Aphthous Ulcers Treatment & Management

Identify and correct predisposing factors for recurrent aphthous stomatitis (RAS). Ensure that patients brush atraumatically (eg, with a small-headed, soft toothbrush) and avoid eating particularly hard or sharp foods (eg, toast, potato crisps) and avoid other trauma to the oral mucosa.

SLS should be avoided if implicated as a predisposing factor. Any iron or vitamin deficiency should be corrected once the cause of that deficiency has been established. If an obvious relationship to certain foods is established, these should be excluded from the diet. Patch testing may be indicated to reveal allergies. The occasional patient who relates ulcers to her menstrual cycle or to use of an oral contraceptive may benefit from suppression of ovulation with a progestogen or a change in the oral contraceptive.

In most cases, the natural history of RAS is one of eventual remission. However, for some patients, remission occurs spontaneously several years later; thus, treatment is indicated in these patients if discomfort is significant. Relief of pain and reduction of ulcer duration are the main goals of therapy. There is a huge range of supposed or possible remedies available, but objective evidence shows the most efficacy from corticosteroids and antimicrobials used topically. ^{[16, 17]}

Topical corticosteroids (TCs) remain the mainstays of treatment. A spectrum of different TCs can be used. At best, TCs reduce painful symptoms but not the rate of ulcer recurrence. The commonly used preparations are as follows:

• Hydrocortisone hemisuccinate pellets (Corlan), 2.5 mg used 4 times daily

• Triamcinolone acetonide in carboxymethyl cellulose paste (Adcortyl in Orabase [withdrawn in some countries], Kenalog), administered 4 times daily

• Betamethasone sodium phosphate as a 0.5-mg tablet dissolved in 15 mL of water to make a mouth rinse, used 4 times daily for 4 minutes each time

Hydrocortisone and triamcinolone preparations are popular because neither causes significant adrenal suppression; however, ulcers still recur.

Betamethasone, fluocinonide, fluocinolone, fluticasone, and clobetasol are more potent and effective than hydrocortisone and triamcinolone, but they carry the possibility of some adrenocortical suppression and a predisposition to candidiasis.

Other topical medications that can reduce discomfort include the nonsteroidal anti-inflammatory drugs (NSAIDs) diclofenac and amlexanox paste; the latter has been found to shorten the time it takes minor aphthae to heal. Swishing three or four times daily with so-called “magic mouthwash” (MMW) can also offer some pain relief. ^[2] MMW can be obtained in several formulations, an example being as follows:

• One part viscous lidocaine 2%
• One part Maalox (do not substitute Kaopectate)
• One part diphenhydramine (12.5 mg per 5 mL)

Benzydamine hydrochloride mouthwash, though no more beneficial than a placebo, can produce transient pain relief. Chlorhexidine gluconate and bioadhesive (Gelclair) mouth rinses reduce the severity and pain of ulceration but not the frequency.

Topical tetracyclines may reduce the severity of ulceration, but they do not alter the recurrence rate. A doxycycline capsule of 100 mg in 10 mL of water administered as a mouth rinse for 3 minutes or tetracycline 500 mg plus nicotinamide 500 mg administered 4 times daily may provide relief and reduce ulcer duration. Avoid tetracyclines in children younger than 12 years who might ingest them and develop tooth staining.

If RAS fails to respond to local measures, systemic immunomodulators may be required. A wide spectrum of agents has been suggested as beneficial, but few studies have been performed to assess the efficacy of these drugs (or their adverse effects are significant). Thalidomide 50-100 mg daily is effective against severe RAS, although ulcers tend to recur within 3 weeks. Teratogenicity, neuropathy, and other adverse effects dissuade most physicians from its use.

Oral vitamin B-12 may significantly reduce or eliminate RAS recurrences. For example, a randomized, double-blind, placebo-controlled study by Volkov et al found that in patients taking 1000 μg of sublingual vitamin B-12 daily for 6 months, there was a significant decrease in the number of ulcers and level of pain, as well as in the duration of outbreaks, at 5 and 6 months no matter what the patients' initial B-12 blood levels had been. Moreover, during the sixth month of treatment, 74.1% of the patients taking B-12 achieved "no aphthous ulcers status," compared with 32.0% of patients in the control group. ^[18]

Few, if any, of the other medications used for RAS have undergone serious scientific evaluation. These include aloe vera, biologics, transfer factor, gamma-globulin therapy, sodium cromoglycate lozenges, dapsone, colchicine, pentoxifylline, levamisole, colchicine, azathioprine, prednisolone, azelastine, alpha 2-interferon, ciclosporin, deglycerinated liquorice, 5-aminosalicylic acid (5-ASA), prostaglandin E2 (PGE2), sucralfate, diclofenac, and aspirin.

A randomized, single-blind, placebo-controlled trial by Albrektson et al indicated that low-level laser therapy can relieve RAS pain. The study, which involved 40 patients with RAS, also found that patients who received laser treatment found it easier to eat, drink, and brush their teeth than did the placebo patients. ^[19]

Similarly, a literature review by Khaleel Ahmed et al suggested that low-level laser therapy is superior to topical medications in reducing pain and lesion size in patients with RAS. Moreover, in one of the reports included in the review, diode laser treatment at 635 nm was found to reduce pain more quickly than did therapy at 450 or 808 nm. ^{[20, 21]}

Patients with oral ulcers typically present to a general dentist. These dentists are usually well versed in primary management of such lesions, but if the presentation is severe or the ulcers are recalcitrant to topical therapy, a systematic workup and management beyond topical therapies may be essential, as the condition may compromise diet and hydration and significantly impact the patient's quality of life. These cases may be beyond the scope of a general dentist, and referral to a specialist in oral medicine may be necessary. Depending on the etiology of the ulcers, interdisciplinary care may be needed with, as applicable, a gastroenterologist, an immunologist/allergologist, a hematologist, a rheumatologist, and a dermatologist.

The patient should avoid consuming any foods that could lead to RAS.