Treatment algorithm

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

ACUTE

all patients

1st line – change toothpaste and avoid triggers

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ACUTE
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all patients
1st line – 

change toothpaste and avoid triggers

Patients should be advised to change their toothpaste to a sodium lauryl sulfate (SLS)-free formulation. An increased frequency of recurrent aphthous stomatitis (RAS) related to SLS-containing dentifrice has been reported, although other studies found no such association.[21] However, because SLS dentifrices are in widespread use, it seems unlikely that this agent truly predisposes to, or causes, most RAS.[6]

Patients should also be instructed to avoid recognized trigger foods, and acidic foods and drinks.[1]

For all patients, the possibility of local trauma (e.g., from sharp and/or broken teeth, dentures and orthodontic appliances, and biting during chewing) should be assessed, and appropriate dental treatment undertaken.[3] 

Plus – symptom relief

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ACUTE
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all patients
Plus – 

symptom relief

Treatment recommended for ALL patients in selected patient group

Topical therapies for symptom relief may be of benefit. These include topical anesthetics (e.g., lidocaine) and over-the-counter topical anti-inflammatory agents.[65]

Primary options

lidocaine oropharyngeal viscous solution: (2%) children: 1.25 mL every 3 hours when required (swish around in mouth and spit out), maximum 4 doses/12 hours; adults: 15 mL every 3 hours when required (swish around in mouth and spit out), maximum 8 doses/day

Consider – antibacterial mouthwash

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ACUTE
|
all patients
Consider – 

antibacterial mouthwash

Treatment recommended for SOME patients in selected patient group

Adjunctive antimicrobial agents may also be of some value, in part by reducing secondary infection. These may reduce the severity and pain of ulceration.[3]

Randomized controlled trials have shown that chlorhexidine oral solution can reduce the duration of recurrent aphthous stomatitis and increase the number of ulcer-free days.[51][52][53][54]

Topical tetracyclines used as rinses may also be effective.[55][56] These formulations need to be specially compounded. They may provide relief and reduce ulcer duration. Should be avoided in children less than 8 years of age as they may cause tooth discoloration and tooth staining. Patients should be advised to thoroughly brush teeth before use (as it stains the plaque on the teeth), and that it is not for regular long-term use.

Primary options

chlorhexidine oropharyngeal: (0.12%) children and adults: 10-15 mL as a mouthwash twice daily

Consider – oral vitamin B12

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ACUTE
|
all patients
Consider – 

oral vitamin B12

Treatment recommended for SOME patients in selected patient group

There is some evidence of benefit from vitamin B12, even in the absence of any deficiency; supplementation with oral vitamin B12 (cyanocobalamin) has been shown to be effective in studies, irrespective of serum B12 levels.[46][47][48]

Primary options

cyanocobalamin (vitamin B12): children: consult specialist for guidance on dose; adults: 1000 micrograms orally once daily

More

Consider – oral iron

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ACUTE
|
all patients
Consider – 

oral iron

Treatment recommended for SOME patients in selected patient group

Iron supplementation in adults and children may be necessary to prevent ulcers that are a result of iron deficiency anemia. Initial treatment is daily oral iron replacement therapy.[49]

Primary options

ferrous sulfate: children: 3 mg/kg orally once daily; adults: 65-130 mg orally once daily

More

OR

ferrous gluconate: children: 3 mg/kg orally once daily; adults: 65-130 mg orally once daily

More

OR

ferrous fumarate: children: 3 mg/kg orally once daily; adults: 65-130 mg orally once daily

More

OR

ferric maltol: adults: 30 mg orally twice daily

2nd line – topical corticosteroid

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ACUTE
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all patients
2nd line – 

topical corticosteroid

Topical corticosteroids are the mainstay of treatment if simple measures alone do not work.

A variety of different agents can be used, including a corticosteroid paste (a combination of a potent topical corticosteroid, such as triamcinolone, and dental paste), hydrocortisone buccal tablets, and betamethasone soluble tablets.[3] However, these specific formulations of hydrocortisone and betamethasone are not available in the US and corticosteroid mouth rinses may need to be specially compounded.

