Choline salicylate

What it is

Choline salicylate is the choline ester salt of salicylic acid. It is liquid and water-soluble, which is why it is formulated as a sticky oral gel for mouth ulcers and teething and as a drinkable analgesic liquid. FDA lists it as a permitted over-the-counter analgesic-antipyretic active ingredient, and a marketed US liquid supplies 870 mg of choline salicylate per 30 mL. The oral gels sold in the UK and Europe contained 8.7% choline salicylate, and a 15 g tube of one of them contained 1.31 g of choline salicylate, equivalent to roughly 930 mg of aspirin.

What the research says

It is a salicylate, so it blocks cyclo-oxygenase and the prostaglandins that carry pain and inflammation signals. The evidence that it works where it is most used, on mouth ulcers and oral mucosal pain, is weak. The only recent randomised trial we found, in 27 denture patients, showed no statistically significant difference between choline salicylate, chlorhexidine and no treatment at all. A 2026 umbrella review of 41 systematic reviews of recurrent mouth ulcers concluded in favour of topical corticosteroids, hyaluronic acid and laser therapy, and did not name salicylates. What is well documented is the other half: the gel is absorbed through the mouth lining into the bloodstream, enough to produce therapeutic salicylate levels, to cause refractory gastric ulceration in an adult and to cause salicylate toxicity in a toddler. The UK contraindicated these gels in anyone under 16 in 2009.

Evidence grade: Limited evidence.

How it works

Drug class: Salicylate non-steroidal anti-inflammatory drug, used topically in the mouth and as an oral liquid analgesic

Choline salicylate is a salicylate, and salicylates work by inhibiting cyclo-oxygenase and so cutting prostaglandin production, which reduces pain and local inflammation. Applied to the mouth lining it acts locally, but the choline ester is suspected to be absorbed more readily than other salicylates and the buccal route bypasses first-pass metabolism in the liver, so a meaningful amount reaches the bloodstream as salicylate and behaves systemically like aspirin. (Source 1)

What it is used for

• This is the use the gels are sold for, and a 2023 narrative review of NSAIDs in dentistry describes them as commonly used in self-treatment of aphthous ulcers with an action of relieving pain and local inflammation. The only recent randomised trial found no significant difference against chlorhexidine or against no treatment, and a 2026 umbrella review of 41 reviews concluded for corticosteroids, hyaluronic acid and laser therapy without naming salicylates. Evidence: limited. (Source 1)
• FDA's over-the-counter monograph permits choline salicylate as an internal analgesic-antipyretic active with a full adult and paediatric dose schedule, and a marketed US liquid is labelled for headache, minor arthritis pain, muscle aches, menstrual cramps, backache and fever. We found no placebo-controlled analgesic trial of choline salicylate itself. Evidence: limited. (Source 2)
• The UK's Commission on Human Medicines contraindicated topical oral salicylate products in anyone under 16 in 2009, after a suspected case of Reye's syndrome in a 20-month-old, and the MHRA concluded the child's picture was more consistent with salicylate toxicity. A separate case of salicylate intoxication from teething gel in infancy was reported in Australia in 2011. This use was withdrawn rather than disproved by trial. Evidence: not-supported. (Source 3)
• In a randomised double-blind trial of 27 patients fitted with partial removable dentures, 8.7% choline salicylate reduced wound surface area by 70.1% at 7 days against 85.1% for chlorhexidine and 59.2% for no treatment, with no statistically significant differences between groups, and the authors recommended chlorhexidine rather than choline salicylate. Evidence: not-supported. (Source 4)

