Anti-epidermal growth factor receptor targeted therapy-associated ulcerations

The well-studied role of epidermal growth factor receptor (EGFR) in metastatic colorectal cancer (mCRC) and non-small cell lung cancer (NSCLC) has enabled the development of drugs that target this molecule, including panitumumab for the former and osimertinib for the latter. Oral adverse events due to those agents are rarely described in the literature and their exact characterization is hampered by inadequate reporting and/or incorrect terminology used. We report two cases of panitumumab- and osimertinib-associated oral ulcerations with emphasis on their possible pathogenesis and optimal management.

Effect of lactobacillus reuteri-derived probiotic nano-formulation on recurrent aphthous stomatitis: a double-blinded randomized clinical trial

OBJECTIVES

We aimed to assess the therapeutic effects of a topical probiotic nano-formulation derived from Lactobacillus reuteri on treating recurrent aphthous stomatitis.

MATERIALS AND METHODS

60 participants were randomly allocated into two groups (control and probiotic). Probiotic group administered topical probiotic nano-formulation three times a day for seven days. The control group administered a standard analgesic oral rinse. The size of ulcer(s) and pain severity were recorded on days 0, 3, 5, and 7 after intervention.

RESULTS

Before the intervention, the groups had no significant differences in terms of pain severity (P-value = 0.28) and lesion size (P-value = 0.24). Both groups exhibited significant reductions in pain severity and lesion size over the course of the intervention. After one week, the probiotic group had a notably larger lesion size reduction than the control group (P-value = 0.01). The probiotic group also showed a significantly greater reduction in pain severity than the control group (P-value = 0.04).

CONCLUSIONS

Applying topical probiotic nano-formulation derived from Lactobacillus reuteri three times a day decreased lesion size and pain severity in RAS patients faster than the local analgesic oral rinse.

CLINICAL RELEVANCE

Lactobacillus reuteri-derived probiotic nano-formulation might be a promising treatment option for RAS.

Systematic review and meta-analysis of oxidative stress and antioxidant markers in recurrent aphthous stomatitis

BACKGROUND

We performed this systematic review and meta-analysis to synthesize all studies that reported the level of oxidative and antioxidative markers in recurrent aphthous stomatitis (RAS) patients compared to controls.

METHODS

We registered our study in PROSPERO (CRD42023431310). PubMed, ProQuest, Scopus, EMBASE, Google Scholar, and Web of Science were searched to find relevant publications up to June 5, 2023. The standardized mean differences (SMDs) with 95% confidence intervals (CIs) were calculated. We included 30 articles after multiple stags of screening.

RESULTS

We found that erythrocyte superoxide dismutase and Glutathione peroxidase activity were significantly lower in patients with RAS compared to healthy controls (SMD = - 1.00, 95%CI = -1.79 to -0.21, p = 0.013, and SMD = - 1.90, 95%CI = -3.43 to -0.38, p = 0.01, Respectively). However, there was not any difference between patients with RAS and healthy controls in erythrocyte Catalase (SMD = - 0.71, 95%CI = -1.56-0.14, p = 0.10). The total antioxidant status (TAS) level, in serum was significantly lower in patients than healthy controls (SMD = - 0.98, 95%CI = -1.57 to -0.39, p = 0.001). In addition, RAS patients had higher levels of serum Malondialdehyde (MDA), Serum total oxidant status, and serum oxidative stress index than healthy controls (SMD = 2.11, 95%CI = 1.43-2.79, p < 0.001, SMD = 1.53, 95%CI = 0.34-2.72, p = 0.01, and SMD = 1.25, 95%CI = 0.25-2.25, p = 0.014, Respectively); However, salivary MDA and TAS, and serum uric acid, vitamin E and C, and reduced glutathione levels of patients with RAS were not different from that of healthy controls.

CONCLUSIONS

The relationship between oxidative stress and RAS is well established in this meta-analysis. Although the molecular processes underlying the etiology of this pathology remain unknown, evidence indicating oxidative stress has a significant role in the pathogenesis of RAS has been revealed.

Risk factors and immunological biomarkers in denture stomatitis: An observational cross-sectional study

OBJECTIVE

Assess risk factors, local and systemic immunological biomarkers in healthy individuals and with Denture Stomatitis (DS).

DESIGN

For this observational transversal study, 27 participants without DS (Group 0), 24 with moderate DS (Group 1), and 25 with severe DS (Group 2) were assessed for sociodemographic, behavioral, and clinical parameters, microbial load of Candida spp., Staphylococcus spp., Streptococcus mutans, Pseudomonas spp., and enterobacteria, and cytokine and C-reactive protein levels. ANOVA, Fisher's exact, Kruskal-Wallis, Mann-Whitney, Wilcoxon and Pearson's chi-square tests were used for data analysis (α = 0.05).

RESULTS

Group 1 had a significantly higher mean age compared to the other groups (P = 0.018), but no correlation was identified between age and DS (P = 0.830; r = 0.025). No significant differences were found among the groups for other sociodemographic and behavioral characteristics. Group 1 had significantly older upper and lower dentures; however, no correlation was identified between age of upper (P = 0.522; r = 0.075) and lower (P = 0.143; r = 0.195) dentures and DS. The microbial load of Candida albicans on the dentures (P = 0.035) and Candida spp. on the palate (P = 0.008) of the groups 1 and 2 was higher than group 0. Group 1 and 2 had higher Candida spp. counts on denture (P = 0.003) than group 0. There was no difference among groups for bacterial analyzed. Group 1 showed higher and Group 2 intermediate salivary levels of IL-6 compared to Group 0. There was no difference in the C-reactive protein levels among groups.

CONCLUSIONS

Microbial load of Candida spp. is the factor with the strongest relationship with DS, with capacity for local signaling through IL-6.

EFFICACY AND SAFETY OF A DEXAMETHASONE-BASED MOUTHWASH TO PREVENT CHEMOTHERAPY-INDUCED STOMATITIS IN WOMEN WITH BREAST CANCER: A MULTICENTRE, OPEN-LABEL, RANDOMISED PHASE 2 STUDY

PURPOSE

No standard approach other than oral care is available for preventing chemotherapy-induced stomatitis in patients with breast cancer. In this randomized, controlled phase 2 trial, we aimed to assess the efficacy and safety of a dexamethasone-based mouthwash in preventing chemotherapy-induced stomatitis in patients with early breast cancer.

BASIC PROCEDURES

Patients with breast cancer scheduled for epirubicin and cyclophosphamide (EC) or docetaxel and cyclophosphamide (TC) therapy were selected and allocated in a 1:1 ratio to the intervention and control groups. The intervention group received chemotherapy, oral care, and a dexamethasone-based mouthwash, whereas the control group received chemotherapy and oral care. The primary endpoint was the incidence of stomatitis. This was a phase 2 study, and the significance level for the analysis of the primary endpoint was set a priori at 0.2.

MAIN FINDINGS

Data pertaining to 58 patients in the control group and 59 patients in the intervention group were analyzed. Stomatitis incidence was 55% and 38% in the control and intervention groups, respectively (risk ratio, 0.68; 80% confidence interval, 0.52-0.88; P = .052). Stomatitis severity was lower in the intervention group than in the control group (P = .03). The proportion of patients who adhered to the mouthwash regimen was 87% (interquartile range, 67.8%-95.3%). No severe oral infections were observed.

PRINCIPAL CONCLUSIONS

The dexamethasone-based mouthwash safely reduced stomatitis incidence and severity in patients receiving chemotherapy for early breast cancer. Phase 3 clinical trials are warranted for validating our results.

Dermatologic toxicities to inhibitors of cyclin-dependent kinases CDK 4 and 6: An updated review for clinical practice

Cyclin-dependent kinase (CDK) 4/6 inhibitors (palbociclib, ribociclib and abemaciclib) have revolutionized the treatment of metastatic breast carcinoma. They currently form the first-line treatment, in combination with endocrine agents, for the management of locally advanced or metastatic hormone receptor-positive (HR + ), human epidermal growth factor receptor 2-negative (HER2-) breast cancer, the largest subtype of breast carcinoma. CDK 4/6 inhibitors have shown comparable efficacy outcomes with predictable and manageable adverse events. In this setting, dermatologic toxicity appears to be relatively frequent, accounting for up to 15% of all reported adverse events. It is usually mild to moderate in intensity and does not normally constitute a dose-limiting toxicity. The range of dermatologic adverse events includes both non-specific entities (maculopapular rash, pruritus, alopecia) and more characteristic toxicities related to CDK4/6 inhibitors, such as vitiligo-like lesions or cutaneous lupus erythematosus. Finally, more severe or life-threatening skin reactions can occasionally occur. The main dermatologic manifestations associated with CDK4/6 inhibitors, as well as management thereof, are described in this comprehensive review.

