Recurrent Aphthous Stomatitis

Hydroxypropyl Cellulose-Based Orally Dissolving Film Loaded with Insoluble Dexamethasone for Treatment of Oral Ulcers

Oral ulcers present as recurrent and spontaneous lesions, often causing intolerable burning pain that significantly disrupts patients' daily lives and compromises their quality of life. In addressing this clinical challenge, oral dissolving films (ODFs) have emerged as promising pharmaceutical formulations for oral ulcer management due to their rapid onset of action, ease of administration, and portability. In this study, ODFs containing the insoluble drug dexamethasone (Dex) were formulated for the treatment of oral ulcers in rabbits using a solvent casting method with ethanol as the solvent. To optimize the composition of the ODFs, a Box-Behnken Design (BBD) experiment was employed to investigate the effects of varying concentrations of hydroxypropyl cellulose (HPC), low-substituted hydroxypropyl cellulose (L-HPC), and plasticizer (glycerol) on key parameters, such as disintegration time, tensile strength, and peel-off efficiency of the films. Subsequently, the film properties of the Dex-loaded ODFs (ODF@Dex) were thoroughly assessed, revealing favorable attributes, including homogeneity, mechanical strength, and solubility. Notably, the use of ethanol as the solvent in the ODF preparation facilitated the homogeneous distribution of insoluble drugs within the film matrix, thereby enhancing their solubility and dissolution rate. Leveraging the potent pharmacological activity of Dex, ODF@Dex was further evaluated for its efficacy in promoting ulcer healing and mitigating the expression of inflammatory factors both in vitro and in vivo. The findings demonstrated that the ODF@Dex exerted significant antiulcer effects by modulating the PI3K/Akt signaling pathway, thus contributing to ulcer resolution. In conclusion, our study underscores the potential of HPC-based ODFs formulated with ethanol as a solvent as a promising platform for delivering insoluble drugs, offering a viable strategy for the clinical management of oral ulcers.

Effectiveness of low-level laser therapy in reducing pain score and healing time of recurrent aphthous stomatitis: a systematic review and meta-analysis

BACKGROUND

Recurrent aphthous stomatitis (RAS) is a common chronic inflammatory oral disease that negatively impacts the quality of life. Current therapies aim to reduce pain and healing process yet challenges such as rapid loss due to salivary flushing in topical drugs and adverse effects due to prolonged use of systemic medications require further notice. Low-level laser therapy is reported with immediate pain relief and faster healing thus preserving the potential for optimal treatment modalities. This review critically analyses and summarizes the effectiveness of LLLT in reducing pain scores and healing time of RAS.

METHODS

A systematic search was conducted in ScienceDirect, PubMed, and Scopus using keywords of low-level laser therapy, photo-biomodulation therapy, and recurrent aphthous stomatitis. RCTs between 1967 to June 2022, presenting characteristics of the laser and reporting pain score and/or healing time of RAS after irradiation were included. Animal studies and recurrent aphthous ulcers with a history of systemic conditions were excluded. Studies were critically appraised using the RoB 2 tool. A meta-analysis was performed using inverse variance random effects.

RESULTS

Fourteen trials with a total of 664 patients were included. Reduced pain was reported in 13 studies, while shortened healing time was presented in 4. The pooling of two studies after CO2 irradiation demonstrated faster healing time compared to placebo (MD - 3.72; 95% CI - 4.18, - 3.25).

CONCLUSION

Pain score and healing time of RAS were reduced after irradiation with LLLT. RoB resulted in "some concerns" urging well-designed RCTs with larger samples to further assess each laser application for comparison.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42022355737.

