Mucosal disease series. Number VI. Recurrent aphthous stomatitis

Impact of haematologic deficiencies on recurrent aphthous ulceration: a meta-analysis

BACKGROUND

Recurrent aphthous ulceration (RAU) is one of the most common oral mucosal diseases, some of which may be secondary to haematologic deficiencies. This meta-analysis aims to evaluate the association between haematologic deficiencies and RAU.

MATERIALS AND METHODS

Case control studies were identified using a predefined search strategy that compared the difference in haematologic deficiencies between a RAU group and a control group. A meta-analysis was performed to estimate the combined odds ratios (ORs) and 95% confidence intervals (95% CIs) in a fixed-effects model and a random-effects model, as appropriate.

RESULTS

In this meta-analysis, nine case control studies, including total 710 cases in RAU groups and 602 cases in control groups, were considered eligible for inclusion. Overall, the combined results based on all studies showed that the rate of haematinic deficiencies was significantly high in the RAU group (vitamin B12: OR=3.75, 95% CI: 2.38-5.94; folic acid: OR=7.55, 95% CI: 3.91-14.60; ferritin: OR=2.62, 95% CI: 1.69-4.06; and haemoglobin: OR=1.77, 95% CI: 1.12-2.80).

CONCLUSION

This meta-analysis suggests that haematologic deficiencies could be a significant risk factor for RAU. Thus, screening and treating any haematologic deficiencies may play an important role in preventing the occurrence of RAU.

Different modalities for treatment of recurrent aphthous stomatitis. A Randomized clinical trial

Background

The underlying etiology of recurrent aphthous stomatitis (RAS) is unclear and treatment aims to provide symptomatic and faster relief. This study compared the efficacy of diode laser, a herbal combination of Acacia nilotica and Licorice (A and L) and Amlexanox in the management of RAS.

Material and Methods

Sixty patients with minor aphthae were selected and randomly divided into four groups of 15 each. Group I and II received adhesive preparations of a herbal mixture of A and L and a 2 mg Amlexanox paste respectively, group III received diode laser and the fourth group (control) used a placebo. Ulcer size, pain score were recorded on days 1, 2 and 5.

Results

Laser group showed the statistically highest mean percentage (%) of reduction in pain scores and ulcer size than the other groups. The mean % of reduction in pain scores was 43.3+20.0 at day 2 and 67.8+21.5 % at day 5 in the laser group while Amlexanox group demonstrated a 29.8 +11.3 and 61.9+24.5 mean % of reduction in pain scores at day 2 and 5 respectively. A and L group showed a lower mean % of reduction in pain scores than laser and Amlexanox groups with a 22.2+10.5 and 43.4+15.8 mean % reduction in pain scores at day 2 and day 5 respectively. Similarly the highest mean % of reduction in ulcer size was seen in the laser group being 52.7+19.8 at day 2 and 85.1+22.0 at day 5, while it was 48.1+16.5 at day 2 and 77.8+28.7 at day 5 in the Amlexanox group and 42.0+11.5 at day 2 and 63.0+20.5 at day 5 in the A and L group.

Conclusions

All treatment modalities reduced pain and ulcer size than placebo group. Laser therapy demonstrated the highest percentage of reduction of pain score and ulcer size.

Key words:Aphthous stomatitis, laser, herbal plants, Acacia nilotica, Licorice.

Is Optimal Management of Recurrent Aphthous Stomatitis Possible? A Reality Check

Recurrent Aphthous Stomatitis (RAS) is a condition in which aphthous ulcers repeatedly occur in the oral cavity. It is prevalent in developed countries, occurring in all ages, geographic regions and races and about 80% of people have one episode of oral aphthous ulcers before the age of 30 years. With no laboratory procedures to confirm the diagnosis, treatment is mainly empirical in nature and focuses on short-term symptomatic management. Although numerous treatment modalities have been recommended, only a few are evidence based and can be considered for the optimal management of RAS. Biologic agents are a new category of drugs which acts by blocking specific pathways associated with the pathophysiology of neoplastic or immune-mediated diseases. These agents have targeted immunosuppressive or anti-inflammatory actions. In patients of RAS who were not responding to standard therapy, etanercept, adalimumab, infliximab and Interferon-Alpha (INF-α) were found to be useful. The objective of this review was to propose and review a treatment protocol to be followed for the optimal management of RAS. We reviewed several evidence-based studies and through this review we recommend topical interventions as the first-line of therapy since they are associated with low risk of systemic side effects. Due to limitations in the number of evidence-based trials and the insufficient data to support or refute the efficacy of the therapies prescribed, larger evidence-based clinical studies and literature reviews are needed to further improvise the optimal methodology for the effective management of RAS.

Assessment of serum interleukin-8 as a sensitive serological marker in monitoring the therapeutic effect of levamisole in recurrent aphthous ulcers: a randomized control study

AIM

The study was designed to evaluate the serum interleukin-8 (IL-8) levels in patients with recurrent aphthous ulcer (RAU) and monitor the immunomodulation and altered IL-8 levels by levamisole before therapy and after levamisole therapy.

MATERIALS AND METHODS

This study was carried as a randomized case-control study involving a study group of 30 patients diagnosed as RAUs and given levamisole (vermisole 150 mg, od for 1 st 3 days of 3 weeks in a month and for 3 months with a gap of 1 week) and these patients were recalled after 3 months and were subjected for estimation of serum IL-8 levels. Control group had 20 age and sex matched individuals with no systemic illness and were not given any levamisole. Good compliance was reported at the end of the study.

RESULTS

Mild gastric irritation was reported and when severe it was managed by H1 blocker. Patients were reviewed after 3 months. The follow-up data at each visit with respect to each other and to base-line values was calibrated using a Students t-test. Highly significant comparisons were obtained in the serum IL-8 between study and control groups before the onset of levamisole (t = 6.53, P ≤ 0.001). IL-8 levels reduced by 72% after levamisole was instituted in RAU patients and comparison was highly significant for before and after levamisole onset (t = 5.54, P ≤ 0.001).

CONCLUSION

This study points to the effectiveness of levamisole as an effective adjunct therapy in the routine management of RAU.

