Systemic treatment in severe cases of recurrent aphthous stomatitis: an open trial

Immune-mediated oral mucosal pathology: a comprehensive review and update for clinicians - part II

The oral mucosa can be involved in a wide variety of mucocutaneous conditions that may present primarily in the mouth or affect other cutaneous or mucosal sites. Many of these conditions are immune mediated and typically present as inflammatory mucosal pathology. Patients experiencing such conditions usually seek medical evaluation and treatment due to the associated pain and discomfort, and occasionally taste disturbance or dysphagia and the overall deterioration in the oral health-related quality of life. These conditions share some common features and there could be some overlap in their clinical presentation, which can lead to delays in diagnosis and proper management of patients. Clinicians dealing with such disorders, including dermatologists, need to be aware of the oral manifestations of mucocutaneous conditions, their clinical features, underlying mechanisms, diagnostic approaches, and treatment options, as well as the recent advances in the research on these conditions. This review provides a comprehensive, evidence-based reference for clinicians, with updated insights into a group of immune mediated conditions known to cause oral mucosal pathology. Part one will cover oral lichen planus, erythema multiforme and systemic lupus erythematosus, while part two will cover recurrent aphthous stomatitis, pemphigus vulgaris and mucous membrane pemphigoid, in addition to the less common disorders linear IgA disease, dermatitis herpetiformis and epidermolysis bullosa.

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.

Characterization of immune landscape and development of a novel N7-methylguanine-related gene signature to aid therapy in recurrent aphthous stomatitis

OBJECTIVES

Recurrent aphthous stomatitis (RAS) is the most common inflammatory disease of the oral mucosa resulting in an impaired life quality and even leading to tumors in susceptible populations. N7-Methylguanine (m7G) plays a vital role in various cellular activities but has not yet been investigated in RAS. We aimed at picturing the immune landscape and constructing an m7G-related gene signature, and investigating candidate drugs and gene-disease association to aid therapy for RAS.

METHODS

For our study, m7G-related differentially expressed genes (DEGs) were screened. We outlined the immune microenvironment and studied the correlations between the m7G-related DEGs and immune cells/pathways. We performed functional enrichment analyses and constructed the protein-protein interaction (PPI) and multifactor regulatory network in RAS. The m7G-related hub genes were extracted to formulate the corresponding m7G predictive signature.

RESULTS

We obtained 11 m7G-related DEGs and studied a comprehensive immune infiltration landscape, which indicated several immune markers as possible immunotherapeutic targets. The PPI and multifactor regulatory network was constructed and 4 hub genes (DDX58, IFI27, IFIT5, and PML) were identified, followed by validation of the corresponding m7G predictive signature for RAS. GO and KEGG analyses revealed the participation of JAK-STAT and several immune-related pathways. Finally, we suggested candidate drugs and gene-disease associations for potential RAS medical interventions.

CONCLUSIONS

The present study pictured a comprehensive immune infiltration landscape and suggested that m7G played a vital role in RAS through immune-related pathways. This study provided new insight for the future investigation of the mechanisms and therapeutic strategies for RAS.

Treatment Options in Pediatric Behçet's Disease

Behçet's disease is a rare and poorly understood vasculitis affecting blood vessels of all types and sizes. Uveitis and oral and genital ulcers represent the typical clinical triad. Populations along the ancient trading route connecting the Mediterranean basin with the Middle and Far East are most affected. Up to a quarter of the cases has a pediatric onset, typically around puberty. The aim of the treatment is early intervention to control inflammation, with symptom relief and prevention of relapses, damage, and complications. The heterogeneous clinical presentation often requires a multidisciplinary and tailored approach. Ocular, neurological, gastrointestinal, and vascular involvement is associated with a worse prognosis and needs more aggressive treatments. In young patients with expected prolonged disease, treatment should also focus on preventive measures and lifestyle advice. In recent years, the pharmacological armamentarium has grown progressively, although only a limited number of drugs are currently authorized for pediatric use. Most evidence for these drugs still derives from adult studies and experience; these are prescribed as off-label medications and are only available as adult formulations. Corticosteroids frequently represent the mainstay for the management of the initial acute phases, but their potential serious adverse effects limit their use to short periods. Different conventional disease-modifying anti-rheumatic drugs have long been used. Many other biologic drugs targeting different cytokines such as interleukin-1, interleukin-6, and interleukin-17 and treatments with small molecules including the phosphodiesterase 4 and Janus kinase inhibitors are emerging as novel promising therapeutic agents. In recent years, a growing interest has developed around anti-tumor necrosis factor agents that have often proven to be effective in severe cases, especially in those with a gastrointestinal and ocular involvement.

