Lorena Baccaglini

Urban legends: recurrent aphthous stomatitis.

Recurrent aphthous stomatitis (RAS) is the most common idiopathic intraoral ulcerative disease in the USA. Aphthae typically occur in apparently healthy individuals, although an association with certain systemic diseases has been reported. Despite the unclear etiopathogenesis, new drug trials are continuously conducted in an attempt to reduce pain and dysfunction. We investigated four controversial topics: (1) Is complex aphthosis a mild form of Behçets disease (BD)? (2) Is periodic fever, aphthous stomatitis, pharyngitis, and adenitis (PFAPA) syndrome a distinct medical entity? (3) Is RAS associated with other systemic diseases [e.g., celiac disease (CD) and B12 deficiency]? (4) Are there any new RAS treatments? Results from extensive literature searches, including a systematic review of RAS trials, suggested the following: (1) Complex aphthosis is not a mild form of BD in North America or Western Europe; (2) Diagnostic criteria for PFAPA have low specificity and the characteristics of the oral ulcers warrant further studies; (3) Oral ulcers may be associated with CD; however, these ulcers may not be RAS; RAS is rarely associated with B12 deficiency; nevertheless, B12 treatment may be beneficial, via mechanisms that warrant further study; (4) Thirty-three controlled trials published in the past 6 years reported some effectiveness, although potential for bias was high.

Urban legends series: lichen planus

Oral Diseases (2012) Lichen planus (LP) is a common disorder affecting the oral cavity (OLP) and skin. Despite intensive research, LP/OLP etiology and treatment remain controversial. We investigated four controversial topics: (i) Is hepatitis C virus (HCV) infection associated with LP and involved in its pathogenesis? (ii) Should all patients with LP be screened for HCV? (iii) Should patients with OLP have all their amalgam restorations removed? (iv) Are there any new treatments for OLP? Results from extensive literature searches suggested that: (i) Robust evidence from three meta-analyses indicate that HCV is associated with LP and might be involved in OLP pathogenesis (ii) It would be prudent to screen patients with LP/OLP at significant risk with an ELISA for HCV antibodies using country-specific screening strategies (iii) There is no evidence that either OLP or oral lichenoid lesions patients would routinely benefit from having all their amalgam restorations replaced. Weak evidence from potentially very biased, small, non-randomized, unblinded studies suggests that a small fraction of patients may benefit from targeted amalgam replacement. (iv) There is weak evidence that, among new OLP treatments, topical pimecrolimus, aloe vera, and oral curcuminoids may be useful. The development of specific formulations for oral delivery of topical medications is a promising field.

A review of malocclusion among individuals with mental and physical disabilities

Oral health disparities between individuals with disabilities and the general population are widely reported in the literature, and malocclusion is no exception. As the number of people living with disabilities grows, so does the need to explore their oral health status. This review examines the reported prevalence of malocclusion in individuals with Down syndrome (DS), cerebral palsy (CP), cleft disorders, mental disabilities, and physical disabilities from 1976 to 2004. Malocclusion was assessed according to Angles classifications, the Dental Aesthetic Index (DAI), and selected occlusion characteristics. The prevalence of malocclusion was higher in individuals with disabilities than in controls without disabilities. Malocclusion was more frequent when the handicap was mental rather than physical in origin. Class II and Class III malocclusions were common in individuals with CP and DS, respectively. Crowding, anterior diastema, and >1/2 cusp antero-posterior molar relations were frequent among people with disabilities. Findings varied according to disability, but were attributed to musculoskeletal abnormalities, altered cranial-base relationships, premature tooth eruption, corrective surgery, and lip incompetence. Only a deep bite was more frequent in controls compared to the individuals with disabilities.

Effect of stressful life events on the onset and duration of recurrent aphthous stomatitis.