Interactions

• Alcohol (label): The marketed choline salicylate liquid's label lists three or more alcoholic drinks a day as a factor raising the chance of severe stomach bleeding. FDA's professional labelling for salicylates says heavy drinkers should be counselled about bleeding risk. (Source 5)
• Other NSAIDs, including aspirin (label): Choline salicylate adds to the salicylate load from any other NSAID. The label lists taking other prescription or non-prescription NSAIDs as a stomach-bleeding risk factor, and FDA's professional labelling says concurrent use should be avoided because it can increase bleeding or reduce kidney function. This matters particularly for the gel, which people may not think of as a medicine at all. (Source 5)
• Anticoagulants and steroids (label): The label lists taking a blood-thinning (anticoagulant) or steroid drug as raising the chance of severe stomach bleeding. FDA's professional labelling adds that salicylate displaces warfarin from protein binding, prolonging both prothrombin time and bleeding time. (Source 5)
• Methotrexate (label): Salicylate reduces the renal clearance of methotrexate and can push it to bone-marrow-toxic levels, especially in older people or those with impaired kidneys. This is a salicylate-class effect and choline salicylate is a salicylate. Limit: FDA's text says 'Salicylate', so it covers the class, but no study has tested choline salicylate with methotrexate specifically. (Source 6)
• Diuretics and ACE inhibitors (label): Salicylates inhibit renal prostaglandins, reducing renal blood flow and causing salt and fluid retention, which can blunt diuretics and ACE inhibitors in people with heart or kidney disease. The label tells people taking a diuretic to ask a doctor first. Limit: The label prints the diuretic line as a single short bullet, so the quote recorded here spans the two adjacent label bullets in document order. The mechanism statement comes from FDA's professional labelling for aspirin, not from a choline salicylate study. (Source 5)
• Caffeine (in the combination product) and caffeine-containing foods and drinks (label): The marketed liquid pairs choline salicylate with 65 mg of caffeine per dose, and its own label warns to limit other caffeine-containing medicines, foods or beverages because too much caffeine can cause nervousness, irritability, sleeplessness and occasionally a rapid heartbeat. (Source 5)
• Willow bark and other salicylate-bearing botanicals (theoretical): Willow bark supplements deliver salicylate of their own and carry no mandatory aspirin-style warnings, so taking them alongside a choline salicylate gel or liquid adds to the same salicylate load. The United States Pharmacopeia review says concurrent use with other salicylate-containing medicines increases the bleeding, pregnancy and Reye's syndrome risks. (Source 7)
• Prescription drugs for diabetes, gout or arthritis (label): The marketed liquid's label tells people taking a prescription drug for diabetes, gout or arthritis to ask a doctor or pharmacist before use. FDA's professional labelling adds that moderate salicylate doses may increase the effect of oral hypoglycaemics and that salicylates antagonise uricosuric agents such as probenecid. (Source 5)
• Food and milk (label): The marketed liquid's label tells people to take it with food or milk if stomach upset occurs. No study of whether food changes choline salicylate absorption or gastric injury was reachable. Limit: The food-and-milk line is under 40 characters by itself, so the recorded quote spans the two adjacent label bullets in document order. There is no evidence behind this beyond the label instruction. (Source 5)

Stopping it

• There is no dependence or withdrawal syndrome and no tapering literature for choline salicylate. The one documented stopping observation is the reverse of a withdrawal problem: in the case of refractory gastric ulceration, five endoscopies over more than a year had shown no healing, and the ulcers healed completely within three months of the gel being stopped, with a year of symptom-free follow-up. (Source 8)
• For the oral liquid, the label sets its own stopping points: stop and ask a doctor if symptoms do not improve, if pain gets worse or lasts more than 10 days, if fever gets worse or lasts more than 3 days, or if ringing in the ears or loss of hearing occurs. Tinnitus is the classic early sign of salicylate excess. (Source 5)
• For the topical gel in anyone under 16, the UK position since 2009 is not tapering but stopping: the Commission on Human Medicines advised that any topical oral product containing salicylate should be contraindicated in children younger than 16, and the MHRA's advice to professionals was to use alternative treatments or products. (Source 9)

What goes wrong

An over-the-counter choline salicylate oral gel caused refractory gastric ulceration in a 39-year-old man that healed completely only when the gel was stopped. (Source 10)

• Case report, Very low certainty.
• Size: one patient.
• Who: a 39-year-old man with three years of dyspepsia, an episode of melaena, multiple gastric and duodenal ulcers and a negative Helicobacter pylori test.
• How long: five upper endoscopies from May 2010 to July 2011 with no resolution; healing confirmed three months after the gel was stopped, with a year of symptom-free follow-up.
• Result: surgery was being considered for refractory ulceration; urine salicylate was positive; haemoglobin fell to 8.1 g/dL during a readmission with melaena; complete endoscopic healing followed withdrawal of a gel containing choline salicylate 8.7%.
• Funding: None declared.