Recurrent Aphthous Stomatitis – An Overview

Recurrent aphthous ulcers are common painful mucosal conditions affecting the oral cavity. Despite their high prevalence and knowledge of many etiological factors, the exact mechanism of disease is still not fully understood. There are three different clinical forms of recurrent aphthous stomatitis and the therapy differs depending on it.

The aim of this article is to provide an overview of current knowledge about the possible causes and treatment of recurrent aphthous stomatitis. We discuss its pathogenesis which is currently the least explained in the literature. This review offers scientists and clinicians useful information about clinical presentation, diagnosis, predisposing aetiological factors and recent trends in the management of recurrent aphthous stomatitis.

Comprehensive management of major aphthous ulcer

Recurrent aphthous ulcers are the most prevalent oral mucosal disease, but the subset major aphthous ulcer is a less frequent type. These ulcers are refractory, may persist for several weeks to months, and interfere with the normal state of health. The aetiology is multifactorial and so is the treatment. We present a case of an adolescent male patient reported with multiple oral ulcers. He developed three ulcers simultaneously and suffered for 10 months despite using topical medications prescribed by different dental practitioners. We executed a multidisciplinary treatment approach that resulted in a long-term disease-free state. The treatment methods followed in our case could be a successful model to implement by medical practitioners and oral physicians when the situation demands.

Effect of Omega-3 on Recurrent Aphthous Stomatitis and Improvement Quality of Life

Objective

Recurrent aphthous stomatitis is one of the most common chronic inflammatory diseases in oral mucosa. Beneficial effects of omega-3 supplements on some inflammatory diseases have been proved. The aim of present study was to evaluate the effect of omega-3 supplements in recurrent aphthous stomatitis management and improve oral health-related quality of life.

Methods

In this double-blind clinical trial, 40 patients with minor recurrent aphthous stomatitis were randomly divided into case and control groups. The case group received 1000 mg capsules of omega-3, while the control group received placebo capsules for 6 months. The questionnaires of the ulcer severity score and the chronic oral mucosal disease questionnaire were filled by the patients in three steps, at the baseline session, after 3 months, and after 6 months. The data were analyzed by SPSS 22 software through ANOVA, Mann-Whitney, and chi-square tests. P < 0.05 was considered as significant.

Results

In the omega-3 group, the ulcer severity score showed significant reduction by three-month and six-month follow-ups (P < 0.0001, P < 0.0001, respectively). The mean score of the chronic oral mucosal disease questionnaire significantly improved by three-month and six-month follow-ups in the omega-3-receiving group.

Conclusion

Use of omega-3 oral supplements decreased the severity of aphthous ulcer and improved oral health-related quality of life.

Colchicine in the treatment of refractory aphthous ulcerations: Review of the literature and two case reports

Colchicine has been known and used for over a millennium for its anti-inflammatory properties, being the treatment of choice for gout and familial Mediterranean fever. A tricyclic alkaloid extracted from the herbaceous plant, Colchicum autumnale, colchicine blocks multiple inflammatory pathways, and has antimitotic and antifibrotic action. Although there are insufficient data on the beneficial mechanism of action, colchicine is a widely used treatment in dermatology, one of the morbid conditions with more evidence of efficacy being recurrent aphthous stomatitis (RAS), a disorder with incompletely known etiopathogenesis and, consequently, with poorly defined treatment. Colchicine is considered as the first therapeutic line in complex or severe aphthoses, significantly relieving pain, decreasing the number of lesions, increasing the free interval between eruptive episodes, without inducing noticeable side effects. We examined the treatment efficacy of colchicine in two cases of chronic, severe RAS, evolving in different morbid contexts, who did not respond to other therapeutic measures. The two cases presented with recurrent aphthous stomatitis with herpetiform aphthae; one patient with Turner syndrome and one patient with major Sutton ulcers.

