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Since many primary and secondary factors are claimed to be responsible in the etiopathogenesis of the disease (Barile et al,1963; Chellemi et al,1970; Glick et al.,1992; Rose et al,1990), different therapy alternatives such as corticosteroids, antibiotics, topical analgesics, vaccines, immunostimulants, antihistaminics, vitamins and laser applications have been used for the treatment of RAS (De Cree et al,1 978; Lozada,1981; MacPhail et al,1992; Miller et al,1993; Pick,1993; Porter et al,1988). Recently, the association between dietary allergens and ulcer mechanism is being investigated by many researchers (Antoon et al,1980; Hay et al,1984; Henricsson et al,1985; Lehner,1992; Regezi et al,1993; Rodu et al,1992), and it is suggested that by eliminating the dietary allergens, the prognosis of the disease may be altered positively (Hay et al,1984).
In this preliminary study, a dietary regulation is used as a palliative treatment modality for the patients with recurrent aphthous ulcer, and the effects of this method on the prognosis of the lesions are discussed.
The diet given to the patients was described as being useful for the management of gastrointestinal allergic disease (Hay et al,1984). The foods which were identified by the patients depending on their experiences as the dietary elements that affect the prognosis of the lesions negatively were excluded from the diet as well.
Full explanations about the diet were given to the patients. At the same time, they were asked to record the number of new forming lesions and their healing times, the length of the ulcer-free periods and the degree of the discomfort (slight, moderate or severe). All patients were asked to visit for recall examinations at the end of every 2 weeks.
The dietary elements eliminated from the diet were wheat and wheat products (breads, pastries, macaroni, etc.); milk and milk products (cheese, yoghurt, etc.); tomatoes, tomato sauces, ketchup, mustard; citrus fruits; lemon, vinegar; cola, tea; aubergine (eggplant); spinach; nuts and figs and chocolate.
During the trial period, the patients were asked to use no medication and they were encouraged to keep their daily routine activities. In addition, they were asked to contact in case of any weight loss since the diet was not intented to be weight reducing.
Patients were reviewed at 2 week intervals and the prognosis of the disease was recorded for each patient. If no positive alteration of the pattern of RAS was observed at the end of 4 weeks, dietary regulation was discontinued and other conventional treatment methods were administered. If there was any improvement, then the patient was asked to add one single item from the restricted elements in each week and when no adverse reaction was observed, that item remained within the normal diet. When new ulcer formation occured or the frequency of new lesions increased markedly after the introduction of a certain food, that food was withdrawn immediately and no new item was added until the ulcers healed.
On the other hand, 5 patients (3 female, 2 male ; ages between 21 - 47) had significant decrease in the frequency and severity of the ulcers and had minor, infrequent, painless ulcers in approximately 12 months observation period. The other features of these patients are listed in Table 1.
| Patient | |||||
|---|---|---|---|---|---|
| Name | A.A. | E.Y. | G.A. | Y.E. | F.C. |
| Sex | F | M | F | M | F |
| Age | 42 | 47 | 21 | 31 | 33 |
| Total Duration | 8 months | 20 years | 10 years | 2 years | 20 years |
| Number of Lesions (Before) |
2-3 per week |
3 per week |
5-6 per week |
1-2 per week |
2-3 per week |
| Number of Lesions (After) |
1-2 per month |
2 per month |
1-2 per 2 months |
none | 1-2 per month |
| Severity of Pain (Before) | severe | severe | severe | moderate- severe | moderate |
| Severity of Pain (After) | slight - moderate | none - slight | slight | none | slight |
| Dietary Allergen | Tomatoes, Orange | Tea, Aubergine (eggplant) | Cola, Orange, Tomatoes | Nuts, Chocolate | Tomatoes, Orange |
In our study, the patients used the diet and waited for 4 weeks to see any improvement. This period appears to be long enough to observe any ulcer pattern changes (Carranza,1990). The results of this preliminary study showed that oranges, tomatoes, nuts, eggplant, tea and cola were the dietary allergens that triggered the ulcer initiation. By reducing the intake of these food, it is observed that the pattern of ulcer prognosis have changed positively and the patients clinical complaints have decreased significantly.
Even though our results confirm
the hypothesis that elimination of food allergens may be beneficial in RAS patients,
it may not be healthy to reach a definite conclusion since the number of patients
in the dietary elimination group is small. Frankly, as is seen in another study
(Hay et al,1984), adherence to a strict diet is quite difficult due to
social and economic reasons, and this is probably the primary cause accounting
for the small number of patients who accepted to participate. However, the results
of this preliminary study are presented in order to remind this new approach
to the practitioners and discuss the results with the other researchers. The
results of the present study are in accordance with the findings of Hay (Hay
et al,1984). In our study, it was observed that chocolate, tomatoes, oranges
and nuts were among the dietary allergens that were previously reported (Hay
et al,1984; Woo et al,1996), but cola and tea were also found to cause exacerbations
in RAS patients. At the end, it is observed that a significantly high percent
(50 %) of recurrent aphthous ulcer patients in this study benefitted from the
dietary regulation.
Therefore, this preliminary result neccessitated a successive research on a
wider patient population (which is currently being carried on) to evaluate the
effect of the elimination of dietary allergens as a probable new palliative
treatment method for aphthous ulcers. Also, in order to confirm this theory,
skin patch testing of these food will be included in this successive project,
as well.
When the type of medications used for the treament of RAS lesions and their potential side effects are considered, dietary regulation appears to be an inoffensive therapy that may be effective on a group of RAS patients. For this reason, it is suggested that after systemic or local factors are eliminated and no contraindications are established, it may be helpful to use dietary regulations on recurrent aphthous ulcer patients before administering any conventional treatment modalities.
Dr. Pelin Gürdal, Assistant Professor
School of Dentistry, Department of Oral Diagnosis and Radiology
Ege University, Bornova 35100,
Izmir, Turkey
Phone: 90-232-3881081
Fax: 90-232-3880325
E-mail: guerdal@dishekimligi.ege.edu.tr
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