Australian Dental Journal

The official journal of the Australian Dental Association

Australian Dental Journal 2010; 55:(1 Suppl): 14–22
doi: 10.1111/j.1834-7819.2010.01195.x

The patient with recurrent oral ulceration
AA Talacko,* AK Gordon,* MJ Aldred*
*Dorevitch Pathology, Heidelberg, Victoria.

ABSTRACT
This paper discusses the range of recurrent oral ulceration which affects the oral mucosa. Types of ulceration covered in this
paper include traumatic, infective, aphthous, ulceration related to the oral dermatoses, drug-induced, ulceration as a
manifestation of systemic disease and ulceration indicating malignancy. Aspects of the aetiology, diagnosis and management
of common oral recurrent ulcerative conditions are reviewed from a clinical perspective as an aid to practising dentists.
Keywords: Ulceration, aetiology, diagnosis, clinical features, histopathological features, treatment.
Abbreviations and acronyms: ANUG = acute necrotizing ulcerative gingivitis; HHV-1 = human herpes virus-1; LE = lupus erythematous;
MMP = mucous membrane pemphigoid; RAU = recurrent aphthous ulceration.

INTRODUCTION
The diagnosis and management of the patient with
recurrent oral ulceration requires a systematic approach
based on the principles of taking an adequate history,
clinical examination, investigations as appropriate,
institution of management and, finally, review to allow
for any necessary modifications of that management. It
is worthwhile to begin with a definition of an ulcer: an
ulcer is a complete breach of the epithelium. This
becomes covered with a fibrin slough and appears as a
yellow ⁄ white lesion surrounded by erythema.
DISCUSSION
History
It is assumed that the patient will be complaining of
ulcers. Patients (and sometimes referring practitioners)
may use the term loosely to include red lesions, normal
structures such as the lingual tonsil and foliate papillae
or the circumvallate papillae of the tongue and ‘‘a
feeling of ulcers’’. It is important at this stage of the
proceedings to establish the precise nature of the
patient’s complaint. Assuming that it can be established
that the patient is describing ulcers, as opposed to other
lesions, the history of the present complaint can be
elicited.
The age of the patient may be of relevance in relation
to the age of onset of the ulceration. A child or
14

adolescent presenting with recurrent oral ulceration
may pose a different diagnostic and management
dilemma compared to an older patient. Some types of
recurrent oral ulceration have a typical onset in
childhood or adolescence (such as recurrent aphthous
ulceration ⁄ stomatitis). This pattern of oral ulceration
can sometimes present in later life but a middle-aged or
elderly patient presenting with recurrent oral ulceration
should also raise other diagnostic possibilities such as
lichen planus and vesiculobullous disorders. The duration of the ulceration is partly related to the age of onset
and age at presentation and will also depend upon
whether the ulcers are persistent or intermittent.
Persistent ulceration may include recurrent oral ulceration but patients may need assistance in clarifying
whether their ulcers are persistent by virtue of successive ulcers appearing over a period of time or persistence of a single ulcer or multiple lesions. A more
typical pattern of recurrent oral ulceration will be
characterized by periods of ulceration with remissions
between bouts of ulceration. The progression of the
ulceration since onset can be helpful in establishing
whether the ulceration is becoming more severe.
Assuming that there are multiple ulcers, their number,
size, shape and location are important factors in
establishing a diagnosis. Some patients complain of an
altered sensation prior to ulcer development which is
known as a prodromal phase.
The patient may have had previous opinions and
details of previous investigations and diagnoses should
ª 2010 Australian Dental Association

