Covid-19 and oral diseases: Crosstalk, synergy or association?

The coronavirus disease 2019 (Covid-19) is a viral infection caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) that clinically affects multiple organs of the human body. Cells in the oral cavity express viral entry receptor angiotensin-converting enzyme 2 that allows viral replication and may cause tissue inflammation and destruction. Recent studies have reported that Covid-19 patients present oral manifestations with multiple clinical aspects. In this review, we aim to summarise main signs and symptoms of Covid-19 in the oral cavity, its possible association with oral diseases, and the plausible underlying mechanisms of hyperinflammation reflecting crosstalk between Covid-19 and oral diseases. Ulcers, blisters, necrotising gingivitis, opportunistic coinfections, salivary gland alterations, white and erythematous plaques and gustatory dysfunction were the most reported clinical oral manifestations in patients with Covid-19. In general, the lesions appear concomitant with the loss of smell and taste. Multiple reports show evidences of necrotic/ulcerative gingiva, oral blisters and hypergrowth of opportunistic oral pathogens. SARS-CoV-2 exhibits tropism for endothelial cells and Covid-19-mediated endotheliitis can not only promote inflammation in oral tissues but can also facilitate virus spread. In addition, elevated levels of proinflammatory mediators in patients with Covid-19 and oral infectious disease can impair tissue homeostasis and cause delayed disease resolution. This suggests potential crosstalk of immune-mediated pathways underlying pathogenesis. Interestingly, few reports suggest recurrent herpetic lesions and higher bacterial growth in Covid-19 subjects, indicating SARS-CoV-2 and oral virus/bacteria interaction. Larger cohort studies comparing SARS-CoV-2 negative and positive subjects will reveal oral manifestation of the virus on oral health and its role in exacerbating oral infection.

Common genetic susceptibility loci link PFAPA syndrome, Behçet's disease, and recurrent aphthous stomatitis

Periodic fever, aphthous stomatitis, pharyngitis, and cervical adenitis (PFAPA) syndrome is the most common periodic fever syndrome in children. The disease appears to cluster in families, but the pathogenesis is unknown. We queried two European-American cohorts and one Turkish cohort (total n = 231) of individuals with PFAPA for common variants previously associated with two other oropharyngeal ulcerative disorders, Behçet's disease and recurrent aphthous stomatitis. In a metaanalysis, we found that a variant upstream of IL12A (rs17753641) is strongly associated with PFAPA (OR 2.13, P = 6 × 10-9). We demonstrated that monocytes from individuals who are heterozygous or homozygous for this risk allele produce significantly higher levels of IL-12p70 upon IFN-γ and LPS stimulation than those from individuals without the risk allele. We also found that variants near STAT4, IL10, and CCR1-CCR3 were significant susceptibility loci for PFAPA, suggesting that the pathogenesis of PFAPA involves abnormal antigen-presenting cell function and T cell activity and polarization, thereby implicating both innate and adaptive immune responses at the oropharyngeal mucosa. Our results illustrate genetic similarities among recurrent aphthous stomatitis, PFAPA, and Behçet's disease, placing these disorders on a common spectrum, with recurrent aphthous stomatitis on the mild end, Behçet's disease on the severe end, and PFAPA intermediate. We propose naming these disorders Behçet's spectrum disorders to highlight their relationship. HLA alleles may be factors that influence phenotypes along this spectrum as we found new class I and II HLA associations for PFAPA distinct from Behçet's disease and recurrent aphthous stomatitis.

Recurrent, Severe Aphthous Stomatitis and Mucosal Ulcers as Primary Manifestations of a Novel STAT1 Gain-of-Function Mutation

Chronic mucocutaneous candidiasis (CMC) characterized by persistent and recurrent Candida infection of the skin, nails, and the mucosa membranes has been proposed as the major infectious phenotype in patients with gain-of-function mutation of signal transducer and activator of transcription 1 (STAT1) 1. However, viral infections caused mostly by herpesviruses, and a broad range of autoimmune disorders may also be part of the clinical phenotype. We report here on a 31 years old female patient suffering from severe mucosal aphthous mucositis and ulcers and recurrent herpes simplex for decades. We found a previously unknown heterozygous sequence variant in STAT1 (c.1219C>G; L407V) affecting the DNA-binding domain of the protein in the patient and her 4 years old daughter. We found this mutation gain-of-function (GOF) by using immunoblot and luciferase assays. We detected low proportion of IL-17A-producing CD4+ T cell lymphocytes by using intracellular staining and flow cytometry. Candida-induced secretion of IL-17A and IL-22 by mononuclear cells from the patient was markedly decreased compared to controls. These data suggest that the novel mutant allele may result in impaired differentiation of CD4+ T cells to CD4+/IL-17+ cells. The clinical phenotype of the disease in this patient was unique as it was dominated primarily by severe aphthous stomatitis and ulcerative esophagitis and only partly by typical CMC resulting in diagnostic delay. We suggest that patients with severe recurrent aphthous stomatitis and esophagitis should be evaluated for STAT1 GOF mutation. Based on the broad clinical spectrum of the disease, we also suggest that CMC and CMC disease may not be an appropriate term to define clinically STAT1 GOF mutation.

Long-term Stabilization of Aqueous Doxycycline Formulations, in Mucoadhesive Hydrogels for Treatment of Oral Mucosal Conditions

BACKGROUND

The main aim of this work was to develop stable (>2 years) doxycycline formulation, at clinically relevant concentrations and using clinically relevant formulation. Doxycycline has a MMP- inhibitory effects that is important for the treatment of various oral mucosal conditions. Therefore, protecting doxycycline from degradation in aqueous formulation requires halting or prevention of oxidation and epimerisation of the active compound.

METHODS

Stabilizing excipients were intuitively put together to enhance the stability as a cumulative effort. A total of 30 hydrogels were compared with different types and concentrations of stability enhancing excipients, pH, storage temperatures (4, 25 and 40°C) and mucoadhesive polymers. The duration of the study was from day 1 and up to 58 months. The gelation temperature was adjusted below the actual body temperature. The complexation efficiency between the doxycycline and HPβCD was studied using the DSC, FTIR and XRPD.

RESULTS

The majority of formulations at 4°C were highly stable by the end of 58 months and their stabilities were improved at all 3 temperatures.

CONCLUSION

In conclusion, it is possible to prevent doxycycline from both oxidation and epimerization in an aqueous formulation, for up to 5 years.

Establishment of Role of IL-2, IL-10 and IL-12 in Patients with Recurrent Aphthous Stomatitis-A Clinical Study

BACKGROUND

Recurrent aphthous stomatitis is a vesiculobul-lous disease characterized by painful ulcers in the oral cavity. The role of interleukins such as IL-2, IL-10 and IL-12 in initiating disease demands careful assessment. The present study was conducted to determine the level of IL-2, IL-10 and IL-12 in patients with recurrent aphthous stomatitis.

MATERIALS AND METHODS

The present study was conducted on 40 patients diagnosed with recurrent aphthous stomatitis. An equal number of age and gender-matched subjects (40) was included as a control. They were divided into 2 age groups from 20 to 40 years and 40 to 60 years. All were made to sit comfortably on a dental chair, and 1 ml of unstimulated saliva was collected in a sterile tube to assess the level of IL-2, IL-10 and IL-12 using ELISA. The level of IL-2, IL-10 and IL-12 was measured in pg/mL.

RESULTS

Each group had 10 males and 10 females. The difference was non-significant (P-1). Age group 20-40 years comprised of 14 patients in group I (eight males and six females) and 12 in group II (five males and seven females). Age group 40-60 years had six patients in group I (two males and four females) and 8 patients in group II (five males and three females). The difference was significant (p < 0.05). The most common form was minor (82%) followed by herpetiform (13%) and major (5%). In group I, the mean value of IL-2 level was 32.24 pg/mL, IL-10 was 1.24 ± 0.6 and IL-12 was 28.34 ± 4.04 and in group II, mean value of IL-2 level was 12.10 pg/mL, IL-10 was 2.56 ± 1.12 and IL-12 was 23.16 ± 4.16. The difference was significant (p < 0.05).

