What is the best approach to manage recurrent aphthous stomatitis?

Management of Recurrent Aphthous Stomatitis (RAS)

Topical corticosteroids combined with chlorhexidine oral rinse are the first-line treatment for recurrent aphthous stomatitis, with laser therapy showing superior short-term efficacy for pain relief and healing in more severe cases. 1, 2

Etiology and Clinical Presentation

Recurrent aphthous stomatitis (RAS) is the most common chronic disease of the oral cavity, affecting 5-25% of the population 3. It is characterized by:

• Combination of genetic predisposition, immune dysfunction, nutritional deficiencies, and environmental triggers 1
• Three clinical types:
  • Minor aphthous ulcers (80-85%): <1cm, healing within 7-14 days
  • Major aphthous ulcers: >1cm, deeper, more painful, healing with scarring
  • Herpetiform ulcers: clusters of multiple small ulcers 1

Diagnostic Approach

Before initiating treatment:

• Identify and control possible predisposing factors 3
• Exclude underlying systemic causes (Crohn's disease, celiac disease) 1
• Consider laboratory investigations for persistent cases:
  • Complete blood count
  • Vitamin B12, folate, iron, and ferritin levels
  • Celiac disease screening 1
• Biopsy may be necessary for atypical presentations or ulcers lasting >2 weeks 1

Treatment Algorithm

1. First-Line Treatment (Mild to Moderate RAS)

A. Topical Treatments:

• Topical corticosteroids: Triamcinolone acetonide 0.1% applied 4 times daily 1, 4
• Chlorhexidine gluconate 0.2% rinse twice daily to prevent secondary infection 1
• Topical anesthetics (benzocaine-containing products) for pain relief 1

B. Protective Measures:

• Protective gels (Gengigel or Gelclair) to form a barrier over ulcers 1
• Non-alcoholic analgesic rinses (benzydamine hydrochloride 0.15%) before eating 1

2. Second-Line Treatment (Moderate to Severe RAS)

A. Advanced Topical Options:

• Amlexanox (anti-inflammatory) shows superior efficacy 1, 2
• Sucralfate suspension for larger ulcers or those present >1 week 1
• Tetracycline hydrochloride applied topically for moderate cases 3, 5

B. Physical Therapy:

• Low-level laser therapy provides significant pain relief and accelerated healing by day 3 compared to topical corticosteroids 4, 2
  • Recommended during exacerbation phase for rapid symptom control
  • Single application on three alternate days 4

3. Third-Line Treatment (Severe, Recurrent RAS)

For constant and aggressive outbreaks with intense pain unresponsive to topical treatments:

• Systemic corticosteroids (prednisone) for short courses 3, 6
• Probiotics for long-term management to reduce recurrence 2
• Thalidomide for severe refractory cases (with careful monitoring) 3, 6

Prevention Strategies

• Maintain good oral hygiene with soft toothbrush 1
• Apply medicated lip balm regularly 1
• Stay hydrated to keep oral tissues moist 1
• Avoid triggers:
  • Hard, acidic, spicy, or salty foods
  • Toothpastes containing sodium lauryl sulfate
  • Alcohol and carbonated drinks 1
• Consider cyclical estrogens for premenstrual aphthosis 5

Monitoring and Follow-up

• Regular follow-up every 3-6 months for persistent symptomatic cases 1
• Daily pain assessment during active episodes 1
• Monitor for signs of systemic disease 1

Important Considerations

• Doxycycline and penicillin have higher risk of adverse events and should be avoided 2
• Systemic interventions should be reserved for patients unresponsive to topical treatments 6
• The evidence for many systemic interventions remains inconclusive due to poor methodological quality of studies 6
• Honey and insulin liposome gel have shown promising results in recent studies but require further validation 2