Oral pathology in inflammatory bowel disease

The incidence of inflammatory bowel diseases (IBD) - Crohn’s disease (CD) and ulcerative colitis (UC) - has been increasing on a global scale, and progressively, more gastroenterologists will be included in the diagnosis and treatment of IBD. Although IBD primarily affects the intestinal tract, extraintestinal manifestations of the disease are often apparent, including in the oral cavity, especially in CD. Specific oral manifestations in patients with CD are as follows: indurate mucosal tags, cobblestoning and mucogingivitis, deep linear ulcerations and lip swelling with vertical fissures. The most common non-specific manifestations, such as aphthous stomatitis and angular cheilitis, occur in both diseases, while pyostomatitis vegetans is more pronounced in patients with UC. Non-specific lesions in the oral cavity can also be the result of malnutrition and drugs. Malnutrition, followed by anemia and mineral and vitamin deficiency, affects the oral cavity and teeth. Furthermore, all of the drug classes that are applied to the treatment of inflammatory bowel diseases can lead to alterations in the oral cavity due to the direct toxic effects of the drugs on oral tissues, as well as indirect immunosuppressive effects with a risk of developing opportunistic infections or bone marrow suppression. There is a higher occurrence of malignant diseases in patients with IBD, which is related to the disease itself and to the IBD-related therapy with a possible oral pathology. Treatment of oral lesions includes treatment of the alterations in the oral cavity according to the etiology together with treatment of the primary intestinal disease, which requires adequate knowledge and a strong cooperation between gastroenterologists and specialists in oral medicine.

Serum zinc levels in 368 patients with oral mucosal diseases: A preliminary study

Background

The aim of this study was to assess the serum zinc levels in patients with common oral mucosal diseases by comparing these to healthy controls.

Material and Methods

A total of 368 patients, which consisted of 156 recurrent aphthous stomatitis (RAS) patients, 57 oral lichen planus (OLP) patients, 55 burning mouth syndrome (BMS) patients, 54 atrophic glossitis (AG) patients, 46 xerostomia patients, and 115 sex-and age-matched healthy control subjects were enrolled in this study. Serum zinc levels were measured in all participants. Statistical analysis was performed using a one-way ANOVA, t-test, and Chi-square test.

Results

The mean serum zinc level in the healthy control group was significantly higher than the levels of all other groups (p < 0.001). No individual in the healthy control group had a serum zinc level less than the minimum normal value. However, up to 24.7% (13/54) of patients with AG presented with zinc deficiency, while 21.2% (33/156) of patients with RAS, 16.4% (9/55) of patients with BMS, 15.2% (7/46) of patients with xerostomia, and 14.0% (8/57) of patients with OLP were zinc deficient. Altogether, the zinc deficiency rate was 19.02% (70/368) in the oral mucosal diseases (OMD) group (all patients with OMD). The difference between the OMD and healthy control group was significant (p <0.001). Gender differences in serum zinc levels were also present, although not statistically significant.

Conclusions

Zinc deficiency may be involved in the pathogenesis of common oral mucosal diseases. Zinc supplementation may be a useful treatment for oral mucosal diseases, but this requires further investigation; the optimal serum level of zinc, for the prevention and treatment of oral mucosal diseases, remains to be determined.

Key words:Oral mucosal diseases, Zinc deficiency, pathogenesis.

Acute oral ulcers

Accurate diagnosis of acute oral ulcers can be challenging. Important historic details include the pattern of recurrence, anatomic areas of involvement within the mouth and elsewhere on the mucocutaneous surface, associated medical symptoms or comorbidities, and symptomology. Careful mucocutaneous examination is essential. When necessary, biopsy at an active site without ulceration is generally optimal. Depending on the clinical scenario, supplemental studies that may be useful include cultures; perilesional biopsy for direct immunofluorescence testing; and evaluation for infectious diseases, gluten sensitivity, inflammatory bowel disease, human immunodeficiency virus infection, connective tissue diseases, or hematinic deficiencies. Clinicians should maintain a broad differential diagnosis when evaluating patients with acute oral ulcers.

Recurrent aphthous stomatitis

Recurrent aphthous stomatitis (RAS) is the most common acute oral ulcerative condition in North America. RAS is divided into a mild, common form, simple aphthosis, and a severe, less common form, complex aphthosis. Aphthosis is a reactive condition. The lesions of RAS can represent the mucosal manifestation of a variety of conditions. These include conditions with oral and genital aphthae such as ulcus vulvae acutum, reactive nonsexually related acute genital ulcers, and Behçet disease. The mouth is the beginning of the gastrointestinal (GI) tract, and the lesions of RAS can be a manifestation of GI diseases such as gluten-sensitive enteropathy, ulcerative colitis, and Crohn disease. Complex aphthosis may also have correctable causes. The clinician should seek these in a careful evaluation. Successful management of both simple and complex aphthosis depends on accurate diagnosis, proper classification, recognition of provocative factors, and the identification of associated diseases. The outlook for patients with both simple and complex aphthosis is positive.

Nicorandil, Gastrointestinal Adverse Drug Reactions and Ulcerations: A Systematic Review

INTRODUCTION

Nicorandil is a popular anti-anginal drug in Europe and Japan. Apart from some common adverse drug reactions (ADR), its safety is satisfactory. Several reports have suggested a link between nicorandil, gastrointestinal (GI) ulceration and fistulas. The review aims to critically appraise, synthesize and present the available evidence of all known GI ADR per anatomical location.

METHODS

The study complied with the PRISMA statement. Literature and pharmacovigilance databases were used to provide rate and/or calculate parameters (median age, median dose, history of symptoms, length of therapy and healing time after withdrawal of the drug). Differences in distribution of quantitative variables were analyzed via Mann-Whitney test. Correlation between quantitative variables was assessed with a Spearman's correlation coefficient. A p value <0.05 was significant.

RESULTS

Oral ulcerations occur in 0.2% of the subjects, anal ulcerations are present between 0.07% and 0.37% of patients. Oral and distal GI involvements are the most common ADR (28-29% and 27-31% of all GI ADR, respectively). The hepatobiliary system, the pancreas and salivary glands are not affected by nicorandil exposure. The time to develop oral ulcerations is 74 weeks among people on <30 mg/day compared to only 7.5 weeks in individuals on higher regimens (p = 0.47). There is a significant correlation between dose and ulcer healing time (Spearman's 0.525, p < 0.001).

