Association between serum zinc levels and recurrent aphthous stomatitis: a meta-analysis with trial sequential analysis

Common Oral Conditions: A Review

Importance

Dry mouth, oral candidiasis, and recurrent aphthous ulcers are 3 of the most common oral conditions that may be associated with patient discomfort, decreased quality of life, and morbidity.

Observations

In a meta-analysis of 26 population-based cohort and cross-sectional studies, the global prevalence of dry mouth symptoms was 23% (95% CI, 18% to 28%), placing individuals at risk of oral candidiasis, dental caries, dysgeusia, masticatory/speech impairment, and oropharyngeal dysphagia. Dry mouth is associated with using more than 3 oral medications per day (odds ratio [OR], 2.9 [95% CI, 1.4 to 6.2]), head and neck radiation, and Sjögren disease. Symptoms may include difficulty swallowing and speaking, thirst, and halitosis. Dry mouth is associated with an 11.5% (95% CI, 3.6% to 27%) higher risk of oral candidiasis, based on a meta-analysis of 6 observational cohorts. Management of dry mouth includes mechanical salivary stimulants, oral moisturizers, and/or systemic sialagogues. Oral candidiasis is an opportunistic fungal infection caused by overgrowth of the Candida genus with C albicans, which accounts for 76.8% of infections. The prevalence of oral candidiasis is higher in patients who are immunosuppressed, for example, those with HIV (35% [95% CI, 28% to 42%]) and those with salivary gland hypofunction (OR, 3.02 [95% CI, 1.73 to 5.28]). Common risk factors associated with oral candidiasis include use of antibiotics (P = .04) and oral mucosal disorders such as lichen planus. Oral burning and dysgeusia are common symptoms of oral candidiasis. Treatment includes addressing risk factors and use of topical and/or systemic antifungal medications. Recurrent aphthous stomatitis is characterized by symptomatic round or oval oral ulcers, which are covered by a gray-white fibrin layer and encircled by an erythematous ring. A meta-analysis of 10 case-controlled studies revealed an increased risk of recurrent aphthous stomatitis associated with polymorphism of IL-1β (+3954C/T) (OR, 1.52 [95% CI, 1.07 to 2.17]) and IL-1β (-511C/T) (OR, 1.35 [95% CI, 1.09 to 1.67]). Another meta-analysis of 9 case-control studies reported that patients with recurrent aphthous stomatitis had a higher frequency of nutritional deficiencies, including vitamin B12 (OR, 3.75 [95% CI, 2.38 to 5.94]), folic acid (OR, 7.55 [95% CI, 3.91 to 14.60]), and ferritin (OR, 2.62 [95% CI, 1.69 to 4.06]). Recurrent aphthous stomatitis can be associated with systemic diseases. A meta-analysis of 21 case-control studies revealed that celiac disease is associated with a higher incidence of recurrent aphthous stomatitis (25% vs 11%; OR, 3.79 [95% CI, 2.67 to 5.39]; P <.001). Topical corticosteroids are first-line agents to manage recurrent aphthous stomatitis; however, systemic medications may be necessary in more severe cases.

Conclusions and Relevance

Dry mouth, oral candidiasis, and recurrent aphthous ulcers are common oral conditions that may be associated with patient discomfort, decreased quality of life, and morbidity. First-line treatment includes over-the-counter sialagogues for dry mouth, topical antifungals for oral candidiasis, and topical corticosteroids for aphthous ulcers. Oral conditions that do not improve with first-line treatment may require treatment with systemic medications.

Dynamic salivary cytokine profile of recurrent aphthous stomatitis patients in thalidomide maintenance treatment

OBJECTIVE

To dynamically compare the longitudinal (time axis) and transverse (between groups) differences of the salivary cytokines during thalidomide maintenance treatment of recurrent aphthous stomatitis.

METHODS

A randomized, controlled, clinical trial was performed. After the initial prednisone treatment, thalidomide (50 mg/d vs. 25 mg/d) was used as a maintenance drug for 4 or 8 weeks. The salivary IL-4, 5, 6, 10, TNF-α, and IFN-γ were dynamically detected with a cytometric bead array.

