How are the symptoms of pediatric aphthous ulcers treated?

Updated: Feb 25, 2019
  • Author: Michael C Plewa, MD; Chief Editor: Russell W Steele, MD  more...
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Symptomatic therapy includes anesthetic and occlusive agents. These agents are commonly used when the ulcers are small and few, to minimize pain and improve oral intake, although some have been found to hasten ulcer healing.

  • Benzocaine is the most commonly used anesthetic agent, applied for temporary relief with cotton-tipped applicator on an as needed basis (usually before meals). Numerous preparations of between 6.4% and 20% benzocaine are available for use over-the-counter, including Anbesol, Hurricaine Liquid and Gel, Kank-A, Orabase B, Oralief, Senso-gard, Tanac, and Zilactin B. Benzocaine has not been studied in clinical trials or shown to improve healing. Excess use can lead to neurotoxicity.

  • Lidocaine 2% gel (by prescription only) can also be used, but can also cause toxicity in children.

  • The antihistamine diphenhydramine used as a swish-and-spit mouth rinse, or applied locally, may provide some pain relief. Diphenhydramine syrup is commonly mixed in a 50:50 dilution with magnesium containing antacid.

  • Local injectable anesthetics (lidocaine, bupivacaine) are discouraged because duration of pain relief is brief.

  • Sucralfate suspension (off-label use) may diminish pain without change in ulcer healing. [46]

  • Paste preparations, such as Orabase alone or in combination with 20% benzocaine (Orabase-B) can be temporarily effective for pain relief.

  • Bioadhesive "super-glues", such as 2-octyl cyanoacrylate or isobutyl cyanoacrylate (Iso-Dent) have been studied in children, [47] and significantly improves ulcer pain, without measurable difference in ulcer healing. [48, 49] Orabase Sooth-N-Seal is a cyanoacrylate product available over-the-counter.

  • Debacterol Canker Sore Pain Relief (available by prescription only in the United States) or HybenX (over-the-counter in Europe) as a single application to the ulcer, significantly diminishes pain. [50] This agent works by disruption (desiccation, denaturation, and coagulation) of the microbial biofilm matrix. [51]

  • Over-the-counter glycyrrhiza (licorice) bioadhesive hydrogel patch (CankerMelts GX patches) enhances ulcer healing in addition to reducing pain. [52, 53, 54]

  • An oral bioadherent containing polyvinylpyrrolidone and sodium hyaluronate gel (Gelclair) is used primarily for relief of oral mucositis associated with cancer chemotherapy or irradiation and is also indicated for pain control in severe, refractory, recurrent aphthous ulcers (canker sores). [55] Available by prescription only, Gelclair is mixed with 15 mL of water, stirred, rinsed around the mouth, gargled, and expectorated. At least 30-60 minutes must elapse after use before eating.

Many natural therapies have been suggested in the treatment of aphthous ulcers. El-Haddad et al noted reductions in ulcer pain, size and erythema with topical honey in a Saudi cohort of 94 subjects with minor aphthous ulcers. [56]  Adhesive patches with 7% alum used three times daily significantly decreased aphthous ulcer size and pain, hastening recovery in subjects with recurrent aphthous ulcers. [57]  A mucoadhesive patch which releases citrus oil and magnesium salt (Canker Cover) has been effective in reducing pain and decreasing healing time without adverse effects. [58, 59] Similarly, adhesive films with extract of Propolis entrapped in niosomes may decrease pain and hasten healing. [60]   Regular use of a chitosan 0.5% mouthwash may decrease ulcer size and pain. [61]   Chronic use of Echinacea tablets may decrease the recurrence, pain and number of lesions. [62]   Ozone in air and ozonated oil have also been shown to be effective in relieving recurrent aphthous ulcer pain and size. [63, 64]  Additional studies are needed to confirm these promising results.

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