CONCLUSIONS

Ulcerative disease is a very commonly reported GI ADR. A delayed ulcerative tendency supports the hypothesis of an ulcerogenic metabolite. Nicorandil seems to act as a cause of the ulcerations, but appears to also work in synergy with other promoting factors. Whether the action of the metabolites relies on a specific mechanism or a simple chemical ulceration is still to be established.

[Aphthous ulcers and oral ulcerations]

Aphthous ulcers are painful ulcerations located on the mucous membrane, generally in the mouth, less often in the genital area. Three clinical forms of aphthous ulcers have been described: minor aphthous ulcers, herpetiform aphthous ulcers and major aphthous ulcers. Many other conditions presenting with oral bullous or vesiculous lesions orulcerations and erosions can be mistaken for aphthous ulcers. Currently, treatment of aphthous ulcers is palliative and symptomatic. Topical treatments (topical anesthetics, topical steroids and sucralfate) are the first line therapy. Recurrent aphthous stomatitis (RAS) is defined by the recurrence of oral aphthous ulcers at least 4 times per year. RAS is often idiopathic but can be associated with gastro-intestinal diseases (i.e. celiac disease, inflammatory bowel diseases), nutritional deficiencies (iron, folates...), immune disorders (HIV infection, neutropenia) and rare syndromes. Behçet's disease is a chronic, inflammatory, disease whose main clinical feature is recurrent bipolar aphthosis. Colchicine associated with topical treatments constitutes a suitable treatment of most RAS. Thalidomide is the most effective treatment of RAS but its use is limited by frequent adverse effects. Oral ulcers can be related to a wide range of conditions that constitute the differential diagnoses of aphthous ulcers. Oral ulcers are classified into three main groups: acute ulcers with abrupt onset and short duration, recurrent ulcers (mainly due to postherpetic erythema multiforme) and chronic ulcers (with slow onset and insidious progression). Acute oral ulcers are due to trauma, bacterial infections (including acute necrotizing ulcerative gingivitis), deep fungal infection, gastro-intestinal (namely inflammatory bowel disease) or systemic diseases. Chronic oral ulcers may be drug-induced, or due to benign or malignant tumors. Every oral solitary chronic ulcer should be biopsied to rule out squamous cell carcinoma. A solitary palatal ulcer can be related with necrotizing sialometaplasia.

The safety and efficacy of AphtoFix® mouth ulcer cream in the management of recurrent aphthous stomatitis

Background

Recurrent Aphthous stomatitis (RAS) is a prevalent ulcerative and painful disorder of the oral cavity with unknown etiology and for which no efficient treatment is currently available.

The present study aimed to evaluate the safety and the efficacy of AphtoFix®, a new mouth ulcer cream that was developed to help treat RAS. Prior to launching the product on the market, two initial safety assessment studies were performed.

Subjects and methods

In a first study, the in vitro biocompatibility of AphtoFix® was evaluated on reconstructed human gingival tissue models according to ISO guidelines 10993. In a second study, the tolerability of AphtoFix® was evaluated in 20 subjects during a 4-weeks daily application in the mouth. The third study investigated both the safety and efficacy of AphtoFix® treatment on 19 patients suffering from RAS. This study was done in compliance with the Helsinki Declaration.

Results

The results of in vitro biocompatibility study showed that AphtoFix® mouth ulcer cream did not induce any detectable cytotoxicity and irritation. These observations were confirmed in the 4 weeks tolerability study where no undesired of adverse reactions were noticed. The results of the post-market clinical efficacy study demonstrated a clear reduction in ulcer size from baseline after 3 days treatment (p < 0.05). Pain intensity reduction was also observed in all subjects.

Conclusion

The application of AphtoFix® did not induce any undesired skin or mucosa reactions. These initial findings demonstrate that AphtoFix® is safe and efficient in reducing ulcer size and decreasing the pain intensity induced by ulcers.

Trial registration

Clinical trial Registry India Nr. CTRI201408004918, Date of registration: 22/08/2014

Electronic supplementary material

The online version of this article (doi:10.1186/s12903-016-0177-0) contains supplementary material, which is available to authorized users.

Oral Ulceration: An Overview of Diagnosis and Management

Mouth ulcers are a common complaint by patients, with individuals regularly presenting to primary care practitioners for diagnosis and treatment. The aetiology and pathogenesis of oral ulceration is, however, both varied and complex. This article highlights the importance of differentiating recurrent aphthous stomatitis (RAS) in otherwise healthy individuals from recurrent oral ulceration (ROU) secondary to known or unknown systemic disease. An overview of the diagnosis and management of such patients is provided as a framework to guide general dental practitioners' with clinical decision making on whether to treat or refer to secondary care.

Quality of life in patients with recurrent aphthous stomatitis treated with a mucoadhesive patch containing citrus essential oil

PURPOSE

To assess 1) patient satisfaction of a mucoadhesive biopatch with citrus essential oil and 2) the change in pain severity and the oral health-related quality of life in patients with recurrent aphthous stomatitis.

PATIENTS AND METHODS

Thirty-seven patients with recurrent aphthous stomatitis participated in the study. Baseline records of personal data, ulcer assessment, visual analog scale, and Oral Health Impact Profile-14 were documented. A mucoadhesive patch was applied over the ulcer. Patients were recommended more applications if pain continued. On the fifth day, a post-therapy assessment was made.

RESULTS

The mean visual analog scale scores at baseline and posttreatment were significantly different (7.3±2.11 and 4.9±2.6, respectively; P=0.001). The mean duration of pain reduced after patch application. The mean total Oral Health Impact Profile-14 scores before and after treatment showed a statistically significant difference (P=0.001). In total, 78.4% of patients reported a considerable improvement in oral functions after treatment (P=0.008).

CONCLUSION

The mucoadhesive biopatch containing citrus essential oil resulted in satisfying pain alleviation and restoration of oral functions with a significant improvement in the oral health-related quality of life.