CONCLUSION

Age group 20 to 40 years showed higher prevalence. The level of IL-2 and IL-12 is highly increased while IL-10 is decreased in patients.

CLINICAL SIGNIFICANCE

Role of interleukins as a precipitating factor along with stress is well established. With the thorough knowledge of the disease process, the newer treatment modality specific against interleukins may be proven useful in controlling the disease.

[Alteration of Th17 cells, immunoglobins and complements levels in peripheral blood of patients with refractory recurrent aphthous ulcer]

PURPOSE

To observe the levels of Th17 cells, immunoglobins and complements in peripheral blood of patients with refractory recurrent aphthous ulcer (refractory RAU) patients.

METHODS

Totally, 30 patients with refractory RAU and 21 healthy controls were enrolled into this study. Flow cytometry was performed to determine the frequency of Th17 cells in the peripheral blood. Immune scatter turbidimetry was adopted to measure the levels of IgA, IgG, IgM, IgE, C3 and C4 in the peripheral blood. Meanwhile, the correlations between the frequency of Th17 cells and the levels of immunoglobins or complements were analyzed. SPSS17.0 software package was used to analyze the date.

RESULTS

Compared with the control group, the percentage of Th17 cells (CD3⁺CD8^-IL17⁺) in all CD4⁺T cells was significantly increased in the refractory RAU group (P<0.01). Similarly, the levels of IgG, IgA, IgE in the refractory RAU group were significantly higher than those in the control group (P<0.05),but there was no significant difference in the levels of IgM, C3 and C4 between the refractory RAU group and control group. There was negative correlation between the frequency of Th17 cells and the level of IgA (r=-0.477, P<0.01).

CONCLUSIONS

The levels of Th17 cells, immunoglobins and complements in refractory RAU patients are significantly different from healthy human, which may play an important role in the pathogenesis of refractory RAU. There may be some relationship between Th17 cells and the change of humoral immunity in refractory RAU.

Oral manifestations of inflammatory bowel disease

Inflammatory bowel diseases (IBD), including Crohn’s disease and ulcerative colitis, have important extraintestinal manifestations, notably in the oral cavity. These oral manifestations can constitute important clinical clues in the diagnosis and management of IBD, and include changes at the immune and bacterial levels. Aphthous ulcers, pyostomatitis vegetans, cobblestoning and gingivitis are important oral findings frequently observed in IBD patients. Their presentations vary considerably and might be well diagnosed and distinguished from other oral lesions. Infections, drug side effects, deficiencies in some nutrients and many other diseases involved with oral manifestations should also be taken into account. This article discusses the most recent findings on the oral manifestations of IBD with a focus on bacterial modulations and immune changes. It also includes an overview on options for management of the oral lesions of IBD.

HLA-DRB and HLA-DQB Allele and Haplotype Frequencies in Iranian Patients with Recurrent Aphthous Stomatitis

Recurrent aphthous stomatitis (RAS) is known as the most common chronic disease of the oral cavity, which affects a range of 5-25% of the population. RAS appears to be associated with some human leukocyte antigen (HLA) class II alleles and haplotypes. This study attempts to survey the distribution of HLA-DRB and -DQB alleles among Iranian RAS patients and healthy controls. In order to evaluate the association of HLA-DR and DQ alleles and haplotypes, 54 patients with RAS and 100 unrelated healthy subjects as control group were investigated. Our data indicated that DRB1*13:17, DRB1*15:01, and DRB5*01 were significantly more frequent in RAS patients in comparison to controls. However, DRB3:01allele frequency was higher in the controls compared to the patients. The significantly frequent allele in the patients compared with the healthy subjects was HLA-DQB1*03:02. However, both HLA-DQB1*02:01 and HLA-DQB1*03:01 alleles were most frequent in the healthy individuals rather than the patients. The DRB*04/DQB1*03:01 and DRB*01:01/DQB1*02:01 haplotypes were significantly distributed in healthy subjects compared with patients. However, DRB*07:01/DQB1*03:02 haplotype was found to be significantly frequent in patients than controls. In respect of HLA genes, factors are involved in the incidence of RAS; various HLA-DRB and HLA-DQB1 alleles and the related haplotypes are suggested to be the three main RAS susceptibility factors in our population study.

[Effectiveness of pidotimod in combination with bacterial lysates in the treatment of the pfapa (periodic fever, aphthous stomatitis, pharyngitis, and cervical adenitis) syndrome]

AIM

PFAPA (periodic fever, aphthous stomatitis, pharyngitis, and cervical adenitis) syndrome is the most common autoinflammatory syndrome in pediatrics, accepted as an hyperimmune condition. Pidotimod is a molecule with immunomodulatory activity on both innate and adaptive immune responses; it also has the capacity to modulate the function of the respiratory epithelial cells through the activation of a NK-KB pathway which would involve the host-virus interaction. Moreover, the proven beneficial effect of Pidotimod in enhancing the immune response during vaccination, and its benefits in the prevention of respiratory tract infections, should be noted.

METHODS

A joint combination of Pidotimod and bacterial lysates was used to treat 37 children with a clinical diagnosis of PFAPA; within the end of the first year of therapy, the healing rate of PFAPA symptoms was 67.5% (25 children), with a 10.8% (4 cases) still in complete remission within the end of the second year of follow-up.

RESULTS

It is important to highlight that 29 children (78.3%) had benefitted from this therapy, in terms of healing, with a marked decrease in the incidence of fever from a total of 360 to 106 episodes, and episodes of periodic fever occurring almost 4 times less frequently. The use of Pidotimod determined a significant reduction of surgical tonsillectomy's treatment.

CONCLUSION

This approach had a strong impact on the children's quality of life; a significant decrement in the use of antipyretic drugs, as well as a lower rate of antibiotic prescription, were also noted. It also had a dramatic impact on families' lives, because the treatment lowers the number of absences of family members from work or school/kindergarten.

Polyclonal, newly derived T cells with low expression of inhibitory molecule PD-1 in tonsils define the phenotype of lymphocytes in children with Periodic Fever, Aphtous Stomatitis, Pharyngitis and Adenitis (PFAPA) syndrome

PURPOSE

PFAPA syndrome is a benign, recurrent inflammatory disease of childhood. Tonsillectomy is one of the therapeutic options with a yet unexplained biological mechanism. We tested whether specific lymphocyte subsets recruited from blood to human tonsils participate in PFAPA pathogenesis.

METHODS

Paired tonsils/peripheral blood (PB) samples were investigated (a) from children with PFAPA that successfully resolved after tonsillectomy (n=10) (b) from children with obstructive sleep apnoea syndrome as controls (n=10). The lymphocyte profiles were analysed using 8-colour flow cytometry, immunoglobulin (IGH) and T-cell receptor (TCR) gene rearrangements via PCR and next generation sequencing; a TREC/KREC analysis was performed using qPCR.

RESULTS

The PFAPA tonsils in the asymptomatic phase had a lower percentage of B-lymphocytes than controls; T-lymphocyte counts were significantly higher in PB. The percentages of cytotoxic CD8pos T-lymphocytes were approximately 2-fold higher in PFAPA tonsils; the transitional B cells and naïve stages of both the CD4pos and CD8pos T-lymphocytes with a low expression of PD-1 molecule and high numbers of TREC were also increased. With the exception of elevated plasmablasts, no other differences were significant in PB. The expression levels of CXCL10, CXCL9 and CCL19 genes were significantly higher in PFAPA tonsils. The IGH/TCR pattern showed no clonal/oligoclonal expansion. DNA from the Epstein-Barr virus, Human Herpervirus-6 or adenovirus was detected in 7 of 10 PFAPA tonsils but also in 7 of 9 controls.

