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Osagie AkhionbareDepartment of Periodontology,School of Dentistry,University of Benin,Benin City, Edo State,Nigeria

Asian Network for Soiontifio Information

Paper

I. lvled. Sci., T (5): 860-864lst Iuly, 200’?

The Palliative Effects of Lidocaine with Adrenaline onRecurrent Aphthous Stomatitis (RAS)

Osagie Akhionbare and Patrick lmioshor Oj ehanon

To study the beneficial effect of lidocair1e with adrenaline used for alliavation ofpain in routine dental procedures on patients with Recurrent Aphthous Stomatitis(RAS). Thirty RAS patients with no known history of any systemic conditions,who reported for the first time for treatment between 2003i2004 at the DentalCentre of the University of Benin Teaching Hospital, Benin City, Nigeria, wereselected for this study. The patients had ulcers located on the tongue, floor of themouth and the buccal mucosa. They were randomly selected into two groups offifteen each. The first group was taught how to apply the solutions, using thesyringe, of 2% lidocaine and the second group 2% lidocair1e in l :80000 adrenaline.The time the solution was applied and the resultant effect before the start of theirmeals and when the feeling of pain became apparent, were noted. Graphic wordrating scale was used to access the level of pain before and after solutionapplication. Complete relief of pain associated with the ulcer after the applicationof either solutions of lidocair1e was reported by 86.’?%. 66.’?% of patients who usedlidocair1e solution had a shorter period of onset of pain relief while the reverse wasthe case with the other group. Patients that used lidocaine with adrenalinesolution, reported a longer period of pain relief as compared to lidocair1e withoutadrenaline. Durir1g this period the patients under study took their meals incomfort. Lidocaine with adrenaline solution could be incorporated with othermethods of managing RAS. This is mostly important in the early period of theulcers, since it gives a faster and almost complete relief of pain during mealtime.

Key words: Effects, lidocair1e, recurrent aphthous stomatitis

Department of Periodontology, School of Dentistry, University of Benin,Benin City Edo State, Nigeria3'

860

J. Med. Sci, 7 (5): 860-864, 2007

INTRODUCTION

Recurrent Aphthous Stomatitis (RAS) is one of themost common oral mucosal inflammatory ulcerativediseases worldwide (Rees and Binnie, l996).Epidemiological studies ir1dicate that the prevalence ofRAS is between 2 and 50% in the general population,most estimates fall between 5 and 25% and three-monthrecurrence rates as high as 50% (Barrons, 200l). It hasbeen observed with a frequency as high as 50-60%. Thepeak age of onset for RAS is between l0 and l9 years.After childhood and adolescence, it may continuethroughout the entire human lifespan without geographicor age-, sex-, or race-related preference (Ship at oi, 2000).

Considerable research attention has been devoted toelucidating the causes of RAS. Local and systemicconditions, genetic, immunologic and infectious microbialfactors have all been identified as potentialaetiopathogenic agents. However, to date, no principalaetiology has been discovered. Since the aetiology isunknown, diagnosis is entirely based on history andclinical criteria. No laboratory procedures exist to confirmthe diagnosis (Natah at oi, 2004).

There are three clinical subtypes on the basis of ulcersize and number as minor, major and herpetifonn. lvlinoraphthous ulcers are the most common subtype,representing 80-90% of all recurrent aphthous ulcers. Theulcers, which usually occur on the nonkeratinized oralmucosa, can cause considerable pain and may interferewith eating, speaking and swallowing. Clinically, itpresents as shallow ulcerations with an erythematoushalo on unattached oral mucosa (Shashy and Ridley,2004)

The lack of clarity regarding the aetiology ofaphthous ulcers has resulted in treatments that are largelyempirical. These treatments include the use of antibiotics(Graykowski and Kingman, l9’?8, Henricsson and Axell,l985, Kerr at oi, 2003), anti-inflammatories (Vincent andLilly, l992, Saxen at oi, l99’?, Rl1odus and Bereuter, l998,Rl1odus at oi, 2001, Gonzalez-lvloles at oi, 2002), immunemodulators (De Cree at oZ., l 928, Drir1r1an and Fischrnan,l9’?8, Olson and Silvennan, l9’?8, lvilatsuda at oi, 2003),anaesthetics, alternative (herbal) remedies (PauloFilho at oi, 2000, lvI[cBride, 200l) and bioadhesives.(Kutcher at oi, 2001, Kutcher, 2001, Andriani at oi, 2000).

lvI[ost studies done, have involved the evaluation ofthe topical and systemic therapeutic agents that basicallysuppress or modulate immune system function. Forexample, levamisole (Graykowski and Kingman, l9’?8,De Cree at oi, l9’?8, Drinnan and Fischrnan, l9’?8,Olson and Silvennan, l9’?8) thalidomide (Barrons, 200l,Iacobson at oZ., l99’?) colchicine (Viguier at oi, 2000,

Fontes at oi, 2002, Katz at oi, l994). However, topicalagents are preferred because they have fewer associatedside effects, but the inability to obtain adequate contacttime may limit their effectiveness.