A more potent topical corticosteroid, such as betamethasone dipropionate, clobetasol, or fluocinonide, may also be used.[3] However, these drugs may need to be specially compounded in dental paste if they are not commercially available.

Treatment duration is case-dependent but there is no evidence of adrenal suppression with low-potency corticosteroids.

There are a limited number of topical corticosteroids that are licensed for oral use in children. If topical corticosteroids are needed, they can be used off-label, but only in children who can follow instructions with regards to spitting out the medication. This means that they usually cannot be used in children under 6 years of age. These treatments should only be started under specialist care after the child has been assessed and other causes of oral ulcers have been excluded.[64]

Primary options

triamcinolone topical: (0.1% paste) children: consult specialist for guidance on dose; adults: apply to the affected area(s) two to three times daily

Plus – symptom relief

Back
ACUTE
|
all patients
Plus – 

symptom relief

Treatment recommended for ALL patients in selected patient group

Topical therapies for symptom relief may be of benefit. These include topical anesthetics (e.g., lidocaine) and over-the-counter topical anti-inflammatory agents.[65]

Primary options

lidocaine oropharyngeal viscous solution: (2%) children: 1.25 mL every 3 hours when required (swish around in mouth and spit out), maximum 4 doses/12 hours; adults: 15 mL every 3 hours when required (swish around in mouth and spit out), maximum 8 doses/day

Consider – antibacterial mouthwash

Back
ACUTE
|
all patients
Consider – 

antibacterial mouthwash

Treatment recommended for SOME patients in selected patient group

Adjunctive antimicrobial agents may also be of some value, in part by reducing secondary infection. These may reduce the severity and pain of ulceration.[3]

Randomized controlled trials have shown that chlorhexidine oral solution can reduce the duration of recurrent aphthous stomatitis and increase the number of ulcer-free days.[51][52][53][54]

Topical tetracyclines used as rinses may also be effective.[55][56] These formulations need to be specially compounded. They may provide relief and reduce ulcer duration. Should be avoided in children less than 8 years of age as they may cause tooth discoloration.

Primary options

chlorhexidine oropharyngeal: (0.12%) children and adults: 10-15 mL as a mouthwash twice daily

Consider – oral vitamin B12

Back
ACUTE
|
all patients
Consider – 

oral vitamin B12

Treatment recommended for SOME patients in selected patient group

There is some evidence of benefit from vitamin B12, even in the absence of any deficiency; supplementation with oral vitamin B12 (cyanocobalamin) has been shown to be effective in studies, irrespective of serum B12 levels.[46][47][48]

Primary options

cyanocobalamin (vitamin B12): children: consult specialist for guidance on dose; adults: 1000 micrograms orally once daily

More

Consider – oral iron

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ACUTE
|
all patients
Consider – 

oral iron

Treatment recommended for SOME patients in selected patient group

Iron supplementation in adults and children may be necessary to prevent ulcers that are a result of iron deficiency anemia. Initial treatment is daily oral iron replacement therapy.[49]

Primary options

ferrous sulfate: children: 3 mg/kg orally once daily; adults: 65-130 mg orally once daily

More

OR

ferrous gluconate: children: 3 mg/kg orally once daily; adults: 65-130 mg orally once daily

More

OR

ferrous fumarate: children: 3 mg/kg orally once daily; adults: 65-130 mg orally once daily

More

OR

ferric maltol: adults: 30 mg orally twice daily

3rd line – systemic corticosteroid or colchicine

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ACUTE
|
all patients
3rd line – 

systemic corticosteroid or colchicine

If recurrent aphthous stomatitis (RAS) fails to respond to topical therapies, systemic therapies may be required.

Oral prednisone as a 1-week course tapered over a second week is one suggested regimen.[3]

The first-line systemic immunomodulator used in RAS and the mucocutaneous manifestations of Behcet syndrome is colchicine.[61]

Systemic treatments for RAS are rarely used in children under the age of 12 years, and are only commenced under specialist care. Colchicine is rarely used in children.