CONCLUSIONS

Our findings suggest that the uninhibited, polyclonal response of newly derived lymphocytes participate in the pathogenesis of PFAPA. Because most of the observed changes were restricted to tonsils and were not present in PB, they partly explain the therapeutic success of tonsillectomy in PFAPA syndrome.

IL-17C and its receptor IL-17RA/IL-17RE identify human oral epithelial cell as an inflammatory cell in recurrent aphthous ulcer

BACKGROUND

Recurrent aphthous ulcer (RAU) is an ulcerative disease of non-keratinized oral mucosa. Colon and bronchial epithelial cells produce interleukin-17C (IL-17C) upon stimulation of Toll-like receptor 2 (TLR2), TLR3 and TLR5, which are highly expressed in epithelial cells in RAU lesions. We therefore investigated the eventual presence and function of IL-17C in cultured human oral keratinocytes (HOK) and control biopsies compared to RAU lesions.

METHODS

Expression of IL-17A, IL-17C, IL-17RA and IL-17RE was analysed in cultured HOK cells using quantitative real-time polymerase chain reaction (qRT-PCR). HOK cells were stimulated with IL-17C and analysed for IL-8 and tumour necrosis factor-α (TNF-α) using qRT-PCR. Control mucosa (n = 5) was immunostained for IL-17A, IL-17C, IL-8, TNF-α and mast cell tryptase and compared with RAU lesions (n = 5) using the mean grey scale value.

RESULTS

IL-17C, but no IL-17A, mRNA was found in cultured HOK cells. Components of the heterodimeric IL-17RA/IL-17RE receptor for IL-17C were also highly expressed. Stimulation of HOK with IL-17C increased TNF-α mRNA (P = 0.03; IL-8 increase was not statistically significant). HOK in RAU lesions stained intensively for IL-17C compared to controls (P = 0.006). This was associated with increased epithelial immunostaining of TNF-α (P = 0.04) and IL-8 (P = 0.02). Most of the inflammatory cells which stained for IL-17A in control mucosa and RAU lesions were also mast cell tryptase positive.

CONCLUSION

IL-17C is highly expressed in epithelial cells in RAU lesions, where it seems to stimulate oral keratinocytes via IL-17RA/IL-17RE to produce pro-inflammatory cytokines. Human oral epithelial cells are probably important inflammatory cells in RAU.

CC chemokine ligand 3 and receptors 1 and 5 gene expression in recurrent aphthous stomatitis

OBJECTIVE

The aim of this study was to investigate the local and systemic expression of CC-chemokine ligand 3 (CCL3) and its receptors (CCR1 and CCR5) in tissue samples and peripheral blood mononuclear cells of recurrent aphthous stomatitis (RAS) patients.

STUDY DESIGN

This case-control study enrolled 29 patients presenting severe RAS manifestations and 20 non-RAS patients proportionally matched by sex and age. Total RNA was extracted from biopsy specimens and peripheral blood mononuclear cells for quatitative reverse-transcription polymerase chain reaction. The data obtained by relative quantification were evaluated by the 2(-ΔΔCt) method, normalized by the expression of an endogenous control, and analyzed by Student t test.

RESULTS

The results demonstrated overexpression in RAS tissue samples of all of the chemokines evaluated compared with healthy oral mucosa, whereas the blood samples showed only CCR1 overexpression in RAS patients.

CONCLUSIONS

These findings suggest that the increased expression of CCL3, CCR1, and CCR5 may influence the immune response in RAS by T(H)1 cytokine polarization.

Periodic fever, aphthous stomatitis, pharyngitis, and adenitis (PFAPA) syndrome and IgA nephropathy

BACKGROUND

A syndrome of periodic fever, aphthous stomatitis, pharyngitis, and adenitis (PFAPA), as well as immunoglobulin A nephropathy (IgAN), may be caused by autoimmune reactivity nephropathy.

CASE-DIAGNOSIS/TREATMENT

A 10-year-old boy presented with periodic fever, exudative tonsillitis, oral aphthous ulcer, and cervical lymph node inflammation. These conditions had occurred at intervals of about 2-6 weeks since the age of 3 years. Microscopic hematuria, first detected at age 8 years, worsened during episodes of PFAPA-related fever; since 10 years of age, the hematuria was accompanied by sustained proteinuria. Examination of a kidney biopsy specimen led to a diagnosis of IgAN. In the kidney specimen, fractalkine immunoreactivity and heavy macrophage infiltration were prominent. Multi-drug cocktail therapy improved the urinalysis findings, and subsequent tonsillectomy succeeded in controlling recurrences of PFAPA and IgAN. In a post-treatment renal biopsy specimen, mesangial proliferation was decreased, and fractalkine immunoreactivity was absent.

CONCLUSION

Immunologic reactions against certain antigens in local mucosa, including tonsils, may be impaired in PFAPA and IgAN, as evidenced by the suppression of both diseases in our patient by tonsillectomy. Accordingly, the concurrence of PFAPA and IgAN in our patient appeared to be a consequence of shared autoimmune mechanisms and systemic and local increases in cytokine concentrations, rather than coincidence.

HLA-A, B (Class I) and HLA-DR, DQ (Class II) antigens in Turkish patients with recurrent aphthous ulceration and Behçet's disease

OBJECTIVE

The aims of the present study were to typify the human leukocyte antigen system (HLA)-A, B (class I) and HLA-DR, DQ (class II) antigens and to assess the frequency of the presence of these antigens in the Turkish population with recurrent aphthous ulceration (RAU) and Behçet's disease (BD) compared to healthy subjects.

SUBJECTS AND METHODS

Thirty patients with RAU, 30 with BD, and 15 healthy subjects were included in the study. HLA typing was performed by serology with commercial kits for HLA class I and II (One Lambda, Canoga Park, Calif., USA).

RESULTS

The HLA-A23 frequency was 26.7% in the RAU patients, which was significantly higher than the 3.3% frequency in the patients with BD (p < 0.05). The HLA-A24 frequency was 33.3% in the RAU patient group, which was significantly higher (p < 0.05) than the frequency in the healthy subjects (6.7%). Significantly higher frequencies (46.7%) of HLA-A30 were found in the healthy subjects compared to the BD (13.3%) and RAU (3.3%) patients (p < 0.05 and p < 0.01, respectively). A higher frequency of HLA-B13 was observed in the RAU (23.3%) patients compared to the BD (0%) patients (p < 0.01). A decrease was observed in HLA-DR10 and HLA-DR17 in the RAU patients (p < 0.05), while a higher frequency of HLA-DR10 was observed in the BD patients compared to the RAU patients (p < 0.01).

CONCLUSIONS

These results showed that RAU and BD were not in the same spectrum and the involvement of other genetic and/or environmental factors might be responsible for the development of these diseases and/or disease progression.

[Effects of dihydromyricetin on tumor necrosis factor and NF-kappaB p65 of RAU rats]

OBJECTIVE

To study the effects of dihydromyricetin (DMY) on tumor necrosis factor (TNF-alpha) and NF-kappaB p65 cells of the recurrent aphthous ulcer (RAU) rat.

METHOD

Sixty of Sprague Dawley (SD) rats are randomly divided into 6 groups. The rat RAU models was established by injection of immunogen composed of the homogenate supernate of homogeneous oral mucosa from SD rats and Freund's complete adjuvant (FCA) into rat backs subcutaneously once every two weeks for 5 times, and the only FCA injected as normal control. DMY(50,100, 200 mg x kg(-1)) and licorzine (67.5 mg x kg(-1)) were given intragastrically once daily for 7 days on the day of the last immunogen injection, respectively. Water was given instead of drugs in normal and model control groups. The blood was got from the fundus oculi vein of rats on the day after last administration, the serum was separated. Then the rats were put to death with the cervical dislocation and decollated on the ice stage. Two sides of rat buccal mucosal tissue were cut. One side of them was put into 4% neutral formalin and another was added into 10 times of phosphate buffer to homogenize it homogenate. The oral mucosa ulcer occurrence of rats was observed by the histopathology. The content of TNF-alpha in serum and oral mucosa was assayed with ELISA; the expression of NF-kappaB cells was determined by the immunohistochemisty and macrophagus was determined by azure-feosin-dyeing in oral mucosa tissue. The expression of TNF-alpha mRNA in serum and oral mucosa was detected by reverse transcription polymerase chain reaction.

