The effect of sodium lauryl sulfate on recurrent aphthous stomatitis
Recurrent aphthous stomatitis (RAS) is a common and painful disease of the oral mucosa. Patients with RAS must practice good oral hygiene, including twice daily toothbrushing. However, most dentifrices contain sodium lauryl sulfate (SLS), a foaming agent that is also a well-documented skin and mucosal irritant. The objective of this systematic review was to compare the effects of SLS-containing dentifrices with those of SLS-free dentifrices in patients with RAS. The results were published in the May 2019 issue of Journal of Oral Pathology & Medicine.Two of the authors independently searched the PubMed, Cochrane, PsycINFO, and OpenGrey electronic databases for double-blinded, randomized controlled trials pertaining to RAS and SLS. The authors also independently evaluated the risk of bias in the included studies using an adapted Cochrane risk of bias assessment tool.
The searches identified a total of 6,518 studies. After removing duplicates, the reviewers screened the titles and abstracts of 3,824 articles. Of these studies, all but 4 were excluded because they did not meet the inclusion criteria. Thus, 4 studies with a total of 124 participants met the eligibility requirements for the systematic review.
Of the 4 randomized crossover trials, 3 included 2 treatments in 2 phases (2T2P) and 1 included 3 treatments in 3 phases. Two of the 2T2P studies compared an SLS-free dentifrice with an SLS-containing dentifrice, while the third 2T2P study compared an SLS-free dentifrice with 1 of 2 SLS-containing dentifrices (that differed in ingredients other than SLS). The 3 treatments in 3 phases study compared 1 dentifrice with no detergent, 1 SLS-containing dentifrice, and 1 dentifrice that contained cocamidopropyl betaine.
The systematic review revealed that use of an SLS-free dentifrice resulted in fewer ulcers, reduced ulcer duration, a reduced number of RAS episodes, and less ulcer pain than use of an SLS-containing dentifrice. Random-effects summary estimates showed a statistically significant reduction in the number of ulcers when patients used an SLS-free dentifrice (n = 66; mean difference [MD] [95% confidence interval {CI}], –1.05 ulcers [–1.87 to –0.23]; P = .01; I2 = 0%).
Of the 4 studies in the systematic review, 2 reported on ulcer duration, number of RAS episodes, and ulcer pain. Again, random-effects summary estimates showed a statistically significant reduction in all 3 parameters when patients used an SLS-free dentifrice.
Sensitivity analyses showed a consistent direction of effect in favor of an SLS-free dentifrice, the authors wrote. Within the 4 studies, use of an SLS-free dentifrice resulted in a reduced number of ulcers (n = 101; MD [95% CI], –4.28 ulcers [–7.58 to –0.98]; P = .01; I2 = 95%).
One limitation of this systematic review was the high risk of bias found in 2 of the 4 studies, the authors wrote. A second limitation is the small number of included studies. However, 1 strength is the crossover design of the trials for which fewer participants are needed to achieve adequate statistical power. Moreover, because each participant served as his or her own control, within-participant variables that might confound the results were eliminated. In addition, all 4 studies incorporated an adequate washout period.
In light of the study findings, people with RAS may benefit from using SLS-free dentifrices. However, more well-designed randomized trials are needed to better assess the effects of using SLS-free dentifrices in this group of patients with RAS, the authors concluded.
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The impact of oropharyngeal health on taste and smell in patients with head and neck cancer
Head and neck cancer (HNC) affects oral and pharyngeal functions that, in turn, impact oral intake. The objective of this prospective study was to evaluate oropharyngeal health and its impact on taste and smell in patients undergoing radiation therapy (RT) for HNC. The study was published online January 7 in Supportive Care in Cancer.
The study sample included 10 patients (7 men, 3 women) with human papillomavirus p16 positive squamous cell carcinoma. All participants were dentate and did not wear dentures. Three of the 10 patients were active cigarette smokers.
Of the 10 patients, 4 completed visits during RT (acute treatment group) and up to 2 years after RT (posttreatment group), 2 attended the acute visit only, and 4 attended the posttreatment visit only.