Primary options

prednisone: children: 0.5 to 1 mg/kg/day orally for 7 days, then taper over 7 days; adults: 30-60 mg orally once daily for 7 days, then taper over 7 days

Secondary options

colchicine: adults: 0.5 mg orally two to three times daily

Plus – symptom relief

Back
ACUTE
|
all patients
Plus – 

symptom relief

Treatment recommended for ALL patients in selected patient group

Topical therapies for symptom relief may be of benefit. These include topical anesthetics (e.g., lidocaine) and over-the-counter topical anti-inflammatory agents.[65]

Primary options

lidocaine oropharyngeal viscous solution: (2%) children: 1.25 mL every 3 hours when required (swish around in mouth and spit out), maximum 4 doses/12 hours; adults: 15 mL every 3 hours when required (swish around in mouth and spit out), maximum 8 doses/day

Consider – antibacterial mouthwash

Back
ACUTE
|
all patients
Consider – 

antibacterial mouthwash

Treatment recommended for SOME patients in selected patient group

Adjunctive antimicrobial agents may also be of some value, in part by reducing secondary infection. These may reduce the severity and pain of ulceration.[3]

Randomized controlled trials have shown that chlorhexidine oral solution can reduce the duration of recurrent aphthous stomatitis and increase the number of ulcer-free days.[51][52][53][54]

Topical tetracyclines used as rinses may also be effective.[55][56] These formulations need to be specially compounded. They may provide relief and reduce ulcer duration. Should be avoided in children less than 8 years of age as they may cause tooth discoloration.

Primary options

chlorhexidine oropharyngeal: (0.12%) children and adults: 10-15 mL as a mouthwash twice daily

Consider – oral vitamin B12

Back
ACUTE
|
all patients
Consider – 

oral vitamin B12

Treatment recommended for SOME patients in selected patient group

There is some evidence of benefit from vitamin B12, even in the absence of any deficiency; supplementation with oral vitamin B12 (cyanocobalamin) has been shown to be effective in studies, irrespective of serum B12 levels.[46][47][48]

Primary options

cyanocobalamin (vitamin B12): children: consult specialist for guidance on dose; adults: 1000 micrograms orally once daily

More

Consider – oral iron

Back
ACUTE
|
all patients
Consider – 

oral iron

Treatment recommended for SOME patients in selected patient group

Iron supplementation in adults and children may be necessary to prevent ulcers that are a result of iron deficiency anemia. Initial treatment is daily oral iron replacement therapy.[49]

Primary options

ferrous sulfate: children: 3 mg/kg orally once daily; adults: 65-130 mg orally once daily

More

OR

ferrous gluconate: children: 3 mg/kg orally once daily; adults: 65-130 mg orally once daily

More

OR

ferrous fumarate: children: 3 mg/kg orally once daily; adults: 65-130 mg orally once daily

More

OR

ferric maltol: adults: 30 mg orally twice daily

4th line – specialist referral

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ACUTE
|
all patients
4th line – 

specialist referral

The use of additional agents above systemic corticosteroids and colchicine are typically provided under specialist supervision. For example, the use of systemic immunomodulators or anti-inflammatory agents, such as azathioprine or thalidomide, may be considered following referral.[1][3][45][59][60] There is weak evidence to support the use of azathioprine.

Thalidomide is rarely used, only prescribed by specialists with experience in its use, and would never be commenced in primary care - there may be tight legislation around the prescribing of it.

The use of thalidomide in RAS is supported by data both in RAS and in patients with aphthous-like ulceration in HIV infection.[62][63] In these patient groups, open and double-blind studies have shown that thalidomide is the most reliably effective agent available for the management of severe, refractory RAS.[6] However, great caution is required for its use in patients with RAS and specialist referral is recommended.[1][3] Men and women require effective contraception during treatment and for 1 month before and 1 month after use of thalidomide.

Thalidomide is not used in children unless in exceptional circumstances and would only ever be instigated by a specialist team.

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Choose a patient group to see our recommendations

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer

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