Compounding: Treating Mouth Ulcers

Aphthous stomatitis, or mouth ulcer,is a very common, often painful problemmost people experience. Alsoknown as "canker sores," mouth ulcersare shallow sores found on the innercheeks, lips, or gums. They often appearwhite, yellow, or red in color and mayoccur in clusters. Approximately 20% ofthe population may experience recurrentmouth ulcers.

Mouth ulcers generally are notcaused by infection and therefore arenot contagious. Most will heal withouttreatment in 1 to 2 weeks. When active,however, sores can be very painful,causing the patient discomfort wheneating, speaking, or swallowing. Somecommercial products are available totreat mouth ulcers, and, due to thechallenges of effectively treating painor trauma in the oral cavity, a compoundingpharmacist may be able toproduce a particularly helpful remedy.

Types and Causes of Mouth Ulcers

There are 3 types of recurrent aphthousstomatitis (RAS): minor, major,and herpetiform.

• Minor aphthae account for 75% to85% of all cases. They are smalland round and are found insidethe cheeks or lips, on or under thetongue, or on the gums, often inclusters.
• Major aphthae generally are deeperand larger and make up 10% to15% of RAS cases. They may exceed1 cm and usually occur singly.
• Herpetiform lesions are the leastcommon, may occur in large numbers,and are 1 to 3 mm in diameter

Although the exact cause of RAS isunknown, several factors appear totrigger it. In most cases, these factorsmay be identified and avoided by thepatient to prevent or reduce outbreaks.In rare cases, however, RAS is caused bya disease or condition outside thepatient's control. Factors affecting RASoutbreaks include the following:

• Low levels of certain nutrients:iron, vitamin B¹², and vitamin C
• Hormonal changes—many womenreport mouth ulcers around thetime of their menstrual periods
• Stress
• Food sensitivities—foods with highacid content or certain preservativesmay affect mouth ulcers
• Mouth trauma, such as a sharptooth or dental appliance
• Bechet's disease, an autoimmunecondition caused by the bodyattacking the cells lining the mouth
• Bowel diseases
• Skin diseases, such as lichenplanus or herpes simplex

Treating Mouth Ulcers

Treatment of RAS typically is palliative,although supplementing the dietwith lysine or the aforementionednutrients may work as a preventivemeasure. There are some OTC and prescriptiontreatments that can be effectivein relieving the pain of mouthulcers. A dentist or physician alwaysshould be consulted prior to beginningany new type of treatment.

OTC Options

Several treatments using commonOTC medications or household itemsmay offer pain relief. They include:

• Salt-water solution: rinse the mouthwith a solution of 1/2 tsp of salt dissolvedin 8 oz (1 cup) of water
• Maalox (or an equivalent product)/diphenhydramine solution:combine 1 to 2 tbsp of Maaloxwith 1/2 tbsp of diphenhydramine(eg, Benadryl) liquid. Swish 1 to 2tsp of the solution in the mouthfor 1 minute, then spit it out.
• OTC numbing medications, such asAnbesol or Orabase: use as directed

Prescription Treatments

When OTC products do not providesufficient symptom relief, a prescriptiontreatment may be appropriate.Commercial preparations include:

• Collagenase inhibitors, such astetracycline or chlorhexidine rinses
• Amlexanox (Aphthasol) paste
• Topical steroids applied directly tothe site, such as triamcinolone
• Viscous lidocaine solutions

Compounded Alternatives

When commercial products proveless effective, in some cases a compoundingpharmacist can preparemedications in special bases thatadhere to the site, as well as someunique treatments and dosage forms.The range of treatment possibilities isgreater, and the dose may be tailored tothe needs of the patient.

One particularly effective preparation,polyphenol sulfonic acid complex,is applied directly to the site.Although it burns upon application,the sore is essentially cauterized, and inmost cases no further symptoms arereported, although in some situationsan additional application is needed.

Another highly effective compoundedtreatment is a preparation of misoprostolmucoadhesive anesthetic powder.This is a dry powder blend ofmisoprostol and dyclonine, which,when applied to the site, forms a stickygel that adheres to the sore and formsa protective barrier. This gel is moreresistant to friction, and, because thesore is protected, pain and irritationare greatly reduced.

Other compounded options for treatingRAS include tetracaine, lidocaine, orbenzocaine lollipops or sprays to numbthe area, and the incorporation of commerciallyavailable products into a moreadherent base or a mouth rinse.

Ms. Fields is with the International Journalof Pharmaceutical Compounding and is apharmacy technician at Innovative PharmacyServices in Edmond, Okla.