Review article: oral ulceration--aetiopathogenesis, clinical diagnosis and management in the gastrointestinal clinic

Deep learning system for the differential diagnosis of oral mucosal lesions through clinical photographic imaging

Background/purpose

Oral mucosal lesions are associated with a variety of pathological conditions. Most deep-learning-based convolutional neural network (CNN) systems for computer-aided diagnosis of oral lesions have typically concentrated on determining limited aspects of differential diagnosis. This study aimed to develop a CNN-based diagnostic model capable of classifying clinical photographs of oral ulcerative and associated lesions into five different diagnoses, thereby assisting clinicians in making accurate differential diagnoses.

Materials and methods

A set of clinical images were selected, including 506 images of five different diagnoses. The images were pre-processed and randomly divided into two sets for training and testing the CNN model. The model architecture was composed of convolutional layers, batch normalization layers, max pooling layers, the dropout layer and fully-connected layers. Evaluation metrics included weighted-precision, weighted-recall, weighted-F1 score, average specificity, Cohen's Kappa coefficient, normalized confusion matrix and AUC.

Results

The overall performance for the image classification showed a weighted-precision of 88.8%, a weighted-recall of 88.2%, a weighted-F1 score of 0.878, an average pecificity of 97.0%, a Kappa coefficient of 0.851, and an average AUC of 0.985.

Conclusion

The model achieved a decent classification performance (overall AUC=0.985), showing the capacity to discern between benign and malignant potential lesions, and laid the foundation of a novel tool that can help clinical differential diagnosis of oral mucosal lesions. The main challenges were the small and imbalanced dataset. Enlarging the minority classes, incorporating more oral mucosal lesion diagnoses, employing transfer learning and cross-validation might be included in future works to optimize the image classification model.

Impact of Photobiomodulation on IL1β and TGFβ-1 concentrations in patients with aphthous stomatitis

Laser therapy has shown effectiveness in promoting wound healing by influencing various physiological factors such as blood flow, cytokines, histamine, nerve signals, lymphocyte function, tissue oxygenation, and cell growth. This study aims to evaluate the therapeutic efficacy of Photobiomodulation (PBM) treatment, by using diode laser, in modifying the levels of interleukin-1 beta (IL1β) and transforming growth factor beta-1 (TGFβ-1) in patients diagnosed with aphthous stomatitis. A before-after interventional design was conducted over 10 months with 20 subjects. Data on demographic details and serum concentrations of IL1β and TGFβ-1 were collected pre-treatment and on Days 3 and 7 post-treatments. The intervention involved a single session of four 30-second applications of a QuickLase dual-wavelength laser operating at 980 nm. Results show significant reductions in IL1β and TGFβ-1 levels after 7 days of treatment, indicating a time-dependent effect of PBM therapy on these inflammatory markers. The findings suggest that PBM therapy holds promise as an intervention for reducing inflammation associated with aphthous stomatitis.

Efficacy and Safety of Propolis for Treating Recurrent Aphthous Stomatitis (RAS): A Systematic Review and Meta-Analysis

The systematic review assessed the efficacy and safety of propolis for treating recurrent aphthous stomatitis (RAS). The review adopted the PICO framework to examine the effects of topical and systemic propolis on RAS while also comparing it to established treatments, placebos, or no treatment. The main focus was on the healing time, pain levels, adverse effects, the likelihood of ulcer recurrence, and accompanying symptoms such as redness. The team included randomised controlled trials (RCTs) and quasi-randomised trials, excluding case reports and studies on oral ulcers other than RAS. In May 2022, the review team comprehensively searched nine databases and trial registries following the PRISMA guidelines. The protocol was registered in the PROSPERO database under the registration number CRD42022327123. Two review authors conducted a comprehensive and autonomous search for pertinent papers and extracted essential data. Where data permitted, the team utilised Review Manager 5 to conduct a random-effects meta-analysis, assessing the risk of bias and heterogeneity of the included studies. Where possible, the GRADE Pro programme was used to assess the certainty of the evidence for all the outcomes. This review included 10 RCTs, comprising 825 participants aged between 18 and 69 years. Seven studies evaluated the efficacy and safety of propolis when applied topically, all of which used different formulations, concentrations, and carriers. The remaining three studies assessed systemic administration in tablet form. The duration of investigations ranged from 5 days to 3 years. The review team classified two studies as having an overall 'high risk' of bias, while the remaining studies were categorised as having an overall 'uncertain risk'. The overall certainty of the evidence was 'very low'. The results indicate that topical and systemic propolis may decrease the duration of healing, alleviate pain, and reduce redness in patients with RAS compared to a placebo. However, the certainty of the evidence is very low. These may be due to the high risk of bias, substantial heterogeneity, and limited sample sizes in the included studies. For these reasons, the results of this review should be interpreted with caution. Nevertheless, the limited number of adverse effects observed suggests that propolis may have a favourable safety profile when used for a short period in treating RAS.

Alogliptin Induced Stomatitis: An Adverse Drug Event Case Report

Background: Dipeptidyl peptidase (DPP)-4 inhibitors are commonly used agents to treat type 2 diabetes mellitus (T2DM). Although generally well tolerated, stomatitis has been previously reported as an adverse event with sitagliptin and linagliptin. Stomatitis with alogliptin has not been reported in post-marketing data to date. Objective: To report a case of suspected drug-induced stomatitis in a patient who received alogliptin for T2DM which resolved upon discontinuation of the offending agent. Summary: A 60-year-old male with T2DM began treatment with a DPP-4 inhibitor, alogliptin. After 4 doses of alogliptin, the patient reported inflammation and irritation along the lateral borders of his tongue, along with open fissures and oral ulcerations on the dorsal surface of the mucosa. He was subsequently diagnosed with stomatitis. Patient discontinued alogliptin and reported improvement in symptoms within 48 hours. Lesions re-epithelialized within 4 weeks after cessation of alogliptin. The Naranjo Algorithm was used to assess causality. The total score was 7, which when interpreted, implicates alogliptin as a "probable" cause of the reaction. Conclusion: A causality assessment determined alogliptin was a "probable" cause of stomatitis experienced by this patient. This adverse effect has not been reported with alogliptin to the authors' knowledge.

