Compounding: Treating Mouth Ulcers

NOVEMBER 01, 2005
Shannon W. Fields, BA, CPhT

Aphthous stomatitis, or mouth ulcer, is a very common, often painful problem most people experience. Also known as "canker sores," mouth ulcers are shallow sores found on the inner cheeks, lips, or gums. They often appear white, yellow, or red in color and may occur in clusters. Approximately 20% of the population may experience recurrent mouth ulcers.

Mouth ulcers generally are not caused by infection and therefore are not contagious. Most will heal without treatment in 1 to 2 weeks. When active, however, sores can be very painful, causing the patient discomfort when eating, speaking, or swallowing. Some commercial products are available to treat mouth ulcers, and, due to the challenges of effectively treating pain or trauma in the oral cavity, a compounding pharmacist may be able to produce a particularly helpful remedy.

Types and Causes of Mouth Ulcers

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

  • Minor aphthae account for 75% to 85% of all cases. They are small and round and are found inside the cheeks or lips, on or under the tongue, or on the gums, often in clusters.
  • Major aphthae generally are deeper and larger and make up 10% to 15% of RAS cases. They may exceed 1 cm and usually occur singly.
  • Herpetiform lesions are the least common, may occur in large numbers, and are 1 to 3 mm in diameter

Although the exact cause of RAS is unknown, several factors appear to trigger it. In most cases, these factors may be identified and avoided by the patient to prevent or reduce outbreaks. In rare cases, however, RAS is caused by a disease or condition outside the patient's control. Factors affecting RAS outbreaks include the following:

  • Low levels of certain nutrients: iron, vitamin B12, and vitamin C
  • Hormonal changes—many women report mouth ulcers around the time of their menstrual periods
  • Stress
  • Food sensitivities—foods with high acid content or certain preservatives may affect mouth ulcers
  • Mouth trauma, such as a sharp tooth or dental appliance
  • Bechet's disease, an autoimmune condition caused by the body attacking the cells lining the mouth
  • Bowel diseases
  • Skin diseases, such as lichen planus or herpes simplex

Treating Mouth Ulcers

Treatment of RAS typically is palliative, although supplementing the diet with lysine or the aforementioned nutrients may work as a preventive measure. There are some OTC and prescription treatments that can be effective in relieving the pain of mouth ulcers. A dentist or physician always should be consulted prior to beginning any new type of treatment.

OTC Options

Several treatments using common OTC medications or household items may offer pain relief. They include:

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

Prescription Treatments

When OTC products do not provide sufficient symptom relief, a prescription treatment may be appropriate. Commercial preparations include:

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

Compounded Alternatives

When commercial products prove less effective, in some cases a compounding pharmacist can prepare medications in special bases that adhere to the site, as well as some unique treatments and dosage forms. The range of treatment possibilities is greater, and the dose may be tailored to the 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 in most cases no further symptoms are reported, although in some situations an additional application is needed.

Another highly effective compounded treatment is a preparation of misoprostol mucoadhesive anesthetic powder. This is a dry powder blend of misoprostol and dyclonine, which, when applied to the site, forms a sticky gel that adheres to the sore and forms a protective barrier. This gel is more resistant to friction, and, because the sore is protected, pain and irritation are greatly reduced.

Other compounded options for treating RAS include tetracaine, lidocaine, or benzocaine lollipops or sprays to numb the area, and the incorporation of commercially available products into a more adherent base or a mouth rinse.

Ms. Fields is with the International Journal of Pharmaceutical Compounding and is a pharmacy technician at Innovative Pharmacy Services in Edmond, Okla.