Various topical analgesics have been tried previouslysuch as benzydamine hydrochloride (lviatthews at oi,l 98’? , Edres at oi, l99’?) diclofenac (Saxen at oi, l99’?) and5-aminosalicylic acid (Collier, l992) which have resultedin various degrees of pain reduction.

It is important to note that the effects of these agentsare not immediate and not much attention has beenfocused at alleviating the pain that occurs when the ulcersfirst appear in the oral cavity. This initial period before thesymptomatic effects of topical and systemic therapy beginto manifest, it is important that palliative measures aretaken which allow these patients to eat, drink and swallowtheir meals in comfort.

The value of lidocaine in the management of ulcerpair1s, has been demonstrated in some studies with theuse of anaesthetic lidocaine-prilocaine cream, ElvILA(Eutectic lvilixture of Local Anaesthetics). This has beenused in the management of numerous medical andsurgical procedures, such as anaesthesia for superficialsurgery and debridement of infected ulcers (Adeoti at oi,1998;, Blanke and Hallem, 2003;, Rosenthal at oZ., 2001;,Holm at oZ., 1990).

Lidocaine (2% concentration), which is commonlyused in various dental procedures to achieve anaesthesia,was used in this study because of its ease of availabilityand ability to prevent the generation and propagation ofaction potentials at any point along a nerve withoutresultant loss of consciousness but loss of pain. This isdue to its surface analgesic properties when appliedlocally or specifically to the ulcer surface. Because of itsintrinsic vasodilator effect with the resultant rapidsystemic absorption, combination with adrenaline(l :80000) was used.

MATERIALS AND METHODS

Thirty patients who had their Recurrent AphthousStomatitis (RAS) located on the tongue, floor of themouth, the buccal mucosa, reported for the first time fortreatment, were selected at random for this study. This isfrom amongst all those seen at the University of BeninTeaching Hospital, Dental Center, between year 2003 and2004. They all had great difficulty in eanng their meals dueto the nature of pain associated with the ulcer. They hadno known history of any systemic condition andconditions that maybe affected by any component of theagents used. Two of the patients had major ulcers, whilethe rest had minor ulcers.

J. Med. Sci, 7 (5): 860-864, 2007

Patients were randomly selected into two groups(15 patients per group). The first group was taught onhow to apply the solutions of 2% lidocaine while thesecond group used 2% lidocaine with 1 :80000 adrenaline.These were applied onto the ulcer surface with the use ofaspirating syring. Two to three drops of the solution wereapplied directly into the ulcer surface after the patient hadswallowed most of the saliva in the mouth. They wereinstructed to allow the mouth remain opened for about2 minute to pennit the solution to remain in contact withthe ulcer before closir1g the mouth to swallowaccumulated saliva. This was repeated a second time. Thepatients were asked to record the time the solution wasapplied and the resultant effect before the start of theirmeal and to note the time when the feeling of the effect ofpain became apparent. They were, to access and recordtheir level of pain, using the Graphic Word Rating Scalebefore and after application of the solutions.

RESULTS

The results of this study showed that 53.3% followedby 36.2 and 10% of the patients felt medium, intense andsevere pain, respectively from their ulcers before theapplications of the agents. Complete relief of painassociated with the ulcer after the application of eitherfonn of lidocaine was reported by 86.2% of the patients.Only 13.3% still felt light pain. However, during the earlypartof meal, 80% reported complete pain relief and20% felt light pair1s from their ulcers (Table 1).

