Etiopathogenesis of recurrent aphthous stomatitis and the role of immunologic aspects: literature review

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

Background

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

Methods

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

Results

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

Conclusions

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

COVID-19-related oral mucosa lesions among confirmed SARS-CoV-2 patients: a systematic review

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is the virus responsible for coronavirus disease 2019 (COVID-19), which manifests as a flu-like respiratory infection affecting multiple organ systems, including the gastrointestinal system, central nervous system, cardiovascular system, skin, and mucosa. In this review, we investigated the literature on specific manifestations of COVID-19 in the oral mucosa. An online literature search in PubMed, Scopus, Google Scholar, and Medline was conducted to retrieve relevant studies on confirmed COVID-19 patients with oral mucosa findings published between December 31, 2019, and April 07, 2021. After an independent review by two authors, 39 articles considering 59 laboratory-confirmed cases of SARS-CoV-2 infection were included in the final analysis. The most common finding, reported in 29 patients (43.9%), was Kawasaki-like syndrome. In addition, oral ulcers including aphthous, hemorrhagic, and necrotic ulcers were reported in 24 patients (36.3%). Other lesions reported included pustules, macules, bullae, maculopapular enanthema, and erythema multiforme-like lesions. Concomitant skin lesions were present in 60.6% of patients. Fever was reported in 86.2% of patients. Forty-eight patients (76.1%) were hospitalized. Loss of taste and smell was present in 30.8% of the patients. A comprehensive understanding of the dermatologic manifestations of COVID-19 can improve and facilitate patient management and referrals.

[Experience of using bacteriophages in the complex treatment of children with aphthous stomatitis]

Aphthous stomatitis (AS) is one of the most common diseases of the oral mucosa in children. A significant role in the pathogenesis of AS is assigned to the infectious-allergic factor.

THE AIM

Of the work was to evaluate the clinical effectiveness of topical application of bacteriophages in the complex treatment of children with aphthous stomatitis.

MATERIALS AND METHODS

The main group included 30 children with AS aged 4 to 15 years. The control group consisted of 20 healthy children without AS and without concomitant somatic pathology at the age of 4 to 15 years. The effectiveness of the therapy was evaluated based on the results of repeated bacteriological examination of the oral microflora, conducted 1 month after phage treatment, as well as the dynamics of clinical manifestations: reduction in size or complete epithelization of defects.

RESULTS

The use of bacteriophage in the complex treatment of children with AS was accompanied by positive dynamics of clinical and laboratory parameters in all patients: a significant decrease in microbial contamination and the number of individual pathogenic microflora species against the background of normalization of local microbiocenosis in the oral cavity.

CONCLUSION

The obtained clinical and laboratory data allowed improving the scheme of complex treatment of AS in children by the use of bacteriophages.

Interleukin-6 gene polymorphism in Saudi population with recurrent aphthous stomatitis

Introduction

Recurrent aphthous ulcers are common but poorly understood mucosal disorder. Local and systemic conditions, genetic, immunological, and microbial factors may play a role in the pathogenesis of recurrent aphthous ulceration (RAS). Different aetiologies and mechanisms might be involved in the aetiopathogenesis of aphthous ulceration. Cytokines are thought to play an important role and high levels of interleukin (IL)-6, a pro-inflammatory cytokine, have been detected in the circulation of ulcer tissue. The purpose of the present study was to investigate if polymorphisms of IL-6 gene are associated with RAS in a cohort of specific population.

Methodology

A total of 37 RAS patients and 18 healthy controls were included in the study. The genotypes of IL-6 gene -174G\C polymorphisms were determined using polymerase chain reaction and sequencing.

Results

Four SNPs were analyzed, one known mutation which been evaluated as a risk factor for RAS, and three new mutations were investigated. The genotype frequencies of -174G\C polymorphism showed no statistically significant differences between RAS patients and controls (p\ 0.629). Polymorphisms of Rs1800795 heterozygous genotype were found in 21.62% of cases, and 33.33% of controls. Homozygous mutant genotype was found in 5.41% of cases and no homozygous mutant genotype was found in control group. The normal alleles were found in 72.97% of cases and 66.67% of control.

Conclusion

Thus, according to our study, IL-6 gene polymorphism is not involved in RAS pathogenesis. Further studies should be done on large sample size to detect any association with pathogenesis. However, an alternative reasoning could point out to a complex interactive effect on IL-6 expression that might exist between any of the detected polymorphisms.

Oral Aphthous: Pathophysiology, Clinical Aspects and Medical Treatment

Oral aphthosis is a painful inflammatory process of the oral mucosa. Oral aphthous can appear alone or secondary to numerous distinct disease processes. If recurrence occurs frequently, it is called recurrent aphthous stomatitis. The pathophysiology of oral aphthous ulcers remains unclear but various bacteria are part of its microbiology. Three morphological types hold great importance in literature because these types help manage the illness properly. Google Scholar and PubMed databases were used to retrieve the relevant data and information. Different keywords including "Aphthous", "Aphthosis", "Canker sores", "Aphthous stomatitis", "Aphthous ulcer causes", "Aphthous ulcer AND Microbiota" and "Aphthous ulcer AND treatment". The causes for oral aphthous ulcerations are widespread and ranges from localized trauma to rare syndromes, underlying intestinal disease, or even malignant disease processes. A detailed history and thorough examination of systems can assist the physician or dermatologist in defining whether it is related to a systemic disease process or truly idiopathic. Management of oral aphthous ulcers is challenging. For oral aphthous or recurrent aphthous ulcers from an underlying disease, topical medications are preferred due to their minimum side effects. Systemic medications are necessary if the disease progresses. Within the limitation of research and literature provided, it is safe to say that topical corticosteroids are the first line of treatment. Herein, the author discusses the pathophysiology, types, causes, diagnosis, and appropriate treatment ladder of oral aphthous stomatitis as described in the literature.

