Management of oral ulcers - PowerPoint Presentation

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Management of oral ulcers

Dr

Febin

Azeezia

medical college

Kollam

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Management and Treatment

The best treatment must control the ulcers for the

longest period with minimal side effects

..

Important

to rule out

predisposing factors

The forms of therapy range from

topical application to systemic administration of drugs

, and even the newer technologies of ultrasound have been tried.

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THE PRIMARY GOAL

Relief of pain

Reduction of ulcer duration

The restoration of normal oral function

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SECONDARY GOAL

Reduction in the frequency and severity of recurrence

Maintenance of remission.

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THE TREATMENT APPROACH

Determined by disease severity (pain)

The patient’s medical history (SYSTEMIC ILLNESS)

The frequency of flare–ups

The patient’s ability to tolerate the medication

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DIETARY AND GENERAL MEASURES

No

reliable studies addressing

 One should

avoid

hard, acidic and salty substances such as fruit juices, citrus fruits, tomatoes, and spices like pepper, paprika and curry, as well as alcoholic and carbonated beverages.

A recent study showed

omega 3 fatty acid

supplementation reduced symptoms

In another study –

no benefit

in use of daily multivitamin tablets

But

vitamin B12 supplementation

– duration ,number and level of pain reduced

Avoiding

dental care products with

sodium lauryl sulfate (SLS)

Maintain

good

oral hygiene

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TOPICAL ANESTHETICS

LIDOCAINE

1% cream

2% gel or spray;

Polidocanol

as paste; and benzocaine lozenges

A mouth wash containing benzocaine and

cetylpyridinium

chloride

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ANTISEPTICS AND ANTI-INFLAMMATORY AGENTS

 Mouth wash containing

0.15%

triclosan

in ethanol and zinc sulfate 

Diclofenac 3%

in a 2.5% hyaluronic acid gel was superior to a lidocaine 3% gel in reducing pain after 2–6 hours

Chlorhexidine

mouthwash reduced the frequency, increased healing speed, and decreased the severity of

aphthous

ulcers

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CAUTERIZATION

Topical application of

hydrogen peroxide 0.5%

solution or silver nitrate 1–2% solution significantly reduced the

pain severity after one day, but did not increase the speed of healing .

Treatment with a CO

2

 or

Nd:YAG

laser brought immediate pain relief which lasted for 4–7 days 

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TOPICAL TETRACYCLINE TREATMENT

 Mouthwash containing

chlortetracycline 2.5%

increased the number of ulcer-free or pain-free days significantly, by 40% compared to a placebo

A mouthwash containing

tetracycline

(dissolve soluble tetracycline capsule 250 mg in 5–10 ml water and rinse)

In regards to pain reduction, a

minocycline 0.2%

mouthwash was superior to a tetracycline 0.25% mouthwash

Other antibiotics such as

aureomycin

(containing 3%chlortetracycline),

doxymycin

, minocycline(0.2% aqueous solution), penicillin G (50 mg penicillin G potassium troches) have been proven to be effective in managing these ulcers.

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TOPICAL ANTI-INFLAMMATORY AGENTS:

Amlexanox

5%

paste or 2 mg tablets – (anti-allergic and anti-inflammatory activities)

when used in the prodromal stage, led to a reduction in the number and size of oral

aphthous

ulcers, as well as reduction in pain 

5-aminosalicylic acid 5%

cream achieved pain reduction and more rapid healing of oral

aphthous

ulcers

Topical sucralfate

is effective in treating RAS ulcerations when administrated at 5ml, 4 times/day.

Sucralfate exerts a soothing effect on the lesions by adhering to mucous membrane tissues and forming a

protective barrier on the affected site.

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TOPICAL CORTICOSTEROIDS

The combination of

topical anesthetics

during the day with an oral paste containing

triamcinolone

in the evening is also effective 

Although both were equally effective in reducing pain,

dexamethasone oral paste

produced more rapid healing than triamcinolone oral paste

The paste is to be applied

2-3 times

a day. Long term use of these steroids may develop

local candidiasis

Betnesol

mouthwash is being used .

