Aphthous Ulcers: Treatment and Case Report

Aphthous ulcers are a common occurrence in the general population. Although not life-threatening, they can be the source of a great deal of patient annoyance and discomfort. If they are recurrent, laboratory tests may be needed to rule out an underlying systemic condition. These tests can include a complete blood count, hemoglobin test, white blood cell count with differential red blood cell indices, iron studies (specifically including serum ferritin levels), red blood cell folate assay, serum vitamin B12 measurements, and a serum antiendomysium antibody and transglutaminase assay, which would be indicative of celiac disease.
The histology of aphthous ulcers may be nonspecific. The ulcer is generally depressed well below the surface, and the inflammation extends deeply. The surface of the ulcer is covered by a fibrinous exudate infiltrated by polymorphs. Directly below is a layer of granulation tissue with dilated capillaries and edema. Beneath this layer is a repair reaction area, with fibroblasts in the surrounding connective tissue laying down fibrous tissue.1,2
A myriad of therapeutic regimens, most of which are palliative and offer no actual cure of the disease process, have been implemented to assist in alleviating the symptoms of the ulcers. Thus, the majority of treatments have been directed toward symptomatic relief of the ulcers until the disease process runs its course. First, topical and systemic antibiotic treatments have been used because it is believed that some infectious agent may be the source of the aphthous ulcer. Tetracycline and minocycline have been the most commonly used agents. The major disadvantage lies in the fact that in children and in women who may be pregnant, tetracycline has a propensity to discolor teeth.3 Although the antibiotic therapy results in a decrease in pain and ulceration, recurrence is not uncommon, and the duration of the disease may still be the same.3
Another therapeutic regimen enlists the use of immune modulators, which have been used mainly in HIV-positive patients. Thalidomide (Thalomid [Celgene]) is frequently used for managing aphthous ulcers that are a source of severe pain associated with eating. Thalidomide, however, is contraindicated in non-HIV-infected patients because of its teratogenic effects.4,5 Amlexa-nox 5% paste (Aphthasol [DiscusDental]) has been investigated in several studies conducted for the treatment of aphthous ulcers. The paste has been shown to improve healing time when applied to ulcers 2 to 4 times a day.6 The disadvantage of this treatment regimen is the amount of times it has to be applied in order to be effective.7
Anesthetic agents such as 2% lidocaine may be applied several times a day for relief of local symptoms.3,8 Localized symptomatic relief may also be achieved with over-the-counter benzocaine preparations such as Anbesol (Wyeth Consumer Healthcare), Zilactin-B (Blairex), and Orajel (Del Pharmaceuticals). These agents help coat the aphthous ulcers and hence provide protection locally around the area, offering palliative relief.8 Silver nitrate sticks have also been used to provide brief anesthesia, with the drawback being that the application itself is quite painful.9 Furthermore, the burning effects of silver nitrate may cause more local necrosis and actually delay healing time. The combination of over-the-counter magnesium hydroxide antacid and diphenhydramine hydrochloride (5 mg per mL) mixed half and half, known as ìmagic mouthwash,î has also been shown to provide symptomatic relief.3  Again, this does not lead to curing the disease itself, only alleviating the symptoms.
Local anti-inflammatory agents have so far proven to be the most helpful in expediting healing and relieving symptoms in the management of recurrent minor aphthous ulcers. Triamcinolone 0.1% (Kenalog in Orabase [Colgate]) provides a protective coating and can be applied to ulcers 2 to 4 times a day. The disadvantage of this is the potential for secondary opportunistic fungal infection.3 Hydrocortisone and triamcinolone preparations are popular because neither causes significant adrenal suppression; however, ulcers still recur. For very painful ulcers, either acetaminophen or systemic nonsteroidal anti-inflammatory agents have been shown to provide some analgesia.9
Lastly, alternative agents have also been employed to combat aphthous ulcers. It has been reported that sucking on zinc gluconate lozenges provides local relief and speeds up the healing time. Vitamin C, vitamin B complex, and lysine have all been shown to speed healing when taken orally at the start of lesions. Some herbal therapies like sage and chamomile mouthwash have also been used. Echinacea is another herbal therapy that has been reported to speed healing via its immune modulatory effect. Some additional agents that have been used are carrot, celery, and cantaloupe juices. These therapeutic regimens are mentioned, but no scientific trials have ever been conducted to test their efficacy.10

CLINICAL CASE PRESENTATION

Figure 1. Preoperative view of the aphthous ulcer.

Figure 2. Laser at 0.25 W with no air or water.

Figure 3. Gradual focusing of the laser.

Figure 4. Immediate postoperative view.

Figure 5. One week postoperatively with complete resolution of the lesion.

Aphthous ulcers are a common cause of oral discomfort in a large part of the patient population. A simple and effective way to become proficient at using a laser for soft-tissue procedures is to use it to treat these aphthous ulcers.11 They are a common finding and usually are treated with palliative care options such as the ones previously mentioned. This generally alleviates the symptoms but does not treat the ulcer itself. Often, the patient is able to tolerate the discomfort until the ulcer subsides.  This, however, is not effective in every patient, and certain patients are forced to endure the course of the ulcer. Using the laser, the clinician can easily treat the ulcer expeditiously and alleviate the patientís discomfort in a relatively short period of time.11-13
This case presents a young male patient with an aphthous ulcer in the lower right lip (Figure 1). The ulcer had been present for several days, and the patient complained of pain and discomfort associated with mastication. Using the Biolase G4 tip, the laser was used with the settings at 0.25 W with no air or water.14-16 The hydrokinetic theory states that the tissue is already hydrated and the laser will utilize this hydration to ablate the soft tissue.13,17
The ulcer was slowly circumscribed by gradually focusing on the lesion until the white outline became more prominent and the entire ulcer was engulfed by the white appearance (Figures 2 to 4).
This patient was followed one week after treatment, and the lesion had resolved (Figure 5). He did not complain of any pain or discomfort immediately following or since the procedure. Continued monitoring of the patient will provide further information as to the recurrence rate of the ulcer in the same location. Although the results can vary from patient to patient, most will experience dissipation of the lesion within 1 to 2 days.18,11 For others it may take upward of a week to resolve completely. Another remarkable advantage of using the laser to treat the ulcer is that in many patients, the ulcer will not return to the same area.11,18,12 For numerous patients, aphthous ulcers recur in the same area for years. Treatment with the laser can eliminate this nuisance and lead to complete resolution of the disease process for a great number of patients.