RESULT

In RAU rats, oral mucosa ulcer occurred, the content of TNF-alpha raised and the expression of TNF-alpha mRNA increased in serum and oral mucosa, the expression of positive NF-kappaB p65 cells and the amount of macrophages went up in oral mucosa. DMY and licorzine significantly reduced occurrence of oral mucosa ulcer in RAU rats, lowered content of TNF-alpha and the expression of TNF-alpha mRNA in serum and oral mucosa, reduced expression of positive NF-kappaB p65 cells and the amount of macrophages.

CONCLUSION

It is considered that DMY could inhibited occurrence of oral mucosa ulcer in RAU rats. One principle of it's effects could be that DMY controlled NF-kappaB p65 regulation on transcription and release of TNF-alpha mRNA in macrophages in oral mucosa ulcer tissue and lead to fall of TNF-alpha content in oral mucosa tissue causing role of anti-oral mucosa ulcer.

[Immunomorphology of recurrent aphthous stomatitis]

The immunohistochemical investigation of native epithelium and recurrent aphthous stomatitis has been carried out. The A, M, G Igs, CD3 fragment of the compliment, and CD16 lymphocytes in the zone of gidropic changes and necrosis of the oral mucosa were founded The distribution of Igs, CD3 fragment of the compliment and natural killers in the same zone - prickle laminated keratinizing epithelium could be signs of immunocomplex and T-cell-dependent mechanisms of ceracinocytes dies. The results of our research prove the theory of immunotoxicity priority in oral mucosa in cases of recurrent aphthosus stomatitis.

Skin prick test with self-saliva in patients with oral aphthoses: a diagnostic pathergy for Behcet's disease and recurrent aphthosis

There may be some difficulties to differentiate Behcet's disease (BD), recurrent aphthosis (RA), and herpetic aphthous ulceration, from other mimicking oral disorders. Despite of unexpected sensitivity and responsiveness, the skin pathergy test regarding a non specific hypersensitivity has long been thought as one of auxiliary diagnostic benefits for BD. To determine the potential usefulness and disease specificity of the prick reaction with saliva, a skin prick test with neat and filter-sterilized saliva was performed on the forearm skin of 26 individuals; 10 patients with BD (8 incomplete type without uveitis, 1 complete type, and 1 neurological type), 5 with RA, 3 with herpetic oral aphthosis, 2 with erythema nodosum alone, and 6 healthy controls. We assessed the skin reaction at 48 hours after pricking, and the pricked skin lesions were biopsied and analyzed immunohistologically. Nine of 10 BD patients (90 %) exhibited an indurative erythema at the skin site pricked with self-saliva, whereas 3 of 5 RA patients (60%) were relatively weak reaction. Pricking with filter-sterilized saliva failed to recapitulate any of positive skin reactions, albeit a faint erythematous dot appeared in a few BD patients, implicating the involvement of causative microorganism(s) in oral bacterial flora. Culture of saliva from 3 randomly chosen BD patients revealed numerous streptococcal colonies on Mitis-Salivarius agar. Histology of the pricked skin sites showed perivascular inflammatory infiltrates, composed of CD4+ T cells and CD68+ monocyte/macrophage lineage, a feature consistent with a delayed type hypersensitive reaction. Our results suggested that skin prick test using self-saliva (a new diagnostic pathergy) can be a simple and valuable in vivo diagnostic approach for differentiating BD and RA from other mimicking mucocutaneous diseases. The positive skin prick may be triggered by resident intra-oral microflora, particularly streptococci, and may in part address the underlying immunopathology in BD.

Evaluating and comparing phagocytic functions of salivary and blood neutrophils in patients with recurrent aphthous ulcers and controls

OBJECTIVE

To assess the possible role of neutrophils in the pathogenesis of recurrent aphthous ulceration (RAU) by evaluating and comparing the phagocytic functions of salivary and peripheral blood neutrophils in patients with recurrent aphthous ulcers and in healthy subjects.

METHOD AND MATERIALS

The study comprised 30 RAU and 30 healthy subjects. Neutrophils were separated from the unstimulated saliva and peripheral blood of RAU patients and healthy subjects. Then, the phagocytic activity and ingestion ability were determined using Candida as targets.

RESULTS

Salivary and peripheral blood neutrophils in RAU patients showed significant reduction (P < .05) in phagocytic activity as compared to controls. The ingestion ability of salivary and blood neutrophils was reduced in RAU patients, but not significantly as compared to controls. The ingestion ability of salivary neutrophils was significantly reduced (P = .019) in comparison to blood neutrophils in RAU patients. There was no significant difference between the phagocytic activities of salivary and blood neutrophils in RAU.

CONCLUSION

Phagocytic functions of salivary and peripheral blood neutrophils were reduced in RAU patients as compared to healthy subjects. The ingestion ability of salivary neutrophils was also decreased with that of peripheral blood neutrophils in RAU patients. All the above findings revealed that RAU is characterized by consistent changes in salivary and peripheral blood neutrophil functions, thus suggesting that the pathophysiology of RAU may be associated with reduction in phagocytic functions of neutrophils.

Elevated immunoglobulin D levels in children with PFAPA syndrome

BACKGROUND

The periodic fever, aphthous stomatitis, pharyngitis and cervical adenitis (PFAPA) syndrome appears to be more common than generally appreciated and should be differentiated from hereditary periodic fever syndromes, particularly from mevalonate kinase deficiency (MKD).

PATIENTS AND METHODS

14 unrelated patients (7 males, 7 females) met clinical criteria for both the PFAPA syndrome and MKD. Immunoglobulin D (IgD) levels, mevalonic aciduria and mevalonate kinase (MVK) genotype was determined in all patients.

RESULTS

Children experienced their first febrile episode at the age of 24.5±5.9 months (mean±SD), the clinical diagnosis of PFAPA syndrome was established with delay at 42.7±11.7 months. The duration of febrile episodes was 3.4±0.2 days, the asymptomatic interval between them lasted 5.4±0.9 weeks. Accompanying symptoms included pharyngitis (92.8%), cervical lymphadenitis (85.7%), aphthous stomatitis (21.4%), arthralgia (14.3%) and skin erythema (35.7%). Neither mevalonic aciduria nor MVK gene mutations were found in any of the subjects, however, unexpectedly, increased plasma IgD (322.2±29.2 U/l) levels were detected in all patients.

CONCLUSION

Raised IgD levels may represent a non-specific epiphenomenon, which frequently accompanies PFAPA syndrome as well as MKD. Because of the overlapping clinical and laboratory features, genetic testing of the MVK gene is indicated to differentiate these two conditions, if clinical criteria for both are fulfilled.

[Effect of shuizhongcao granule on cellular immune function of experimental animal with recurrent aphthous stomatitis]

OBJECTIVE

To investigate the effect of Shuizhongcao Granule (SZCG) on cellular immune function in animal model of recurrent aphthous stomatitis (RAS).

METHODS

Experimental animal model of RAS were established by immunological method. The modeled animals were randomized into 4 groups, Group A was the model control group, Group B was treated by Levamisole (2.5 mg/mL), Group C and D was treated with high-dose (0.5 g/mL) and low-dose (0.24 g/mL) SZCG respectively. The medication was administered via gastric perfusion, starting from the 7th week of the experiment, and continued for 28 days. Meanwhile, a normal control group was set up. Percentage of T-lymphocyte subsets, CD3, CD4 and CD8, and serum levels of interleukin 10 and 12 (IL-10 and IL-12) in peripheral blood were detected before and after treatment.

