My patient is a 26-year-old woman who has severe aphthous ulcers. These ulcers first appeared after a motor vehicle accident in which the patient saw her fianc die. Since then, she has tried selective serotonin reuptake inhibitors, various mouthwashes, special toothpastes, nystatin, doxycycline, and "swish and spit" corticosteroids. None have been effective. She is gradually losing weight. Are there any other treatments?
----- Garrick Olsen, MD
Current evidence suggests that the etiology of aphthous stomatitis involves an immune dysfunction. Several systemic disorders have oral aphthae as a common presenting symptom; in addition, stress seems to play a relevant role in facilitating lesion recurrence.
Special mouthwashes and toothpastes address symptoms, but they do not affect the onset or duration of the ulcers. Topical products reduce the intensity of the pain by physical (covering of the ulcer) or chemical (cautery) means.
Other treatments decrease symptoms and hasten healing. Gel formulations of high-potency corticosteroids (eg, fluocinonide) or ultra high-potency corticosteroids (betamethasone/dexamethasone) can be effective: the gel prolongs the time the drug is in contact with the affected mucosa.
A rinse/solution formulation of a corticosteroi (dexamethasone) is recommended for patients with lesions in multiple areas of the mouth. For major ulcers, injected corticosteroids (eg, triamcinolone) are appropriate. For recalcitrant major aphthae, some experts advocate treatment with other types of systemic immune modulators, such as corticosteroids, azathioprine, or thalidomide. The therapeutic alternatives of last resort are pentoxifylline and colchicine. A few controlled studies have shown that these agents have some efficacy at reducing the frequency and duration of attacks.1,2 However, these medications have potential adverse effects (which can include neutropenia and GI discomfort), and recent research does not support the efficacy of pentoxifylline in this setting.3
If there is an oral medicine or oral pathology specialist in your area, he or she will be able to offer you further guidance.
----- Andres Pinto, DMD, MPH
Assistant Professor of Oral Medicine
Director, Oral Medicine Clinic
University of Pennsylvania School of Dental Medicine
1. Katz J, Langevitz P, Shemer J, et al. Prevention of recurrent aphthous stomatitis with colchicine: an open trial. J Am Acad Dermatol. 1994;31:459-461.
2. Chandrasekhar J, Liem AA, Cox NH, Paterson AW. Oxypentifylline in the management of recurrent aphthous oral ulcers: an open clinical trial. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 1999;87:564-567.
3. Thornhill MH, Baccaglini L, Theaker E, Pemberton MN. A randomized, double-blind, placebo-controlled trial of pentoxifylline for the treatment of recurrent aphthous stomatitis. Arch Dermatol. 2007;143:463-470.