Correlation Of Recurrent Aphthous Ulceration With Gastrointestinal Diseases: A Clinical Study

Introduction: Recurrent aphthous ulceration (RAU) is a disease of oral mucosawith high occurrence. Its clinical manifestations include periodic episode, singular ormultiple lesions in a round or an oval shape. It is usually accompanied by severe painwith spontaneous cure. The intervals of episodes range from several days to 2-3months. Generally, 20% population have episodes of RAU, which is more commonlyseen in young and middle-aged population and is more commonly seen in female thanin male. RAU severely impairs the patients' quality of life by taking great mentalpressure upon the patients and its causes are still unclear now.There are many ways for the treatment of RAU, which have been used to relievepain and to promote healing. Due to its unclear causes, it is difficult to prevent itsrecurrent attacks. In recent years, the infection cause of disease theory more and morereceived the attention in the multitudinous initiation RAU etiology theory, manyscholar experiment and the clinical research discovery, the oral cavity internal causevarying degree pathogen infection, directly had RAU easily. Has the differentviewpoint about the infection pathogen type, the bacterium, the virus all has therelated report, but all lacks the strong evidence to prove RAU directly the morbidityand it correlation. Helicobacter pylori (Hp) are gram negative microaerophilic bacteria, which especially adapt to the acid environment in human stomach. It hasbeen confirmed that Hp is the etiologic bacteria causing chronic reactive gastritis andplays important role in pathogenesis of peptic ulcer (PU). Oral mucosa, whichbelongs to digestive system and is histologically similar to gastric mucosa, is anextension of oral environment in digestive system. Therefore, the correlation of RAUwith oral Hp infection has aroused great interest among the scholars of this field.Recently, studies indicate that Hp can be found by human oral plaques culture andhuman saliva culture, which are morphologically, biochemically and immunologicallysame as endogastric Hp, indicating Hp causing chronic gastrosis and Hp causingRAU are the same antigen-determined group of Hp. Domestic and foreign has manyscholars to report that, the recurrence aphtha (RAU) morbidity and the pylorus spiralbacillus (helicobacter pylori, Hp) has certain relatedness. Hp eradication has been theimportant measures for treatment of commonly seen gastrointestinal diseases and theproton pump inhibitor (PPI) (Omeprazole) containing triple therapy has achievedfavorable therapeutic efficacy.The following studies are reported hereafter: 1) a clinical investigation on thecorrelation of RAU with gastrointestinal diseases; 2) the correlationship betweenRAU and gastrointestinal diseases by detection of Hp positive rate among patientswith RAU using sensitive and specific polymerase chain reaction (PCR).Objective: The purposes of the studies are to explore correlationship betweenRAU and gastrointestinal diseases as well as the correlationship between RAU andHp infection. Confirms two kind of diseases the relatednesses, discusses its possibleconnection way, for further studies in the RAU treatment the control ache, acceleratesulcer to heal, reduces the recrudescence accumulation theory and the practice basis.Materials and Methods: 1) Totally 208 cases definitely diagnosed as havingRAU during the period from Oct. 2005 to Oct. 2006 in Mucosa Department, Provincial Stomatology Hospital of Guangdong received an epidemiological survey,including 76 males and 132 females with their age ranging from 12 years to 73 years,averaging 36.9 years. The healthy control group was 168 cases patients with non-RAUin stomatology, General Hospital of Guangzhou Command. including 81 males and87 females with their age ranging from 18 years to 65 years. They were performedroutine oral examinations and their history was inquired in detail with uniform styles.The questionnaire was designed to record the gender, age, location of aphthousulceration, numbers of ulceration, size, lesion depth, pain severity, ulceration type,mental condition of the patient, eating habits, family history of ulceration, healingperiod, intervals, history of digestive diseases, symptoms of digestive diseases,diagnosis by gastroscopy, present state of ulceration (episode or interval) and anymedications for ulceration to explore the correlation between aphthous ulceration andgastrointestinal diseases. 