Oral hygiene protocols reduce the severity and incidence of oral mucositis during antineoplastic treatment: a systematic review and meta-analysis of randomized and non-randomized clinical trials

OBJECTIVE

The objective of this systematic review was to determine whether oral and dental hygiene protocols (DHPs) reduce the incidence and severity of oral mucositis (OM) during antineoplastic treatment.

MATERIALS AND METHODS

This PROSPERO-registered systematic review (CRD42021295322) was based on searches of publicly accessible databases, including PubMed, Scopus, Web of Science, LILACS, EBSCOhost, LIVIVO, Embase, and gray literature (Google Scholar, ProQuest, and Energy) until December 2021. Twenty-five articles from these searches and 14 articles retrieved from the references therein were evaluated in this systematic review and meta-analysis. The risk of bias (RoB) was assessed using RoB-2 and ROBINS-I for randomized (RCT) and non-randomized (n-RCT) clinical trials, respectively. A meta-analysis was performed on RCTs and n-RCTs in two subgroups to evaluate oral mouth rinses or DHP. GRADE-pro was used to assess the degree of certainty of the evidence.

RESULTS

Of the 3367 articles retrieved, 25 RCTs and 14 n-RCTs involving 2109 and 754 patients, respectively, were included in the analyses. RoB was low for RCTs and moderate-to-very severe for n-RCTs. High heterogeneity and publication RoB were identified. In RCTs, mouth rinses (p = 0.830) and DHP (p = 0.100) did not reduce the incidence of OM. However, mouth rinses strongly reduced the severity of OM (p < 0.001; Cohen's d =  - 1.87, 95% confidence interval [CI] =  - 2.49 to - 1.24). In non-RCTs, mouth rinses (p < 0.001) and DHP (p < 0.001) reduced the relative risk of OM 0.38 (95% CI = 0.24 to 0.59) and 0.64 (95% CI = 0.53 to 0.70) times, respectively. In addition, DHP strongly reduced OM severity (Cohen's d =  - 0.81, 95% CI =  - 1.03 to - 0.59). GRADE-pro showed high certainty of OM severity and incidence in RCTs and non-RCTs, respectively, and low (OM incidence in RCTs) to very low (OM severity in non-RCTs) certainty in other outcomes.

CONCLUSION

DHPs strongly reduce the severity and moderately reduce the incidence of OM. However, further studies with low heterogeneity are needed to validate these findings.

Efficacy of bioadhesives in the management of oral mucositis in patients undergoing radio-chemotherapy for treatment of head and neck cancer-a systematic review and meta-analysis

BACKGROUND

Management of head and neck cancers requires a multidisciplinary approach where surgery followed by radio and chemotherapy is the mainstay of treatment. The above-mentioned treatment can cause mucositis, a severely debilitating side effect. This can have a significant impact on quality of life. A recent advancing mode of drug delivery is the bioadhesive system. This interacts with mucosa by adhering to it and thereby improving the efficacy of the therapeutic agent delivered.

AIM AND OBJECTIVE

The purpose of this systematic review is to evaluate the effectiveness of bioadhesives in reducing oral mucositis and relieving pain associated with mucositis in head and neck cancer patients receiving radio-chemotherapy.

MATERIALS AND METHOD

Studies assessing the effectiveness of bioadhesives for the treatment of radiation-induced oral mucositis were retrieved from specialized databases (PubMed/MEDLINE, Scopus, ProQuest, Google Scholar, LILACS, OpenGrey) as well as institutional repositories. Data on incidence, pain reduction, resolution, and improvement of oral mucositis using bioadhesive were compiled. A Cochrane tool was used for randomized controlled trials and a JBI tool for non-randomized controlled trials and observational studies to assess the quality of included studies. Based on the eligible study data, a meta-analysis was conducted with STATA version 16, 2019 software, and 95% confidence intervals and p values greater than 0.05.

RESULTS

A total of 15 studies were included which assessed the effectiveness of bioadhesives in managing mucositis and its associated pain. Studies included in the review described either reduction, resolution, or incidence of oral mucositis respectively. A total of three meta-analyses were conducted to assess the incidence of oral mucositis and the pain associated with it, as well as the reduction in incidence. Bioadhesives showed statistically significant differences in the incidence of severe mucositis (p = 0.04). A meta-analysis comparing bioadhesives efficacy in reducing mucositis and pain associated with it found no statistically significant differences (p = 0.36).

CONCLUSION

Bioadhesives are emerging as a novel drug delivery method for treating radio-chemotherapy-induced oral mucositis because of their rapid absorption and easy application. Regardless of its benefits, clinical trials comparing it with conventional treatment methods are necessary to assess its efficacy in treating oral mucositis.

Lachnoanaerobaculum orale bacteremia in a patient with acute myeloid leukemia and stomatitis: An emerging pathogen

Background

Lachnoanaerobaculum orale is a newly described, obligately anaerobic gram-positive bacillus. The first report of invasive disease caused by L. orale was described in a patient with acute lymphocytic leukemia following systematic chemotherapy. Here we describe another case of L. orale bacteremia in a patient with a hematologic malignancy following chemotherapy-induced neutropenia.

Methods

We present a case of a 46-year-old woman with a recent diagnosis of AML who presented to Sunnybrook Health Sciences Center with febrile neutropenia following induction chemotherapy with daunorubicin-cytarabine (3 +7 regimen) with Gemtuzumab and Ozogamycin. Despite being on intravenous pipercillin-tazobactam she remained febrile. Following our clinical assessment and investigations, potential sources of infection included a swollen digit and severe mucositis.

Results

One blood culture from admission grew Lachnoanaerobaculum orale in the anaerobic bottle, identified by Matrix-Assisted Laser Desorption Ionization-Time of Flight (MALDI-TOF). The isolate also underwent whole-genome sequencing using methods that have been described previously. Results demonstrated the organism was susceptible to cefoxitin, clindamycin, meropenem, metronidazole, penicillin, and piperacillin-tazobactam. We concluded that the source of this patient's bloodstream infection to be chemotherapy-induced stomatitis.

Conclusion

With the increasing use of intensive immunosuppressive regimens and hematopoietic stem cell transplantation for patients with hematologic malignancies, there has been an increase in the incidence and detection of bloodstream infections due to anaerobic organisms. This is only the second case report of L. orale bacteremia, highlighting its emerging role as an opportunistic pathogen in immunocompromised patients.

Clinical guidance for maintaining oral hygiene in patients under-going chemotherapy or radiation therapy: a scoping review

The aim of this scoping review was to identify clinical guidance for maintaining oral hygiene in patients undergoing chemotherapy, radiation therapy, or both. Electronic searches were conducted in PubMed, Embase, Cochrane Library, and Google Scholar for articles published between January 2000 and May 2020. Systematic reviews, meta-analyses, clinical trials, case series, and expert consensus reports were considered eligible for inclusion. The SIGN Guideline system was used to evaluate the level evidence and the grade of recommendations. A total of 53 studies met the eligibility criteria. The results showed the presence of recommendation for oral care in three domains: management of oral mucositis, prevention and control of radiation caries, and management of xerostomia. However, most of the included studies had low levels of evidence. The review provides recommendations for healthcare professionals caring for patients undergoing chemotherapy, radiation therapy, or both, but a standard oral care protocol could not be established owing to a paucity of evidence-based data.

Dual roles of ANGPTL4 in multiple inflammatory responses in stomatitis mice

BACKGROUND

Stomatitis is inflammation of the oral mucosa. Angiopoietin-like protein 4 (ANGPTL4) has pleiotropic functions both anti-inflammatory and pro-inflammatory properties. In the present study, we tested whether there is a correlation between increased ANGPTL4 expression and inflammation in stomatitis mice and the mechanisms involved.

METHODS AND RESULTS

In this study, the oral mucosa of mice was burned with 90% phenol and intraperitoneal injection of 5-fluorouracil to establish the model of stomatitis mice. The pathological changes of stomatitis mice were observed by H&E staining of paraffin section. The expressions of cytokines and ANGPTL4 were detected by fluorescence quantitative PCR, and the protein levels of ANGPTL4 were detected by western blot. Compared with control group, the oral mucosal structure of model mice was damaged. The expression of ANGPTL4 were significantly increased concomitantly with elevated production of anti-inflammatory cytokine (peroxisome proliferator-activated receptor alpha) and pro-inflammatory cytokines [nuclear transcription factor-kappa B, interleukin-6 (IL-6), IL-1β, and tumor necrosis factor-α] in mice with stomatitis.

