Recurrent aphthous ulceration: an epidemiological study of etiological factors, treatment and differential diagnosis

Assessment of Quality of Life in Patients with Chronic Oral Mucosal Diseases Using the Indonesian Version of the Chronic Oral Mucosal Disease Questionnaire-15 (COMDQ-15)

INTRODUCTION

Chronic oral mucosal diseases (COMDs) can significantly impair the quality of life (QoL) of affected individuals. Monitoring the overall disease's impact and the efficacy of treatments requires the use of the Chronic Oral Mucosal Diseases Questionnaire-15 (COMDQ-15) as a standardized instrument for measuring QoL in these patients.

OBJECTIVE

This study aimed to assess QoL in patients with COMDs using an Indonesian version of the COMDQ-15.

METHODS

Seventy patients diagnosed with recurrent aphthous stomatitis (RAS), oral lichen planus, autoimmune blistering diseases (ABD), and cheilitis were included. Levels of QoL among different groups of disease were compared. Various potential factors influencing QoL were evaluated. Bivariate analysis was performed to identify factors associated with overall and specific aspects of QoL.

RESULTS

The mean total COMDQ-15 score was 20.83 ± 10.07. The highest scores were in the physical discomfort domain (8.76 ± 4.65), while the lowest was in the medication and treatment domain (2.13 ± 1.99). Physical discomfort was significantly associated with gender, major RAS, and cheilitis. Social and emotional aspects were significantly associated with age and ABD, while patient support was linked to employment status, RAS types, and cheilitis.

CONCLUSIONS

The Indonesian version of the COMDQ-15 is a valid and reliable tool for assessing QoL in patients with COMDs.

Evaluation of the Effects of Punica granatum Flower Tablets on Pain and Healing of Minor Recurrent Aphthous Stomatitis: A Randomized Clinical Trial

OBJECTIVES

The purpose of this study was to determine the therapeutic effect of the Punica granatum (PG) flower on recurrent aphthous stomatitis in comparison with corticosteroid therapy.

MATERIALS AND METHODS

This cross-over randomized clinical trial was conducted on the patients who had been referred to Shiraz Dental School for their RAS in 2021. All the participants used both P. granatum flower tablets and Triadent a month apart for wash-out time and all compared themselves. In the experimental group, 30 patients received pomegranate flower tablets, three tablets daily, for 6 days. In the control group, oral paste Triadent has been prescribed three times a day for 6 days. The visual analog scale (VAS) and the size of RAS were evaluated on Days 0-6. Data were analyzed by SPSS version 21. The Wilcoxon test was used.

RESULTS

The mean age of participants was 27.8 ± 14.77 years old. In this study, 15 patients (50%) were men and 15 patients (50%) were women. The mean value of VAS after using prescribed treatment in both evaluated groups on all days was significantly different such that the VAS values were lower for PG flower tablets than Triadent (p value < 0.05). The size of oral lesions in participants who used PG flower tablets was significantly less than those who used Triadent on all evaluation days (p value < 0.05) except on Day 1 (p value = 0.29). The descending slope of VAS from Days 1 to 6 for both Triadent and PG flower tablet users was significant and noticeable. (p value < 0.05).

CONCLUSION

According to the result of this study, both P. granatum flower tablet and Triadent are useful in reducing the size, period of healing, and VAS of patients with RAS, but the PG flower tablet is more effective.

Oral and oropharyngeal mucosal lesions: clinical-epidemiological study of patients attended at a reference center for infectious diseases

OBJECTIVE

To determine the prevalence, epidemiological profile, and clinical characteristics of Oral or Oropharyngeal Mucosal Lesions (OOPML) in patients attended at the Otorhinolaryngology Service of the Evandro Chagas National Institute of Infectious Diseases (INI-FIOCRUZ) from 2005 to 2017.

METHODS

Statistical analysis of descriptive data from medical records (gender, age, education level, skin color, origin, smoking, alcoholism, HIV co-infection, time of disease evolution, first symptom, and OOPML location) was performed.

RESULTS

Of 7551 patients attended at the service, 620 (8.2%) were included in the study. OOPML were classified into developmental anomalies (n = 3), infectious diseases (non-granulomatous n = 220; granulomatous n = 155), autoimmune diseases (n = 24), neoplasms (benign n = 13; malignant, n = 103), and unclassified epithelial/soft tissue diseases (n = 102). OOPML of infectious diseases (60.5%) and neoplasms (18.7%) were the most frequent. The predominant demographics of patients with OOPML were: males (63.5%), white (53.5%), and those in the fifth to sixth decades of life (43.3%). Local pain (18.1%) and odynophagia (15%) were the most reported first symptoms, and the most frequent OOPML sites were the palatine tonsil (28.5%), hard palate (22.7%), and tongue (20.3%). The median evolution time was three months.

