Recurrent Aphthous Stomatitis:Do We Know What Patients Are Using

to Treat the Ulcers?

Faleh A. Sawair, F.D.S., R.C.S. (Eng.), Ph.D.

Abstract

Objectives: The objectives of this study were to determine prevalence and types of treatments used by patientswith recurrent aphthous stomatitis (RAS), and to study the sources of information about treatments used.Methods: The study was a cross-sectional survey. The participants were 530 students who had a history of RASand were studying at the University of Jordan, Amman.Results: Of the 530 patients, 267 (50.4%) have attempted treatment of RAS. Of those who treated RAS, 86(32.2%) have used alternative treatments (ATs). Topical anaesthetics/analgesics, antiseptic mouthwashes, andtopical steroids represented 84.5% of the conventional medicines used. Of those who used ATs, 34 (39.5%) usedtahini, 21 (24.4%) used salt/salt and warm water mouthrinse, and 7 (8.1%) used lemon/lemon salt. Thetendency to treat RAS or not was not significantly affected by sociodemographic variables, but ATs were moresignificantly used by students living in rural areas. Relatives were the most frequently cited source of infor-mation about treatment (44.6%), followed by medical practitioners (22.9%), and only 9.4% sought treatmentadvice from dentists. Interestingly, 7% of the ATs were recommended by health care providers and 38.7% ofthe conventional treatments were recommended by non-health-care providers including 15 cases of topicalsteroids.Conclusions: This survey revealed a high prevalence of ATs use among Jordanian patients with RAS. There is aneed to educate patients with RAS on the treatment options available to reduce their distress and to improvetheir quality of life. Health care providers such as medical practitioners and pharmacists are frequently consultedby patients with oral lesions, so they should provide patients with better education in the diagnosis andtreatment of oral diseases. Randomized clinical trials are needed to examine the potential usefulness of thecommonly used ATs in this study such as tahini/sesame oil in the treatment of RAS.

Introduction

Recurrent aphthous stomatitis (RAS) is characterizedby recurrent painful, small ulcers, appearing first in

childhood or adolescence.1 It is the most common oral ul-cerative disease, with a prevalence rate ranging from 5% to60% depending on the ethnic and socioeconomic groupsstudied.2,3 The etiology of RAS is unknown, but the patho-genesis primarily involves activation of a cell-mediatedimmune response, mainly T lymphocytes, in which the pro-duction of tumor necrosis factor-a and other cytokines resultsin epithelial cell death and ulceration.4 A strong genetic pre-disposition has been demonstrated; children with RAS-positive parents have around a four times greater risk todevelop RAS compared to those with RAS-negative parents.5

RAS results in considerable pain and distress and maylead to difficulty in speaking, eating, and swallowing, andthus may negatively affect patients’ quality of life.1 There isno curative treatment available for RAS. When systemicdisease is ruled out, current conventional medications areused only to suppress the local immune response, to relievesymptoms, and to prevent secondary infection.2 A widevariety of different agents are currently used for the man-agement of RAS depending on the severity of the ulcers.Therapies include (1) local physical treatment such as sur-gical removal and laser ablation; (2) antimicrobials such aschlorhexidine mouthrinse and topical tetracycline; (3) topicalanti-inflammatory and coating agents such as orabase, su-cralfate, aspirin mouthrinse, diclofenac in hyaluronase, andamlexanox; (4) topical analgesics or anesthetics such as

Department of Oral and Maxillofacial Surgery, Oral Medicine, Oral Pathology and Periodontology, Faculty of Dentistry, University ofJordan, Amman, Jordan.

THE JOURNAL OF ALTERNATIVE AND COMPLEMENTARY MEDICINEVolume 16, Number 6, 2010, pp. 651–655ª Mary Ann Liebert, Inc.DOI: 10.1089/acm.2009.0555

651

benzydamine hydrochloride and lidocaine gel; (5) topicalcorticosteroids such as triamcinolone acetonide and dexa-methasone, currently the mainstay of RAS treatment in mostcountries; and (6) systemic immunosuppressants such asprednisolone, colchicines, and thalidomide. Many of theseagents can minimize patient discomfort and decrease thehealing time of RAS.1,6,7