Minor recurrent aphthous ulceration will tend to present with several more or less circular ulcers on ª 2010 Australian Dental Association Trauma Traumatic ulceration may be recurrent if the offending irritant is not removed. Intraoral examination should assess the presence or absence of ulcers. Assessment of skin and conjunctival pallor may assist in identifying anaemic patients. Because some patients with recurrent oral ulceration may have extraoral manifestations. Bleeding. The medical history will include ascertaining any medication taken by the patient.Recurrent oral ulceration Oral ulceration which appears after dental treatment can be an indicator of minor recurrent aphthous ulceration. Viral infection Recurrent intraoral viral infection is usually limited to secondary herpes simplex virus. This may occur in the palate or buccal sulcus and would raise a suspicion of recurrent intraoral herpes simplex virus infection – effectively an oral ‘‘cold sore’’. whereas in mucous membrane pemphigoid the blisters. A pattern of more ragged ulceration. they heal with scarring. thermal or chemical in nature. The presence or absence of scarring should be established. methotrexate. Recurrent 15 . the provisional diagnosis will be based on the history alone and the patient should be asked to return when the ulcers next appear. would raise the possibility of a vesiculobullous disorder. Similarly. Some medications are associated with oral ulceration. The regional lymph nodes should be palpated as these may be enlarged in the case of persistent or large ulcers. Erythema of the buccal mucosa and ⁄ or lateral ⁄ ventral surfaces of the tongue with superimposed striae would be typical of lichen planus and this may become ulcerated by breakdown of the erythematous (eroded) epithelium into an irregular ulcer. shape. It is helpful to establish whether there has been any benefit from any of these treatments. The number. These may include anaemia. If this is not the case then a presumptive diagnosis can be made at the end of the initial consultation and the patient reviewed when the ulcers next appear. Minor trauma to the tissues can precipitate ulcers in susceptible patients. autoimmune disease and diabetes. blood dyscrasias. Clinical distinction between the two can be difficult but in pemphigus vulgaris the vesicles are short-lived and therefore infrequently seen. Ulcers related to a denture margin may also come within the category of recurrent oral ulceration. can persist for longer. Alternatively. which would raise a clinical suspicion of Behc¸et’s syndrome. Medical history Many patients with recurrent oral ulceration are in good health but some may have pre-existing medical problems which may be of relevance.. At this stage it is reasonable to ask the patient whether they have any ulcers present at the time of the consultation. perhaps with peeling of the adjacent epithelium. crusting and ulceration of the lips should raise a suspicion of erythema multiforme. Examination Causes of oral ulceration be sought. Some patients with recurrent oral ulceration may have a vesiculobullous disorder and questioning regarding any awareness of blistering before the ulcers appear should be pursued. The recurrences are most commonly due to human herpes virus-1 (HHV-1) (which usually causes orofacial infections). Major aphthous ulcers tend to be larger (>10 mm diameter) and are more commonly seen in the oropharynx. Specific investigations may be performed. by virtue of their full-thickness roof. This requires some flexibility in appointments so that the patient can be seen in the period when the ulcers are present. the buccal ⁄ labial mucosa and lateral and ventral surfaces of the tongue. questions should be directed to any skin involvement or other systems being affected such as the eyes or genital regions. The irritant may be mechanical. these may comprise haematological investigations.g.1 Dental history Extraoral examination should focus on general appearance including a crude measure of nutritional status. size and location of the ulcers should be recorded. the presence of the denture could localize recurrent minor aphthous ulceration. lichen planus or a vesiculobullous disorder. e. In such a case it may simply be a recurrent traumatic ulcer related to the denture. At this stage. In a patient with herpetiform ulceration. If there are no ulcers at the time of the consultation. multiple pinpoint ulcers would typically be seen on the non-keratinized mucosa with the possibility of more ragged ulcers by virtue of adjacent ulcers enlarging and fusing. it may be possible to establish a provisional diagnosis based on the history and examination. any previous proprietary or prescribed treatments should be elicited. such as mucous membrane pemphigoid or pemphigus vulgaris. Some patients may report a crop of ulcers at the same site in the mouth occurring after dental treatment.

