THE JOURNAL OF ALTERNATIVE AND COMPLEMENTARY MEDICINE Volume 16, Number 6, 2010, pp.

651655 Mary Ann Liebert, Inc. DOI: 10.1089/acm.2009.0555

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 patients with 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 RAS and 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, and topical steroids represented 84.5% of the conventional medicines used. Of those who used ATs, 34 (39.5%) used tahini, 21 (24.4%) used salt/salt and warm water mouthrinse, and 7 (8.1%) used lemon/lemon salt. The tendency to treat RAS or not was not signicantly affected by sociodemographic variables, but ATs were more signicantly used by students living in rural areas. Relatives were the most frequently cited source of information about treatment (44.6%), followed by medical practitioners (22.9%), and only 9.4% sought treatment advice from dentists. Interestingly, 7% of the ATs were recommended by health care providers and 38.7% of the conventional treatments were recommended by non-health-care providers including 15 cases of topical steroids. Conclusions: This survey revealed a high prevalence of ATs use among Jordanian patients with RAS. There is a need to educate patients with RAS on the treatment options available to reduce their distress and to improve their quality of life. Health care providers such as medical practitioners and pharmacists are frequently consulted by patients with oral lesions, so they should provide patients with better education in the diagnosis and treatment of oral diseases. Randomized clinical trials are needed to examine the potential usefulness of the commonly used ATs in this study such as tahini/sesame oil in the treatment of RAS.

Introduction ecurrent aphthous stomatitis (RAS) is characterized by recurrent painful, small ulcers, appearing rst in childhood or adolescence.1 It is the most common oral ulcerative disease, with a prevalence rate ranging from 5% to 60% depending on the ethnic and socioeconomic groups studied.2,3 The etiology of RAS is unknown, but the pathogenesis primarily involves activation of a cell-mediated immune response, mainly T lymphocytes, in which the production of tumor necrosis factor-a and other cytokines results in epithelial cell death and ulceration.4 A strong genetic predisposition has been demonstrated; children with RASpositive parents have around a four times greater risk to develop RAS compared to those with RAS-negative parents.5

RAS results in considerable pain and distress and may lead to difculty in speaking, eating, and swallowing, and thus may negatively affect patients quality of life.1 There is no curative treatment available for RAS. When systemic disease is ruled out, current conventional medications are used only to suppress the local immune response, to relieve symptoms, and to prevent secondary infection.2 A wide variety of different agents are currently used for the management of RAS depending on the severity of the ulcers. Therapies include (1) local physical treatment such as surgical removal and laser ablation; (2) antimicrobials such as chlorhexidine mouthrinse and topical tetracycline; (3) topical anti-inammatory and coating agents such as orabase, sucralfate, aspirin mouthrinse, diclofenac in hyaluronase, and amlexanox; (4) topical analgesics or anesthetics such as

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

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652 benzydamine hydrochloride and lidocaine gel; (5) topical corticosteroids such as triamcinolone acetonide and dexamethasone, currently the mainstay of RAS treatment in most countries; and (6) systemic immunosuppressants such as prednisolone, colchicines, and thalidomide. Many of these agents can minimize patient discomfort and decrease the healing time of RAS.1,6,7 While many investigations have been conducted on the use of alternative treatments (ATs) to treat gastric ulcers,8 a few clinical trials investigated their usefulness in RAS. Controlled clinical trials have shown the use of Glycyrrhiza glabra (licorice) herbal extract,9 red mangrove tree bark extract,10 aloe vera (acemannon),11 and myrtle12 to be effective in RAS treatment. On the other hand, trials have failed to nd benets from the use of other herbs such as LongoVital (a product containing paprika, rosemary, peppermint, milfoil, hawthorn, and pumpkin),13 or perilla oil.14 A commonly touted herbal medicines as effective in treating RAS is the dried sap of Commiphora myrrha (myrrh).6,15,16 Although in vitro studies have shown that pretreatment with myrrh provided stomach protection against the ulcerogenic effects of necrotizing agents such as ethanol and indomethacin,17 its publicized benecial effects on RAS are yet unproven. Other herbs promoted as effective in RAS treatment but unsupported by controlled trials include sage, agrimony, cranesbill, tormentil, periwinkle, caraway, oak bark, witch hazel, calendula, slippery elm, tea, goldthread, goldenseal, geranium maculatum, and echinacea.15,16 Although many of these remedies may be valid candidates for RAS treatment, there are legitimate concerns about using some of these agents without guidelines. Some of these products may interact with conventional medicines and some may even cause oral manifestations. Licorice, chamomile, and aloe vera may interact with aspirin, corticosteroids, and depressant drugs.18 Echinacea use may result in tongue