Recurrent Aphthous Stomatitis

Recurrent aphthous stomatitis is a chronic inflammatory disease of the oral mucosa. It is characterized by painful mouth ulcers that cannot be explained by an underlying disease. Recurrent oral mucosal ulcers require a proper differential diagnosis to rule out other possible causes before recurrent aphthous stomatitis is diagnosed. The condition is common, with prevalence rates ranging from 5 to 60% in different series. Its pathogenesis is unknown, but multiple factors are considered to play a part. There are no standardized treatments for this condition and none of the treatments are curative. The goal of any treatment should be to alleviate pain, reduce the duration of ulcers, and prevent recurrence.

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.

Recurrent aphthous stomatitis - Etiology, serum autoantibodies, anemia, hematinic deficiencies, and management

Recurrent aphthous stomatitis (RAS) is one of the most common oral mucosal diseases characterized by recurrent and painful ulcerations on the movable or nonkeratinized oral mucosae. Clinically, three types of RAS, namely minor, major, and herpetiform types, can be identified. RAS more commonly affects labial mucosa, buccal mucosa, and tongue. Previous studies indicate that RAS is a multifactorial T cell-mediated immune-dysregulated disease. Factors that modify the immunologic responses in RAS include genetic predisposition, viral and bacterial infections, food allergies, vitamin and microelement deficiencies, systemic diseases, hormonal imbalance, mechanical injuries, and stress. Our previous study found the presence of serum gastric parietal cell antibody, thyroglobulin antibody, and thyroid microsomal antibody in 13.0%, 19.4%, and 19.7% of 355 RAS patients, respectively. We also found anemia, serum iron, vitamin B12, and folic acid deficiencies, and hyperhomocysteinemia in 20.9%, 20.1%, 4.8%, 2.6%, and 7.7% of 273 RAS patients, respectively. Therefore, it is very important to examine the complete blood count, serum autoantibody, hematinic, and homocysteine levels in RAS patients before we start to offer treatments for RAS. Because RAS is an immunologically-mediated disease, topical and systemic corticosteroid therapies are the main treatments of choice for RAS.

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

BACKGROUND

Recurrent aphthous ulcerations are common benign ulcerated lesions on the mouth, whose etiology is poorly understood, with controversial treatment and difficult to control in clinical practice.

OBJECTIVE

To evaluate the cases of recurrent aphthous ulcerations with a focus on treatment, diagnosis and etiology.

METHODS

This is a retrospective study of the cases of the Oral Diagnosis service of the Rio Grande do Norte Federal University in Natal/RN. Data such as sex, age, race, location, smoking habits, types of treatment, relapsing episodes, laboratory test results and clinical characteristics were collected. The associations between the variables were analyzed using the Pearson Chi-square test (p <0.05).

RESULTS

A total of 4895 patients were seen in the service over a period of 11 years. Of these, 161 (3.3%) had complaints of oral aphthous ulcerations, of which 76 (47.2%) were diagnosed as suffering from recurrent aphthous ulcerations and 68 (42.2%) with clinical information necessary for evaluation. The tongue was the most affected anatomical region, with 27 individuals (39.7%), followed by the buccal mucosa, with 22 cases (32.3%).

STUDY LIMITATIONS

Retrospective study with data from medical records.

CONCLUSION

Dental surgeons, dermatologists and otorhinolaryngologists are the main responsible for the first contact with patients with this disease and should be attentive to the clinical aspects and treat each patient in an individualized way, since the therapy is palliative, its diagnosis is by exclusion and its etiology is unknown.