References

1. Freedberg IM. Fitzpatrick's Dermatology in General Medicine. Vol 1. 5th ed. New York, NY: McGraw-Hill; 1999.
2. Cotran RS, Kumar V, Collins T, et al. Robbins Pathologic Basis of Disease. 4th ed. Philadelphia, Pa: WB Saunders; 1989:817.
3. Burgess JA, Johnson BD, Sommers E. Pharmacological management of recurrent oral mucosal ulceration. Drugs. 1990;39:54-65.
4. Jacobson JM, Greenspan JS, Spritzler J, et al. Thalidomide for the treatment of oral aphthous ulcers in patients with human immunodeficiency virus infection. National Institute of Allergy and Infectious Diseases AIDS Clinical Trials Group. N Engl J Med. 1997;336:1487-1493.
5. Ball SC, Sepkowitz KA, Jacobs JL. Thalidomide for treatment of oral aphthous ulcers in patients with human immunodeficiency virus: case report and review. Am J Gastroenterol. 1997;92:169-170.
6. Greer RO Jr, Lindenmuth JE, Juarez T, et al. A double-blind study of topically applied 5% amlexanox in the treatment of aphthous ulcers. J Oral Maxillofac Surg. 1993;51:243-249.
7. Binnie WH, Curro FA, Khandwala A, et al. Amlexanox oral paste: a novel treatment that accelerates the healing of aphthous ulcers. Compend Contin Educ Dent. 1997;18:1116-1124.
8. Clinical Manual for Management of the HIV-Infected Adult. Section 6: Disease-Specific Treatment: Oral ulceration. AIDS Education and Training Centers Web site. Available at: http://www.aidsed.org/aetc/aetc?page=cm-413_oral_ulcer#S5X. Accessed July 31, 2006.
9. McBride DR. Management of aphthous ulcers. Am Fam Physician. 2000;62:149-160.
10. Strohecker J, ed. Alternative Medicine: The Definitive Guide. Fife, Wash: Future Medicine Publishing; 1995:264.
11. Pick RM, Powell GL. Laser in dentistry. Soft-tissue procedures. Dent Clin North Am. 1993;37:281-296.
12. Shulkin NH, Shulkin GH. The American dental laser: initial patient response. Dent Today. 1991;10:60-61.
13. Kutsch VK. The history of dental lasers. Proceedings from the World Clinical Laser Institute; August 2003; Atlantic City, NJ.
14. Rizoiu IM, Eversole LR, Kimmel AI. Effects of an erbium, chromium: yttrium, scandium, gallium, garnet laser on mucocutanous soft tissues. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 1996;82:386-395.
15. Coluzzi DJ. An overview of laser wavelengths used in dentistry. Dent Clin North Am. 2000;44:753-765.
16. Sulieman M. An overview of the use of lasers in general dental practice: 1. Laser physics and tissue interactions. Dent Update. 2005;32:228-236.
17. Marx I, Opít Hof J. The Er,Cr:YSGG hydrokinetic laser system for dentistry: clinical applications. SADJ. 2002;57:323-326.
18. Smith TA, Thompson JA, Lee WE. Assessing patient pain during dental laser treatment. J Am Dent Assoc. 1993;124:90-95.


Dr. Asgari is currently a first-year pediatric dentistry resident at Mount Sinai Hospital. After receiving his BS from the University of California, Santa Barbara, in biology, he attended Columbia University School of Dental and Oral Surgery, where he was awarded a DDS degree in 2004.  Dr. Asgari was the editor-in-chief of the Columbia Dental Review Student Journal and received the Lawrence H. Meskin nationwide recognition award for his outstanding publication. He is a co-author of the instructional DVD and handbook Laser Dentistry for Children. He can be reached at (212) 241-6505.

Dr. Jacobson is the director of pediatric dentistry at Mount Sinai Hospital in New York City, where he actively teaches postgraduate dentists and performs complete dental rehabilitation on children under general anesthesia. He is a board-certified specialist in dental care for children, the former director of pediatric dentistry at Downstate Medical Center (Brooklyn, NY), and also is an assistant professor and clinical instructor at Maimonides Medical Center (Brooklyn, NY). Dr. Jacobson is a former assistant professor at Columbia University School of Dental and Oral Surgery, where he instructed post-graduate pediatric dental residents. He has extensive experience in dental treatment using both conscious sedation and general anesthesia, and can be reached at (212) 997-6453.

Dr. Mehta earned a masterís degree in health informatics from the University of Alabama at Birmingham in 2003. Subsequently she completed her DMD at the University of Pennsylvania in 2005 and went on to complete her GPR at Mount Sinai Hospital in 2006. Her research interests include use of orthodontic microscrew implants in the correction of malocclusion as well as the use of lasers in dentistry. She can be reached at (212) 241-6505.

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