may be recurrent. ulcerative colitis or a malabsorption syndrome can present with recurrent oral ulceration. After primary infection. Gastrointestinal disease Gastrointestinal disease such as coeliac disease. In most patients. Nutritional deficiency Xerostomia A nutritional deficiency such as a deficiency of iron. do not automatically assume that any medication being taken by a patient with oral ulceration is the cause of their ulcers. the successive bouts of ulceration along the gingival margins lead to blunting of the interdental papillae. but in immunocompromised patients secondary herpetic lesions can be widespread. The xerostomia may be multifactorial in origin and may be due to autoimmune disease such as Sjo¨gren’s syndrome or the side effects of medications such as antidepressant medications. Ulceration due to bacterial infection. These infections may become recurrent if the patient is immunocompromised.AA Talacko et al. e. (a) (b) Fig 1. Haematological disorders Haematological disease such as leukaemia. where it lies dormant.. Xerostomia may predispose to recurrent oral ulceration. In perhaps one-third of individuals the virus can be reactivated by non-specific stimuli. especially if dentures are worn. folate or vitamin B12 may predispose the patient to recurrent oral ulceration and it may aggravate RAU. the ulcers first appear in childhood or adolescence. methotrexate may have a side-effect of oral ulceration (Fig 1). The lesions usually resolve in about 7 to 10 days in healthy individuals. In this case. the ulceration is persistent and progressive in nature.. the initial presentation is of fluid-filled vesicles which rapidly break down to form a cluster of small ulcers with ragged margins. However.g. when it travels back to the periphery to cause secondary oral mucosal lesions. 16 Neoplastic disease Although oral neoplastic disease may present with oral ulceration. The aetiology of the condition is not completely understood but is thought to be immunologically-based. the virus is not eliminated from the body but migrates along nerve fibres to the trigeminal ganglion. Crohn’s disease. Drug-induced ulceration of the tongue (a) and palate (b).g. very slow to heal and refractory to treatment. illnesses associated with fever. Factors that predispose to or precipitate the disease are more fully understood ª 2010 Australian Dental Association . there may be a slight female predisposition and in some patients there is a family history of similar ulceration which suggests a genetic factor. pancytopaenia. Clinically. reportedly affecting up to 20% of the population. Medications A number of medications. Other viral infections occurring in the mouth are due to varicella-zoster virus and coxsackie virus. oral HHV-2 lesions (which are usually associated with genital infections) are rare. This sideeffect may be dose-related. as in acute necrotizing ulcerative gingivitis (ANUG). Recurrences may be more likely if the patient has compromised general health. Specific conditions to consider Recurrent aphthous ulceration (RAU) is the most common form of recurrent oral ulceration. ANUG tends to be more prevalent in winter months and there is an association with smoking. aplastic anaemia or agranulocytosis may present clinically with ulceration but this ulceration is unlikely to be recurrent. e.

major aphthae or herpetiform ulceration may have difficulty eating and talking. Oral dermatoses These conditions largely comprise lichen planus. This form of ulceration begins as small round ulcers. although less common conditions such as dermatitis herpetiformis also affect the mucosa and may present clinically as recurrent oral ulceration. The ulcers can take up to two weeks to heal (without scarring) and later recur. but occur on any part of the oral mucosa including keratinized regions such as the hard palate and dorsum of the tongue as well as the oropharynx and can be larger than 10 mm in diameter (Fig 3). they tend to occur on the lip and cheek mucosa and lateral margins of the tongue. mucous membrane pemphigoid. Recurrent aphthous ulceration can occur in three forms: (1) Minor recurrent aphthous ulceration – this is the most common form. They tend to be persistent. palate and gingivae. All forms of aphthous ulceration produce significant discomfort and patients with severe minor aphthae. Fig 4. lasting for at least one month. heal with scarring. accounting for approximately 80–90% of cases. A major aphthous ulcer on the soft palate. Note the erythematous margin. although some patients are rarely without ulcers. Thus. usually at intervals of a few weeks or months. which are present in large numbers (up to 100). approximately 1 mm in diameter (Fig 4). The ulcers are usually round or oval and occur on the non-keratinized oral mucosa. sometimes termed severe minor RAU. In the buccal or labial sulcus the ulcers may be linear (Fig 2). ª 2010 Australian Dental Association This condition has been estimated to affect 1% of the population. The ulcers are similar to those of minor recurrent aphthous ulceration. Minor aphthous ulcers in the maxillary buccal sulcus.2 being more prevalent with increasing age. (2) Major recurrent aphthous ulceration – this form is much less common and accounts for about 5–10% of cases. (3) Herpetiform ulceration – this has a similar prevalence to major RAU. The ulcers heal without scarring after 1 to 2 weeks and then recur. It can occur as a skin or a mucosal disorder or may 17 . sparing the dorsum of the tongue. Some patients have ulceration which is intermediate between minor and major RAU. Lichen planus Fig 2. They usually occur on the non-keratinized mucosa but any part of the oral mucosa may be affected. Although these ulcers commonly develop in childhood. Herpetiform ulceration on the lower lip mucosa. These coalesce to produce larger ulcers with irregular margins.Recurrent oral ulceration and identification and elimination of these factors may be useful in management of the patient. The ulcer is large and irregular in shape. One to five ulcers usually occur at a time and they are approximately 5 mm in diameter. some patients develop them later in life. Fig 3. pemphigus vulgaris and erythema multiforme. and then recur. One or two ulcers generally occur at any one time.