RESULTS

Percentages of CD3, CD4 and CD4/CD8 ratio in the model control group were 40.50 +/- 7.46%, 30.80 +/- 5.33% and 79.56 +/- 8.32 respectively, all lower than those in the normal control group (P<0.05); level of serum IL-10 was higher (8.02 +/- 0.53 ng/L) and that of IL-12 was lower (15.51 +/- 1.35 ng/L) in the model animal than those in normal control (P<0.05). After treatment, levels of CD3, CD4, CD4/CD8 and IL-12 in Group B were 55.30 +/- 6.33%, 43.50 +/- 5.33%, 99.29 +/- 13.84 and 17.72 +/- 1.70 ng/L, those in Group C were 61.50 +/- 4.32%, 47.20 +/- 4.37%, 103.30 +/- 7.42 and 18.18 +/- 1.54 ng/L, and in Group D were 58.50 +/- 6.03%, 42.80 +/- 3.17%, 110.27 +/- 12.85 and 17.74 +/- 1.96 ng/L, respectively, all were higher than those in Group A, but levels of IL-10 in the three treatment groups were lower than that in Goup A (P<0.05 or P<0.01).

CONCLUSION

The immune function of RAS model animals is in the suppressed condition; SZCG can improve the immune suppression to achieve its therapeutic effect on the disease.

Secretory A immunoglobulin, total proteins and salivary flow in Recurrent Aphthous Ulceration

Clinical and experimental study. Introduction. Of debatable etiology, Recurrent Aphthous Ulcerations (R.A.U), is most of the time considered an immunological deficiency. Aim: The aim of this paper is to review the literature and clinical investigations regarding IgA-s, total proteins salivary concentration and basal salivary flow of patients with R.A.U. during activity and quiescence. Methodology. Nephelometry was used to measure salivary IgA-s; Pyrogallol red was used for total salivary proteins and the gravimetrical analysis for salivary flow measurement. Results. Results demonstrated a significant increase in salivary IgA-s in active lesions in relation to quiescence. On the other hand, protein concentration rates were similar in both periods. Conclusion. Salivary IgA-s can be used as a parameter to study the immune status of the oral mucosa.

[Immunological aspects of aphthous stomatitis]

The purpose of the present work was to study the role of cellular and humoral immunity in patients with aphthous stomatitis. The research was conducted at Tbilisi Hospital for War Veterans. Immunologic parameters of 61 patients aged from 15 to 60 years old were analyzed. The statistical data processing included calculation of average arithmetic values and their standard deviations. Parameters of the immune status of the patients during exacerbation and under treatment were investigated. It was revealed that during exacerbation of stomatitis the quantity of CD3, CD4, cytophagous activity, and NK were diminished. Indices of CD8, CD72, and IgA, were within the norm. Indices of IgM, IgG, IgE, parameter of IL-6, antimicrobial and antitoxic antibody titer were increased. After treatment increase and approach to standard CD3, CD4, NK, and parameters of phagocytosis. IgG, IgM and antitoxic antibody titer decrease and approach to standard. During exacerbation of recurrent aphthous stomatitis the immune status of the human decrease, this is restored after treatment.

Detection, Enumeration and Characterization of T Helper Cells Secreting Type 1 and Type 2 Cytokines in Patients with Recurrent Aphthous Stomatitis

One of the factors involved in the pathogenesis of recurrent aphthous stomatitis (RAS) is a cell-mediated immune response in which several cytokines seem to play a major role. The aim of this study was to detect, enumerate and characterize T helper cells which are secreting type 1 cytokines (interleukin [IL]-2, IL-12, interferon [IFN]-gamma, and tumor necrosis factor [TNF]-alpha) and type 2 cytokines (IL-4, IL-5, IL-6, and IL-10) in the peripheral blood of patients with RAS. Thirty-two patients in the active phase of RAS (14 men and 18 women) and 40 healthy individuals participated in the study. T helper (T) cells were detected and characterized using Elispot assay. T cells secreting IL-2, IL-12 or IFN-gamma were increased in patients with RAS compared with the controls (p < 0.05, p < 0.001 and p < 0.001, respectively). T cells secreting TNF-alpha in RAS patients and controls were not statistically different (p > 0.05). T cells secreting IL-10 were increased in patients with RAS compared with the controls (p < 0.05). T cells secreting IL-4 were decreased in patients with RAS compared with the controls (p < 0.001), No statistical difference was observed between T cells secreting IL-5 or IL-6 in patients with RAS and controls. Our findings suggest that the increased numbers of T cells secreting type 1 cytokines may influence the immune response against RAS. Whether this action is of etiological importance or epigenetic phenomenon is a question that needs to be answered.

Frequency and prognostic value of IgA and IgG endomysial antibodies in recurrent aphthous stomatitis

Recurrent aphthous stomatitis is a common disease of the oral mucous membranes. Currently a hypothesis is being discussed that it might be pathogenetically related to coeliac disease. We evaluated the frequency of coeliac disease anti-endomysial (or anti-transglutaminase) antibodies in patients with recurrent aphthous stomatitis. Blood samples from 42 patients were evaluated and 2/42 (4.7%) were IgA- and IgG-endomysial antibody-positive. None of the 42 persons in the control group had antibodies, which was not statistically different from the patient group. The two antibody-positive patients had episodes of mild gastrointestinal symptoms only, but histopathology of duodenal mucous membranes confirmed coeliac disease. All symptoms related to aphthous stomatitis responded well to a gluten-free diet. We conclude that every patient with recurrent aphthous stomatitis should be asked about a history of gastrointestinal complaints and screened for markers of coeliac disease, since recurrent aphthous stomatitis may in some cases respond to a gluten-free diet.

Mucosal disease series. Number VI. Recurrent aphthous stomatitis

Recurrent aphthous stomatitis (RAS; aphthae; canker sores) is a common condition which is characterized by multiple recurrent small, round or ovoid ulcers with circumscribed margins, erythematous haloes, and yellow or grey floors typically presenting first in childhood or adolescence. RAS occurs worldwide although it appears most common in the developed world. The aetiology of RAS is not entirely clear. Despite many studies trying to identify a causal microorganism, RAS does not appear to be infectious. A genetic predisposition is present, as shown by strong associations with genotypes of IL-1beta; IL-6 in RAS patients, and a positive family history in about one-third of patients with RAS. Haematinic deficiency is found in up to 20% of patients. Cessation of smoking may precipitate or exacerbate RAS in some cases. Ulcers similar to RAS may be seen in human immunodeficiency virus disease and some other immune defects, and drugs, especially non-steroidal anti-inflammatory drugs and nicorandil may produce lesions clinically similar to RAS. Topical corticosteroids can often control RAS. However, the treatment of RAS remains unsatisfactory, as most therapies only reduce the severity of the ulceration and do not stop recurrence.

Serum autoantibodies to desmogleins 1 and 3 in patients with oral lichen planus

AIM

To determine the presence of circulating autoantibodies to desmoglein (Dsg) 1 and Dsg 3 in patients with oral lichen planus.

METHODS

Serum concentrations of circulating autoantibodies to Dsg 1 and Dsg 3 were determined by ELISA in 32 patients with erosive form and 25 patients with reticular form of oral lichen planus, 13 patients with acute recurrent aphthous ulcerations and 50 healthy controls. Indirect immunofluorescence analysis was also performed.

RESULTS

Concentrations of circulating autoantibodies to both Dsg 1 and Dsg 3 detected in the sera of patients with erosive form of oral lichen planus were significantly increased in comparison with those in healthy controls, patients with recurrent aphthous ulceration, and those with reticular oral lichen planus (P<0.001 for both anti-Dsg autoantibodies). Indirect immunofluorescence also revealed significantly more positive findings in patients with erosive oral lichen planus (18 positive of 22 tested) than in healthy controls (1 positive of 20 tested; P<0.001), patients with recurrent aphthous ulceration (1 positive of 10 tested; P<0.001), and those with reticular oral lichen planus (3 positive of 15 tested; P<0.001).