Limit of this finding: A single case report, and the patient had also taken aspirin earlier, although he had stopped it and the ulcers persisted on high-dose proton pump inhibitor before the gel was identified.

frequent use of a common ulcer soothing oral gel which contains choline salicylate 8.7% was identified as a potential cause. This was discontinued leading to symptom resolution, and a repeat OGD three months later demonstrated complete endoscopic healing

The authors report this as the first case of oral choline salicylate gel implicated in refractory gastric ulceration. (Source 8)

• Case report, Very low certainty.
• Size: one patient.
• Who: as above.
• How long: as above.
• Result: no rate can be derived from a first case report.
• Funding: None declared.

Limit of this finding: This is a single case report, so it can raise a suspicion but cannot show how often this happens or that the gel was the cause. The same discussion also prints "(3.2% vs. 3.4)" where the second figure is missing its per-cent sign; that typographical slip is in the published paper and has been left as the source prints it.

Our case is the first report of oral choline salicylate gel implicated in refractory gastric ulceration.

A choline salicylate paste caused a mucosal burn and then oral ulcers, malaise and fever in an 8-year-old boy with G6PD deficiency. (Source 11)

• Case report, Very low certainty.
• Size: one patient.
• Who: an 8-year-old boy with glucose-6-phosphate dehydrogenase deficiency.
• How long: mucosal burn at application, ulcers and systemic symptoms three days later.
• Result: mucosal burn, then oral ulcers with malaise and fever; the authors discuss a possible connection between systemic absorption of choline salicylate and haemolytic anaemia.
• Funding: not stated in the abstract.

Limit of this finding: A single case in a child with an inherited enzyme deficiency; the haemolysis link is discussed as a possibility, not demonstrated.

This report shows a case of an 8 year old boy with G6PD deficiency, who had a mucosal burn caused by application of a cholinsalicylate paste. Three days later, the child developed oral ulcers, malaise and fever.

Excessive use of a choline salicylate teething gel delivered an aspirin-equivalent dose of 93 mg/kg a day to a 20-month-old child, in the range at which chronic salicylate toxicity has been reported. (Source 3)

• Official position, Low certainty.
• Size: one reported case, assessed by the regulator.
• Who: a 20-month-old child, and by inference small children given these gels.
• How long: one tube a day for an unspecified period; chronic toxicity reported after 2 days or longer at 100 mg/kg per day.
• Result: a 15 g tube contains 1.31 g choline salicylate, equivalent to approximately 930 mg aspirin; at 10 kg body weight that is 93 mg/kg aspirin per day; plasma salicylate half-life rises from 2-4.5 hours to 18-36 hours once metabolism saturates.
• Funding: not applicable (regulatory review)

Limit of this finding: The regulator's own text stresses that serum salicylate levels are a poor indicator of toxicity and that the diagnostic criteria for Reye's syndrome were not all met in this case, so the harm established here is salicylate toxicity, with Reye's syndrome described as a theoretical risk only.

Chronic toxicity has been reported after doses of 100 mg/kg per day for 2 days or longer.

Children under 4 are more likely than older children to develop hypoglycaemia and metabolic acidosis under chronic salicylate toxicity and appear particularly vulnerable to salicylate liver injury. (Source 3)

• Official position, Low certainty.
• Size: not applicable; a regulatory review citing earlier case literature.
• Who: children, particularly those younger than age 4 years.
• How long: chronic ingestion, defined in the review as more than 2 days.
• Result: no rates are given.
• Funding: not applicable (regulatory review)

Limit of this finding: This is the MHRA's summary of earlier published case literature, not new data, and it gives no rates, so it cannot say how likely these complications are. The quoted sentence ends on a comma in the source because it runs into a footnote marker.

Under conditions of chronic toxicity, children (particularly those younger than age 4 years) are more likely to develop serious complications such as hypoglycaemia and metabolic acidosis,

The marketed US choline salicylate liquid carries the full NSAID stomach-bleeding warning and a Reye's syndrome warning against use in children and teenagers recovering from chicken pox or flu-like symptoms. (Source 5)

• Official position, Certainty not rated.
• Size: not applicable.
• Who: over-the-counter users of a choline salicylate liquid analgesic.
• How long: not applicable.
• Result: no rates are given at all on the label.
• Funding: not applicable (product label)

Limit of this finding: A label position with a DailyMed publication date of 2025-11-17 (SPL version 10). It carries no frequencies, so it cannot tell a reader how likely any of this is.