CONCLUSIONS

This study suggests that ANGPTL4 may be a double-edged sword in multiple inflammatory responses in stomatitis mice.

Anti-inflammatory mouthwashes for the prevention of oral mucositis in cancer therapy: an integrative review and meta-analysis

PURPOSE

Mucositis is severely painful and often reported as one of the most distressing adverse effects of cancer therapy; it is a significant threat to quality of life as well as life itself. Anti-inflammatory agents may modulate physiologic mechanisms that perpetuate mucositis and be useful in prevention efforts. Because systemic anti-inflammatory agents are not appropriate for many patients, locally acting agents (mouthwashes) may be more feasible for use. This review and meta-analysis evaluates the role that anti-inflammatory mouthwashes have in preventing or reducing oral mucositis associated with chemotherapy and radiation therapy.

METHODS

A systematic literature review was conducted to identify studies evaluating the efficacy of anti-inflammatory mouthwashes to prevent therapy-associated mucositis. Meta-analysis was conducted to determine efficacy in preventing any mucositis and dose-limiting mucositis.

RESULTS

Eight peer-reviewed publications were identified; corticosteroid and nonsteroidal anti-inflammatory mouthwashes are effective in reducing overall incidence of mucositis and are associated with lower severity of mucositis. Meta-analysis reveals significant reduction in symptomatic mucositis incidence (OR 6.00, 95% CI 4.39-8.20, p < 0.0001) and reduction of dose-limiting mucositis (OR 2.12, 95% CI 1.07-4.28, p = 0.032).

CONCLUSION

Mouthwashes containing anti-inflammatory agents are a potential effective means to prevent or reduce mucositis associated with cancer therapy. There are limited adverse effects from these agents, and adherence is high, indicating safety and feasibility of use. Anti-inflammatory mouthwashes should be considered for supportive care in persons at risk for mucositis and must be further evaluated to investigate efficacy across multiple chemotherapy agents, adverse effects, and impacts on symptoms, pain, and quality of life.

Milk thistle (Silybum marianum (L.)Gaertn.): An overview about its pharmacology and medicinal uses with an emphasis on oral diseases

BACKGROUND

Milk thistle, a medicinal plant, has different uses and benefits. Pathologies of the oral cavity manifest as different diseases with various therapeutic options. The main phytochemical extract of the milk thistle plant is silymarin. It has optimistic, protective, and therapeutic properties. However, evidence about the role of milk thistle extracts in oral diseases is lacking.

HIGHLIGHT

The pharmacology of milk thistle was overviewed. The role of the plant in some systemic diseases was reviewed. Furthermore, its role in various oral diseases was discussed. The presented articles described such effects in the context of periodontal disease, dental caries, oral candidiasis, oral lichen planus, oral cancer, and oral mucositis. Results on the promising effects of milk thistle extracts with a preference for silymarin were presented from different research designs. A summary of the previously used doses and the currently available pharmaceutical products was proposed for future research.

CONCLUSION

Milk thistle has antioxidant, anti-inflammatory, anticancer, antifungal, immunomodulatory, and other properties. The evidence from human research about the role of milk thistle in oral diseases is limited. Further studies, particularly clinical trials, to test milk thistle either as a potential treatment modality or a supplementary therapy for oral diseases on higher levels would be useful in the future.

[State of art of photobiomodulation in the management of radiotherapy adverse events: Indications and level of evidence]

PURPOSE

To evaluate the current and potential indications of photobiomodulation (PBM) and their level of evidence in the prevention or management of radiation therapy-related side effects.

MATERIALS AND METHODS

The Embase, Medline/PubMed, Cochrane, EBSCO, Scopus, and LILACS databases were systematically reviewed to include and analyze publications of clinical studies that have assessed PBM in the prevention or management of radiotherapy-related side effects. The keywords used were "photobiomodulation"; "low level laser therapy"; "acute oral mucositis"; "acute dysphagia"; "acute radiation dermatitis"; "lymphedema"; "xerostomia"; "hyposalivation"; "trismus"; "bone necrosis"; "osteoradionecrosis"; and "radiation induced fibrosis". Prospective studies were included, whereas retrospective cohorts and non-original articles were excluded from the analysis.

RESULTS

PBM in the red or infrared spectrum has demonstrated efficacy in randomized controlled trials in the prevention and management of radiotherapy-related side effects, especially acute oral mucositis, acute radiation dermatitis, and upper extremity lymphedema. The level of evidence associated with PBM was heterogeneous, but overall was still moderate. The main shortcomings were the diversity and lack of detail in treatment protocols, which could have compromised efficiency and reproducibility of PBM results.

CONCLUSION

The published data suggest that PBM may be considered as a full-fledged supportive care for patients treated with radiotherapy, or at least in the setting of a therapeutic clinical trial. However, until strong evidence has been published on its long-term safety, the use of PBM should be considered with caution, specifically when applied near areas with proven or potential tumors. The patient should be informed of the theoretical benefits and risks of PBM in order to obtain his informed consent before treatment.

Oral ulcers in children- a clinical narrative overview

The prevalence of oral ulcers in children is reported to be 9%, however diagnosis of oral lesions can be challenging, being an unspecific symptom of several diseases. Differential diagnosis can range from classic infectious disease of childhood (e.g. herpangina, hand-foot-and-mouth-disease) over nutritional deficiencies, gastrointestinal disorders, inflammations (e.g. pemphigus vulgaris, lichen planus, mucous membrane pemphigoid) to side effects of medications (Stevens-Johnson Syndrome) or chronic dieseases (e.g. sarcoidosis, systemic Lupus erythematodes, familial Mediterrenean fever). Therefore, children with oral ulcers are treated by many different specialists such as dentists, family doctors, paediatricians, rheumatologists, haematologists, gastroenterologists and otorhinolaryngologists.A systematic literature search and a narrative literature review about the potential 48 diseases connected to oral ulcers were performed. According to the duration of symptoms and size of the lesions, a tabular overview was created to support the clinician in making a correct diagnosis, additionally different treatment options are presented.

Medicinal plants used for the treatment of mucositis induced by oncotherapy: a systematic review

PURPOSE

This systematic review aimed to identify effective medicinal plants for the treatment of mucositis induced by oncotherapy.

METHODS

The clinical question was the following: "Which medicinal plants are effective in the treatment of oral mucositis induced by cancer treatment?" (PubMed, Medline, Web of Science, Scopus, Lilacs, and SciELO). The keywords were the following: phytotherapy OR "herbal drug" OR "plant extract" OR plant OR "medicinal plant" OR pharmacognosy OR ethnobotany OR ethnomedicine OR ethnopharmacology OR "flower essences" OR "natural product" AND mucositis OR mucositides OR stomatitis OR stomatitides OR "oral ulcer" AND chemotherapy OR radiotherapy OR immunotherapy OR cancer OR neoplasm OR neoplasm OR tumor OR tumor. The inclusion criteria for the selection of articles were the type of study design (clinical trials) and the studied population (cancer patients presenting lesions of oral mucositis having undergone treatment with medicinal plants).

RESULTS

After evaluation of the works, 24 of 893 articles were selected. Matricaria chamomilla (chamomilla) presented promising results, such as a reduction in severity and lesion incidence with improved pain symptomatology. The plant extracts Isatis indigótica, Olea europaea, Calendula officinalis, A. digitatae, and M. sylvestris improved the lesions. Mucotrol™ and QRLYD herbal products improved the degree of severity of the lesions, while SAMITAL® and MUCOSYTE allowed for greater pain control.

CONCLUSION

The complementary treatment of oral mucositis in cancer patients, with analgesic and anti-inflammatory actions with lower side effects, is an alternative for healthcare professionals.

Oral Candidiasis and COVID-19 in Users of Removable Dentures: Is Special Oral Care Needed?

Elderly patients with systemic disorders and immunocompromised patients seem to have a higher risk of developing morbidity from COVID-19. Candida albicans (C. albicans) is a potentially dangerous pathogen for these patients, especially for denture wearers with prosthetic stomatitis who require mechanical ventilation. C. albicans infection, the main candidiasis infection associated with denture wear, can complicate COVID-19 and increase the associated morbidity and mortality. Therefore, early diagnosis of C. albicans infection in COVID-19 patients is important to establish more effective antifungal treatment methods and prophylaxis strategies. Hospitalized COVID-19 patients should undergo an oral examination to assess their oral health, and those with poor oral health should receive the appropriate care and monitoring.

