Recurrent aphthous stomatitis and Behcet's disease. A review

Symptomatic changes of oral mucosa during normal hormonal turnover in healthy young menstruating women

INTRODUCTION

Changes in hormonal levels, such as those that occur during puberty, pregnancy, menstruation and menopause, have varying effects on oral cavity. Many researchers have proposed a direct link between changing hormonal status and oral health among females.

OBJECTIVES

To study the various symptoms and clinical manifestations of oral cavity during normal course of menstrual cycle in healthy women.

METHOD

Our study comprised of forty healthy young women volunteers with normal menstrual cycle of 28 to 30 days. A proper menstrual history was recorded from the study subjects. The entire cycle was divided into four phases comprising of bleeding, proliferative, ovulation and secretory. All the study subjects had a menstrual cycle of 28 to 30 days. Thorough recording of oral discomforts during various phases of the cycle was done during the study period.

RESULTS

30% of study subjects complained of aphthous ulcers, 5% had herpes labialis, 25% of them complained of depression, 8% showed gingival bleeding.

CONCLUSION

Complaints, like oral ulcerations, mood variations, recurrent herpetic lesions, gingival bleeding in females during normal menstrual period, are attributed to the role of female sex hormones.

CLINICAL SIGNIFICANCE

Lesions, like oral ulcers, recurrent herpetic lesions and increased gingival bleeding, seen in females during normal menstrual periods, could be related to hormonal turnover and therefore treated accordingly.

Prevalence and handedness correlates of recurrent aphthous stomatitis in the Turkish population

OBJECTIVES

The present study was designed to determine the relationship between recurrent aphthous stomatitis (RAS) and handedness, and to assess the prevalence of RAS in the Turkish population.

METHODS

The present study was conducted among 11,360 persons (5,705 males and 5,655 females) with a mean age of 30.4 years. A questionnaire focusing on handedness was administered to these patients. Handedness was assessed according to the Edinburgh Handedness Inventory. The diagnosis of RAS was made on the basis of clinical appearance, location, and the patient's health history. RAS information of patients was collected by means of a data form specifically designed for this study. Subjects were informed about RAS. We took anamneses and filled out the investigation forms. Apart from patients with registration of current aphthae (average point prevalence, APP), patients who had a past two-year history (self-reported two-year prevalence, SRTP) of the lesion were also included in this study. Data were analyzed using the chi-square and logistic regression tests.

RESULTS

The prevalence of RAS (APP) was 2.7 percent and that of a history of RAS (SRTP) 22.8 percent. Thus, the total prevalence (APP+SRTP), including present lesions and a two-year history (SRTP), was 25.5 percent. Adjusted results showed that females, left-handers, 10-30-year-olds, and nonsmokers were 1.53, 1.69, 2.05, and 1.61 times more likely to have RAS (APP+SRTP) than males, right-handers, 31-50-year-olds, and smokers, respectively (P<.0001).

CONCLUSION

The present study suggests that left-handedness appears to be a predictor factor for RAS.

Problems and abnormalities found on routine clinical head and neck examination

During the initial examination of a patient, the orthodontist may encounter various findings that will, for the most part, be normal or variants of normal. Most pathological conditions encountered will be derived from structures normally found in the anatomic locations examined. Knowledge of the anatomy and common pathological entities based on location can prove helpful when abnormalities are encountered. This article describes anatomic locations and their contents in and around the oral cavity and discusses pathological processes commonly encountered in these locations. Syndromes involved with various abnormalities also are briefly mentioned. The intent of this article is to give the clinician a working knowledge of commonly occurring pathological entities.