SAWAIR numbness and, interestingly, the use of some herbs such as feverfew has been reported to be associated with the development of aphthous ulcers.18 The purposes of this investigation were to describe the prevalence and types of treatments used by patients with RAS, to study their use of ATs, and to study the sources of information about treatments used. Materials and Methods Face-to-face interviews were conducted with randomly selected students studying at the University of Jordan, Amman in the period between May and September 2008. The students were given sufcient details about RAS and were shown pictures of typical cases of the condition. Subsequently, they were asked if they have ever had such ulcers inside their mouth. Subjects who reported positively were considered to have a history of RAS and were recruited in the study. Data on demographic characteristics were collected. Included subjects were then asked if they have treated the latest episode of ulcers. If the answer was yes, the subjects were asked about the nature of treatment used, the person who recommended the treatment, and whether they have found this treatment helpful in reducing their distress. Statistical analysis was performed using SPSS for Windows release 16.0 (SPSS Inc., Chicago, IL). Frequency distributions were obtained and w2 test and t test were used to compare differences between groups. Statistical signicance was set at p < 0.05. Results Characteristics of the study sample are summarized in Table 1. The sample consisted of 530 students, 198 males and 322 females and their ages ranged from 18 to 29 years (mean

Table 1. Demographic Variables of Students Total (n 530) Variable Gender Female Male Address Amman Other regions Marital status Single Married College Health Science Humanitarian Household income/month <500 JD 500 JD Smoking No Yes
a b

Treat ulcers (n 267) n (%)a 168 (50.6) 99 (50) 222 (50.5) 45 (50) 263 (50.8) 4 (33.3) 70 (46.1) 115 (54.8) 82 (48.8) 81 (52.9) 186 (49.3) 175 (48.6) 92 (54.1) p-valueb 0.89 0.94 0.23 0.23

Alternative treatment (n 86) n (%)a 55 (32.7) 31 (31.3) 61 (27.5) 25 (55.6) 85 (32.3) 1 (25) 20 (28.6) 37 (32.2) 29 (35.4) 32 (39.5) 54 (29) 52 (29.7) 34 (37) p-valueb 0.92 P < 0.001 1.0 0.37

n (%)a 332 (62.6) 198 (37.4) 440 (83) 90 (17) 518 (97.7) 12 (2.3) 152 (28.7) 210 (39.6) 168 (31.7) 153 (28.9) 377 (71.1) 360 (67.9) 170 (32.1)

0.45 0.24

0.09 0.29

Raw percentage. p-value of w2 test. JD, Jordanian dinar (1 JD & 1.4$).

WHAT PEOPLE USE TO TREAT APHTHOUS STOMATITIS Table 2. Medicines/Products Used in the Treatment of Recurrent Aphthous Stomatitis Nature of treatment Conventional medicines Topical anesthetic/analgesic Antiseptic mouthwash Topical steroid Covering agent Antibiotics Antifungals Analgesic Vitamins Antivirals Alternative treatments Tahini Salt/salt and warm water Lemon/lemon salt Pomegranate Chamomile Na bicarbonate powder Others (cumin, sage, coffee, ice, strawberry, berry, olive oil, yeast, tomato paste, castor oil, squeezing ulcers, smoking, cigarette ash) Total Frequency 181 58 49 46 8 8 6 3 2 1 86 34 21 7 5 3 3 13 Percent 67.8 21.7 18.4 17.2 3.0 3.0 2.2 1.1 0.7 0.4 32.2 12.7 7.9 2.6 1.9 1.1 1.1 4.9