Statherin-derived peptides as antifungal strategy against Candida albicans

OBJECTIVE

The aim of this in vitro study was to evaluate the effect of statherin and its naturally occurring peptides (DR9-2, DR9, GE-12, IT-32, GQ-19, IP-18) on Candida albicans metabolism and biofilm development.

DESIGN

After the killing assay, a peptide pellicle was formed on the bottom of a polystyrene plate at the IC₅₀ of each peptide. Over the peptide pellicle, Candida albicans biofilm (48 h) was grown. The peptides antimicrobial activity after the peptides treatment was evaluated by alamarBlue, total biofilm biomass and colony forming units (CFU) counting.

RESULTS

The pellicle with statherin and the peptides (DR9-2, DR9, GE-12, IP-18, GQ-19) was able to reduce he viability of Candida albicans compared to the negative control. They also decreased cell proliferation by 20 % and total biomass. IT-32 showed the highest reduction in cell proliferation and biomass, which was similar to the positive control, histatin 5.

CONCLUSIONS

These results suggest that the naturally occuring peptides from statherin are able to decrease Candida albicans colonization and biofilm proliferation.

Impact of severe oral mucositis in pediatric cancer patients on resource utilization and cancer treatment plans

BACKGROUND

Oral mucositis is a common chemotherapy-related adverse event that may result in serious complications. Few studies have evaluated mucositis in pediatric patients.

OBJECTIVE

To evaluate the impact of severe mucositis on resource utilization and on treatment plans of pediatric cancer patients.

SETTING

Comprehensive cancer center in Amman, Jordan.

METHOD

Retrospective study on pediatric patients undergoing active cancer treatment with a hospital admission diagnosis of severe oral mucositis (January 2015-December 2019). Patients undergoing bone marrow transplant were excluded. Severe oral mucositis was defined as interfering with oral intake and requiring intravenous opioids.

MAIN OUTCOME MEASURE

We reviewed the electronic billing system and patient medical charts to determine the resources utilized during hospitalization, cost, and the impact on subsequent treatment protocols.

RESULTS

During the study period, 200 patients were eligible; the average age was 8.6±5.6 years (SD) and 45% had acute lymphoblastic leukemia. The median hospital stay was 6 days (range 2-21) with a total median cost of US$ 2,176 (range 635-13,976) per admission. The median medication cost was US$ 1,075 (range 135-9010), and 85% of the patients received antibiotics during hospitalization, at a median cost of US$ 487 (range 23-2,193). Modification of the chemotherapy treatment protocol was required in 110 patients, which included dose reduction (60%), delay (38%), and discontinuation (2%).

CONCLUSION

Severe oral mucositis is associated with significant resource utilization and modification of the treatment protocols. Further studies are needed to identify strategies to reduce the impact of mucositis in this patient population.

Lifetime prevalence of recurrent aphthous stomatitis and its related factors in Northern Iranian population: The PERSIAN Guilan Cohort Study

OBJECTIVES

Recurrent aphthous stomatitis (RAS) is one of the most prevalent oral inflammatory ulcerative lesions. The aim of this large population base study was estimated lifetime prevalence of RAS and its related factors among the Northern Iranian population.

MATERIALS AND METHODS

This study was conducted on 10,520 participants aged 35-70 years based on the PERSIAN Guilan Cohort Study (PGCS). Prevalence proportions and multivariate logistic regression models were constructed for lifetime RAS prevalence using the SPSS software. Data on potential correlates of RAS including demographic profiles, lifestyle habits, and self-reported past medical histories were obtained.

RESULTS

The lifetime prevalence of RAS was 8.3%. Multivariate logistic models showed that urbanization (adjusted odds ratio (AOR) = 1.2) and having a history of systemic disease, including rheumatic disease (AOR = 2.1), genital aphthous disease (AOR = 11.7), depression (AOR = 1.3), chronic headaches (AOR = 1.8), diabetes mellitus (AOR = 1.6), and epilepsy (AOR = 2), were independent predictors of RAS. In addition, smokers (AOR = 0.5) and individuals older than 50 years of age (AOR = 0.8) were less likely to have a history of RAS. The lifetime prevalence of RAS among the Northern Iranian population was relatively low.

CONCLUSIONS

It seems that predisposing factors, such as younger age, urbanization, and systemic disease, including rheumatic disease, genital aphthous disease, depression, chronic headaches, diabetes mellitus, epilepsy, and not smoking, could contribute to RAS prevalence.

Strong association between herpes simplex virus-1 and chemotherapy-induced oral mucositis in patients with hematologic malignancies

BACKGROUND/AIMS

A link between oral cavity infections and chemotherapy-induced oral mucositis (CIOM) in patients with hematological malignancies (HMs) undergoing intensive chemotherapy (IC) or hematopoietic stem cell transplantation (HSCT) has been suggested. However, conclusive data are lacking, and there are no current guidelines for the prophylactic use of antimicrobials to prevent CIOM in these populations.

METHODS

The relationships between herpes simplex virus (HSV) reactivation and Candida colonization in the oral cavity and CIOM in patients with HMs undergoing IC or HSCT were evaluated. Patients aged ≥ 19 years with HMs undergoing IC or HSCT were enrolled. Each patient was evaluated for HSV and Candida in the oral cavity along with CIOM at baseline and during the 2nd, 3rd, and 4th weeks.

RESULTS

Seventy presentations among 56 patients were analyzed. CIOM was observed in 23 presentations (32.9%), with a higher incidence associated with HSCT (17 of 35 presentations, 48.6%) than with IC (six of 35 presentations, 8.6%). The reactivation of HSV-1 was significantly associated with an increased incidence of CIOM after adjusting for age, sex, type of disease, and treatment stage. A higher HSV-1 viral load was associated with an increased incidence of CIOM. The presence of Candida was not associated with CIOM.

CONCLUSION

HSV-1 reactivation in the oral cavity was highly associated with CIOM in patients with HMs undergoing high-dose chemotherapy.

Use of a natural multicomponent mouthwash plus oral hygiene vs oral hygiene alone to prevent everolimus-induced stomatitis: the STOP multicenter, randomized trial

BACKGROUND

Stomatitis is highly prevalent in patients with cancer treated with the mammalian target of rapamycin inhibitor everolimus; it usually has an early onset and may compromise treatment dose intensity and patients' quality of life. Within the randomized controlled Stomatitis Prevention trial (STOP, ISRCTN14568888), we investigated the possibility of using a commercial natural multicomponent mouthwash (Orasol Plus®) to prevent the development of stomatitis of any grade in patients with advanced renal cell carcinoma (RCC) treated with everolimus.

METHODS

Overall, 62 patients were randomized to receive either Orasol Plus in addition to oral hygiene or oral hygiene alone (31 patients per treatment arm).

RESULTS

In the whole study population, 28 episodes of stomatitis were observed (41.9%); in only 2 patients, stomatitis occurred more than once (2 episodes). As expected, the episodes of stomatitis occurred early in the course of treatment with everolimus. Treatment with Orasol Plus prevented the onset of everolimus-induced stomatitis: only 8 episodes of stomatitis were observed in the treated group with Orasol Plus in addition to oral hygiene vs 20 episodes in the group treated with oral hygiene only (p = 0021). Also, a reduction in the average duration of mucositis in patients treated with Orasol Plus compared to patients treated with oral hygiene only was observed (8 days vs 11.2 days, p = 0.0416).

CONCLUSION

This study showed that the use of a natural multicomponent mouthwash coupled with regular oral hygiene was able to reduce the severity and duration of everolimus-induced stomatitis in patients with RCC.

TRIAL REGISTRATION NUMBER

ISRCTN14568888.

Newly formulated 5% 5-aminolevulinic acid photodynamic therapy on Candida albicans

BACKGROUND

A large number of systemic diseases can be linked to oral candida pathogenicity. The global trend of invasive candidiasis has increased progressively and is often accentuated by increasing Candida albicans resistance to the most common antifungal medications. Photodynamic therapy (PDT) is a promising therapeutic approach for oral microbial infections. A new formulation of 5-aminolevulinic acid (5%ALA) in a thermosetting gel (t) (5%ALA-PTt) was patented and recently has become available on the market. However, its antimicrobial properties, whether mediated or not by PDT, are not yet known. In this work we characterised them.

METHODS

We isolated a strain of C. albicans from plaques on the oral mucus membrane of an infected patient. Colonies of this strain were exposed for 1 24 h, to 5%ALA-PTt, 5%ALA-PTt buffered to pH 6.5 (the pH of the oral mucosa) (5%ALA-PTtb) or not exposed (control). The 1 h-exposed samples were also irradiated at a wavelength of 630 nm with 0.14 watts (W) and 0.37 W/cm2 for 7 min at a distance of <1 mm.