Behçet's disease in Kuwait, Arabia. A report of 29 cases and a review

Twenty-nine patients with Behçet's disease were studied. Of these, 17 patients were followed up for a mean duration of 37 months and 12 for a mean of 18 months. Male to female ratio was 3.1:1. Of the 29 patients, 26 were Arab, 2 Asian and 1 Black African. The prevalence in the country was 2.1:100,000 population, in Kuwaitis 1.58:100,000, in non-Kuwaiti Arabs, 2.9:100,000 and in non-Arabs, 1.35:100,000 population. The frequencies of the various manifestations were: oral ulcers, 100%; genital ulcers, 93%; skin manifestations, 76%; arthropathy and ocular disease, 69% each; psychiatric disorders, 38%; vascular complications and positive Pathergy test, 34% each; gastrointestinal symptoms, 21%; oesophageal and CNS involvement, 14% each; and peritonism, renal and pulmonary involvement, 7% each. Kuwaiti bedouins seemed to be resistant to the disease, probably due to environmental and/or dietary factors. The hot arid climate of the Gulf had no effect on the course of the disease once it had developed.

Treatment of recurrent aphthous ulcers with Aureomycin mouth rinse or Zendium dentifrice

Clinical trials with a cross-over double-blind technique were undertaken to test chlortetracycline (Aureomycin) and the enzyme-containing dentifrice Zendium with regard to therapeutic effects on recurrent aphthous ulcers. Aureomycin was found to reduce the number of ulcers and diminish pain when compared with placebo. When groups of patients treated with Zendium and placebo dentifrice, respectively, were compared, no statistically significant difference could be demonstrated. However, when the pH value of Zendium was stepwise changed from 5.9 to 6.8, an increased fraction of patients reported complete relief from pain and ulcer(s) during the trial periods.

Stereologic analysis of leukocyte infiltration in oral ulcers of developing Mikulicz aphthae

Biopsy specimens of 1- to 7-day-old oral ulcers from patients with minor (Mikulicz), herpetiform, and Behcet's aphthae and of nonulcerated oral mucosa of aphthous patients were subjected to a quantitative, stereologic, electron microscopic analysis of the connective tissue infiltrate residing both at the center of and lateral to the ulcers. The data representing volume fractions and the numerical density of cellular and other infiltrate components demonstrated that (1) the infiltrate under the epithelium lateral to the ulcer is different from that at the ulcer's center, (2) at both sites, composition of the gross infiltrate does not change with age of the ulcer, (3) a large population of leukocytes (about 18% in the lateral and 23% in the central region) belong to the monocyte/macrophage series, (4) blast-forming T-lymphocytes are consistently present, blast-forming B-lymphocytes and plasma cells are very rare, and (5) mast cells are several times more numerous than in normal mucosa. In a comparison of the infiltrates of Mikulicz aphthae with those of herpetiform and Behcet's ulcers, it appears that the pathogenesis of the various oral ulcerations may well be diverse.

Effect of zendium toothpaste on recurrent aphthous stomatitis

A double-blind clinical trial with cross-over was conducted for a period of 12 months in 25 patients with recurrent aphthous stomatitis (RAS). The effect of the amyloglucosidase and glucoseoxidase containing Zendium toothpaste on the discomfort, number of exacerbations, duration of exacerbation, number of ulcers and number of days with pain caused by RAS was studied. The use of Zendium significantly reduced the sensation of discomfort from RAS as compared to the use of placebo toothpaste (0.025 greater than p greater than 0.01). However, the patients were unable to discriminate significantly between Zendium and placebo when asked to choose one of the toothpastes (0.10 greater than p greater than 0.05) and no significant differences were demonstrated as far as the above mentioned parameters of disease severity were concerned. Therefore, it is concluded that the reducing effect of Zendium containing amyloglucosidase and glucoseoxidase on RAS is weak as compared to a similar toothpaste without these enzymes.

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.

Double-blind study of levamisole therapy in recurrent aphthous stomatitis

Forty-eight patients with diagnosed recurrent aphthous stomatitis participated in a randomized double-blind study of levamisole therapy. Each patient's response to treatment was determined by the following criteria: (1) days between attacks, (2) duration of lesions, (3) patient's self-evaluation of pain, (4) investigator's clinical evaluation of patient's subjective treatment response. Statistical analysis of the levamisole and placebo groups of criteria 1 and 2 above revealed no significant difference. In contrast to the above findings, analysis of the investigator's recordings of patient's subjective treatment response showed that 26% of the levamisole patients experienced marked or moderate improvement. None of the placebo patients were recorded as having experienced the same degree of benefit. Fourteen of 15 patients who complained of side effects were taking levamisole. The most common side effects were dysgeusia and hyperosmia.

