Studies on recurrent oral aphthae. I. Clinical and laboratory comparisons

Determination of levels of salivary IgA subclasses in patients with minor recurrent aphthous ulcer

Context:

Recurrent Aphthous Ulcer (RAU) is an inflammatory disease characterized by recurrent, painful oral ulcers. It is of multifactorial etiology. Salivary immunoglobulins have important role in the protection of mucosal surfaces.

Aim:

The aim of this study was to determine salivary immunoglobulin A1 (IgA1) and IgA2 in acute and remission phases of the disease.

Materials and Methods:

Thirty clinically confirmed cases of RAU and 30 age-and sex-matched controls were included in the study. After detailed case history and thorough clinical examination, 2 mL of saliva was collected in both acute and remission phases of the disease. The obtained saliva samples were subjected to quantification of IgA1 and IgA2 levels using RID kit.

Results:

The mean IgA2 level was significantly higher (P<.001) in both acute and remission phase of the study group. The mean IgA1 level also showed a significant increase in the acute phase compared to remission as well as controls (P<.05). Females exhibited a higher level in acute phase for IgA1 and in both phases for IgA2 (P<.05).

Conclusion:

The results associated with clinical observations suggest that acute phase is characterized with increase in IgA2 that might reflect increased immune response as a possible result of the microbial stimulation seen in the acute phase in comparison to the remission period. IgA plays an important role in the pathogenesis of RAU and it can be used as a parameter to assess the mucosal immune status

Recurrent aphthous ulcers today: a review of the growing knowledge

Recurrent aphthous ulcers represent a very common but poorly understood mucosal disorder. They occur in men and women of all ages, races and geographic regions. It is estimated that at least 1 in 5 individuals has at least once been afflicted with aphthous ulcers. The condition is classified as minor, major, and herpetiform on the basis of ulcer size and number. Attacks may be precipitated by local trauma, stress, food intake, drugs, hormonal changes and vitamin and trace element deficiencies. Local and systemic conditions, and genetic, immunological and microbial factors all may play a role in the pathogenesis of recurrent aphthous ulceration (RAU). However, to date, no principal cause has been discovered. Since the aetiology is unknown, diagnosis is entirely based on history and clinical criteria and no laboratory procedures exist to confirm the diagnosis. Although RAU may be a marker of an underlying systemic illness such as coeliac disease, or may present as one of the features of Behcet's disease, in most cases no additional body systems are affected, and patients remain otherwise fit and well. Different aetiologies and mechanisms might be operative in the aetiopathogenesis of aphthous ulceration, but pain, recurrence, self-limitation of the condition, and destruction of the epithelium seem to be the ultimate outcomes. There is no curative therapy to prevent the recurrence of ulcers, and all available treatment modalities can only reduce the frequency or severity of the lesions.

Recurrent aphthous stomatitis

Recurrent aphthous stomatitis (RAS) is one of the most common oral mucosal disorders. Nevertheless, while the clinical characteristics of RAS are well-defined, the precise etiology and pathogenesis of RAS remain unclear. The present article provides a detailed review of the current knowledge of the etiology, pathogenesis, and management of RAS.

Immunoglobulin G subclass measurements in recurrent aphthous stomatitis

We have measured serum levels of IgG subclasses and total IgG, IgA and IgM in a group of 34 recurrent aphthous stomatitis (RAS) patients. At the time of blood collection, 23 of the 34 patients had active oral lesions. The remaining 11 patients were at an inactive stage. All measurement were performed in the Beckmann 360 Array Protein System. Serum levels of IgG2 subclass were significantly lower (P < 0.05) in the whole group of patients (34) when compared to the control group. This relationship was still significant (P < 0.05) when only the 11 patients without active oral lesions were considered but disappeared in patients at an active stage. We conclude that low serum levels of IgG2 may play a role in the pathogenesis of RAS, just as in other recurrent infectious diseases, and that serum levels of this immunoglobulin subclass, as well as total IgA, may undergo transient changes, depending on the different periods of activity and quiescence of the disease.

Immunoglobulin G subclasses in recurrent aphthous stomatitis

Serum levels of immunoglobulin G (IgG) subclasses were examined in 71 adult patients with minor recurrent aphthous stomatitis (MiRAS). Seven patients (10%) had altered IgG subclasses: six had marginally raised IgG1 levels and one had a low level of IgG3. It is concluded that abnormalities of IgG subclass levels do not underlie MiRAS.

Recurrent aphthous stomatitis: current concepts of etiology, pathogenesis and management

Recurrent aphthous stomatitis (RAS) is a common oral disorder, however, despite detailed clinical, immunologic, hematologic and microbiologic investigation, the etiology of RAS remains unknown. At present, topical steroids and antimicrobial mouth rinses are the mainstays of treatment, but there is still no means of preventing recurrence of the oral ulceration.