hence long-term review is recommended. but may also affect other mucosal surfaces including the conjunctiva to produce scarring (and sometimes blindness). such as some dysplastic lesions. Lichen planus presenting as a desquamative gingivitis. 18 The clinical features may be of assistance in establishing a diagnosis. Diagnosis of mucous membrane pemphigoid Fig 5. Diagnosis of lichen planus The clinical features of lichen planus often make it relatively simple to recognize. The erythematous areas may merge into regions of ulceration which are invariably painful (Fig 5). but a definitive diagnosis can only be ª 2010 Australian Dental Association . Clinical features of mucous membrane pemphigoid (b) Mucous membrane pemphigoid (MMP) is a vesiculobullous disease which can cause lesions anywhere on the oral mucosa. The vesicles may sometimes present as blood blisters. with some evidence of a female predilection. This will assist in the distinction between lichen planus and lupus erythematosus and white patches mimicking lichen planus. Symptomatic lesions tend to have the typical striations or plaques on an erythematous mucosal base. Some drugs and other agents can cause ‘‘lichenoid’’ reactions. There may be little evidence of vesicle formation in these cases and the differential diagnosis will need to include lichen planus. they tend to rupture within 24 hours to produce ulceration (Fig 7). but it is advisable for the patient to have a biopsy for histopathological examination. The cause is unknown. Asymptomatic lichen planus is often seen clinically as white lace-like patterns or plaques on uninflamed mucosa of the cheeks. it may be asymptomatic or cause a range of symptoms from occasional minor discomfort to distressing pain some. Fig 6. This involvement of the gingivae is more extensive than the more common gingivitis due to poor oral hygiene and may be painful to varying degrees. It is more common in older patients. the mechanism appears to be immunologically-mediated. There is a very small but recognized risk of malignant transformation in lichen planus. which may heal with scarring. Occasionally only the gingivae are affected and appear red and inflamed in the absence of dental plaque (desquamative gingivitis). Lichen planus presenting as ulceration surrounded by faint white striae on the ventral surface of the tongue (a) and erythema of the buccal mucosa (b). hence the term cicatricial pemphigoid. tongue and sometimes the gingivae. Although the vesicles are more robust than in pemphigus vulgaris. Lichen planus may affect only the gingivae – appearing as a ‘‘desquamative gingivitis’’ with erythema of the marginal and attached gingivae (Fig 6). which are identical to lichen planus. Mucous membrane pemphigoid (a) This autoimmune disease is uncommon and is often limited to the oral mucosa. Clinical features of lichen planus When lichen planus affects the oral mucosa. affect both skin and mucosa. particularly if the lesions are bilateral and symmetrical. all or most of the time. including immunofluorescence.AA Talacko et al.

reported to have a greater prevalence in Ashkenazi Jews. The lips are often swollen. either in sections or in smears from the lesions. Serological tests may demonstrate the presence of circulating autoantibodies. Clinical features of pemphigus vulgaris The disorder typically presents first in older patients. Fig 9. Acantholytic cells (Tzanck cells) may be found in the vesicle fluid. which soon rupture. typical ‘‘target’’ lesions may be produced. oral mucosa. By this means. It appears to be an immunological disorder of a hypersensitivity type in which immune complexes are formed and consequent tissue damage occurs. A collapsed vesicle on the maxillary alveolar mucosa in a patient with mucous membrane pemphigoid. Patients develop thin-walled intraepithelial vesicles. Ulceration of the tongue mucosa in a patient with pemphigus vulgaris. In a significant number of cases. The condition is seen most commonly in adolescents and young adults and may be drug-induced or associated with an infection.Recurrent oral ulceration Diagnosis of pemphigus vulgaris Because of the often non-specific clinical appearance of the oral lesions. ª 2010 Australian Dental Association Clinical features of erythema multiforme When the skin is involved. ulcerated and crusted with blood – this is regarded as a sine qua non for diagnosis by some people (Fig 9). patients are often unaware of blistering because of the rapid breakdown to form ulcers (Fig 8). it will be seen that there is separation of the epithelium from the connective tissue at the level of the basement membrane zone and that the basement membrane zone in adjacent intact epithelium gives positive (usually IgG) immunofluorescence. However. oral mucosal lesions are the first presentation of the disease. Pemphigus vulgaris This is a relatively uncommon autoimmune disease. 19 . which involves the skin. Fig 7. Stevens-Johnson syndrome is a more severe and generalized form of erythema multiforme. Immunofluorescence is invariably positive for IgG around the prickle cells. including immunofluorescence. diagnosis is almost entirely dependent on histopathological examination including positive immunofluorescence findings. The episode(s) may last for several weeks. the clinical appearance is often nonspecific. reached by histopathological examination. which may be recurrent. The characteristic histological finding is an intraepithelial split occurring close to the basal cells. commonly Herpes simplex or Mycoplasma pneumoniae. but when the mucosa of the mouth is the only site involved. Erythema multiforme with extensive bleeding. This has recently ruptured but will soon become an ulcer covered by a fibrin slough. Widespread irregular shallow mucosal ulceration is usually present with sloughing and haemorrhage. Fig 8. ulceration and crusting of the lower lip. Erythema multiforme This is an acute onset disorder.