BACKGROUND Recurrent aphthous stomatitis (RAS) is a common and painful oral mucosal disease. Possible etiologies include genetics, vitamin deficiencies, trauma, immune dysfunction, and stress. The goal of this study was to examine the relationship between the occurrence, type, and magnitude of stressful events and the onset and duration of RAS episodes. METHODS One hundred and sixty subjects with a history of RAS completed a weekly phone survey for up to 1 year, providing data on the occurrence of RAS episodes and details of any stressful events they experienced during the previous week. During RAS episodes, subjects also completed daily paper diaries that recorded incidence and duration of the RAS episode. Stressful events were quantified using the validated Recent Life Changes Questionnaire (RLCQ) and were classified as mental or physical stressors. RESULTS Stressful life events were significantly associated with the onset of RAS episodes (P < 0.001), however, not with the duration of the RAS episodes. Experiencing a stressful life event increased the odds of an RAS episode by almost three times (OR = 2.72; 95% CI = 2.04-3.62). When controlled for each other, mental stressors had a larger effect (OR = 3.46, 95% CI = 2.54-4.72) than physical stressors (OR = 1.44; 95% CI = 1.04-1.99) on the occurrence of RAS episodes. RAS episodes did not occur more frequently or last longer with increasing stress severity. CONCLUSIONS In patients with a history of RAS, stressful events may mediate changes involved in the initiation of new RAS episodes. Mental stressors are more strongly associated with RAS episodes than physical stressors.

Design and statistical analysis of oral medicine studies: common pitfalls.

A growing number of articles are emerging in the medical and statistics literature that describe epidemiologic and statistical flaws of research studies. Many examples of these deficiencies are encountered in the oral, craniofacial, and dental literature. However, only a handful of methodologic articles have been published in the oral literature warning investigators of potential errors that may arise early in the study and that can irreparably bias the final results. In this study, we briefly review some of the most common pitfalls that our team of epidemiologists and statisticians has identified during the review of submitted or published manuscripts and research grant applications. We use practical examples from the oral medicine and dental literature to illustrate potential shortcomings in the design and analysis of research studies, and how these deficiencies may affect the results and their interpretation. A good study design is essential, because errors in the analysis can be corrected if the design was sound, but flaws in study design can lead to data that are not salvageable. We recommend consultation with an epidemiologist or a statistician during the planning phase of a research study to optimize study efficiency, minimize potential sources of bias, and document the analytic plan.

Urban Legends Series: Recurrent Aphthous Stomatitis

Recurrent aphthous stomatitis (RAS) is the most common idiopathic intraoral ulcerative disease in the USA. Aphthae typically occur in apparently healthy individuals, although an association with certain systemic diseases has been reported. Despite the unclear etiopathogenesis, new drug trials are continuously conducted in an attempt to reduce pain and dysfunction. We investigated four controversial topics: (1) Is complex aphthosis a mild form of Behçets disease (BD)? (2) Is periodic fever, aphthous stomatitis, pharyngitis, and adenitis (PFAPA) syndrome a distinct medical entity? (3) Is RAS associated with other systemic diseases [e.g., celiac disease (CD) and B12 deficiency]? (4) Are there any new RAS treatments? Results from extensive literature searches, including a systematic review of RAS trials, suggested the following: (1) Complex aphthosis is not a mild form of BD in North America or Western Europe; (2) Diagnostic criteria for PFAPA have low specificity and the characteristics of the oral ulcers warrant further studies; (3) Oral ulcers may be associated with CD; however, these ulcers may not be RAS; RAS is rarely associated with B12 deficiency; nevertheless, B12 treatment may be beneficial, via mechanisms that warrant further study; (4) Thirty-three controlled trials published in the past 6 years reported some effectiveness, although potential for bias was high.

Distribution, Determinants, and Prevention of Falls among the Elderly in the 2011–2012 California Health Interview Survey:

Objectives. Falls in the geriatric population are a major public health issue. With the anticipated aging of the population, falls are expected to increase nationally and globally. We estimated the prevalence and determinants of falls in adults aged ≥65 years and calculated the proportion of elderly who fell and made lifestyle changes as a result of professional recommendations. Methods. We included adults aged ≥65 years from the 2011–2012 California Health Interview Survey (CHIS) and categorized them into two groups based on whether or not they had had at least two falls in the previous 12 months. We performed logistic regression analysis adjusted for the complex survey design to determine risk factors for falls and compare the odds of receiving professional recommendations among elderly with vs. without falls. Results. Of an estimated 4.3 million eligible elderly participants in the CHIS (2011–2012), an estimated 527,340 (12.2%) fell multiple times in the previous 12 months. Of those, 204,890 (38.9%) were told how to avoid falls by a physician and 211,355 (40.1%) received medical treatment, although fewer than 41.0% had made related preventive changes to avoid future falls. Falls were associated with older age, less walking, and poorer physical or mental health. Non-Asians had higher odds of falling compared with Asians (adjusted odds ratio 5 1.69, 95% confidence interval 1.16, 2.45). Most participants reported changing medications, home, or daily routines on their own initiative rather than after professional recommendations. Conclusion. Patients with a history of falls did not consistently receive professional recommendations on fall prevention-related lifestyle or living condition changes. Given the high likelihood of a serious fall, future interventions should focus on involving primary care physicians in active preventive efforts before a fall occurs.