CONCLUSIONS

Infectious OOPML were the most frequent, as expected in a reference center for infectious diseases, and thus, they are likely to be less frequent in general care and/or dental services. Underreporting of OOPML is possible, as oral/oropharyngeal examination is often not included in the routine medical examination. Oral cavity/oropharynx examination should be performed by specialists, such as dentists and otorhinolaryngologists, who have the expertise in identifying OOPML, even in incipient/asymptomatic cases. Given the numerous diseases in which OOPML can present, diagnosis could be facilitated by multidisciplinary teams, potentially enabling the early treatment of diseases, and thus, reduce morbidity and improve prognosis. The use of standardized medical records for oral/oropharyngeal systematic examination could provide relevant tools for differential diagnoses and information for new clinical-epidemiological studies.

LEVEL OF EVIDENCE

Level 3.

Optimization and preparation of a compound cod liver oil film former agent: an orthogonal design

Background: Cod liver oil has anti-inflammatory properties and could help regulate recurrent aphthous stomatitis (RAS). An orthogonal experiment was used to evaluate and improve the dosage form of compound cod liver oil, which has replaced the previously used liniment preparation based on film method. Methods: An orthogonal experiment was adopted, and the appearance and film-forming time of the film coating agents were used as indicators. The optimal ratio in the preparation process for the compound cod liver oil film agent was then optimized. A method for determination of compound cod liver oil film was established using High-Performance Liquid Chromatography (HPLC). Results: The results indicate that the blank films prepared using 55 mg polyvinyl alcohol (PVA) (PVA low), 45 mg of PVA (PVA medium), and 10 mg glycerol had the optimal performance, which was defined as PVAa. The drug-carrying film prepared from 3 mL PVAa (i.e., film-forming material with the optimal proportion), 30 mg dexamethasone acetate, and 30 mg metronidazole had the optimal performance. The verified sample has a complete and smooth appearance, uniform thickness and color, and no evident bubbles, which meets the requirements for a film agent defined in the Chinese Pharmacopoeia, 2020 edition. HPLC was used to determine the major components: dexamethasone acetate, metronidazole, and dyclonine hydrochloride, and the optimal separation effect was obtained. The method has advantages of good specificity, good linear results, high recovery rate, and good repeatability. Conclusion: This study proposes an optimized compound cod liver oil film former agent and preparation method. The results indicate that the compound cod liver oil film former agent had good performance, reflecting the high feasibility of this research method. The detection method of compound cod liver oil film was established by HPLC. The method was feasible, and the validity and stability of the formulation and preparation technology were guaranteed. The role of the newly developed agent in patients with RAS should be investigated further.

Deep learning algorithms for classification and detection of recurrent aphthous ulcerations using oral clinical photographic images

Background/purpose

The application of artificial intelligence diagnosis based on deep learning in the medical field has been widely accepted. We aimed to evaluate convolutional neural networks (CNNs) for automated classification and detection of recurrent aphthous ulcerations (RAU), normal oral mucosa, and other common oral mucosal diseases in clinical oral photographs.

Materials and methods

The study included 785 clinical oral photographs, which was divided into 251 images of RAU, 271 images of the normal oral mucosa, and 263 images of other common oral mucosal diseases. Four and three CNN models were used for the classification and detection tasks, respectively. 628 images were randomly selected as training data. In addition, 78 and 79 images were assigned as validating and testing data. Main outcome measures included precision, recall, F1, specificity, sensitivity and area under the receiver operating characteristics curve (AUC).

Results

In the classification task, the Pretrained ResNet50 model had the best performance with a precision of 92.86%, a recall of 91.84%, an F1 score of 92.24%, a specificity of 96.41%, a sensitivity of 91.84% and an AUC of 98.95%. In the detection task, the Pretrained YOLOV5 model had the best performance with a precision of 98.70%, a recall of 79.51%, an F1 score of 88.07% and an AUC of Precision-Recall curve 90.89%.

Conclusion

The Pretrained ResNet50 and the Pretrained YOLOV5 algorithms were shown to have superior performance and acceptable potential in the classification and detection of RAU lesions based on non-invasive oral images, which may prove useful in clinical practice.