Systemic and local effect of oxidative stress on recurrent aphthous stomatitis: systematic review

Recurrent aphthous stomatitis (RAS) is a chronic and recurrent inflammatory disease of the mouth. It is characterised by the appearance of painful ulcers in the oral mucosa. RAS is believed to be a multifactorial disease with genetic predisposition, environmental factors and alterations in the immune system. Oxidative stress, caused by an imbalance between free radicals and the antioxidant system, also appears to be involved in the pathogenesis of RAS. Several risk factors, such as smoking, iron and vitamin deficiency and anxiety, may contribute to the development of the disease. Understanding the underlying mechanisms may help in the prevention and treatment of RAS. We searched PubMed, Scopus and Web of Science databases for articles on oxidative stress in patients with RAS from 2000 to 2023. Studies analysing oxidant and antioxidant levels in the blood and saliva of RAS patients and healthy controls were selected. Of 170 potentially eligible articles, 24 met the inclusion criteria: 11 studies on blood samples, 6 on salivary samples and 7 on both blood and salivary samples. Multiple oxidative and antioxidant markers were assessed in blood and saliva samples. Overall, statistically significant differences were found between RAS patients and healthy controls for most markers. In addition, increased oxidative DNA damage was observed in patients with RAS. Patients with RAS show elevated levels of oxidative stress compared to healthy controls, with a significant increase in oxidative markers and a significant decrease in antioxidant defences in saliva and blood samples.

α-Mangostin hydrogel film with chitosan alginate base for recurrent aphthous stomatitis (RAS) treatment: study protocol for double-blind randomized controlled trial

Background: Recurrent Aphthous Stomatitis (RAS) is a common ulcerative disease of the oral mucosa which is characterized by pain, and recurrent lesions in the oral cavity. This condition is quite painful, causing difficulty in eating, speaking and swallowing. Topical medications have been used for this condition, but the obstacle in using topical medications is the difficulty of achieving drug effects due to saliva wash out. This problem can be overcome by film hydrogel formulation which can protect the ulcer and reduce the pain to some extent. α-mangostin is a xanthone isolated from the rind of the mangosteen fruit. One of the activities of α-mangostin is anti-inflammatory effects, which operate through the characteristic mechanism of inhibiting the inflammatory response. This protocol study aims to investigate the efficacy of an α-mangostin hydrogel film with a chitosan alginate base for recurrent aphthous stomatitis (RAS) in comparison with a placebo over a period of 7 days. Study design: This is a two-arm, double blinding, randomized controlled trial enrolling patients with RAS. The efficacy test of α-mangostin Hydrogel Film will be tested against the placebo. Patients with RAS will be allocated randomly into the two arms and the hydrogel film will be administered for 7 days. The diameter of ulcer and visual analog scale (VAS) score will be used as the primary efficacy endpoint. The outcome measure will be compared between the two arms at the baseline, day 3, day 5, and at the end of 7 days. Discussion: The purpose of this clinical research is to provide scientific evidence on the efficacy of α-mangostin hydrogel film with a chitosan alginate basis in treating recurrent aphthous stomatitis. The trial is expected to improve our capacity to scientifically confirm the anti-inflammatory effectiveness of α-mangostin compounds in a final formulation that is ready to use. Trial registration: NCT06039774 (14 September 2023).

Current Drug Delivery Strategies for Buccal Cavity Ailments using Mouth Dissolving Wafer Technology: A Comprehensive Review on the Present State of the Art

BACKGROUND

Mouth-dissolving wafer is polymer-based matrice that incorporates various pharmaceutical agents for oral drug delivery. This polymeric wafer is ingenious in the way that it needs not be administered with water, like in conventional tablet dosage form. It has better compliance among the pediatric and geriatric groups owing to its ease of administration.

OBJECTIVE

The polymeric wafer dissolves quickly in the oral cavity and is highly effective for a targeted local effect in buccal-specific ailments. It is a safe, effective, and versatile drug delivery carrier for a range of drugs used to treat a plethora of oral cavity-specific ailments that inflict common people, like thrush, canker sores, periodontal disease, benign oral cavity tumors, buccal neoplasm, and malignancies. This review paper focuses thoroughly on the present state of the art in mouth-dissolving wafer technology for buccal drug delivery and targeting. Moreover, we have also addressed present-time limitations associated with wafer technology to aid researchers in future developments in the arena of buccal drug delivery.

CONCLUSION

This dynamic novel formulation has tremendous future implications for designing drug delivery systems to target pernicious ailments and diseases specific to the buccal mucosa. In a nutshell, this review paper aims to summarize the present state of the art in buccal targeted drug delivery.

