive and specialized treatments are available for patients with persistent or severe lesions.

  • Laser therapy is perhaps one of the most intriguing treatments. Studies have shown that laser therapy of most aphthae immediately relieves pain, speeds healing, and reduces recurrences. [55, 56, 57, 58, 88] Limitations include impracticality of the treatment. Lasers are expensive, and specialized training is required to operate them. Patients who have severe disease or frequent recurrences may benefit from referral to a laser treatment center or specialist.

  • Controversy continues to surround the application of silver nitrate. This therapy promotes changing the lesion to a burn. Some studies revealed decreased pain severity [59] ; however, none have demonstrated shortened healing time. Additional and large studies are needed before this therapy can be recommended on a routine basis.

  • One of the more controversial therapies involves removing biopsy specimens from lesions as a therapeutic modality. When biopsy is performed, the lesion is changed from an immune-mediated lesion to a traumatic lesion. Some believe that these traumatic lesions are less painful and heal faster than typical aphthous ulcers. Limited data support this practice, and it cannot be recommended.

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Consultations

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  • Consultation may be necessary if an additional disease is strongly suggested or found.

  • Patients with severe disease may be referred to a laser specialist for evaluation and treatment.

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Diet

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  • Supplementation with vitamins (especially B12 and C), [60, 61, 62, 63] zinc, or iron may prevent recurrence in some individuals. Studies of lysine supplementation are preliminary and equivocal. [64]  A randomized, double-blind study on 42 patients reported data showing that vitamin B12 can be an effective analgesic treatment for aphthous ulcers. [65]

  • A gluten-free diet is unlikely to improve recurrent aphthous ulcers (canker sores) unless the patient has celiac disease (gluten-sensitive enteropathy), which may be present in as many as 5% of patients in whom recurrent aphthous ulcers (canker sores) are initially diagnosed.

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