Crosstalk between the oral microbiota, mucosal immunity, and the epithelial barrier regulates oral mucosal disease pathogenesis

Oral mucosal disease (OMD), which is also called soft tissue oral disease, is described as a series of disorders or conditions affecting the mucosa and soft tissue in the oral cavity. Its etiology is unclear, but emerging evidence has implicated the influence of the composition of the oral mucosa and saliva-resident microbiota. In turn, this dysbiosis effects the immune response balance and epithelial barrier function, followed by the occurrence and progression of OMD. In addition, oral microbial dysbiosis is diverse in different types of diseases and different disease progressions, suggesting that key causal pathogens may exist in various oral pathologies. This narrative literature review primarily discusses the most recent findings focusing on how microbial dysbiosis communicates with mucosal adaptive immune cells and the epithelial barrier in the context of five representative OMDs, including oral candidiasis (OC), oral lichen planus (OLP), recurrent aphthous ulcer (RAU), oral leukoplakia (OLK), and oral squamous cell carcinoma (OSCC), to provide new insight into the pathogenetic mechanisms of OMDs.

Effects of natural extracts in the treatment of oral ulcers: A systematic review of evidence from experimental studies in animals

Background

To evaluate the clinical and histopathological effects of natural extracts in the treatment of oral ulcers induced in animal experimental models.

Material and Methods

We carried out a search in the Medline, Scopus, WoS and Embase databases from the start of the databases to December 2020, and also made a manual search of the references. The search and selection were carried out by two researchers independently. The inclusion criteria were: experimental studies in animal models, in english, which complied with the study object.

Results

A total of 705 articles were identified. After selection by title, abstract and full text, 19 articles were finally included. Natural extracts of Jasminum grandiflorum, Ficus deltoidea, curcumin and Bixina orellana provoked a significantly greater reduction in the size of the ulcer. Extracts of Salvatora persica, Musa acuminate, Ganoderma lucidum mycelia and Bixina Orellana, as well as preparations of Kouyanqing Granule and curcumin, were able to reduce levels of pro-inflammatory cytokines and increase the expression and serum levels of growth factors and anti-inflammatory cytokines. Extracts of Piper sarmentosus, Cannabis sativa and Bletilla striata provoked a reduction in the severity of the histological inflammation. No significant differences were observed compared to controls in the treatments with extracts of Cannabis sativa, Aloe barbadensus Miller and Malva sylvestris in reducing the area of the oral ulcers.

Conclusions

Most of the natural extracts described in this review presented a positive clinical and histological effect on the cicatrisation of oral ulcers induced in animal models.

Key words:Recurrent aphthous stomatitis, oral ulcer, plants, herbs, extracts, medicine, treatment.

STAT1: a novel candidate biomarker and potential therapeutic target of the recurrent aphthous stomatitis

BACKGROUND

The recurrent aphthous stomatitis (RAS) frequently affects patient quality of life as a result of long lasting and recurrent episodes of burning pain. However, there were temporarily few available effective medical therapies currently. Drug target identification was the first step in drug discovery, was usually finding the best interaction mode between the potential target candidates and probe small molecules. Therefore, elucidating the molecular mechanism of RAS pathogenesis and exploring the potential molecular targets of medical therapies for RAS was of vital importance.

METHODS

Bioinformatics data mining techniques were applied to explore potential novel targets, weighted gene co-expression network analysis (WGCNA) was used to construct a co-expression module of the gene chip data from GSE37265, and the hub genes were identified by the Molecular Complex Detection (MCODE) plugin.

RESULTS

A total of 16 co-expression modules were identified, and 30 hub genes in the turquoise module were identified. In addition, functional analysis of Hub genes in modules of interest was performed, which indicated that such hub genes were mainly involved in pathways related to immune response, virus infection, epithelial cell, signal transduction. Two clusters (highly interconnected regions) were determined in the network, with score = 17.647 and 10, respectively, cluster 1 and cluster 2 are linked by STAT1 and ICAM1, it is speculated that STAT1 may be a primary gene of RAS. Finally, genistein, daidzein, kaempferol, resveratrol, rosmarinic acid, triptolide, quercetin and (-)-epigallocatechin-3-gallate were selected from the TCMSP database, and both of them is the STAT-1 inhibitor. The results of reverse molecular docking suggest that in addition to triptolide, (-)-Epigallocatechin-3-gallate and resveratrol, the other 5 compounds (flavonoids) with similar structures may bind to the same position of STAT1 protein with different docking score.

CONCLUSIONS

Our study identified STAT1 as the potential biomarkers that might contribute to the diagnosis and potential therapeutic target of RAS, and we can also screen RAS therapeutic drugs from STAT-1 inhibitors.

Salivary proteome of aphthous stomatitis reveals the participation of vitamin metabolism, nutrients, and bacteria

There are currently no preventative options for recurrent aphthous stomatitis, and the only available treatments are palliative. This is partly due to a poor understanding of its etiopathogenesis. In this case-control study, we characterized the salivary proteome of patients with recurrent aphthous stomatitis in the presence and absence of lesions. Through mass spectrometry-based proteomics and bioinformatics tools, we identified that the presence of oral ulcers is associated with several specific biological processes, including the metabolic pathways of vitamin B9, B12, nitrogen, selenium, and the bacterium Neisseria meningitidis. These changes occurred only in the presence of clinically visible lesions, and there were no relevant differences between patients in anatomical regions unaffected by ulcers. Additionally, using western blot and ELISA assays, we verified that carbonic anhydrase 1 (CA1) and hemoglobin subunit beta (HBB) proteins are highly expressed during the ulcerative and remission phases of recurrent aphthous stomatitis. Our results cumulatively support saliva as an indicator of the pathophysiological changes, which occur during the clinical course of lesions. From a clinical perspective, we suggest that recurrent aphthous stomatitis is a condition triggered by temporary biological changes in people with lesions.

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.