Patients 18 years or older with HNC who were scheduled to receive RT with or without platinum-based chemotherapy (CT) for up to 24 months met the enrollment criteria. Exclusion criteria were a history of treatment for HNC, induction CT, and cancer involving more than 50% of the dorsal tongue surface.
All examinations were performed by 1 examiner. The examinations included a mucosal examination and completion of the validated oral mucositis assessment scale. Oral hygiene was evaluated during routine dental examinations by means of the plaque index and gingivitis index.
The researchers collected unstimulated and stimulated saliva from patients. While seated in a reclined position, patients swallowed the saliva, and immediately thereafter spit any accumulated saliva into a preweighed cup every 30 seconds for 3 minutes (unstimulated flow). The procedure was the same for stimulated saliva, except that after the initial swallow, patients chewed a preweighed piece of unflavored, unpowdered vinyl glove for 3 minutes, during which they spit the saliva into a preweighed container.
The researchers assessed taste perception in 2 ways. The first involved the use of drops to evaluate taste stimuli. Drops were formulated by using distilled water and these constituents: sweet, 300 milligrams per milliliter of sucrose; sour, 0.3 mg/mL of citric acid; salty, 80 mg/mL sodium chloride; and bitter, 0.06 mg/mL of quinine hydrochloride. Umami (savory) was evaluated by applying 50 grams-per-liter solutions of L-monosodium glutamate.
The second taste test involved use of edible strips composed of the polymers pullulan-hydroxypropyl methylcellulose, which dissolve rapidly on the tongue. The researchers used these strips to assess patients’ perceptions of umami, fat, and spicy or pungent tastes.
Patients selected the taste experienced from a table containing the words “sweet, salty, bitter, sour, tasty (savory), and no taste.” Using a 7-point Likert scale, they ranked the strength of the stimulus. They also ranked the pleasantness of the taste on a 7-point Likert scale.
The investigators also assessed olfactory function using the Smell Identification Test, a validated 40-item forced-choice “scratch and sniff” test.
The study findings showed that patients maintained good plaque control and experienced little gingival inflammation during and after RT. However, the mean (standard deviation [SD]) mucositis ulcer score was higher in patients in the acute treatment group (0.86 [0.37]) than in those in the posttreatment group (0.0 [0.0]). Similarly, the mean (SD) total mucositis score was higher in patients during RT (2.1 [0.45]) than during posttreatment follow-up (0.31 [0.43]).
The results also revealed that mean (SD) unstimulated salivary flow was lower in patients during treatment (1.54 [1.76] mL/minute) than after treatment (5.27 [11.32] mL/minute), but mean (SD) stimulated salivary flow decreased slightly after RT (3.19 [3.56] mL/minute in the acute treatment group compared with 2.64 [2.13] mL/minute in the posttreatment group).
Patients rated the spicy or pungent taste as having the strongest intensity, and it was the most strongly disliked stimulus. During treatment, patients’ response to the bitter taste was in the weak intensity range, but during posttreatment follow-up, the response was most frequently reported as strong intensity. Patients most often reported that fat and sweet tastes produced a strong intensity during RT, whereas at follow-up, they primarily reported that fat taste was moderate and sweet taste ranged from weak to strong intensity.
Sweet was the only taste to receive a positive pleasantness rating as the most frequent response. Both groups of patients rated the intensity of salt taste as very strong, and it was extremely disliked by 3 of the 4 patients in the posttreatment group.
Only 3 of 10 patients reported a change in smell function during treatment, and it improved during posttreatment follow-up. Patients also experienced a mean weight loss of 5% during RT and a 12% weight loss after treatment.
The results of this study suggest that clinicians should assess and manage oral changes and symptoms in patients with HNC during and after treatment. These findings also indicate the need for dietary modifications and food product development.
