Canker Sores are a Pain!
As dental professionals, we regularly encounter a wide variety of oral health conditions, and among these, Aphthous Ulcers, commonly referred to as canker sores, are a frequent challenge for patients.
Despite being a commonplace oral issue, aphthous ulcers present a complexity due to their recurrent nature and multifaceted etiology, which includes factors like stress, trauma, allergies, and nutritional deficiencies. In this article we aim to delve into the current pharmacological and non-pharmacological treatment options available for managing this prevalent condition.
Be certain to read all the way to the end of this article; we have provided a highly utilized and requested resource for you to use for free!
Pharmacological Management
First-line Treatment
First-line treatment for aphthous ulcers often involves the use of topical corticosteroids, primarily for their anti-inflammatory properties. Agents such as triamcinolone acetonide (Kenalog) and fluocinonide (Lidex) are frequently utilized. These reduce the inflammatory response, alleviate pain, and potentially shorten the healing time.
These agents are supplied as dental pastes and are can now be prescribed by pharmacists in BC. This is part of the new Minor Ailments and Contraception Service (MACS) that was released in the Spring of 2023. A standard prescription for triamcinolone which may be prescribed by pharmacists would look like this:
- triamcinolone 0.1% paste AAA orally QID x 3 days
If you are a dental professional in BC, feel free to take advantage of the pharmacist prescribing program and contact DentalRx or your local pharmacy for more information!
Second-line and Other Treatment Options
Second-line treatments include systemic corticosteroids, typically used for severe or refractory cases. Prednisone can be particularly effective but should be employed judiciously due to the associated potential systemic side effects and adrenal suppression. A standard prescription may look like this:
- Prednisone 25 mg PO daily x 5 days
Another beneficial approach involves using topical analgesics like benzocaine or lidocaine to manage the pain associated with aphthous ulcers. These are offered as a variety of Over-the-Counter (OTC) products that can be found at your local pharmacy. While these can offer immediate symptomatic relief, they don’t expedite the healing process.
Amongst oral analgesics, there are also a variety of anesthetic mouthwashes that can be helpful in the treatment of aphthous ulcers. While usually used for mucositis, the following is an extensive list of mouthwashes that can also be prescribed for oral pain:
- Magic Mouthwash – 20 mL swish and spit q4h PRN
- Akabutus Mouthwash – 20 mL swish and spit q6h PRN
- Pink Lady – 20 mL swish and spit q6h PRN
- HSC (Hospital for Sick Children) Mouthwash – 10 mL swish and spit q6h PRN
- Viscous Lidocaine 2% – 15 mL swish and spit q6h PRN
- Benzydamine – 15 mL swish and spit q6h PRN
- Diphenhydramine 7.5 mL + Magnesium Hydroxide 7.5 mL swish and spit q4h PRN
In instances where aphthous ulcers are triggered by a bacterial infection, topical antiseptics like chlorhexedine 0.12% or doxycycline mouthwash can be used. For recurrent and severe cases, systemic agents such as colchicine may be considered, albeit the risk-benefit ratio must be carefully evaluated due to their significant side effect profiles.
Non-Pharmacological Management
Patient Education and Lifestyle Modifications
A cornerstone of non-pharmacological management is patient education, including instructing patients on avoiding known triggers like certain foods (nuts, chocolate, spicy foods), stress, and trauma from sharp teeth or dental appliances.
Oral Hygiene
Oral hygiene also plays a pivotal role in managing aphthous ulcers. Patients should be advised to maintain good oral hygiene habits, including regular tooth brushing and flossing, using a soft toothbrush, and avoiding abrasive toothpaste.
Nutritional Considerations
Supplemental therapy can be considered for patients with nutritional deficiencies. For example, vitamin B12, folate, and iron supplementation can be beneficial in patients with recurrent ulcers and these specific deficiencies. A standard prescription for these supplements would be the following:
- Vitamin B12 (cyanocobalamin) 1000 mcg PO daily
- Folic Acid (folate) 1-3 mcg PO daily
- Ferrous Fumarate 300mg PO Q2D (Heme iron may also be used to avoid GI distress)
- You can also combine iron supplements with Vitamin C to increase absorption!
Laboratory studies to identify deficiency are not always ordered by physicians, but if you are suspicious of vitamin or mineral deficiency I encourage you to practice to the full scope of your profession! Ordering lab values is entirely within the scope of dental professionals if there is a potential indication (such as recurrent aphthous ulcers).
If you are not comfortable ordering lab values for your patients, you can always refer to a physician, or provide symptomatic treatment recommendations with frequent recall/ follow-up.
Protective Pastes and Gels
The use of protective pastes and gels can provide a physical barrier to shield the ulcer from further irritation, promoting healing, and reducing pain. These can be particularly useful for ulcers caused by trauma or irritation from orthodontic appliances.
Resources for your Dental Clinic
At DentalRx we are passionate about providing value to all dental clinics. The guidelines stated here, and many more, are available for FREE on the DentalRx web and mobile app. Also available on the mobile app are prescription templates and handouts to help improve your patients’ recovery.
