Recurrent Aphthous Stomatitis: Towards Evidence-Based Treatment?

Recurrent aphthous stomatitis is one of the most common oral mucosal diseases seen by dental professionals, and yet its aetiology remains unclear, and its management based on less than robust evidence. The literature remains confused because of the lack of clarity in diagnosis and the lack of a standardised ulcer severity scoring system and agreed outcome measures. However, recent literature is encouraging in meeting these aims. There is agreement that recurrent aphthous stomatitis (RAS) is a localized mucosal disease not secondary to systemic disease and therefore distinguishable from over 40 other types of oral ulcers. Disease severity scores have been introduced and outcome measures have become more standardised. RAS appears to be an auto-immune disease directed at epitopes of heat shock proteins whilst most recent work on aetiology has focused on cytokines and genetics. Pro-inflammatory cytokines including TNF-a and IL-6 and IL-17 are raised in RAS and TNF inhibitors can inhibit episodes of ulceration. Many local anti-inflammatory agents will help ulcers heal, and local steroids remain the treatment of choice. Some systemic drugs have evidence-based data indicating efficacy at preventing new ulcers including colchicine, prednisolone, thalidomide, pentoxyfilline and dapsone. The field would benefit from further trials combining local and systemic therapy using defined outcome measures.