CONCLUSION

Humoral autoimmunity seems to be involved in the pathogenesis of oral lichen planus. The differences in the serum concentration of desmoglein autoantibodies suggested that pathological mechanisms in erosive and reticular forms of oral lichen planus might not be the same.

AIDS and Recurrent Aphthous Stomatitis

The immunodeficiency state in HIV infected patients has been the cause of severe episodes of Recurrent Aphthous Stomatitis (RAS). Aim: Our study aims to establish correlation between the manifestations of RAS and the immunosuppression state caused by HIV infection, through counting of CD4+ cells, CD8+ cells, CD4+:CD8+ cells ratio and viral load. Study design: series study. Material and Method: Ninety-four HIV infected patients (25 women and 69 men) with RAS were evaluated in the ENT Department of the University of Sao Paulo-Medical School from January 1998 to December 2003. The age ranged between 19 and 63 years (mean = 35.3 years). The patients were divided in two groups: AIDS group and HIV infected group. Results: The patients with AIDS and HIV infection presented, respectively, eight ulcers and two ulcers by outbreaks. Similarly, patients with major RAS presented smaller counting of cells CD8+, CD4+ and CD4+/CD8+ cells, and higher mean value of viral load than the patients with herpetiform and minor RAS. Between patients with minor and herpetiform RAS there were no statistical differences. Conclusions: The emergence of the lesions, mainly in major RAS, is directly related to the immunological state of the HIV infected patient. These patients frequently present nutritional deficits and worsening in life style. Thus, diagnosis and treatment of RAS is a challenge that should not be neglected.

Comparison of Behcet's disease and recurrent aphthous ulcer according to characteristics of gastrointestinal symptoms

Behcet's disease (BD) is a multisystemic chronic inflammatory disease. It is characterized by recurrent oral and genital ulcers, uveitis, skin lesions and other manifestations, including neurologic, vascular, joint, and gastrointestinal ulcers of variable severity. Recurrent aphthous ulcer (RAU) represents a very common, but poorly understood, mucosal disorder. If a patient of RAU without any other typical symptoms of BD has gastrointestinal symptoms, it is difficult to distinguish this RAU from true BD with gastrointestinal involvement. Because pathognomonic clinical features and tools are absent, the differential diagnosis of these two diseases relies on the characteristic clinical features and the judgement of an experienced physician. Sixty-five out of a total 960 RAU patients and forty-four of 556 BD patients with gastrointestinal symptoms between January 1996 and December 2003 participated in this study. All were evaluated with esophagogastroduodenoscopy and colonoscopy. Clinical, endoscopic and histopathologic findings were analyzed and ELISA tests were conducted to detect serum levels of ASCA and pANCA. No significant difference was found between the two groups. Differential diagnosis between RAU with gastrointestinal symptoms and BD with gastrointestinal involvement requires further prospective, large-scale study.

"Tien-Hsien liquid" can modulate antigen-stimulated cytokine production by T-cells isolated from patients with recurrent aphthous ulcerations

Recurrent aphthous ulcerations (RAU) represent a common oral mucosal disease with altered humoral and cellular immunities. Tien-Hsien liquid (THL) is an extract of Chinese medicinal herbs with immunomodulating effects. Our previous study found that THL can modulate the antigen-stimulated proliferative response of peripheral blood mononuclear cells and T-cells isolated from RAU patients. In this study, we further tested whether THL can modulate the antigen-stimulated cytokine production by T-cells isolated from RAU patients. To achieve this goal, T-cells isolated from 19 RAU patients were incubated with phytohemagglutinin (PHA), glutaraldehyde-inactivated tetanus toxoid (TT), glucosyltransferase D (GtfD), or antigens of Streptococcus mutans in the presence or absence of THL. The levels of interleukin (IL)-2, interferon-gamma (IFN-gamma), tumor necrosis factor-alpha (TNF-alpha), IL-6, or IL-10 in the supernatants of T-cell cultures were measured by cytokine enzyme-linked immunosorbent assay (ELISA) kits. We found that THL significantly increased the PHA- or TT-stimulated TNF-alpha, IL-6, and IL-10 production by T-cells isolated from RAU patients. However, THL could also significantly decrease the TT-stimulated IL-2 production, the GtfD-stimulated IL-2, TNF-alpha, IL-6 and IL-10 production, and the S. mutans-stimulated IFN-gamma, TNF-alpha, and IL-10 production by T-cells isolated from RAU patients. These results indicate that THL can modulate the antigen-stimulated cytokine production by T-cells isolated from RAU patients. Because RAU is probably a Thl-mediated disease with elevated levels of IL-2, IFN-gamma, TNF-alpha and IL-6 in either the patient's sera or oral lesions and these increased levels of cytokines can be reduced by THL, we suggest that THL may be a potential immunoceutical agent for treatment of RAU.

Pemphigus mimicking aphthous stomatitis

BACKGROUND

The aim of this report is to highlight the case that pemphigus vulgaris (PV) may mimic aphthous stomatitis. Pemphigus classically causes persistent oral ulceration.

METHODS AND RESULTS

We report five patients from southern Europe, who presented with recurrent oral ulceration mimicking aphthous stomatitis, but who proved by histology, immunostaining and antibodies against epithelial intercellular substance to have PV.

CONCLUSION

It is advisable to assay antibodies against desmoglein 3 in patients who appear to suffer recurrent aphthous stomatitis (RAS) with atypical ulceration for location and in adulthood.

Predominance of Type 1 cytokines and decreased number of CD4CD25 T regulatory cells in peripheral blood of patients with recurrent aphthous ulcerations

Recurrent aphthous ulcerations (RAU) are a chronic inflammatory disease with evidence of inappropriate immune response. Previous studies have suggested cell-mediated activation of immune response towards common micro-organisms of oral cavity in RAU. In this investigation, we explored cytokine production by peripheral blood mononuclear cells (PBMC) and T regulatory cell population in blood of active and remission RAU patients as crucial factors for maintenance of peripheral tolerance. Ten patients with minor RAU and 12 healthy individuals were selected for the study. Cytokine levels were analysed in supernatants using Cytometric Bead Array Kit for flow cytometry and ELISA. We have demonstrated increased production of Type 1 cytokines IL-2, IFN-gamma and TNF-alpha as well as IL-5, IL-6 and IL-8 by peripheral blood mononuclear cells in RAU. In contrast, IL-10 and TGF-beta anti-inflammatory cytokine production was decreased in RAU patients compared to healthy individuals. Moreover, we have found that CD4(+)CD25(+high) T regulatory cell proportion was decreased in RAU and represented 3.58+/-0.654% of CD4(+) T cells in active RAU, 4.66+/-0.561% of CD4(+) T cells in remission RAU, whereas in healthy controls CD4(+)CD25(+high) T cells represented 7.30+/-1.238% of CD4(+) T cells (p<0.001). Thus, the obtained results indicate that disproportion in cytokine production may be contributing factor in the pathogenesis of RAU. Alteration in the number of CD4(+)CD25(+high) T regulatory cells in RAU may additionally influence the development of the disease. We propose that imbalance in pro- and anti-inflammatory cytokine network may lead to the breakdown of peripheral tolerance in RAU and the excessive immune response towards harmless micro-organisms colonized oral mucosa or self-antigens.

Outcome following treatment for Helicobacter pylori in patients with recurrent aphthous stomatitis

OBJECTIVE

The aim of the current study was to investigate any association of Helicobacter Pylori (HP) in recurrent aphthous stomatitis (RAS) and the effect of eradication of the microorganism in the clinical course of the disease.