The profile of Oral Health Branch of Rafsanjan Cohort Study (OHBRCS) in Rafsanjan City, southeast of Iran

Oral health status can be affected by some factors including drug abuse, systemic conditions and environmental pollutants. The present study was designed to investigate the most important and prevalent dental and oral conditions in adult population of Rafsanjan with the age of 35-70 years. Dental and oral health cohort center as part of the Rafsanjan Cohort Study (RCS) included in the prospective epidemiological research studies in IrAN was established in 2015. Of 9991 subjects enrolled in the RCS, 8682 people participated in the Oral Health Branch of Rafsanjan Cohort Study (OHBRCS). The OHBRCS included 4021 men and 4661 women with the mean age of 49.94 ± 9.51. The most prevalent of oral lesion in total population was candidiasis and the least was aphthous lesion. The prevalence of candidiasis, white and red lesions, periodontal pocket, dental calculus, CAL and the mean of DMFT were higher in the male group than that of female group (p < 0.05). Candidiasis, herpes, oral cancer, white and red lesions were more prevalent in the older age groups (p < 0.05). The mean of DMFT index in total population was 21.30 and was higher among opium users, men and older age (p < 0.05). Also, the opium users had a higher rate of CAL, periodontal pocket, red and white lesions, and candidiasis but a lower rate of BOP (p < 0.05). Younger people had more decayed and filling teeth compared to other age groups, whereas older people had more missing teeth and a higher DMFT index (p < 0.001).

The effect of Jiaweidaochi powder on Th1/Th2 in rats with recurrent aphthous ulcer

OBJECTIVE

To elucidate the effect of Jiaweidaochi powder on the Th1/Th2 ratio in rats with recurrent aphthous ulcers (RAU).

DESIGN

40 Sprague-Dawley rats were included in this study, randomly divided into a control group, a model group, and three treatment groups (0.5 g/ ml, 1 g/ml, 2 g/ml Jiaweidaochi powder). The RAU model of rats was established by autoantigen injection. The effects of Jiaweidaochi powder on the expression of INFG, IL-4, TBX21, and GATA3 mRNA were detected by real-time PCR. The expression of IFN-γ, IL-4, and IFN-γ/IL-4 proteins in oral ulcer tissue and serum of rats were analyzed by Western blot and ELISA, respectively. The proportion of Th1 cells and Th2 cells in RAU rats was analyzed by flow cytometry.

RESULTS

Jiaweidaochi powder reduced the number, diameter, and duration of oral ulcers in RAU rats. Real-time PCR showed that middle and high-dose Jiaweidaochi powder decreased the expression of INFG TBX21 mRNA and increased the expression of IL-4 and GATA3 mRNA in the oral tissue of RAU rats. ELISA and western blot confirmed that the expression of IFN-γ protein was significantly decreased, and the level of IL-4 protein was increased both in oral tissue and serum of RAU rats treated with middle or high doses of Jiaweidaochi powder. Flow cytometry found that the Jiaweidaochi powder decreased the proportion of Th1 cells and increased the proportion of Th2 cells in RAU rats.

CONCLUSION

This study found that Jiaweidaochi powder promoted the balance of Th1/Th2 in RAU rats, contributing to the healing of RAU.

The Correlation Between IFNG Gene Methylation and Th1|Th2 Cell Balance in ROU and the Interventional Study of Jiaweidaochi Powder

The pathogenesis of recurrent oral ulcers (ROU) is complex, with a long duration of illness and challenging to cure. According to traditional Chinese medicine (TCM),"heat accumulation in the heart-spleen" is one of the main causative factors. Jiaweidaochi powder (JWDCP) is based on the ancient Chinese medicine formula JWDCS, with the addition of Tongcao and gypsum and the removal of Mu Tong. It is generally used to treat "heat accumulation in the heart-spleen." Previous studies have demonstrated that it effectively reduces recurrence rates and is anti-inflammatory in modulating immunity. The ROU rats' model for JWDCP intervention treatment had been established, and histological tests revealed that JWDCP has a therapeutic effect on the pathological changes in the oral mucosa. In addition, the methylation levels of peripheral blood IFNG gene were detected by bisulfite sequencing PCR (BSP), and the methylation levels of the IFNG promoter region in the model group and each dose group were lower than those in the control group. However, no significant methylation differences were observed. Furthermore, the results of enzyme-linked immunosorbent assay (ELISA) and RNA quantitative polymerase chain reaction showed that JWDCP could reduce IFN-γ and IL-4 protein concentrations, with high GATA-3 mRNA production, T-bet mRNAproduction was upgraded, elevated IL-4 mRNA levels, and reduced IFN-γ mRNA levels after treatment (P < 0.001). The expression of transcription factor T-betmRNA and GATA-3 gene mRNA was accompanied by changes in IFN-γmRNA and IL-4mRNA, demonstrating that Th2 type differentiation in RAS suppresses the body's immunity and that the imbalance of transcription factor expression further leads to Th1/Th2 drift. JWDCP is likely to reduce the protein concentration by regulating the imbalance of transcription factors and enhancing antioxidant capacity, thus achieving therapeutic effects. Treatment of recurrent oral ulcer models is not sufficient to reset IFNG methylation levels, correlating with the refractoriness of ROU, further confirming the complexity of epigenetic mechanisms and that epigenetic alterations in specific mediators may persist locally.

