Demystifying Recurrent Oral Ulcerations - IneedCE.com

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Figure 4. Intraoral herpes lesions Figure 5. Trauma-induced ulcer following lip biting Figure 6a. Intraoral ulcer associated with benign mucous membrane pemphigoid Figure 6b. Ocular lesion associated with benign mucous membrane pemphigoid If patients have skin, ocular, genital or other non-oral mucosal lesions, the diagnosis is unlikely to be RAU unless there are coincidental one-time unrelated lesions. Similarly, the diagnosis is unlikely to be RAU if fever is present. Single lesions that do not heal within 2 weeks (including following removal of a traumatic irritant), particularly if there is no previous history of similar lesions, should be viewed with suspicion. The differential diagnosis must include squamous cell carcinoma (SCC), and a definitive biopsy may be required (Figure 8). Patients with long-lasting RAU that are particularly severe and refuse to heal are suspect for HIV infection or another immunocompromised condition. RAU in these patients are more severe, are of long duration, heal poorly and are debilitating. 98 In cases of frequent or severe outbreaks of RAU, a referral for systemic disease and vitamin deficiency screening should be given, if such conditions were not previously diagnosed. Sensitivity screening may also be considered to rule out reactions to foods and chemicals such as SLS. Palliative Care There is no definitive cure for aphthous ulcers. Palliative care can be provided to relieve pain, promote healing and prevent secondary infection. Various topical and systemic medications are available. Topical medications Pain-relieving topical gels that can be dabbed on the lesion include 2% lidocaine and 20% benzocaine-based products. Lidocaine mouth rinse or spray can also be used. Topical pain-relieving barrier agents that have been shown to promote healing include octylcyanoacrylate 99 and 5% amlexanox paste (Aphthasol ® ). 100,101 5% amlexanox paste can reduce the severity of ulcers if applied two to four times daily in the initial phase of ulcer development. Rinses that form a bioadherent protective mucosal coating are available; these are useful if lesions are widespread. Topical corticosteroids are available in varying potencies. Topical hydrocortisone hemisuccinate pellets (2.5 mg) can be used for nonsevere cases. 102 Triamcinolone acetonide paste (Kena log in Orabase ® ) is a medium-potency prescription topical corticosteroid that helps to reduce pain, inflammation and ul cera tion when applied two or three times daily for five days. An alternative is fluocinonide dental paste (Lidex in Orabase). 103 Four to five days’ use of tetracycline or minocycline rinse four times daily has also been found to be helpful in treating RAU. Tetracycline rinse can be made using a 250 mg capsule dissolved in 180 cc water. 104 These rinses should not be used in young children because of the risk of intrinsic staining in developing teeth should the child swallow the rinse. For severe RAU, higher potency anesthetic rinses, topical corticosteroids, tetracycline and/or systemic medications are needed. Palliative rinses combining equal parts 2% lidocaine, a bioadhesive coating agent (such as kaopectate) and an antihistamine are effective. Betamethasone mouth rinse is more effective than are hydrocortisone and triamcinolone rinses. However, there is a risk of opportunistic candidal infections, and a greater risk for adrenal suppression with long-term use. 105 6 www.ineedce.com
Figure 7a. Oral ulcerations in a pemphigus patient Figure 7b. Skin lesions in pemphigus patient Figure 8. Squamous cell carcinoma Courtesy of Denis P. Lynch, DDS, PhD If long-term use of topical corticosteroids is necessary, antifungal lozenges or mouth rinses may be required to help prevent candidiasis. An á-interferon rinse — an immunomodulator — may also be effective in treating severe cases of RAU. 106 Systemic medications Systemic medications may be required for the most severe cases. Prednisone (60 mg) four times daily for five to seven days is effective; its use should be avoided in HIV-infected and other immunocompromised patients. If prednisone is used for longer than seven days, slow tapering off is required due to adrenal suppression. For focally severe resistant ulcers, a local triamcinalone injection into the lesion may help. 107 For refractory cases, thalidomide (200 mg four times daily for four weeks), dapsone, colchicine and pentoxifylline may be helpful. 108,109,110 Colchicine administered three times daily (0.5 mg) over two months has been found to decrease the number of ulcers and to reduce pain. 111,112 Thalidomide must never be used in pregnant women or women who may become pregnant, as it is a potent teratogen. Other systemic Table 3. Topical medications Mild and moderate RAU 2% lidocaine Triamcinalone acetonide 20% benzocaine Fluocinonide Cyanoacrylate Tetracycline/minocyline rinses 5% amlexanox L-lysine Bioadhesive rinses Hydrocortisone hemi succinate Zinc lozenges Severe RAU Combination rinses á-interferon rinse Betamethasone rinse Table 4. Additional care Nutritional Other Vitamins Elimination of food allergens Non-spicy food and drink Elimination of gluten (Celiac’s) Adequate fluid intake Reduced dose SLS dentifrice Oral Hygiene SLS-free dentifrice Ultra soft toothbrush Elimination of other chemicals Adjunctive rinsing Drug reactions — Remove sharp points discontinue drugs medications have also been used. Alternative therapies, such as bee propolis (500mg/day), show promise in reducing the number of recurrences of RAU. 113 Nutrition and oral hygiene Aphthae make eating and drinking painful. Patients should avoid hard or crunchy foods and snacks, spicy and salty foods, hot drinks, and acidic drinks (such as orange juice). Using a straw or sipping liquid slowly will help, as will eating soft, bland foods. Patients must drink an adequate amount of fluid. 114 Sipping cold, nonacidic drinks may also help soothe lesions. Maintaining oral hygiene, in addition to its usual benefits, helps prevent secondary infection. Patients should use an ultrasoft toothbrush. Adjunctive use of chlorhexidine gluconate or cetylpyridinum chloride mouth rinse helps reduce the bacterial load and plaque while patients are having difficulty brushing. 115 Twice-daily rinsing with 0.12% chlorhexidine gluconate can increase the number of days without ulcers, although it has not been found to influence the incidence or severity of RAU. If vitamin deficiencies are present, supplements can be given. RAU patients have been shown to respond to B12 replacement therapy. 116 Sharp areas on the dentition or restorations should be smoothed to help prevent trauma if a lesion is present and to help reduce pain during eating and drinking. While discontinuation of medications associated with oral ulcers is indicated to prevent oral ulcers, such discontinuation may be medically contraindicated if an alternative is not avail- www.ineedce.com 7
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Demystifying Recurrent Oral Ulcerations - IneedCE.com

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