Stomach bleeding warning This product contains an NSAID, which may cause severe stomach bleeding. The chance is higher if you:

In humans, auditory perception changes after salicylate or aspirin, including word discrimination and temporal integration. (Source 12)

• Expert review, not systematic, Low certainty.
• Size: not applicable; a narrative review of animal, cell-culture and human work.
• Who: animal models and human listeners.
• How long: acute and chronic dosing studies.
• Result: no pooled effect size; the review describes frequency-dependent reductions in otoacoustic emissions and compound action potentials in animals and decreased word discrimination in humans.
• Funding: not stated in the abstract.

Limit of this finding: This is a narrative review with no stated search method, and it reports no doses and no rates. It concerns salicylate and aspirin in general, not choline salicylate specifically, so it does not show that a choline salicylate product produces these effects.

In humans, auditory perception changes following salicylate or aspirin, including decreased word discrimination and temporal integration ability.

What the evidence supports

Choline salicylate gel applied to the mouth is absorbed well enough to put therapeutic levels of salicylate into the bloodstream. (Source 9)

• Official position, Low certainty.
• Size: one reported case plus a regulatory review of the product class.
• Who: a 20-month-old child given one tube a day of a choline salicylate teething gel.
• How long: unspecified period of daily use before a 1-day history of vomiting, lethargy and photophobia.
• Result: a 15 g tube containing 1.31 g choline salicylate is equivalent to approximately 930 mg aspirin; in a 10 kg child one tube a day equates to 93 mg/kg aspirin per day.
• Funding: not applicable (regulatory review)

Limit of this finding: This is a regulator's assessment of a single published case, dated June 2009, not a pharmacokinetic study. No measured absorption study of choline salicylate gel was reachable.

Irrespective of the diagnosis, it is clear that a choline salicylate gel, if applied chronically and excessively, can result in systemic levels of salicylate of at least therapeutic levels.

A narrative review of NSAIDs in dentistry describes choline salicylate gels as commonly used for self-treatment of mouth ulcers, with an action of relieving pain and local inflammation. (Source 1)

• Expert review, not systematic, Very low certainty.
• Size: not applicable; an expert review with no stated search method for this statement.
• Who: people self-treating aphthous ulcers and oral mucosal injuries.
• How long: not applicable.
• Result: no effect size is reported; the review asserts the action without citing a trial result for it.
• Funding: not stated in the abstract.

Limit of this finding: This is an unquantified assertion in a narrative review, and the review itself notes there are few topical NSAID preparations on the market. It is the weakest kind of support and should not be read as evidence of efficacy.

These preparations are commonly used as part of the self-treatment of aphthous ulcers and injuries to the oral mucosa. Their action consists in relieving pain and local inflammation.

What the evidence does not support

In a randomised double-blind trial of denture-related mouth lesions, choline salicylate was no better than chlorhexidine or no treatment at all. (Source 4)

• Randomized trial, Very low certainty.
• Size: 27 patients randomised to 0.2% chlorhexidine digluconate, 8.7% choline salicylate, or no intervention.
• Who: healthy patients fitted with new partial removable dentures who developed oral mucosa lesions during adaptation.
• How long: measurements on days 1, 3, 7, 10 and 14.
• Result: no statistically significant differences between groups; wound surface area fell 85.1% in the chlorhexidine group, 70.1% in the choline salicylate group and 59.2% in the control group at 7 days; complete reduction at 7 days for chlorhexidine, 10 days for choline salicylate and 14 days for control.
• Funding: not stated in the abstract.

Limit of this finding: Twenty-seven patients across three arms is far too small to detect a modest difference, so this is an absence of evidence rather than evidence of no effect. The abstract also contradicts itself: it states that there were no statistically significant differences between groups while printing 85.1%, 70.1% and 59.2% reductions for the three arms, and it says the fastest complete healing was with chlorhexidine while printing the largest residual wound area for that arm. Treat the percentages as descriptive, not as a measured difference between treatments. The abstract prints "WAS" where it means wound surface area; that typing slip is the source's and has been left as printed.

There were no statistically significant differences between groups.

The authors of that trial recommended chlorhexidine, not choline salicylate, as adjunctive therapy for oral mucosa lesions. (Source 13)

• Randomized trial, Very low certainty.
• Size: 27 patients.
• Who: as above.
• How long: 14 days.
• Result: the fastest reduction in wound surface area was with chlorhexidine at 7 days, slightly slower with choline salicylate at 10 days, and slowest in the untreated group at 14 days.
• Funding: not stated in the abstract.

