Pathomorphologic features of the ulcerative stage of oral aphthous ulcerations

Association of neutrophil defects with oral ulcers but undetermined role of neutrophils in recurrent aphthous stomatitis

Objective

Recurrent oral ulcers and severe periodontal diseases in patients with quantitative or qualitative neutrophil defects highlight the important role of neutrophils in maintaining oral mucosal barrier homeostasis. Recurrent aphthous stomatitis (RAS) is a common oral mucosal disease affecting up to 25% of the population, yet its etiopathogenesis remains unclear, and management is unsatisfactory. This review aims to gain insight into the pathogenesis of RAS.

Design

This narrative review examines the characteristics of oral and blood neutrophils, the associations between neutrophil defects and the occurrence of oral ulcers, and the evidence for the involvement of neutrophils in RAS. To conduct the review, relevant literature was searched in PubMed and Google Scholar, which was then thoroughly reviewed and critically appraised.

Results

Neutropenia, specifically a decrease in the number of oral neutrophils, impaired extravasation, and defective ROS production appear to be associated with oral ulcers, while defects in granule enzymes or NETosis are unlikely to have a link to oral ulcers. The review of the histopathology of RAS shows that neutrophils are concentrated in the denuded area but are latecomers to the scene and early leavers. However, the evidence for the involvement of neutrophils in the pathogenesis of RAS is inconsistent, leading to the proposal of two different scenarios involving either impaired or hyperactive neutrophils in the pathogenesis of RAS.

Mucocutaneous manifestations of Behçet's disease: Pathogenesis and management from perspectives of vasculitis

Behçet's disease (BD) is a systemic inflammatory disorder characterized by vasculitis affecting blood vessels of any caliber or type. It can present with a wide spectrum of vasculitic lesions, including erythema nodosum-like lesions and retinal vasculitis, and may also lead to larger vessel diseases, such as aortic aneurysm and deep vein thrombosis. The full etiology of BD remains unclear, but it is considered a polygenetic disease with multiple genetic risk factors that promote immune dysregulation and thrombophilia. Inflammation can be triggered by environmental factors, such as bacteria or viruses, and the dysregulation of innate and adaptive immune cell subsets. Neutrophils and lymphocytes are the primary players involved in BD pathogenesis, with specific innate (i.e., neutrophil-derived reactive oxygen species and neutrophil extracellular traps) and adaptive (i.e., anti-endothelial cell antibodies) processes inducing endothelial cell activation and chemotaxis of inflammatory cells, leading to coagulation and vasculitis. These inflammation-induced vasculitic or vasculopathic features are observed in most mucocutaneous BD lesions, although vasculitis per se is often pathologically evident only during a brief period of the disease process. Due to the multifactorial nature of BD-associated inflammation, broad-spectrum anti-inflammatory medications, including glucocorticoids and immunosuppressive drugs, have been the mainstay for managing BD. In addition, inhibitors of interleukin (IL)-1, tumor necrosis factor (TNF)-α, and IL-17, which target innate and adaptive immune functions dysregulated in BD, have emerged as promising new therapeutics. In this review, we discuss the muco-cutaneous manifestations of BD by focusing on the underlying vasculitic components in their pathologies, as well as the current array of treatment options.

Natural History of Behçet's Disease Focusing on Remission of Oral Ulcers

OBJECTIVES

To describe the long-term clinical course of each manifestation of Behçet's disease (BD) and clarify factors involved in oral ulcer (OU) remission using clinical information of BD patients.

METHODS

We retrospectively studied 155 BD patients visiting our hospital (1989-2020). We defined remission criteria for each manifestation and examined long-term clinical changes. Classification and regression trees and multivariable analyses were performed to investigate OU prognostic factors; hazard ratios were used to assign scores to prognostic factors deemed significant (OU prognosis score: OuP score). Risk stratification was examined by dividing the OuP scores into four stages.

