Impact of haematologic deficiencies on recurrent aphthous ulceration: a meta-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.

Serum level of vitamin D in patients with recurrent aphthous stomatitis: A systematic review and meta-analysis of case control studies

OBJECTIVES

Recurrent aphthous stomatitis (RAS) is an ulcerative condition with unknown etiology. The effect of vitamin D in the etiology of RAS is still a matter of controversy. In this study, we aimed at review the available evidence on the role of vitamin D deficiency in RAS etiology.

MATERIAL AND METHODS

PubMed, Cochrane Library for Systematic Reviews, ISI Web of Science, Scopus, and EmBase were systematically searched for evidence on RAS and vitamin D up to January 2020. Retrieved records were screened and assessed by two of the authors independently. Newcastle-Ottawa scale was used to assess the quality of individual studies. AMSTAR tool was used for assessing the quality of the study.

RESULTS

Eight studies including 383 healthy control and 352 patients with RAS were eligible for the meta-analysis. Serum vitamin D levels were significantly lower in RAS patients. The weighted mean difference was -7.90 (95% CI: -11.96 to -3.85).

CONCLUSIONS

The results highlighted the importance of vitamin D deficiency in the etiology of RAS. However, more studies are needed to reach a robust decision. The observed association between vitamin D and RAS is probably due to the effect of vitamin D on the immune system.

Hematological parameters, obesity, stress and oxidant - antioxidant indicators in patients with or without recurrent aphthous stomatitis: A case control study

INTRODUCTION

Recurrent Aphthous Stomatitis (RAS) is a frequent chronic disease of the oral cavity that affects 5-25 % of the population with a plethora of predisposing factors. Despite its equivocal etiology, immune alterations, hematologic deficiencies and oxidative stress has been reported to be significant etiologic factors. Stress and obesity are other environmental factors that have been studied to understand associations with RAS.

OBJECTIVES

This study investigated the association of stress, hematologic parameters, oxidative indices and other selected salivary factors in a case control study on RAS Methods: Twenty-two participants each in both case and control groups were recruited with saliva and serum samples collected from them after a self-administered Recent Life Changing Questionnaire (RLCQ). OHI-S and salivary flow rate (SFR) were calculated with selected hematologic parameters and oxidative indices such as Total oxidant (TOS) and anti-oxidant (TAS) levels and their ratio - Oxidative Stress Index (OSI). Anti-oxidative indices of Ferric-Reducing Antioxidant Power (FRAP) and Glutathione Peroxidase Activity (GsPHx) were also estimated.

RESULTS

The RAS group had a significantly higher RLCQ scores at a median of 145 more than the control (57.5). There was no significant in their obesity indices, however there was a significant higher mean in the ESR (p< 0.0001) and Vit B12 (p = 0.0001); OHI-S was also significantly higher in the RAS group with a median of 1.65. Both the salivary and serum TOS were significantly higher in the RAS (10.0 ± 3.8, 15.4 ± 8.9) compared to the control group (7.92 ± 1.49, 9.56 ± 3.5). GsPHx activity was significantly higher in both the saliva and serum in the control group (0.08 ± 0.08, 0.19 ± 0.11) while nil significant difference was found in the FRAP activity. Regression showed most important variables to be the salivary GsPHx activity, followed by serum OSI and GsPHx activity.

CONCLUSION

The oxidative indices of TOS, TAS and GsPHx can serve as significant biomarkers in detecting RAS. This further corroborates the role of immune dysregulation in the etiology and predisposition to 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.

Evaluation of biochemical variables in patients with recurrent aphthous stomatitis

PURPOSE

We investigated the effects of various biochemical agents on the etiopathogenesis of recurrent aphthous stomatitis (RAS).

METHODS

We enrolled 70 RAS patients and 70 healthy volunteers. Peripheral venous blood samples were collected. We performed complete blood counts, then measured the levels of ferritin, vitamin B12, iron, magnesium, phosphorus, calcium, thyroid-stimulating hormone, T3, T4, and 25-hydroxy D3.

RESULTS

The groups did not differ in terms of age (p = 0.912) or sex (p = 0.612). The levels of ferritin and 25-hydroxy vitamin D were significantly lower in RAS patients (both p ˂ 0.05).

CONCLUSION

Vitamin D and/or ferritin deficiency may induce RAS. Measurements of vitamin D and ferritin may assist diagnosis and follow-up.

Relationship between dietary factors and recurrent aphthous stomatitis in China: a cross-sectional study

Objective

Recurrent aphthous stomatitis (RAS), a common oral mucosal disorder characterized by chronic, inflammatory, and ovoid ulcers, has a complex etiology. The purpose of the study was to investigate the specific dietary factors influencing the prevalence of RAS.