Possibility of a viral etiology in recurrent aphthous ulcers and Behçet's syndrome

The clinical signs, laboratory data, and histological features of recurrent aphthous ulcers (RAU) and Behçet's syndrome suggest a viral etiology. In fact, there are reports of adenovirus isolations in herpetiform oral ulcers and on the isolation of a filterable agent in sporadic cases of Behçet's syndrome. However, isolation studies on the major and minor aphthous ulcers and more recent studies on Behçet's syndrome have been negative. A review of the literature on the role of viruses and autoimmunity in RAU and Behçet's syndrome is presented. Biopsy specimens of ulcerative lesions were grown in vitro for up to 300 days. Those cultures, along with leukocytes and body fluids, were examined by a variety of techniques for the presence of virus or viral antigens. Although a persistent or latent virus was not detected, these negative studies cannot exclude a viral etiology. In fact, the hypothesis of an infectious and viral etiology is still reasonable.

Effect of levamisole on the incidence and prevalence of recurrent aphthous stomatitis. A double-blind clinical trial

Twenty patients with severe recurrent aphthous stomatitis were treated with a new drug, levamisole, to determine its effects upon the incidence and prevalence of recurrent aphthous stomatitis. The trial, conducted in a non-crossover, double-blind fashion, did not demonstrate any statistically significant differences when levamisole and placebo groups were compared over time either in the number of ulcers, number of ulcer-days, mean duration of ulcers, or mean number of ulcers per day. Positive subjective results were experienced by the 10 patients receiving levamisole but these were not of sufficient magnitude to affect group mean differences.

A randomized double-blind trial of levamisole in the therapy of recurrent aphthous stomatitis

A Controlled, double-blind study was performed to compare the effects of levamisole and placebo in eighteen patients with recurrent aphthous stomatitis. Levamisole is a drug which enhances defective cellular immune responses. It was administered in a flexible dosage schedule: 50 mg. three times daily for three consecutive days at the start of an aphthous lesion but with an interval of at least 2 weeks between courses of therapy. Placebo consisted of pills that were identical in appearance, taken according to the same schedule. Statistical evaluation showed decreased frequency of lesions, shorter duration, and diminished pain of lesions in the group receiving levamisole. Subsequent follow-up in an open trial confirmed these results.

Recurrent aphthous stomatitis: clinical characteristics and evidence for an immunopathogenesis

Recurrent aphthous stomatitis is one of the most common diseases affecting the oral mucosa, and one of its variants is the most painful affliction of the oral mucosa. The lesions of recurrent aphthous stomatitis can be manifested as part of a broad spectrum of clinical disease ranging from the common minor aphthous ulcers to Behçet's syndrome. Differential diagnosis, although not often difficult, must include many conditions capable of producing erosive and ulcerative oral mucosal lesions. The salient features of recurrent aphthous stomatitis suggest that it is a heterogeneous entity. Recent immunologic investigations have focused attention on a possible immunopathogenesis and the evidence for this is reviewed.

Inheritance patterns in recurrent aphthous ulcers: twin and pedigree data

Nineteen sets of twins and 318 individuals from six families were examined and interviewed in order to ascertain whether a genetic component could be established for recurrent aphthous ulcers (RAU). While no specific mode of inheritance could be established, the data strongly support the hypothesis of a genetic factor involved in susceptibility to the disease.