RESULTS

Overall, the level of six elevated salivary cytokines after prednisone treatment was significantly downregulated, remained low during thalidomide maintenance, and rebounded at recurrence. The effect of 50 mg/d thalidomide on the salivary cytokines was not superior to 25 mg/d medication. The relapse-free period following drug withdrawal was the longest in the subgroup using 25 mg/d thalidomide for 8 weeks. The order of magnitude of IL-6 was the most obvious, and at week 8, only the level of IL-6 in the group (25 mg/d thalidomide for 8 weeks) continued to decline compared with the other groups.

CONCLUSION

Thalidomide maintenance treatment can effectively sustain low levels of salivary IL-4, 5, 6, 10, TNF-α, and IFN-γ of recurrent aphthous stomatitis patients. IL-6 displayed a good correlation with the disease and is expected to become an index for diagnosis and follow-up.

CLINICAL RELEVANCE

Low-dose long-term thalidomide maintenance treatment was supported for recurrent aphthous stomatitis.

TRIAL REGISTRATION

Trial registration number of ChiCTR-IPR-16009759 at http://www.chictr.org/index.aspx .

Management of Recurrent Aphthous Stomatitis: An Indian Expert Consensus

Recurrent aphthous stomatitis (RAS) is characterized by painful, oral mucosal ulcers with wide range of prevalence ranging from 2 to 78%. Etiology of RAS is idiopathic and multifactorial. There are numerous gaps in assessment and management of RAS and the absence of guidelines or a consensus document makes the treatment further difficult. The aim of this document is to provide an Indian expert consensus for management of RAS. Experts from different specialties such as Otorhinolaryngology, Oral Medicine/Dentistry and Internal Medicine from India were invited for face to face and online meetings. After a deliberate discussion of current literature, evidence and clinical practice during advisory meetings, experts developed a consensus for management of RAS. We identify that the prevalence of RAS may lie between 2 and 5%. In defining RAS, we advocate three or more recurrences of aphthous ulcers per year as criterion for RAS. Investigation should include basic hematological (complete blood count) and nutritional (serum vitamin B12, and iron studies) parameters. Primary aim of treatment is to reduce the pain, accelerate ulcer healing, reduce the recurrences and improve the quality of life. In treating RAS, initial choice of medications is determined by pain intensity, number and size of ulcers and previous number of recurrences. Topical and systemic agents can be used in combination for effective relief. In conclusion, this consensus will help physicians and may harmonize effective diagnosis and treatment of RAS.

Vitamin D deficiency and risk of recurrent aphthous stomatitis: updated meta-analysis with trial sequential analysis

Background

Growing evidence suggests a significant association between vitamin D deficiency and RAS. Hence, the present meta-analysis and trial sequential analysis sought to investigate the potential association between low serum vitamin D levels and RAS.

Methods

PubMed, Scopus, Embase, and Web of Science were comprehensively searched on December 1^st, 2022 to retrieve all relevant studies. The grey literature was also searched via ProQuest. All case-control studies on the association between vitamin D and RAS were considered. The quality appraisal of the included studies was done using Newcastle-Ottawa scale. RevMan 5.0 and trial sequential analysis (TSA) programs were used for analyses.

Results

A total of 14 case-control studies with 1468 subjects (721 RAS patients and 747 controls) were included. The pooled data revealed a significant association between low serum levels of vitamin D and the risk of RAS (mean difference = - 8.73, 95% CI: - 12.02 to - 5.44, I² = 94%, P < 0.00001). Additionally, TSA findings indicated that the current studies surpassed the required information size, confirming that the differences were reliable.

Conclusion

The available evidence suggests that Vitamin D deficiency may have a role in the pathogenesis of RAS. Therefore, evaluation of vitamin D should be considered in RAS patients. Additionally, the results support the possibility of using vitamin D supplements in the management of RAS patients with inadequate serum levels of vitamin D. Future interventional studies are required to evaluate the benefits of vitamin D replacement in prevention and treatment of RAS.

Assessment of serum, dietary zinc levels, and other risk factors during the third trimester among pregnant women with and without pregnancy-induced hypertension: a case-control study

Background

This study assessed serum, dietary zinc levels, and other risk factors during the third trimester among pregnant women with and without pregnancy-induced hypertension (PIH).

