Single application of topical doxycycline in management of recurrent aphthous stomatitis: a systematic review and meta-analysis of the available evidence

The Impact of Vitamin Deficiencies on Oral Manifestations in Children

Vitamins play a vital role in human health, particularly in the development and maintenance of oral health in children. These nutrients are broadly categorized into fat-soluble and water-soluble types, crucial for children's well-being. The objective of this study is to investigate the impact of vitamin deficiencies on the oral health of children, focusing on how these deficiencies contribute to various oral health issues and determining the relationship between specific vitamin shortages and oral diseases. Findings indicate that shortages in vitamins A and D lead to enamel issues and a higher susceptibility to dental diseases, vitamin E assists in treating oral mucositis, and vitamin K is essential for blood clotting in dental surgeries. Deficits in B-complex and vitamin C result in enamel hypomineralization and soft tissue ailments, including aphthous stomatitis and gingival petechiae. Additionally, a lack of vitamin B7 compromises the immune response, increasing oral candidiasis risk. Therefore, vitamin deficiencies markedly affect children's oral health, highlighting the need for joint efforts between dental professionals and caregivers for effective pediatric care. Addressing vitamin deficiencies through supplementation and tailored dental care emphasizes the significance of nutritional health in children's overall and dental well-being, advocating for a collaborative approach to achieve optimal health outcomes.

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.

[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.

Management of Recurrent Aphthous Stomatitis: An Indian Expert Consensus

Recurrent aphthous stomatitis (RAS) is characterized by painful, oral mucosal ulcers with wide range of prevalence ranging from 2 to 78%. Etiology of RAS is idiopathic and multifactorial. There are numerous gaps in assessment and management of RAS and the absence of guidelines or a consensus document makes the treatment further difficult. The aim of this document is to provide an Indian expert consensus for management of RAS. Experts from different specialties such as Otorhinolaryngology, Oral Medicine/Dentistry and Internal Medicine from India were invited for face to face and online meetings. After a deliberate discussion of current literature, evidence and clinical practice during advisory meetings, experts developed a consensus for management of RAS. We identify that the prevalence of RAS may lie between 2 and 5%. In defining RAS, we advocate three or more recurrences of aphthous ulcers per year as criterion for RAS. Investigation should include basic hematological (complete blood count) and nutritional (serum vitamin B12, and iron studies) parameters. Primary aim of treatment is to reduce the pain, accelerate ulcer healing, reduce the recurrences and improve the quality of life. In treating RAS, initial choice of medications is determined by pain intensity, number and size of ulcers and previous number of recurrences. Topical and systemic agents can be used in combination for effective relief. In conclusion, this consensus will help physicians and may harmonize effective diagnosis and treatment of 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.

Efficacy of Topical Intervention for Recurrent Aphthous Stomatitis: A Network Meta-Analysis

Background and objectives: To compare the efficacy and safety of topical interventions used for recurrent aphthous stomatitis. Materials and Methods: This network meta-analysis was conducted in accordance with the PRISMA statement. We searched four electronic databases, PubMed, Web of Science (WOS), Cochrane Central Register of Controlled Trials and Embase, for randomized controlled trials reporting efficacy and safety data on topical interventions for recurrent aphthous stomatitis. We performed a quality evaluation using a methodology based on the Cochrane Handbook. Two authors independently extracted data on healing effect, size reduction effect, symptom reduction effect, recurrence and safety assessment. Network meta-analysis was then performed using ADDIS and RevMan. Results: A total of 72 trials (5272 subjects) involving 29 topical interventions were included. Honey, lnsulin liposome gel, laser, amlexanox, glycyrrhiza and triamcinolone had better efficacy performance. Probiotics and chlorhexidine helped to prolong ulcer intervals and reduce recurrence. Doxycycline and penicillin had a high risk of adverse events. Hematologic evaluation showed no preference. The rank possibility of size-reducing effect and symptom-reducing effect supported the short-term effect of laser and the long-term effect of probiotics. Conclusions: We recommend the use of laser as a short-term intervention during the exacerbation phase of RAS and probiotics as a long-term intervention during the exacerbation and remission phases of RAS.