RESULTS

OUs appeared earliest, with the slowest decline in prevalence observed post-BD diagnosis. OU presence was the most common factor inhibiting complete remission. Young age at OU onset, never smoker, presence of genital ulcers, positive pathergy test, no usage of tumour necrosis factor inhibitors or of immunosuppressants, and long-term non-treatment or symptomatic treatment for OUs were poor OU prognostic factors. Based on multivariable analysis, the area under the curve of the OuP score to predict OU prognosis was 0.678.

CONCLUSIONS

Remission criteria for each symptom clarified that OU had the greatest impact on complete BD remission. Faster OU remission was associated with earlier OU therapeutic intervention other than symptomatic treatment.

S, Palaneeswari M. S, Devi A.J. M. Significance of ferritin in recurrent oral ulceration

BACKGROUND

Ferritin is the storage form of iron. Hence, the sensitive test which can be used for diagnosing iron deficiency anaemia is estimation of ferritin in serum. One of the causative factors of oral ulceration is nutritional deficiency, which includes iron also.

AIM

To study the meaningful association between recurrent oral ulcer and ferritin.

MATERIALS AND METHODS

Fifty oral ulcer cases which were diagnosed clinically in the ENT Department of Sree Balaji Medical College and Hospital and Twenty Five controls were included in this study. Serum ferritin was estimated by doing a particle enhanced turbidimetric immunoassay for both cases and controls.

RESULTS

66% of cases had decreased ferritin values and 34% had normal values, which was significant.

CONCLUSION

From this study, it can be concluded that it is mandatory to screen oral ulcer patients for iron deficiency anaemia by estimating serum ferritin and it is also advisable for the patients to have iron supplementation on regular basis, along with diet rich in iron in addition to vitamins.

Mucosal disease series. Number VI. Recurrent aphthous stomatitis

Recurrent aphthous stomatitis (RAS; aphthae; canker sores) is a common condition which is characterized by multiple recurrent small, round or ovoid ulcers with circumscribed margins, erythematous haloes, and yellow or grey floors typically presenting first in childhood or adolescence. RAS occurs worldwide although it appears most common in the developed world. The aetiology of RAS is not entirely clear. Despite many studies trying to identify a causal microorganism, RAS does not appear to be infectious. A genetic predisposition is present, as shown by strong associations with genotypes of IL-1beta; IL-6 in RAS patients, and a positive family history in about one-third of patients with RAS. Haematinic deficiency is found in up to 20% of patients. Cessation of smoking may precipitate or exacerbate RAS in some cases. Ulcers similar to RAS may be seen in human immunodeficiency virus disease and some other immune defects, and drugs, especially non-steroidal anti-inflammatory drugs and nicorandil may produce lesions clinically similar to RAS. Topical corticosteroids can often control RAS. However, the treatment of RAS remains unsatisfactory, as most therapies only reduce the severity of the ulceration and do not stop recurrence.

Recurrent aphthous stomatitis

The cause of recurrent aphthous stomatitis (RAS) remains unknown despite considerable research. This article reviews the evidence for current theories regarding this disorder, including possible suspected relationships with microbial and immunologic factors, and presents medical diseases that mimic RAS lesions in certain patients. Topical management of the common form of minor RAS is described along with systemic therapy currently available to patients with severe forms of this disease.

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.

Salivary levels of vascular endothelial growth factor (VEGF) in recurrent aphthous ulceration

BACKGROUND

Vascular endothelial growth factor (VEGF) is a multifunctional angiogenic cytokine involved in angiogenesis and wound healing. Its presence in recurrent aphthous ulceration has not been reported to date. The aim of this study was to investigate the association of salivary levels of VEGF with various stages of recurrent aphthous ulceration (RAU).

METHODS

VEGF levels were determined in a group of 27 age and sex-matched healthy controls and in 30 patients with minor and major RAU grouped into the three stages: (I) early active stage, (II) active stage, and (III) remission period. VEGF levels (pg/ml; mean +/- SD) in unstimulated whole saliva were determined by enzyme immunoassay.