A retrospective study of the prevalence and incidence of recurrent aphthous ulcers in a professional population, 1958-1971

A 12-year retrospective investigation of 1,788 professional school students from the University of Pennsylvania was conducted. Because of changes in profession, location, marital status, and names, only 651 proband subjected were available for the follow-up investigation. Techniques of subjective evaluation of disease status (mailed schedules describing disease and color photographs) were used in making an assessment of RAU, including both current disease and histories of prior disease. The data presented suggested a trend toward decreased RAU prevalence and severity among physicians, dentists, veterinarians, and nurses as compared with 12 years previously when they were professional school students. The prevalence rate, however, was still very high, indicating that 48.3 per cent of the men and 57.2 per cent of the women had RAU at the time. It has been suggested that the student years may represent the highest levels of RAU and that special features of the life patterns of the student favor disease expression; the data from study support this hypothesis, since reduction in severity was observed in all groups.

Herpetiform ulceration

The rationale for the clinical existence of a less commonly found form of recurrent oral ulceration, herpetiform ulceration (HFU), is presented, illustrated by six clinical cases. The clinical and laboratory features that separate it from recurrent herpetic ulceration (RHU) and recurrent minor aphthous ulceration (RHU) are discussed. Although a viral cause has been proposed for the condition, based on the finding of intranuclear bodies, electron microscopic and other laboratory investigations by the authors indicate that there is insufficient evidence at present to confirm this. Since HFU does have a significant number of histologic and immunologic features in common with recurrent apthous ulceration, it is thought that it should be considered to be a variant of this condition until the true cause of it is revealed.

Recurrent oral and oculogenital ulcerations (Behçet's syndrome)

The literature on Behçet's syndrome is reviewed and four cases are presented. Two of the patients were men and two were women. The age at presentation varied from 21 to 55 years. All patients had the first manifestations of the disease before the age of 25 and two before the age of 10. None presented with the complete triad of symptoms. All four had oral ulceration and either ocular lesions (two cases) or lesions on the genitals (two cases). According to the present theories, the diagnosis of Behçet's syndrome is established by the presence of any two of the triad of symptoms. We suggest that in order to be classified as having Behçet's syndrome, a patient should have oral lesions and either genital and/or ocular ulcerations.

[Inflammatory and systemic reactions of the mouth mucosa]

The field of oral medicine is fundamental to the practice of general medicine as well as dentistry, oral surgery, and other special fields of medicine concerned with diseases of organs beneath the oral cavity. Disorders of the oral mucosa may reflect many dermal and internal diseases, and may focus the physician's diagnostic attention to systemic pathological conditions which otherwise could be misdiagnosed. As to their morphological appearance, however, the oral mucosa shows other forms of reactivity than the skin. When the dermal and oral manifestations of many skin diseases are compared the influence of distinct local factors on the intraoral clinical picture becomes evident. This comparative view, as well as the dermatologist's practical experience that many dermatoses either spread to, or even are restricted to the oral mucosa, may explain why most dermatologists are very interested in oral diagnosis. In this report, the interdisciplinary view and some aspects of clinical stomatology are stressed which are of actual interest in oral diagnosis and therapy. The following topics are dealt with: Diseases with aphthous lesions, Allergic reactions to drugs, Pemphigus and pemphigoid disorders, Oral infections by Candida albicans, Melkersson-Rosenthal syndrome, Lingual anomalies of different types, Leukoplakias.

Recurrent necrosis of the skin and the mouth

A patient suffering from an unusual syndrome, in which the following triad was present, is described: (1) Recurrent necrosis of the skin and mouth; and necrosis following intradermal injection of saline. (2) Disappearance of the necrotic episodes following the administration of prednisone. (3) Mental retardation. This syndrome does not appear to have been previously reported.

Histopathological and electron microscopic studies of lymphangiectasia of the small intestine in Behçet's disease

The gastrointestinal involvement and immunological findings in 16 patients with Behçet's disease are described. Four of 15 biopsy specimens of jejunal mucosa showed marked lymphangiectasia in the lamina propria similar to the appearance which was thought to be a characteristic finding in protein-losing enteropathy. None of the patients had hypoproteinaemia. Increases in serum immunoglobulin IgA were proved in six of 15 cases; in IgM, five of 15; and in IgG, one of 15. Electron microscopic studies showed that there were thousands of precipitated lymph protein bodies in the extracellular spaces of the lamina propria. Ulcers and healed ulcers of the large intestine were studied by light microscopy.