Low-level laser therapy versus 5% amlexanox: a comparison of treatment effects in a cohort of patients with minor aphthous ulcers

OBJECTIVE

The aim of the study was to compare the treatment effects of 5% amlexanox and low-level laser therapy (LLLT) in a cohort of patients who experienced minor aphthous stomatitis.

STUDY DESIGN

A clinical trial was performed between 2012 and 2014 on 50 participants having minor aphthous ulcers. Group A participants were treated with amlexanox oral paste (lexanox 5% oral paste), and group B participants were treated with LLLT. Pain scores and sizes of ulcers were measured on the first, third, and seventh days of treatment in both groups. Data were analyzed using paired t test and independent t test.

RESULTS

No significant difference was observed between the two groups with respect to pain level on the first and seventh days of treatment.

CONCLUSIONS

Both amlexanox and LLLT were equally effective in relieving pain associated with minor aphthous stomatitis. Both groups showed significant reduction in ulcer sizes and in pain scores.

Management of Recurrent Aphthous Stomatitis in Children

Recurrent oral ulceration is common and may present in childhood. Causes of recurrent oral ulceration are numerous and there may be an association with underlying systemic disease. Recurrent aphthous stomatitis (RAS) is the most common underlying diagnosis in children. The discomfort of oral ulcers can impact negatively on quality of life of a child, interfering with eating, speaking and may result in missed school days. The role of the general dental practitioner is to identify patients who can be treated with simple measures in primary dental care and those who require assessment and treatment in secondary care. Management may include topical agents for symptomatic relief, topical corticosteroids and, in severe recalcitrant cases, systemic agents may be necessary.

Highly sensitive method for simultaneous determination of nine alkaloids of Shuanghua Baihe tablets in human plasma by LC-MS/MS and its application

Shuanghua Baihe tablets (SBT) is a traditional Chinese medicinal formula which has been used to treat recurrent aphthous stomatitis for many years. To study the pharmacokinetic profiles of berberine, epiberberine, coptisine, palmatine, jatrorrhizine, magnoflorine, berberrubine, corynoline and acetylcorynoline in human after administration of SBT, a sensitive liquid chromatography-tandem mass spectrometry method was developed and fully validated for the simultaneous quantification of these nine alkaloids in human plasma. After protein precipitation, the nine alkaloids in human plasma sample was separated on a Hanbon C18 (150mm×2.1mm, 5μm) column with gradient elution using methanol and 0.5% formic acid water solution, and detected by a triple quadrupole mass spectrometer with an electrospray ionization source. It is a challenge to design different calibration ranges for different analytes in a bioanalytical method for simultaneous determination of multi-analytes in bio-samples. To ensure that each alkaloid in the plasma was determined accurately by the simultaneous quantitation method, the upper limits of quantification for the nine alkaloids were designed at 100, 300, 800, 1800 and 5000pg/mL, respectively, according to the maximum plasma concentration value of each alkaloid obtained from the pilot pharmacokinetic study. The lower limit of quantification was 15pg/mL for berberine, epiberberine, coptisine, magnoflorine, berberrubine, corynoline and acetylcorynoline, while for palmatine and jatrorrhizine it was 1.5pg/mL. This method was successfully applied to investigate the pharmacokinetic profiles of the nine alkaloids in healthy Chinese volunteers after a single oral administration of SBT.

Enhanced mucosal healing with curcumin in animal oral ulcer model

OBJECTIVES/HYPOTHESIS

Oral ulcers are very common and can compromise the quality of life of patients with pain. The objective of this study was to evaluate mucosal healing with curcumin in an animal oral ulcer model.

STUDY DESIGN

Experimental study.

METHODS

Twenty New Zealand white rabbits were used. Round filter paper 6 mm in diameter was soaked with 15 μl 50% acetic acid and applied over the upper labial gingiva, creating a uniform circular ulcer. After creation of an oral ulcer, curcumin, the active substance in tumeric, was applied twice over the ulcer in the experimental group but not in the control group. The ulcer area was calculated by maximal (D) and minimal (d) diameter : π × D × d/4. All animals were weighed, and the area was measured on days 0, 7, and 14. On days 7 and 14, half of the animals were sacrificed and gingival specimens were acquired.

RESULTS

Curcumin treatment exhibited accelerated healing such that the gross appearance of the ulcer demonstrated a recognizable difference in wound healing between the curcumin-treated and control groups with time. Weight loss was observed after the creation of oral ulcer in the control group. However, the curcumin-treated group gained weight with time, resulting in a significant weight difference. On day 14, epithelial regeneration was completed in the treated group but incomplete in the control group.

CONCLUSION

Topical application of curcumin enhanced the wound-healing process of oral ulcer in the animal model, which implicate that curcumin can be used as an effective and safe medical tool in the treatment of oral ulcer.

LEVEL OF EVIDENCE

NA.

Presence and distribution of dental enamel defects, recurrent aphthous lesions and dental caries in children with celiac disease

Objective:

To determine presence and distribution of enamel defects, recurrent oral aphthous lesions (RAS) and dental caries in children with Celiac Disease (CD) and compare the results with a healthy control group.

Methods:

Twenty- five CD patients age between 4- 16 years with no other systemic disease, were examined in Pediatric Gastroenterology Clinic of Erciyes University, Faculty of Medicine (Kayseri, Turkey) and then referred to Department of Pediatric Dentistry, Faculty of Dentistry for dental examination and treatment. The control group (25 patients) consisted healthy patients referred to the Department of Pediatric Dentistry, Faculty of Dentistry, Erciyes University for restorative treatment. Both the CD group and control group was examined by the same investigator for the following; (1) enamel defects, (2) recurrent aphthous stomatitis, (3) dental caries.

Results:

The mean dmft values for the CD group and control group were 3.25±3.25 and 4.56±2.87 respectively. The difference was not statistically significant.(P>0.05). The mean DMFT values for the CD and the control group were 3.75±2.62 and 1.83±1.7, respectively. There was a significant difference between the two groups (P<0.01). The prevalence of enamel defects and recurrent apthous stomatitis (RAS) was greater in celiac patients than in the control group. Enamel defects (in at least one permanent tooth) were observed in 12 out of 25 (48%) children in the CD group and four out of 25 children (16%).(P =0.01). Recurrent apthous stomatitis was found in 11/25 (44%) CD group, while no RAS was detected in the control group.