RESULTS

Patients with major RAU - stages I and II - had decreased VEGF values (765 +/- 458 and 341 +/- 109, respectively) when compared both to healthy controls (1652 +/- 567; P < 0.01) and to stage III major RAU (1524 +/- 784; P < 0.005).

CONCLUSION

Salivary VEGF levels seemed to be associated with ulcer development in major RAU, showing stage-dependent alterations during the course of this disorder.

Examination of the oral mucosa and peripheral blood cells of patients with recurrent aphthous ulceration for human herpesvirus DNA

OBJECTIVE

The purpose of this study was to exam the oral mucosa and peripheral blood cells of patients with recurrent aph-thous ulceration (RAU) for the presence of the following human herpesviruses: herpes simplex viruses 1 and 2, varicella zoster virus, Epstein-Barr virus, cytomegalovirus, human herpesvirus-6, and human herpesvirus-7.

STUDY DESIGN

Fifty-eight subjects with RAU and 10 control subjects were recruited at an academic referral center and enrolled in this prospective, nonrandomized, case-controlled study. Each of the subjects with RAU was seen during an acute episode, and swab specimens from lesional (RAU-acute/lesion) and clinically normal (RAU-acute/normal) oral mucosa were obtained. Each of 2 subjects with RAU was evaluated during more than one acute episode. Three subjects with RAU were seen between active episodes, and swab specimens were taken from clinically normal (RAU-convalescent) oral mucosa. Swab specimens from clinically normal (control/normal) oral mucosa were obtained from the control subjects. Peripheral blood specimens were obtained from subjects with RAU and control subjects at the time the swab specimens were performed. Through use of polymerase chain reaction, all swab and peripheral blood specimens were examined for the presence of human herpesvirus DNA. Statistical significance was determined by means of chi(2) analysis.

RESULTS

Herpes simplex virus and human herpesvirus-6 were found in a higher percentage of mucosal specimens from the control subjects (herpes simplex virus, 4/10; human herpesvirus-6, 5/9) than from the subjects with RAU (RAU-acute/lesion: 3/45 herpes simplex virus, 13/53 human herpesvirus-6; RAU-acute/normal: 7/48 herpes simplex virus, 9/53 human herpesvirus-6). No difference was demonstrated between RAU-acute/lesion, RAU-acute/normal, and RAU-convalescent mucosal specimens for any of the human herpesviruses. Different human herpesviruses were identified from individual subjects with RAU during subsequent episodes of disease. Epstein-Barr virus (6/35), human herpesvirus-6 (3/40), and human herpesvirus-7 (7/43) were detected in the peripheral blood mononuclear cells during acute RAU but not in RAU-convalescent or control peripheral blood mononuclear cells.

CONCLUSIONS

The detection of human herpesvirus DNA from the oral mucosa and peripheral blood mononuclear cells of patients with RAU appears to represent normal viral shedding rather than a direct causal mechanism in this disorder.

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.

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.

Raised levels of circulating VCAM-1 and circulating E-selectin in patients with recurrent oral ulceration

Endothelial cell (EC) adhesion molecules VCAM-1 (vascular cell adhesion molecule-1), E-selectin and ICAM-1 (intercellular adhesion molecule-1) are essential for the binding of inflammatory cells to ECs. Recently, circulating forms of these molecules have been detected in a number of vasculitic disease processes. Recurrent oral ulceration (ROU) has some features of a vasculitic disease process. The purpose of this study was, therefore, to compare cVCAM-1, cE-selectin and cICAM-1 levels in 50 patients with ROU and 50 age- and sex-matched controls. Levels of circulating adhesion molecules were quantified using specific "sandwich" ELISA assays. The cVCAM-1 and cE-selectin levels were significantly raised in ROU patients (P < 0.00005 and P < 0.05, respectively) but there was no significant increase in cICAM-1 levels. These findings may result from endothelial cell activation or damage at the ulcer site.