RESULTS AND CONCLUSION

The 5% ALA-PTt preparation was shown to be effective in reducing the growth of biofilm and inoculum of C. albicans. This effect seems to be linked to the intrinsic characteristics of 5%ALA-TPt, such acidic pH and the induction of free radical production. This outcome was significantly enhanced by the effect of PDT at relatively short incubation and irradiation times, which resulted in growth inhibition of both treated biofilm and inoculum by ∼80% and ∼95%, respectively.

The effectiveness of probiotics in prevention and treatment of cancer therapy-induced oral mucositis: A systematic review and meta-analysis

Oral mucositis (OM) is a common and troublesome adverse side effect of many cancer therapy modalities (chemotherapy, radiotherapy, and chemo-radiotherapy), which can cause pain, ulceration, dysphagia, malnutrition, even treatment interruption. Probiotics may be effective in preventing and treating of cancer therapy-induced OM. We performed a systematic review and meta-analysis of the effectiveness of probiotics in prevention and treatment of cancer therapy-induced OM. Four databases and one trial registry were searched as of the 12th of May 2019 to identify all eligible randomized controlled trials (RCT). Five studies involving 435 patients were included in this study. Methodological quality and outcomes were evaluated in every study included. Pooled results showed a moderate heterogeneity (P = 0.15, I² = 44%). The pooled RRs indicated that the use of probiotics decreased the risk of OM for grade ≥3 (RR = 0.66, 95%CI = 0.54-0.81, P < 0.0001) as well as all grades (RR = 0.83, 95% CI = 0.72-0.97, P = 0.02). There was no significant difference between probiotics and placebo for cancer therapy completion rate (RR = 1.14, 95%CI = 0.65-2.00, P = 0.64). The subgroup analysis indicated that the use of probiotics was not statistically significant for patients receiving chemo-radiotherapy (RR = 0.52, 95% CI = 0.26-1.04, P = 0.07). In conclusion, probiotics may reduce the incidence and mitigate the severity of cancer therapy-induced OM. Further trials with a randomized, double-blind and multicentric study design are needed to confirm this effect. The PROSPERO registration number of this systematic review and meta-analysis is CRD42019130414.

Silent celiac disease in dermatology

INTRODUCCIÓN

La enfermedad celíaca puede estar asociada de forma silente a varias enfermedades de la piel y las mucosas.

OBJETIVO

Determinar la frecuencia de enfermedad celíaca en portadores de urticaria crónica, vitíligo, alopecia areata, psoriasis y estomatitis aftosa, en el Hospital Nacional de Itauguá, Paraguay, en los años 2017 y 2018.

MATERIAL Y MÉTODOS

Diseño observacional de corte transversal, prospectivo. Se determinaron los anticuerpos IgA antitransglutaminasa tisular e IgA sérica en pacientes adolescentes y adultos que otorgaron su consentimiento informado. En los casos positivos se realizó la confirmación histológica con biopsias duodenales.

RESULTADOS

Se incluyeron 79 pacientes, con predominio del sexo femenino (75%). La mediana de edad fue de 33 años y el índice de masa corporal medio fue de 24.7 kg/m2. La enfermedad celíaca se demostró histológicamente en 4 de 32 portadores de estomatitis aftosa, en 2 de 24 con vitíligo y en 1 de 17 con alopecia areata. No se detectó en pacientes con urticaria crónica ni psoriasis.

CONCLUSIÓN

La frecuencia de enfermedad celíaca confirmada histológicamente en pacientes con estomatitis aftosa, vitíligo o alopecia areata fue del 8.8%.

BACKGROUND

Silent celiac disease may be associated to various skin and mucous membranes diseases.

OBJECTIVE

Determine the frequency of celiac disease in carriers of chronic urticaria, vitiligo, alopecia areata, psoriasis and aphthous stomatitis treated in the National Hospital of Itauguá, Paraguay, in years 2017 and 2018.

MATERIAL AND METHODS

An observational cross-sectional, prospective design was used. IgA tissue antitransglutaminase antibody and serum IgA was determined in adolescents and adult patients who gave their informed consent. In positive cases, histological confirmation was performed with duodenal biopsies.

RESULTS

79 patients were included, with a predominance of females (75%). Median age was 33 years, and the average body mass index 24.7 kg/m2. Celiac disease was demonstrated histologically in 4/32 carriers of aphthous stomatitis, in 2/24 with vitiligo, and in 1/17 with alopecia areata. It was not detected in patients with chronic urticaria or psoriasis.

CONCLUSION

Frequency of celiac disease histologically confirmed in patients with aphthous stomatitis, vitiligo or alopecia areata was 8.8%.

Exfoliative Erythroderma: An Unusual Presentation of Paraneoplastic Pemphigus Associated with Castleman's Disease

We report a 23-year-old woman who presented with generalized scaly erythematous rash predominately on the upper trunk and hemorrhagic stomatitis. The histopathologic and immunopathologic findings were consistent with the diagnosis of paraneoplastic pemphigus. Castleman's tumor was diagnosed with computed tomography and exploratory laparotomy. A partial clinical improvement was observed after complete tumor removal and intravenous immunoglobulin administration. However, the patient died as a result of septicemia.

Photobiomodulation and photodynamic therapy for the treatment of oral mucositis in patients with cancer

BACKGROUND

Photobiomodulation therapy (PBM-T) can penetrate soft tissues and exert analgesic and healing effects, and is thus a promising alternative for prevention and treatment of oral mucositis (OM). The aim of this study was to evaluate the efficacy of PBM-T, alone or combined with photodynamic therapy (PDT), for treatment of OM in cancer patients.

METHODS

Fifty-six patients were recruited from the Oncology Department of a teaching hospital. Patients underwent grading of OM and were divided into two groups (n = 28 each): PBM-T and PBM-T + PDT. In the PBM-T group, low-level laser was applied to 61 points in the oral cavity, once weekly for 4 weeks (wavelength 660 nm, power 100 mW, energy density 142 J/cm², spot energy 4 J, irradiation time 40 s). In the PBM-T + PDT group, in addition to PBM-T as described above, patients rinsed with 20 ml of photosensitizing mouthwash (curcumin 1.5 g/L) and the oral cavity was irradiated with a blue (468 nm) LED for 5 min.

RESULTS

Significant reductions in OM grade were observed after application of PBM-T or PBM-T + PDT (p < 0.0001). PBM-T + PDT resulted in a shorter time to resolution of lesions compared to PBM-T alone (p = 0.0005).

CONCLUSIONS

PBM-T, alone or combined with PDT, can be used for the treatment of OM. PDT + PBM-T in particular accelerated the OM healing process, reducing time to lesion remission from 15 to 11 days.

Hygiene protocols for the treatment of denture-related stomatitis: local and systemic parameters analysis - a randomized, double-blind trial protocol

Background

Denture-related stomatitis (DS) is chronic multifactorial inflammation, strongly related to the presence of the biofilm that is the complex structure formed by microorganisms held together by a mucus-like matrix of carbohydrate that adheres to different surfaces, including the denture surface. DS has recently been correlated with deleterious cardiovascular alterations. The potential effect of hygiene protocols in the control of DS and randomized clinical trials that address this oral condition with cardiovascular complications are important in clinical decision-making.

Material/design

A clinical trial, randomized, double-blind, and with parallel groups, will be conducted in Brazil The sample will consist of 100 patients without teeth in both arches, users of at least maxillary complete dentures, and diagnosed with DS, who will be allocated to groups (n = 25 per group) according to the different hygiene protocols: (1) brushing of the palate and immersion of the prosthesis in 0.25% sodium hypochlorite solution (positive control); (2) brushing of the palate and immersion of the prosthesis in 0.15% triclosan solution; (3) brushing of the palate and immersion of the prosthesis in lactose monohydrate; or (4) brushing the palate with citric acid and immersing the prosthesis in lactose monohydrate. The response variables will be heart rate variability and alteration of blood pressure (systemic level), remission of DS, removal of biofilm, reduction of microbial load (colony-forming units (CFU)), mouth and prosthesis odor level, expression of MUC1, proinflammatory cytokines, C-reactive protein (CRP), viscosity, pH and salivary flow (locally); patient-centred qualitative analysis will also be undertaken. Measurements will be performed at baseline and 10 days after the interventions. The results obtained will be statistically analyzed as pertinent, with a level of significance of 0.05.