Conclusion:

Celiac Disease (CD) has adverse effects on oral health in term of enamel defect, recurrent aphthous stomatitis and caries score. Pediatricians and dentists especially pediatric dentists should be knowledgeable about oral symptoms of CD. Increased awareness can provide an early diagnosis and prevent long- term complications of this disease. On the other hand, further comprehensive investigations of CD patients can add to our understanding of the efficacy of CD on oral health in children.

Recurrent Aphthous Stomatitis in Childhood and Adolescence: A Single-Center Experience

BACKGROUND

Recurrent aphthous stomatitis (RAS) is a common oral ulcerative condition in children. The objective was to describe the clinical features of RAS in children with accompanying clinical and laboratory findings.

METHODS

The study included 120 patients younger than 18 years of age (mean age 9.6 ± 4.3 years) with three or more oral aphthous ulcers per year between August 2008 and February 2014. Demographic characteristics of the patients, clinical features of the ulcers, and associated clinical and laboratory findings were evaluated.

RESULTS

The mean number of aphthae per year was 12.8 ± 8.5 and the mean duration of the disease was 3.6 ± 2.9 years. Minor aphthae were the most common type (87%), papulopustules were the most common accompanying cutaneous lesions (13.3%), and family history of RAS was the most common associated factor (35.8%). Genital scarring (p = 0.04) and pathergy (p = 0.01) were significantly more common in the adolescent group. Pathergy was significantly related to genital scarring (p = 0.04) and Behçet's disease (p = 0.02). There was no association between the number of aphthae per year and the duration of the disease and hematologic and immunologic abnormalities.

CONCLUSION

Our study is consistent with previous reports in terms of clinical features of aphthous ulcers, related diseases, and family history of RAS, but no associated laboratory abnormalities were noted.

Detection of salivary interleukin-2 in recurrent aphthous stomatitis

OBJECTIVE

The present study was undertaken to estimate and compare salivary interleukin-2 (IL-2) levels in patients with recurrent aphthous stomatitis, among healthy controls and their variation with age and sex.

STUDY DESIGN

Saliva was collected from 60 patients within the age range of 16-60 years which included 30 patients (17 Females and 13 Males) with recurrent aphthous stomatitis and healthy control group consisted of 30 participants (18 Females and 12 Males). IL-2 estimation was done in both the groups using enzyme linked immunosorbent assay (ELISA). Statistical analysis of the data was done using Independent 't' test.

RESULTS

The results showed increased salivary IL-2 levels in patients with recurrent aphthous stomatitis compared to the healthy controls. The IL-2 levels were also increased in patients with the age group of 16-30 years compared to other age groups. Similar increase of IL-2 was also seen in female patients.

CONCLUSION

Age related and sex related alterations of IL-2 in recurrent aphthous stomatitis patients were observed.

"Ozone" - the new NEMESIS of canker sore

BACKGROUND

Recurrent aphthous ulceration or recurrent aphthous stomatitis is one of the most debilitating and painful oral mucosal disease. This disease entity has no specific cause to occur and no proper laboratory procedures are present to elicit the diagnosis. The treatment options are largely palliative and aimed at reducing symptoms thereby improving patient's oral condition. In the present study the subjects witnessed alleviation of clinical symptoms related to the aphthous ulceration.

AIMS AND OBJECTIVES

The aim of the study was to explore the effectiveness of ozonated oil in the treatment of recurrent aphthous ulcer and to compare with sessame oil in order to analyse the effectiveness between the two topical oil medications.

MATERIALS AND METHODS

A single-blinded placebo-controlled trial comprising of 30 subjects with recurrent aphthous ulcers were divided into Group 1, Group 2 and Group 3 with 10 subjects in each group was performed. Patients in Group 1 received ozonated oil, Group 2 received sesame oil and Group 3 received placebo. Treatment response was assessed by measures of pain reduction, ulcer duration on 2(nd), 4(th) and 6(th) day. Data were analyzed using Wilcokson signed rank test and Friedman test.

RESULTS

Participants treated with ozonated oil showed significant reduction in ulcer size, erythema and also alleviated the ulcer pain on 4(th) day of evaluation when compared to sesame oil and placebo group. On 6(th) day subjects treated with ozonated oil and sesame oil showed significant reduction in ulcer size and erythema. No significant difference was observed in placebo group when compared with other two groups on subsequent 2(nd), 4(th) and 6(th) day of evaluation.

CONCLUSION

Ozonated oil and sessame oil, both showed similar effectiveness in relieving the ulcer pain. Ozone with its wide variety of inherent properties has proven to be choice of treatment in completely relieving the ulcer pain and ulcer size when compared with that of its counter medication (i.e. sesame oil).Therefore the results obtained in the present study forecast ozone to be used as a novel treatment approach in recurrent aphthous ulcers.

Recurrent aphthous ulcers among tobacco users- hospital based study

CONTEXT

Current evidence shows ambiguous relationship between tobacco use and the occurrence of aphthous.

OBJECTIVES

We studied the relationship between the occurrence of recurrent aphthous ulcers and various forms of tobacco usage.

MATERIALS AND METHODS

A hospital based case control study was carried out in a dental teaching hospital in Cochin, India. One hundred and two outpatient subjects (Males 56.9%) were identified having aphthous ulceration using Natha's diagnostic criteria and were classified as cases. One hundred and eight subjects (Males, 70.4%) with no aphthous ulceration were selected randomly as controls. Exposure ascertainment of tobacco usage was done by structured interview.

RESULTS

The adjusted odd ratio was found to be 0.41 (95% CI 0.19-0.87) for tobacco usage and occurrence of aphthous ulceration compared to non tobacco users. The odds ratio of 0.41 for tobacco usage infers that subjects using tobacco were 59% less likely to have aphthous ulcerations compared to nontobacco users.

CONCLUSION

The tobacco consumers have less frequency of aphthous ulceration compared non users.

Levamisole and low-dose prednisolone in the treatment of reccurent aphthous stomatitis

CONTEXT

Recurrent aphthous stomatitis (RAS) is the most common oral mucosal disease. However, the available therapies for RAS only relieve symptoms and do not provide a cure.