Methods

This case-control study was conducted in 2022, in the three main Obstetrics and Gynecology departments in Gaza Strip, Palestine. One hundred sixty pregnant women, during the third trimester, aged ≥20 years, were selected using a convenient sampling method. Data were obtained using an interview-based questionnaire, food frequency questionnaire, anthropometric measures, and biochemical tests. Statistical analysis was performed using SPSS version 24.

Results

The participants' mean age was 30.7 ± 5.6 years. A total of 47 (58.8%) of cases and 6 (7.5%) of controls were insufficiently active; and the mean of blood pressure (mmHg) was 133.3 ± 11.9/85.11 ± 10.0 for cases and 112.8 ± 9.5/68.02 ± 7.2 for controls with significant differences between the two groups (P = <0.005). The mean serum zinc level (μg/dl) was 67.15 ± 16.5 for cases and 68.45 ± 18.0 for controls without significant differences between the two groups (P = 0.636). For newborns, the mean birth weight (g) was 2,904.6 ± 486 for cases, and 3,128.3 ± 501 for controls, and the mean Apgar score was 8.03 ± 0.62 for cases and 8.30 ± 1.17 for controls, with significant differences between the two groups (P = <0.005). Furthermore, 43 (53.8%) of cases have family history of hypertension; 5 (6.2%) were primiparous; 19 (23.8%) have previous caesarian section; 33 (41.2%) have history of preeclampsia; and 62 (77.5%) have edema, with significant differences between the two groups (P = <0.005). Additionally, the total zinc dietary daily intake (mg/day) was 4.15 ± 2.10 for cases and 4.88 ± 3.02 for controls, with significant differences between the two groups (P = 0.041). After adjustment for confounding variables, participants in the case group have higher odds of having low total zinc dietary intake compared to those in the control group [OR = 1.185, 95% CI = (1.016-1.382), P = 0.030].

Conclusion

The current study showed the main risk factors of PIH among pregnant women in the Gaza Strip, Palestine. Furthermore, low maternal dietary zinc intake was associated with a high level of PIH. Moreover, having PIH could increase the risk of low birth weight and low Apgar scores. Therefore, reducing the main risk factors of PIH could reduce the adverse effect on both mother and birth outcomes.

Efficacy of Topical Intervention for Recurrent Aphthous Stomatitis: A Network Meta-Analysis

Background and objectives: To compare the efficacy and safety of topical interventions used for recurrent aphthous stomatitis. Materials and Methods: This network meta-analysis was conducted in accordance with the PRISMA statement. We searched four electronic databases, PubMed, Web of Science (WOS), Cochrane Central Register of Controlled Trials and Embase, for randomized controlled trials reporting efficacy and safety data on topical interventions for recurrent aphthous stomatitis. We performed a quality evaluation using a methodology based on the Cochrane Handbook. Two authors independently extracted data on healing effect, size reduction effect, symptom reduction effect, recurrence and safety assessment. Network meta-analysis was then performed using ADDIS and RevMan. Results: A total of 72 trials (5272 subjects) involving 29 topical interventions were included. Honey, lnsulin liposome gel, laser, amlexanox, glycyrrhiza and triamcinolone had better efficacy performance. Probiotics and chlorhexidine helped to prolong ulcer intervals and reduce recurrence. Doxycycline and penicillin had a high risk of adverse events. Hematologic evaluation showed no preference. The rank possibility of size-reducing effect and symptom-reducing effect supported the short-term effect of laser and the long-term effect of probiotics. Conclusions: We recommend the use of laser as a short-term intervention during the exacerbation phase of RAS and probiotics as a long-term intervention during the exacerbation and remission phases of RAS.

Zinc supplementation for prevention and management of recurrent aphthous stomatitis: a systematic review

BACKGROUND

Recurrent aphthous stomatitis (RAS) is a very common oral ulcerative disease with no definitive cure. Growing evidence suggests a significant association between zinc deficiency and RAS.

OBJECTIVES

To assess the efficacy of systemic zinc supplementations in the prevention and management of RAS.