Is Optimal Management of Recurrent Aphthous Stomatitis Possible? A Reality Check

Recurrent Aphthous Stomatitis (RAS) is a condition in which aphthous ulcers repeatedly occur in the oral cavity. It is prevalent in developed countries, occurring in all ages, geographic regions and races and about 80% of people have one episode of oral aphthous ulcers before the age of 30 years. With no laboratory procedures to confirm the diagnosis, treatment is mainly empirical in nature and focuses on short-term symptomatic management. Although numerous treatment modalities have been recommended, only a few are evidence based and can be considered for the optimal management of RAS. Biologic agents are a new category of drugs which acts by blocking specific pathways associated with the pathophysiology of neoplastic or immune-mediated diseases. These agents have targeted immunosuppressive or anti-inflammatory actions. In patients of RAS who were not responding to standard therapy, etanercept, adalimumab, infliximab and Interferon-Alpha (INF-α) were found to be useful. The objective of this review was to propose and review a treatment protocol to be followed for the optimal management of RAS. We reviewed several evidence-based studies and through this review we recommend topical interventions as the first-line of therapy since they are associated with low risk of systemic side effects. Due to limitations in the number of evidence-based trials and the insufficient data to support or refute the efficacy of the therapies prescribed, larger evidence-based clinical studies and literature reviews are needed to further improvise the optimal methodology for the effective management of RAS.

Colchicine for prevention of cardiovascular events

BACKGROUND

Colchicine is an anti-inflammatory drug that is used for a wide range of inflammatory diseases. Cardiovascular disease also has an inflammatory component but the effects of colchicine on cardiovascular outcomes remain unclear. Previous safety analyses were restricted to specific patient populations.

OBJECTIVES

To evaluate potential cardiovascular benefits and harms of a continuous long-term treatment with colchicine in any population, and specifically in people with high cardiovascular risk.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, ClinicalTrials.gov, WHO International Clinical Trials Registry, citations of key papers, and study references in January 2015. We also contacted investigators to gain unpublished data.

SELECTION CRITERIA

Randomised controlled trials (parallel-group or cluster design or first phases of cross-over studies) comparing colchicine over at least six months versus any control in any adult population.

DATA COLLECTION AND ANALYSIS

Primary outcomes were all-cause mortality, myocardial infarction, and adverse events. Secondary outcomes were cardiovascular mortality, stroke, heart failure, non-scheduled hospitalisations, and non-scheduled cardiovascular interventions. We conducted predefined subgroup analyses, in particular for participants with high cardiovascular risk. .

MAIN RESULTS

We included 39 randomised parallel-group trials with 4992 participants. Colchicine had no effect on all-cause mortality (RR 0.94, 95% CI 0.82 to 1.09; participants = 4174; studies = 30; I² = 27%; moderate quality of evidence). There is uncertainty surrounding the effect of colchicine in reducing cardiovascular mortality (RR 0.34, 95% CI 0.09 to 1.21, I² = 9%; participants = 1132; studies = 7; moderate quality of evidence). Colchicine reduced the risk for total myocardial infarction (RR 0.20, 95% CI 0.07 to 0.57; participants = 652; studies = 2; moderate quality of evidence). There was no effect on total adverse events (RR 1.52, 95% CI 0.93 to 2.46; participants = 1313; studies = 11; I² = 45%; very low quality of evidence) but gastrointestinal intolerance was increased (RR 1.83, 95% CI 1.03 to 3.26; participants = 1258; studies = 11; I² = 74%; low quality of evidence). Colchicine showed no effect on heart failure (RR 0.62, 95% CI 0.10 to 3.88; participants = 462; studies = 3; I² = 45%; low quality of evidence) and no effect on stroke (RR 0.38, 95% CI 0.09 to 1.70; participants = 874; studies = 3; I² = 45%; low quality of evidence). Reporting of serious adverse events was inconsistent; no event occurred over 824 patient-years (4 trials). Effects on other outcomes were very uncertain. Summary effects of RCTs specifically focusing on participants with high cardiovascular risk were similar (4 trials; 1230 participants).

AUTHORS' CONCLUSIONS

There is much uncertainty surrounding the benefits and harms of colchicine treatment. Colchicine may have substantial benefits in reducing myocardial infarction in selected high-risk populations but uncertainty about the size of the effect on survival and other cardiovascular outcomes is high, especially in the general population from which most of the studies in our review were drawn. Colchicine is associated with gastrointestinal side effects based on low-quality evidence. More evidence from large-scale randomised trials is needed.

Management of Recurrent Aphthous Stomatitis in Children

Recurrent oral ulceration is common and may present in childhood. Causes of recurrent oral ulceration are numerous and there may be an association with underlying systemic disease. Recurrent aphthous stomatitis (RAS) is the most common underlying diagnosis in children. The discomfort of oral ulcers can impact negatively on quality of life of a child, interfering with eating, speaking and may result in missed school days. The role of the general dental practitioner is to identify patients who can be treated with simple measures in primary dental care and those who require assessment and treatment in secondary care. Management may include topical agents for symptomatic relief, topical corticosteroids and, in severe recalcitrant cases, systemic agents may be necessary.