Performance of a hydroxypropyl cellulose film former in normal and ulcerated oral mucosa

Although oral ulcers are commonly encountered in clinical dental and medical practice, current therapeutic options with respect to pain relief are limited. This study evaluated the mucosal binding characteristics and the pain relief and protection properties of Zilactin, a hydroxypropyl cellulose film former. In 12 healthy volunteers, the mean duration of mucosal adherence of Zilactin was 3.92 hours, which was significantly longer than that of a widely available topical preparation (1.38 hours, p = 0.0001). When evaluated in 20 subjects with recurrent aphthous ulcerations, Zilactin demonstrated the ability to significantly decrease ulcer pain over a 4-hour period when compared with the subjects' individual standardized level of initial discomfort, which was used as an internal control for all subsequent steps. Challenge with an irritating citrus beverage was made before and after application of the medication. A significant difference in premedication and postmedication sensitivity was shown (p = 0.0001), indicating that the film provides protection, as well as pain relief. As a result of its unique and tenacious film-forming characteristics, this agent is exceptionally effective in the treatment of oral mucosal ulcerations. Greater awareness on the part of physicians and dentists may lead to the development of additional applications.

Pathomorphologic features of the ulcerative stage of oral aphthous ulcerations

Macroscopic, histopathologic, and immunohistochemical features of eight 1- to 7-day-old minor (Mikulicz) aphthae, one herpetiform ulcer, and one ulcer from a patient with Behcet's syndrome were studied. In addition to light and electron microscopy, methods included the peroxidase-antiperoxidase (PAP) technique to disclose binding of IgA, IgG, IgM, Clq, and C3. Observations revealed the presence and distribution of extravasates of erythrocytes at and around the ulcers, extravascular neutrophilic granulocytes undermining the oral epithelium of the ulcer margin, the presence of numerous macrophages loaded with phagolysosomes containing debris of neutrophilic granulocytes, particular pathomorphologic features of a Behcet lesion and a herpetiform lesion, and the occurrence in diseased and normal oral mucosa of particular stratum spinosum cells binding nonselectively all immune components tested in this study, probably by leakage and passive diffusion of serum proteins. The observations fit the concept of immune complex vasculitis being essential in the pathogenesis of oral aphthous ulcerations.

Immunogenetic markers and immune response in patients with recurrent oral ulceration

20 patients, aged 20 to 72 years (mean 36.5 years), 14 with recurrent (RAS) and 6 with recurrent cicatrizing (RCAS) aphthous stomatitis were studied. 3 patients (15%) had the HLA locus A11 antigen, whose frequency in the Finnish population is 8%. 5 patients (25%) had B12, which occurs in 15% of the normal population. Results of routine serological tests were normal. All had normal serum levels of IgG, IgM, IgA and complements C3 and C4. 4 patients, 2 with RAS and 2 with RCAS, had raised serum IgE. Precipitating antibodies against milk protein were detected in 2 patients and against gluten in 1. In 4 patients, tests for immediate allergy were positive. 5 patients had antibodies to double-stranded DNA. Delayed hypersensitivity reactions were normal, and the PHA stimulation of lymphocytes elicited normal T-cell responses in all patients except one with RCAS. In this patient, there was a striking parallelism between an increase in PHA-reactive lymphocytes and clinical improvement. The serum of this patient contained a binder for 125I-labelled PHA, a binder not consistently detected in the other patients with ROU. Lymphocyte dysfunction may play a rôle in ROU. Of the 16 biopsy specimens of aphthous tissue studied by direct immunofluorescence for IgG, IgM, IgA, fibrinogen and C3, 15 specimens contained deposits of C3 in and along mucosal vessels, whereas among the 15 controls only 1 specimen of erosive lichen planus showed deposits of C3 along capillary walls. Immune complexes precipitating in capillary walls appear to be a common feature of ROU.

Quantitative distribution of inflammatory cells in recurrent aphthous stomatitis

Histologic quantitation of leukocytes in biopsies of recurrent aphthous ulcers revealed at least two morphologically-distinct inflammatory infiltrates. Lymphocytes were found consistently in pre-ulcerative lesions and in the expanding margins of the developing ulcer. In contrast, polymorphonuclear leukocytes predominated only in areas of frank ulceration.

Aphthous ulcer--a treatment complication. Report of a case

Multiple theories of the cause and treatment of aphthous ulcers are described in the medical and dental literature. A case is reported in which there were posttreatment sequelae from the application of a sillver-nitrate stick (pencil) to an aphthous ulcer on the tongue. Compications subsequent to the use of silver nitrate may contraindicate the use of this agent in its highly concentrated form on the mucous membranes of the mouth.

Deposits of immunoglobulin G and complement C3 in recurrent aphthous ulcerations

Deposits of immunoglobulin G (IgG) were demonstrated at the basement membrane zone in lesions from 14 out of 16 patients with recurrent aphthous ulcerations (RAU) by means of an immunofluorescent (IF) staining technique. Deposits of complement C3 were demonstrated at the same localization in lesions from 16 out of 16 patients with RAU. Similar deposits of C3 were demonstrated in 11 out of 12 experimentally produced oral wounds (EOW). Immunoglobulin deposits were not detected in the EOW. No deposits of immunoglobulin or C3 were revealed in 12 biopsies from normal oral mucosa (NOM). Further, the IF investigation demonstrated circulating autoantibodies against the cytoplasm of autologous oral epithelial cells in patients with RAU. The specificity of the present immunologic reactions and their possible role in the pathogenesis of RAU are discussed.