Neutropenic ulcers in oncology: terminology, diagnosis, and management

Neutropenic ulcerations are characterized by mucosal ulcerations which occur in the presence of neutropenia, suggesting a direct link between neutropenia and mucosal ulceration. An oral ulcer can be labeled as "neutropenic" only if the patients have primary (typically congenital) or secondary neutropenia, and neutropenia is the sole causative factor. Oral mucosal ulcers observed in patients undergoing oncologic therapy may also be termed as "neutropenic ulcers", but the pathogenesis of these oral ulcers more likely involves mucosal events related to trauma, microbial factors, and direct cytotoxicity. In cancer patients, the early appearance of oral ulcers is often attributed to oral mucositis which is a condition primarily caused by the direct mucosal cytotoxicity of chemotherapeutic agents and radiation therapy. Oral ulcers that develop later during or after active cancer therapy may result from intraoral trauma and typically manifest on non-keratinized areas of the oral mucosa which are more susceptible to mucosal damage. In patients undergoing chemotherapy, factors such as disturbances in mucosal barrier function as well as bone marrow suppression lead to reduced neutrophil count and function, and can contribute to the development of oral ulcers. While the etiology of oral ulcers in cancer therapy receiving patients can vary, it is important to emphasize that the host's response plays a crucial role in the progression and repair process of these lesions. This narrative review presents the etiopathogenesis, clinical presentation, and potential management approaches for oral ulcerations in neutropenic patients, with a particular focus on clarifying the usage of the term "neutropenic ulcer" since this term lacks diagnostic specificity and can be misleading in clinical practice regarding the underlying causes and treatment strategies.

Thymus satureioides Coss. combats oral ulcer via inhibition of inflammation, proteolysis, and apoptosis

Oral ulcer is a frequent condition that commonly affects the tongue and in which 75% of the patients experience pain, and 25% report taste changes. The available therapies are not sufficiently effective for rapid and complete healing of tongue ulcers. We previously annotated the metabolites of Thymus satureioides (TS) aerial parts and reported their antioxidant, dermacosmeceutical and hepatoprotective properties. In this study, we performed in silico analysis, by applying network pharmacology and molecular docking, followed by experimental validation of the effect of local application of T. satureioides (TS) gel at two different concentrations on the healing of acetic-acid-induced tongue ulcer in rats. Salvianolic acid A, phloretic acid caffeate, rosmarinic acid, apigenin, and luteolin were the top bioactive ingredients of TS extract. Network pharmacology showed that the most relevant targets of these active constituents were TLR4, COX-2, MMP-9, TNF-α, and Caspase-3. Molecular docking showed that rosmarinic acid and salvianolic acid had a relatively strong binding affinity, compared to the other compounds, toward all the target proteins. Experimental validation in tongue ulcer model in rats and immunohistochemistry experiments showed that application of a gel containing TS extract (5 and 10%) was effective in healing the tongue ulcer via downregulation of COX-2, TNF-α, MMP-9, and Caspase-3. This study suggests that T. satureioides extract could act as a topical treatment for tongue ulcers by combating inflammation, apoptosis, and proteolysis. The possible treatment potential of some constituents including rosmarinic acid and salvianolic acid in oral ulcerations awaits further investigations to confirm their potency.

Oral microbiota in active and passive states of recurrent aphthous stomatitis: An analysis of case-control studies

OBJECTIVE

This study was presented to reveal the most distinct microbial prevalence in recurrent aphthous stomatitis (RAS) lesions compared to healthy controls.

DESIGN

The case-control studies were selected in electronic databases until Nov 2022 with key search terms, and the eligible publications were screened and analyzed by independent authors.

RESULTS

A total of 14 studies were identified, which included 531 cases of active states of RAS (AS-RAS), 92 cases of passive states of RAS (PS-RAS) and 372 healthy controls. The most sample pattern was the mucosa swab performed in 8 of 14 studies, biopsies in 3 studies, followed by micro-brush, and saliva. A variety of bacteria in higher or lower abundance were observed in RAS lesions.

CONCLUSIONS

The etiopathogenesis of RAS may not be ascribed to a single pathogen. A possible explanation is that microbial interactions modify immune response or destroy the epithelial integrity, thus contributing to the development of the condition.

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

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

Psychological Functioning of Women Diagnosed with Lichen Planus and Other Diseases of the Oral Cavity-Explorative Study

The role of psychosocial factors in the development of changes in lichen planus and other diseases of the oral cavity has been implicated, but is still understudied. Therefore, the aim of our study was to describe the specific profile of psychological functioning of patients with these diseases, including the role of temperamental traits, action-oriented personality components, and self-esteem. In total, 94 adult women participated in the study: (1) with lichen planus (LP; n = 46; Mage = 54.80, SD = 12.53), (2) with other oral conditions (n = 25; Mage = 34.76, SD = 16.03), (3) without chronic disease (n = 24; Mage = 40.96, SD = 13.33). The following questionnaires were used: ZKA-PQ/SF, Polish Adaptive and Maladaptive Perfectionism Questionnaire, ACS-90, PROCOS, and MSEI. Results indicated no significant differences in temperament dimensions between studied groups. However, women diagnosed with LP presented lower levels of maladaptive perfectionism and social support than healthy women. Furthermore, women with LP also obtained lower scores for social resourcefulness and higher scores for moral self-approval than healthy women. Summarizing, patients with LP often use compensatory mechanisms that negatively affect their social functioning; thus diagnostic/therapeutic programs directed towards those group should be holistic, including psychologists and psychiatrists who support patients' psychological well-being.

