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Palliative cancer care - oral problems - Management
How should I treat aphthous ulcers?

  • Correct any underlying iron, folate, or vitamin B12 deficiency if the prognosis allows.
  • Topical corticosteroids:
    • Hydrocortisone lozenges are best used in the prodromal period, before the ulcer develops.
    • Beclometasone spray or betamethasone soluble tablets are more potent and are generally reserved for use when ulceration is extensive, or is at a difficult-to-reach site.
  • Use doxycycline mouthwash for severe recurrent aphthous ulceration.
  • Chlorhexidine mouthwash can be used to prevent secondary bacterial infection.
  • For management of pain associated with aphthous ulcers, see Managing oral pain.
  • For severe persistent ulceration, seek specialist advice.
Clarification / Additional information
  • Treatment choices should be guided by disease severity (pain), the frequency of flare-ups, and the tolerability of medication.
  • When using topical corticosteroids, a short course should be given. Beclometasone inhaler or betamethasone soluble tablets are more potent, but the risk of systemic adverse effects and oral candidiasis is increased. They are generally reserved for use when ulceration is extensive or is at a difficult-to-reach site.
  • Doxycycline mouthwash can be made up by dispersing the contents of a doxycycline 100 mg capsule in water and rinsing the solution around in the mouth for 2 to 3 minutes, four times a day [BNF 52, 2006]. It may cause oral candidiasis and a burning sensation of the pharynx [Porter et al, 2000].
  • Chlorhexidine gluconate 0.2% mouthwash is used for aphthous ulcers (particularly if it is too painful to brush teeth). It should not be used at the same time as nystatin because it reduces the activity of nystatin [Milligan et al, 2001].
  • Persistent and severe ulcers may respond to thalidomide (unlicensed use), but this can only be prescribed under specialist supervision.
Basis for recommendation
  • The recommendations are based on those in the CKS topic on Aphthous ulcer.
  • Topical corticosteroids: there are few studies to support their use, but some evidence indicates that they reduce the duration of ulcers and hasten pain relief without causing notable local or systemic adverse reactions [Porter and Scully, 2006]. Triamcinolone in an adhesive paste (Adcortyl in Orabase®) has been discontinued.
  • Chlorhexidine mouthwash: some evidence indicates that it reduces the duration and severity of aphthous ulcers [Porter and Scully, 2006]. It can stain the plaque on teeth brown.
  • Tetracycline used to be recommended, but because tetracycline capsules are no longer available in the UK, doxycycline capsules are generally used.

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