AIMS

This study assessed the response to treatment with levamisole and low-dose prednisolone drug combination in patients with RAS.

METHODS AND MATERIAL

Fifty RAS subjects were enrolled in the single-blind randomized placebo-controlled trial. Study medications were administered thrice daily for 3 consecutive days/week for 3 consecutive weeks. Patients in Group 1 received placebo, Group 2 received levamisole (50 mg) and Group 3 received levamisole (50 mg) and low-dose prednisolone (5 mg). Patients were followed up for 60 days after treatment. Response to treatment was assessed using the following clinical parameters: pain due to ulcers, number of ulcers/episode, size of ulcers, duration of ulcers, and frequency of ulcers (episodes/month).

STATISTICAL ANALYSIS USED

Mann–Whitney U-test.

RESULTS

A statistically significant improvement was noted in all parameters except for the size of ulcers in patients treated with levamisole alone and with combination of levamisole and low-dose prednisolone. There was no statistically significant improvement in the placebo group. Both active groups had significantly better improvement when compared to placebo group, while there was no significant difference between the two active groups.

CONCLUSIONS

Levamisole alone and combination of levamisole and low-dose prednisolone are effective modes of therapy for RAS.

Mucosal microbiome in patients with recurrent aphthous stomatitis

Recurrent aphthous stomatitis (RAS) is the most common disease affecting oral mucosae. Etiology is unknown, but several factors have been implicated, all of which influence the composition of microbiota residing on oral mucosae, which in turn modulates immunity and thereby affects disease progression. Although no individual pathogens have been conclusively shown to be causative agents of RAS, imbalanced composition of the oral microbiota may play a key role. In this study, we sought to determine composition profiles of bacterial microbiota in the oral mucosa associated with RAS. Using high-throughput 16S rRNA gene sequencing, we characterized the most abundant bacterial populations residing on healthy and ulcerated mucosae in patients with RAS (recruited using highly stringent criteria) and no associated medical conditions; we also compared these to the bacterial microbiota of healthy controls (HCs). Phylum-level diversity comparisons revealed decreased Firmicutes and increased Proteobacteria in ulcerated sites, as compared with healthy sites in RAS patients, and no differences between RAS patients with healthy sites and HCs. Genus-level analysis demonstrated higher abundance of total Bacteroidales in RAS patients with healthy sites over HCs. Porphyromonadaceae comprising species associated with periodontal disease and Veillonellaceae predominated in ulcerated sites over HCs, while no quantitative differences of these families were observed between healthy sites in RAS patients and HCs. Streptococcaceae comprising species associated with oral health predominated in HCs over ulcerated sites but not in HCs over healthy sites in RAS patients. This study demonstrates that mucosal microbiome changes in patients with idiopathic RAS--namely, increased Bacteroidales species in mucosae of RAS patients not affected by active ulceration. While these changes suggest a microbial role in initiation of RAS, this study does not provide data on causality. Within this limitation, the study contributes to the understanding of the potential role of mucosal microbiome changes in oral mucosal disease.

Efficacy of rebamipide and levamisole in the treatment of patients with recurrent aphthous ulcer - a comparative study

Context (Background): Recurrent aphthous stomatitis is an inflammatory condition of unknown aetiology characterized by painful recurrent, single or multiple ulcerations of the oral mucosa.

AIMS

To compare the efficacy of rebamipide, a gastro-protective agent and levamisole, an immunomodulating agent in the treatment of recurrent aphthous stomatitis.

MATERIALS AND METHODS

Hundred patients diagnosed with recurrent aphthous stomatitis were enrolled in the study. Fifty patients were assigned randomly to each of the two treatment groups. After the clinical diagnosis and ulcer measurement, a subjective evaluation of symptoms was done for each subject. Both the drugs were given orally at specified intervals. Ulcer measurements and subjective evaluations were made at day one.

STATISTICAL ANALYSIS

Analysis was done using various test like Mann Whitney and t-test.

RESULTS AND CONCLUSION

The overall results showed mean number of episodes whose values were not statistically significant (p=0.43), neither were the mean number of ulcers (p=0.75), or values for mean size of ulcers (p=0.91). However, the overall results suggested that efficacy of rebamipide is almost same as that of the efficacy of previously proved drug levamisole. The current study with a three months follow up, including patients with high scores of pain, aphthae count, ulcer size and frequency of occurrence showed better results in both the study groups. However, rebamipide is suggested to be well tolerated and may therefore be useful in the treatment and prevention of frequently recurrent aphthous ulcers not restricted to Behcet's disease.

Prescribing for mucosal disease in primary dental care

Oral mucosal disease has a variety of causes, some of which are due to dysfunction of the immune system. Recurrent aphthous stomatitis and oral lichen planus are the mucosal diseases of unknown cause seen most frequently in dental practice, and the most likely mucosal diseases for which a dentist will prescribe. This paper briefly reviews the clinical features of these conditions, their causation and pertinent information for managing them in a primary care setting. The prescribing of appropriate medications to treat the conditions in a general dental practice is described and discussed.

The oral microbiota of patients with recurrent aphthous stomatitis

BACKGROUND

Specific pathogenic bacteria have been implicated in recurrent aphthous stomatitis (RAS), a chronic inflammatory condition characterised by ulcerations in the oral mucosa. However, the aetiology behind this condition still remains unclear.

OBJECTIVE

The buccal microbiota of patients with RAS was compared to that of control subjects to investigate its potential role for this condition.

DESIGN

Buccal swabs were obtained from non-ulcerative areas of 60 patients, of whom 42 patients had lesions at the time of sampling, and 60 healthy age- and gender-matched controls. Bacterial DNA was extracted and analysed by Terminal-Restriction Fragment Length Polymorphism, using enzymatic digestion of the polymerase chain reaction-amplified 16S rRNA gene, yielding a series of peaks, each representing a bacterial taxon.

RESULTS

Two peaks, 60 and 489, were more prevalent in patients with RAS than controls. Conversely, peaks 58 and 490 were less common in patients than controls. When the patients were divided into subgroups, we found that the observed differences in peak-pattern were related to the presence of lesions during sampling.