Oral Wound Healing Potential of Polygoni Cuspidati Rhizoma et Radix Decoction—In Vitro Study

Polygoni Cuspidati Rhizoma et Radix (syn. rhizomes of Reynoutria japonica Houtt.) is a pharmacopoeial raw material in Europe and China. In traditional medicine, one of the applications for Reynoutria japonica rhizomes is wound healing. In a recent in vitro study, we demonstrated that ethanol and acetone extracts from this herbal drug have the potential to heal oral gum wounds. However, considering that a majority of herbal medicines have been traditionally administered as water decoctions, in the present study, a decoction of Reynoutria japonica rhizomes was prepared and detailed tests to determine its in vitro gingival wound healing activity were conducted. We used the primary human gingival fibroblasts (HGF) incubated with a decoction to determine cell viability (MTT assay), cell proliferation (the confocal laser scanning microscope—CLSM), and cell migration (wound healing assay). Moreover, the collagen type III expression was examined using immunocytochemical staining. The studied decoction was qualitatively and quantitatively characterized using the validated HPLC/DAD/ESI-HR-QTOF-MS method. The Folin–Ciocalteu assay was used to determine the total phenols and tannins content. Additionally, HPLC-RI analysis of decoction and the previously obtained ethanol and acetone extracts was used to determine the composition of saccharides. Low concentration (from 50 to 1000 µg/mL) of decoction after 24 h incubation caused a significant increase in HGF cell viability. No cytotoxic effect was observed at any tested concentration (up to 2000 µg/mL). The lowest active concentration of decoction (50 µg/mL) was selected for further experiments. It significantly stimulated human gingival fibroblasts to proliferate, migrate, and increase the synthesis of collagen III. Phytochemical analysis showed significantly fewer polyphenols in the decoction than in the ethanol and acetone extracts tested earlier. In contrast, high levels of polysaccharides were observed. In our opinion, they may have a significant effect on the oral wound healing parameters analyzed in vitro. The results obtained encourage the use of this raw material in its traditional, safe form—decoction.

MED1 Ablation Promotes Oral Mucosal Wound Healing via JNK Signaling Pathway

Mediator complex subunit 1 (MED1) is a coactivator of multiple transcription factors and plays a key role in regulating epidermal homeostasis as well as skin wound healing. It is unknown, however, whether it plays a role in healing oral mucosal wounds. In this study, we investigate MED1's functional effects on oral mucosal wound healing and its underlying mechanism. The epithelial-specific MED1 null (Med1epi-/-) mice were established using the Cre-loxP system with C57/BL6 background. A 3 mm diameter wound was made in the cheek mucosa of the 8-week-old mice. In vivo experiments were conducted using HE staining and immunostaining with Ki67 and uPAR antibodies. The in vitro study used lentiviral transduction, scratch assays, qRT-PCR, and Western blotting to reveal the underlying mechanisms. The results showed that ablation of MED1 accelerated oral mucosal wound healing in 8-week-old mice. As a result of ablation of MED1, Activin A/Follistatin expression was altered, resulting in an activation of the JNK/c-Jun pathway. Similarly, knockdown of MED1 enhanced the proliferation and migration of keratinocytes in vitro, promoting re-epithelialization, which accelerates the healing of oral mucosal wounds. Our study reveals a novel role for MED1 in oral keratinocytes, providing a new molecular therapeutic target for accelerated wound healing.

Recognition and management of drug-associated oral ulceration: a review

The number of people who are using prescribed medications is on the rise, largely due to an ageing population in the UK, but also because of early diagnosis and prompt medical management of a variety of conditions. Systemic medications may contribute to the development of oral side effects and translate into an increasing number of patients presenting in general dental practice settings. The aim of this paper is to provide an outline of oral side effects of systemic medications followed by a review of drug-associated oral ulcers (DAOUs). The paper also provides recommendations for early recognition and management of DAOUs in general dental practice settings, including referral to general medical practitioners and specialists in oral medicine.

Oral manifestations serve as potential signs of ulcerative colitis: A review

As an immune dysregulation-related disease, although ulcerative colitis (UC) primarily affects the intestinal tract, extraintestinal manifestations of the disease are evident, particularly in the oral cavity. Herein, we have reviewed the various oral presentations, potential pathogenesis, and treatment of oral lesions related to UC. The oral manifestations of UC include specific and nonspecific manifestations, with the former including pyostomatitis vegetans and the latter encompassing recurrent aphthous ulcers, atrophic glossitis, burning mouth syndrome, angular cheilitis, dry mouth, taste change, halitosis, and periodontitis. Although the aetiology of UC has not been fully determined, the factors leading to its development include immune system dysregulation, dysbiosis, and malnutrition. The principle of treating oral lesions in UC is to relieve pain, accelerate the healing of lesions, and prevent secondary infection, and the primary procedure is to control intestinal diseases. Systemic corticosteroids are the preferred treatment options, besides, topical and systemic administration combined with dietary guidance can also be applied. Oral manifestations of UC might accompany or precede the diagnosis of UC, albeit with the absence of intestinal symptoms; therefore, oral lesions, especially pyostomatitis vegetans, recurrent aphthous ulcer and periodontitis, could be used as good mucocutaneous signs to judge the occurrence and severity of UC, thus facilitating the early diagnosis and treatment of UC and avoiding severe consequences, such as colon cancer.

Lingua Plicata Associated with Increased Level of Proinflammatory Cytokines in Gingival Cervical Fluid: Possible New Sign in Ulcerative Colitis

Ulcerative colitis (UC) is a complex disease in which the interaction of genetic, environmental, and microbial factors drives chronic intestinal inflammation. Gastrointestinal symptoms are predominant including pathological manifestations in the oral cavity, as well as extra-intestinal complications.

Lingua plicata (LP) is a condition characterized by an increased number of fissures and grooves at the central and lateral aspects of the dorsal surface of the tongue. LP is usually asymptomatic and discovered incidentally, but the accumulation of food in the fissures and grooves can lead to focal glossitis and halitosis.

In this study, we analyzed the level of proinflammatory cytokines in gingival crevicular fluid (GCF) and demonstrated that proinflammatory cytokines IFN-γ, IL-12, and IL-1β were significantly increased in the group of UC patients when compared with healthy controls. Obtained results have shown that 35% of UC patients have lingua plicata. The GCF levels of IFN-γ and IL-12 were higher in UC patients with LP compared with UC patients without lingua plicata.

In conclusion, increased GCF values of IFN-γ and IL-12, in UC patients with LP may be considered as a sign of the disease progression and, consequently, of a poor prognosis for patients.