Discussion

This study will provide a guideline for clinical practice regarding the use of hygiene protocols in the treatment of oral diseases (DS) mediated by biofilm. Also, it may provide evidence of correlation of oral manifestation with cardiac risk.

Trial registration

Brazilian Registry of Clinical Trials, RBR-4hhwjb. Registered on 9 November 2018.

Comparative Study of Punica granatum Gel and Triadent Oral Paste Effect on Recurrent Aphthous Stomatitis, a Double Blind Clinical Trial

Statement of the Problem

Recurrent aphthous stomatitis is a common oral lesion, and the use of herbal remedies containing tannin and flavonoid has been reported to be effective in treating aphthous stomatitis.

Purpose

This study was aimed to evaluate the effect of Punica granatum muco-adhesive gel on controlling the oral recurrent aphthous stomatitis and its comparison with Triadent oral paste.

Materials and Method

In this double-blind clinical trial, 60 patients with minor aphthous stomatitis were enrolled. These patients had no systemic diseases and were not on any medications. The patients were randomly treated with Punica granatum formulated gel, Triadent oral paste and placebo. The time of pain elimination and the time of complete healing were recorded and the pain degree was assessed and recorded by each patient. The data were analyzed using survival analysis and ANOVA test.

Results

The Kaplan-Meier survival analysis demonstrated that pain relief time in Punica granatum group was lower than placebo group (p= 0.002), even so, it caused no significant difference with the Triadent group in comparison with the placebo group (p= 0.08). The survival analysis also indicated that the wound healing time in Punica granatum group was significantly lower than the other two groups (p< 0.05).

Conclusion

Punica granatum gel has a successful effect in controlling and treating recurrent aphthous stomatitis. It can be considered as an affordable and inexpensive treatment.

Effectiveness of booster dose of tetanus and diphtheria toxoids (Td) vaccine in management of recurrent aphthous stomatitis: a prospective, randomized, triple-blind and placebo-controlled clinical trial

BACKGROUND

Recurrent aphthous stomatitis (RAS) is the most common oral disease. The activation of the immune system by vaccines might reduce the interactions between oral mucosa and microorganisms.

AIM

To evaluate the effect of the tetanus-diphtheria toxoids (Td) vaccine in management of RAS.

DESIGN AND SETTING

This prospective, randomized, triple-blind and placebo-controlled clinical trial study was conducted on 70 eligible patients with minor RAS at the dermatology outpatient clinic.

METHOD

Finally, a total of 66 participants (48 male, 18 female; mean age: 38.56 ± 10.98 years) completed the study in two groups, one in which colchicine and a single dose of vitamin B6 (placebo group) was treated and one in which colchicine and a single dose of Td vaccine (intervention group) was treated.

RESULTS

After six months of follow-up, the patients were evaluated, which revealed significant effects of the Td vaccine on pain intensity, ulcer size, recovery time, and the interval between episodes. At the end of the six month follow-up, 27 patients (81.8%) in the intervention group and 13 patients (39.4%) in the placebo group showed partial or complete recovery, and there was statistically significant difference between the groups (p < .001). Recovery was not significantly associated with sex, education level, marital status and duration of RAS. However, occupation and positive family history of RAS had significant relations with recovery.

CONCLUSIONS

A booster dose of Td vaccine had relatively favorable effects on pain intensity and recurrence of RAS, but further research is needed to confirm its efficacy.

A cross-sectional study on oncology nurses' knowledge and practice of oral mucositis among cancer patients in Jordan

Objectives

This study was conducted to evaluate oncology nurses' knowledge and compliance with oral mucositis (OM) management guidelines.

Methods

A cross-sectional design with a nonparticipant observation approach was utilized. In phase Ⅰ, a cross-sectional convenience sample (n = 140) of oncology nurses completed the knowledge test. In phase Ⅱ, a random sample (n = 20) of oncology nurses from participants in phase Ⅰ was observed during their practice.

Results

Fifty-seven (40.7%) of the participants had an unsatisfactory level of knowledge. Most of them had knowledge deficits regarding pathology, OM definition, assessment, scoring, treatment, and patient education and advice. A significant difference existed among nurses with diploma, bachelor, and postgraduate degrees as determined by one-way ANOVA (P = 0.001). There were no significant difference between average scores of male and female nurses were higher than those of nurses (P = 0.45). No significant difference was observed among knowledge scores of nurses with different job titles (P = 0.51). The average score of male nurses in terms of skill performance was higher than that of female nurses (29.20 ± 2.10 vs 27.10 ± 1.80) without statistical significance.

Conclusion

The knowledge and compliance with OM management guidelines among Jordanian oncology nurses need to be improved. National OM prevention and management guidelines are adopted in Jordan. Continuing education and training are also recommended.

A novel prognostic biomarker for recurrent aphthous stomatitis: calprotectin

OBJECTIVE

This study aims to investigate whether there is a correlation between serum calprotectin concentration and oral ulcer activity in patients with active recurrent aphthous stomatitis.

METHOD

This prospective, cross-sectional, historical cohort study included 52 patients (26 with active lesions and 26 with inactive lesions) with recurrent aphthous stomatitis and 27 healthy volunteers. The relationship between the groups was statistically evaluated in terms of serum calprotectin level and other inflammatory parameters.

RESULTS

The median calprotectin value of the active lesion group (80.5 ng/ml) was significantly higher than that of the control group (55.4 ng/ml, p = 0.002). Furthermore, the median calprotectin value of the active lesion group was significantly higher than that of the inactive lesion group (72.5 ng/ml, p = 0.017).

CONCLUSION

In patients with recurrent aphthous stomatitis and active ulcer lesions, the serum calprotectin value can be used as a reliable and robust prognostic marker for inflammation.

A single-arm, phase 2 study of steroid-containing mouthwash for the prevention of everolimus-associated stomatitis in multiple tumor types

BACKGROUND

Everolimus is a mammalian target of rapamycin inhibitor used in the treatment of multiple tumor types, and its most common toxicity, stomatitis, can affect patient quality of life. Recent studies in breast cancer have supported the efficacy of steroid mouthwash for the prevention of everolimus-associated stomatitis. However, a few studies have been reported to date, and none have examined this effect in other tumor types.

METHODS

This single-arm phase 2 study was designed to evaluate the efficacy of steroid-containing mouthwash for the prevention of stomatitis in patients with multiple tumor types receiving everolimus. The primary outcome was incidence of grade ≥ 2 stomatitis at 8 weeks of everolimus with steroid-containing mouthwash prophylaxis. We also assessed the stability of steroid-containing mouthwash components.

RESULTS

Twenty-nine patients were evaluated, of which 76% had breast cancer and 24% had neuroendocrine tumors originating in the lung, gastrointestinal tract, pancreas, or of unknown primary origin. Grade ≥ 2 stomatitis incidence at 8 weeks was 28.1% (90% CI 16.2-46.1); the higher confidence limit exceeded the prespecified threshold of 30%. No patients developed grade ≥ 3 stomatitis. Most stomatitis occurred behind the oral cavity, with no lesions observed on the lips or floor of the mouth.

CONCLUSIONS

Our findings did not support a prophylactic effect of steroid-containing mouthwash on everolimus-associated stomatitis. Given the needs of prevention of everolimus-associated stomatitis in various tumor types, further studies in a larger population using a randomized controlled trial design are, therefore, required to confirm the efficacy of steroid-containing mouthwash.

Oral Health Status and Oral Health-related Quality of Life According to Presence or Absence of Mucositis in Head and Neck Cancer Patients

Background

Oral mucositis during radiotherapy which is harmful to the patients with head and neck is suggested to be related to the oral hygiene and health. Therefore, we evaluated the oral health status in relation to the occurrence of mucositis among patients with head and neck cancer during radiotherapy.

Methods

Tooth plaque index (PI), periodontal depth, and oral mucositis in 50 patients with head and neck cancer were examined by a dentist for 8 weeks after radiotherapy initiation. Cancer type and site were recorded based on the patients’ medical records. In addition, we assessed oral health-related quality of life.

Results

The mean age of participants was 56.3 ± 11.6 years, with patients aged > 60 years comprising the largest proportion of the mucositis group. The median (range) of the PI index were 0 (0–3) and 1 (0–3) among participants with mucositis and those without, respectively, with no significant difference (P = 0.761). The median (range) of the total Oral Health Impact Profile score were 54 (42–58) and 41 (14–70) among participants without mucositis and those with mucositis, respectively (P = 0.037).

