• Table 1 shows the types of mouth ulcers that may be evident.

• Perform a full history and examination. Assess concurrent symptoms, psychological state, social needs, and spiritual needs. See the CKS topic on Palliative cancer care - general issues.
• Assess the person's:
• Understanding of the diagnosis and their current problems, and how they and their family/carer are coping.
• Nutritional status and whether their fluid intake is adequate.
• Level of oral hygiene, and whether they can carry out routine oral care.
• Estimate the likely prognosis, if possible. For further information, see Prognostic Indicator Guidance (pdf).

In depth

• Treat the cause of the ulcer.
• Prevent secondary infection with regular mouth care. Twice-daily chlorhexidine mouthwashes can also be used in the short term but may not be suitable for all people, as the alcohol content can sting. See Choice of mouthwash for more information.
• Treat the pain of the ulcer (see Managing oral pain for further information).

In depth

• 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.
• Triamcinolone in an adhesive paste (Adcortyl in Orabase^®) has been discontinued.
• For severe recurrent aphthous ulcers doxycycline mouthwash can be used (which can be made up by stirring the contents of a doxycycline 100 mg capsule into a small amount water and rinsing around in the mouth for 2 to 3 minutes, four times a day).
• 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.

In depth

• Advise bed rest, maintenance of adequate fluid intake and use of antipyretics where necessary.
• In immunocompetent people who are in the early stages of an uncomplicated herpes simplex infection in the locality of the lips, commence topical aciclovir or penciclovir.
• In immunocompetent people who are in the early stages of an intraoral herpes infection, commence oral aciclovir.
• In immunocompromised people commence oral aciclovir urgently wherever the herpes simplex infection is located.
• Admit people with severe infection or people who are severely immunocompromised.

In depth

• Ensure effective wound cleansing through regular mouth care.
• If anaerobic organisms are present (as indicated by a foul smell), metronidazole is recommended. Discuss the dose and length of treatment with a specialist. Long-term use of metronidazole may be appropriate in some people.
• For bleeding ulcers, seek the advice of a specialist.

In depth

• Seek urgent specialist advice if neutropenia is suspected from the appearance of the ulcer (see Examination) or if confirmed by a blood test.

In depth

• Follow-up depends on the underlying cause.

• Refer or seek specialist advice if there is doubt about diagnosis or management of any oral problem. Refer if:
• Oral problems are causing a decrease in oral intake or there are concerns about nutrition.
• Mucositis is uncontrolled or problematic.
• Oral ulcers are bleeding.
• Taste disturbance is likely to be prolonged. Refer to a dietitian.
• Pain is difficult to manage.
• There is severe candida infection.
• There are communication problems. Consider referral to a speech and language therapist.