Combination of Levamisole with Prednisone in Treating Recurrent Major Aphthous Ulcer in a Young Boy: A Case Report

Recurrent aphthous stomatitis (RAS) is an oral condition characterized by painful oral ulcerations. While the clinical features of this disease are easily defined, the etiology remains unclear. Thus, existing treatments are still unsatisfactory in reducing the severity, healing, and recurrence rate; however, there is no permanent and definitive treatment. Effective treatment for aphthous stomatitis is not available, and those treatments available mainly focus on suppressing its symptoms. We are reporting a case of a 17-year-old boy who presented with a 3-year history of multiple recurrent major ulcers in the oral cavity. Levamisole with steroids has been used in many clinical trials to treat aphthous ulcers, showing an improvement in pain, discomfort, healing time, and reduction in the number of ulcers. The same method was used to treat our patient, who showed promising results, with no recurrence for one year. Levamisole is a safe, easily tolerable and promising drug for the treatment of RAS.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Altered oral microbiota composition associated with recurrent aphthous stomatitis in young females

Oral microbiota has been implicated in pathogenesis of recurrent aphthous stomatitis (RAS), which is a common mucosal disorder with unclear etiology. This study has explored the association between oral microbiota disorder and RAS in high-risk young female population.Forty-five young females were enrolled, including 24 RAS patients and 21 healthy individuals. Oral microbiome was analyzed by Illumina Miseq sequencing.Oral microbiota associated with RAS was characterized by the lower alpha-diversity indices (Chao1 and ACE). Several infectious pathogens increased in RAS, such as genera Actinobacillus, Haemophilus, Prevotella and Vibrio. The PICRUSt analysis indicated that the oral microbiota might be related with the up-regulation of genes involving infectious and neurodegenerative diseases, environmental adaptation, the down-regulation of genes involving basal metabolism, such as carbohydrate, energy, and amino acid metabolism.This study indicated that oral microbiota may play a significant role in RAS development.

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.

Recent advances in the aetiology of recurrent aphthous stomatitis (RAS)

Recurrent aphthous stomatitis (RAS) is the most common disease of oral mucosa, which almost attacks each individual once in their lifespan. Although plenty of factors have been suggested to play a role in the pathogenesis of RAS, the aetiology of RAS is still controversial, which might lead to limited clinical therapies in accordance with each RAS patient. This review mainly illustrates recent advances in potential causes associated with RAS in detail. Deeper comprehension of the aetiology of RAS will support doctors and researchers to make a better management of RAS patients and to discover new treatments. The aetiology of RAS is complicated, hence we should take a comprehensive view into its aetiology, with multiple potential factors being considered. Sample collection of RAS patients have greatly limited the progress in the aetiology of RAS. A research model of multiagency cooperation can help achieve perfect sample collection of year-round and multiposition.

Combined signatures of serum proteome and transcriptome in patients with recurrent aphthous ulcer

OBJECTIVES

Recurrent aphthous ulcer (RAU) is a common oral disease with unclear mechanism. This study aimed to explore the serum signatures of RAU patients via proteomic and transcriptomic analysis.

METHODS

This study was based on clinical observation. Part of serum was used for clinical tests, while the rest was processed for isobaric tags for relative and absolute quantitation (ITRAQ) labeling coupled with two-dimensional liquid chromatography-tandem mass spectrometry (2D LC-MS/MS) combined with microRNA (miRNA) microarrays. Bioinformatic analysis was then used to obtain significant signatures, which was verified by ELISA, qRT-PCR, and dual-luciferase reporter gene assays.

RESULTS

Clinical data showed that triglyceride level, white blood cell count, and neutrophils percentage were increased in RAU group, while lymphocytes percentage was decreased. ITRAQ-2D LC-MS/MS identified 22 upregulated and 33 downregulated proteins in RAU group. Simultaneously, miRNA microarrays identified 64 upregulated and 31 downregulated miRNAs. After integrative bioinformatic analysis and verification, three miRNA-protein pairs, mainly involved in oxidative stress and inflammation responses, were obtained. Additionally, the interaction network indicated the crucial role of complement and coagulation cascade pathway in RAU.

CONCLUSIONS

Our study revealed that complement and coagulation cascade pathway, oxidative stress, and inflammation responses may act as vital factors in pathogenesis of RAU.

Association of bedtime with recurrent aphthous stomatitis: A cross-sectional study among health.care professional students

Background:

Although recurrent aphthous stomatitis (RAS) is the most common oral mucosal disease, the etiology remains poorly understood till date. In addition, RAS lacks definitive therapeutic options, and hence, it becomes even more important to know the etiological factor so as to relieve the symptoms and render treatment effectively. Recently, late bedtime has been shown to be associated with RAS. Due to prolonged duty hours along with lengthy learning and training periods, late bedtime is a frequent observation among health-care professional students. However, this is a less explored field in the previous studies on RAS.

Aims:

This study aimed to evaluate the role of bedtime in the causation of RAS among health-care professional students.

Methods:

This present cross-sectional survey was carried out among medical, dental and nursing students studying in our medical campus, using an anonymous, self-administered questionnaire consisting of 18 items. The collected data was statistically analyzed and interpreted. Descriptive analysis and Chi-square tests were employed to assess the association of RAS with various variables.

Results:

Among a total of 1111 students who participated in the study, 39.8% (n = 442) experienced RAS. Factors such as history of digestive tract disease, family history and stress showed a positive correlation with RAS. Interestingly, both during examination and nonexamination period, RAS was more prevalent among students with bedtime >11pm than in students with bedtime <11 pm.

Conclusion:

The study indicates that late bedtime is an independent risk factor for RAS and thus clinicians should focus on recommending a healthy lifestyle with adequate sleep to patients with RAS. This would benefit patients with RAS, especially health-care professional students, and could probably contribute to long-term remission in RAS.

Penicillin in oral aphthosis, new insight for an old drug: A randomized, double-blind, controlled clinical trial

BACKGROUND

Oral aphthosis is a painful ulceration of mucus membranes characterized by round or oval lesions with central necrosis and erythematous haloes. Due to unknown etiology, treatment is highly controversial and based mainly on individual experience. The aim of this study was to investigate the safety and efficacy of topical penicillin 6.3.3 for the treatment of recurrent aphthous stomatitis.