Conclusions

This study showed that patients who developed mucositis during radiotherapy had lower oral health-related quality of life than those who did not. However, there was no difference in oral health status according to mucositis.

Evaluation of Miracle Mouthwash plus Hydrocortisone Versus Prednisolone Mouth Rinses as Prophylaxis for Everolimus-Associated Stomatitis: A Randomized Phase II Study

BACKGROUND

Mammalian target of rapamycin (mTOR) inhibitor-associated stomatitis (mIAS) is a frequent adverse event (AE) associated with mTOR inhibitor therapy and can impact treatment adherence. The objectives are to evaluate two steroid-based mouthrinses for preventing/ameliorating mIAS in patients with metastatic breast cancer (MBC) treated with everolimus.

MATERIALS AND METHODS

This prospective, randomized phase II study enrolled 100 postmenopausal patients with hormone receptor-positive MBC within the US Oncology Network who were initiating therapy with an aromatase inhibitor + everolimus (AIE; 10 mg/day). Patients were randomized to prophylactic therapy with one of two oral rinses (Arm 1: Miracle Mouthwash [MMW] 480 mL recipe: 320 mL oral Benadryl [diphenhydramine; Johnson & Johnson, New Brunswick, NJ, USA], 2 g tetracycline, 80 mg hydrocortisone, 40 mL nystatin suspension, water; or Arm 2: prednisolone [P] 15 mg/5 mL oral solution, 1.8% alcohol). Patients were instructed to swish/expectorate 10 mL of the assigned rinse for 1-2 minutes four times daily starting with day 1 of AIE treatment, for the first 12 weeks.

RESULTS

A total of 100 patients received treatment (49 MMW; 51 P). The incidence of stomatitis/oral AEs during the first 12 weeks was 35% (n = 17/49) and 37% (19/51) in the MMW and P arms, respectively. The incidence of grade 2 oral AEs was 14% (7/49) and 12% (6/51) with MMW or P, respectively. There were two grade 3 oral AEs (MMW arm) and no grade 4 events. There was one everolimus dose reduction (MMW) and six dose delays (four MMW, two P) and one dose reduction + delay (MMW) during the first 12 weeks of treatment. No patients stopped steroid mouthwash therapy because of rinse-related toxicity.

CONCLUSION

Prophylactic use of steroid-containing oral rinses can prevent/ameliorate mIAS in patients with MBC treated with AIE. MMW + hydrocortisone is an affordable option, as is dexamethasone oral rinse.

IMPLICATIONS FOR PRACTICE

This prospective phase-II study showed that two steroid-containing mouthrinses substantially reduced incidences of all-grade and grade ≥2 stomatitis and related oral adverse events (AEs), and the number of everolimus dose-delays and/or dose-reduction in metastatic breast cancer (MBC) patients receiving everolimus treatment plus an aromatase inhibitor. Both oral rinses were well tolerated and demonstrated similar efficacy. Prophylactic use of steroid mouth rinse provides a cost-effective option that substantially decreases the incidence and severity of mammalian target of rapamycin (mTOR) inhibitor-associated stomatitis and related oral AEs as well as the need for dose modification in MBC patients undergoing treatment with an mTOR inhibitor.

Frictional Keratosis, Contact Keratosis and Smokeless Tobacco Keratosis: Features of Reactive White Lesions of the Oral Mucosa

White lesions of the oral cavity are quite common and can have a variety of etiologies, both benign and malignant. Although the vast majority of publications focus on leukoplakia and other potentially malignant lesions, most oral lesions that appear white are benign. This review will focus exclusively on reactive white oral lesions. Included in the discussion are frictional keratoses, irritant contact stomatitis, and smokeless tobacco keratoses. Leukoedema and hereditary genodermatoses that may enter in the clinical differential diagnoses of frictional keratoses including white sponge nevus and hereditary benign intraepithelial dyskeratosis will be reviewed. Many products can result in contact stomatitis. Dentrifice-related stomatitis, contact reactions to amalgam and cinnamon can cause keratotic lesions. Each of these lesions have microscopic findings that can assist in patient management.

Staged lower lip reconstruction following gangrenous stomatitis in an immunosuppressed patient

A 70-year-old male with a history of diabetes mellitus, hypertension, and coronary stent insertion visited our hospital 7 days after biting his lower lip. Swelling and inflammation had worsened despite debridement and antibiotic treatment. On the 8th hospital day, fungal infection with Candida albicans and superimposed bacterial infection with Klebsiella pneumoniae were found on tissue culture. Extensive necrosis resulted in a defect of approximately 3/4 of the entire lower lip and a full-layer skin defect from the vermilion to the gingivobuccal sulcus at the right corner of the mouth. To correct drooling, incomplete lip sealing, and trismus, staged reconstruction was performed with consideration of cosmetic and functional features. The treatment process using staged reconstruction and antifungal treatment for an extensive lower lip defect caused by fungal stomatitis is described.

Kinetics of antifungal activity of home-generated ozonated water on Candida albicans

Background and Purpose:

Candida-associated denture stomatitis is one of the most common forms of oral candidiasis among denture wearers. Regarding this, the aim of the present study was to evaluate the antifungal effects of home-generated ozonated water on the adhesion of the C. albicans attached to the surface of the denture base acrylic resins.

Materials and Methods:

For the purpose of the study, different concentrations of C. albicans were added to the tubes containing acrylic resin blocks, and then incubated for 2 h at 35°C. The samples were assigned into three groups, each of which contained 42 samples, including normal saline (NS) solution as the negative control, nystatin (N) solution as the positive control, and ozonated water as the test group. The samples were washed and placed in an ultrasonic bath. Subsequently, the saline solution was cultured on Sabouraud dextrose agar. The concentrations of Candida were evaluated during the contact times.

Results:

The test group (i.e., ozonated water) with 114 colony-forming units (CFU) showed a significant reduction of Candida colonies, compared to the NS group with 2,172 CFU. The 120- and 1-minute incubation with ozonated water showed the highest and lowest effects on the viability of Candida adhered to the acrylic resin, respectively.

Conclusion:

Based on the findings, home-generated ozonated water can be applied to remove the Candida attached to the surface of the denture plates.

The association between minor recurrent aphthous stomatitis (RAS), children's poor oral condition, and underlying negative psychosocial habits and attitudes towards oral hygiene

BACKGROUND

Minor Recurrent Aphthous Stomatitis (RAS) represents a disease which is very difficult to prevent. This case-control study focused on possible associations between minor Recurrent Aphthous Stomatitis in children, their oral health, and underlying behavioral indexes of children's attitudes and habits pertaining to (home) oral hygiene, with the further goal of enabling the dentist to prevent these specific kind of lesions, both from a clinical and a broader psychosocial perspective.

METHODS

Four hundred one school-children (5-10 years old) in Milan (Italy) were submitted to an intra-oral examination, and interviewed with the aid of a brief psychosocial questionnaire.

RESULTS

At the clinical level, statistically significant associations were observed between the presence of decayed teeth and minor Recurrent Aphthous Stomatitis (Odds Ratio: 3.15; 95% CI: lower limit 1.06; upper limit: 9.36; Z-test: 2.07, p = 0.039; Chi-square = 4.71, p = 0.030), and between the Decayed Missing or Filled Teeth (DMFT) index and minor aphthous stomatitis (Odds Ratio: 3.30; 95% CI: lower limit 1.13; upper limit: 9.67; Z-test = 2.18, p = 0.029; Chi-square = 5.27; p = 0.022), both results pointing to a significant increase-by circa 3 times-in the risk of developing minor Recurrent Aphthous Stomatitis in children exposed to the two above-identified factors (i.e., the presence of decayed teeth and a clearly compromised oral condition, as signaled by the DMFT index), if compared with the risk run by their non-exposed counterparts. At the psychosocial level of analysis, statistically significant associations were observed (1) between children's practice of spontaneously brushing teeth when not at home and a comparatively lower (i.e. better) Decayed Missing or Filled Teeth index (Chi-square: 8.95; p = 0.011), and (2) between receiving parental aid (e.g., proper brushing instructions) while practicing home oral hygiene and a significantly reduced presence of decayed teeth (Chi-square = 5.40; p = .067; Spearman's Rho, p = .038). Further, significant associations were also observed between children's reported severity of dental pain and both (a) the presence of decayed teeth (Chi-square = 10.80; p = 0.011), and (b) children's (poor) oral health condition as expressed by the Decayed Missing or Filled Teeth index (Chi-square = 6.29; p = 0.043). Interestingly, specific lifestyles and social status, showed no systematic association to other clinical or psychological/psychosocial indices.