HPLC/MSn Profiling and Healing Activity of a Muco-Adhesive Formula of Salvadora persica against Acetic Acid-Induced Oral Ulcer in Rats

Salvadora persica L. (S. persica, Siwak) is an ethnic plant that is widely used for improving oral hygiene. This study aimed to provide a phytochemical profiling of S. persica ethyl acetate fraction (SPEAF) and to evaluate the healing activity of a muco-adhesive formula of the fraction against acetic acid-induced oral ulcers in rats. HPLC-ESI-QTOF-MS-MS analysis of SPEAF resulted in the tentative identification of 56 metabolites containing fatty acids (23%), urea derivatives (10.5%) and sulphur compounds (10%), in addition to several amides, polyphenols and organic acids (6.5%, 5% and 2%, respectively). For the first time, 19 compounds were identified from S. persica. In vitro and in vivo experiments indicated that the extract is non-toxic. SPEAF exhibited superior healing activities compared to both the negative and positive control groups on days 7 and 14 of tongue ulcer induction. This was confirmed by histopathological examinations of haematoxylin and eosin-stained (H&E) and Masson's trichrome-stained tongue sections. Moreover, SPEAF showed potent anti-inflammatory activities, as evidenced by the inhibited expression of interleukin-6 (IL-6) and tumour necrosis alpha (TNF-α). Moreover, SPEAF exhibited potent antioxidant activity, as it prevented malondialdehyde (MDA) accumulation, reduced glutathione (GSH) depletion and superoxide dismutase (SOD) exhaustion. SPEAF significantly enhanced hydroxyproline tongue content and upregulated collagen type I alpha 1 (Col1A1) mRNA expression. SPEAF also improved angiogenesis, as shown by the increased mRNA expression of the angiopoietin-1 (Ang-1). In conclusion, S. persica has a wide range of secondary metabolites and ameliorates acetic acid-induced tongue ulcers in rats. This can be attributed, at least partly, to its anti-inflammatory, antioxidant, procollagen and angiogenic activities. These findings provide support and validity for the use of S. persica as a traditional and conventional treatment for oral disorders.

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

OBJECTIVES

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSION

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

Effect of nano-chitosan and nano-doxycycline gel on healing of induced oral ulcer in rat model: histological and immunohistochemical study

OBJECTIVES

The aim of this study was to investigate the effect of nano-chitosan and nano-doxycycline gel on healing of oral ulcers.

METHODS

In this study, 37 rats were used, four of which acted as normal controls (group 1), while the remaining 33 were distributed into three groups, each with 11 rats. Oral ulcers were chemically induced in the labial mucosa, after which (group 2), ulcer group received no treatment, (group 3) received nano-chitosan gel, and (group 4) received nano-doxycycline gel. They were scarified after 14 days and histologically examined as well as immunostaining for vascular endothelial growth factor (VEGF) and proliferating cell nuclear antigen (PCNA).

RESULTS

The best clinical and histologic healing results were shown in nano-chitosan group, followed by nano-doxycycline group, while the ulcer group showed incomplete healing. This was confirmed by immunostaining as area % of VEGF and number PCNA were the highest in nano-chitosan group followed by nano-doxycycline group, then ulcer group.

CONCLUSION

Both nano-chitosan and nano-doxycycline gels improved the healing of chemically induced oral ulcers; however, nano-chitosan exhibited better healing outcomes.

CLINICAL RELEVANCE

Nano-chitosan and nano-doxycycline gels are both viable and safe alternatives to current ulcer treatments.

In Vitro Gingival Wound Healing Activity of Extracts from Reynoutria japonica Houtt Rhizomes

Rhizomes of Reynoutria japonica Houtt. are a traditional Chinese medicinal herb (Polygoni cuspidati rhizoma, hu zhang) used for treatment of numerous diseases including wound healing support. The aim of this study was to provide evidence for the value of this herbal drug’s traditional use as a gingival healing treatment as well as to obtain the most active extract. In vitro studies were performed using primary human gingival fibroblasts (HGFs) with determination of viability (MTT assay), cell proliferation (the confocal laser scanning microscope (CLSM) was used to visualize histone 3 expression), cell migration (wound healing assay), and evaluation of the expression of collagen type III (immunocytochemical staining) after incubation with extracts from R. japonica rhizomes (25% or 40% ethanol or 60% acetone). In addition to these extracts, commercial dental rinse (containing chlorhexidine digluconate 0.2%) was tested as the gold standard of choice for gum healing in dental practice. The studied extracts were qualitatively and quantitatively characterized using the validated HPLC/DAD/ESI-HR-QTOF-MS method. Total phenols and tannins content were determined using the Folin–Ciocalteu assay. Low concentration of all extracts after 24 h incubation caused significant increase in HGF viability. This effect was most pronounced at a concentration of 50 µg/mL, which was selected for further experiments. All extracts (at 50 µg/mL) stimulated HGF to proliferate, migrate, and increase collagen III synthesis, but with different strength. The highest stimulated proliferation and migration activity was observed after incubation with 25% EtOH, which according to phytochemical analysis may be related to the highest content of resveratrol and an appropriate composition of procyanidins. The 25% EtOH extract from R. japonica rhizomes appears to be a promising gingival wound healing agent worthy of animal and clinical trials.

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.

Assessment of Prevalence of Recurrent Aphthous Stomatitis in the North Indian Population: A Cross-Sectional Study

Aim and Objective

The present study was undertaken for assessing the prevalence of recurrent aphthous stomatitis (RAS) in the North Indian population.

Materials and Methods

Assessment of a total of 4255 patients was done over a period of 2 years, who came for a routine dental checkup. Recording of the complete demographic and clinical details of all the patients was done. The prevalence of RAS was assessed. Profile of patients with RAS was assessed separately. A pro forma was made and the type of treatment protocol followed by patients with RAS was also recorded. All the results were recorded in a Microsoft Excel sheet and were analyzed using SPSS software.

Results

Analysis of a total of 4255 patients was done. RAS was found to be present in 800 patients. The overall prevalence of RAS was found to be 18.93%. Significant results were obtained when analyzing age, gender, and occupation as risk factors for RAS. Labial/buccal mucosa involvement occurred in 51.875% of the cases. In 44% of the cases, the size of the RAS was between 1 cm and 3 cm. Home remedy was followed in 17.875% of the cases.