Recurrent Aphthous Stomatitis in Childhood and Adolescence: A Single-Center Experience

BACKGROUND

Recurrent aphthous stomatitis (RAS) is a common oral ulcerative condition in children. The objective was to describe the clinical features of RAS in children with accompanying clinical and laboratory findings.

METHODS

The study included 120 patients younger than 18 years of age (mean age 9.6 ± 4.3 years) with three or more oral aphthous ulcers per year between August 2008 and February 2014. Demographic characteristics of the patients, clinical features of the ulcers, and associated clinical and laboratory findings were evaluated.

RESULTS

The mean number of aphthae per year was 12.8 ± 8.5 and the mean duration of the disease was 3.6 ± 2.9 years. Minor aphthae were the most common type (87%), papulopustules were the most common accompanying cutaneous lesions (13.3%), and family history of RAS was the most common associated factor (35.8%). Genital scarring (p = 0.04) and pathergy (p = 0.01) were significantly more common in the adolescent group. Pathergy was significantly related to genital scarring (p = 0.04) and Behçet's disease (p = 0.02). There was no association between the number of aphthae per year and the duration of the disease and hematologic and immunologic abnormalities.

CONCLUSION

Our study is consistent with previous reports in terms of clinical features of aphthous ulcers, related diseases, and family history of RAS, but no associated laboratory abnormalities were noted.

Treatment of recurrent aphthous stomatitis. A literature review

Recurrent aphthous stomatitis (RAS) is the most common chronic disease of the oral cavity, affecting 5-25% of the population. The underlying etiology remains unclear, and no curative treatment is available. The present review examines the existing treatments for RAS with the purpose of answering a number of questions: How should these patients be treated in the dental clinic? What topical drugs are available and when should they be used? What systemic drugs are available and when should they be used? A literature search was made of the PubMed, Cochrane and Scopus databases, limited to articles published between 2008-2012, with scientific levels of evidence 1 and 2 (metaanalyses, systematic reviews, phase I and II randomized clinical trials, cohort studies and case-control studies), and conducted in humans. The results obtained indicate that the management of RAS should be based on identification and control of the possible predisposing factors, with the exclusion of possible underlying systemic causes, and the use of a detailed clinical history along with complementary procedures such as laboratory tests, where required. Only in the case of continuous outbreaks and symptoms should drug treatment be prescribed, with the initial application of local treatments in all cases. A broad range of topical medications are available, including antiseptics (chlorhexidine), antiinflammatory drugs (amlexanox), antibiotics (tetracyclines) and corticosteroids (triamcinolone acetonide). In patients with constant and aggressive outbreaks (major aphthae), pain is intense and topical treatment is unable to afford symptoms relief. Systemic therapy is indicated in such situations, in the form of corticosteroids (prednisone) or thalidomide, among other drugs.

Key words:Recurrent aphthous stomatitis, treatment, clinical management.

Therapeutic Effects of "Ibuprofen, Diphenhydramine and Aluminium MgS" on Recurrent Aphthous Stomatitis: A Randomized Controlled Trial

OBJECTIVE

Recurrent aphthous stomatitis (RAS) is the most common and painful oral inflammatory lesion with an unknown etiology. This study aims to determine the therapeutic effects of ibuprofen, diphenhydramine and aluminum magnesium simethicone (AlMgS) syrup on reducing oral aphthous ulcer pain.

MATERIALS AND METHODS

Thirty-one patients with RAS participated in this double-blind clinical trial. Subjects were randomly divided into two groups. The control group (n=14) received drug mixture as drug A (diphenhydramine and AlMgS) and the case group (n=17) received drug B (ibuprofen, diphenhydramine and AlMgS). Drugs were topically applied on ulcers by the patients three times a day for 3 days. Patients were re-examined for the symptoms on the fourth day following their first visits using VAS (Visual Analogue Scale) tool. Statistical analysis was performed using paired t-test, independent t-test and chi-square test.