While many investigations have been conducted on the useof alternative treatments (ATs) to treat gastric ulcers,8 a fewclinical trials investigated their usefulness in RAS. Controlledclinical trials have shown the use of Glycyrrhiza glabra (lico-rice) herbal extract,9 red mangrove tree bark extract,10 aloevera (acemannon),11 and myrtle12 to be effective in RAStreatment. On the other hand, trials have failed to find benefitsfrom the use of other herbs such as LongoVital (a productcontaining paprika, rosemary, peppermint, milfoil, hawthorn,and pumpkin),13 or perilla oil.14 A commonly touted herbalmedicines as effective in treating RAS is the dried sap ofCommiphora myrrha (myrrh).6,15,16 Although in vitro studieshave shown that pretreatment with myrrh provided stomachprotection against the ulcerogenic effects of necrotizing agentssuch as ethanol and indomethacin,17 its publicized beneficialeffects on RAS are yet unproven. Other herbs promoted aseffective in RAS treatment but unsupported by controlledtrials include sage, agrimony, cranesbill, tormentil, periwin-kle, caraway, oak bark, witch hazel, calendula, slippery elm,tea, goldthread, goldenseal, geranium maculatum, and echi-nacea.15,16 Although many of these remedies may be validcandidates for RAS treatment, there are legitimate concernsabout using some of these agents without guidelines. Some ofthese products may interact with conventional medicines andsome may even cause oral manifestations. Licorice, chamo-mile, and aloe vera may interact with aspirin, corticosteroids,and depressant drugs.18 Echinacea use may result in tongue

numbness and, interestingly, the use of some herbs such asfeverfew has been reported to be associated with the devel-opment of aphthous ulcers.18

The purposes of this investigation were to describe theprevalence and types of treatments used by patients withRAS, to study their use of ATs, and to study the sources ofinformation about treatments used.

Materials and Methods

Face-to-face interviews were conducted with randomlyselected students studying at the University of Jordan, Am-man in the period between May and September 2008. Thestudents were given sufficient details about RAS and wereshown pictures of typical cases of the condition. Subse-quently, they were asked if they have ever had such ulcersinside their mouth. Subjects who reported positively wereconsidered to have a history of RAS and were recruited inthe study. Data on demographic characteristics were col-lected. Included subjects were then asked if they have treatedthe latest episode of ulcers. If the answer was yes, the sub-jects were asked about the nature of treatment used, theperson who recommended the treatment, and whether theyhave found this treatment helpful in reducing their distress.

Statistical analysis was performed using SPSS for Win-dows release 16.0 (SPSS Inc., Chicago, IL). Frequency dis-tributions were obtained and w2 test and t test were used tocompare differences between groups. Statistical significancewas set at p< 0.05.

Results

Characteristics of the study sample are summarized inTable 1. The sample consisted of 530 students, 198 males and322 females and their ages ranged from 18 to 29 years (mean

Table 1. Demographic Variables of Students

Total (n¼ 530) Treat ulcers (n¼ 267) Alternative treatment (n¼ 86)

Variable n (%)a n (%)a p-valueb n (%)a p-valueb

GenderFemale 332 (62.6) 168 (50.6) 0.89 55 (32.7) 0.92Male 198 (37.4) 99 (50) 31 (31.3)

AddressAmman 440 (83) 222 (50.5) 0.94 61 (27.5) P< 0.001Other regions 90 (17) 45 (50) 25 (55.6)

Marital statusSingle 518 (97.7) 263 (50.8) 0.23 85 (32.3) 1.0Married 12 (2.3) 4 (33.3) 1 (25)

CollegeHealth 152 (28.7) 70 (46.1) 0.23 20 (28.6) 0.37Science 210 (39.6) 115 (54.8) 37 (32.2)Humanitarian 168 (31.7) 82 (48.8) 29 (35.4)

Household income/month<500 JD 153 (28.9) 81 (52.9) 0.45 32 (39.5) 0.09�500 JD 377 (71.1) 186 (49.3) 54 (29)

SmokingNo 360 (67.9) 175 (48.6) 0.24 52 (29.7) 0.29Yes 170 (32.1) 92 (54.1) 34 (37)

aRaw percentage.bp-value of w2 test.JD, Jordanian dinar (1 JD¼& 1.4$).

652 SAWAIR

20.3� 1.8 years). Nearly half (267, 50.4%) of the subjects haveused products to treat the last episode of RAS. The nature oftreatment is shown in Table 2. There were 181 (67.8%) whoused conventional medicines and 86 (32.2%) who used onlyATs. Topical anesthetics/analgesics, antiseptic mouthwa-shes, and topical steroids represented 84.5% of the conven-tional medicines used. Of the 86 subjects who used ATs, 34(39.5%) used tahini, 21 (24.4%) used salt/salt and warmwater, and 7 (8.1%) used lemon/lemon salt.