CONCLUSIONS

The microbiota of the non-inflamed buccal mucosa differed between patients and controls. The differences were most pronounced in patients who presented with lesions during sampling, suggesting that a disturbance in the normal buccal microbiota triggers the presence of lesions or that presence of lesions alters the microbiota.

The treatment of chronic recurrent oral aphthous ulcers

BACKGROUND

Chronic recurrent oral aphthous ulcers are the most common type of inflammatory efflorescence of the oral mucosa, with a prevalence of 2% to 10% in Caucasian populations. To treat them properly, physicians should know their clinical appearance and course, conditioning factors, underlying causes, and differential diagnosis.

METHOD

This review is based on pertinent articles that were retrieved by a selective search in PubMed and in the Cochrane Central Register of Controlled Trials.

RESULTS

Hard, acidic, and salty foods and toothpastes containing sodium lauryl sulfate should be avoided, along with alcohol and carbonated drinks. In Germany, the only drugs that have been approved to treat oral aphthous ulcers are corticosteroids, topical antiseptic/anti-inflammatory agents such as triclosan and diclofenac, and local anesthetics such as lidocaine. Antiseptic agents and local anesthetics should be tried first; if these are ineffective, topical cortico steroids should be used. In severe cases, local measures can be combined with systemic drugs, e.g., colchicine, pentoxifylline, or prednisolone. The efficacy of systemic treatment is debated. Other immunosuppressive agents should be given systemically only for refractory or particularly severe oral aphthous ulcers due to Adamantiades-Behçet disease.

CONCLUSION

The treatment of chronic recurrent oral aphthous ulcers is symptomatic, mainly with topically applied agents. It is tailored to the severity of the problem in the individual case, i.e., the frequency of ulcers, the intensity of pain, and the responsiveness of the lesions to treatment. Effective treatment relieves pain, lessens functional impairment, and lowers the frequency and severity of recurrences.

Interventions for the management of oral ulcers in Behçet's disease

BACKGROUND

Behçet's disease is a chronic inflammatory vasculitis that can affect multiple systems. Mucocutaneous involvement is common, as is the involvement of many other systems such as the central nervous system and skin. Behç̧et's disease can cause significant morbidity, such as loss of sight, and can be life threatening. The frequency of oral ulceration in Behçet's disease is thought to be 97% to 100%. The presence of mouth ulcers can cause difficulties in eating, drinking, and speaking leading to a reduction in quality of life. There is no cure for Behçet's disease and therefore treatment of the oral ulcers that are associated with Behçet's disease is palliative.

OBJECTIVES

To determine the clinical effectiveness and safety of interventions on the pain, episode duration, and episode frequency of oral ulcers and on quality of life for patients with recurrent aphthous stomatitis (RAS)-type ulceration associated with Behçet's disease.

SEARCH METHODS

We undertook electronic searches of the Cochrane Oral Health Group Trials Register (to 4 October 2013); the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2013, Issue 9); MEDLINE via Ovid (1946 to 4 October 2013); EMBASE via Ovid (1980 to 4 October 2013); CINAHL via EBSCO (1980 to 4 October 2013); and AMED via Ovid (1985 to 4 October 2013). We searched the US National Institutes of Health trials register (http://clinicaltrials.gov) and the World Health Organization (WHO) Clinical Trials Registry Platform for ongoing trials. There were no restrictions on language or date of publication in the searches of the electronic databases. We contacted authors when necessary to obtain additional information.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) that looked at pre-specified oral outcome measures to assess the efficacy of interventions for mouth ulcers in Behçet's disease. The oral outcome measures included pain, episode duration, episode frequency, safety, and quality of life. Trials were not restricted by outcomes alone.

DATA COLLECTION AND ANALYSIS

All studies meeting the inclusion criteria underwent data extraction and an assessment of risk of bias, independently by two review authors and using a pre-standardised data extraction form. We used standard methodological procedures expected by The Cochrane Collaboration.

MAIN RESULTS

A total of 15 trials (n = 888 randomised participants) were included, 13 were placebo controlled and three were head to head (two trials had more than two treatment arms). Eleven of the trials were conducted in Turkey, two in Japan, one in Iran and one in the UK. Most trials used the International Study Group criteria for Behçet's disease. Eleven different interventions were assessed. The interventions were grouped into two categories, topical and systemic. Only one study was assessed as being at low risk of bias. It was not possible to carry out a meta-analysis. The quality of the evidence ranged from moderate to very low and there was insufficient evidence to support or refute the use of any included intervention with regard to pain, episode duration, or episode frequency associated with oral ulcers, or safety of the interventions.

AUTHORS' CONCLUSIONS

Due to the heterogeneity of trials including trial design, choice of intervention, choice and timing of outcome measures, it was not possible to carry out a meta-analysis. Several interventions show promise and future trials should be planned and reported according to the CONSORT guidelines. Whilst the primary aim of many trials for Behç̧et's disease is not necessarily reduction of oral ulceration, reporting of oral ulcers in these studies should be standardised and pre-specified in the methodology. The use of a core outcome set for oral ulcer trials would be beneficial.

Infliximab for refractory oral ulcers

Recurrent oral ulcer (ROU) is a common condition that significantly impacts quality of life. It is often related to systemic diseases, such as Behçet's disease (BD), Crohn's disease, and ulcerative colitis. Treatment of ROU depends on its severity: from topical agents for mild cases to systemic agents, such as corticosteroids, azathioprine, or other immunosuppressants for severe cases. Recently, good results have been reported with infliximab in refractory ROU. However, the optimal dosage and treatment duration have not been determined and the cost and potential side effects should be considered. We report on four patients who received a single-dose infliximab for refractory ROU. Two patients had refractory ROU with no underlying disease; one of them had soft palate perforation accompanied by severe oral ulcers. The two other patients had ROU of BD without major organ involvement. All patients received a single infusion of infliximab and an additional infusion was given on demand in one patient. Infliximab showed a rapid, good response in three patients and was also effective in improving the acute inflammation in the perforation of the soft palate, which had been resistant to conventional therapies. These effects diminished over a few weeks, but the ROU were tolerable and it was not necessary to increase steroids or add another medicine for about 1 year. We suggest that a single infusion of infliximab can be considered for refractory ROU.