RESULTS

The mean of pain reduction was 3.17±2 (P<0.001) and 3.82±1.79 (P<0.001) in the case and control group, respectively. The difference in pain reduction between both groups was not statistically significant. In addition, no significant difference was detected between the two groups regarding the duration of pain or burning sensation (P=0.57).

CONCLUSION

The results of this study demonstrate that in comparison with diphenhydramine and AlMgS syrup, the studied mixture did not effectively reduce the level of pain, duration and burning sensation.

Recurrent aphthous stomatitis

Recurrent aphthous stomatitis (RAS) is the most common ulcerative disease affecting the oral mucosa. RAS occurs mostly in healthy individuals and has an atypical clinical presentation in immunocompromised individuals. The etiology of RAS is still unknown, but several local, systemic, immunologic, genetic, allergic, nutritional, and microbial factors, as well as immunosuppressive drugs, have been proposed as causative agents. Clinical management of RAS using topical and systemic therapies is based on severity of symptoms and the frequency, size, and number of lesions. The goals of therapy are to decrease pain and ulcer size, promote healing, and decrease the frequency of recurrence.

Comparing the Effect of Phenytoin Syrup and Triamcinolone Acetonide Ointment on Aphthous Ulcers in Patients with Behcet's Syndrome

BACKGROUND

Recurrent aphthous stomatitis (RAS) appears to be the most common type of oral ulcers. The lesion is usually self limited but its painful presentation results in some difficulties. Therefore, an efficient therapeutic strategy is required and currently existing therapies seem to be inadequate because of its unclear etiology. Here the therapeutic effect of triamcinolone acetonide ointment as a relatively expensive medication has been compared with phenytoin syrup on aphthous ulcers in patients with Behcet's syndrome.

METHODS

Thirty out of 60 our patients with Behcet's syndrome were randomly treated by phenytoin syrup and the remaining were advised to use 0.1% triamcinolone acetonide ointment. After a week, they were visited again to determine the status of aphthous ulcers.

RESULT

Positive response in the triamcinolone acetonide group and phenytoin group was 86.7% and 53.3%, respectively.

CONCLUSION

The effectiveness of triamcinolone acetonide ointment was more than phenytoin on aphthous ulcers in patients with Behcet's syndrome.

Urban legends: recurrent aphthous stomatitis

Recurrent aphthous stomatitis (RAS) is the most common idiopathic intraoral ulcerative disease in the USA. Aphthae typically occur in apparently healthy individuals, although an association with certain systemic diseases has been reported. Despite the unclear etiopathogenesis, new drug trials are continuously conducted in an attempt to reduce pain and dysfunction. We investigated four controversial topics: (1) Is complex aphthosis a mild form of Behçet's disease (BD)? (2) Is periodic fever, aphthous stomatitis, pharyngitis, and adenitis (PFAPA) syndrome a distinct medical entity? (3) Is RAS associated with other systemic diseases [e.g., celiac disease (CD) and B12 deficiency]? (4) Are there any new RAS treatments? Results from extensive literature searches, including a systematic review of RAS trials, suggested the following: (1) Complex aphthosis is not a mild form of BD in North America or Western Europe; (2) Diagnostic criteria for PFAPA have low specificity and the characteristics of the oral ulcers warrant further studies; (3) Oral ulcers may be associated with CD; however, these ulcers may not be RAS; RAS is rarely associated with B12 deficiency; nevertheless, B12 treatment may be beneficial, via mechanisms that warrant further study; (4) Thirty-three controlled trials published in the past 6 years reported some effectiveness, although potential for bias was high.

Urban legends: recurrent aphthous stomatitis

Recurrent aphthous stomatitis (RAS) is the most common idiopathic intraoral ulcerative disease in the USA. Aphthae typically occur in apparently healthy individuals, although an association with certain systemic diseases has been reported. Despite the unclear etiopathogenesis, new drug trials are continuously conducted in an attempt to reduce pain and dysfunction. We investigated four controversial topics: (1) Is complex aphthosis a mild form of Behçet's disease (BD)? (2) Is periodic fever, aphthous stomatitis, pharyngitis, and adenitis (PFAPA) syndrome a distinct medical entity? (3) Is RAS associated with other systemic diseases [e.g., celiac disease (CD) and B12 deficiency]? (4) Are there any new RAS treatments? Results from extensive literature searches, including a systematic review of RAS trials, suggested the following: (1) Complex aphthosis is not a mild form of BD in North America or Western Europe; (2) Diagnostic criteria for PFAPA have low specificity and the characteristics of the oral ulcers warrant further studies; (3) Oral ulcers may be associated with CD; however, these ulcers may not be RAS; RAS is rarely associated with B12 deficiency; nevertheless, B12 treatment may be beneficial, via mechanisms that warrant further study; (4) Thirty-three controlled trials published in the past 6 years reported some effectiveness, although potential for bias was high.