STUDY DESIGN

Forty-eight patients with RAS were included in the study. Twenty-six were women and 22 men, of average age 41.3 +/- 2.44. Thirty-four out of these 48 patients were HP positive and the rest 14 who were negative were used as a control group. The diagnosis of HP infection was based on the detection of specific immunoglobulin G (IgG), and immunoglubulin A (IgA) antibodies using the enzyme-linked immunoabsorbent assay technique in the serum and the saliva of the patients. In all HP carriers an eradication therapy was administered. After a 2-month period the patients were checked for HP status, using 13C-UBT. The follow up period was 6-12 months following the eradication therapy.

RESULTS

At entry patients with HP infection suffered from more severe symptoms compared with HP negative patients (P < 0.05). After the administration of HP eradication therapy, patients who had become negative showed a remarkable improvement (62.5%) with reference to recurrence of RAS as well as to symptom intensity. In 29.2% of patients symptoms had disappeared and in 33.3% of patients there was a decrease in both the frequency of recurrence and the intensity of symptoms. After the eradication treatment, the periods between recurrence of RAS in patients who had become negative were statistically significantly longer compared with those before treatment (P < 0.001). Another important observation was that patients who became negative after eradication therapy were of comparable clinical status with those who were HP negative from the beginning of the study (P > 0.05).

CONCLUSIONS

These findings support the concept of a potential association between RAS and HP.

Aphthous ulcers associated with imiquimod and the treatment of actinic cheilitis

Our case series report is the first documented depiction of the appearance of aphthous ulcers secondary to imiquimod application. This case series presentation discusses the underlying pathophysiology of aphthous ulcer development and imiquimod therapy in terms of the stimulation of proinflammatory cytokines, such as tumor necrosis factor alpha (TNF-alpha). The literature review suggests more than just a mere coincidence for the development of aphthous ulcers subsequent to the treatment of actinic cheilitis with imiquimod application.

Immunomodulating effects of "tien-hsien liquid" on peripheral blood mononuclear cells and T-lymphocytes from patients with recurrent aphthous ulcerations

Recurrent aphthous ulcerations (RAU) represent a common oral mucosal disease with altered humoral and cellular immunities. In our institution, an immunomodulating agent, levamisole, is used to treat RAU with satisfactory therapeutic effect. Tien-Hsien liquid (THL) is an extract of Chinese medicinal herbs with immunomodulating effects. To test whether THL has immunomodulating effects on antigen-stimulated proliferation response (PR) of peripheral blood mononuclear cells (PBMC) and T-cells isolated from RAU patients and to test whether THL is a potential drug for treating RAU, PBMC or T-cells isolated from RAU patients were incubated with lipopolysaccharides (LPS) from Escherica coli, phytohemagglutinin (PHA), staphylococcal enterotoxin B (SEB), glutaraldehyde-inactivated tetanus toxoid (TT), glucosyltransferase D (GtfD), or antigens of Streptococcus mutans in the presence or absence of THL. We found that THL significantly increased the LPS-stimulated PR of PBMC from active RAU patients, the GtfD-stimulated PR of PBMC and of T-cells from inactive RAU patients, and the S. mutans-stimulated PR of PBMC from inactive RAU patients. However, THL could also significantly reduce the SEB-stimulated PR of PBMC and of T-cells from active RAU patients and S. mutans-stimulated PR of T-cells from active RAU patients. These results suggest that THL can modulate the antigen-stimulated PR of PBMC and T-cells from RAU patients. Therefore, it may be a potential immunoceutical agent for treatment of RAU.

Low frequency of anti-endomysial antibodies in recurrent aphthous stomatitis

INTRODUCTION

The aetiology of recurrent aphthous stomatitis (RAS) remains unknown. An association between RAS and coeliac diseases (CD) has previously been suggested, but the supporting evidence remains equivocal. The aim of the present study was to determine the likely frequency of CD in a large cohort of patients with well-defined RAS, by detailed haematological and serological analysis, including the detection of anti-endomysium and anti-reticulin antibodies.

MATERIALS AND METHODS

The study comprised 87 patients with minor RAS. Full blood counts and the presence of IgA anti-endomysial and IgA anti-reticulin antibodies were estimated in all patients.

RESULTS

The frequency of anti-endomysium and anti-reticulin antibodies was not elevated in patients with RAS and no patients with RAS had other serological features of CD.

CONCLUSIONS

It is concluded that there is little significant aetiological link between RAS and CD, and that screening RAS patients for key serological markers of CD is of little clinical value.

The Th1 /Th2 immune-type response of the recurrent aphthous ulceration analyzed by cDNA microarray

BACKGROUND

The reduced ability to activate oral tolerance plays a role in the pathogenesis of some gastrointestinal inflammatory diseases. This activation may reflect a preferential reduction of a T-helper (Th)2- or Th3-type response. In recurrent aphthous ulceration (RAU), genetic and environmental factors may contribute to low tolerance, permitting a cytotoxic reaction against the oral epithelium. The cytokine profile has not permitted the definition of RAU as resulting from enhanced Th1 or Th2 responses. A cDNA microarray study would allow the identification of differentially expressed genes and provide a basis for classification of the immune response.

METHODS

The cDNA from 29 samples of aphthae and from 11 samples of normal mucosa from aphthae-free volunteers were hybridized on microarray membranes with 1176 genes.

RESULTS

Forty-one differentially expressed genes were identified, and a higher expression level of the Th1 gene cluster in RAU was found.

CONCLUSIONS

Microarrays permitted us definition of the gene expression profile of the lesion and identify an increased Th1 activity in RAU lesions.

Polymorphisms in the IL-10 and IL-12 gene cluster and risk of developing recurrent aphthous stomatitis

BACKGROUND

Recurrent aphthous stomatitis (RAS) is a common, painful, ulcerative condition of the mouth. Although there is no clear genetic mode of inheritance, there is evidence that inheritance of specific gene polymorphisms may predispose individuals to RAS. AlsoTh1 cell mediated immune responses under the control of IL-10/IL-12 are thought to play an important role in its pathogenesis.

OBJECTIVE

The objective of this study was to investigate the possibility that susceptibility to RAS is associated with the inheritance of specific gene polymorphisms for the T cell regulatory cytokines interleukin-10 (IL-10) and interleukin-12 (IL-12).

PATIENTS AND METHODS

One hundred RAS patients and 91 ethnically matched controls were genotyped for the IL-10-592, and -1082 polymorphisms, and the IL-12 1188 polymorphism. Chi-square analysis was used to compare the allele frequencies and genotypes of cases and controls.

RESULTS

No significant association was identified between inheritance of specific alleles or genotypes of the IL-10-592 and -1082 polymorphisms or IL-12 1188 polymorphism and susceptibility to RAS.

CONCLUSIONS

We were unable to demonstrate an association between the inheritance of specific IL-10 or IL-12 gene polymorphisms and RAS susceptibility.

Herpes simplex and aphthous ulcerations: presentation, diagnosis and management--an update

The most common pathologic alterations seen by dentists are oral mucosal ulcerations, particularly those related to the herpes simplex virus and those produced by the autoimmune phenomenon known as recurrent aphthous stomatitis. Because the general frequency and clinical similarity of these conditions often make it difficult to distinguish one from the other, therapeutic intervention may be inappropriate. An improved understanding of the virologic and local immunologic alterations within the oral mucosa has led to a better understanding of these conditions and to the development of improved treatment strategies within the general practice setting for a significant number of otherwise healthy patients.

Innate immune system is implicated in recurrent aphthous ulcer pathogenesis

BACKGROUND

Recurrent aphthous ulcers (RAU) is a chronic inflammatory disease with evidence of inappropriate immune response. This study presents the status of innate immune system in RAU.

METHODS

Twenty RAU patients and 19 healthy individuals were selected. The status of peripheral blood neutrophils (reactive oxygen intermediates (ROI) production, CD11b, TNF-RI and TNF-RII expression), concentration of antioxidants, sTNF-R, C3c, C4 and haemolytic activity of the complement system, as well as mannose-binding lectin (MBL), in the serum of RAU patients in active stage and in remission of the disease were determined.

