My PD prescribes
-Doxycycline 100 capsule BID. The patient will open it up and put in small amount of water and swish and swallow.
-Peridex 0.12% Mouthwash.
-Pain medication – Ibuprofen 600 mg
*Some people use magic mouthwash preparation.
I’ve also worked with another attending who just gave a z-pack as the antibiotic.
Topical and systemic antibiotic treatments are empiric and are used because of a belief that some as-yet-undiscovered infectious agent is causing the aphthous ulcer. Tetracycline and minocycline are the best.
I’ve also seen similar treatment used for significant oral ulcers caused by Herpes (HSV1 and HSV2). Antibiotic therapy in this case would prevent bacterial superimposition.
Common Treatments for Aphthous Ulcers, AAFP
Treatment for oral aphthous ulcers can bed divided into:
- Antibiotics,
- Anti-inflammatory,
- Immune modulatory,
- Symptomatic Relief.
| AGENT | DOSAGE | |
|---|---|---|
| Tetracyclines (Antibiotics) |
Tetracycline capsule, 250 mg |
1 capsule dissolved in 180 mL of water; rinse with this suspension four times daily for 4 to 5 days |
|
Tetracycline syrup, 250 mg per 5 mL |
5 mL “swish and spit” four times daily for 4 to 5 days |
|
|
Minocycline tablet, 100 mg |
1 tablet dissolved in 180 mL of water; rinse with this suspension twice daily for 4 to 5 days |
|
|
Steroids
|
Triamcinolone 0.1% in Orabase (Kenalog in Orabase) |
Apply to dried ulcer 2 to 4 times daily until healed |
|
Dexamethasone elixir, 0.5 mg per 5 mL |
Swish and spit with 5 mL every 12 hours |
|
|
Immune Modulatory
|
Thalidomide |
200 mg, one to two times daily for 3 to 8 weeks Warning: contraindicated in pregnancy |
|
Amlexanox 5% paste |
Apply to dried ulcer two to four times daily |
|
|
Symptomatic Relief
|
Viscous lidocaine, 2% |
Apply to ulcer as needed |
|
Zinc lozenges |
Suck one lozenge four to six times daily |
|
In children and in women who may be pregnant, tetracycline should be avoided because of its tendency to discolor teeth.
Silver nitrate
An AAFP letter to the editor in 2001 explained how to use silver nitrate sticks to treat aphthous ulcers.
“Touch them with a silver nitrate stick. Obviously, one needs to be sure there is no other apparent etiology but, because the most common cause is not related to underlying disease, the silver nitrate stick works wonders, and patients walk out of the office pain free.
The procedure is simple: wet the tip of the stick and gently touch it to the ulcer. When the ulcer turns white, remove the stick. Have patients swish out the silver nitrate and send them home. You should warn them that the procedure may sting for a moment but, considering that they are already in pain, they don’t really notice much difference. Although silver nitrate cautery may cause more tissue necrosis and longer healing time if it is left in place too long, I have not found this to be a problem.”
Lesions can be numbed with topical lidocaine prior to chemical cautery, and patients should rinse with water for several minutes after the procedure.
A RCT published in the British Journal of Dermatology found that “One application of silver nitrate can decrease the severity of pain in aphthous ulceration without significantly shortening or prolonging healing time. We did not observe any side-effects in our study. The effect is rapid and lasts for the duration of the lesion. The treatment is simple and cost-effective in patients with infrequent recurrences.” Br J Dermatol 2005
References and Further Reading
Br J Dermatol. 2005 Sep;153(3):521-5. Silver nitrate cautery in aphthous stomatitis: a randomized controlled trial. https://www.ncbi.nlm.nih.gov/pubmed/16120136
Am Fam Physician. 2001 Sep 1;64(5):737. Silver Nitrate Stick Helps Manage Aphthous Ulcers. https://www.aafp.org/afp/2001/0901/p737a.html
Am Fam Physician. 2000 Jul 1;62(1):149-154. Management of Aphthous Ulcers. http://www.aafp.org/afp/2000/0701/p149.html