Aphthous ulcers usually clear within 7-10 days without treatment (6,7) The following are some non-pharmacological treatments of RAUs

1. Determine possible nutritional deficiencies or allergies causing the onset of the disease and encourage the patient to take appropriate supplementation such as multivitamins. It should, however, be noted that there is conflicting evidence with respect to supplementation and correcting nutritional deficiency. 

Food allergies/ hypersensitivity: Encourage the patient to avoid eating foods that may be triggers and result in recurrent aphthous ulcers/stomatitis (RAS). Irritating agents include (5,8,9):

• Acids- Citrus fruits and juices, tomato juice)

• Alcoholic beverages

• Benzoic acid

• Certain spices e.g. Cinnamon

• Cheese

• Chocolate

• Coffee

• Cow’s milk- Antibodies to cow's milk and wheat protein (celiac disease) have been reported in RAU patients (7,8,9)

• Crusty/hard/sharp foods (potato chips, hard pretzels, cut apples, and hard sweets)

• Essential oils

• Figs

• Flavoring agents

• Gluten

• Nuts  

• Peanut butter

• Potatoes

• Seafood

• SLS (sodium lauryl sulfate) a common additive in toothpastes has been found to irritate oral mucosa

• Spicy/salty foods

• Wheat products

 Nutritional Supplementation: is believed to benefit patients with RAS (3)

• Lactobacillus acidophilus 

Daily consumption of the bacteria lactobacillus acidophilus is believed to be helpful in preventing outbreaks of RAS. A good source of these beneficial organisms can be yoghurt. Yoghurts that contain an active culture of acidophilus are recommended (5)

2. Determine the presence of underlying disease states that may cause recurrent aphthous ulceration 

   Disease States include (3,7)

• IBD (Inflammatory Bowel Diseases)

• Behçet’s disease

• Coeliac disease

• HIV-seropositive patients with CD4+ lymphocyte counts below 100 cells/mm³

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3. Complete Haematologic work-up should be undertaken in patients presenting with recurrent aphthous ulceration. Tests include 

• Complete blood count

• Serum ferritin

• Serum folate

• B-vitamin levels 

If the patient is deficient initiate replacement therapies and/or make appropriate referrals. The correction of any haematinic deficiency has been found to be of limited benefit unless the cause of the deficiency is corrected. Supplementation with Zinc sulfate, vitamins, or iron may prevent recurrence in some individuals, though (9) therapy has been found to be ineffective in many individuals, and LongoVital® (unavailable in Australia), a herbal-based vitamin tablet with a wide range of trace elements also seems to be of limited benefit (2).

4. Manage stress- Stress is known to be a cause of RAS. Encourage patients to detect early signs of ulcers and treat ulcers as early as possible 

5. Advise the patient to maintain good daily oral hygiene 

Vigorous tooth brushing and biting of the cheek or tongue are not recommended as they can cause irritation. Consider referring the patient to their dentist if 

• Dental appliances do not fit well as they may be damaging to oral tissue

• The patient has broken teeth, rough or broken fillings and sharp teeth 

• Tooth braces are causing irritation. Braces should be covered with wax to prevent oral trauma

6. It is recommended that patients keep an aphthous ulcer diary to assess possible causes of flare-ups and identify triggers