Betamethasone sodium phosphate tablet 500 mcg dissolved in 10 ml of water and used as a mouthwash for 3 min then discarded.

It is administered

four times a day

(QID) in the presence of ulcers and twice a day (BID) in between ulcer attacks.

Painful, deep ulcers can be treated

with

intralesional

triamcinolone suspension

0.1–0.5 mL per lesion 

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IMMUNOMODULATORY AGENTS:

Topical non-corticosteroid based immunomodulatory agents :-

Azelastine

Human alpha-2-interferon in cream

Topical cyclosporine

Topical 5-aminosalicylic acid and prostaglandin E2 (PGE2) gel

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PHYSICAL THERAPY

Surgical removal, debridement or laser ablation of ulcers, low intensity ultrasound, chemical cautery

Laser therapy

–

Studies have shown that laser therapy of most

apthae

immediately relieves pain, speeds

healing, and reduces recurrence.

Silver nitrate

-changing the lesion to a burn.

Some studies revealed decreased severity of pain.

However, none have demonstrated shortened healing time.

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ULTRASOUND THERAPY

Twice–daily application of low intensity medical ultrasound may have a modest beneficial effect

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SYSTEMIC THERAPY

The main goals of systemic therapies are

To reduce the frequency of recurrences

To

minimise

the duration of ulcers

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COLCHICINE

Colchicine (0.5–2 mg daily) is helpful for the majority of patients with chronic recurrent oral

aphthous

ulcers

Is an anti-inflammatory agent that limits leukocyte activity by binding to beta-Tubulin, a cellular

microtubular

protein, and therefore inhibiting protein polymerization.

The

aphthous

ulcers frequently recurred when the treatment was stopped

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PENTOXIFYLLINE

Anti-inflammatory, immunomodulatory,

methylxanthine

derivative that blocks neutrophil adherence and is indicated for peripheral vascular disease

In case reports and older non-controlled studies, both

pentoxifylline

and

oxypentoxifylline

300 mg 1–3 times daily or 400 mg

t.I.D

.

Achieved good response rates (in children 36–50%) .

in a more recent controlled study,

pentoxifylline

(400 mg

t.I.D

.) Was only able to reduce the size of oral

aphthous

ulcers (p = 0.05) 

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SYSTEMIC CORTICOSTEROIDS

Systemic corticosteroids

should be considered if colchicine and

pentoxifylline

do not produce improvement

.

Prednisolone or prednisone equivalents (10–30 mg daily)

can be used on a short-term basis (up to one month) during a flare of the disease to speed healing.

In a small controlled study, prednisolone 5 mg daily for 3 months was comparable to colchicine 0.5 mg daily. It produced a clear reduction in pain, as well as in number and size of oral

aphthous

ulcers .

Prednisone (25 mg daily tapered over 2 months) was more effective than the leukotriene inhibitor

montelukast

in managing oral

aphthous

ulcers

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SUCRALFATE

Sucralfate is used as an antacid in treating gastric and duodenal ulcers.

Sucralfate suspension produced more rapid healing and reduced pain of both oral and genital

aphthous

ulcers 

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DAPSONE

It is an

antioxidant

which exerts its effects primarily through

suppression of inflammatory cell migration

.

Dapsone

significantly

reduced the number and size

of oral and genital

aphthous

ulcers 

A dose of

100–150 mg/day

can be used for oral and genital aphthae.

Haemolysis

,

methaemoglobulinemia

and agranulocytosis are serious side-effects that may occur

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ANTIMETABOLITES: AZATHIOPRINE AND METHOTREXATE

In a placebo-controlled study, azathioprine reduced the frequency and severity of

orogenital

aphthous

ulcers

In a case series, methotrexate 7.5–20 mg in a single weekly dose was helpful for severe

orogenital

aphthous

ulcers 

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CYCLOSPORINE

Dose of

3 to 6 mg/kg/day

was found to be effective in about 50% of patients with recurrent

aphthosis

either as a monotherapy or in combination with steroids to achieve a higher

antiinflammatory

effect.

Its use is absolutely contraindicated in nursing women.