[Prevalence of recurrent aphthous stomatitis in a family medical office, Manzanillo, Cuban. A cross-sectional study]

Introduction

Recurrent Aphthous Stomatitis, also known as aphthous ulcers or simply aphthous, is considered the most common of oral mucosal lesions.

Objective

To describe the prevalence of recurrent aphthous stomatitis.

Methods

Descriptive, cross-sectional and prospective study. 847 patients who attended the Family Medical Office No. 28, San Francisco comunity, Manzanillo, from July 1, 2021 to June 30, 2022, Cuba, were evaluated. A calibrated and trained assistant investigator evaluated the following variables: Clinical classification of recurrent aphthous stomatitis (minor aphthosis, major aphthosis, or aphthosis herpetiformis), lesion pain intensity, lesion location, and risk factors (viral infection), bacterial infection, immunological alterations, psychosomatic alterations, oral trauma, gastrointestinal alterations, endocrine factors, allergic conditions, heredity, blood and nutritional deficiencies, smoking), age group, sex, race, and duration of the lesion.

Results

Aphthous stomatitis occurred in 30.46%, with greater frequency in the age group 30 - 39 years (24.42%). Minor aphthosis was the most frequent with 91.09%. The duration of the lesion of 10 to 12 days predominated with 37.60%, the most frequent location corresponded to the edge and tip of the tongue with 32.94% and the most representative pain intensity was mild with a total of 63.18%. The highest frequency among the risk factors corresponded to psychosomatic alterations with 100%.

Conclusions

Recurrent Aphthous Stomatitis had a prevalence greater than 30% with a predominance of the female sex and young adults. Minor Aphtosis and a stay time of more than 10 days were the most frequent. The most common location is the tongue and bottom of the vestibular sulcus with the possible existence of a relationship between the mobile parts of the mouth. Stress, the main risk factor, exacerbated by Covid-19.

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.

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.

Association of Surfactant Protein D Single Nucleotide Polymorphisms rs721917, rs2243639, rs3088308 with Recurrent Aphthous Stomatitis in Pakistani Population

Recurrent aphthous stomatitis (RAS) is a benign ulcerative condition, defined by the recurrent formation of non-contagious mucosal ulcers. Surfactant protein D (SP-D) is secreted frequently at surfaces exposed directly to body fluids. This study aims to investigate the association of SP-D single nucleotide polymorphisms (SNPs) with the onset of RAS. Blood samples from 212 subjects (106 cases/controls each) were collected during 2019 and genotyped for SP-D SNPs (rs721917, rs2243639, rs3088308) by polymerase chain reaction and restriction fragment length polymorphism followed by 12% polyacrylamide gel electrophoresis. Minor aphthous (75.5%) was the commonly observed ulcer type as compared to herpetiform (21.7%) and major aphthous ulcers (2.8%). A family history of RAS was reported in 70% of cases. RAS was found significantly associated with rs3088308 genotypes T/A (95% (Cl): 1.57-5.03, p = 0.0005), A/A (95% (Cl): 1.8-6.7, p = 0.0002), T-allele (95% (Cl): 1.09-2.36, p = 0.01), A-allele (95% (Cl): 1.42-3.91, p = 0.01), rs721917 genotype T/T (95% (Cl): 1.15-25.35, p = 0.03), and T-allele (95% (Cl): 1.28-3.10, p = 0.002). Female gender and obese body mass index (BMI) were significantly associated with rs3088308 genotypes T/A (95% (CI): 1.89-15.7, p = 0.001), T/T (95% (Cl): 1.52-11.9, p = 0.005), A-allele (95% (Cl): 1.65-7.58, p < 0.001), and T-allele (95% (Cl): 1.4-10.1, p <0.001) and rs721917 genotype T/T (95% (CI) = 1.3-33, p = 0.02), respectively. This study describes the association of SP-D SNPs (rs721917, rs3088308) with RAS in the Pakistani population.

Prevalence and risk factors of recurrent aphthous stomatitis among college students at Mangalore, India

Background

Recurrent aphthous stomatitis (RAS) is one of the most common oral mucosal diseases affecting an approximate 25% of the world's population. Some common etiological factors are genetics, nutritional deficiencies, stress and immune dysfunction. There is currently no specific medication to treat the condition but RAS tends to heal by itself within a week or two. We aimed to explore about the prevalence and related risk factors of recurrent aphthous ulcers among college students aged 18-30 years who had been affected within the preceding six months prior to the study duration.