ª 2010 Australian Dental Association . associated events (such as recent medication or herpes labialis) will help establish a diagnosis. Investigations The first indication of this systemic disease can be the occurrence of oral mucosal lesions. e.g. Some form of stress management counselling may be considered in some of these cases. When it involves the oral mucosa it may have an appearance identical to that of oral lichen planus. those patients who do report such an association may benefit from suitable hormone therapy. conjunctival and genital mucosa. 20 Hormones In some female patients. eggs. A food diary may be helpful in identification of specific precipitating foods. wheat or dairy products) and other agents (e. The patient is febrile and unwell and requires hospital admission. sometimes depressed below the level of the surrounding mucosa. perhaps bordered by radiating white striae or white papules.g. Diagnosis of erythema multiforme Clinical features (particularly crusting and bleeding of the lips) and. Psychological factors Psychological factors may be an important factor as some patients notice that their ulcers become worse in periods of illness. stress or extreme fatigue. A haematological screen should be carried out on all patients with RAU. Biopsies are unproductive in minor and major aphthae and herpetiform ulceration.3 In occasional patients certain foods (e. For patients with a provisional diagnosis of minor or major aphthous ulceration or herpetiform ulceration. RAU episodes appear to be related to their menstrual cycle. Discoid lupus erythematosus Investigations of recurrent oral ulceration The investigations appropriate for a patient with recurrent oral ulceration will depend upon the provisional diagnosis.. Histopathological examination with immunofluorescence will help to exclude other vesiculobullous disorders but is rarely diagnostic in itself. Control trauma Eliminate or control possible sources of mucosal trauma. the reason for the deficiency should be identified and corrected and supplement treatment instituted. Such haematological problems can precipitate oral ulceration and can aggravate ulceration in patients susceptible to aphthous ulceration. Nevertheless. cheek or lip biting. overly vigorous brushing of teeth or using a hard toothbrush. cosmetics) can initiate or exacerbate RAU. Rare cases of drug-associated LE have been reported. and surrounded by erythematous mucosa. with a female predilection. a biopsy should be carried out. contact should be made with the patient’s medical practitioner to discuss the possibility of prescribing an alternative medication. Clinical oral features of lupus erythematosus Diet LE is most commonly seen in older patients. folate or vitamin B12 deficiencies.AA Talacko et al. sharp teeth ⁄ dental prostheses or ingestion of sharp ⁄ rough foods. Management of recurrent oral ulceration Diagnosis Ensure an accurate diagnosis has been made on the basis of a typical history and clinical appearance.. If a deficiency is detected. oranges. with tissue also removed for immunofluorescent investigations to assist in a firmer diagnosis. Toxic epidermal necrolysis (Lyell syndrome) may represent the most severe end of the spectrum where epithelial necrosis is the predominant feature. Investigate for deficiency states.g. Consider possible dietary factors and food sensitivities. Lupus erythematosus (LE) is an autoimmune disease in which auto-antibodies are directed against nuclear components... However. but oral lesions in lupus are relatively uncommon. Should the provisional diagnosis include lichen planus and ⁄ or a vesiculobullous disorder. iron. haematological investigations should be instituted to exclude an anaemia or haematinic deficiency. vitamin B12 and folic acid levels should be requested and any abnormalities investigated further and ⁄ or corrected. e. Medications If medication is a suspected cause of the recurrent oral ulceration. iron studies.g. If the deficiency is not corrected with supplements then referral to a gastroenterologist is recommended. in the case of recurrent episodes. A full blood count. the evidence for a hormonal basis is inconsistent. It may appear as a relatively nondescript ulcer with an irregular outline.

