[Nicorandil-induced giant lingual aphthosis in a patient with Behcet's disease]

BACKGROUND

Even in patients with Behçet's disease, disease, the development of severe aphthosis should suggest the possibility of a drug reaction.

CASE REPORT

We observed a case of giant lingual aphthosis that developed four months after adding microrandil to the regimen of a patient with Behçet's disease who had been treated with colchicine for 16 years. The aphthosis healed after withdrawal of nicorandil.

DISCUSSION

There have been 21 cases of nicorandil-induced buccal aphthosis reported in the literature. All healed at drug withdrawal. He delay between initiation of treatment of the stomatitis in most patients, the development of the aphthosis after increasing he nicorandil dose in two patients, its regression after reducing the dose in one and pathology date from biopsied cases suggest a dose-dependent toxic mechanism rather than an immunoallergic process is involved. To our knowledge, our case is the first reported with Behçet's disease. In our opinion, nicorandil should not be given to patients with Behçet's disease.

Role of drug exposure in aphthous ulcers: a case-control study

BACKGROUND

Drug-induced aphthous ulcers have been the subject of several isolated and heterogeneous case reports for the last three decades.

OBJECTIVES

To perform a case-control study to evaluate the risks linked to drug exposure in aphthous ulcers.

METHODS

Eighty patients with typical clinical patterns of aphthous ulcers and 152 control patients who had had consultations for skin tumours were studied. A standardized questionnaire, concerning clinical features, life-style and medications taken during the last month, was completed for each patient.

RESULTS

Case patients had a much higher intake of medications than control patients, respectively, 5.1 and 2. 8 medications per patient (P < 0.0001). Multivariate paired analysis showed an association between aphthous ulcers and two classes of drugs: non-steroidal anti-inflammatory drugs (P < 0.001) and beta-blockers (P = 0.002). Smoking could have a protective effect against aphthous ulcers (P < 0.001).

CONCLUSIONS

Previous case reports and the results of this study suggest a real link between beta-blockers and aphthous ulcers. Our study did not confirm a role of other drugs but a few interesting case reports with positive reintroduction have to be considered. These results could be beneficial for patients, as healing may occur when the incriminated drug is discontinued.

[Aphthae or painful ulcers induced by nicorandil]

A RECOGNIZED CAUSE OF BUCCAL APHTHOSIS: Nicorandil is the leading drug in a new pharmacology class of well tolerated anti-angina products with vasodilating action. The first cases of buccal aphthosis or ulcerations induced by nicorandil were reported in 1996. Among drugs inducing buccal aphthosis or ulcerations, the largest body of information available on reported cases concern nicorandil. CHARACTERISTIC LESIONS: Forty cases of painful buccal lesions induced by nicorandil have been recorded. Among the 8 publications in the literature, 7 were reported by French groups. The prevalence of this adverse effect is an estimated 5%. Patient age varies from 60 to 90 years with an even gender distribution. A history of aphthosis is noted in 23% of the cases. The lesions vary in size from 0.5 cm to 3 cm and in number from 1 to 10, generally localized on the inner aspect of the cheeks or on the tongue. The lesions develop for about 3 to 36 before diagnosis and the delay to onset of signs after initiating nicorandil treatment is 15 days to 24 months (generally 2 months). Lesions basically develop after high-dose treatments and, for a few cases, after increasing the dosage. Cure is obtained in all cases after 1 to 12 weeks.

OPEN QUESTIONS

The probability that nicorandil is the cause of these ulcerations or aphthae is very high. Certain terms do however need to be defined with precision. Are we talking about aphthae or ulcerations? The term painful ulceration would appear to be preferable because it includes both ulcerations and aphthae in cases lacking further information. The wide variability in the geographical distribution could likely be linked to underreporting. The notion of a dose effect suggests a toxic mechanism that could develop in predisposed populations (ethnic origin...) and would be directed against buccal targets (salivary glands...) via the active drug or its metabolites or via drug interactions. This new adverse effect of nicorandil is quite spectacular and very painful. However, no life-threatening event has been observed.

[Analysis of the literature about drug-induced aphthous ulcers]

OBJECTIVES

Analysis of the literature on drug-induced aphthous ulcers and mucosal ulcerations and evidence-based grading.