MATERIALS AND METHODS

This randomized, double-blind, controlled clinical trial was done in Shahid Sadoughi Hospital Clinic in Yazd (2011-2012). Fifty patients aged 15-45 with recurrent oral aphthosis were randomly divided into two groups. After obtaining informed consents, patients in the case and control groups were treated (four times/day for a week), respectively, by topical penicillin 6.3.3 powder and placebo in similar vial. The patients who had acute-onset oral aphthae (≤48 h of appearance) with diameter ≥5 mm were included. History of sensitivity to β-lactam antibiotics and cephalosporin; spontaneous recovery during <5 days in previous episodes; concurrent systemic, infectious, or any autoimmune disorders; history of taking drugs (local or systemic) from 2 weeks prior to presentation; alcohol or drug abuse; smoking cigarette or tobacco; and poor compliance were exclusion criteria. Patients were examined in days 0, 3, 6, and 8. The main outcome measure was reduction in the median pain. Burning, pain, erythema, and inflammation were recorded as complications.

RESULTS

Of 25 patients receiving penicillin, 13 were female and 12 were male. Regarding the pain score (mean difference = 1.6 vs. 0.88, P = 0.012) and size of aphthus (mean difference = 9.43 vs. 1.24, P = 0.008), patients who received penicillin had significantly better results than the placebo group on day 8 after the treatment. The mean duration to healing was 3 days for penicillin group and 6 days for placebo group (P = 0.016). No topical or systemic adverse effects were observed.

CONCLUSION

Our study showed a dramatic response to topical penicillin with respect to placebo. Hence, it seems that penicillin could be a safe and effective option in managing oral aphthosis.

The efficacy of probiotics in management of recurrent aphthous stomatitis: a systematic review and meta-analysis

There is currently a lack of effective drugs to cure recurrent aphthous stomatitis. This study aimed to evaluate the efficacy of probiotics alone or as an adjunct in recurrent aphthous stomatitis (RAS) patients. Seven randomized controlled trials (RCTs) were included, of which three were included in quantitative analysis. Of five studies evaluating the efficacy of probiotics alone compared with placebo or Oracure gel, two reported no significant difference in relieving oral pain, while probiotics exhibited a higher capacity for decreasing oral pain in the other three. A significant decrease in ulcer severity was found in one, while no significant difference was found in the other four. The remaining two studies demonstrated that probiotics, as an adjunct to steroids or anaesthetic antiseptic gel, significantly reduced the ulcer severity and oral pain. The meta-analysis showed a significant decrease in oral pain (- 1.72, P = 0.0001) with probiotics compared with placebo. In conclusion, probiotics alone were capable of relieving oral pain but not effective in reducing ulcer severity. A combination of probiotics and steroids or anaesthetic antiseptic gel was more effective than steroids or anaesthetic antiseptic gel alone in RAS patients. Probiotics are promising for the treatment of recurrent aphthous stomatitis.

Effect of different treatments on recurrent aphthous stomatitis: laser versus medication

Recurrent aphthous stomatitis (RAS) is a common disease with ulcers in oral cavity which may trigger chewing, speaking, and swallowing difficulties to patients. Treatment of RAS is primarily aimed at pain relief and the promotion of wound healing. However, few agents have been found to have definite effect in the management of RAS and most of the medicinal products may cause adverse reactions or other disadvantages, which makes their clinical usage questionable. The purpose of this randomized controlled clinical trial (RCT) was to assess the clinical effect of diode laser and traditional medication treatment on RAS. In this study, 56 patients were randomly assigned to two groups (n = 28). Laser group was treated using diode laser (810 nm, 1.0 W, CW, irradiation time 20 s for 3 applications) once daily for continuous 3 days. Medication group was treated with triamcinolone acetonide 0.1% three times a day until the lesion was healed. Spontaneous and functional pain level on the third day of treatment was significantly less in the laser group. Significant difference was observed with respect to healing time; however, the order of difference is small albeit of statistical significance. Diode laser with the chosen parameters had better effects on pain relief and no distinct advantage on wound healing comparing with medication. Trial registration number: ChiCTR2000030298; date of registration: 26 February 2020 (retrospectively registered).

Oral ulcerations in a patient with autosomal dominant hyper-IgE syndrome (AD-HIES)

A 23-year-old woman with autosomal dominant hyper-IgE syndrome complicated by recurrent pneumonia and sinusitis presented with 1 week of multiple painful oral ulcers unresponsive to empiric antiviral and antifungal treatment. Her ulcers progressively worsened and she required hospitalisation for intravenous hydration and pain control. PCR swab of an ulcer was positive for varicella-zoster virus. Her symptoms never fully resolved despite antiviral therapy, and within 2 weeks, she relapsed with new and worsening ulcers. Biopsy revealed chronic active inflammation with no evidence of viral inclusion bodies or fungal hyphae. She was diagnosed with recurrent aphthous stomatitis and referred to a local dentist for CO₂ laser treatments with rapid resolution of her symptoms. This case highlights the broad differential for recurrent oral ulcers in people with a primary immunodeficiency. It also raises awareness of the benefits of laser therapy for aphthous stomatitis treatment and the importance of partnering with our colleagues in dentistry.

Do Heavy Metals Accumulated in Saliva Involve in the Etiopathogenesis of Recurrent Aphthous Stomatitis?

Recurrent aphthous stomatitis (RAS) is one of the most common diseases of oral mucosa characterized by recurrent painful ulcers. Although many factors have been implicated in its etiology, they are not fully identified. To investigate the involvement of heavy metals accumulated in saliva in the etiopathogenesis of RAS. This is a prospective, comparative, and controlled clinical study investigating the relationship between heavy metal exposure and RAS. The study consisted of 75 patients with idiopathic RAS who presented to our clinic with recurrent oral wound complaints and 74 healthy volunteers. All subjects were interviewed regarding age, acute or chronic diseases, dietary habits, and possible chemical exposure. Lead (Pb), cadmium (Cd), mercury (Hg), copper (Cu), and manganese (Mn) was measured in saliva by inductively coupled plasma-mass spectrometer (ICP-MS). Significance was considered at p < 0.05. Salivary levels of Pb (15.2 ± 1.1 vs. 7.6 ± 9.9 μg/l; p < 0.003), Hg (0.50 ± 0.60 vs. 0.13 ± 0.30 μg/l; p < 0.001; p < 0.001), Cd (0.11 ± 0.14 vs. 0.06 ± 0.13 μg/l; p < 0.021), and Cu (34.9 ± 22.5 vs. 21.6 ± 21.9 μg/l; p < 0.001) were significantly higher in the patient group than that in the control group. There was no significant difference between Mn levels (57.9 ± 41.6 μg/l). Higher heavy metal content of saliva in the patients with RAS may induce apoptosis and ulcer in oral mucosa cells through triggering release of reactive oxygen species resulting from oxidative stress resulting DNA damage.

