How to Treat Apthous Ulcers

Treatment

There is no specific treatment for recurrent aphthous ulcers although, over the years, many drugs have been advocated. The results of an excellent comparative clinical trial of a variety of drugs have been reported by Graykowski and his co-workers.

Briefly, it was found that a tetracycline mouthwash (250 mg. per 5ml.), used four times daily for 5 to 7 days, produced a good response in nearly 70% of the patients tested by relieving the pain, reducing the size of the lesions and reducing the healing time.

A steroid ointment, 1.5% cortisone acetate-antibiotic lozenges also showed some effectiveness but not as great as the tetracycline.

Chemical cautery reduced pain but had no other beneficial effects. No significant improvement was found with the use of antihistaminics, gamma globulin, multiple smallpox vaccinations or a lactobacillus acidophilus-l. bulgaricus preparation, all of which have variously been reported to be effective.

There has also been extensive clinical trail of levamisole, originally developed as an anthelmintic drug against nematodes in both man and animals, which has been found also to potentiate the immune response in a variety of ways.

The result of a number of these studies in treating recurrent aphthous Stomatitis have been reported, some showing a reduction in the duration of symptoms, some showing a decrease in the duration of lesions, some showing a diminished frequency of lesions, but others concluding that the drugs had magnificent on severity or incidence of lesions.

It was concluded at the previously mentioned workshop on aphthous Stomatitis-behcet’s syndrome, where a number of these reports were presented, that further clinical evaluation of this drug is necessary.

An excellent summary of the many drugs and chemicals which have been used to treat recurrent aphthous Stomatitis over the years has been prepared by antoon and miller. Unfortunately, despite any from of therapy, there is no known cure for the disease.

Management:

RAS is the most common cause of recurring oral ulcers an d is essentially diagnosed by exclusion of other disease. A detailed history and examination by a knowledgeable clinician should distinguish.

RAS form primary acute lesions such as viral Stomatitis or chronic multiple lesions such as pemphigoid, as well as other possible causes of recurring ulcers such as connective tissue disease, drug reactions, and dermatologic disorders.

The history should emphasize symptoms of blood dyscrasias, systemic complaints, and associated skin, eye, genital, or rectal lesions. Laboratory investigation should be used when ulcers worsen or begin past the age of 25. biopsy-like laboratory tests are only necessary to exclude other disease.

Patients with severe minor aphthae or major apthous ulcer should have known associated factor investigated, including levels of serumiron, folate, vitamin B-12, and ferritin. Patients with abnormalities in these values should be referred to an internist to rule out malabsorption syndromes and proper replacement therapy.

The clinician may also choose to have food allergy or gluten sensitivity investigated in severe cases resistant to other forms of treatments.
Medications prescribed should depend on the severity of the disease. In mild cases with two or three small lesion, the application of a topical protective emollient such as Orabase is all that is necessary.

In more severe cases the use of topical corticosteroid preparations is helpful in decreasing the healing time of the lesions. Preparation such as triamcinolone or fluocinolone may be applied topically to the lesions three or four times daily, after eating and at bedtime.

Treatment of severe RAS is challenging and difficult. Use of high-potency topical steroids such as fluocinonide gel, clobetasol cream or beclomethasone spray is suggested.

Intralesional steroid injections are helpful in large, indolent major aphthae. Chlortetracycline used either mouthrinse or placed on individual large lesions crease the pain and number of ulcers in a number of studies.

In severe cases of major RAS not responsive to steroids or tetracycline, the clinician may attempt trials of dapsone, or if that fails, thalidomide, understanding that the severity of the disease must warrant the risk of potential severe side-effects.

Revuz and associates performed a random trail of thalidomide versus placebo in 73 patients with major RAS and reported complete remission in 32.

Thalidomide is not approved for use in the united states owing to its frequently causing peripheral neuropathy. Other therapy showing potential benefit but requiring further investigation is recombinant interferon alpha, nicotine tablets, and colchicines.

 

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