Current Concepts in the Treatment of Recurrent Aphthous Stomatitis

A. Altenburg, MD; C.C. Zouboulis, MD

Disclosures

Skin Therapy Letter. 2008;13(7):1-4. 

In This Article

Topical Therapy

Certain foods should be avoided as they appear to trigger the eruption of new aphthae and prolong the course of the lesions (e.g., foods that are hard, acidic, salty, or spicy, as well as nuts, chocolate, citrus fruits, and alcoholic or carbonated beverages). In addition, because surfactants and detergents can cause irritation, dental care products containing sodium lauryl sulphate should be avoided.[4]

Pain relief can be attained using topical lidocaine 2% gel or spray, polidocanol adhesive dental paste, or benzocaine lozenges. Available combination preparations include a pump spray with tetracaine and polidocanol, and a mouth rinse solution that uses benzocaine and cetylpyridinium chloride as the active ingredients. As well, anesthetic-containing solutions, e.g., a viscous lidocaine 2% solution, can be applied carefully on the lesions.

Mouth washes with ingredients known to mildly inhibit inflammation can be used, e.g., chamomile extract solution (Kamillosan®, MEDA Pharma). Research has shown that the use of chlorhexidine (CHX) mouth rinses on RAS may be particularly helpful.[5] Other dosing forms of CHX include dental gels or throat sprays. Triclosan is a broad spectrum antibacterial agent that also exhibits antiseptic, anti-inflammatory, and analgesic effects. Available formulations include toothpastes and mouthrinses. A randomized, double-blind study that explored the topical application of diclofenac 3% in hyaluronan 2.5% reported a significant reduction in pain.[6] For adjuvant therapy, dexpanthenol, which acts as an humectant, emollient, and moisturizer, can be used in different application forms and is available without prescription.

Applications of hydrogen peroxide 0.5% solution, silver nitrate 1%-2% solution, or a silver nitrate caustic stick represent several older therapeutic methods that can reduce the duration of solitary aphthae. Cauterizing chemical treatments must be administered by a dentist or physician to avoid burning healthy tissues.

Localized therapy with tetracycline can effectively reduce the duration and pain of oral aphthae.[7] To avoid difficulties related to the chemical stability of tetracycline when it is formulated in an aqueous solution, a prescription for compounding and preparation, as shown in Table 1 , has been proposed.[8] Due to acidic pH values, patients may experience a brief burning sensation, but contact sensitization has not been reported in the context of intra-oral topical tetracycline applications. Marked improvement has been described with the use of a dental paste containing chlortetracycline 3%.[9]

Topical sucralfate is effective in treating RAS ulcerations when administered at 5mL, 4 times/day. Sucralfate exerts a soothing effect on lesions by adhering to mucous membrane tissues and forming a protective barrier on the affected site. This drug is commonly used to treat peptic ulcers.

Topical steroids, such as triamcinolone acetonide and prednisolone (2 times/day), are formulated as oral pastes, and are commonly used in the management of RAS. Additionally, therapeutic benefit can be derived from a mouthwash containing betamethasone. Of concern is the fact that the long-term use of steroids may predispose patients to developing local candidiasis. Combination therapy with a topical anesthetic during the day and a steroid paste at night is widely accepted as the optimal treatment regimen. An intralesional injection of triamcinolone (0.1-0.5mL per lesion) can be considered for painful single aphthae. For the treatment of genital aphthous ulcers, a combination of fluorinated steroids and antiseptics that are formulated in a cream base can be effective (e.g., dexamethasone 0.1% + chlorhexidine 1% or flumetasone 0.02% + clioquinol 3%).

Application of 5-aminosalicylic acid 5% cream (applying a small amount to cover the aphthae 3 times/day), or a toothpaste containing amyloglucosidase and glucose oxidase can reduce pain and lessen the duration of oral aphthae.[10] A topical prostaglandin E2 gel prevented the appearance of new aphthae in a short-term study involving a small number of patients.[11] According to the experience of several patients, raw egg white may partially soften oral pain in RAS. Interestingly, the number of aphthae and frequency of recurrence are reduced during phases of smoking compared with phases of abstinence; experimental data confirmed the anti-inflammatory effect of nicotine and biochanin A on keratinocytes.[12,13] Also, a small study showed the remission of aphthosis during therapy with chewable nicotine tablets.[14]

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