Aphthous stomatitis research and natural treatment
July 16 2017 by
Ray Sahelian, M.D.

The cause of recurrent aphthous stomatitis is unknown and over the years a variety of treatments, including adhesive pastes, antiseptics, vitamins, herbs, and steroids have been tested. Although these treatments may reduce pain or the number of lesions in the short term, very few have had any lasting beneficial effect. This condition is the most common oral mucosal ailment in the general population.

Natural treatments
Dietary supplementation with iron, zinc, or vitamins B1, B2, B6, B12, or C may be useful in individuals with deficiencies of these. A gluten free diet is important only for those individuals diagnosed with celiac disease. Stress may make it more likely for symptoms to recur.

Bee propolis health supplement
Recurrent aphthous stomatitis is a common, painful, and ulcerative disorder of the oral cavity of unknown etiology. No cure exists and medications aim to reduce pain associated with ulcers through topical applications or reduce outbreak frequency with systemic medications, many having serious side effects. The purpose of this pilot study was to evaluate the potential of a product to reduce the number of outbreaks of RAS ulcers. Propolis is a bee product used in some cultures as treatment for mouth ulcers. In this randomized, double-blind, placebo-controlled study, patients were assigned to take 500 mg of propolis or a placebo capsule daily. Subjects reported a baseline ulcer frequency and were contacted biweekly to record recurrences. Data were analyzed to determine if subjects had a decrease of 50% in outbreak frequency. The data indicated a statistically significant reduction of outbreaks in the propolis group. Patients in the propolis group also self-reported a significant improvement in their quality of life. This study has shown propolis to be effective in decreasing the number of recurrences and improve the quality of life in patients who suffer from RAS. Clin Oral Investig. 2007. The effect of bee propolis on recurrent aphthous stomatitis: a pilot study. Harvard School of Dental Medicine, Boston, MA, USA.

Fish oils and omega-3 fatty acids
Chin J Dent Res. 2016. Efficacy of Omega-3 in Treatment of Recurrent Aphthous Stomatitis: A Randomised, Double-blind, Placebo-controlled Study. In this double-blind clinical trial, 50 patients with recurrent aphthous stomatitis were randomly divided into the omega-3 group and placebo group. Patients in the omega-3 group received 1000 mg omega-3 group capsules (Daroupakhsh Company, Tehran, Iran) for 6 months; while those in the placebo group received placebo capsules with the same instructions. The recurrence of ulcers in the omega-3 group showed a significant decrease in the fifth and sixth months compared with the placebo group. The current study indicated that omega-3 consumption decreased the symptoms of recurrent aphthous stomatitis.

Quercetin topically used
Management of aphthous ulceration with topical quercetin: a randomized clinical trial. Department of Oral Medicine and Periodontology of Minia University in Minia, Egypt.
Forty male patients with no known pathology of the oral mucosa other than minor aphthous ulcers were enrolled in this study. Patients were randomly divided into two groups, each consisting of 20 patients. Group 1 (control group) patients used a benzydamine hydrochloride mouthwash three times daily. Group 2 patients placed two to three dabs of quercetin three times daily directly on their ulcers. Clinical evaluation of patients included assessment of ulcer size, pain measure, and interviews regarding the topical application of quercetin in terms of consistency, taste, local tolerability, and ease of application. The topical application of quercetin cream to minor mouth ulcers relieved pain and produced complete healing in seven of the Group 2 patients (35 percent) in 2-4 days, 18 patients (90 percent) in 4-7 days, and 20 patients (100 percent) in 7-10 days. When comparing the mean ulcer size after 10 days, lesions in the Group 2 patients were smaller than those in Group 1, and the size difference between the two groups was significantly different. Also, 90 percent of patients responded that they appreciated the ease of application when using the topical quercetin, and they did not object to its consistency or taste. Quercetin is a safe, well-tolerated, and highly effective promising new, adjunctive treatment for healing common aphthous ulcers. Although aphthous ulcers typically resolve on their own in one to two weeks, the daily topical application of quercetin may be useful in accelerating the healing process of minor cases. J Contemp Dental Pract. 2010.

Vitamin B12 for aphthous stomatitis
Vitamin B12 is a safe, effective, and inexpensive treatment for recurrent aphthous stomatitis. Dr. Ilia Volkov, from Ben-Gurion University of the Negev, Beer-Sheva, Israel, had 58 patients randomized to receive sublingual vitamin B12 (1000 mcg) or placebo daily for 6 months. Relative to placebo, treatment with vitamin B12 significantly reduced pain, the number of ulcers, and the duration of outbreaks at 5 and 6 months. Moreover, the improvements were not affected by the patients' initial serum vitamin B levels. In the last month of treatment, 74% of vitamin B12-treated patients were aphthous ulcer-free compared with 32% of those given placebo. Exactly how vitamin B12 achieves these beneficial effects is not well understood. The fact that the treatment worked equally well regardless of the initial vitamin B12 level suggests that the vitamin may possess some unrecognized functions. Journal of the American Board of Family Medicine 2009.