MATERIAL AND METHODS

Four literature sources were analyzed. Three groups of key words were used: 1) oral, buccal, genital, mucosal; 2) ulcer, ulceration, aphthous, aphthosis; 3) induced, drug, adverse-effects, with cross-overs. Four grading patterns were used: presence of aphthous term or synonym, typical clinical description of aphthous ulcer, presentation suggesting diagnosis of aphthous ulcer, criteria defining likelihood of drug causality.

RESULTS

We examined 66 of the 220 publications responding to our selection criteria. Typical clinical description of aphthous ulcer and/or clinical presentation suggesting the diagnosis of aphthous ulcer were noted for 8 compounds with likely or palausible patterns of causality. For 21 compounds, we found only aphthous term or synonym without a clinical description or presentation.

DISCUSSION

Our review of the literature individualized a group of 8 compounds where the diagnosis of aphthous ulcers was plausible and another group of 21 compounds where the diagnosis of aphthous ulcers requires confirmation. The clinical relevance and limitations of this analysis are discussed.

CONCLUSION

Drug-induced aphthosis is probably a real phenomenon. Causality of the 8 compounds in the first group is simply more fully documented than for the 21 compounds in the second group. A low evidence level may not confirm these hypotheses. Some drugs may have been incorrectly ruled out due to lack of information.

The effect of a sodium lauryl sulfate-free dentifrice on patients with recurrent oral ulceration

OBJECTIVE

Sodium lauryl sulphate (SLS) is the most commonly used detergent in dentifrices. Recent reports have suggested that it may exacerbate conditions with compromised epithelial integrity. The aim of this study was to compare the effect of an SLS-free dentifrice and an SLS-containing dentifrice on recurrent oral ulceration (ROU).

DESIGN

A double-blind crossover clinical trial was carried out during which subjects used an SLS dentifrice for 8 weeks and an SLS-free dentifrice for 8 weeks. Each phase was preceded by a 2-week washout period.

SETTING

A UK dental teaching hospital.

SUBJECTS AND METHODS

Forty-seven subjects completed the trial. They were all in the age range 10-62 years, had regularly recurrent oral ulceration reporting at least one to two ulcers per month and had normal levels of vitamin B12, ferritin and folate.

MAIN OUTCOME MEASURES

The trial phases were compared for the following ulcer parameters--number of ulcer days, total pain scores, number of ulcer episodes, and number of ulcers. Additional parameters compared were the number of ulcers per episode, ulcer duration, total pain per episode and ulcer size.

RESULTS

None of the ulcer parameters measured was significantly affected by the use of the SLS-free dentifrice as compared with the SLS dentifrice.

CONCLUSION

SLS-free dentifrice had no significant effect on ulcer pattern in the ROU study group.

[Oral aphthae induced by nicorandil. Anatomopathologic aspects. Apropos of a case]

Major apthous stomatitis induced by nicorandil is exceptional, the mechanism is still unknown and the histological aspect of these lesions have not been previously reported. Our case reports a man who was treated by nicorandil for coronary artery disease. He was referred for major aphtous stomatitis; one element was biopsied. The histological aspect was an aspecific sialadenitis, with granulous reaction, and without vasculitis or eosinophilic infiltration. We conclude that aphtous stomatitis induced by nicorandil could to be explain by a toxic effect, rather than a toxicallergic or immunologic mechanism.

Colorectal inflammation and increased cell proliferation associated with oral sodium phosphate bowel preparation solution