Methods

A questionnaire survey was conducted among 681 students from four colleges in Mangalore, Karnataka, India after obtaining the approval for the same from the respective colleges. Consenting participants returned a survey containing various questions. The collected data was then analyzed using descriptive statistics. The study was approved by the Institutional Ethics Committee.

Results

Of the 681 participants, 322 (47.2%) were affected with RAS in the past six months which included 131 (40.6%) males and 191 (59.3%) females. Single mouth ulcers were the most common presentation seen among the study participants (74.2%). Factors showing statistically significant association were: family history of RAS (P < 0.001), known diabetics (P < 0.001), history of smoking (P < 0.001), oral trauma (P < 0.001), history of wearing braces/dentures (P < 0.001) as well as those using toothpastes containing sodium lauryl sulphate (P < 0.001), stress and lack of sleep (P < 0.001). The most common form of medication used were topical agents (43.1%) (P < 0.001).

Conclusions

There was a statistically significant association between the occurrence of RAS and family history of RAS, diabetes, smoking, history of braces/dentures, oral trauma, sodium lauryl sulphate toothpastes, lack of sleep, stress, menstruation, consumption of particular foods and beverages. Further research is needed in this field to truly understand the prevalence and risk factors of RAS and to help in discovering a treatment modality for this condition.

Healing of Recurrent Aphthous Stomatitis by Non-Thermal Plasma: Pilot Study

Recurrent aphthous stomatitis (RAS) is a common disease in the oral cavity characterized by recurrent ulcers (RU). Usually, these cause acute pain without definitive treatment. The present study determines the efficacy of non-thermal plasma (NTP) for treating RU. NTP is applied to the patient's RU using a radiofrequency generator connected to a point reactor. The power density applied to the ulcer is 0.50 W/cm², less than 4 W/cm², which is the maximum value without biological risk. Each patient received two treatments of three minutes each and spaced 60 min apart at a distance of 5 mm from the RU. From a sample of 30 ulcers in patients treated for RU with an average age of 37 years, they stated that the pain decreased considerably and without the need for ingestion of analgesics and antibiotics. Regeneration took place in an average of three days. The NTP proved to be an excellent therapeutic alternative for the treatment of RU since it has a rapid effect of reducing pain and inflammation, as well as adequate tissue regeneration.

The association of recurrent aphthous stomatitis with general health and oral health related quality of life among dental students

BACKGROUND

Recurrent aphthous stomatitis (RAS) is one of the most common oral mucosa diseases. This study aimed to investigate the association of RAS with general health and oral health-related quality of life among dental students of Shahrekord University of Medical Sciences in 2020.

METHODS

In this cross-sectional study, a researcher-made checklist about the type, size, location, number, and recurrence rate of ulcers, oral health-related quality of life questionnaire (OHIP-14), and a 28-item general health questionnaire (GHQ-28) were completed by 100 dental students.

RESULTS

The proportion of RAS was significantly higher among females than males (61.1 versus 38.9, P=0.03) and was associated with family involvement history (P<0.001) and a Tendency to eat spicy foods (P=0.02). Moreover, the oral health-related quality of life was significantly lower among students with a history of RAS (8.17 ± 8.33 versus 4.22 ± 4.10, P=0.003). The results showed that GHQ-positive status was significantly associated with ulcer size (P=0.01). The general health status was positively correlated with RAS prevalence (p=0.04). Also, an investigation of the OHIP questionnaire showed that there was a significant correlation between physical status (r=0.31, P<0.001), insomnia, and mental status (r=0.33, P<0.001) with OHIP total score.

CONCLUSION

The results of this study confirmed a significant association between aphthous stomatitis and general health and oral health-related quality of life. So possibly improving general health and oral health-related quality of life may be effective in preventing aphthous stomatitis.

Composite dissolvable microneedle patch for therapy of oral mucosal diseases

A composite microneedle patch (MN patch) is developed for oral transmucosal administration. To improve the oral transmucosal drug delivery efficiency, the composite MN patch is designed to consist of an array of 100 dissolvable microneedles (MNs) with drug-loaded tips and a backing layer. The MNs are composed of two parts, the hyaluronic acid (HA) tip part and the polyvinylpyrrolidone (PVP) base part. Due to the small size and sufficient mechanical strength, the HA-PVP MNs can painlessly penetrate the oral mucosa barrier and deliver drugs directly to the basal layer or submucosa. Betamethasone sodium phosphate (BSP), as the model drug, is concentrated in the HA tip parts to avoid the drug waste caused by mucosa elasticity. Considering the special moist environment and saliva flow in the mouth, a double-layer backing layer composed of a poly(vinyl alcohol) (PVA) adhesive layer and an ethyl cellulose (EC) waterproof layer is designed and constructed, which could reduce the saliva flow effects. The in vitro and in vivo results demonstrate that the MN patch could achieve rapid and efficient BSP release in oral mucosa due to the rapid dissolution of HA. The proposed MN patch provides a novel strategy for the therapy of oral mucosal diseases.