2) Saliva samples from 82 cases of RAU that had beendefinitely diagnosed during May 2006 to Oct. 2006 in Mucosa Department,Provincial Stomatology Hospital of Guangdong and General Hospital of GuangzhouCommand were collected to detect Hp positive rate among patients with RAU usingPCR method.Results: All the 208 cases included 76 males, occupying 36.54% (76/208) and132 females, occupying 63.46% (132/208). There were 124 cases with slight ormoderate RAU, occupying 59.62% (124/208), 30 cases of severe RAU, occupying14.42% (30/208) and 54 cases of stomatitis RAU, occupying 25.96% (54/208).Among the 124 cases with slight sore mouth, 12 had accompanied gastritis and 14had pressure ulcer (PU) with a gastrosis occurrence of 20.97%. Among 30 cases withsevere sore mouth, 7 had accompanied gastritis and 8 had PU, with a gastrosisoccurrence of 50.00%. In the 54 cases of stomatitis sore mouth, had accompanied3 had gastritis and 4 had PU, with a gastrosis occurrence of 12.96%. In the 48 cases of RAU with accompanied digestive diseases, 23 had one episode each month, 16 hadtwo episodes each month and 9 had no obviously regular intervals. In 160 RAU caseswith no accompanied digestive diseases, the interval between episodes was more than2 months, including 69 cases with occasional episodes or long-term intervals and 91cases with frequent episodes and less than one month intervals, In the 208 cases ofRAU, 48 had gastrointestinal diseases with an occurrence rate of 28.08%. In the 168non-RAU patients, 16 had gastrointestinal diseases, with an occurrence rate of 9.57%,which was significantly lower than that of the RAU patients (P＜0.01). 2) In thedetected 82 cases of RAU, there were 36 cases of Hp positive with an Hp positiverate of 43.9%, which was significantly higher than that of non-RAU cases (12/74,16.2%) (P＜0.001). Hp positive rate among patients with RAU was higher than that ofhealthy population. Additionally, the patients with RAU had their disease courses ofRAU and gastrointestinal diseases being more than 1 year and the gastrointestinaldiseases occurred previously to RAU.Discussion: RAU is nowadays a common disease of oral mucosa with no causecan be found. It has been believed in biomedicine that it is correlated to decreasedimmunologic function, microcirculation disturbance, local oral infection anddeficiency of trace elements. However, the correlationship between RAU and theserisk factors has not been confirmed. Due to its unclear cause, there have been no idealways for its treatment. We conducted an epidemiological survey among 208 patientswith RAU and 168 patients with no RAU for their occurrence rate of gastrointestinaldiseases, which indicates that the occurrence rates of gastrointestinal diseases hassignificant difference between the two groups. The occurrence rate of gastrointestinaldiseases among patients with RAU was significantly higher than that among patientswith no RAU, indicating occurrence of RAU has correlation with gastrointestinaldiseases. Oral cavity is the beginning of gastrointestinal tract, which is anatomically close to gastrointestinal tract. So do pathogenic bacteria. Hp was firstly found insamples of gastric mucosa, which was confirmed to be the important factorscontributing to chronic reactive gastritis and pressure ulcer. Thereafter, Hp wasdetected in samples of oral cavity. Therefore, oral cavity, as another habitation of Hpinfection, has gained focused concern in this field. Endogastric bacteria may be amixture of bacteria that is food origin, oral cavity origin and intestine origin. On theother hand, some scholars believe that Hp in oral cavity may be from the stomach dueto esophageal regurgitation and diseases can be spread to each other between oralcavity and gastrointestinal tract. Therefore, simple endogastric Hp radical correctioncan not prevent gastrointestinal diseases and recurrence of RAU.Hp is a kind of gram-negative microaerophilic bacteria, which are especiallyadaptable to the acid environment of human stomach. In periodontal pocket of oralcavity, there is low grade oxidation reduction potential. And the additionalfermentation and acid produced within bacterial plaque, the oral cavity becomes afavorable ecological environment for the growth of Hp. Hu Wenjie et al. used singlestrand conformation polymorphism (SSCP) to pair and analyze the genotype of oralHp strain and gastric Hp strain within one human