Epigenetic dysregulation of Insulin-like growth factor (IGF)-related genes and adverse pregnancy outcomes: a systematic review

Abstract Objectives: Preterm birth (PTB), low birth weight (LBW) and small for gestational age (SGA) are leading causes of neonatal mortality and morbidity around the world. Epigenetic alterations of the human genome may be involved in the causal chain of adverse pregnancy outcomes. In this systematic review we investigated whether PTB, LBW and SGA are associated with epigenetic dysregulation of insulin-like growth factor-related genes (IGF). Methods: We searched MEDLINE and EMBASE for peer-reviewed articles about IGF and PTB, LBW and SGA published up to February 2015. Two independent reviewers selected original, controlled, human studies published in any language and graded them using the Newcastle–Ottawa Quality Assessment Scale. Disagreements were resolved by consensus with a third reviewer. Results: Eighteen observational studies of low-to-moderate quality met the eligibility criteria out of 210 unique studies. There was substantial heterogeneity across studies. Most studies reported no, limited or borderline association between epigenetic changes (methylation or imprinting) of IGF-related genes and LBW or SGA. There were no IGF-related epigenetic studies of PTB. Conclusions: Overall, evidence of an association between epigenetic abnormalities of IGF-related genes and LBW or SGA was weak and inconsistent. Methodological concerns limited results validity.

Psychological Screening Test Results for Stress, Depression, and Anxiety are Variably Associated With Clinical Severity of Recurrent Aphthous Stomatitis and Oral Lichen Planus

Article Title and Bibliographic Information The role of anxiety, depression, and psychological stress on the clinical status of recurrent aphthous stomatitis and oral lichen planus. Gavic L, Cigic L, Lukenda DB, Gruden V, Pokupec JSG. J Oral Pathol Med 2014;43(6):410-7. Reviewers Saad Alshahrani, MD, Lorena Baccaglini, DDS, MS, PhD Purpose/Question In patients with recurrent aphthous stomatitis (RAS) or oral lichen planus (OLP), is there a difference in severity of certain signs or symptoms comparing patients with higher vs. lower screening test results for psychological factors (stress, anxiety, and depression)? Source of Funding None stated Type of Study/Design Cross-sectional Level of Evidence Level 3: Other evidence Strength of Recommendation grade Not applicable

Epigenetic modifications of human placenta associated with preterm birth: a systematic review

Abstract Objective: Preterm birth (PTB) is one of the leading causes of neonatal mortality and morbidity around the world. Epigenetic alterations of the human placenta may be involved in the causal chain of adverse pregnancy outcomes specifically PTB. In this systematic review, we investigated whether epigenetic dysregulation of the human placenta is associated with PTB. Methods: We searched MEDLINE and EMBASE and systematically reviewed all relevant studies on epigenetic placental modifications in PTB. Two independent reviewers selected controlled human studies published in any language, evaluated their quality, and graded them using the Newcastle–Ottawa Quality Assessment Scale. We resolved disagreements by consensus with a third reviewer. Results: Eleven observational studies of low to moderate quality met the eligibility criteria out of 60 unique studies. Most studies reported an association between placental epigenetic changes (methylation, mRNA and miRNA) and PTB, although research methods were highly heterogeneous. Conclusions: Studies reported various associations between specific epigenetic findings and PTB, although methodological concerns limited results’ validity. Additional high quality studies are needed to assess the repeatability of these findings. The STROBE guidelines can be used to improve the quality of reporting.