Evidence is emerging that sodium phosphate (NaP), a commonly used oral cathartic agent, causes aphthoid ulcers or focal active colitis (FAC) in the colon and rectum. The aims of this study were (1) to assess the incidence of such ulcers diagnosed endoscopically ("aphthoid ulcers"), (2) to assess the incidence of histologically detected FAC and neutrophilic infiltration overlying lymphoid follicles ("aphthoid lesions"), and (3) to determine whether this effect of NaP is associated with epithelial cell proliferation. Aphthoid ulcers, unexplained by other diagnoses, were found in 18 of 687 consecutive patients (2.6%) who underwent colonoscopic examination after oral NaP preparation during a 12-month period; biopsy specimens showed FAC or aphthoid lesions. FAC was present in 11 of 316 patients (3.5%) who had biopsies but were endoscopically normal. Eight patients with aphthoid ulcers in the rectosigmoid showed no abnormalities when reexamined by flexible sigmoidoscopy after an interval as short as 7 days (range, 7 to 56 days). Mucosal biopsy specimens from these patients were assessed for apoptosis and epithelial proliferation by determining the MIB-1 labeling index (LI). The LI was increased by 136% after NaP preparation (55 +/- 6) compared with biopsy specimens obtained from the same patients during reexamination without NaP preparation (23 +/- 6, P = .01). This correlated with the number of apoptotic bodies per 10 colonic crypts (1.2 +/- 0.3 v 0.5 +/- 0.2, respectively). To determine whether these proliferative changes represent a response to mucosal ulceration, rectosigmoid biopsy specimens were compared in two additional patient groups: an NaP group in whom no gross lesions were evident and a no-NaP group who were not exposed to NaP. Although more modest, similar changes in the LI (42 +/- 4 and 30 +/- 3, respectively, P = .03) and in the occurrence of apoptotic bodies per 10 colonic crypts (1.3 +/- 0.4 and 0.4 +/- 0.1, respectively) were observed. We conclude that use of NaP is associated with increased colorectal crypt epithelial cell proliferation. This proliferative response to NaP exposure is evident in the absence of colonoscopically or other histologically recognizable abnormalities. In a proportion of patients, aphthoid ulcers, FAC, or aphthoid lesions serve as markers of mucosal damage by NaP.

The effect of sodium lauryl sulfate on recurrent aphthous ulcers: a clinical study

This study measured the incidence of recurrent aphthous ulcers during the use of dentifrices with and without sodium lauryl sulfate (SLS). A single-blind, crossover design was used. A statistically significant reduction in recurrent aphthous ulcers was observed during 2 months' use of SLS-free dentifrice compared to 2 months' use of the SLS-containing dentifrice. These results support the results of an earlier independent study, and suggest that use of an SLS-free dentifrice should be considered for individuals suffering from recurrent aphthous ulcers.

Clearance of sodium lauryl sulphate from the oral cavity

Sodium lauryl sulphate (SLS) is used in toothpaste and mouth rinses as an emulsifying and surface cleaning agent. SLS has been implicated in an increased incidence of oral irritation in subjects predisposed to recurrent aphthous stomatitis (RAU). Hence, the purpose of this study was to determine the levels of SLS found in the oral cavity following rinsing with an SLS containing mouth rinse and brushing with a SLS containing dentifrice. An analytical method to separate SLS from saliva and other complex systems was developed. The method used high performance liquid chromatography (HPLC) and detection performed using conductivity measurements. Standard curves with known concentrations showed a detection limit of less than 0.4 ug SLS/ml of fluid. 2 clinical studies were conducted to determine the amount of SLS retained in the mouth by a healthy population after rinsing or brushing with commercially available products. The results showed, after rinsing, that 96% of the available SLS from the rinse was recovered in the collected samples within 2 min. Similarly, after brushing, 86% of the SLS contained within the toothpaste was recovered from the collected samples within the first 10 min. These results showed that the amount of SLS retained in the oral cavity was minimal and the contact time between SLS and the oral cavity was very short. A 2nd study was conducted to measure the amount of SLS retained in the mouth by a population susceptible to RAU. After rinsing, 97% of the available SLS was recovered within the first 2 min. Following brushing, 89% of the SLS in the dentifrice was recovered within the first 10 min. These results were comparable to those determined by the study involving the healthy population.

An association between recurrent oro-genital ulceration and non-steroidal anti-inflammatory drugs

Recurrent oro-genital ulceration is a common condition of unknown aetiology. This paper describes a patient who had severe recurrent oro-genital ulceration which was unresponsive to conventional therapy. The patient was taking non-steroidal anti-inflammatory drugs (NSAIDs) prescribed for osteoarthritis. When she stopped this medication, she had no further genital ulceration and the pattern of her oral ulceration was dramatically improved. There have been no previously reported cases of recurrent oro-genital ulceration associated with NSAIDs.