Recurrent aphthous ulcers: a review of diagnosis and treatment

Recurrent aphthous ulcers, or RAU--also called canker sores--are among the oral mucosal conditions that dentists and physicians see most commonly in their patients. Several systemic conditions are associated with oral aphthouslike ulcers, and aphthae themselves often are mistaken for recrudescent oral herpes simplex virus, or HSV, infections. This article will review RAU, describe systemic conditions associated with aphthous-like ulcerations and discuss the differences between RAU and recrudescent oral HSV infections.

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

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

Triamcinolone acetonide versus chlorhexidine for treatment of recurrent stomatitis

This study compared the efficacy of pain control of two medications, used to treat recurrent aphthous stomatitis, placed under a physical barrier of cyanoacrylate. Thirty patients with recurrent aphthous stomatitis were selected from the records of the Diagnostic Referral Clinic at Indiana University School of Dentistry and randomly divided into three groups; one group was a control. Experimental groups received a topical application of either triamcinolone acetonide (0.025%) or chlorhexidine digluconate (0.12%). Medications were covered by isobutyl cyanoacrylate (Iso-Dent). Controls received the Iso-Dent only. Patients kept a diary to record their pain level on a 10 cm visual analog scale until the lesion healed. Ulcer episodes were treated for 12 weeks. Because some patients had multiple episodes, a total of 35 ulcer episodes were available for analysis. The mean number of ulcer days for each group was not significantly different. ANOVA with repeated measures for 10 days on each patient was first performed. A highly significant difference in pain intensity and perception was found at different days (p < 0.0001). No significant difference was found between the triamcinolone acetonide and chlorhexidine gluconate (p < 0.49).

Collagenase and stromelysin in recurrent aphthous ulcers (RAU)

Six patients with recurrent aphthous ulcers were studied for the presence of matrix metalloproteinases (MMP) 1, 3, and 8 in the lesions and in the clinically unaffected control mucosa obtained from the opposite side. MMP-type specific antisera were applied in the avidin-biotin-peroxidase complex staining method. Neutrophil-type collagenase (MMP-8) was found intracellularly in the connective tissue under the necrotized epithelium, and also laterally to the ulcer in association with the basement membrane. Fibroblast-type collagenase (MMP-1) and stromelysin (MMP-3) were found in the epithelial cells adjacent to the ulcerous lesion. They were found also in the endothelium of capillary blood vessels and postcapillary venules and also in some macrophage- and fibroblast-like mononuclear cells in the lamina propria laterally to the ulcer. A small number of MMP-1 and MMP-3 positive cells were noted in the control biopsies obtained from the clinically uninvolved control mucosa. These findings suggest regional differences in the distribution of the two main collagenases, implying distinct roles in tissue destruction and remodeling.

Are recurrent oral aphthous ulcers of viral etiology?

The etiology of recurrent oral aphthous ulcers (RAU) remains unsolved. The present article relates previous immunopathologic findings in RAU to a possible viral etiopathogenesis with special reference to the herpes virus family. It is concluded that RAU might be of viral etiology, and it is furthermore speculated that the aphthous ulcers may be the clinical manifestation of 'latent' varicella-zoster virus reactivation (reinfection).

Recurrent aphthous stomatitis. A study of the clinical characteristics of lesions in 93 cases

We studied the clinical characteristics of 93 patients with recurrent aphthous stomatitis (RAS); 66 corresponded to minor aphthae (MiRAS), 20 to major aphthae (MaRAS), and 7 to herpes-like ulcerations (HU). MiRAS was seen to present the lowest rate of recurrences, as well as the shortest duration and the fewest lesions per episode. In turn, MaRAS presented the longest duration per recurrence, along with a number of lesions and recurrences that was lower than in HU but greater than in cases of MiRAS. Finally, HU developed the greatest number of lesions and recurrences. When we classified RAS according to the rate of episodes, no statistically significant differences were observed among the three types in terms of patient age, number and duration of lesions, or evolution time of the oral disorder.

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.