• If possible, identify any predisposing factors and discuss how these may be minimized or avoided.
• Offer symptomatic treatment for pain, discomfort, and swelling, especially when ulcers are causing problems with eating. Treatment includes:
• A short course of a low-potency topical corticosteroid (e.g. hydrocortisone lozenges).
• Encourage people with prodromal symptoms, such as tingling or swelling, to apply corticosteroids at this stage. Otherwise, corticosteroids should be applied as soon as the ulcers appear.
• An antimicrobial mouthwash (e.g. chlorhexidine gluconate) to prevent secondary bacterial infection, particularly if it is too painful to brush the teeth.
• A topical analgesic (e.g. benzydamine hydrochloride) if ulcers are very painful.
• If ulcers are infrequent, mild, and not interfering with daily activities (e.g. eating), treatment may not be needed.
• Advise the person to return if there is worsening of, or no improvement in, symptoms with treatment, or if the ulcer persists after 3 weeks.
• Consider referral for a biopsy for anyone who has an ulcer lasting longer than 3 weeks.

• Minimization of precipitating factors might include:
• Oral trauma: use a softer toothbrush, and avoid hard or sharp foods such as toast.
• Anxiety or stress: try relaxation techniques (e.g. yoga, meditation, exercise).
• Certain foods: if there is an obvious relationship to particular foods these are best avoided.
• Stopping smoking: explain that smoking cessation may precipitate ulceration, but that this will settle and the overall health benefits are greater than the short-term discomfort; nicotine replacement therapy may provide some relief.

[Scully et al, 2003; Scully, 2006; Gonsalves et al, 2007]

• Aphthous ulcers will usually heal within 14 days, even without treatment. If an ulcer persists for longer than 3 weeks without an apparent cause, the ulcer may be malignant and the person should be referred for a biopsy.

• These recommendations are consistent with expert opinion from current medical literature [Scully et al, 2003; Scully, 2006; Gonsalves et al, 2007].
• Stopping smoking has been identified as a risk factor for recurrent aphthous ulceration, with people often citing this as one of the reasons they started smoking again. Case studies [Bittoun, 1991] and one non-randomized study [Marakolu et al, 2007] suggest that smokers quitting with nicotine replacement therapy (NRT) may be less likely to develop mouth ulcers than those quitting without. One further study found that people using bupropion to stop smoking had similar mouth ulcer ratings to those using NRT [McRobbie et al, 2004].
• There is only limited evidence to support the use of topical treatments:
• Topical corticosteroids: there is some evidence that they reduce the duration and severity of ulcers, but not the incidence of new ulcers. Triamcinolone in adhesive paste (Adcortyl in Orabase^®) has been discontinued.
• Antimicrobial mouthwashes: there is some evidence that they reduce the duration and severity of ulcers, but not the incidence of new ulcers.
• Local analgesics: there is very limited evidence available to make a recommendation regarding their use, but some people may find them useful if ulcers are very painful.