A clinical and biochemical assessment of methotrexate in rheumatoid arthritis

Low-dose methotrexate has gained widespread acceptance as a second-line agent in rheumatoid arthritis (RA). The Leeds Human Model Screening System (LHMSS) is a validated screening mechanism allowing the rapid evaluation of compounds for their potential as anti-rheumatic agents, the results of which have been confirmed in longer term studies. We have evaluated methotrexate in patients with RA using the LHMSS at a maintenance dose of 10mg/week. Significant change occurred in four out of eleven variables over a 24-week period (p < 0.01). This degree of change is greater than that seen with nonsteroidal anti-inflammatory agents but less than with other recognised second-line agents such as D-penicillamine, suggesting that methotrexate may have less potential as a second-line agent than D-penicillamine.

[Mercury sensitization in amalgam fillings. Assessment from a dermatologic viewpoint]

Epicutaneous tests were performed on 88 patients (27 men, 61 women; mean age 36.8 [18-68] years) thought to have an allergy against amalgam or mercury. In addition their oral mucosa was assessed clinically. The epicutaneous test was positive for mercury sensitization in seven patients, five of them reporting oral mucosa symptoms. Such symptoms also occurred, although less frequently, in non-sensitized patients (30 of 81). In three sensitized patients there was evidence of perioral dermatitis which in two of them cleared up after removal of the amalgam fillings. Two further patients had no further complaints, such as burning sensation on the oral mucosa, recurrent aphthous ulcers or gingivitis, after removal of amalgam fillings. In one patient each peroral eczema and diarrhoea aggravated after amalgam fillings had been taken out. These observations indicate that responses to mercury allergy are not uniform and show considerable individual variations. There is no reason to advise against or prohibit the use of amalgam fillings. Their substitutions by other materials may well bring about other types of allergy.

[Treatment of polycythemia vera with hydroxyurea or pipobroman. Efficacy and toxicity analysed from a protocol of 96 patients under 65 years of age. Le Groupe d'Etude des Polyglobulies]

Between 1980 and 1991, 96 patients with documented polycythemia vera were treated by hydroxyurea or pipobroman, according to a protocol including randomization, and maintenance therapy. Complete remission was induced in all cases. Two cases treated with hydroxy-urea had a very severe granulothrombocytopenia during the initial phase. Maintenance was generally satisfactory on pipobroman, but the platelet count often remained high (400 to 900.10(9)/l) on low-dosage hydroxy-urea, with a risk of vascular events. Progressive resistance to these drugs was observed in 5 cases. Digestive and cutaneous troubles were more frequent on pipobroman maintenance, sometimes enough to legitimate a therapeutic change. It may be concluded that such a treatment is less easy to use and to follow than is currently accepted. In the present series (397/years/patients follow-up, median 5-3 years), only one leukemia and one cancer were observed, which however only demonstrates the absence of any carcinogenic risk at short- but not at long-term.

Management of oral health in persons with HIV infection

Prevention and treatment of oral disease is required to maintain quality of life and to improve prognosis of patients infected with the human immunodeficiency virus (HIV). Management requires a team approach, and close collaboration with the appropriate responsible physicians and other health care workers is necessary. Oral infection is frequent and usually opportunistic, and management is based on certain principles. Infections may disseminate and can be persistent and severe; multiple concurrent or consecutive infections with different microorganisms are frequent; fungal, viral, and parasitic infections are rarely curable; and long-term antimicrobial therapy may be required. This article reviews the management of oral candidiasis, hairy leukoplakia, and infections with herpes simplex virus, varicella-zoster virus, and cytomegalovirus. The management of Kaposi's sarcoma, lymphomas, aphthous ulceration, gangrenous stomatitis, bleeding, xerostomia, and adverse drug reactions is also described. Treatment should avoid further immunosuppression and inducement of xerostomia or caries, and should be designed to avoid adverse drug reactions and possible drug interactions.

Oral ulceration and iatrogenic disease in HIV infection

Ulcerative lesions of oropharyngeal mucous membranes are less commonly seen than other lesions in HIV infection and may be associated with mycotic, bacterial, and viral infection, as well as neoplasia. Differential diagnosis may be difficult because of the clinical similarity of ulcerations that can represent various causes. The term "atypical ulceration" has been suggested because it may be impossible to differentiate some of the oral ulcerations from each other. Iatrogenic ulceration is seen occasionally, as the consequence of chemotherapy or irradiation.