Comparison of the main pathogenic microorganisms of various common oral diseases in children and adults

The microorganisms in the human body gradually change and maintain a dynamic balance with the development of physiology and pathology. Oral microbiota is one of the most important microbiota in human body. It is not only closely related to the occurrence and development of oral diseases, but also plays an important role in the overall health. In childhood, the population of oral microorganisms is relatively small, but with the growth of age and tooth development, the species and quantity of oral microorganisms are gradually increasing. Different oral diseases also have their corresponding main microorganisms, and these dominant microorganisms change at different stages of the disease. In this review, we summarized and compared the main pathogenic microorganisms of several common oral diseases in children and adults. In addition, the possible association and difference between adults and children of the main pathogenic microorganisms in different stages of the same or different diseases are also discussed in order to provide research data for the development and diagnosis of common oral diseases in children and adults.

[Recurrent aphthous stomatitis]

Recurrent aphthous stomatitis (RAS) is the most common clinical disease of the oral mucosa. Its prevalence in the general population varies between 5 and 25%, with its peak appearance in the second decade of life. So far, the etiopathogenesis is not clear. In genetically predisposed patients, the effect of certain triggering factors would initiate the proinflammatory cytokine cascade directed against certain regions of the oral mucosa. Ulcers are round or oval with well-defined erythematous margins and a shallow ulcerated center covered with a gray or yellowish fibrinous pseudomembrane. The ulcers may reappear at intervals of a few days and months. Given the appearance of periodic thrush in the oral mucosa, the first thing to do is to make a correct differential diagnosis, rule out associated systemic diseases and assess treatable causes before reaching the diagnosis of RAS. At present, there is no curative treatment.

Topical Licorice for Aphthous: A Systematic Review of Clinical Trials

Background

Recurrent aphthous stomatitis (RAS) is the most common ulcerative disease that affects oral mucosa. The coating agents, topical analgesics, and topical steroids are usually used as treatment methods. Glycyrrhiza glabra has been used for RAS treatment based on its anti-inflammatory, antioxidant, and immunomodulatory properties. In this study, a systemic review on the therapeutic effect of topical licorice on RAS management was performed.

Methods

Science Direct, Scopus, Cochrane databases, PubMed Google Scholar, and ResearchGate were searched up to September 2021 to find all English randomized clinical trials studying the effect of G. glabra, or its compositions on RAS. Meta-analysis was not conducted because of data heterogeneity. Articles were reviewed qualitatively, and only those with a Jadad score ≥3 were included. Animal studies, in vitro, review papers, non-English papers, and case reports were excluded.

Results

Six studies with 314 subjects were included after screening. The result showed licorice has significant effects on RAS pain reduction, ulcer size, and healing time. Its effectiveness is related to its dose-dependent anti-inflammatory and antioxidant effects through several mechanisms. It also has antibacterial effects against Streptococci mutans and Porphyromonas gingivalis as another mechanism of action in RAS treatment. In addition, licorice can elevate the epidermal growth factor (EGF) level compared to the control group, which has an essential role in oral mucosal tissue integrity.

Conclusion

Licorice extract has been used in different dosage forms, including paste, patch, and mouthwash with concentrations of 1% or 5%. The healing time after licorice therapy is expected to be within 4-8 days. Licorice did not show any adverse effect in the intervention groups, indicating its effectiveness and safety in RAS treatment.

Probiotic-loaded calcium alginate/fucoidan hydrogels for promoting oral ulcer healing

Probiotics are beneficial bacteria located in the oral cavity which exhibit antimicrobial properties and contribute to the regulation of immune function and the modulation of tissue repair. Fucoidan (FD), a marine prebiotic, may further enhance the ability of probiotics to promote ulcer healing. However, neither FD nor probiotics are attached to the oral cavity and neither are well-suited for oral ulcer healing owing to the wet and highly dynamic environment. In this study, probiotic-loaded calcium alginate/fucoidan composite hydrogels were developed for use as bioactive oral ulcer patches. The well-shaped hydrogels exhibited remarkable wet-tissue adhesion, suitable swelling and mechanical properties, sustained probiotic release, and excellent storage durability. Moreover, in vitro biological assays demonstrated that the composite hydrogel exhibited excellent cyto/hemocompatibility and antimicrobial effects. Importantly, compared to commercial oral ulcer patches, bioactive hydrogels show superior therapeutic capability for promoting ulcer healing in vivo by enhancing cell migration, inducing epithelial formation and orderly collagen fiber deposition, as well as facilitating neovascularization. These results demonstrate that this novel composite hydrogel patch demonstrates great potential for the treatment of oral ulcerations.