Prevalence of recurrent aphthous ulceration in the Indian Population

Objective: Patients with an oral ulcer may present initially to a general physician or a dental practitioner. Majority of the ulcers are benign and resolve spontaneously but small proportions are malignant. The aim of the present study was to determine the prevalence of recurrent aphthous ulcerations in the Indian population. Material and Methods: 3244 patients attending the Department of Oral Medicine and Radiology during the period from November, 2010 to December, 2012 with various complaints were examined. Of the patients examined 1669 were females and 1575 were males. Results: 705 patients presented with recurrent aphthous ulceration (21.7%). Females (56.3%) were more commonly affected than males (43.7%). Patients in the third and fourth decade were most commonly affected. Stress was the most common factor associated with recurrent aphthous stomatitis (386 patients). 54.5% patients did not take any medications and 72.9% patients opined that the condition needed no dental consultation. Conclusion: The results of the present study indicate that recurrent aphthous ulceration is a common mucosal disorder in the Indian population. The early and proper diagnosis of the ulcers will help the dental practitioner in providing information to the patient regarding awareness and management of the condition.

Key words:Recurrent aphthous ulcers, prevalence, Indian population.

Recurrent aphthous stomatitis

Recurrent aphthous stomatitis (RAS) is the most common ulcerative disease affecting the oral mucosa. RAS occurs mostly in healthy individuals and has an atypical clinical presentation in immunocompromised individuals. The etiology of RAS is still unknown, but several local, systemic, immunologic, genetic, allergic, nutritional, and microbial factors, as well as immunosuppressive drugs, have been proposed as causative agents. Clinical management of RAS using topical and systemic therapies is based on severity of symptoms and the frequency, size, and number of lesions. The goals of therapy are to decrease pain and ulcer size, promote healing, and decrease the frequency of recurrence.

Remission of severe aphthous stomatitis of celiac disease with etanercept

Celiac disease is a common autoimmune disease triggered by gluten-containing foods (wheat, barley and rye) in genetically predisposed individuals. We present a patient with celiac disease complicated by severe aphthous stomatitis resulting in impairing swallowing, chewing and speaking. This led to weight loss, psychosocial problems as well as inability to perform her work. A variety of topical and systemic medications used resulted in either no improvement or only partial alleviation of the patient’s symptoms. After informed consent, etanercept was initiated and resulted in complete remission of aphthous stomatitis, decrease in arthralgia and fatigue and considerable improvement in her quality of life. The use of newer biological agents for selected and severe manifestations of celiac disease may lead to improved morbidity in these patients, but more studies are needed to determine long-term efficacy as well as safety of these drugs in the mucosal and/or systemic complications of this disease.

Efficacy of omega-3 in treatment of recurrent aphthous stomatitis and improvement of quality of life: a randomized, double-blind, placebo-controlled study

OBJECTIVE

This study assessed the effects of systemic omega-3 on the treatment of recurrent aphthous stomatitis and on the improvement of quality of life.

STUDY DESIGN

Fifty participants were randomly assigned to receive either omega-3 (1 g, 3 times daily) or placebo for 6 months. Assessment of outcome measures including monthly number of new ulcers, average duration of ulcer episodes, and pain level of ulcers was carried out at baseline and monthly for 6 months. Analysis of potential impact on quality of life using the Oral Health Impact Profile 14 was carried out at baseline and 6 months.

RESULTS

Daily omega-3 treatment achieved a significant reduction in number of ulcers, duration of ulcers, and level of pain by 3 months that persisted for 6 months. Mean score on Oral Health Impact Profile 14 also significantly improved by 6 months.

CONCLUSIONS

A daily omega-3 regimen shows promise as therapy for treatment and management of patients with recurrent aphthous stomatitis.

Relationships between self-rated oral health, subjective symptoms, oral health behavior and clinical conditions in Japanese university students: a cross-sectional survey at Okayama University

Background

Self-rated oral health is a valid and useful summary indicator of overall oral health status and quality of life. However, few studies on perception of oral health have been conducted among Japanese young adults. This study investigated whether oral health behavior, subjective oral symptoms, or clinical oral status were associated with self-rated oral health in Japanese young adults.

Methods

This cross-sectional survey included 2,087 students (1,183 males, 904 females), aged 18 and 19 years, at Okayama University, Japan. A self-administered questionnaire was distributed and an oral examination was performed.

Results

In a structural equation modeling analysis, the score of decayed, missing and filled teeth (DMFT) significantly affected self-rated oral health (p <0.05) and the effect size was highest. Malocclusion, subjective symptoms of temporomandibular disorders (TMD) and stomatitis, and poor oral health behavior significantly induced self-rated poor oral health with small effect sizes (p <0.05). Clinical periodontal conditions and Oral Hygiene Index-simplified were not related to self-rated oral health.

Conclusion

Self-rated oral health was influenced by subjective symptoms of TMD and stomatitis, oral health behavior, the score of DMFT, and malocclusion. The evaluation of these parameters may be a useful approach in routine dental examination to improve self-rated oral health in university students.

Oral mucositis in patients receiving low-dose methotrexate therapy for rheumatoid arthritis: report of 2 cases and literature review

BACKGROUND

The differential diagnosis of ulcerative oral lesions is diverse. This report discusses the rare causes of oral mucosal ulceration and suggests approaches for diagnosis and treatment.

METHODS

Two cases of methotrexate-induced stomatitis in patients receiving low dose methotrexate for rheumatoid arthritis are presented with a review of the current literature. In case 1, mucositis was caused by an unintended methotrexate overdose. In case 2, oral lesions were the result of chronic methotrexate toxicity. The treatment for methotrexate-induced mucositis required hospitalization in case 1, methotrexate discontinuation in both cases and oral folic acid supplementation in case 2.

RESULTS

In both cases, the mucositis healed and no relapse was observed.

CONCLUSION

Mucositis may be an early sign of systemic conditions, and dental providers are often the first doctors involved in the assessment of oral mucosal diseases. Meticulous questioning of the patient's history and the physical examination is important for elucidating the underlying cause.