Limit of this finding: The same trial's results section states that there were no statistically significant differences between the groups, so this recommendation is the authors' interpretation rather than a measured effect. With 27 patients the trial was far too small to separate the treatments. Do not read it as evidence that chlorhexidine outperformed choline salicylate.

Topical medications containing 0.2% chlorhexidine digluconate are indicated as adjunctive therapy in the process of the supportive treatment and disinfection of oral mucosa lesions.

A 2026 umbrella review of 41 systematic reviews of recurrent mouth ulcer treatment concluded for corticosteroids, hyaluronic acid and laser therapy, and did not name salicylates among the supported options. (Source 14)

• Review of reviews, Moderate certainty.
• Size: 41 systematic reviews, meta-analyses or network meta-analyses, searched to August 2025.
• Who: people with recurrent aphthous stomatitis.
• How long: short-term symptom control and recurrence prevention.
• Result: topical corticosteroids and low-level laser therapy consistently reduced pain and shortened healing time; hyaluronic acid and herbal agents showed favourable short-term efficacy; no salicylate intervention appears in the stated conclusions.
• Funding: not stated in the abstract.

Limit of this finding: This is an absence from the review's conclusions, not a direct test of choline salicylate. We cannot say the review tested and rejected it; we can only say it is not among the interventions the review found evidence for.

Evidence supports topical corticosteroids, hyaluronic acid, and laser therapy for short-term symptom control in RAS, while systemic agents should be reserved for selected refractory cases.

Where the research disagrees

Whether the 20-month-old child who triggered the UK restriction had Reye's syndrome or salicylate toxicity

• The authors of the published case report, as summarised by MHRA, single case report (Oman TK et al, BMJ 2008; 336: 1376), which we were not able to retrieve directly: The authors diagnosed Reye’s syndrome after exclusion of metabolic disorders and because the systemic salicylate concentration was only just above the therapeutic range. (Source 3)
• MHRA and the Commission on Human Medicines, June 2009, regulatory review of the same single case, noting the child was young for classic Reye's syndrome and that normal plasma ammonia with raised transaminases would be atypical: are more consistent with salicylate toxicity than with Reye’s syndrome. Our assessment is based on the fact that all of the diagnostic criteria for Reye’s syndrome were not met (Source 9)

Whether children should be given salicylate analgesics at all

• US FDA, OTC Monograph M013, document dated 10.14.2022, regulatory monograph permitting oral choline salicylate from age 2, with a Reye's syndrome warning limited to viral illness: Children 2 to under 4 years of age: Oral dosage is 215 milligrams every 4 hours while symptoms persist, not to exceed 5 doses or 1,087.5 milligrams in 24 hours. (Source 2)
• UK Commission on Human Medicines, June 2009, regulatory review of a single suspected Reye's syndrome case, restricted to topical oral products: The Commission on Human Medicines (CHM) has recommended that topical oral pain-relief products that contain salicylate salts should be contraindicated in those younger than age 16 years. (Source 3)

How much

• Reference intake: For the oral liquid, dose is set by the label or the prescriber. As a dated position, FDA's over-the-counter monograph M013 (document dated 10.14.2022) gives an adult oral dosage of 435 to 870 mg every 4 hours, or 435 to 669 mg every 3 hours, or 870 to 1,338 mg every 6 hours while symptoms persist, with a paediatric schedule down to age 2. A marketed US liquid supplies 870 mg per 30 mL and is labelled as 30 mL every 6 hours for adults and children 12 and over. For the topical gel, no dose in mg is set; the UK contraindicated these products in anyone under 16 in 2009. This is reported as a position, not as advice to any reader. (Source 2)
• Upper limit: FDA's monograph sets an adult ceiling of 5,352 mg of choline salicylate in 24 hours, and ceilings of 3,262.5 mg for children 11 to under 12 years down to 1,087.5 mg for children 2 to under 4 years, with children under 2 told to consult a doctor. The marketed US liquid label prints its own limit as four doses in 24 hours. We found no toxicological upper limit for choline salicylate established by study. The monograph's own arithmetic does not hold for the children's ceilings: 430 mg five times a day is 2,150 mg, not the 2,175 mg printed; 322.5 mg five times is 1,612.5 mg, not 1,632.5 mg; and 215 mg five times is 1,075 mg, not 1,087.5 mg. The figures are quoted as FDA prints them and have not been corrected here. (Source 2)
• Studied: The denture-lesion trial applied 8.7% choline salicylate gel against 0.2% chlorhexidine digluconate and no treatment in 27 patients over 14 days. (Source 4)
• Studied: The case of refractory gastric ulceration involved frequent use of an oral gel containing choline salicylate 8.7%. (Source 10)
• Studied: In the paediatric case the regulator assessed, a 15 g tube containing 1.31 g of choline salicylate was used daily, equivalent to approximately 930 mg of aspirin. (Source 3)
• Studied: The marketed US liquid contains caffeine 65 mg and choline salicylate 870 mg per 30 mL. (Source 15)

A common belief, and what the research shows

The belief: A mouth ulcer gel is not really a medicine, so it cannot do you any systemic harm.