Extraintestinal Manifestations of Inflammatory Bowel Disease in Middle Eastern Patients

Background and Aims: The Inflammatory Bowel Diseases (IBDs), Crohn’s Disease (CD) and Ulcerative Colitis (UC), are gastrointestinal autoimmune disorders with many Extraintestinal Manifestations (EIMs). Previously reported incidences of EIMs in IBD patients have ranged from 10% to 50%. The large variation in occurrence of EIMs has been linked to genetic predisposition. Correlations between individual EIMs are unclear. Therefore, we aim to estimate the incidence of EIMs in a Middle Eastern cohort of patients with IBD and examine possible relationships with EIMs.

Patients and Methods: We conducted a retrospective study involving all patients included in the King Abdulaziz University IBD information system registry between 2013 and 2018. Data on demographics, disease characteristics, and EIMs were extracted and analyzed using descriptive statistics: the standard Student’s t-test and chi-squared test. Logistic regression analysis was used to examine associations using STATA software version 11.2 (StataCorp, TX, USA).

Results: We reviewed the electronic medical files of 284 patients with confirmed IBD, of which 158 (55.6%) were females, the mean age was 27.8 (±15) years; 146 (51.4%) patients had CD and 138 (48.6%) UC. The overall incidence risk of EIMs was 138 (52.3%) over a mean duration of follow up of 7.3 (±3.9) years. The most common EIM was arthritis (33%), followed by aphthous ulcers (16%). Pyoderma gangrenosum occurred in 8% of patients and appeared to be specific for CD patients (p = 0.002), whereas Primary Sclerosing Cholangitis (PSC) was more specific for UC (p = 0.001). Certain EIMs appeared to occur together such as arthritis with PSC (p = 0.001). Regression analysis identified disease type (in favor of UC; odds ratio = 0.50, p = 0.03) and age at the time of diagnosis (odds ratio = 1.04, p = 0.001) as the only significant predictors of EIMs.

Conclusion: Our results demonstrate that more than half of IBD patients have at least one EIM. Contrary to what has often been reported, we found that EIMs occur more commonly in UC than CD. A multidisciplinary assessment is recommended as part of IBD management to improve overall health outcomes.

Discovery of the possible mechanisms in kouyanqing granule for treatment of oral ulcers based on network pharmacology

BACKGROUND

Oral ulcer diseases are complex inflammatory diseases caused by multi-factors, which severely impact patient quality of life. Kouyanqing Granule (KYQG) has been used to treat inflammatory diseases of the mouth and throat, including recurrent aphthous stomatitis (RAS), traumatic ulcers, oral leukoplakia and so on. However, the underlying molecular mechanisms of KYQG in treating these diseases are still unclear. We aimed to explore the possible mechanisms in KYQG for the treatment of oral ulcers.

METHODS

An innovative network pharmacology method was established by incorporating targets searching and fishing, network analysis, and silico validation to discover the pharmacological mechanisms of action of KYQG for the treatment of oral ulcers. Then, we verified the reliability of this method by an animal experiment.

RESULTS

Our data indicated that a total of 47 key targets were screened, which mainly involved in three function modules including the inhibition of inflammation, the regulation of immunological response, and the suppression of oxidative stress. The implementation of these functions relies on the complex multi-pathways network, especially TNF signaling pathway and HIF-1 signaling pathway. The results of the experimental verification indicated that KYQG significantly inhibited the serum levels of cyclooxygenase-2 (COX2), matrix metalloproteinase 9 (MMP9) and tumor necrosis factor-alpha (TNF-α) in rats with oral ulcer.

CONCLUSION

KYQG exhibited the therapeutic effects on oral ulcers probably by inhibiting inflammation, regulating immunological response, and suppressing oxidative stress through a complex multi-pathways network. Particularly, TNF signaling pathway and HIF-1 signaling pathway may play crucial roles in the protection of KYQG against oral ulcers. This work not only offers a method for understanding the functional mechanisms of KYQG for treating oral ulcer diseases from a multi-scale perspective but also may provide an efficient way for research and development of complex composition formula.

Low-level laser therapy in the treatment of recurrent aphthous stomatitis and oral lichen planus: a literature review

Recurrent aphthous stomatitis (RAS) and oral lichen planus (OLP) present inflammatory, recurrent diseases of the oral mucosa with not fully understood aetiology. Despite numerous attempts to discover an effective treatment for RAS and OLP, the current main treatment strategies are largely confined to the reduction of symptoms. Low-level laser therapy (LLLT) is of interest as a novel treatment modality. The aim of the paper was to discuss the mechanism of action and the biological effects of LLLT and to critically review and summarize recent clinical reports on the management of RAS and OLP. Most of the studies demonstrated the beneficial effect of LLLT in accelerating the healing process and pain reduction. However, the results should be interpreted with caution due to the limited number of studies available and empirical design using various irradiation parameters.

Gene mapping and functional annotation of GWAS of oral ulcers using FUMA software

Oral ulcers not only influence the physical health of patients, but they also interfere with their quality of life. However, the exact etiology of oral ulcers is not clear. To explore the roles of genetic factors in oral ulcers, a genome-wide association study of the condition in European individuals was re-evaluated by the FUMA v1.3.5e online tool. A total of 380 independent significant single nucleotide polymorphisms (SNPs) and 89 lead SNPs were identified in 34 genomic risk loci. Out of these identified genomic risk loci, 280 possible causal genes were pinpointed by positional mapping and expression quantitative trait locus mapping. Among these genes, 216 novel genes were identified. Furthermore, some genomic loci were mapped to a single gene. Functional annotation of these prioritized genes revealed that the immune response pathway was implicated in the onset of oral ulcers. Overall, our findings revealed novel possible causal genes and demonstrated that the immune response has a crucial role in the occurrence of oral ulcers.