Triamcinolone acetonide release modelling from novel bilayer mucoadhesive films: an in vitro study

OBJECTIVES

Recurrent aphthous stomatitis (RAS) is a painful disorder that commonly appears as ulcers on the oral mucosa, lasting ∼two weeks (minor) to months (major and herpetiform). Current treatment often necessitates the use of topical steroids in the form of pastes, mouthwashes, or gels, but these forms are often ineffective due to inadequate drug contact time with the ulcers. In this study, the performance of novel bilayer mucoadhesive buccal films loaded with triamcinolone acetonide (TA) has been evaluated for targeted drug delivery.

METHODS

Experimental mucoadhesive films of hydroxypropyl methylcellulose (HPMC), polyvinyl alcohol (PVA), and polyvinyl pyrrolidone (PVP) were prepared by the solvent casting method, and ethyl cellulose (EC) was applied as the backing layer. The films were characterized for their physical properties, including swelling index (SI), folding endurance, adhesion force with porcine buccal mucosa, residence time and in-vitro drug release.

RESULTS

The data showed that the films were flexible with folding endurance> 300 times. With porcine buccal mucosa i) suitable adhesion forces were obtained (between 2.72 and 4.03 N), ii) residence times of> 24 h, and iii) surface pH between 6.8 and 7.1 indicating they would be non-irritant. All films released 100% TA over 6 h, but with varying profiles. The release of TA (over 6 h) from PVP-free films followed Fickian diffusion kinetics (diffusion-controlled release of drug), whereas the mechanism of release from PVP-containing films was found to be a superposition of diffusion-controlled and erosion-controlled release (anomalous).

SIGNIFICANCE

The developed films hold great promise for potentially treating RAS and other oral conditions.

Study of hematoporphyrin monomethyl ether-mediated blue-light photodynamic therapy in the treatment of oral ulcers infected with Staphylococcus aureus: In vivo evaluation

Clinical suppurative infection is mainly caused by Staphylococcus aureus. Although many antibiotics can be used to kill S. aureus, the resulting resistance problem is difficult to solve. Therefore, it is necessary to seek a new sterilizing method to solve the problem of drug resistance of S. aureus and improve the therapeutic effect of infectious diseases. Photodynamic therapy (PDT) has become an alternative for the treatment of a variety of drug-resistant infectious diseases due to its advantages of non-invasive, specific targeting, and no drug resistance. We have confirmed the advantages and experimental parameters of blue-light PDT sterilization in vitro experiments. This study aimed to treat buccal mucosa ulcer of hamster infected with S. aureus according to the parameters obtained in vitro experiment, and observe the bactericidal effect of hematoporphyrin monomethyl ether (HMME) mediated blue-light PDT in vivo and its therapeutic effect on tissue infection. The results indicated that HMME mediated blue-light PDT can effectively kill S. aureus in vivo and promote the healing of the oral infectious wound.The study findings lay a foundation for carrying out more HMME mediated blue-light PDT sterilizing therapy.

Network pharmacology and bioinformatics analyses identify the intersection genes and mechanism of Huang Bai for recurrent aphthous stomatitis