Predisposing Factors for Recurrent Aphthous Stomatitis among Undergraduate Dental Students

Objectives The prevalence of recurrent aphthous stomatitis (RAS) among the general population worldwide is 20%. This study aims to discover any correlations between RAS predisposing factors and the gender and year of study of undergraduate dental students at the Faculty of Dental Medicine at Airlangga University.

Methods A cross-sectional analytical study using simple random sampling was performed. The respondents answered seven questions on a self-reported online questionnaire set up using Google Forms. Chi-square analyses were conducted to determine any correlation between RAS predisposing factors and the gender and year of study of the students.

Results The highest predisposing factors for RAS in undergraduate dental students were local trauma (77.7%) followed by stress (71.3%) and nutritional deficiencies (41.5%). Stress correlated strongly with the year of study (p = 0.015). There was no correlation between gender and RAS predisposing factors (p > 0.05).

Conclusion There was a correlation between stress, one of the predisposing factors for RAS, and the year of study, but there was no correlation between gender and RAS predisposing factors including local trauma, stress, nutritional deficiency, genetics, allergies, and systemic diseases.

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.

Association of the angiotensin I converting enzyme (ACE) gene polymorphisms with recurrent aphthous stomatitis in the Czech population: case–control study

Background

Recurrent aphthous stomatitis (RAS) is multifactorial disease with unclear etiopathogenesis. The aim of this study was to determine distribution of the angiotensin I converting enzyme (ACE) gene polymorphisms and their influence on RAS susceptibility in Czech population.

Methods

The study included 230 subjects (143 healthy controls and 87 patients with RAS) with anamnestic, clinical and laboratory data. Five ACE gene polymorphisms (rs4291/rs4305/rs4311/rs4331/rs1799752 = ACE I/D) were determined by TaqMan technique.

Results

The allele and genotype distributions of the studied ACE I/D polymorphisms were not significantly different between subjects with/without RAS (P_corr > 0.05). However, carriers of II genotype were less frequent in the RAS group (OR = 0.48, 95% CI = 0.21–1.12, P = 0.059). Stratified analysis by sex demonstrated lower frequency of II genotype in women (OR = 0.33, 95% CI = 0.09–1.17, P < 0.035, P_corr > 0.05, respectively) than in men with RAS (P > 0.05). Moreover, the frequency of AGTGD haplotype was significantly increased in RAS patients (OR = 13.74, 95% CI = 1.70–110.79, P = 0.0012, P_corr < 0.05). In subanalysis, TGD haplotype was significantly more frequent in RAS patients (P < 0.00001) and CGI haplotype was less frequent in RAS patients (P < 0.01), especially in women (P = 0.016, P_corr > 0.05).

Conclusions

Our study indicates that while the AGTGD and TGD haplotypes are associated with increased risk of RAS development, CGI haplotype might be one of protective factors against RAS susceptibility in Czech population.

Improved healing and macrophage polarization in oral ulcers treated with photobiomodulation (PBM)

OBJECTIVES

The effect of photobiomodulation (PBM) treatment on wound healing and macrophage polarization was investigated in vivo. Animal models of oral ulcers were simulated through chemically induced oral ulcers in rats.

MATERIALS AND METHODS

PBM treatment using an infrared pulsed laser was used to treat oral ulcers in the animal models. Twelve Sprague-Dawley rats were randomly divided into four groups depending on set absorbed energy: Group 1 (control), Group 2 (30 J), Group 3 (60 J), and Group 4 (100 J). Laser treatment was performed every other day for 8 days after ulcer confirmation. Parameters used were as follows: wavelength 808 nm, power output 50 mW, spot size 10 mm, frequency 10 Hz, and pulse duration 1 millisecond. Ulcers were measured to determine the effect of the treatments over time. Histology, immunostaining, and real-time polymerase chain reaction analyses were performed to evaluate the effect of PBM treatment on macrophage-related (IL-6/IL-10) and wound-healing-related (TNF-α/TGF-β/MMP-2) cytokine expression.