Pharmacodynamic and Metabolomics Studies on the Effect of Kouyanqing Granule in the Treatment of Phenol-Induced Oral Ulcer Worsened by Sleep Deprivation

Oral ulcers are the most prevalent oral mucosal diseases globally, and no specific treatment schemes are currently available due to the complexity of oral ulcer diseases. Sleep deprivation increases the risk of a deterioration in oral health. Kouyanqing Granule (KYQG) has been used for decades in China to treat inflammatory diseases of the mouth and throat associated with the hyperactivity of fire due to yin deficiency syndrome. However, the mechanisms underlying the effects of KYQG in the treatment of oral ulcers are still unclear. The aims of this study were to investigate whether KYQG treatment could attenuate the symptoms of oral ulcers worsened by sleep deprivation and identify the involved metabolic pathways. First, we conducted chemical profiling of KYQG via UPLC–MS analysis. We then combined pharmacological and metabolomics approaches in a phenol-induced rat model of oral ulcers worsened by sleep deprivation. A total of 79 compounds were initially identified. Our observations showed that KYQG treatment induced a significantly higher healing rate in oral ulcers worsened by sleep deprivation. KYQG significantly reduced the levels of 5-HT and GABA in serum, and only decreased the 5-HT level in brain tissue after phenol injury followed by sleep deprivation. Moreover, KYQG administration significantly suppressed systemic inflammation by inhibiting TNF-α, IL-1β, IL-6, IL-18, and MCP-1. Immunohistochemical analysis further revealed that KYQG inhibited IL-6 expression in buccal mucosa tissues. KYQG treatment also significantly decreased the serum levels of ACTH, CORT, IgM, and 8-OHdG. Serum metabolomics analysis showed that a total of 30 metabolites showed significant differential abundances under KYQG intervention, while metabolic pathway analysis suggested that the altered metabolites were associated with the dysregulation of eight metabolic pathways. Taken together, our results indicated that KYQG attenuates the symptoms of oral ulcers worsened by sleep deprivation probably through the regulation of the neuroimmunoendocrine system, oxidative stress levels, and tryptophan metabolism. This study also provides a novel approach for addressing the increased health risks resulting from sleep deficiency using an herbal medicine formula.

Celiac disease and hematological abnormalities in children with recurrent aphthous stomatitis

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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.

The effects of licorice containing diphenhydramine solution on recurrent aphthous stomatitis: A double-blind, randomized clinical trial

OBJECTIVES

The aim of this study was to compare the efficacy of the diphenhydramine solution (DS) and diphenhydramine-containing glycyrrhiza glabra (DSG) in the treatment of recurrent aphthous stomatitis (RAS).

DESIGN

It was a double-blind randomized clinical trial that was conducted from July to September 2018 at the Faculty of Dentistry, Birjand University of Medical Sciences, Birjand, Iran.

INTERVENTION

DSG was made by adding 5% hydroethanolic extract of licorice to the diphenhydramine elixir. A total of 70 patients diagnosed with RSA were randomly assigned to the DS and DSG groups, each containing 35 patients. Participants were instructed to swish 3 ml of either solution around their mouth for about three minutes four times a day (at least 20 min before each meal and before bedtime) until the complete healing of the oral lesions.

MAIN OUTCOME MEASURES

The primary outcome of this study was to assess the severity of pain prior to the intervention and on the first, third, and fifth days of it. This was done using the visual analog scale (VAS). The duration of wound healing was also measured through photography. The secondary outcome was to record the adverse effects of the intervention. This trial was registered at the Iranian Registry of Clinical Trials under number¹ IRCT20180407039213N1.

RESULTS

The average pain score before the treatment in the DS and DSG groups was 8. 1 ± 1.17 and 7.97 ± 1.72, respectively, and there was apparently no significant difference between them. However, there was a significant difference between the two groups in terms of the average pain scores on the first (7 ± 1.28 versus 5.31 ± 1.28), third (4.02 ± 1.8 vs. 2.86 ± 1.56) and fifth days (1.71 ± 1.69 vs. 0.54 ± 1.31) of the intervention. Indeed, DSG significantly reduced the average wound healing duration by 1.5 days, as compared to DS (P = 0.0001). No adverse effects were observed with the intervention.

CONCLUSION

According to our results, DSG appeared to be more effective in treating RAS than DS alone.

TRIAL REGISTRATION

The trial was registered at Iranian Registry of Clinical Trials before the enrolment of the first patient on June 29, 2019 (registration no: IRCT20180407039213N1, http://www.irct.ir/trial/31497).

Mean Platelet Volume, Neutrophil-To-Lymphocyte Ratio, and Platelet-To-Lymphocyte Ratio as İnflammatory Markers in patients with Recurrent Aphthous Stomatitis

Objective

The aim of this study is to examine the associations between white blood cell (WBC), hemoglobin (Hb), neutrophil, lymphocyte, platelet, mean platelet volume (MPV), neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), erythrocyte sedimentation rate (ESR), and C-reactive protein (CRP) levels in patients with recurrent aphthous stomatitis (RAS).

Materials and Methods

For this study, 137 patients with RAS and 137 healthy controls were recruited. The study participants had no systemic diseases except RAS. Serum WBC, Hb, neutrophil, lymphocyte, platelet, MPV, PLR, NLR, ESR, and CRP levels were recorded in the active period for all patients with RAS and controls.

Results

There was no statistically significant difference in the WBC, Hb, neutrophil, lymphocyte, platelet, MPV, NLR PLR, ESR, and CRP levels between patients with RAS and controls.

Conclusion

No differences were observed for WBC, Hb, neutrophil, lymphocyte, platelet, MPV, NLR, PLR, ESR, and CRP levels between patients with RAS and controls. These parameters therefore cannot be used as markers for inflammation or inflammation severity in patients with RAS.

Gene variability in matrix metalloproteinases in patients with recurrent aphthous stomatitis

BACKGROUND

The development of recurrent aphthous stomatitis (RAS), inflammatory disease of oral mucosa, is influenced by both environmental and genetic factors. The aim of this study was to investigate polymorphisms located in seven genes coding different types of matrix metalloproteinases (MMPs)-collagenases (MMP1, MMP8, and MMP13), gelatinases (MMP2 and MMP9), stromelysin (MMP3), and membrane-type metalloproteinase (MMP16) in patients with RAS and healthy controls.