Methods

A total of 754 participants aged 18 to 59 years were enrolled in this descriptive cross-sectional study. An anonymous questionnaire was adopted to investigate the distribution of RAS, dietary factors, self-reported trigger factors, and therapeutic methods.

Results

Among all participants, the prevalence rate of RAS was 21.4%. Univariable analysis showed that fruit, dairy products, vegetables, and water, but not fried foods, fermented foods, spicy foods, and eggs, were preventive factors against RAS. After adjusting for age and sex, multivariable regression analysis suggested that fruit (adjusted odds ratio [aOR] = 0.430, 95% confidence interval [CI] = 0.218–0.847) and water (aOR = 0.294, 95% CI = 0.119–0.726) were protective factors against RAS.

Conclusion

This study found that the consumption of fruit and water was negatively associated with RAS. These results imply a potential adjunctive and complementary role of food in RAS treatment and some feasible means of RAS prevention.

Psychological factors as the risk factor of mouth ulcers: A two-sample Mendelian randomization study

To examine whether psychological traits (PT) had causal effects on Mouth Ulcers (MU), we applied two-sample Mendelian randomization (MR) to genetics association summary statistics of eleven PT and MU. After the adjustment of outlier variants, genetic correlations and multiple testing, well-being (WB) spectrum PT like life satisfactory (odds ratio [OR] = 0.638 per one standard deviation increment of PT score) had protective effects on MU. Reverse WB traits like neuroticism (OR = 1.60) increased the risk of MU. The lack of well-being characteristics may increase the risk of MU, which highlighted the value of preventive oral care for people who have a reverse mental condition.

Oral mucosal pellicle as an immune protection against micro-organisms in patients with recurrent aphthous stomatitis: A hypothesis

Recurrent Aphthous Stomatitis (RAS) is the most common ulcerative diseases of oral mucosa affecting an estimate of 20% of the world's population. Majority of the people affected by RAS are under 30 years of age. RAS is located on the lining (non-keratinized) oral mucosa, i.e. buccal mucosa, lateral side of the tongue, soft palate, lip mucosa, or the floor of mouth. An aphthous ulcer develops when lymphocytic cells infiltrate into the epithelium and cause an edema due to transient inflammatory stimuli. Bacteria, viruses and fungi have been suggested to cause aphthous lesions, but findings regarding oral pathogens are conflicting. Prior consensus has been that RAS is a multifactorial condition, with microbes, allergies, nutritional deficiencies, genetic factors, certain illnesses, immunodeficiency, hormonal changes, trauma and stress among others, contributing to the condition. In spite of many suggestions and investigations, the etiology and pathophysiology of RAS remains uncertain. Our hypothesis focuses on mucin proteins that have been shown to play a role in the formation of protective mucosal pellicle, which serves as the first line of defense between oral epithelium and pathogens within the oral cavity. Mucins, including transmembrane mucin 1 (MUC1), and salivary mucins MUC5B and MUC7 form a protein network that is strongly retained to oral epithelium. The role of the mucosal pellicle in pathophysiology of RAS is unknown. Structural variations have been found in the salivary MUC7 terminal end oligosaccharides in RAS patients, rendering the protein unable to agglutinate pathogens. Furthermore, low levels of MUC1 fail to provide a scaffold for assembly of salivary mucins. We introduce a new hypothesis, the alterations in the structure of these glycoproteins could have a profound impact on the oral mucosal barrier function. On the other hand, micro-organisms secreting their mucolytic enzymes destroy the mucosal pellicle causing oral ulcers.

Role of vitamin B12 in treating recurrent aphthous stomatitis: A review

Vitamin B12, a water-soluble vitamin, plays a vital role in the formation of hematopoietic stem cells and has been associated with oral mucosal diseases, mainly recurrent aphthous stomatitis (RAS). The latter is a debilitating condition, and B12 was proposed as a potential treatment given its role in regenerating oral mucosal tissue. There is conflicting evidence that B12 deficiency causes RAS. Five of the seven randomized controlled trials reviewed used the inactive form of B12 (cyanocobalamin) as intervention, while the other two used the active form (methylcobalamin). Of the latter two, buccal discs (500 μg B12) showed significant improvement and reduced perceived pain in 77% of the subjects, and submucosal injections showed a significant difference in pain, starting from the second day. Moreover, three studies administered vitamin B12 sublingually with different dosages, which revealed that the higher dose (1000 μg) achieved a significant reduction in outbreaks, number, and duration of ulcers, especially after six months. Multivitamins showed no difference in new RAS episodes and duration. Injectable B12 was compared with the oral form, and nearly 50% of the injection group reported a desired response by the eighth week. An ointment form (500 μg) showed a significant reduction in pain levels after two days of treatment. Based on the available literature, we suggest that a daily dose of 1000 μg of vitamin B12 sublingually for six months can be used to treat RAS. Nevertheless, this conclusion should be considered tentative due to the lack of high quality, large scale studies.

