In your dental clinic, right after tooth decay and toothache, the most frequent complaint you’ll likely hear is an oral ulcer. It might be a tiny spot, but its pain can be so debilitating that patients struggle to eat or even speak. Given that this is a condition we encounter almost daily, it’s absolutely essential for us as dentists to be able to diagnose it accurately at first glance. We need to clearly differentiate between its various types to ensure we prescribe the precise treatment that truly brings the patient relief.
A patient arriving with an ulcer is fundamentally seeking a solution to their pain. Your confidence in both diagnosis and treatment is what will make all the difference.
In this article, we’re going to dissect the entire subject of oral ulcers, piece by piece. We’ll learn how to distinguish between infectious and non-infectious types, and then we’ll lay out a clear treatment protocol for each.
First Step: The Right Diagnosis is the Key to Everything
Before you prescribe any medication, you simply must know exactly what you’re dealing with. Diagnosis always begins with two fundamental steps:
1. Take a Thorough Patient History
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When did it appear? Is this the first time, or does it recur?
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How many? Is it a single ulcer or multiple ones?
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Does it hurt? How severe is the pain level?
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Are there any other symptoms? Such as fever, general fatigue, or a skin rash?
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Are they taking any medications? Many medications can induce ulcers.
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Do they smoke? What are their general lifestyle habits?
2. Conduct a Systematic Clinical Examination
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Look Closely: Examine the ulcer itself—its size, shape, color, and margins. Also, meticulously inspect all surrounding tissues. And don’t forget to check the rest of the mouth.
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Palpate Gently: Is the ulcer soft or indurated (hardened)? An indurated, firm ulcer is a definite red flag that demands your immediate attention.
A correct diagnosis is what will empower you to categorize ulcers into two main types, which will then dictate your treatment plan.
Type One: Non-Infectious Oral Ulcers
These are the most prevalent type. Simply put, they are not caused by a virus or bacteria, and therefore, they are not contagious.
1. Traumatic Ulcer
This is by far the most common type.
Causes: These are usually clear and direct.
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Mechanical: Such as cheek biting, a stiff toothbrush, a sharp filling edge, or irritating orthodontic appliances.
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Thermal: Eating or drinking something too hot that scalds the tissues.
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Chemical: Like placing an aspirin directly on the gums—a very ill-advised traditional habit.
Appearance: Typically, it’s a single ulcer, irregular in shape, with a clear association to its cause. For instance, you’ll find it precisely where an orthodontic appliance is rubbing.
Treatment: Simple and straightforward. “Remove the cause, and the problem often resolves itself.” Fix the sharp filling, adjust ill-fitting dentures. Once the cause is eliminated, this type of ulcer heals spontaneously within 7-14 days. Our role here is primarily to manage the pain during this healing period.
2. Recurrent Aphthous Stomatitis (RAS)
Now, this one is often the “persistent nuisance” of oral ulcers. It comes and goes and can be extremely painful.
Causes: The exact cause isn’t 100% known, but many factors can trigger its appearance, including stress, hormonal changes, vitamin deficiencies (like B12, iron, folic acid), and sensitivities to certain foods (1).
Appearance: The most common form is the Minor aphthous ulcer. It typically presents as one or more small, round ulcers, surrounded by a red halo, with a yellowish-white base.
Crucial Point: This type of ulcer heals on its own within 10-14 days without leaving a scar. If you encounter an ulcer in a patient’s mouth that has persisted for more than 3 weeks and hasn’t healed, you must immediately suspect the possibility of malignancy. The immediate next step is to refer the patient to a specialist for a biopsy.
Treatment Protocol for Non-Infectious Ulcers (Traumatic & Aphthous)
Since both these types heal spontaneously, our primary goal is effective pain control.
First Line: Topical Analgesics
These are the most common and safest options to start with:
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Benzydamine HCl Mouthwash: Such as Tantum Verde. It acts as a local analgesic and anti-inflammatory.
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Benzydamine HCl Spray: Like BBC Spray. Its advantage is more concentrated application directly to the ulcer site.
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Topical Gel: Such as Oracure Gel, which forms a protective, pain-relieving barrier over the ulcer.
Second Line (for Severe Cases): Topical Corticosteroids
Corticosteroids significantly reduce inflammation, thereby decreasing pain and accelerating healing.
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The First and Best Option: Triamcinolone Acetonide 0.1% in Orabase ointment, like Kenacort-A Orabase. Apply a thin layer to the ulcer after thoroughly drying it. The challenge is it’s not always readily available.
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Smart Alternatives (if Kenacort isn’t available): We can use systemic corticosteroids, but apply them topically.
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How? Instruct the patient to rinse with it and then spit it out without swallowing.
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Options:
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Betamethasone Tablets: Like Betasone 500 tablets. Crush one tablet in a small amount of water, and the patient rinses with this solution.
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Dexamethasone Syrup: Such as Orazone syrup. One small spoon for rinsing.
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Dexamethasone Ampoule: The patient can rinse with half the ampoule.
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Type Two: Infectious Oral Ulcers
Here, the situation is entirely different. These ulcers are caused by an infection, with fungal infections being the most common.
Fungal Ulcer (Candidiasis)
Most Common Cause: A fungus called Candida Albicans. This fungus normally resides in all our mouths but causes problems when immunity is lowered or with poorly cleaned dentures (2).
The Priceless Clinical Diagnostic Tip:
A fungal ulcer often presents as a creamy white layer or patch, resembling cottage cheese.
The Decisive Test: Take a gauze pad and gently wipe away this white layer. If it comes off, revealing a red, slightly bleeding surface underneath, then it’s 99% a fungal infection. Aphthous or cancerous ulcers’ white layers typically do not wipe off.
Treatment for Fungal Oral Ulcers
Treatment here must be antifungal.
The First and Strongest Option: Miconazole Oral Gel, such as Daktarin Oral Gel.
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Dosage: Apply a thin layer to the affected area twice a day.
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Why it’s the best? Because it’s a gel, it adheres to the affected site for a longer period, providing a more potent effect.
Other Alternatives:
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Nystatin Oral Drops: These reach the entire mouth, but their localized effect is less intense.
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Fluconazole Tablets: These are reserved for severe cases or those that don’t respond to topical treatment.
Golden Advice: It’s crucial to instruct the patient to continue the treatment for an additional two to three days even after symptoms have completely disappeared.
In Summary: Dr. LOD’s Protocol for Any Oral Ulcer
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Listen and Examine Thoroughly First: The correct diagnosis accounts for 90% of the effective treatment.
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Differentiate Between Infectious and Non-Infectious: The “gauze wipe test” will be incredibly helpful here.
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Topical Treatment is the Foundation: About 95% of cases respond well to topical medications.
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Never Forget the Cause: If the ulcer is trauma-induced, your pain management will only be temporary relief unless you address the root cause.
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Stay Vigilant: Any ulcer that doesn’t heal within 3 weeks is a red flag. It is your professional duty to refer the patient to a specialist immediately.