METHODS

Totally, 223 subjects were included in this case-control study and their detailed anamnestic, clinical, and laboratory parameters were recorded. Seventy-seven patients with RAS and 146 controls were genotyped for seventeen polymorphisms in the MMPs genes using the real-time polymerase chain reaction (PCR) or PCR with restriction analysis.

RESULTS

Allele, genotype, and haplotype frequencies of the studied polymorphisms between RAS patients and controls were similar, except for allele distributions of MMP1 rs1144393, MMP9 rs3918242, and MMP16 rs10429371, which were different between patients with RAS and healthy controls (P = .023, P = .049 and P = .025, all P_corr  > 0.05, respectively). Moreover, the comparison of genotype frequencies (TT vs CC + CT) of the MMP16 rs10429371 variant showed a marginally significant difference between RAS patients and controls (P = .05, P_corr  > 0.05, OR = 1.68, 95% CI = 0.95-2.98).

CONCLUSIONS

No significant relationship between investigated polymorphisms in seven MMPs genes and RAS development in the Czech population was observed in this study.

A Novel Predictor Parameter for Active Recurrent Aphthous Stomatitis: C-Reactive Protein to Albumin Ratio

Objective

Laboratory analysis results may provide an opportunity to predict the activity process of recurrent aphthous stomatitis. The goal of this study was to investigate whether there is a correlation between C-reactive protein to albumin ratio (CAR) and oral ulcer activity in patients with recurrent aphthous stomatitis.

Materials and methods

We included 72 patients (39 with active and 33 with inactive lesion) with recurrent aphthous stomatitis and 60 healthy controls. We compared blood test parameters including CAR, white blood cell count (WBC) and neutrophil to lymphocyte ratio (NLR) among the groups. Additionally, we investigated the most significant parameter for the activity of oral ulcers.

Results

NLR was significantly higher both in the active (p<0.001) and inactive lesion groups (p<0.001), compared to the control group but did not significantly differ between active and inactive lesion groups (p=0.17). A significant difference in median CAR (p<0.001) and WBC (p<0.001) was evident among the three groups. Median WBC was significantly higher in the active lesion group compared to the control group (p<0.001) but did not significantly differ between active and inactive lesion groups (p=0.095). Median CAR was significantly higher in the active lesion group, compared both to the inactive lesion group (p=0.002) and the control group (p<0.001). Median CAR was also significantly higher in the inactive lesion group compared to the control group (p<0.001). Median hemoglobin, platelet to lymphocyte ratio and mean platelet volume did not significantly differ among three groups (p=0.16, p=0.85, p=0.19, respectively).

Conclusion

CAR could be used as a predictive parameter for inflammation and activity of oral ulcers in patients with recurrent aphthous stomatitis.

Vitamin D Levels in Children With Recurrent Aphthous Stomatitis

BACKGROUND

Recurrent aphthous stomatitis is one of the most prevalent oral mucosa diseases and the etiology is unclear. As a potent anti-inflammatory and immunomodulating agent, vitamin D can significantly affect oral cavity homeostasis. However, to the best of our knowledge, no study has been conducted in pediatric population on the potential role of vitamin D in recurrent aphthous stomatitis to date. The aim of the present study is to determine the vitamin D status in recurrent aphthous stomatitis in children.

METHODS

This study is conducted retrospectively. Seventy-two patients with minor recurrent aphthous stomatitis and 70 age-matched healthy controls included in the study. 25-Hydroxyvitamin D levels were measured in all patients using enzyme immunoassay.

RESULTS

Serum vitamin D levels were 16.4 (8.6) ng/mL in patient group and 23.1 (11.5) ng/mL in healthy controls. There was a statistically significant difference between the groups in terms of serum vitamin D levels (P = .002). There was no significant correlation between serum vitamin D levels and the severity of the recurrent aphthous stomatitis (r = 0.54, P = .76).

CONCLUSIONS

Our study showed a significant difference in vitamin D levels between patients with recurrent aphthous stomatitis and the healthy control group. We also found no correlation between vitamin D status and the severity of the disease.

Oral Ulcers Presentation in Systemic Diseases: An Update

BACKGROUND

Diagnosis of oral ulceration is always challenging and has been the source of difficulty because of the remarkable overlap in their clinical presentations.

AIM

The objective of this review article is to provide updated knowledge and systemic approach regarding oral ulcers diagnosis depending upon clinical picture while excluding the other causative causes.

METHODS

For this, specialised databases and search engines involving Science Direct, Medline Plus, Scopus, PubMed and authentic textbooks were used to search topics related to the keywords such as oral ulcer, oral infections, vesiculobullous lesion, traumatic ulcer, systematic disease and stomatitis. Associated articles published from 1995 to 2019 in both dental and medical journals including the case reports, case series, original articles and reviews were considered.

RESULTS

The compilation of the significant data reveals that ulcers can be classified according to (i) duration of onset, (ii) number of ulcers and (iii) etiological factors. Causation of oral ulcers varies from slight trauma to underlying systemic diseases and malignancies.

CONCLUSION

Oral manifestations must be acknowledged for precise diagnosis and appropriate 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.

Expression of endocan and vascular endothelial growth factor in recurrent minor aphthous ulcers

Background

Recurrent aphthous ulcers (RAU) are common painful inflammatory lesions of the mucous lining of the mouth. Endocan, previously identified as endothelial cell specific molecule-1, is implicated as a vital player in the regulation of several inflammatory processes. A number of inflammatory cytokines and pro-angiogenic growth factors including VEGF upregulate endothelial cells synthesis and expression of endocan.

Material and Methods

Clinical scores of pain and ulcer size as well as level of endocan and VEGF were determined in swaps from aphthous ulcer and contra lateral normal mucosa in 30 patients (nine males and twenty one females) with age ranging from 18 to 45 years and mean age is 31.5 years.