Multivitamins not found to be of use
Evid Based Dent. 2013. No effect seen for multivitamin therapy on recurrent aphthous stomatitis patients. NYU College of Dentistry, New York, USA. Patients with a validated history of at least three episodes of idiopathic recurrent aphthous stomatitis were randomised to either a once-daily multivitamin containing 100% of the U.S. reference daily intake (RDI) of essential vitamins or a placebo for at least one year.

Medical treatment
The objective of treatment is to minimize discomfort and prevent recurrence. Many treatment options are available for aphthous stomatitis, including topical agents such as local anesthetics (benzocaine), coating or occlusive agents (bismuth subsalicylate, sucralfate, and various emollient pastes), anti-inflammatory agents such as glucocorticosteroids (clobetasol, dexamethasone, fluocinonide, and triamcinolone), amlexanox and metalloprotease inhibitors (antimicrobials tetracycline, doxycycline, or minocycline), honey, and immune influencing agents (amlexanox, colchicine, cyclosporine, cyclophosphamide, dapsone, methotrexate, montelukast, thalidomide, or retinoids).

Practical treatment
An approach to the treatment of aphthous stomatitis involves at first topical anesthetic and occlusive or antiseptic agents for symptom relief of minor cases. First-line treatment of major or minor aphthous stomatitis with significant symptoms is typical with topical steroids in gel or emollient paste (e.g., Orabase) to shorten the duration. Another option would be a one-time local steroid injection, such as triamcinolone. Severe persistent cases may further be treated with systemic steroids (dexamethasone or prednisone), immunomodulatory agents (listed above), pentoxifylline, or quercetin.

Med Oral Patol Oral Cir Bucal. 2017. An evaluation of the efficacy of a topical gel with Triester Glycerol Oxide (TGO) in the treatment of minor recurrent aphthous stomatitis in a Turkish cohort: A randomized, double-blind, placebo-controlled clinical trial. Triester glycerol oxide gel (Protefix® Queisser Pharma, Germany) is a new topical agent that has the property of adherence to the oral mucosa by forming a lipid film which protects against mechanical trauma and may help to reduce oral tissue moisture loss and inflammation. Topical application of TGO gel could decrease pain intensity, accelerate ulcer healing without any side effects, utilizing an easy appliable and accessible procedure. Therefore TGO gel could be a well-tolerated, safe, topical therapeutic agent in the clinical practice of RAS treatment.

Laser therapy
J Clin Exp Dent. 2016. Different modalities for treatment of recurrent aphthous stomatitis. A Randomized clinical trial. This study compared the efficacy of diode laser, a herbal combination of Acacia nilotica and Licorice (A and L) and Amlexanox in the management of RAS. Sixty patients with minor aphthae were selected and randomly divided into four groups of 15 each. Group I and II received adhesive preparations of a herbal mixture of A and L and a 2 mg Amlexanox paste respectively, group III received diode laser and the fourth group (control) used a placebo. All treatment modalities reduced pain and ulcer size than placebo group. Laser therapy demonstrated the highest percentage of reduction of pain score and ulcer size.

Cause, why it occurs
The exact causes are difficult to determine but consider the following: citrus fruits such as lemons and oranges, stress, poor sleep patterns, food allergies, immune system reactions, and deficiencies in vitamin B12, iron, and folic acid. Some people may be allergic to cow's milk. Trauma to the mouth is a trigger such as that caused by toothbrush abrasions, laceration with sharp or abrasive foods (such as toast or potato chips), accidental biting (particularly common with sharp canine teeth). Eating a lot of citrus fruits day after day is a common cause.

Celiac disease is regarded as an autoimmune disorder that is common in the general population (affecting 1 in 100 individuals), with possible onset at any age and with many possible presentations. The identification of CD is challenging because it can begin not only with diarrhea and weight loss but also with atypical gastrointestinal (constipation and recurrent abdominal pain) and extra-intestinal symptoms (anemia, raised transaminases, osteoporosis, recurrent miscarriages, aphthous stomatitis and associated autoimmune disorders), or it could be completely symptomless.

Int J Dermatol. 2017. Is there a role of food additives in recurrent aphthous stomatitis? A prospective study with patch testing. The most common allergen that elicited positive patch test results in the patient group was cochineal red, followed by azorubine and amaranth. The present findings show that food additives might play a role in the etiology of RAS and that patch testing could be a method for determining the etiology of RAS.

Association with blood sugar
Clin Oral Investig. 2014 Oct 28. Elevated insulin resistance in patients with recurrent aphthous stomatitis. The role of glucose metabolism disorders in periodontal diseases including recurrent aphthous stomatitis (RAS) is currently attracting attention. The aim of this study is to investigate insulin resistance (IR) in patients with RAS in otherwise healthy individuals.

Prescription medications as cause
Severe aphthous stomatitis is associated with the use of oral calcineurin and mTOR inhibitors.

Emails
For many years I have suffered from recurring aphthous ulcers - large painful oral ulcers that last for weeks and make eating and drinking painful (as well as sleeping and other normal activities). I have tried both Eastern and Western medicine approaches and so far not had any success. Please let me know if you might be available for either an appointment or a telephone consultation.
   A.