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Management of recurrent aphthous stomatitis

ORAL MEDICINE

ORIGINAL ARTICLE

MANAGEMENT OF RECURRENT APHTHOUS STOMATITIS WITH


CHLORHEXIDINE GLUCONATE MOUTHWASH
AND VITAMIN B-COMPLEX
1

NABIKHAN ATHANI, MDS


2
RAVIKUMAR H R, MDS
3
KALLALLI B N, MDS
4
CHOPRA S S, MDS

ABSTRACT
The aim of this study was to assess the efficacy of 0.2% Chlorhexidine gluconate mouth wash and
vitamin B-complex on minor recurrent aphthous stomatitis with respect to reduction in duration of
ulcer, recurrence of ulcers and to increase the gap between ulcer free days during a specific period.
A single blind therapeutic trail was carried out on 96 minor recurrent aphthous stomatitis
patients which were divided into four groups. Group I was given 0.2% Chlorhexidine gluconate mouth
wash, Group II received vitamin B-complex, Group III was given both. (I+II), and Group IV received
placebo.
Results showed reduction in ulcer duration, recurrence of ulcers and ulcer free days were
increased.
The clinical results of this study were promising and suggested that further investigation should
be done with large study groups.
Key words: Recurrent aphthous stomatitis, chlorhexidine gluconate, vitamin B-complex
INTRODUCTION
Oral diseases especially ulcers of the oral mucosa
are most common in human beings. It carries no
mortality but a high morbidity: The first use of the
term aphthae in relation to mouth is credited to
Hippocrates as far back as 460-370 BC. The term
aphthae is a plural of aphtha. The word aphtha is
derived from the Greek word Thrush which means, a
small ulcer, especially the reddish or white spots in the
mouth that characterize aphthous stomatitis. By definition recurrent aphthous stomatitis is a chronic inflammatory disease of oral mucosa, characterized by

recurrent painful ulcers of the oral mucosa1,2,3 and is


also termed as recurrent aphthous ulcer.4 Recurrent
aphthous stomatitis affects 20% of the general population and is the most common form of oral ulcerative
disease. Amongst various types of oral ulcers aphthous
ulcers are quite common entity. In fact it is found one
in five of the population in their lives.3 Many investigators have classified recurrent aphthous stomatitis into
three subtypes: minor aphthous ulcers, major aphthous ulcers and herpetic form ulcer. Minor aphthous
ulcers typically start in childhood or adolescence and
are the most common form accounting for up to 87 %
of aphthous ulcers.5,6 It is an interesting point to note

Correspondence to: Dr Nabikhan Athani, MDS, Professor and Head Dept Oral Medicine and Radiology, RKDF
Dental College & Research Centre, Bhopal-462001(M.P) India. E-mail: nabik23@rediffmail.com
2
Prof & Head Dept Oral Maxilo-facial Surgery, RKDF Dental College and Research Centre, Bhopal-462001(M.P)
India
3
Dean & Head Dept Oral Medicine and Radiology, Naribhai Patel Nootan Dental College, Visnagar-384315
(Gujarat) India
4
Prof & Head Dept Oral Medicine and Radiology, P M N M Dental College, Bagalkot-587101 Karnataka - India
1

Pakistan Oral & Dental Journal Vol 32, No. 2 (August 2012)

214

Management of recurrent aphthous stomatitis

that in spite of minor recurrent aphthous stomatitis of


the oral cavity being a common phenomenon the
etiology remains poorly understood. However the current concept is that, there could be various provoking
factors namely stress, allergy, trauma, heredity, infections (viral and bacterial) and nutritional deficiency.7
Although a variety of treatment modalities have been
suggested to either eliminate or reduce the duration of
recurrences, their clinical value remains unproven and
can be controversial. The combined problems of multiple etiologies, lack of specific therapy and frequent
recurrence of ulcers have made the management of the
aphthous ulcers difficult.5 Current study was carried
out to compare and determine whether 0.2% chlorexidine
gluconate mouthwash and vitamin B -complex has a
place in the management of these ulcers.
METHODOLOGY
A total of 96 patients with minor recurrent aphthous stomatitis formed the study groups irrespective of
their sex and were in the age group of 19 to 30 years.
These patients were randomly selected from the outpatient department of Oral Medicine and Radiology,
P.M.N.M Dental College, Bagalkot. All patients fulfilled the criteria of diagnosis and clinical criteria of
minor recurrent aphthous stomatitis. These 96 patients were divided in to four groups (24 patients in
each group). Group I was given 0.2% Chlorexidine
gluconate mouthwash (2 teaspoonful) mouthwash to be
swished around the mouth for one minute, twice daily
for 30 days. Group II received vitamin B-complex one
capsule daily for 30 days. Group III was given both
(I+II) for 30 days and Group IV received Placebo for 30

days. The study comprised of 30 days treatment and 90


days follow up period. All observations of patients
ulcers from beginning of the trail to the end of follow up
period were noted by clinician in separate diary for
each individual patient. From these diaries duration of
ulcers, possible recurrence of ulcers, their duration
and ulcer free days during 90 days follow up were
recorded.
Clinical criteria for selection of aphthous ulcer
patients. 2,4,6,7,8,9,10,11
A. Inclusion criteria: (i) Recurrent occurrence of
the minor recurrent aphthous stomatitis in the
oral cavity. (ii) Patients of either sex, suffering
from recurrent episode of minor recurrent
aphthous stomatitis. (iii) Availability during
the study period.
B. Exclusion criteria: (i) Pregnancy. (ii) Suffering
from systemic disease. (iii) Undergone
treatment for minor recurrent aphthous stomatitis.
Statistical analysis: Multiple group comparison were
done by one way ANOVA F-test, followed by StudentNewman- keel. Range test for pair wise comparisons.
Wilcoxon Ranksum test was used for comparing two
groups in recurrent case. Fishers exat was used for
categorical data.
RESULTS
The present single blind study was carried out on
96 minor recurrent aphthous stomatitis patients to
assess the efficacy of 0.2% chlorexidine gluconate
mouthwash and vitamin B-complex.