Genome wide analysis for mouth ulcers identifies associations at immune regulatory loci

Mouth ulcers are the most common ulcerative condition and encompass several clinical diagnoses, including recurrent aphthous stomatitis (RAS). Despite previous evidence for heritability, it is not clear which specific genetic loci are implicated in RAS. In this genome-wide association study (n = 461,106) heritability is estimated at 8.2% (95% CI: 6.4%, 9.9%). This study finds 97 variants which alter the odds of developing non-specific mouth ulcers and replicate these in an independent cohort (n = 355,744) (lead variant after meta-analysis: rs76830965, near IL12A, OR 0.72 (95% CI: 0.71, 0.73); P = 4.4e−483). Additional effect estimates from three independent cohorts with more specific phenotyping and specific study characteristics support many of these findings. In silico functional analyses provide evidence for a role of T cell regulation in the aetiology of mouth ulcers. These results provide novel insight into the pathogenesis of a common, important condition.

Oral ulcerations are sores of the mucous membrane of the mouth and highly prevalent in the population. Here, in a genome-wide association study, the authors identify 97 loci associated with mouth ulcers highlighting genes involved in T cell-mediated immunity and T_H1 responses.

Healthy lifestyle habits benefit remission of recurrent aphthous stomatitis and RAS type ulceration

In a clinical setting, it is not practical to separate recurrent aphthous stomatitis (RAS) from RAS-type ulceration in every case, so both conditions have been considered together for the purpose of this article. Due to the lack of consistently effective therapeutic options for RAS, other approaches to treat the disease are considered here, beginning with an analysis of possible aetiological factors. The aetiology of RAS, the most common mucosal disease, remains undefined thus far. A few researchers have proposed psychological disorders as a major factor impacting RAS. Some systemic diseases and lifestyle habits are also reported to be associated with RAS; these also impact mental health. I believe that all habits contributing to mental health might also benefit patients with RAS. I suggest that practitioners of oral medicine should recommend a healthy lifestyle to patients with RAS, before prescribing medicines.

Recurrent aphthous ulceration: a review of potential causes and novel treatments

Purpose of article: This review examines studies published between May 2012 and 2017 with a specific interest in potential recurrent aphthous ulceration (RAU) etiologies and treatment modalities/efficacy, including topical treatments, systemic regimens, vitamin repletion, and laser therapy, among others.

MATERIALS AND METHODS

PubMed MEDLINE and Cochrane Database of Systematic Reviews were searched using various combinations of: 'aphthous', 'ulcer', and 'treatment'. The titles and abstracts from the initial literature search were appraised to identify articles for full review and reference sections from each article were searched manually for relevant publications. Both randomized controlled trials and observational reports were included in this review, as some treatment types have not been formally examined in randomized trials. Relevant studies were reviewed, compared, and summarized.

RESULTS

RAU can result from systemic disease and trauma, but recent studies have shown a variety of potential etiologies, ranging from vitamin deficiencies, oral microbiota derangements, hematological considerations, stress, genetic polymorphisms to oxidant-antioxidant imbalances, among others. Many modalities of therapy are available and have proven efficacious.

CONCLUSIONS

As the exact etiology of RAU is still unknown, therapy is based on symptomatic relief.

Oral mucosal injury caused by mammalian target of rapamycin inhibitors: emerging perspectives on pathobiology and impact on clinical practice

In recent years oral mucosal injury has been increasingly recognized as an important toxicity associated with mammalian target of rapamycin (mTOR) inhibitors, including in patients with breast cancer who are receiving everolimus. This review addresses the state-of-the-science regarding mTOR inhibitor-associated stomatitis (mIAS), and delineates its clinical characteristics and management. Given the clinically impactful pain associated with mIAS, this review also specifically highlights new research focusing on the study of the molecular basis of pain. The incidence of mIAS varies widely (2-78%). As reported across multiple mTOR inhibitor clinical trials, grade 3/4 toxicity occurs in up to 9% of patients. Managing mTOR-associated oral lesions with topical oral, intralesional, and/or systemic steroids can be beneficial, in contrast to the lack of evidence supporting steroid treatment of oral mucositis caused by high-dose chemotherapy or radiation. However, steroid management is not uniformly efficacious in all patients receiving mTOR inhibitors. Furthermore, technology does not presently exist to permit clinicians to predict a priori which of their patients will develop these lesions. There thus remains a strategic need to define the pathobiology of mIAS, the molecular basis of pain, and risk prediction relative to development of the clinical lesion. This knowledge could lead to novel future interventions designed to more effectively prevent mIAS and improve pain management if clinically significant mIAS lesions develop.