RESULTS

Histological examinations indicate that the PBM treatment stimulated a higher level of wound recovery after 8 days of treatment at 60 J absorbed energy compared to other treatment groups. Analyses of relative gene expression of proinflammatory, anti-inflammatory, and tissue remodeling cytokines indicate that the macrophages in the tissue samples were predominantly characterized as M2 subtypes (alternatively activated), which possibly accounts for the accelerated tissue repair in the animal model of oral ulcer.

CONCLUSION

This preliminary study stands as a proof of concept regarding the potential use of infrared laser PBM treatment for oral ulcers which have not been previously investigated upon. PBM treatment affects macrophage polarization and enhances wound healing. Further experimentation will be conducted to expand the understanding of how PBM treatment affects the healing mechanism of ulcers.

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.

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.

Low-Level Laser Therapy and Topical Medications for Treating Aphthous Ulcers: A Systematic Review

Objective

The study compares low-level laser therapy with topical medications for treating aphthous ulcers.

Methods

A search of articles in this systematic review was completed in six databases. Treatment and comparative groups comprised of patients subjected to laser therapy and topical medications, respectively. Two different treatment outcomes were considered; pain and size of the lesion. Risk of bias was assessed using the Revised Cochrane risk-of-bias tool for randomized trials.

Results

From 109 articles, five randomized control trials fulfilled the selection criteria. The overall sample comprised of 98 males and 232 females, with a mean age of 32.4 years. The laser therapies in each included study had different active media and varying wavelengths. Topical medication used in the comparative group were triamcinolone acetonide, amlexanox, granofurin, and solcoseryl. Findings showed that patients who reported lower pain and decreased aphthous ulcer lesions were more in the laser therapy group than in the topical medication group.

Conclusion

Low-level laser therapy was better in treating aphthous ulcer lesions in comparison to topical medications, and all laser wavelengths in the included reports were seen to be effective. However, the results should be interpreted with caution, because no study demonstrated low-risk of bias in all the assessed domains.

The Epidemiology and Clinical Manifestations of Autoimmunity in Selective IgA Deficiency

Selective immunoglobulin A deficiency (SIgAD) is the most common primary immunodeficiency, defined as an isolated deficiency of IgA (less than 0.07 g/L). Although the majority of people born with IgA deficiency lead normal lives without significant pathology, there is nonetheless a significant association of IgA deficiency with mucosal infection, increased risks of atopic disease, and a higher prevalence of autoimmune disease. To explain these phenomena, we have performed an extensive literature review to define the geoepidemiology of IgA deficiency and particularly the relative risks for developing systemic lupus erythematosus, hyperthyroidism, hypothyroidism, type 1 diabetes mellitus, Crohn's disease, ulcerative colitis, rheumatoid arthritis, juvenile idiopathic arthritis, ankylosing spondylitis, and vitiligo; these diseases have strong data to support an association. We also note weaker associations with scleroderma, celiac disease, autoimmune hepatitis, immune thrombocytopenic purpura, and autoimmune hemolytic anemia. Minimal if any associations are noted with myasthenia gravis, lichen planus, and multiple sclerosis. Finally, more recent data provide clues on the possible immunologic mechanisms that lead to the association of IgA deficiency and autoimmunity; these lessons are important for understanding the etiology of autoimmune disease.

Evaluation of the effect of probiotic lozenges in the treatment of recurrent aphthous stomatitis: a randomized, controlled clinical trial

OBJECTIVES

The study aimed to explore the effectiveness of probiotics in the treatment of minor recurrent aphthous stomatitis (RAS).

MATERIALS AND METHODS

We performed a randomized, controlled clinical study. Sixty adult (group A) and 60 children patients (group B) with diagnosis of minor RAS were included. Both groups were divided into two subgroups; AI and BI (test subgroups) and AII and BII (control subgroups). For test subgroups, probiotic lozenges were consecutively administered twice daily, for 5 days. The size and pain level of ulcers were recorded on treatment days 0, 3, and 5. The outbreak frequency of RAS within 6 months was investigated for all subgroups.

RESULTS

Compared with baseline, an improvement was evident for all subgroups. However, for effectiveness in pain reduction, a statistically significant difference in favor of AI was observed for all evaluation periods when compared with control subgroup. Regarding effectiveness in ulcer size reduction, a statistically significant difference in favor of BI was observed at day 5 when compared with control subgroup. No significant difference was observed in the effectiveness index between subgroups AI and BI (test subgroups) except in effectiveness in pain reduction at day 3. The outbreak frequency decreased significantly in subgroup BI.

CONCLUSIONS

Topical application of probiotics decreased pain intensity and accelerates RAS healing. The effectiveness in pain reduction is more evident in adult patients while acceleration of healing is more evident in children.