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Oral lesions in patients with primary Sjögren syndrome
The primary objective of this cross-sectional study was to evaluate the presence of oral lesions in patients with primary Sjögren syndrome (pSS) and compare the findings with those in of a control group. The secondary aim was to examine the association between oral lesions and various risk factors in patients with the disease. The study was published online January 1 in Medicina Oral Patologia Oral y Cirugia Bucal.
The study sample included 61 patients (60 women) with pSS whose care was managed by various rheumatology services in Madrid, Spain. The control group consisted of 122 matched patients (120 women) attending health centers in Madrid for routine medical check-ups. The mean (standard deviation [SD]) age of participants was 57.64 (13.52) years in the group with pSS and 60.02 (13.13) years in the control group.
In the pSS group, inclusion criteria were being older than 18 years and having a diagnosis of pSS according to the diagnostic criteria proposed by the American-European Consensus Group. Exclusion criteria were physical or psychological difficulties that prevented patients from attending appointments in the school of dentistry or a history of systemic autoimmune connective tissue disease apart from pSS. For patients in the control group, exclusion criteria were receiving treatment with corticosteroids, antibiotics, or antifungal agents or a history of systemic autoimmune connective tissue disease.
One clinician in the Faculty of Odontology, Complutense University of Madrid, conducted orofacial examinations in all participants and recorded the number of oral lesions detected, type of lesion, location, size, clinical appearance, time of evolution, and signs and symptoms. A second clinician collected stimulated and unstimulated saliva from patients with pSS. Patients were asked not to brush their teeth, eat, drink, or smoke for at least 90 minutes before the appointment. The researchers defined hyposalivation as a flow rate less than 0.7 milliliter per minute for stimulated saliva and less than 0.1 mL/minute for unstimulated saliva. The clinician also asked patients in the pSS group if they had a sensation of dry mouth, dysphagia, alteration in taste, or pain in the tongue.
Of the 61 patients in the pSS group, 35 (57.4%) had an oral lesion compared with 31 of the 122 patients in the control group (25.4%) (P = .0001). The mean (SD) number of oral lesions was 0.75 (0.79) in the pSS group and 0.27 (0.51) in the control group (P = .0001).
The most common types of oral lesions detected in participants in the pSS and control groups were candidiasis (13.1% compared with 2.5%, respectively; P = .007), traumatic lesions (13.1% compared with 4.1%; P = .03), aphthae (8.2% compared with 0%; P = .004), and grooves or fissuration of the tongue (8.2% compared with 0.8%; P = .02). Denture stomatitis was the most common type of oral candidiasis in the pSS and control groups (8.2% compared with 1.6%, P = .04).
The study findings also showed a statistically significant relationship between systemic manifestations of pSS and the presence of oral lesions. Of the 33 patients in the pSS group with any type of systemic manifestation of the disease, 23 (69.7%) had oral lesions (P = .03). In addition, of the 20 patients in the pSS group with a history of parotid gland enlargement, 15 (75%) had oral lesions (P = .05).
Finally, more patients in the pSS group with oral lesions had unstimulated and stimulated hyposalivation than those without oral lesions, and mean (SD) salivary flow rates were lower in those with oral lesions (0.63 [0.67] mL/minute compared with 0.76 [0.71] mL/minute). However, the differences were not statistically significant.
Overall, the results of this cross-sectional case-control study show that patients with pSS had more oral lesions than those in the control group. Longitudinal studies with a larger number of patients with pSS are needed to assess participants at different time points, the authors wrote. In addition, owing to the complexity of the disease, a multidisciplinary team approach, including rheumatologists, ophthalmologists, and dentists, is needed to manage the care of patients with pSS, the researchers concluded.
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A measles guide for health care professionals
Measles has reemerged in the United States for several reasons, including an increase in the number of parents who refuse to have their children vaccinated. In a review article, published online in the January issue of Nursing2020, the author presents important information for health care professionals regarding epidemiology, pathophysiology, presentation, diagnosis, management, and prevention of this viral illness.
In 2004, only 37 cases of measles were reported in the United States, but by 2019, the number had risen to more than 1,200 cases in at least 31 states. In 2019, the World Health Organization pointed to vaccine hesitancy as 1 of the top threats to global health.