A higher proportion of the patients (66.2%) who usedlidocaine solution had a shorter period of onset of painrelief (within 0-2 mir1) while the reverse was the case where

Table 1: Pain severity ofulcers ofpatientsBefore appt

Characteristics No. (%)No pain -Light pain - 4 (13.3) 6 (20.0)Medium pain 16 (53.3) - -Intense pain 12 (36. 2) - -Severe pain 2 (10.0) - -Unbearable pain - - -Total 30 (100.0) 30 (100.0) 30 (100.0)

During mealsNo. (%)

24 (80.0)

After apptNo. (‘%)

26 (86.2)

Table 2: Onset ofpain reliefTime Lidocaine solu (%) Lidocaine with adren. solu. (%)0-2 min 10 (66.2) 3 (20)2-4 min 5 (33. 3) 12 (80)"P4 min None NoneTotal 15 (100.0) 15 (100)

Table 3: Period ofpain reliefTime Lidocaine solu (%) Lidocaine with adren. solu. (%)0-5 min 13 (86.2) None5-10 min 2 (13.3) 11 (23.3)10-15 min None 4 (26.2)3==15 min None NoneTotal 15 (100.0) 15 (100.0)

80% of the other group that used lidocair1e withadrenaline solution had a longer period of onset of painrelief (2-4 min) (Table 2).

The patients who used the solution of lidocaine withadrenaline reported to have had a longer period of painrelief as compared to those that used only lidocainesolution. Gradually reappearance of pain by both groupswas experienced. During this period the patient tookhisther meals without difficulty (Table 3).

DISCUSSION

Various studies have reported that the aetiology ofRecurrent Aphthous Stomatitis (RAS) which usuallycauses considerable pain and interferes with eating,speaking and swallowing is unknown (Natah at oi, 2004,Burruano and Tortorici, 2000, Zunt, 2003, Petersen andBaughrnan, 1996). This therefore means that variousmethods of management are geared towards relief ofsymptoms (Rhodus and Bereuter, 1998, Kutcher at oi,2001, Kutcher, 2001). Reports have also indicated thatthese methods of managements results in the earlyremission of signs and symptoms of the conditions and insome cases increases the interval between reoccurrences(Barrons, 2001 , De Cree at oZ., 1928;, lvfuzio at oZ., 2001).This involves the use of single or a combination(Ylikontiola at oZ., 1992) of various methods such as,antibiotics, anti-inflammatories, immune modulators,anaesthetics and alternative (herbal) remedies (PauloFilho at ol'., 2000, lvIcBride, 2001) and bioadhesives(Kutcher at oi, 2001, Kutcher, 2001, Andriani at oi, 2000).

Not much have been reported on the use of lidocaineas a fonn of pain relief in RAS while attention has noteven been focused on combination of lidocaine withadrenaline, which is usually used to achieve localanaesthesia in various dental procedures. This study hasshown that combination of lidocaine with adrenalinegives a longer period of pain relief, which allows thepatients enough time to take their meals. This was anindication that adrenaline may have had a role to play inthe period of pain relief.

It is important to note that most of the managementmethods apart from the use of anaesthetics like lidocaineonly reduces the inter1sity of pain after a certain period(Saxen at oi, 1992) and not elirnir1atir1g it, as is in this casewhich allows the patients to eat their meals with somecomfort.

Previous studies with the use of lidocaine for ulcerpains did not incorporate adrenaline in their fonnulation(Blanke and Hallern, 2003, Rosenthal at oi, 2001,Holm at oi, 1990).

The use of benzydarnine hydrochloride mouthwashwhich is available in the UK as an over the counter

J. Med. Sci, 7 (5): 860-864, 2007

preparation has been used. It contains some degree oflocal anaesthetic properties, this produces transienttopical anaesthesia thereby giving symptomatic relief onlyto patients with ulcers of minor severity (Edres, 1992). Butits adverse effects of numbness or stinging sensation ofthe oral mucosa makes this study important because theeffect of numbness in this study is only located in theimmediate locality of the ulcer which is of benefit topatients in tenns of oral activities.

Cyanoacrylate (2-octyl cyanoacrylate), which istopical medical adhesive fonnulation (Narang, 2001) hasalso been used as a fonn of pain relief. It polymerizesinstantly upon application ir1to a thin, flexible polymer filmthereby creating a mechanical barrier and providing painrelief of oral ulcerations and irritations and maintains anatural healing enviromnent for the area to heal. However,it is important to note that this is only a mechanical barrierthat prevents substances getting to the surface of theulcer but does not affect the generation and propagationof impulses in an inflammatory enviromnent of RAS, as inthe case of lidocair1e in this study. Further studies can beundertaken to see the beneficial effect of lidocaine!adrenaline with any other method of managing both maj orand minor RAS.

CONCLUSIONS

This study has indicated the ability of lidocaine inreliefing pain associated with Recurrent Aphthous ulcersand combination with adrenaline further increase theperiod of pair1 relief which allows the patients enough timeto take their meals.

Lidocaine with adrenaline solution can beincorporated with other methods of managing RAS. Thisis most important in the early period of the ulcers, since itgives a faster and almost complete relief of pain duringmealtime.

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