body. Finally, 3 patients were foundhaving their SSCP banding pattern of gastric mucosa Hp the same as that of oralplaque, that is to say, the 3 patients had the same strain infections in their oral cavityand stomach. Their findings are similar to the findings by another domestic team,Zhang Ying et al, in that another primer was used to analyze the SSCP bandingpattern of gastric mucosa positive samples and saliva positive samples. Otheroverseas and domestic studies also confirmed it. Wang Shuli et al reported theirdetection of blood anti-Hp antibody level using ELISA in patients with RAU with anHp detected rate of 53.3%. Chen Faming et al reported their detection of plaque inpatients with RAU using PCR with an Hp positive rate of 56.94%. In our study, we used PCR to detect the Hp positive rate among patients with RAU, which was 43.9%,being slightly lower than the other reports. The difference may be related to thesampling location, sampling method, sensitivity and specificity of detectingtechniques. However, all the reported Hp positive rates among patients with RAU arehigher than that of the healthy population (P＜0.001), which backs to our hypothesis.Thereafter, we administered anti-Hp triple therapy for partial RAU patients withaccompanied gastrointestinal diseases, whose therapeutic efficacy was morefavorable to the routine medication group. It has been confirmed from anotherperspective that occurrence of RAU is correlated to Hp infection.In the year of 2003, Zhang Hui, et al studied occurrence rate of RAU and Hppositive rate among patients with definitive chronic gastrosis. It has been concludedthat the two diseases have correlationship. From a reverse perspective, our studyexplored occurrence rate of chronic gastrosis and Hp positive rate among patientswith RAU as well as the clinical therapeutic efficacy of anti-Hp therapy, whichindicates that Hp may be involved in the pathogenesis link of aphthous ulceration ormay reinforce the power of other etiologic factors contributing to aphthous ulceration.Due to the accompanied gastrointestinal diseases among RAU patients in theexperimental group, killing of Hp can also treat and prevent gastrointestinal diseases.However, due to the difficulty in preventing its recurrence, the recurrence preventingefficacy of anti-Hp triple therapy still needs long-term observation and study.This findings showed Hp between the recurrence oral cavity ulcer andgastro-intestinal tract disease, indeed has certain relatedness. The RAU patient has theremarkable difference with the non-RAU patient gastro-intestinal tract disease diseaseincidence rate (P＜0.01), moreover three kind of types (light aphtha, heavy aphtha,mouth inflammation aphtha) the RAU patient's gastro-intestinal tract disease diseaseincidence rate also has the remarkable difference (P＜0.01), along with ulcer degree aggravation, the RAU patient partner has the gastro-intestinal tract disease theproportion to increase obviously. Moreover the partner has the digestive tract diseasethe RAU patient compares with the non-digestive tract disease RAU patient, theformer oral cavity ulcer dormant period is short, the outbreak frequency are many,this has also prompted the RAU morbidity and gastro-intestinal tract disease fromanother stratification plane has the connection, Hp possibly participated in the oralcavity ulcer pathogenesis process in some link, or strengthened other factorpathogenicity by some way, aggravated the RAU clinical manifestation. Theseetiology prompt, all further explored RAU for us the clinical treatment to establish thegood theory and the practice foundation.Conclusion1. The experiment research showed, patients with RAU and patients with non-RAU for their occurrence rate of gastrointestinal diseases has significant differencebetween the two groups. The occurrence rate of gastrointestinal diseases amongpatients with RAU was significantly higher than that among patients with no RAU,and Hp detection rate was higher.2. Three kind of types (light aphtha, heavy aphtha, mouth inflammation aphtha)the RAU patient's gastro-intestinal tract disease incidence rate also has the remarkabledifference (P＜0.01), along with ulcer degree aggravation.3. Hp can be found by human oral plaques culture and human saliva culture,which are morphologically, biochemically and immunologically same as endogastricHp.4. Hp positive rates among patients with RAU are higher than that of the healthypopulation (P＜0.001).