Conclusion

A significant proportion of patients in the North Indian population is affected by RAS. In comparison to males, females are more commonly affected.

Analysis of Interleukin-1 Receptor Antagonist Variable Number Tandem Repeat Variant in Recurrent Aphthous Stomatitis

BACKGROUND/AIMS

Recurrent aphthous stomatitis (RAS) is one of the common oral inflammatory diseases. As immunological and genetic factors have been held responsible for the pathogenesis of RAS, the objective of this study was to determine whether the interleukin-1 receptor antagonist (IL-1Ra) gene variable number tandem repeat (VNTR) variant is a risk factor for the development of RAS in Turkish patients and to define its contribution to the increased risk.

METHODS

The IL-1Ra VNTR variant was evaluated in 169 RAS patients and 171 healthy controls by the polymerase chain reaction (PCR) method.

RESULTS

No statistically significant difference was found in the genotype distributions and allele frequencies of IL-1Ra VNTR variant between RAS patients and healthy controls.

CONCLUSION

Lack of association between IL-1Ra VNTR variant and RAS could indicate that IL-1Ra has no significant role in the pathophysiology of RAS. However, it still appears to be very worthwhile to continue to search for cytokine gene variants in order to predict the development of such disease.

Risk of autoimmune diseases in recurrent aphthous ulcer patients: A nationwide population study

OBJECTIVE

To estimate the risk of developing autoimmune disease in patients diagnosed having recurrent aphthous stomatitis (RAS) through a nationwide population-based cohort study.

METHODS

This study included two group of patients who had three or more episodes with aphthae diagnosed from their physician (RAS group) and a similar matched group of patients without aphthae (control group). Both groups were collected within the period of 2005-2007 from the Korean National Health Insurances claims database. Non-RAS cohort was matched after frequency matching. The final enrolled subjects were observed during a follow-up period from 2008 to 2015 and those who received autoimmune diseases diagnoses during follow-up were identified. The hazard ratio (HR) for developing autoimmune diseases was estimated.

RESULTS

A total of 4,637 patients with RAS and 4,637 controls were included. The risk of overall autoimmune diseases was significantly increased in the RAS group (adjusted HR [aHR)], 1.19). With regard to each disease entity, patients with RAS showed an increased risk of Behcet's disease (31.16), systemic lupus erythematous (SLE) (1.74), ankylosing spondylitis (AS) (1.47), gout (1.47), Hashimoto thyroiditis (1.42), Graves' disease (1.37), and rheumatoid arthritis (RA) (1.19).

CONCLUSION

RAS-like lesion may be an early sign of systemic autoimmune disease, as it was associated with an increased risk of Graves' disease, Hashimoto thyroiditis, SLE, AS, gout, RA, and Behcet's disease from real-world data.

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.

A family-based genome-wide association study of recurrent aphthous stomatitis

OBJECTIVES

The aetiology of recurrent aphthous stomatitis (RAS) remains unknown. Individuals may share features of genetic susceptibility, and there may also be a hereditary component. The aim was to identify patterns of association and segregation for genetic variants and to identify the genes and signalling pathways that determine the risk of developing RAS, through a family-based genome-wide association study (GWAS).

SUBJECTS AND METHODS

DNA was extracted from buccal swabs of 91 individuals in 16 families and analysed in an Illumina core exome single nucleotide polymorphism (SNP) array. A family-based association test (dFAM) was used to derive SNP association values across all chromosomes.

RESULTS

None of the final 288,452 SNPs reached the genome-wide significant threshold of 5 × 10^-8 . The most significant pathways were the Ras and PI3K-Akt signalling pathways, pathways in cancer, circadian entrainment and the Rap 1 signalling pathway.

CONCLUSIONS

This confirms that RAS is not monogenic but results as a consequence of interactions between multiple host genes and possibly also environmental factors. The present approach provides novel insights into the mechanisms underlying RAS and raises the possibility of identifying individuals at risk of acquiring this condition.

Lactic acid 5% mouth wash vs Kenalog in Orabase 0.1% for treatment and prophylaxis of recurrent aphthous ulcer

BACKGROUND

The outcomes of most therapeutic modalities for recurrent aphthous ulcer (RAU) are still unsatisfactory.

AIM

To evaluate lactic acid 5% mouth wash vs Kenalog in Orabase for treatment and prophylaxis of RAU.

PATIENTS/METHODS

Forty cases with early-onset idiopathic RAU were enrolled in this study. Patients were divided into two equal groups; group A patients had used Kenalog in Orabase twice daily, and group B patients had used lactic acid 5% mouth wash 3 times daily. All patients had used the therapy for 1-2 weeks according to patients' clinical response that was evaluated according to oral clinical manifestations index (OCMI); before therapy, during course of treatments and in follow-up visits.

RESULTS

At the ends of both first and second weeks, from beginning of therapy, OCMI was reduced more in group B patients than in group A with statistically significant results. These results revealed that group B achieved more reduction in the size, pain, and healing time of RAU. During the follow-up period, group A showed 40% recurrence rate while group B showed 5% only.

CONCLUSIONS

Lactic acid 5% mouth wash is natural, safe, and effective so it is better alternative to corticosteroids for treatment and prophylaxis of RAU without any side effects.

Ustekinumab Successfully Treats and Maintains Remission of Pyostomatitis Vegetans Associated with Crohn's Disease

Pyostomatitis vegetans (PV) is a rare inflammatory stomatitis often associated with inflammatory bowel diseases (IBD). Treatment of PV depends on the presence of coexisting IBD. To date, there have been no reports on the use of ustekinumab for PV. There have been recent cases on the use of ustekinumab for treatment of pyoderma gangrenosum and uveitis. We report the case of a 26-year-old female with moderately severe Crohn's disease (CD) and PV who was successfully treated with ustekinumab monotherapy. Since initiation of ustekinumab, she has been in clinical and biochemical remission from a CD and PV standpoint for the last 12 months.