Procyanidins and Their Therapeutic Potential against Oral Diseases

Procyanidins, as a kind of dietary flavonoid, have excellent pharmacological properties, such as antioxidant, antibacterial, anti-inflammatory and anti-tumor properties, and so they can be used to treat various diseases, including Alzheimer’s disease, diabetes, rheumatoid arthritis, tumors, and obesity. Given the low bioavailability of procyanidins, great efforts have been made in drug delivery systems to address their limited use. Nowadays, the heavy burden of oral diseases such as dental caries, periodontitis, endodontic infections, etc., and their consequences on the patients’ quality of life indicate a strong need for developing effective therapies. Recent years, plenty of efforts are being made to develop more effective treatments. Therefore, this review summarized the latest researches on versatile effects and enhanced bioavailability of procyanidins resulting from innovative drug delivery systems, particularly focused on its potential against oral diseases.

Mannose-binding lectin serum levels and (Gly54asp) gene polymorphism in recurrent aphthous stomatitis: A case-control study

Objectives: Dysregulation of the immune response appears to play a significant role in recurrent aphthous stomatitis (RAS) development. The main objective of this case–control study is to investigate the blood levels of mannose-binding lectin (MBL) and the frequency of the MBL2 gene (gly54asp) polymorphism in RAS patients, including 40 RAS patients and 40 healthy controls. Methods: Serum MBL levels were determined by ELISA, while the PCR-restriction fragment length polymorphism was used in MBL2 genotyping. Results: The median serum MBL level was significantly lower in the RAS group than in the control group (975 ng/mL (545–1320) vs. 1760 ng/mL (1254–2134); p≤ 0.001). The MBL levels were significantly lower in the BB genotype, whereas they were significantly higher in the wild type AA with a median of 525 and 1340 ng/mL, respectively (p =0.005). The B allele was expressed in significantly higher percentages of RAS patients than in controls. There was no significant association between MBL serum levels (p=0.685) or MBL2 codon 54 genotypes (p=0.382) with the type of ulcers. Conclusion: There was an association between low MBL serum levels and the variant allele B of the MBL2 (gly54asp) gene, and the susceptibility to RAS. As a result, potential novel therapeutic options for RAS patients with MBL deficiency should be investigated.

Zinc supplementation for prevention and management of recurrent aphthous stomatitis: a systematic review

BACKGROUND

Recurrent aphthous stomatitis (RAS) is a very common oral ulcerative disease with no definitive cure. Growing evidence suggests a significant association between zinc deficiency and RAS.

OBJECTIVES

To assess the efficacy of systemic zinc supplementations in the prevention and management of RAS.

METHODS

Five databases were searched for all English and Chinese studies published up to November 2020. All clinical trials that assessed the efficacy of zinc supplementations in the management and/or prevention of RAS were included.

RESULTS

Seven clinical trials comprising 482 RAS patients (250 in zinc group) fulfilled the inclusion criteria. The follow-up period ranged from three months to one year. Five studies showed significantly better efficacy of zinc in reducing the recurrence rates of RAS, whereas two studies did not report any significant differences compared to the controls. Four studies reported on signs/symptoms of RAS, three of which showed superior outcomes in favour of zinc, while one study reported comparable results.

CONCLUSION

Zinc supplementation seems to be efficacious in the management and prevention of RAS. However, further clinical trials with standardized methodologies and adequate follow-up periods are required to confirm the efficacy of zinc supplementations.

Efficacy of hyaluronic acid for recurrent aphthous stomatitis: a systematic review of clinical trials

OBJECTIVES

Recurrent aphthous stomatitis (RAS) is a very common oral mucosal disease, and its management is quite challenging with no definitive cure being available so far. Many studies have tried hyaluronic acid (HA) for alleviating signs and symptoms of RAS. The present systematic review sought to assess the available evidence regarding the efficacy of HA in management of RAS.