What the research shows: Choline salicylate gel is aspirin's chemical relative applied to a thin, well-supplied mucosa, and the buccal route bypasses the liver's first pass. One 15 g tube contained the salicylate equivalent of about 930 mg of aspirin, which in a 10 kg child amounts to 93 mg/kg a day, in the range at which chronic salicylate toxicity has been reported. A 39-year-old man had five endoscopies over more than a year for gastric ulcers that would not heal on double-dose omeprazole; he had a positive urine salicylate, and when questioned closely he turned out to be using a mouth gel he had never counted as medication. The ulcers healed completely three months after he stopped it. In the authors' words, he 'had not considered the oral gel to be a medication nor had he appreciated that it contained salicylates.' The UK contraindicated these gels in anyone under 16 in 2009.

Questions and answers

What is it?

Choline salicylate is the choline salt of salicylic acid, the same acid aspirin breaks down into. Being liquid and water-soluble, it is made into sticky oral gels for mouth ulcers and teething and into drinkable analgesic liquids. FDA lists it as a permitted over-the-counter analgesic-antipyretic active ingredient. The gels sold in the UK and Europe contained 8.7% choline salicylate; a marketed US liquid contains 870 mg per 30 mL. (Source 16)

What does it do in the body?

It is a salicylate, so it inhibits cyclo-oxygenase and cuts the prostaglandins that signal pain and inflammation. Applied in the mouth it is meant to work locally, and a review of NSAIDs in dentistry describes the action as relieving pain and local inflammation. It also crosses the mouth lining into the bloodstream, where it behaves as systemic salicylate; the choline ester is suspected to be absorbed more readily and the buccal route avoids first-pass metabolism. (Source 8)

Is it good or bad for you?

The evidence for benefit is weak and the evidence for harm is concrete, which is an unusual balance. The only recent randomised trial, in 27 denture patients, found no significant difference between choline salicylate, chlorhexidine and no treatment, and the authors recommended chlorhexidine. A 2026 umbrella review of 41 systematic reviews of mouth ulcer treatment concluded for corticosteroids, hyaluronic acid and laser therapy without naming salicylates. On the harm side there are documented cases of refractory gastric ulceration in an adult, a mucosal burn with ulcers and fever in a child with G6PD deficiency, and salicylate toxicity in a toddler; the UK contraindicated these gels in under-16s in 2009. (Source 4)

How do you get more of it?

Choline salicylate liquid analgesics are sold over the counter in the United States, and FDA's monograph sets an adult oral dose range of 435 to 870 mg every 4 hours while symptoms persist. The 8.7% topical gels were sold over the counter in the UK and Europe but are contraindicated there in anyone under 16 since 2009, and the manufacturer withdrew choline salicylate from its teething gel. This is reported as a regulatory and market position, not as advice to any reader. (Source 2)

If it is harmful, what reduces it?

Stopping the product is what the literature documents. In the refractory ulcer case, the ulcers healed completely three months after the gel was withdrawn, after more than a year of failing to heal on high-dose acid suppression. In salicylate overdose the measures are supporting vital functions, increasing salicylate elimination with activated charcoal early and alkaline diuresis where kidney function allows, and dialysis in severe cases; the MHRA review notes that once hepatic metabolism saturates, the plasma salicylate half-life rises from 2 to 4.5 hours up to 18 to 36 hours, so salicylate leaves the body much more slowly than usual. (Source 3)

Why might someone be low in it or missing it?

The question does not apply in the nutrient sense; choline salicylate is a manufactured drug, not something the body makes or needs. People do not have it either because nobody has indicated it, because it has been withdrawn or restricted where they live, or because they cannot take salicylates. The label rules out anyone who has ever had an allergic reaction to salicylates including aspirin, and since 2009 the UK contraindicates topical oral salicylate products in anyone under 16. (Source 5)

Which whole foods contain it or feed it?