653 7% of the ATs were recommended by health care providers and 38.7% of the conventional treatments, including 15 cases of topical steroids, were recommended by ordinary people. When asked if they have found the treatment useful, 216 (80.9%) subjects responded positively, with no signicant difference between those who used conventional or ATs. Discussion The sample forming the current study was composed of university students because RAS lesions are more prevalent at this age group and recur with decreasing frequency and severity thereafter.4,19 The highest incidence of RAS reported in the literature was found in university students.1 In addition, it is expected that young educated people, such as this cohort, may have higher probability to remember names of medicines or products they use to treat RAS. The high proportion of females forming the study sample is explained by the fact that 64.2% of the students studying at the University of Jordan in the year 2008 were females.20 No studies have been conducted before to study the types of treatments used by patients with RAS to assess the level of patient awareness of the disease. The results indicated the need for patient education on RAS treatment. While medications can alleviate pain and lessen severity, around half of the studied subjects with RAS did not attempt to treat the lesions. In addition, some individuals were using antifungals, antivirals, or even cigarette ash. This was not unexpected because the majority consulted relatives and friends regarding treatment of RAS or conducted personal trials and only 43.8% took advice from health care providers. Of interest was the nding that around one third of those who used topical steroids reported that the drugs were recommended by relatives and friends. This nding further justies our previous concern about the widespread habit of self-medication in Jordan.21 Disappointingly, only 9.3% of those who treated the RAS lesions reported consulting dental practitioners; of these, only 2 (0.7%) consulted oral medicine specialists. Patients often consult their general medical practitioners rather than their general dental practitioners regarding oral lesions.22 In this study, around one fourth of the subjects who treated the RAS lesions consulted medical practitioners. Even among this young cohort, there was a high prevalence of ATs use; around one third of those who treated the RAS lesions were using only ATs. Its use was signicantly more prevalent among individuals who were living in rural areas. In rural areas, the families are poorer and relatives and friends encourage the use of ATs to treat simple conditions. They are usually recommended by elderly people who are more familiar with the traditional indications for its use. In

267

100.0

20.3 1.8 years). Nearly half (267, 50.4%) of the subjects have used products to treat the last episode of RAS. The nature of treatment is shown in Table 2. There were 181 (67.8%) who used conventional medicines and 86 (32.2%) who used only ATs. Topical anesthetics/analgesics, antiseptic mouthwashes, and topical steroids represented 84.5% of the conventional medicines used. Of the 86 subjects who used ATs, 34 (39.5%) used tahini, 21 (24.4%) used salt/salt and warm water, and 7 (8.1%) used lemon/lemon salt. The tendency of whether or not to treat RAS was not signicantly affected by age, gender, residency, marital status, college, household monthly income, or smoking (Table 1). However, the nature of treatment was signicantly affected by place of living; ATs were used more signicantly by those who lived in rural areas outside the capital city of Amman. As expected, those who had low household monthly income used more ATs; however, the difference did not reach statistical signicance. The persons who recommended the RAS treatment are shown in Table 3. Treatment was recommended mostly by relatives (44.6%), followed by medical practitioners (22.9%). Only 9.4% sought treatment advice from dentists. Interestingly,

Table 3. Sources of Information about Treatment Treatment recommended by Treatment Alternative medicine Conventional medicine Total Him/herself 8 (9.3) 16 (8.8) 24 (9.0) Friends 4 (4.7) 3 (1.7) 7 (2.6) Relatives 68 (79.1) 51 (28.2) 119 (44.6) Pharmacist 2 (2.3) 29 (16) 31 (11.6) GDP 1 (1.2) 22 (12.2) 23 (8.6) OM specialist 0 (0) 2 (1.1) 2 (0.7) MP 3 (3.5) 58 (32) 61 (22.9) Total 86 (100) 181 (100) 267 (100)