The tendency of whether or not to treat RAS was not sig-nificantly affected by age, gender, residency, marital status,college, household monthly income, or smoking (Table 1).However, the nature of treatment was significantly affected byplace of living; ATs were used more significantly by those wholived in rural areas outside the capital city of Amman. Asexpected, those who had low household monthly income usedmore ATs; however, the difference did not reach statisticalsignificance.

The persons who recommended the RAS treatment areshown in Table 3. Treatment was recommended mostly byrelatives (44.6%), followed by medical practitioners (22.9%).Only 9.4% sought treatment advice from dentists. Interestingly,

7% of the ATs were recommended by health care providersand 38.7% of the conventional treatments, including 15 casesof topical steroids, were recommended by ordinary people.When asked if they have found the treatment useful, 216(80.9%) subjects responded positively, with no significantdifference between those who used conventional or ATs.

Discussion

The sample forming the current study was composed ofuniversity students because RAS lesions are more prevalentat this age group and recur with decreasing frequency andseverity thereafter.4,19 The highest incidence of RAS reportedin the literature was found in university students.1 In addi-tion, it is expected that young educated people, such as thiscohort, may have higher probability to remember names ofmedicines or products they use to treat RAS. The high pro-portion of females forming the study sample is explained bythe fact that 64.2% of the students studying at the Universityof Jordan in the year 2008 were females.20

No studies have been conducted before to study the typesof treatments used by patients with RAS to assess the level ofpatient awareness of the disease. The results indicated theneed for patient education on RAS treatment. While medi-cations can alleviate pain and lessen severity, around half ofthe studied subjects with RAS did not attempt to treat thelesions. In addition, some individuals were using antifun-gals, antivirals, or even cigarette ash. This was not unex-pected because the majority consulted relatives and friendsregarding treatment of RAS or conducted personal trials andonly 43.8% took advice from health care providers. Of in-terest was the finding that around one third of those whoused topical steroids reported that the drugs were re-commended by relatives and friends. This finding furtherjustifies our previous concern about the widespread habit ofself-medication in Jordan.21 Disappointingly, only 9.3% ofthose who treated the RAS lesions reported consulting dentalpractitioners; of these, only 2 (0.7%) consulted oral medicinespecialists. Patients often consult their general medicalpractitioners rather than their general dental practitionersregarding oral lesions.22 In this study, around one fourth ofthe subjects who treated the RAS lesions consulted medicalpractitioners.

Even among this young cohort, there was a high preva-lence of ATs use; around one third of those who treated theRAS lesions were using only ATs. Its use was significantlymore prevalent among individuals who were living in ruralareas. In rural areas, the families are poorer and relatives andfriends encourage the use of ATs to treat simple conditions.They are usually recommended by elderly people who aremore familiar with the traditional indications for its use. In

Table 2. Medicines/Products Used in the Treatment

of Recurrent Aphthous Stomatitis

Nature of treatment Frequency Percent

Conventional medicines 181 67.8Topical anesthetic/analgesic 58 21.7Antiseptic mouthwash 49 18.4Topical steroid 46 17.2Covering agent 8 3.0Antibiotics 8 3.0Antifungals 6 2.2Analgesic 3 1.1Vitamins 2 0.7Antivirals 1 0.4

Alternative treatments 86 32.2Tahini 34 12.7Salt/salt and warm water 21 7.9Lemon/lemon salt 7 2.6Pomegranate 5 1.9Chamomile 3 1.1Na bicarbonate powder 3 1.1Others (cumin, sage, coffee, ice,

strawberry, berry, olive oil,yeast, tomato paste, castor oil,squeezing ulcers, smoking,cigarette ash)

13 4.9

Total 267 100.0

Table 3. Sources of Information about Treatment

Treatment recommended by

Treatment Him/herself Friends Relatives Pharmacist GDP OM specialist MP Total

Alternative medicine 8 (9.3) 4 (4.7) 68 (79.1) 2 (2.3) 1 (1.2) 0 (0) 3 (3.5) 86 (100)Conventional medicine 16 (8.8) 3 (1.7) 51 (28.2) 29 (16) 22 (12.2) 2 (1.1) 58 (32) 181 (100)

Total 24 (9.0) 7 (2.6) 119 (44.6) 31 (11.6) 23 (8.6) 2 (0.7) 61 (22.9) 267 (100)

GDP, general dental practitioner; OM specialist, oral medicine specialist; MP, medical practitioner.