There has not been a systemic (Cochrane) review of oral ulceration published. Alcohol-free mouthwashes will generally be more comfortable for the patient to use. corticosteroids. Tetracycline mouthwashes were used for many years in recurrent oral ulceration. Some clinicians believe that mouthwashes are more effective if used for 2–4 minutes at a time. ultrasound. These may be based upon antiseptics. Intralesional injections of triamcinolone acetonide 10 mg ⁄ mL are used by some clinicians for lesions of lichen planus. vitamins.4–31 Systemic treatment may be appropriate for more severe and resistant cases. Despite the lack of clear evidence for any particular treatment for oral ulceration. cryotherapy. An alternative is to use minocycline. Ideally. They reported that chlorhexidine could reduce ulcer severity and ⁄ or duration but not incidence. particularly in the management of major RAU. Some patients with oral ulceration of various types may find benefit from using a chlorhexidine mouthwash followed by the use of an asthma inhaler. For more extensive ulceration. The immunosuppressant pimecrolimus 1% cream applied to lesions twice daily may be an effective alternative to other topical treatments. herpetiform ulceration and oral dermatoses. cautery. helicobacter eradication. some of the more widely accepted treatments used in oral medicine practice are outlined below: a 0. Triamcinolone in Orabase 0. 21 . chlorhexidine mouthwashes are an appropriate first line of treatment for recurrent oral ulceration. colchicine. some patients find this preparation difficult to apply and dislike the feel of the paste in the mouth. hence the persistence of treatment based as much on empiricism as evidence. antibiotics. Topical corticosteroids used from the time of the earliest indication of prodromal symptoms provide symptomatic relief and reduce the duration of minor RAU and localized oral dermatoses. It should be made clear to the patient that the objective of treatment is symptomatic and that the ulcers cannot be ‘‘cured’’. A logical treatment approach for patients with recurrent oral ulceration In patients in whom no predisposing factors are detected. A corticosteroid mouthwash may be helpful for widespread oral ulceration. However. antivirals. crushing a 50 mg tablet in 10 mL of warm water and using this as a mouthwash four times daily for five days. Betamethasone diproprionate OV 0. lactobacillus as well as sundry other management strategies and combinations of various medications. A short course of systemic corticosteroids may occasionally be necessary in the management of major RAU and oral dermatoses. the use of such measures will affect the patient’s sense of taste and the numbness may cause them to traumatize the oral mucosa. Concurrent antifungal treatment may be considered in patients with medical histories which might promote the development of an oral candidosis ª 2010 Australian Dental Association A number of corticosteroid preparations have been used in the treatment of recurrent oral ulceration. pentoxifylline. Some patients find that topical local analgesics provide relief from symptoms and these may be offered if necessary. herbal remedies.Recurrent oral ulceration Many treatments have been advocated for recurrent aphthous ulceration.05% ointment or cream can be applied to the ulcers two or three times daily. antirheumatics. However. the solution washed around the mouth and then expectorated. Occasionally systemic corticosteroids will be necessary. various acids. zinc. This can be made from a 5 mg tablet of prednisolone crushed into 10 mL of warm water (or 1 mL of Redipred or Predmix in 10 mL water) or one dexamethasone 0. There is clearly a lack of robust data to allow a synthesis of published papers. laser. this preparation is no longer available in Australia. steroids could reduce ulcer duration and may reduce pain. Some patients do not like the sensation or taste of ointments and creams and some may have difficulty applying these oil-based preparations on a moist mucosal surface. such as more severe minor RAU. interferon. bioadhesives. these should be applied from the first indication of ulcer onset. gastric ulcer treatments. hormone therapy.2% aqueous solution of chlorhexidine gluconate mouthwash used twice or three times daily while ulcers are present may provide relief in some mild cases. homeopathy. thalidomide. hyaluronic acid. Lignocaine 2% gel or mouthwash can be used for pain relief. Behc¸et’s syndrome and some patients with oral dermatoses.5 mg tablet in 10 mL water. It has the theoretical advantage of incorporating a corticosteroid in an adhesive base. leading to further ulcers. immunosuppressants. There is some discomfort in administering the medication and questions remain regarding the benefits after injections. However. sodium cromoglycate. topical minocycline or corticosteroid mouthwashes may be of assistance. anti-inflammatories. The plethora of treatments used for the treatment of oral ulceration is testament to the lack of any single effective treatment. The region(s) of ulceration should ideally be dried before application of the cream or ointment which can also be difficult and painful. A beclomethasone diproprionate 50 mcg ⁄ dose or fluticasone proprionate 100 mcg ⁄ dose asthma inhaler directed onto each ulcer (rather than inhaled) three or four times daily may be a convenient and effective means of medication application. Porter and Scully32 summarized the outcomes of a number of random clinical trials on oral ulceration. In their review. This is especially helpful with extensive ulceration and major aphthous ulceration.1% is often advocated for use on oral ulcers. being particularly helpful when extensive ulceration is present.

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