An update on investigations of autoimmune diseases affecting orofacial region

Autoimmune diseases are better diagnosed currently with advances in cellular immunology, molecular biology, and genetics. Clinical diagnosis of systemic and organ specific autoimmune diseases is a challenging task for the Oral physicians and the development of chairside investigation methods has not only saved the time but also cost factor. To understand patient's immune status, the clinical chair side diagnostic aids along with laboratory testing methods are necessary. Laboratory investigations have great importance in detecting, confirming and analyzing the severity, and predicting the prognosis of the autoimmune disease. This article aims to list out the diagnostic methods to diagnose autoimmune conditions and focuses on various diagnostic methods to effectively evaluate autoimmune disease of orofacial region.

The effects of pomegranate peel extract on recurrent aphthous stomatitis

As high as 20% of the population is thought to have recurrent aphthous stomatitis (RAS), hence, finding new therapeutic agents may be needed. Pomegranate (Punica granatum), has been extensively used in the folk medicine of many cultures, as it possesses antioxidant, anti-inflammatory and anti-bacterial properties. In this study, it is hypothesized that a topical form of pomegranate peel extract (PPE) may shorten the duration, accelerate the healing and reduce the pain of RAS patients. The presented randomized, double-blind study was conducted on 56 patients. Herein, 28 patients were advised to apply PPE gel, and the other 28 patients were given placebo gel, twice daily for one week. Efficacy evaluations were made at days 0 (before using the gel), 3, 5 and 7. The mean values of ulcer size, pain and healing duration of ulcers were compared in both groups. PPE gel was significantly effective in reducing the pain (p<0.001), ulcer size (p<0.001), and healing duration of ulcers (p<0.001) over a period of one week. PPE in the form of oral gel can be used in the management of aphthous ulcers.

Salivary cortisol and dehydroepiandrosterone as oral biomarkers to determine stress in patients with recurrent aphthous stomatitis

Background

Recurrent aphthous stomatitis (RAS) is one of the most common oral ulcerative diseases with a multifactorial etiology. Although psychological stress is an exacerbating factor, the role of salivary stress hormones, cortisol, and dehydroepiandrosterone (DHEA) in this oral disease has not been extensively reported. The study aimed to estimate and compare the salivary cortisol and DHEA levels in RAS patients and healthy control group with the aid of ELISA microplate reader.

Subjects and Methods

Sixty patients were enrolled in our study, which included 30 patients with clinically diagnosed RAS and 30 healthy controls. Two mL of unstimulated whole saliva was collected and salivary cortisol and DHEA levels were measured using ELISA kit, and the values were read by microplate ELISA reader and recorded in both groups.

Results and Conclusion

The mean salivary cortisol and DHEA levels were elevated in the RAS patients compared to the healthy controls and were statistically significant. Salivary cortisol and DHEA can serve as oral biomarkers to determine stress in patients with RAS. However, the present study necessitates further studies with larger sample size and an improved protocol to ascertain the actual role of these presumed oral biomarkers as well as anxiety and stress as triggers in the pathogenesis of RAS.

Citric acid treatment of oral ulcers refractory to conventional treatment: a case study

Oral ulcers are painful sores that appear in the mouth. Most of them are usually harmless and clear up on their own. Sometimes, they are non-responsive and difficult to manage. This report describes the case of an 80-year-old female patient with chronic oral ulcers of three years duration and which were refractory to conventional therapy. The ulcers were subsequently treated using 3% citric acid as a sole topical agent, applied three times a day that resulted in complete healing of oral ulcers by day 10 of treatment. The findings of this case report suggest that topical citric acid is a possible alternative treatment for chronic oral ulcers unresponsive to conventional treatment.

Nortriptyline-induced oral ulceration: A case report

Drug-induced oral ulcers are lesions of the oral mucosa accompanied by painful symptoms, such as burning mouth, metallic taste, dysgeusia, or ageusia. This report demonstrates the first documented case of drug-induced oral ulcers with the tricyclic antidepressant nortriptyline. In this case, a 49-year-old female initiated treatment for refractory neuropathy with nortriptyline. Within 2 weeks of therapy, painful, oral, bubble-like ulcers developed. Complete symptom resolution occurred approximately 1 month after discontinuation of nortriptyline. Clinicians should be cognizant of nortriptyline's ability to potentially induce oral ulcers; however, the exact mechanism for this adverse event is unknown.

A Skeptical Approach to the Management of Persistent Oral Ulceration in a Child

The diagnosis of oral lesions is sometimes difficult due to both the clinician's limited experience with the conditions that may cause the lesions and their similar appearances, especially in children. Correctly establishing a definitive diagnosis is of major importance to clinicians who manage patients with oral mucosal diseases. In patients with Fanconi anaemia (FA), oral ulcers occur frequently, which are quite variable, and may lead to a misdiagnosis or failure to diagnose. Here, we report the case of a 15-year-old boy who was examined for squamous cell cancer of the tongue and diagnosed as having FA without any haematological manifestations. While surgery could not be done, both radiotherapy and chemotherapy had to be decreased. He died of progressive disease 6 months after the diagnosis. Unexplained ulcers in a child with a duration longer than 2 weeks should be further evaluated, especially for FA, even without the presence of anaemia.

Gastrointestinal diseases and their oro-dental manifestations: Part 2: Ulcerative colitis

Ulcerative colitis is a rather common inflammatory bowel disease, especially in the industrialised world. A limited number of studies have reported the prevalence of oral signs and symptoms in these patients, and widely varying prevalence rates have been reported ranging from 2 to 34%. Pyostomatitis vegetans is the most pathognomonic oral sign but also other abnormalities as oral ulcerations, caries and periodontitis are more often seen in patients with ulcerative colitis. In this review we describe the oral manifestations of ulcerative colitis and their potential dental implications.

Gastrointestinal diseases and their oro-dental manifestations: Part 1: Crohn's disease

Widely varying prevalence rates of oral lesions in patients with Crohn's disease have been reported, ranging from 0.5% to 37%. These manifestations may coincide with or precede intestinal symptoms. Oral manifestations can be classified as specific lesions, when macroscopic examination shows similar changes to those observed endoscopically in the intestine, and non-specific lesions including aphthous ulcerations. The most frequently observed oral lesions are oedema, ulcers and hyperplastic lesions on the buccal mucosa. In most patients these lesions are asymptomatic, however, some patients may experience discomfort. In this review we describe the most relevant oro-dental manifestations observed in patients with Crohn's disease and discuss the potential implications for oro-dental management.