WHAT PEOPLE USE TO TREAT APHTHOUS STOMATITIS 653

addition to low cost and availability, an important motive forthe widespread use of ATs in Jordan is the belief that theseproducts are natural and, therefore, safer than conventionalmedications.23 Claims about the safety and effectiveness ofthese products, however, are based largely on testimonialsand tradition. Extensive search of the literature revealed adeficiency of randomized controlled trials to prove the ben-efit of the vast majority of herbal medicines or ATs touted ashelpful in treating RAS and other oral ulcerations. The bulkof information about its use is only available from InternetWeb sites.15,16,24

One of the major ATs observed here was the application oftahini on RAS lesions. This treatment was performed byaround 13% of subjects who treated RAS and form around40% of ATs noted in this study. Tahini, an Arabic loanwordto English, is a paste made from ground sesame seeds thatoriginates in Mediterranean Arab countries.25 Tahini-basedsauces are common in most Middle East Arab restaurants asa side dish or a garnish; however, its consumption currentlyis widespread in the United States and Europe.25 All subjectswho used this material believed that it was effective in re-ducing their discomfort. The mechanism to explain itsclaimed beneficial effects is unknown, and no previousstudies have been conducted to investigate the effectivenessof this material or sesame oil on mouth ulcerations. How-ever, a recent study has shown that pretreatment with ses-ame oil reduced acidified ethanol-induced gastric mucosalulceration by reducing mucosal lipid peroxidation in rats.26

Sesame seeds are exceptionally rich in iron, magnesium,manganese, copper, calcium, zinc, and phosphorus.27 Theseeds are a good source of vitamin B1, B2, B3, B6, folate, andvitamin E, and have high antioxidant and anticancer prop-erties. The nutrients of sesame seeds are better absorbed ifthey are ground before consumption, as in tahini.27

Dentists usually recommend saline mouthwash followingsurgery or dental extraction. This salt water homemademouthrinse was used by a significant number of surveyedstudents to treat RAS. However, the author failed to find asingle article in the literature that proves that saline mou-thrinse is effective in promoting healing of injured oral tis-sues or more beneficial than water in treating or preventinginfection, or in maintaining oral hygiene. However, hyper-tonic saline solution had significant ulcer-protective effects inall gastric ulcer models studied in rats.28 In addition to en-hanced mucin secretion and decreased cell shedding, theprotective effects of hypertonic saline involved a significantincrease in gastric mucosal prostaglandin biosynthesis com-pared to normal saline.28 Additionally, endoscopic local in-jection of hypertonic saline was used to arrest hemorrhagefrom gastric ulcer.29 These findings may rationalize theclaimed benefits of applying salt directly to the ulcers re-ported by some surveyed subjects.

Although clinicians usually instruct patients with RAS toavoid acidic and spicy food, some surveyed individuals wereusing lemon or lemon salt (citric acid) to treat their lesions.Interestingly, citric acid was reported to be effective inmanagement of chronic wound infections. Local applicationof the acid on the wounds caused significant reduction ofinfectious agents and boosted fibroblastic growth and neo-vascularization, enabling healthy granulation tissue forma-tion and faster wound healing.30 While no previous studiestested the usefulness of pomegranate in RAS to justify its use

by some surveyed subjects, the fruit extract was reportedto offer protection against aspirin- and ethanol-inducedgastric ulceration.31 Pomegranate was reported to have im-munomodulatory, strong antioxidant, and antibacterialcharacteristics.31

Conclusions

The results highlighted the need to educate patients withRAS on the treatment options available to reduce their dis-tress and to improve their quality of life. They should also beeducated on possible side-effects of some conventional andalternative medicines commonly used to treat RAS lesions.Since patients with oral lesions consult medical practitionersand pharmacists, better education in the diagnosis andtreatment of oral diseases should include these health careproviders. Clinical trials are needed to examine the potentialusefulness of tahini/sesame oil, hypertonic saline mou-thrinse, citric acid, and pomegranate in the treatment of RAS.

Disclosure Statement

No competing financial interests exist.

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Address correspondence to:Faleh Sawair, F.D.S., R.C.S. (Eng.), Ph.D.

Faculty of DentistryUniversity of Jordan

Amman 11942Jordan

E-mail: sawair@ju.edu.jo

WHAT PEOPLE USE TO TREAT APHTHOUS STOMATITIS 655

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