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

654 addition to low cost and availability, an important motive for the widespread use of ATs in Jordan is the belief that these products are natural and, therefore, safer than conventional medications.23 Claims about the safety and effectiveness of these products, however, are based largely on testimonials and tradition. Extensive search of the literature revealed a deciency of randomized controlled trials to prove the benet of the vast majority of herbal medicines or ATs touted as helpful in treating RAS and other oral ulcerations. The bulk of information about its use is only available from Internet Web sites.15,16,24 One of the major ATs observed here was the application of tahini on RAS lesions. This treatment was performed by around 13% of subjects who treated RAS and form around 40% of ATs noted in this study. Tahini, an Arabic loanword to English, is a paste made from ground sesame seeds that originates in Mediterranean Arab countries.25 Tahini-based sauces are common in most Middle East Arab restaurants as a side dish or a garnish; however, its consumption currently is widespread in the United States and Europe.25 All subjects who used this material believed that it was effective in reducing their discomfort. The mechanism to explain its claimed benecial effects is unknown, and no previous studies have been conducted to investigate the effectiveness of this material or sesame oil on mouth ulcerations. However, a recent study has shown that pretreatment with sesame oil reduced acidied ethanol-induced gastric mucosal ulceration by reducing mucosal lipid peroxidation in rats.26 Sesame seeds are exceptionally rich in iron, magnesium, manganese, copper, calcium, zinc, and phosphorus.27 The seeds are a good source of vitamin B1, B2, B3, B6, folate, and vitamin E, and have high antioxidant and anticancer properties. The nutrients of sesame seeds are better absorbed if they are ground before consumption, as in tahini.27 Dentists usually recommend saline mouthwash following surgery or dental extraction. This salt water homemade mouthrinse was used by a signicant number of surveyed students to treat RAS. However, the author failed to nd a single article in the literature that proves that saline mouthrinse is effective in promoting healing of injured oral tissues or more benecial than water in treating or preventing infection, or in maintaining oral hygiene. However, hypertonic saline solution had signicant ulcer-protective effects in all gastric ulcer models studied in rats.28 In addition to enhanced mucin secretion and decreased cell shedding, the protective effects of hypertonic saline involved a signicant increase in gastric mucosal prostaglandin biosynthesis compared to normal saline.28 Additionally, endoscopic local injection of hypertonic saline was used to arrest hemorrhage from gastric ulcer.29 These ndings may rationalize the claimed benets of applying salt directly to the ulcers reported by some surveyed subjects. Although clinicians usually instruct patients with RAS to avoid acidic and spicy food, some surveyed individuals were using lemon or lemon salt (citric acid) to treat their lesions. Interestingly, citric acid was reported to be effective in management of chronic wound infections. Local application of the acid on the wounds caused signicant reduction of infectious agents and boosted broblastic growth and neovascularization, enabling healthy granulation tissue formation and faster wound healing.30 While no previous studies tested the usefulness of pomegranate in RAS to justify its use

SAWAIR by some surveyed subjects, the fruit extract was reported to offer protection against aspirin- and ethanol-induced gastric ulceration.31 Pomegranate was reported to have immunomodulatory, strong antioxidant, and antibacterial characteristics.31 Conclusions The results highlighted the need to educate patients with RAS on the treatment options available to reduce their distress and to improve their quality of life. They should also be educated on possible side-effects of some conventional and alternative medicines commonly used to treat RAS lesions. Since patients with oral lesions consult medical practitioners and pharmacists, better education in the diagnosis and treatment of oral diseases should include these health care providers. Clinical trials are needed to examine the potential usefulness of tahini/sesame oil, hypertonic saline mouthrinse, citric acid, and pomegranate in the treatment of RAS. Disclosure Statement No competing nancial interests exist. References
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Address correspondence to: Faleh Sawair, F.D.S., R.C.S. (Eng.), Ph.D. Faculty of Dentistry University of Jordan Amman 11942 Jordan E-mail: sawair@ju.edu.jo

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