RESULTS

Peripheral blood neutrophils were primed in RAU, which resulted in increased ROI production by resting and fMLP-stimulated neutrophils and diminished ROI production after in vitro priming. The increased expression of CD11b on resting and fMLP-stimulated neutrophils in RAU may also point to their previous in vivo stimulation. The decreased total antioxidant status of serum observed in RAU may be a result of increased ROI production by peripheral blood neutrophils. The levels of C3c, C4 and haemolytic activity of the complement system were higher in RAU than in healthy people. No significant differences between active and remission RAU were noted.

CONCLUSION

Presented observations confirm that the innate immune system is involved in RAU pathogenesis.

Serum Levels of IL-4, IL-10, IL-12, IL-13 and IFN-gamma in Behçet's disease

Behçet's disease (BD) is an inflammatory disease of unknown etiology. Although its pathogenesis is not fully understood, recent studies have suggested that immunological abnormalities and neutrophil hyperfunction may be involved in its etiology and pathophysiology. The immune system in BD can be characterized as a divergent cytokine production profile of the mixed Th1/Th2 cell type. In this study, we investigated the levels of interleukin (IL)-4, IL-10, IL-12, IL-13 and interferon-g in the sera of patients with BD, in comparison with recurrent aphthous stomatitis and healthy controls, to determine the Th1/Th2 profile of the disease. The levels of IL-4, IL-10 and IL-13 were found to be high in active BD patients, and IL-12 and interferon-gamma levels were lower in active BD patients than in inactive BD, recurrent aphthous stomatitis, and control patients.

Results of double-blind placebo-controlled challenge with nickel salts in patients affected by recurrent aphthous stomatitis

BACKGROUND

The aetiology of recurrent aphthous stomatitis (RAS) has so far not been completely clarified. Recently, several studies reported that patients affected by cutaneous diseases (i.e. dermatitis, eczema and urticaria) with positive patch test to nickel have a positive oral nickel challenge.

OBJECTIVE

A retrospective data analysis of patch test and oral nickel challenge in 380 patients (204 women and 176 men) affected by RAS was performed.

PATIENTS AND METHODS

We examined 380 consecutive patients affected by RAS during the period 1990-1999. In 28/380 patients the appearance of their oral symptoms coincided with the fitting of orthodontic appliance, while 352/380 reported that their oral symptoms worsened after the fitting of orthodontic appliance. All patients were studied with the series (European standard series and series for dental materials) for patch tests.

RESULTS

Seventy out of 380 patients (18.4%) presented a contact sensitization to nickel sulphate (positive patch test). In all of these, the orthodontic appliance was replaced with one made of nickel-free materials. All patients were re-examined by the dentist 6 months after the removal of the orthodontic appliance. The symptoms had completely remitted in 28/70 patients, partially had improved in 31/70 patients and had remained unchanged in 11/70 patients. In all patients (n = 70) with a positive patch test to nickel we performed an oral double-blind placebo-controlled challenge (DBPC) test with nickel sulphate. The DBPC was positive in 32/70 patients, 21 of whom had partially improved and 11 had not, even after the replacement of the orthodontic appliance with material not containing nickel. None of the 28 patients in complete remission showed an adverse reaction to oral nickel challenge.

CONCLUSION

The results of this study demonstrate that, in some patients with a positive patch test to nickel sulphate, the perpetuation of RAS can be related to a hypersensitivity to ingested nickel salts, independently of local contact to nickel.

[Role of total IgE in unspecified burning oral symptoms. Serum and salivary comparative levels in a case-control study]

BACKGROUND

Oral burning symptom is often taken into account in Oral Medicine for its high prevalence and respective management problems. The clinical evidence that exclusion from the diet of some foods, considered potentially allergenic, would relieve this symptom represented the rationale of the present study. So, the main aim was to investigate the role of the IgE-mediated pathogenesis in patients with unspecified oral burning symptoms and positivity to the challenge with some foods.

METHODS

Comparative levels of total serum and salivary IgE were investigated in 97 patients referred to the Sector of Oral Medicine (University of Palermo), of whom 50/97 as a Test group, symptomatic for burning complaint and affected by burning mouth syndrome (BMS), oral lichen planus (OLP) and recurrent aphtous stomatitis (RAS) and 47/97 as Control group, non-symptomatic, matched for gender, age-decade group and affected with different oral mucosal lesions.

RESULTS

In the Test group, the following results were found: total average values for serum IgE of 71.5 (SD+/-100.3; range 4-424) and for salivary IgE of 8.7 (SD+/-30.4; with range 0-218). In the Control group total average values for serum IgE were 85.8 (SD+/-210.7; range 5-1390) and for salivary IgE 20.6 (SD+/-66.6; range 2-408). Statistical evaluation of serum and salivary total IgE levels did not find any significant difference in the Test group vs controls (p>0.2) with respect to gender, age-decade or different type of oral disease with burning symptoms. Of note, in the Test group a positive correlation was found between serum IgE levels and salivary total IgE.

CONCLUSIONS

On the basis of our results, no evidence of IgE-mediated allergic process can be suggested in such a generic oral burning symptom, even after a positive challenge for selective diet.

Levamisole and Chinese medicinal herbs can modulate the serum interleukin-6 level in patients with recurrent aphthous ulcerations

BACKGROUND

Recurrent aphthous ulcerations (RAU) are common oral inflammatory lesions. Interleukin-6 (IL-6) is a pro-inflammatory cytokine that has effects on cellular and humoral immunities. Previous studies have shown that the high serum IL-6 levels in some RAU patients can be reduced by drug treatment. This finding suggests that IL-6 may be a useful marker in evaluating therapeutic effects of RAU.

METHODS

In this study, we used a solid phase, two-site sequential chemiluminescent immunometric assay to determine the baseline serum levels of IL-6 in a group of 228 patients with RAU, erythema multiforme (EM), traumatic ulcers (TU), oral submucous fibrosis (OSF), pemphigus vulgaris (PV), or Sjögren's syndrome (SS), and in 77 normal control subjects. Some RAU patients were treated with levamisole plus Chinese medicinal herbs or levamisole only for 0.5-5 months and their serum IL-6 levels were measured after treatment.

RESULTS

We found that about 99% of the normal control subjects and the patients with EM, TU, or OSF had a serum IL-6 level within the normal limit of 5.0 pg/ml. However, 24% (48/197) RAU patients, 14% (1/7) EM patients, 43% (3/7) PV patients, and 100% (6/6) SS patients had a serum level of IL-6 greater than 5.0 pg/ml. The mean serum level of IL-6 in patients with RAU (3.6 +/- 3.5 pg/ml, P < 0.001), minor type RAU (2.7 +/- 2.0 pg/ml, P < 0.05), major type RAU (5.2 +/- 4.6 pg/ml, P < 0.001), or herpetiform type RAU (4.1 +/- 3.8 pg/ml, P < 0.01) was higher than that in normal control subjects. The mean serum level of IL-6 in major type (P < 0.001) or in herpetiform type RAU patients (P < 0.05) was higher than that in minor type RAU patients. The mean reduction of serum IL-6 level (10.0 +/- 7.1 pg/ml) in RAU patients after treatment with levamisole plus Chinese medicinal herbs was significantly higher than that (5.1 +/- 3.7 pg/ml) in RAU patients after treatment with levamisole only (P < 0.005), suggesting that the combination therapy is superior to the single therapy of levamisole only.

CONCLUSION

We conclude that levamisole and levamisole plus Chinese medicinal herbs can modulate the serum IL-6 level in RAU patients. Although the therapeutic effect of RAU can be assessed by a decrease in the frequency, duration and number of the oral ulcerations, it can also be monitored by a reduction of serum IL-6 level in RAU patients.