TABLE 1: MEAN NUMBER OF ULCER FREE DAYS IN EACH GROUP.


Groups

I
II
III
IV

Patients
treated
Number
5
6
5
8

Recurred patients
during follow up
Mean
+-SD
64.2
57.0
65.2
42.5

9.60
6.26
10.89
10.86

Comparison between groups


Group
compared

U
Value

Significant

I-II
I-III
I-IV
II-III
II-IV
III-IV

5.5
11.5
2
7
5
1.5
III< I< II< IV

NS
NS
P<.01
NS
NS
P<.01

One factor ANOVA (F=5.02, P<0.1)


*Wilcoxns Rank-sun test.
Pakistan Oral & Dental Journal Vol 32, No. 2 (August 2012)

215

Management of recurrent aphthous stomatitis

TABLE 2: SHOWS RECURRENCE OF ULCERS DURING FOLLOW UP


Groups

Patients
treated
Number

I
II
III
IV

Recurred patients
during follow up
Number
%

24
24
24
24

NS

5
6
5
8

Recurrence of ulcers in recurred


patients
Number
Means
+-

20.8
25.00
20.8
32.3

8
14
7
16

Significance Deference not significant (P>0.05)

**F=1.96

4.8
5.2
4.2
6.0

0.84
0.75
0.84
0.92

P>0.05 NS

TABLE 3: NUMBER OF ULCER FREE DAYS IN RECURRED PATIENTS OF EACH GROUP


Groups

Patients
treated
Number

Recurred patients
during follow up
Mean
+-SD

Comparison between groups


Group
compared

U
Value

Significant

64.2

9.60

I-II

5.5

NS

II

57.0

6.26

I-III

11.5

NS

III

65.2

10.89

I-IV

P<.01

IV

42.5

10.86

II-III

NS

II-IV

NS

III-IV

1.5

P<.01

III< I< II< IV


One factor ANOVA (F=5.02, P<0.1)

*Wilcoxns Rank-sun test.

Table 1 shows mean number of ulcer days and


comparisons between each group treatment
modality.
Table 2 provides information about recurrence of
ulcers during follow up.
Table 3 gives mean number of ulcer free days in
each group.
DISCUSSION
Research has been done on recurrent aphthous
stomatitis since last century but etiology and pathogenesis of this disease remain elusive till now. Although a variety of treatment modalities have been
suggested either to eliminate or reduce the duration of
recurrences, their clinical value remains unproven. 2
Use of 0.2% chlorexidine gluconate mouthwash and
vitamin B -complex alone or in combination attempted
to reduce the duration of ulcers, number of new ulcers
and to enhance gap of ulcer free days in minor recurrent aphthous stomatitis.
Pakistan Oral & Dental Journal Vol 32, No. 2 (August 2012)

The present single blind therapeutic trial consisted


of a total of 96 minor recurrent aphthous stomatitis
patients, irrespective of their sex. Age ranged from 19
to 30 years.
Findings of this study regarding placebo used patients ulcer duration is in agreement with other similar studies.2,12 The results of this study in order of
superiority in reducing ulcer duration of particular
group were as III<1<II<IV.
As regards number of new ulcers in recurred
patients during 90 days follow up. Present study
revealed that mean number of ulcer were not significant between different groups (>0.05)
However mean number of ulcers in group I was 4.8.
This mean value was lesser than group II and group IV.
It could be due to .2% chlorehexidine gluconate mouthwash. The possibility must be considered that
chlorehexidine by reducing mucosal flora, particularly
the streptococci, interferes with an immunological
cross reaction between the bacterial and oral epithe216

Management of recurrent aphthous stomatitis

lium antigens thus inhibiting the actual initiation of


the onset. Chlorehexidine does in fact reduces number
of new ulcers.11 In group II (vitamin B -complex)
recurrence duration of ulcers were 5.2 followed by
group III 6.0.
Nolan A1 suggested that replacement therapy of
vitamin B1, B2, B6 in deficient patients of one of these
vitamins were useful in reducing recurrence of ulcers.
As regards duration of recurrence of ulcers, this study
did not find much difference except group III 6.0(0.92)
other groups were statistically insignificant. In group
III it could be due to combined action of both drugs.
Miller 6 suggested that long term use of 0.2%
chlorehexidine gluconate mouthwash will reduce duration of ulcers.
Nolan A further suggested that use of vitamin B1,
B2, B6 in deficiency patients significantly reduced
duration of recurred ulcers with p (<0.01) which is
statistically significant. A recent similar study indicated that foliate and Vitamin B12 will reduce duration of aphthous ulcer.15 As regards ulcer free days
present study showed statistically significant p (<0.01)
results.
Hunter 3, suggested that 0.2% chlorexidine gluconate mouthwash used 6 weeks would significantly affect
the duration and successive ulcer free days p ( <00.2).
It has been shown that chlor-hexidine mouthwash
reduces the incidence, duration and severity of recurrent minor aphthous ulcera-tion.16
CONCLUSION
It was concluded that, as a treatment modality
for minor recurrent aphthous stomatitis 0.2% Chlorhexidine gluconate mouthwash in combination with
vitamin B-complex were statistically significant (p<0.01)
in reducing duration of ulcers, recurrence of ulcers and
increasing the gap between successive ulcer free days.
The clinical result of this study is promising and
suggests that further investigations should be done
using large sample size.

Pakistan Oral & Dental Journal Vol 32, No. 2 (August 2012)

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