Candida is a protractive factor of chronic oral ulcers among usual outpatients

Although many oral ulcers have similar clinical appearances, their etiologies can range from reactive to neoplastic to oral manifestations of dermatological diseases. In patients with an HIV infection, fungal diseases may cause ulceration in the oral cavity; however, there have been few studies of oral ulcerative lesions associated with Candida in patients without an HIV infection. Nevertheless, we encountered chronic oral ulcer associated with Candida among our frequent outpatients without an HIV infection. The present article reviews the causes of oral ulcers, focusing on Candida as a protractive factor for chronic oral ulcers, and it is recommended that Candida involvement be considered in diagnosis of a certain chronic oral ulcer, that remains of unknown origin even if some examinations have been performed.

Systemic and Topical Steroids in the Management of Oral Mucosal Lesions

From the time of its introduction in the 1040s, glucocorticoids have provided a panacea for many diseases. The therapeutic benefit of corticosteroids lies in their anti-inflammatory and immunosuppressive properties which makes them highly effective in the management of oral mucosal lesions. This article aims to present to the clinician, the plethora of options available as steroid therapy and enables one to choose based on the underlying disease and the properties of the drug.

A Clinical and Microbiological Evaluation of Helicobacter pylori in Recurrent Aphthous Stomatitis

AIM

The aim of this study is to evaluate the association of Helicobacter pylori in recurrent aphthous stomatitis (RAS) with or without peptic ulcer.

MATERIALS AND METHODS

A total of 42 patients were selected for the present study from outpatient Department of Oral Medicine, and divided into control (group I) and test groups (groups II, III). A total number of 15 patients suffering from RAS based on history and clinical examination was selected as group II. A total number of 12 patients suffering concomitantly from RAS and duodenal ulcer based on history and clinical examination were selected as group III. A total number of 15 healthy subjects were selected as controls in group I. All selected subjects belonged to the age group of 16 to 45 years. Data were tabulated and statistically analyzed with Statistical Package for the Social Sciences (SPSS) statistical software version 19 of IBM, Chicago, Illinois, USA.

RESULTS

Among all three groups, 54.8% was negative and 45.2% was positive for H. pylori. No significant relation was established between H. pylori and RAS.

CONCLUSION

In the present study, there was no association of H. pylori in patients with RAS and in patients with RAS along with gastric ulcers.

CLINICAL SIGNIFICANCE

This clinical study evaluated the relation of H. pylori in RAS patients.

Beyond Human Leukocyte Antigen Class I Antigens: Hereditary Hemochromatosis Gene Mutations in Recurrent Aphthous Oral Ulcers and Behçet Disease in the South of Tunisia

OBJECTIVE

The aim of this work was to establish human leukocyte antigen (HLA) class I and hereditary hemochromatosis gene (HFE) mutation associations with recurrent aphthous oral ulcers (RAOU) and Behçet disease (BD) in a cohort of Southern Tunisian patients.

SUBJECTS AND METHODS

A total of 232 patients with RAOU and 123 healthy controls (HCs) were enrolled in this study. The patients were divided into 2 groups based on the presence (BD+: n = 62) or absence of BD (BD-, n = 170). In the BD+ group, 28 patients had severe manifestations of BD. In the BD- group, RAOU was isolated in 81 patients, associated with mucocutaneous manifestations in 58 and with joint symptoms in 25. Complement-dependent microlymphocytotoxicity assay and polymerase chain reaction-restriction fragment length polymorphism were used to study HLA class I polymorphism and HFE mutations, respectively.

RESULTS

HLA-B51 was positively associated with BD, particularly in those with severe manifestations. No association was detected with HLA class I polymorphism among the BD group. Based on stratification to clinical manifestations, the isolated RAOU was negatively associated with HLA-A1 with a difference close to significance (12 [14.81%] vs. 32 [26.02%] in HCs; p = 0.06). Furthermore, patients with mucocutaneous features had a higher frequency of HLA-B51 (14, 24.14%) than patients without mucocutaneous involvement (11, 11.37%). Considering HFE mutations, patients with isolated RAOU had a higher frequency of H63D when compared with other subgroups, especially after limiting the comparison to 27 patients of at least 5 years of follow-up.

CONCLUSION

This study showed that, unlike BD, RAOU were not associated with HLA-B51. Moreover, we suggest that H63D mutation was positively associated with isolated RAOU.

Myrtus communis L. and its application in treatment of Recurrent Aphthous Stomatitis

ETHNOPHARMACOLOGICAL RELEVANCE

In Iranian Traditional Medicine, M. communis is a famous plant in treatment of oral ulcers and "Gholaa"- the ancient name of aphthous.

OBJECTIVE

The aim of this review is to create a bridge between the traditional claims about the application of M. communis in treatment of "Gholaa" and its prescription for aphthous, the current form of "Gholaa" in modern medicine METHODS: We extracted the information about the application of M. communis in treatment of aphthous from different resources including Google scholar, Pubmed, ScienceDirect, Springer, ethnobotanical, the traditional books from Traditional Medicine Tehran University of Medical Sciences.

RESULTS

In Iranian traditional texts, "Gholaa" was the corrosive diseases on the surface and inner layer of mouth and tongue and divided into three types of bloody, phlegmatic and burned black bile types. Recurrent Aphthous Stomatitis (RAS) is equal to the black bile and phlegmatic types and minor aphthous type can be matched with phlegmatic type. The corrosive propagated lesions can be herpetic aphthous. In modern medicine, M. communis essential oil and its decoction decreased the average time of pain relief and decreased the size of ulcers in patients with minor RAS without any adverse effects. The number of ulcers was not the subjects of any different clinical trials. All patients were satisfied with M. communis topical essential oil (5%), and 81% patients were satisfied with M. communis topical decoctions (5%). It appears the efficacy of M. communis is related to its analgesic, anti-inflammatory, antiseptic and wound healing effects.