No whole food contains choline salicylate; it is a synthesised salt. Salicylates themselves occur in plants, and willow bark supplements deliver them: a United States Pharmacopeia safety review calculated that 240 mg of salicin from willow bark could yield 113 mg of salicylic acid, more than an 81 mg aspirin tablet delivers, and warned that concurrent use with other salicylate-containing medicines increases the risks. That is the sense in which a food or botanical can add to the same salicylate load. (Source 7)

What happens if you do not have it?

Nothing happens; choline salicylate is not something the body needs. For a mouth ulcer, the untreated group in the denture-lesion trial still had its wound area fall by 59.2% over the first 7 days and reach its smallest recorded area at 14 days with no treatment at all, which is the most useful figure in this whole entry: mouth lesions of this kind settle on their own. The trial reported no statistically significant differences between the treated and untreated groups, so these percentages describe what happened in each small group rather than a measured difference between the treatments. The 2026 umbrella review points to corticosteroids, hyaluronic acid and laser therapy for people who need faster symptom control. (Source 4)

How can you test for it?

There is no test for whether you need choline salicylate. There is a test that matters for hidden exposure: urine salicylate. In the refractory ulcer case, a positive urine salicylate was the finding that led to the gel being identified after five endoscopies had failed to explain the ulcers. Blood salicylate level is used to judge the severity of poisoning, but the MHRA review cautions that serum salicylate levels are a poor indicator of toxicity because metabolism, protein binding and movement into tissues all distort them. (Source 3)

References

1. Medical Science Monitor. A Review of Preclinical and Clinical Studies in Support of the Role of Non-Steroidal Anti-Inflammatory Drugs in Dentistry (full text, paragraph on topical NSAID preparations). 2023. PMID 37355769, DOI 10.12659/MSM.940635. Read the source
2. US Food and Drug Administration; monograph document dated 10.14.2022. OTC Monograph M013: Internal Analgesic, Antipyretic, and Antirheumatic Drug Products for Over-the-Counter Human Use (§ M013.50(d) Directions, complete: the children-only dosage-unit example table and the consumer oral dosage schedules in paragraphs (1) to (6)). 2022. Read the source
3. Medicines and Healthcare products Regulatory Agency (Drug Safety Update, article date June 2009; page published 11 December 2014). Oral salicylate gels: not for use in those younger than age 16 years - Drug Safety Update (unheaded opening paragraph, Case details section and complete Salicylate toxicity section). 2009. Read the source
4. Clinics and practice. Comparison of the Effects of Mucosa Tissue Healing with Chlorhexidine Digluconate and Choline Salicylate in Patients Wearing a Removable Prosthetic Restoration-A RCT. (abstract, Results section). 2024. PMID 39585012, DOI 10.3390/clinpract14060184. Read the source
5. DailyMed (US National Library of Medicine); DailyMed publication date 2025-11-17 (SPL version 10). TEXACLEAR PAIN RELIEVER (CAFFEINE, CHOLINE SALICYLATE) LIQUID - Drug Facts label (Warnings; Do not use; Ask a doctor before use if; Ask a doctor or pharmacist before use if; When using this product; Stop use and ask a doctor if; If pregnant or breast-feeding; Keep out of reach of children). 2025. Read the source
6. US Food and Drug Administration; monograph document dated 10.14.2022. OTC Monograph M013: Internal Analgesic, Antipyretic, and Antirheumatic Drug Products for Over-the-Counter Human Use (Professional labeling, complete PRECAUTIONS section: General, Laboratory Tests, Drug Interactions, Carcinogenesis Mutagenesis Impairment of Fertility, Pregnancy, Labor and Delivery, Nursing Mothers, Pediatric Use). 2022. Read the source
7. Planta medica. United States Pharmacopeia Safety Review of Willow Bark. (abstract). 2019. PMID 31604354, DOI 10.1055/a-1007-5206. Read the source
8. JRSM Open. Oral gel choline salicylate induced refractory gastric ulceration (full text, Discussion section, final two paragraphs). 2014. PMID 25057393, DOI 10.1177/2054270414527931. Read the source
9. Medicines and Healthcare products Regulatory Agency (Drug Safety Update, article date June 2009; page published 11 December 2014). Oral salicylate gels: not for use in those younger than age 16 years - Drug Safety Update (MHRA conclusions and CHM advice section). 2009. Read the source
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