Oral cancer: a new therapeutic agent

Sir, because mouth ulceration has a wide range of causes, treatment is most likely to be effective if based on the diagnosis. Aphthous ulceration is common but generally poorly responsive to

antibiotics and antipyretics, and the range of agents trialled is testimony to their low efficacy.1 Some ulceration that clinically mimics aphthae is serious and the differential diagnosis

in a patient with oral ulceration and systemic lesions, such as genital ulceration, accompanied by fever, skin rashes and arthritis includes the possibility of aphthous-like ulceration2 such

as seen in Behcet syndrome3 or other auto-inflammatory diseases.2 These are disorders of innate immunity characterised by an exaggerated inflammatory response in the absence of

autoantibodies or any identifiable infection which manifest as recurring ulcers but closer scrutiny will reveal episodes of fever and systemic inflammation affecting other mucosae, skin and

joints – and with raised inflammatory markers such as the erythrocyte sedimentation rate.4 These disorders may show dramatic responses to systemic anti-inflammatory agents such as

corticosteroids, colchicine, thalidomide or biologics5 but unfortunately adverse effects – some serious – are possible with these agents. Now a new agent apremilast, currently used in

psoriasis, has appeared to give some hope at least in Behcet syndrome6 and has proved effective in treating oral ulcers, the cardinal manifestation of Behcet syndrome. Whether apremilast

could be beneficial in aphthous ulceration is unclear as yet but this possible advance, appearing in the medical literature, should also be flagged up to the dental world. Apremilast

specifically inhibits phosphodiesterase-4 inhibitor (PDE) that hydrolyses cyclic adenosine monophosphate (cAMP) within immune cells and thus modulates several inflammatory pathways and

inhibits spontaneous production of tumor necrosis factor-alpha (TNF). Inhibition of PDE4 blocks hydrolysis of cAMP, thereby increasing levels of cAMP within cells of the immune system and

CNS. Adverse effects may include weight loss and depression. More extensive evidence of efficacy in mouth ulceration is keenly awaited. REFERENCES * Baccaglini L, Lalla R V, Bruce A J et al.

Urban legends: recurrent aphthous stomatitis. _Oral Dis_ 2011; 17: 755–770. Article  Google Scholar  * Scully C . Aphthous ulceration. _N Engl J Med_ 2006; 355: 41–48. Article  Google

Scholar  * Case records of the Massachusetts General Hospital. (Case 7-2015.). _N Engl J Med_ 2015; 372: 864–872. * Scully C, Hodgson T, Lachmann H . Auto-inflammatory syndromes and oral

health. _Oral Dis_ 2008; 14: 690–699. Article  Google Scholar  * Ter H N, Lachmann H, Ozen S et al. Treatment of autoinflammatory diseases: results from the Eurofever Registry and a

literature review. _Ann Rheum Dis_ 2013; 72: 678–685. Article  Google Scholar  * Hatemi G, Melikoglu M, Tunc R et al. Apremilast for Behcet's syndrome — A phase 2, placebo-controlled

study. _N Engl J Med_ 2015; 372: 1510–1518. Article  Google Scholar  Download references AUTHOR INFORMATION AUTHORS AND AFFILIATIONS * Singapore A.N. Robinson * London C Scully Authors *

A.N. Robinson View author publications You can also search for this author inPubMed Google Scholar * C Scully View author publications You can also search for this author inPubMed Google

Scholar RIGHTS AND PERMISSIONS Reprints and permissions ABOUT THIS ARTICLE CITE THIS ARTICLE Robinson, A., Scully, C. Oral cancer: A new therapeutic agent. _Br Dent J_ 218, 557 (2015).

https://doi.org/10.1038/sj.bdj.2015.396 Download citation * Published: 22 May 2015 * Issue Date: 22 May 2015 * DOI: https://doi.org/10.1038/sj.bdj.2015.396 SHARE THIS ARTICLE Anyone you

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