Use of Lozenges Containing Lactobacillus brevis CD2 in Recurrent Aphthous Stomatitis: A Double-Blind Placebo-Controlled Trial

Recurrent aphthous stomatitis is a common disorder of the oral cavity, affecting mainly young people. It is characterized by small ulcers which can be very painful and generally heal spontaneously within 7–14 days. There is currently no therapy that can provide rapid healing. This study evaluated the efficacy and rapidity of response of a lozenge containing Lactobacillus brevis CD2. 30 patients were randomized to take 4 lozenges a day of active product or placebo for 7 days. Signs and symptoms as well as laboratory parameters in the saliva were assessed at the start of the study and after 7 days of treatment. The study demonstrated the efficacy and the rapidity of response of the Lactobacillus brevis CD2 lozenges in resolving the clinical signs and symptoms of aphthous stomatitis, with a significantly rapid improvement of pain. This is the first study confirming the efficacy of a probiotic product in this pathology.

Diagnosis and management of vulvar ulcers

The diagnosis and management of the following non-infectious vulvar ulcers are reviewed: vulvar aphthae in adult and pediatric patients, aphthae associated with Behçet's disease, vulvar ulcers resulting from Crohn's disease, and vulvar ulcers associated with human immunodeficiency virus infection. There are many resources providing excellent reviews of infectious ulcers; therefore this topic will not be covered here.

Innovative uses of thalidomide

Thalidomide is approved for treating erythema nodosum leprosum and multiple myeloma, but it has also emerged as a useful treatment option for many refractory dermatologic disorders. Some of the innovative but off-label uses of thalidomide include aphthous stomatitis, Behçet's disease, lupus erythematosus, prurigo nodularis, sarcoidosis, actinic prurigo, graft-versus-host disease, Langerhans cell histiocytosis, erythema multiforme, lichen planus, Kaposi sarcoma, Jessner lymphocytic infiltrate, uremic pruritus, pyoderma gangrenosum, scleroderma, scleromyxedema, and necrobiosis lipoidica. This article reviews the background, pharmacology, and innovative uses of thalidomide in dermatology.

Dental approach in the pediatric oncology patient: characteristics of the population treated at the dentistry unit in a pediatric oncology brazilian teaching hospital

OBJECTIVES

The objective of this paper was to characterize the population seen at the dentistry unit of the hematology-oncology service of the Oncology-Hematology Service, Instituto da Criança at the Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo. Oral problems resulting from cancer therapy increase the risk of infection, length of hospital stay, treatment cost and negative impact on the course and prognosis of the disease.

METHOD

Of the 367 medical records of cancer patients seen from November 2007 until December 2008: 186 with a cancer diagnosis and complete clinical data were selected, while 20 with a cancer diagnosis and incomplete records were excluded; 161 medical records with only hematological diagnosis were also excluded. The following characteristics were assessed: ethnicity, gender, age, diagnosis and characteristics of the neoplasm, cancer therapy status and performed dental procedures.

RESULTS

Review of 1,236 visits indicated that 54% (n=100) of the patients had blood cancers, 46% (n=86) had solid tumors and 63% were undergoing anticancer therapy. The proportion of males (52.7%) in the study population was slightly greater. The most common cancer was acute lymphocytic leukemia (32.2%). Cancer occurred more often among those patients aged 5 to 9 years. The most common dental procedures were restorative treatment, preventive treatment and removal of infectious foci.

CONCLUSION

The characteristics of the studied population were similar to those of the general Brazilian and global populations, especially regarding gender and diagnosis distributions. The aim of implementation of the dentistry unit was to maintain good oral health and patients' quality of life, which is critical to provide oral care and prevent future oral problems.