CLINICAL RELEVANCE

Probiotics could be a well-tolerated, topical therapeutic agent in the treatment of minor RAS.

TRIAL REGISTRATION

ClinicalTrials.gov ID: NCT04383236.

Evaluation of zinc sulfate mucoadhesive formulation on recurrent aphthous stomatitis: a randomized double-blind, placebo-controlled clinical trial

BACKGROUND

Recurrent aphthous stomatitis (RAS) is a common lesion that affects the oral mucosa. There are several methods to treat RAS, including systemic and topical formulations. This study was conducted to evaluate the anti-inflammatory effect of topical zinc sulfate and its efficacy in the treatment of RAS.

METHODS

A double-blind randomized clinical trial was conducted on 46 patients with RAS. They were randomly assigned into two groups to receive a zinc sulfate mucoadhesive tablet or placebo for 7 days. The pain severity was measured at baseline and daily while the diameter of the lesion was measured at baseline and on days 3, 5, and 7. The obtained data were analyzed in SPSS V.16.

RESULTS

There was no significant difference in the mean diameter of lesions and pain at baseline between the two groups (P = 0.643 and P = 0.842, respectively). However, on the third, fifth, and seventh days of the study, the diameter of the lesion significantly reduced in the intervention group (P = 0.001) and the pain intensity became significantly different between groups from the fourth day of the study (P = 0.001).

CONCLUSION

Zinc sulfate mucoadhesive tablet was effective in recovery and reducing the pain and diameter of the aphthous lesion and could be considered for the treatment of RAS.

TRIAL REGISTRATION

Evaluation of the effectiveness of zinc sulfate mucoadhesive tablet in the improvement of recurrent aphthous stomatitis (RAS), IRCT20151109024975N9. Registered August 1, 2018, https://en.irct.ir/trial/32423 . This project was registered by the Iranian Registry of Clinical Trials ( http://www.irct.ir ). The IRCT ID was IRCT20151109024975N9.

Celiac disease and hematological abnormalities in children with recurrent aphthous stomatitis

BACKGROUND

Recurrent aphthous stomatitis (RAS) is one of the most common diseases of the oral mucosa and may be related to vitamin deficiencies or systemic diseases such as celiac disease (CD). The aim of this study was to investigate the frequency of hematinic deficiency and CD in children with RAS.

METHODS

The medical records of patients diagnosed with RAS were reviewed for the presence of hematinic deficiencies (hemoglobin, mean corpuscular volume, ferritin, vitamin B₁₂ , folic acid), and CD. The study group included 108 children with RAS and 57 healthy children who were evaluated for hematological abnormalities in routine evaluation.

RESULTS

The frequency of a family history of RAS was significantly higher in the RAS group compared to the control group (34.2% vs 7%, respectively; P < 0.001). A hematological abnormality was detected in 32.4% of the RAS group and 10.5% of the control group (P = 0.02). The prevalence of iron deficiency anemia was significantly higher in the RAS group (P = 0.037). Three (2.7%) patients with RAS were diagnosed with CD, which is a significantly higher frequency than that observed in healthy children in Turkey (P < 0.01; OR 6.03, 95% CI [2.37, 4.56]). These children had mild malnutrition, iron deficiency, and iron deficiency anemia.

CONCLUSIONS

Children with RAS should be evaluated for nutritional status and hematological indices, and in the case of hematological abnormalities and malnutrition screening for CD should be considered.

Recent Progress of Basic Studies of Natural Products and Their Dental Application

The present article reviews the research progress of three major polyphenols (tannins, flavonoids and lignin carbohydrate complexes), chromone (backbone structure of flavonoids) and herbal extracts. Chemical modified chromone derivatives showed highly specific toxicity against human oral squamous cell carcinoma cell lines, with much lower toxicity against human oral keratinocytes, as compared with various anticancer drugs. QSAR analysis suggests the possible correlation between their tumor-specificity and three-dimensional molecular shape. Condensed tannins in the tea extracts inactivated the glucosyltransferase enzymes, involved in the biofilm formation. Lignin-carbohydrate complexes (prepared by alkaline extraction and acid-precipitation) and crude alkaline extract of the leaves of Sasa species (SE, available as an over-the-counter drug) showed much higher anti-HIV activity, than tannins, flavonoids and Japanese traditional medicine (Kampo). Long-term treatment with SE and several Kampo medicines showed an anti-inflammatory and anti-oxidant effects in small size of clinical trials. Although the anti-periodontitis activity of synthetic angiotensin II blockers has been suggested in many papers, natural angiotensin II blockers has not yet been tested for their possible anti-periodontitis activity. There should be still many unknown substances that are useful for treating the oral diseases in the natural kingdom.