Results

In the early days of ulcer development, ulcer showed statistically significantly higher mean endocan (8.2 ±5.3) and VEGF levels (1220.7 ±294.6) than control healthy mucosal site (1.1 ±0.5) and (518.6 ± 61.7) respectively. An increase in endocan is associated with an increase in pain score and vice versa. A statistically significant positive correlation were also found between endocan and VEGF levels.

Conclusions

Endocan and VEGF are strongly associated with the destructive phase of minor aphthous ulcers especially Endocan which was positively correlated with pain severity.

Key words:Endocan, ESM-1, VEGF, Recurrent Apthous Ulcer.

Treatment of recurrent aphthous stomatitis (RAS; aphthae; canker sores) with a barrier forming mouth rinse or topical gel formulation containing hyaluronic acid: a retrospective clinical study

BACKGROUND

Use of hyaluronic acid-based products has become a valuable alternative to drug-based approaches in the treatment of recurrent aphthous stomatitis (RAS). The presented study aimed to investigate the effect of a barrier forming hyaluronic acid containing mouth wash or a topical gel formulation on the healing of RAS and patient's quality of life.

METHODS

For this single-center retrospective study, medical records of the Dental School of the University of Brescia were screened for adult and systemically health patients suffering from minor recurrent aphthous stomatitis (RAS) and treated with either a barrier forming, hyaluronic acid containing mouth wash (GUM® AftaClear® rinse) or a topical gel (GUM® AftaClear® gel) in 2015. All patients fulfilling the in-/exclusion criteria and presenting full data sets on lesion diameter, lesion color, as well as pain perception for baseline (day 0) and 4 and 7 days after treatment were enrolled into the presented study.

RESULTS

Out of 60 screened patients, a total of 20 patients treated with the Rinse formulation and 25 treated with the Gel formulation were eligible for the enrollment into this study. Both groups showed equal distribution in patient's age, sex and presented a similar mean lesion size (3.0 ± 1.0 mm), lesion color distribution as well as pain perception at baseline. All patients showed significant normalization of lesion color, reduction of pain, and lesion dimension within the course of their treatment. After 7 days, the mean percentage of lesion reduction was highly significant for both groups attaining 77.4 ± 30.1% in the Rinse group and 81.2 ± 23.1% in the Gel group with a complete lesion closure obtained in 60 and 56% of the cases, respectively. However, a significant (p < 0.05) higher percentage of lesions in the Gel group (72%) compared to the Rinse group (40%) showed an improvement in lesion size already after 3 days.

CONCLUSIONS

Within the limitation of retrospective design, it can be concluded that both the barrier forming hyaluronic acid containing mouth rinse as well as the topical gel formulation are effective in the treatment of minor recurrent aphthous stomatitis (RAS), with a trend for an earlier healing onset for the topical Gel formulation.

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.

Sleep deprivation worsened oral ulcers and delayed healing process in an experimental rat model

AIMS

Sleep deficiency has been reported to be associated with some oral health problems. Oral ulcers are very common lesions of the oral mucosa, which severely impact patients' quality of life. However, the association between sleep deficiency and the oral ulcer remains unknown. The present study aims to explore the effects of sleep deficiency on oral ulcers.

MAIN METHODS

Rats were divided into normal control group (n = 30) and oral ulcer group (OU group, n = 50). Model rats with phenol-induced oral ulcers were deprived of sleep for 72 h by using the modified multiple platform technique.

KEY FINDINGS

Sleep deprivation worsened oral ulcers and delayed healing process in rats. In addition, sleep deprivation increased the γ-aminobutyric acid (GABA, P < 0.01) and 5-hydroxytryptamine (5-HT, P < 0.05) levels in serum and brain, the corticotrophin (ACTH, P < 0.05), corticosterone (CORT, P < 0.01), immunoglobulin (Ig)M (P < 0.01), tumor necrosis factor-alpha (TNF-α) (P < 0.01), interleukin (IL)-1β (P < 0.01), IL-6 (P < 0.01), IL-8 (P < 0.01), monocyte chemoattractant protein-1 (MCP-1) (P < 0.01), and 8-hydroxy-deoxyguanosine (8-OHdG, P < 0.01) levels in serum. Sleep deprivation also up-regulated malonaldehyde (MDA) (P < 0.05), TNF-α (P < 0.05), and IL-1β (P < 0.01) levels in oral mucosa tissue and delayed superoxide dismutase (SOD, P < 0.05) activity recovery.

SIGNIFICANCE

These data suggest that sleep deprivation impaired the oral ulcer healing in rat oral mucosa, and the mechanisms of this effect are probably related to neuro-immuno-endocrine system and oxidative stress.

Diagnostic Value of Neutrophil-Lymphocyte Ratios and Mean Platelet Volumes in the Activation of Recurrent Aphthous Stomatitis

Recurrent aphthous stomatitis (RAS) is associated with endothelial dysfunction and chronic inflammation. The neutrophil-to-lymphocyte ratio (NLR) and mean platelet voume (MPV) are markers of inflammation and endothelial dysfunction, respectively. In the present report, we discuss the NLR and MPV values of patients with active and inactive RAS. In total, 42 patients (24 females and 18 males) with inactive RAS, 19 patients (12 females and 7 males) with active RAS and 40 healthy controls (24 females and 16 males) were enrolled. MPVs were measured and NLRs calculated. We sought correlations among the MPV and NLR findings in the active and inactive RAS groups and compared them with those of healthy controls. The MPV and NLR values were significantly higher in patients with active than inactive RAS (MPV, 10.6 ± 2.9 vs. 7.1 ± 2.4 fL, p < 0.001; NLR, 3.74 ± 1.9 vs. 2.1 ± 1.43, p = 0.015). In addition, both MPV and NLR values in patients with inactive RAS didn't differ significantly compared to values observed in the controls (MPV, 7.1 ± 2.4 vs. 6.9 ± 2.1 fL, p = 0.126; NLR, 2.1 ± 1.43 vs. 2.07 ± 0.96, p = 0.525). Both the NLR and MPV were significantly higher in patients with active RAS, emphasising the importance of inflammation and endothelial dysfunction in the pathophysiology of RAS activation.

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.