CONCLUSION

M. communis is effective in minor RAS as its traditional claims and confirming its efficacy in major and herpetiform RAS and comparing the efficacy of its decoction topical formulations or essential oil topical ones are required more and larger experimental and clinical investigations in future.

Treatment of chemically induced oral ulcer using adipose-derived mesenchymal stem cell sheet

BACKGROUND

This study investigated the effects of mesenchymal stem cell (MSC) sheet transplantation on healing of chemically induced oral ulceration in a rabbit animal model.

METHODS

Oral mucosal ulcers were induced by topical application of filter paper soaked with 70% acetic acid to the anterior gingiva and buccal mucosa of 12 New Zealand white rabbits. The animals were randomly assigned to two groups: with (treatment group, n = 6) or without (control group, n = 6) cell sheets applied to ulcers. Gross findings were sequentially evaluated, and histologic examination was performed on day 7.

RESULTS

Based on gross inspection, ulceration resolved before day 5 in the treatment group; however, in the control group, healing was incomplete on day 7. In the treatment group, the total area of the ulcer decreased significantly from day 2 to day 5 (P < 0.001) and from day 5 to day 7 (P = 0.020), whereas the area decreased significantly from day 5 to day 7 in the control group (P < 0.001). Histologic and immunofluorescence examination revealed full-thickness mucosa healing and complete basal cell coverage in the treatment group; in contrast, only partial healing was observed on day 7 in the control group.

CONCLUSIONS

Cell sheet technology using MSC can be an alternative treatment for oral ulcerations in that it can decrease healing time without invasive properties.

Oral Manifestations of Inflammatory Bowel Diseases: Two Case Reports

Inflammatory bowel diseases (IBD) are known as chronic inflammatory disorders of the digestive tract, represented mainly by Crohn's disease (CD) and ulcerative colitis (UC). Among the main oral manifestations of IBD are cobblestoning of the oral mucosa, labial swellings with vertical fissures, pyostomatitis vegetans, angular cheilitis, perioral erythema, and glossitis. In this sense, understanding these nosological entities by dentists would help reach early and differential diagnosis. Thus, two case reports are presented and discussed based on theoretical references obtained by a literature review. The first case report refers to an adult patient whose IBD diagnosis was established after stomatological assessment. The second case was a patient with CD diagnosed in childhood with characteristic oral lesions.

Nicorandil, Gastrointestinal Adverse Drug Reactions and Ulcerations: A Systematic Review

INTRODUCTION

Nicorandil is a popular anti-anginal drug in Europe and Japan. Apart from some common adverse drug reactions (ADR), its safety is satisfactory. Several reports have suggested a link between nicorandil, gastrointestinal (GI) ulceration and fistulas. The review aims to critically appraise, synthesize and present the available evidence of all known GI ADR per anatomical location.

METHODS

The study complied with the PRISMA statement. Literature and pharmacovigilance databases were used to provide rate and/or calculate parameters (median age, median dose, history of symptoms, length of therapy and healing time after withdrawal of the drug). Differences in distribution of quantitative variables were analyzed via Mann-Whitney test. Correlation between quantitative variables was assessed with a Spearman's correlation coefficient. A p value <0.05 was significant.

RESULTS

Oral ulcerations occur in 0.2% of the subjects, anal ulcerations are present between 0.07% and 0.37% of patients. Oral and distal GI involvements are the most common ADR (28-29% and 27-31% of all GI ADR, respectively). The hepatobiliary system, the pancreas and salivary glands are not affected by nicorandil exposure. The time to develop oral ulcerations is 74 weeks among people on <30 mg/day compared to only 7.5 weeks in individuals on higher regimens (p = 0.47). There is a significant correlation between dose and ulcer healing time (Spearman's 0.525, p < 0.001).

CONCLUSIONS

Ulcerative disease is a very commonly reported GI ADR. A delayed ulcerative tendency supports the hypothesis of an ulcerogenic metabolite. Nicorandil seems to act as a cause of the ulcerations, but appears to also work in synergy with other promoting factors. Whether the action of the metabolites relies on a specific mechanism or a simple chemical ulceration is still to be established.

"Ozone" - the new NEMESIS of canker sore

BACKGROUND

Recurrent aphthous ulceration or recurrent aphthous stomatitis is one of the most debilitating and painful oral mucosal disease. This disease entity has no specific cause to occur and no proper laboratory procedures are present to elicit the diagnosis. The treatment options are largely palliative and aimed at reducing symptoms thereby improving patient's oral condition. In the present study the subjects witnessed alleviation of clinical symptoms related to the aphthous ulceration.

AIMS AND OBJECTIVES

The aim of the study was to explore the effectiveness of ozonated oil in the treatment of recurrent aphthous ulcer and to compare with sessame oil in order to analyse the effectiveness between the two topical oil medications.

MATERIALS AND METHODS

A single-blinded placebo-controlled trial comprising of 30 subjects with recurrent aphthous ulcers were divided into Group 1, Group 2 and Group 3 with 10 subjects in each group was performed. Patients in Group 1 received ozonated oil, Group 2 received sesame oil and Group 3 received placebo. Treatment response was assessed by measures of pain reduction, ulcer duration on 2(nd), 4(th) and 6(th) day. Data were analyzed using Wilcokson signed rank test and Friedman test.

RESULTS

Participants treated with ozonated oil showed significant reduction in ulcer size, erythema and also alleviated the ulcer pain on 4(th) day of evaluation when compared to sesame oil and placebo group. On 6(th) day subjects treated with ozonated oil and sesame oil showed significant reduction in ulcer size and erythema. No significant difference was observed in placebo group when compared with other two groups on subsequent 2(nd), 4(th) and 6(th) day of evaluation.

CONCLUSION

Ozonated oil and sessame oil, both showed similar effectiveness in relieving the ulcer pain. Ozone with its wide variety of inherent properties has proven to be choice of treatment in completely relieving the ulcer pain and ulcer size when compared with that of its counter medication (i.e. sesame oil).Therefore the results obtained in the present study forecast ozone to be used as a novel treatment approach in recurrent aphthous ulcers.