Recurrent aphthous stomatitis (RAS) are complex inflammatory diseases caused by multi-factors, which severely impact patient quality of life. However, there is still no effective treatment method for RAS without side effects. Traditionally, Cortex Phellodendri known as "Huang Bai" was used to treat RAS for antibacterial and anti-inflammatory properties in China. Network pharmacology methods and bioinformatics analysis were utilized to search and fish incorporating target. Network analysis and silico validation were used to discover the pharmacological mechanisms of "Huang Bai" for the treatment of RAS. A total of 25 active ingredients in HB, 200 drug targets, and 578 differentially expressed genes (DEGs) between Recurrent aphthous stomatitis and normal samples were obtained. The Gene Ontology enrichment analysis revealed that the immune response was the most significantly enriched term within the DEGs. The KEGG pathway analysis identified 60 significant pathways, most of which involved in the inhibition of inflammation and regulation of immunological response. The functions are dependent on a multi-pathway, particularly the TNF signaling pathway and the HIF-1 signaling pathway. We identified six hub genes in the PPI network, most of which were validated as highly expressed in oral ulcers by DiseaseMeth databases. In addition, molecular docking displayed that the primary molecule combined well with the key targets. "Huang Bai" contains potential anti-RAS active compounds. This study reflects the multi-component multi-target multi-pathway action characteristics of "Huang Bai." Our study provides potential biomarkers or treatment targets for further research.

Observations on the clinical efficacy of rhaFGF combined with Vitamin B complex for patients with Severe Recurrent Aphthous Ulcer

Objectives:

To observe the therapeutic effect of rha FGF combined with vitamin B complex on severe recurrent aphthous ulcers (RAUs).

Methods:

Ninety patients with severe RAU (grade III and IV) admitted to Chinese PLA General Hospital from May 2018 to May 2019 were selected and divided into two groups using a random number table, 45 patients/group. Patients in the control group gargled with a mixture of vitamin B complex (250 ml of 9% normal saline +250 ml of vitamin B complex +160,000 U of gentamicin +25 ml of lidocaine) after oral cleaning; patients in the observation group gargled with a mixture of the same ratio after oral cleaning and then sprayed rhaFGF on their oral ulcers. The clinical symptoms and treatment effects of the 2 groups within 1 week of medication were compared.

Results:

The total effective rate of treatment was 97.78% in the observation group and 82.22% in the control group; the difference was statistically significant (P <0.05). The time to ulcer pain disappearance and eating recovery and the ulcer healing time in the observation group were significantly shorter than those in the control group (P <0.05).

Conclusion:

rhaFGF combined with vitamin B complex has a significant therapeutic effect for patients with severe RAU; it can relieve pain and illness faster and shorten the healing time of ulcers.

Occurrence of Recurrent Aphthous Stomatitis (RAS) as a Rare Oral Manifestation in a Patient with Gilbert's Syndrome

Recurrent aphthous stomatitis is an ulcerative disease of the oral cavity and can occur in isolation or as a manifestation of many systemic diseases. It is a quite common entity and may hence often be overlooked as an isolated lesion. Gilbert's syndrome is a genetic disorder where a deficiency of an enzyme associated with the conjugation of bilirubin results in unconjugated hyperbilirubinemia. The disease is generally asymptomatic and is aggravated by certain trigger factors. No associated oral manifestations are known. In this case report, we discuss the concomitant presence of recurrent aphthous stomatitis in a patient of Gilbert's syndrome. The presence of such recurrent stomatitis may represent as an oral manifestation of Gilbert's syndrome. Early identification of these entities may improve the overall quality of life of the patient.

Nanozymes go oral: nanocatalytic medicine facilitates dental health

Nanozymes are multi-functional nanomaterials with enzyme-like activity, which rapidly won a place in biomedicine due to their number of nanocatalytic materials types and applications. Yan and Gao first discovered horseradish peroxidase-like activity in ferromagnetic nanoparticles in 2007. With the joint efforts of many scientists, a new concept-nanocatalytic medicine-is emerging. Nanozymes overcome the inherent disadvantages of natural enzymes, such as poor environmental stability, high production costs, difficult storage and so on. Their progress in dentistry is following the advancement of materials science. The oral research and application of nanozymes is becoming a new branch of nanocatalytic medicine. In order to highlight the great contribution of nanozymes facilitating dental health, we first review the overall research progress of multi-functional nanozymes in oral related diseases, including treating dental caries, dental pulp diseases, oral ulcers and peri-implantitis; the monitoring of oral cancer, oral bacteria and ions; and the regeneration of soft and hard tissue. Additionally, we also propose the challenges remaining for nanozymes in terms of their research and application, and mention future concerns. We believe that the new catalytic nanomaterials will play important roles in dentistry in the future.