CONCLUSIONS

These systematic relations suggest that, in the presence of Recurrent Aphthous Stomatitis in pediatric patients, the dentist should carefully monitor children for potential carious lesions, implement protocols of prevention to control Recurrent Aphthous Stomatitis disease in children affected by caries, and also be particularly aware of the right or wrong habits children may acquire in the course of continued social exchange with their caregivers and peers.

New paste for severe stomatitis in patients undergoing head-and-neck cancer radiotherapy and/or chemotherapy with oral appliance

Background

The aim of the present study was to evaluate the physical properties of “admixture paste”, which is a commercially available gel containing hinokitiol for use against severe stomatitis, and its characteristics as a moisturizing gel and denture adhesive.

Methods

The admixture paste, which contained dexamethasone (Dexaltin®), gel for oral care (Refrecare H®) and petrolatum, and its 3 components, either alone or in different combinations, were subjected to viscosity, adhesiveness and elution testing to compare their physical properties. Viscosity was measured with a stress-controlled rheometer. Adhesive force was measured by tension test. Elution under a simulated oral environment was evaluated by monitoring with a fixed-point camera and absorbance. Both adhesiveness and elution were evaluated every hour for 6 h. A linear mixed-effects model was used to assess differences in the time course of elution between samples. In 3 og-rank test was used to compare time to elution into saliva among samples.

Results

The results of viscosity testing demonstrated that the admixture paste had similar viscosity to cream-type denture adhesives and this was temperature independent. In the adhesiveness tests, the admixture paste showed stronger adhesiveness than that of cream-type denture adhesives. In the elution test, the admixture paste demonstrated gradual dissolution and apparent temporal changes for 6 h in a simulated oral environment.

Conclusions

The results of the present study demonstrated that the admixture paste has adhesive force similar to those of denture adhesives and good local retention in saliva, and that it might be suitable for therapeutic use in patients with severe stomatitis derived from radiotherapy and/or chemotherapy for cancer.

Electronic supplementary material

The online version of this article (10.1186/s12885-018-4017-2) contains supplementary material, which is available to authorized users.

Stomatitis associated with mammalian target of rapamycin inhibition: A review of pathogenesis, prevention, treatment, and clinical implications for oral practice in metastatic breast cancer

BACKGROUND

Patients with metastatic breast cancer may develop oral morbidities that result from therapeutic interventions. Mammalian target of rapamycin (mTOR) inhibitor-associated stomatitis (mIAS) is a common adverse event (AE), secondary to mTOR inhibitor therapy, that can have a negative impact on treatment adherence, quality of life, and health care costs. A multidisciplinary team approach is important to minimize mIAS and to maximize treatment benefits to patients with breast cancer. In this review, we discuss the pathophysiology, diagnosis, and natural history of mIAS. Current and new management strategies for the prevention and treatment of mIAS are described in the context of fostering a coordinated team care approach to optimizing patient care.

TYPES OF STUDIES REVIEWED

The authors conducted a PubMed search from 2007 through 2017 using the terms "stomatitis," "mIAS," "everolimus," "mTOR," "metastatic breast cancer," and "oral care." They selected articles published in peer-reviewed journals that reported controlled trials and evidence-based guidelines.

RESULTS

mIAS can be distinguished from mucositis caused by cytotoxic chemotherapy or radiotherapy on the basis of cause, clinical presentation, and treatment paradigms. Specific preventive and therapeutic management strategies can be implemented across the continuum of patient oral health care.

PRACTICAL IMPLICATIONS

Oral health care providers are on the frontline of oral health care for patients with metastatic breast cancer and are uniquely positioned to provide patient education, advocate accurate reporting of mIAS, and support early identification, monitoring, and prompt intervention to mitigate the severity and duration of this manageable, potentially dose-limiting AE.

Association of Transforming Growth Factor-Beta Gene Polymorphisms in Recurrent Aphthous Stomatitis

This study has been conducted to evaluate the allele, genotype and haplotype frequencies of the polymorphic gene coding TGF-β in recurrent aphthous stomatitis (RAS). TGF-β gene typing was done by polymerase chain reaction with sequence-specific primers (PCR-SSP) assay. Allele frequencies were estimated by direct gene counting. C allele at codon 25 was significantly increased, while G allele at this position was significantly decreased in patients compared to the controls. A significantly higher frequency of CG genotype at codon 25 was found in control group. CC genotype and TT genotype at codon 10 of the gene was significantly decreased, while CT genotype at the same position was significantly increased in patients, indicating that CT heterozygosity at codon 10 TGF-β is associated with greater risk of RAS. CG and TG haplotypes were significantly decreased while CC and TC haplotypes were significantly increased in patients compared with controls. This study indicates the TGF-β single nucleotide polymorphisms could play a role in RAS pathogenesis. Thereby certain SNPs of TGF-β gene have an association with RAS pathogenesis.

from denture-related stomatitis in Pará, Brazil

The aim of this study was to isolate and identify Candida species from the oral cavity of denture wearers with denture-related stomatitis who were attended at the University Federal of Pará (Belém City, Pará State, Brazil). A total of 36 denture wearers with denture-related stomatitis were included, and type I (50%), type II (33%) and type III (17%) stomatitis were observed. Candida spp. were isolated from 89% of the cases and included five different Candida species. C. albicans was the most frequently recovered species (78% of the cases), followed by C. famata and C. tropicalis. We observed a significant association between Candida species isolation and unsatisfactory denture condition (p = 0.0017). Our results demonstrated the highly frequency of Candida species isolation in denture wearers with denture-related stomatitis and showed the relationship between these species and poor denture maintenance.

A Case Report of Paraneoplastic Pemphigus Associated With Retroperitoneal Inflammatory Myofibroblastic Tumor

Paraneoplastic pemphigus (PNP) is an autoimmune bullous disease associated with underlying neoplasms, both malignant and benign. The most constant clinical presentation of PNP is the presence of intractable stomatitis. Herein we present a 25-year-old male with a 3-month history of refractory stomatitis especially involving the lips and widespread vesiculobullous eruption on his trunk and extremities. The diagnosis of PNP was confirmed based on histological and serological results. Investigation for the underlying neoplasm revealed a retroperitoneal tumorous mass which was biopsied and diagnosed as the inflammatory myofibroblastic tumor (IMT). The tumor was surgically excised, and different treatment regimens were used to treat the mucocutaneous lesions. Skin lesions responded favorably to treatment, but oral stomatitis still persists which is the case in most PNP patients. This combination of PNP and IMT has rarely been reported in the literature. Treatment started with corticosteroid and rituximab then tumor excised.

Treatment of recurrent aphthous stomatitis with Er,Cr:YSGG laser irradiation: A randomized controlled split mouth clinical study

The present randomized controlled split mouth clinical study aimed to investigate the efficacy of Er,Cr:YSGG laser irradiation on pain reduction and healing rate of recurrent aphthous stomatitis. 40 patients with RAS were recruited for this study and RAS ulcerations of each patient were randomly assigned to the control or test group. In the test group, Er,Cr:YSGG laser with non-contact mode was used to irradiate RAS lesions. In the placebo group, RAS lesions were irradiated with the same device without laser emission. Pain was evaluated with visual analog scale (VAS) while a clinician graded healing of RAS (HRAS). In the placebo group at immediate; scores of VAS presented no statistically significance; in the test group, laser application showed significant pain reducing, at 1st day control. In the test group, a significantly healing effect at 1st day control was observed and this effect was maintained throughout the study. In the placebo group, scores of HRAS were statistically significant at controls on 3, 7, 10days. Statistically significant difference between the scores of VAS and HRAS was found for all control days except day 10 according to the intergroup comparisons. Based on these findings, Er,Cr:YSGG laser application at 0.25W without water may be appropriate to reduce pain and also accelerate the healing of RAS.

Herbs in Oral Mucositis

Oral mucositis is an inflammatory mucosal destruction as a result of chemotherapy and/or radiation therapy, which in severe cases can impair patients' quality of life. Moreover, mucosal infection and/or systemic involvement due to compromised immunity leads to delay or discontinuation of the treatment. Many strategies and agents have been suggested for the management of this condition. Because of their lower side effects compared to chemical drugs, general interest in evaluating therapeutic effects of herbs has been increased intensively. Herbal plants apply their effect through different mechanisms of action: antioxidant, analgesic, anti-inflammatory, antifungal, antiseptic, and anticarcinogenic activity. Recently, various natural agents in plants have been noticed in mucositis, which may improve the symptoms through different interventions. The purpose of this review is to focus on the preventive or therapeutic use of herbal medicine to alleviate oral mucositis.