METHODS

Five databases were searched for all English and Chinese studies published up to November 2020. All clinical trials that assessed the efficacy of zinc supplementations in the management and/or prevention of RAS were included.

RESULTS

Seven clinical trials comprising 482 RAS patients (250 in zinc group) fulfilled the inclusion criteria. The follow-up period ranged from three months to one year. Five studies showed significantly better efficacy of zinc in reducing the recurrence rates of RAS, whereas two studies did not report any significant differences compared to the controls. Four studies reported on signs/symptoms of RAS, three of which showed superior outcomes in favour of zinc, while one study reported comparable results.

CONCLUSION

Zinc supplementation seems to be efficacious in the management and prevention of RAS. However, further clinical trials with standardized methodologies and adequate follow-up periods are required to confirm the efficacy of zinc supplementations.

A Randomized controlled clinical trial on dose optimization of thalidomide in maintenance treatment for recurrent aphthous stomatitis

BACKGROUND

Recurrent aphthous stomatitis (RAS) is the most common oral mucosal disease, and ulcer-free periods are a major concern for patients. Thalidomide has been shown to be an effective systemic drug in the treatment of RAS, but the value of undertaking a trial to evaluate various maintenance doses was warranted.

METHODS

We performed this randomized controlled clinical trial with a two-stage design. Firstly, all the 125 cases of RAS received prednisone at a starting dose of 15 mg/d for one week as an initial therapeutic drug. Secondly, the 100 cases of RAS in the experimental group received thalidomide (50 mg/d vs. 25 mg/d) as a maintenance drug to observe its efficacy and safety.

RESULTS

During maintenance medication at the fourth and eighth weekend, the two doses (50 and 25 mg/d) of thalidomide were equivalent in reducing the incidence of ulcers, ulcer number, and ulcer pain, respectively (all p > 0.05). Notably, the ulcer-free period in the group using 25 mg/d thalidomide for eight weeks was longer (mean, >3 months) than those in the other groups (all p < 0.05). Importantly, the total adverse events in the group using 25 mg/d thalidomide were significantly less than those in the group using 50 mg/d (p < 0.001). Moreover, the effect of 50 mg/d thalidomide on the levels of various salivary cytokines was not superior to 25 mg/d medication (p > 0.05).

CONCLUSION

This dose optimization study concluded that 25 mg/d thalidomide had a long-term effect on extending the recurrence interval of RAS with better safety.

Efficacy of hyaluronic acid for recurrent aphthous stomatitis: a systematic review of clinical trials

OBJECTIVES

Recurrent aphthous stomatitis (RAS) is a very common oral mucosal disease, and its management is quite challenging with no definitive cure being available so far. Many studies have tried hyaluronic acid (HA) for alleviating signs and symptoms of RAS. The present systematic review sought to assess the available evidence regarding the efficacy of HA in management of RAS.

METHODS

Two reviewers independently conducted extensive search in four online databases (PubMed, Scopus, Web of Science, and Google Scholar) and the gray literature, with no restriction to date or language of the publication. All clinical trials that assessed the efficacy of HA in reducing signs and symptoms of RAS were included. Risk of bias was assessed by two reviewers independently, using the Cochrane assessment tool. Due to substantial heterogeneity, no meta-analysis was feasible.

RESULTS

Out of the 75 identified articles, nine clinical trials involving 538 RAS patients (259 in HA group) were included. The risk of bias was high in five studies, low in one study, and unclear in three studies. The comparative groups varied greatly across the included studies: triamcinolone (in three studies), chlorhexidine mouthwash, lidocaine, placebo, iodine glycerin, diclofenac, and laser therapy. Overall, the results revealed a good efficacy of HA in alleviating pain and shortening the healing time of RAS, without any reported side effects. Compared to triamcinolone, HA showed superior results in one study, and comparable results in two studies.

CONCLUSIONS

The available evidence suggests that HA is a promising treatment option for RAS. However, given the huge heterogeneity of the included studies and high risk of bias in some of these studies, the evidence is inconclusive. Further well-designed clinical trials with standardized methodologies and adequate sample sizes are warranted to discern the efficacy of HA for RAS.

CLINICAL RELEVANCE

Hyaluronic acid might be a viable alternative therapeutic option for patients with RAS.