METHODS

Two reviewers independently conducted extensive search in four online databases (PubMed, Scopus, Web of Science, and Google Scholar) and the gray literature, with no restriction to date or language of the publication. All clinical trials that assessed the efficacy of HA in reducing signs and symptoms of RAS were included. Risk of bias was assessed by two reviewers independently, using the Cochrane assessment tool. Due to substantial heterogeneity, no meta-analysis was feasible.

RESULTS

Out of the 75 identified articles, nine clinical trials involving 538 RAS patients (259 in HA group) were included. The risk of bias was high in five studies, low in one study, and unclear in three studies. The comparative groups varied greatly across the included studies: triamcinolone (in three studies), chlorhexidine mouthwash, lidocaine, placebo, iodine glycerin, diclofenac, and laser therapy. Overall, the results revealed a good efficacy of HA in alleviating pain and shortening the healing time of RAS, without any reported side effects. Compared to triamcinolone, HA showed superior results in one study, and comparable results in two studies.

CONCLUSIONS

The available evidence suggests that HA is a promising treatment option for RAS. However, given the huge heterogeneity of the included studies and high risk of bias in some of these studies, the evidence is inconclusive. Further well-designed clinical trials with standardized methodologies and adequate sample sizes are warranted to discern the efficacy of HA for RAS.

CLINICAL RELEVANCE

Hyaluronic acid might be a viable alternative therapeutic option for patients with RAS.

Association between serum zinc levels and recurrent aphthous stomatitis: a meta-analysis with trial sequential analysis

OBJECTIVES

The present meta-analysis sought to investigate the potential association between zinc levels and recurrent aphthous stomatitis (RAS).

METHODS

A comprehensive search of online databases (PubMed, Scopus, Web of Science, and China National Knowledge Infrastructure (CNKI)) was conducted to identify all English and Chinese studies published up to August 2020. All case-control studies that assessed plasma/serum zinc levels were eligible for inclusion. Data were analyzed using Comprehensive Meta-Analysis software version 2.2.046 (Biostat, Englewood, NJ, USA). Trial sequential analysis (TSA) was conducted with the trial sequential analysis program.

RESULTS

Nineteen case-control studies, involving 1079 RAS cases and 965 controls, were included in the meta-analysis. The pooled results of 19 studies showed that zinc level was significantly lower in RAS patients than in healthy controls (weighted difference in means = - 21.092, 95% CI - 26.695 to - 15.490, I² = 95.375%, P < 0.001). Upon subgroup analysis by geographic distribution of the sample (Chinese vs. others), the association remained significant in each individual subgroup, although the association was more pronounced among Chinese populations. TSA indicated that the current studies surpassed the required information size, confirming that the differences were reliable.

CONCLUSION

The results suggest a significant association between low serum zinc levels and the occurrence of RAS. Although TSA confirmed a solid conclusion, conducting large-scale studies with the highest standards of quality is encouraged.

CLINICAL RELEVANCE

Determining zinc levels should be considered in diagnosis, management, and prevention of RAS.

The clinical efficacy and safety of traditional Chinese medicine in the treatment of recurrent aphthous stomatitis: A protocol of systematic review and meta-analysis

BACKGROUND

The objective of this meta-analysis was to summarize and identify the available evidence from studies to estimate the clinical value of traditional Chinese medicine (TCM) in the treatment of recurrent aphthous stomatitis (RAS) and provides clinicians with evidence on which to base their clinical decision making.

METHODS

This review will include all studies comparing clinical efficacy of TCM in the treatment of RAS. The search strategy will be performed in 9 databases. We will not establish any limitations to language and publication status, published from inception to the August 2020. Two reviewers will screen, select studies, extract data, and assess quality independently. Outcome is clinical efficacy, pain relief, duration of wound healing, effect on wound healing, rate of recurrence, adverse events, and safety. The methodological quality including the risk of bias of the included studies will be evaluated. We will carry out statistical analysis using RevMan 5.3 software.

RESULTS

This study will summarize current evidence to assess the efficacy and safety of TCM in the treatment of RAS.

CONCLUSION

The findings of this study will provide helpful evidence for the clinician, and will promote further studies, as well as studying the value of TCM.

REGISTRATION NUMBER

INPLASY202080126 (DOI number: 10.37766/inplasy2020.8.0126).