Aphthous stomatitis

Management Strategy

The therapeutic approach to aphthae is dependent on the frequency of recurrence, duration, and severity of symptoms. In addition, underlying hematologic abnormalities, nutritional deficiencies, and medications should be considered as causative agents, as well as systemic disorders such as Crohn disease, Behçet disease, mouth and genital ulcers with inflamed cartilage (MAGIC) syndrome, cyclic neutropenia, Sweet syndrome, reactive arthritis, HIV infection, and autoinflammatory syndromes such as periodic fever, aphthous stomatitis, pharyngitis, and cervical adenitis syndrome (PFAPA syndrome). Stress is also thought to play a role in exacerbation of the disease. Unfortunately, because there is no curative treatment to date, the emphasis of treatment is on measures that may afford symptomatic relief and decrease occurrence, without causing significant adverse effects.

Topical corticosteroids are the mainstay of therapy. For milder disease, corticosteroids such as fluocinonide can be used. Superpotent corticosteroids such as clobetasol or halobetasol are appropriate for more severe episodes. Most practitioners suggest the use of topical therapy after meals. These can be applied in equal parts with an occlusive agent such as Orabase for better adherence. Drug delivery can be enhanced by cotton-tip applications for 30 seconds and avoidance of eating and drinking for 30 minutes after application. Initial concentrations of 3–10 mg/mL of intralesional triamcinolone acetonide are helpful for major aphthae. Repeat injections over 2- to 4-week intervals are suggested. Dexamethasone elixir 0.5 mg/5 mL three times daily used as a mouthwash or beclomethasone dipropionate aerosol spray can target ulcers on the soft palate or oropharynx. Elixirs can be combined with sucralfate or Kaopectate to improve adhesion to ulceration. When used for less than 3 weeks, systemic absorption and hypothalamic–pituitary–adrenal axis suppression are unlikely.

RAS that elicits severe pain may require intermittent systemic corticosteroid therapy . Prednisone 1 mg/kg (40–60 mg) daily can be given with a 2-week taper or as ‘burst therapy’ for shorter periods. Concomitant therapy with topical corticosteroids may be helpful. Thalidomide 50–200 mg daily is the most effective steroid-sparing agent. It is also the only Food and Drug Administration (FDA)–approved treatment for major aphthae in HIV-positive patients. Dapsone 100 mg daily, pentoxifylline 400 mg three times daily, and clofazimine 100 mg daily may also lead to suppression of aphthae. Oral rofecoxib 50 mg on the first day and 25–50 mg per day on the following days or oral tinidazole 1 g per daily may have some benefit. Anti-tumor necrosis factor (TNF)-α therapies may be effective in recalcitrant cases. The use of oral phosphodiesterase-4 inhibitor apremilast in treatment of recalcitrant RAS has also been proposed. Those patients who require suppressive therapy but cannot tolerate the side effects of systemic agents can try medications such as topical ciclosporin rinse 500 mg/5 mL three times daily, or interferon - α _2a 1200 IU daily as a 1-minute rinse and swallow.

Application of amlexanox 5% paste four times daily has been shown to reduce aphthous ulcer healing time, and the application of amlexanox OraDisc four times daily to prodromal areas of the buccal mucosa has shown promise in the prevention of recurrent minor aphthous ulceration.

Lidocaine gel or spray , dyclonine, diphenhydramine (12.5/5 mL), or benzocaine are helpful for pain reduction. Patients must avoid desensitization of the entire oral vault, which may lead to self-induced trauma. A compounded anesthetic mouthwash (aluminum hydroxide–magnesium hydroxide, diphenhydramine, and lidocaine) has better mucosal adherence. Systemic nonsteroidal antiinflammatory drugs ( NSAIDs ), sucralfate suspension , 0.2% chlorhexidine gluconate mouthwash, triclosan, or tetracycline suspension (250 mg/5 mL) may provide pain relief and reduce healing time, although these are less effective than potent topical corticosteroids. Bioadhesives, such as carboxymethylcellulose , provide a protective film and may reduce healing time. Use of laser therapies, including CO ₂ laser, Nd:YAG, and low-level light therapies in RAS, has also been shown to improve symptoms caused by consumption of food, beverages, and brushing of teeth.

Trigger avoidance can be useful. Predisposing factors include food (nuts, chocolate, tomatoes, citrus fruits, and spices), alcohol and carbonated beverages, trauma, menstruation, and stress. A food diary may be of value in identifying an offending agent. Certain medications, such as β-blockers, NSAIDs, and antioxidants, as well as sensitivity to sodium lauryl sulfate found in toothpaste, may contribute to the recurrence of aphthae. Hormonal therapy may alleviate RAS associated with menstruation. Reassurance of the benignity of this condition is paramount, and relaxation techniques or biofeedback can be discussed if stress is found to be a significant trigger.