Pregnancy and renal insufficiency are considered relative contraindications.

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THALIDOMIDE

Inhibits the production of various cytokines as a result of its

effects on T lymphocytes, monocytes, and

polymorphonuclear

cells and selectively

inhibits the production of TNF

.

Is considered effective against

orogenital

aphthous

ulcers.

In older open or retrospective studies, initial doses of

100–300 mg daily

were tapered to

50 mg

daily or the medication was discontinued after 3 months, in order to avoid a sensory neuropathy .

The therapy with thalidomide

(anti-

tnf

-a actions

), proved to be effective in

lowdose

of 50 mg/day

against major type of

ras

and

oro

-genital ulcers

Thalidomide should only be used in exceptional cases. Because of its teratogenicity, it is absolutely contraindicated in pregnancy .

When it is discontinued, recurrences may develop rapidly

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IMMUNE ENHANCEMENT:

Levamisole

is an

immunopotentiating

agent that has demonstrated the ability to normalize the CD4+ cell/CD8+ cell ratio and improve symptoms in recurrent

aphthous

ulcers (RAU) patient

Dosage of

10-15-mg/day

for 2-3 months can reduce the pain, number, frequency and duration of ulcer.

Adverse effects like nausea, hyperemia, dyspepsia and agranulocytosis limits the use of this drug.

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INTERFERON-Α

Interferon-α can achieve complete or partial remission

(reduction in pain, duration and frequency)

of recurrent

orogenital

aphthous

ulcers within 1–4 months .

A low-dose (3 million IU 3 times weekly) maintenance therapy is recommended after 6 months.

Combination therapy with corticosteroids, colchicine, or

benzathine

penicillin is possible

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OTHER SYSTEMIC AGENTS

In a controlled study, sub-antimicrobial doses of

doxycycline (40 mg daily)

prolonged the interval between

aphthous

ulcers .

Zinc sulfate 300 mg

daily reduced the number and size of

aphthous

ulcers in comparison to placebo .

In patients with pre-menstrual flares of oral

aphthous

ulcers,

once yearly subcutaneous injections of testosterone

helped in some cases .

Estrogen-dominant oral contraceptives

can also be employed . An effect is first to be expected after

3 to 6 months

.

Irsogladin

: This drug used for treatment of

gastritis and peptic ulcer

studies shown that

irsogladin

when

administered orally 2 to 4 mg/day,

reduce

ulcer counts increments

and also taking it regularly

prevent the recurrent

aphthous

stomatitis

.

Apremilast

– PDE4 inhibitor also tried .

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BIOLOGICS

Infliximab

- a

chimeric anti-TNF antibody

, is very effective in the management of refractory and recurrent oral and genital ulcers.

It is usually given in a dose of

5 mg/kg body

weight

intravenously

in different schemes (e.g. 2, 6 and 32 weeks after the first injection).

Efalizumab

and

Adalimumab

other biological agents - highly efficient and completely prevented the development of aphthae

Etanercept

: recombinant TNF-soluble receptor

can be used cases of recalcitrant, recurrent ulceration in a dose of

25mg subcutaneously

twice a week.

The only adverse effect reported is mild erythema, induration and tenderness at injection site.

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REBAMIPIDE

Is an

amino acid

analog of 2 (1h)-

quinolinone

.

First antiulcer drug

that

increases the endogenous prostaglandins

in mucosa and

inhibits oxygen

derived

free radical production

.

Increase in blood flow

and

production of protective prostaglandins

in ulcer mucosa, which accelerates the process of healing.

Rebamipide

2-(4-chlorobenzoylamine)-3-[2-(1h)-quinolinon-4-yl] is a

new

mucoprotective

agent

which enhances

preservation of existing epithelial cells

and replacement of lost tissue through a multifactorial mode of action

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Dosage

The adult dosage of

rebamipide

is

100 mg orally three times daily.

Rau: 3 tablets/day for 7-14 days.

Behcet's

disease: 3 tablets/day for 2 months.

Reduced aphthae count and decreased pain with excellent recovery by seventh day.

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THANK YOU

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