Salivary IgA and serum IgG and IgA in recurrent aphthous stomatitis

Salivary flow rate and sIgA were measured in twenty-one patients suffering from recurrent aphthous stomatitis (RAS). Out of this group ten volunteered for continuous study. In these patients salivary IgA and serum IgA and IgG were measured every 3 days for 3 weeks. All parameters were in the physiologic range of healthy people. No correlation with the clinical condition of the patients was found.

Comparison of cellular and humoral immunity against streptococcal and adult human oral mucosa antigens in relation to exacerbation or recurrent aphthous stomatitis

Cell-mediated immunity (CMI) and humoral mediated immunity (HMI) against streptococcal and adult human oral mucosa (AHOM) antigens were investigated in patients with inactive and active recurrent aphthous stomatitis (RAS). The CMI and HMI were examined by means of the leucocyte migration test (LMT) and a double layer immunofluorescence (IF) technique. The CMI against Streptococcus sanguis strain 2A, streptococcus pyogenes strain M5, and AHOM was significantly increased in inactive and active RAS. Significant difference between active and inactive RAS was only demonstrated when Strep. 2A was used as antigen in the leucocyte migration cultures. Longitudinal observations in relation to exacerbation of RAS revealed significant changes in the migration indices (MI) when Strep. 2A and AHOM were used as antigens. Extracts of Strep. M5 and other tissues as kidney and uterus did not show any significant changes of MI in relation to the exacerbation of RAS. The IF-investigations detected significantly raised IgG antibodies against washed whole cells of Streptococcus sanguis strain 2A and Streptococcus pyogenes strain M5 in sera from patients with RAS. The autoantibodies in RAS belonged to the immunoglobulin classes IgG and IgM. The detected antibodies were able to blind serum complement (C3). The distribution of endpoint titres (EPT) against Strep. 2A, Strep. M5, and AHOM antigens did not differ significantly in patients with active RAS in relation to those with inactive RAS. Furthermore, the EPT against Strep. 2A and AHOM were not significantly changed in relation to exacerbation of RAS. The present investigations show that CMI and HMI against streptococcal and AHOM antigens are characteristic features of RAS and indicate that the CMI against Strep. 2A and AHOM is significantly increased in relation to exacerbation of RAS.

Recurrent aphthous ulcerations in a mixed Arab community

Twenty thousand Arabs of various nationalities living in Kuwait have been investigated over the past 5 years; 5,470 (27%) manifested recurrent aphthous ulcerations (RAU). Non-Kuwaiti Arabs were affected more the Kuwaitis and the prevalence of the disease was respectively 35% and 18%. Among Kuwaitis, only 5% of the Bedouins manifested the diseases whereas 22% of urbanized Arabs were affected. The ratio of the affected females to males in this study was 6:5. The clinical course of RAU in Arabs was similar to that reported in other populations. Various environmental factors such as stressful conditions, social tradition and obligations, and the allergenic Arabic food seemed to affect the prevalence of RAU in different Arab communities.

A leucocyte migration study on the cell-mediated immunity against adult human oral mucosa and streptococcal antigens in patients with recurrent aphthous stomatitis

In vitro demonstration of cell-mediated immunity (CMI) against adult human oral mucosa antigen (AHOM) and streptococcal antigens was accomplished by means of the leucocyte migration test (LMT) in patients with recurrent aphthous stomatitis (RAS). If antigenic extracts of AHOM, Streptococcus sanguis strain 2A or Streptococcus pyogenes strain M5 were used in the LMT experiments, the distribution of migration indices (MI) over patients with RAS differed significantly from the distribution over the controls. In patients with other oral lesions, these MI-distributions did not differ significantly from those among the controls. Extracts of other tissues such as kidney and uterus tissues or of other bacterial antigens such as Brucella abortus and Escherichia coli did not reveal any significant differences between the LMT responses in RAS and controls. The present findings show that CIM against AHOM antigen and streptococcal antigens are features characteristic of RAS. Furthermore, the results indicate that common antigenic determinants might be shared by AHOM and streptococci.

An immunofluorescence study on the cross-reaction between strep. 2a and human oral mucosa

Immunologic cross-reactions between Strep. 2A, fetal human oral mucosa (FHOM), and adult human oral mucosa (AHOM) were investigated by the use of a double layer immunofluorescence staining technique. Rabbit sera were prepared against Strep. 2A and FHOM. Seventeen sera from patients with recurrent aphthous stomatitis (RAS) and with known antibodies against Strep. 2A and AHOM were examined for antibodies against FHOM. The distribution of endpoint titers against FHOM in the sera from RAS differed significantly from the distribution in 17 controls. The immune absorptions in the rabbit sera and in the 17 sera from patients with RAS indicate that some cross-reacting antigenic determinants are shared between Strep. 2A, FHOM, and AHOM. Further, the present results indicate that antibodies are produced against antigenic determinants which are not shared by Strep. 2A, FHOM, and AHOM. The role of cross-reacting antigens in the pathogenesis of RAS is discussed but remains obscure.