People without immunity, including infants, have the highest risk of contracting measles, and immunocompromised patients, such as heart transplant recipients and adults receiving immune-modulating medications, are also at risk.
When inhaled, the measles virus targets immune cells in the nose, throat, lungs, and corneas and focuses on CD150 stem cells, enabling the virus to invade, rapidly replicate, and spread to immune cells of the bone marrow, tonsils, lymph nodes, and spleen and eventually to the respiratory tract. Diagnosis is best established and confirmed with a polymerase chain reaction test. Clinicians can send nasal, throat, or nasopharyngeal swabs to a state public health laboratory, which can report the results within 24 hours.
The clinical presentation of measles is similar to that of other common upper respiratory tract infections. Patients usually have a high fever (40°C or higher), cough, coryza, and conjunctivitis. The prodrome typically lasts 2 to 4 days and is followed by 1 day of Koplik spots, which are tiny bluish lesions that appear on the buccal mucosa and posterior pharynx.
The maculopapular erythematous rash that immediately follows Koplik spots starts near the hairline or face and moves down to the trunk and limbs. The infectious period begins 4 days before onset of the rash and ends 4 days after onset. Children with measles usually feel miserable and often refuse to eat or drink.
More than 30% of patients with measles experience complications, such as dehydration, keratitis, and otitis media. Although most recover, the virus can result in serious, and sometimes fatal, complications including pneumonia, encephalitis, and subacute sclerosing panencephalitis.
No antiviral treatment exists for measles. Therefore, treatment generally consists of supportive care, such as intravenous fluids for dehydration, antibiotics for otitis media, and ventilatory support for pneumonia. Children who have low concentrations of vitamin A experience more severe illness, and those who are hospitalized should receive 1 dose of vitamin A daily for 2 days.
One dose of the measles, mumps, and rubella (MMR) vaccine administered at 12 to 15 months of age confers 93% coverage to prevent measles, the author wrote. A second dose, typically administered at about age 4 through 5 years, raises the coverage to 97%. Susceptible people who have been exposed to measles should receive the MMR vaccine within 72 hours of exposure. Immunocompromised pregnant women should receive a single dose of immune globulin intramuscular.
For military personnel, international travelers, and health care professionals, 2 doses of vaccine administered at least 28 days apart is proof of immunity.
Health care professionals need to convey the message that the MMR vaccine is safe, protects against a deadly disease, and is the best protection against severe complications, such as neurologic or immunologic impairment, the author concluded. To allay any concerns about vaccination, clinicians can direct patients and parents to several online resources, such as the Centers for Disease Control and Prevention website (www.cdc.gov/vaccines) and the National Foundation for Infectious Diseases (www.nfid.org).
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Understand the etiology of your patients’ lesions, dental erosions to improve their health
It’s not every day that a patient comes in with premalignant lesions or significant dental erosion. Recognize the signs and the causes, so you effectively treat the patient and improve their health in any instance. The ADA offers CE courses that teach you how to conduct a comprehensive visual tactile exam and develop a differential diagnosis of common oral lesions and dental erosion:
- Differential Diagnosis of Oral Lesions –John Alonge
- Oral Cancer Screening and Radiotherapy Morbidity Management
- Management and Prevention of Dental Erosion
Visit ADACEOnline.org to find out more information about these and other pathology courses. Use promo code CESCAN2020 to take 10% off individual courses or a one-year, full access subscription.
The consulting editor for JADA+ Specialty Scan — Oral Pathology is Faizan Alawi, DDS, Associate Dean for Academic Affairs and Associate Professor of Pathology, School of Dental Medicine; Associate Professor of Dermatology, Perelman School of Medicine; Director, Penn Oral Pathology Services; University of Pennsylvania. |
The associate consulting editor for JADA+ Specialty Scan — Oral Pathology is Nasser Said-Al-Naief, DDS, MS, Professor, Dept. of Integrated Biomedical and Diagnostic Sciences, Oregon Health and Sciences University, School of Dentistry and School of Medicine. |
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