• Ask about possible precipitating factors.
• Ask about the frequency and duration of episodes, and the severity of any associated pain, as this will guide management.
• Ask about previously tried treatments (either over-the-counter or prescribed medicines).
• Consider alternative diagnoses or an underlying condition if the ulcers first occur later in life (e.g. more than 30 years of age), have lasted for longer than 3 weeks, affect atypical sites in the mouth (e.g. the palate or gums), affect extra-oral sites (e.g. genitalia), or are associated with systemic features (see Differential diagnosis).
• Consider investigations (e.g. full blood count, eosinophil sedimentation rate, ferritin, folate and vitamin B₁₂) to rule out underlying disease if ulceration frequently recurs.

• Frequency and duration of episodes, and severity of pain can be considered as follows:
• A single one-off ulcer is often caused by damage to the mouth, like biting the cheek, or damage to the gum with a toothbrush or a sharp tooth or filling. They usually go away once the source of the problem is treated.
• Some people have ulcers that occur just a few times a year and last for only a few days. Pain is usually tolerable.
• In some people ulcers occur at monthly intervals and are usually painful.
• Less commonly, ulcers occur continuously; by the time one ulcer heals, another has developed. These ulcers are usually extremely painful.

[Scully et al, 2003; Scully, 2006]

• Experts recommend identification and avoidance of precipitating factors where possible, to minimize recurrence [Scully et al, 2002].
• Frequency, duration, and severity of pain will help to determine the management of aphthous ulcers [Scully et al, 2003].
• Onset of aphthous ulceration after 30 years of age, systemic symptoms, and presence of extra-oral ulcers suggest that the ulcers are part of a more complex disorder that warrants further investigation [Scully et al, 2003].

• 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.

• Refer people with suspected malignancy:
• Anyone with persistent symptoms or signs related to the oral cavity in whom a definitive diagnosis of a benign lesion cannot be made should be referred or followed up until the symptoms and signs disappear. An urgent referral should be made if the symptoms and signs have not disappeared after 6 weeks.
• An urgent referral should be made for anyone who presents with unexplained red and white patches (including suspected lichen planus) of the oral mucosa that are painful, swollen, or bleeding.
• An urgent referral should be made for anyone with unexplained ulceration of the oral mucosa or mass persisting for more than 3 weeks.
• A non-urgent referral should be made for anyone with unexplained red and white patches (including suspected lichen planus) of the oral mucosa that are not painful, swollen, or bleeding. If oral lichen planus is confirmed the patient should be monitored for oral cancer as part of routine dental examination.
• Refer people with a suspected underlying cause of aphthous-like ulceration, suggested by history, examination, or results of investigations (see Differential diagnosis).
• Refer people if ulceration is particularly painful and disabling, or if recurrences are frequent and severe and not adequately relieved by symptomatic treatments.
• Refer to a dentist anyone with a suspected localized dental cause of recurrent ulceration, such as poorly-fitting dentures or a damaged tooth. This may be suggested by recurrent ulceration in the same place.

• Referral routes may vary depending on locality, but would usually be to an oral medicine department or to an oral and maxillofacial department.

• The recommendations for referral of people with suspected malignancy are based on the referral guidelines for suspected cancer published by the National Institute for Health and Clinical Excellence (NICE) [NICE, 2005]. A biopsy should be considered for solitary or multiple ulcers that last more than 3 weeks [Scully, 2006].
• Referral is recommended for people with a suspected underlying cause of aphthous-like ulceration, to identify and manage any underlying disease [Scully et al, 2003].
• For people whose symptoms are not adequately relieved by topical corticosteroids, antimicrobial mouthwashes, and local analgesia, experts recommend referral to an oral medicine specialist for further treatment (e.g. more potent topical corticosteroids, doxycycline mouthwash, systemic corticosteroids, or immunosuppressants) [Scully et al, 2003].