Position Paper: Oral Features of Mucocutaneous Disorders

Oral biopsy in mucous membrane pemphigoid and pemphigus vulgaris with gingival expression: the optimal site. A systematic review and meta-analysis

PURPOSE

In order to diagnose mucous membrane pemphigoid (MMP) and pemphigus vulgaris (PV) with gingival expression, clinical data must be compared with immunohistochemical data obtained using direct immunofluorescence (DIF). It is therefore essential to carry out a good quality mucosal biopsy for this vital additional test. To date, no study has been able to effectively guide clinicians in their choice of oral site for biopsy to guarantee the efficient contribution of DIF to diagnosis. We propose a systematic review of the literature and a meta-analysis to clarify this issue.

MATERIALS AND METHODS

Electronic databases and bibliographies of articles were searched in April 2023. The primary outcome was the rate of DIF + contribution to diagnosis according to the location of the oral site biopsied.

RESULTS

16 studies were included. Gingival biopsies showed a rate of DIF + 100% [97%-100%] p = 0.998 I2 = 0.0% with no heterogeneity for PV, and 90.2% [66.5%-100%] p < 0.001 I2 = 89.6% with high heterogeneity for MMP. For the other oral sites, this rate was 95.7% [87.4%- 100%] p = 0.011 I2 = 73.0% with moderate heterogeneity for PV, and 87.4% [70.1%- 98.7%] p < 0.001 I2 = 92.6% with high heterogeneity for MMP. In addition, meta-regression confirmed the significant association between the appearance of the biopsied mucosa and the rate of DIF + in MMP (p < 0.001), with no influence on residual heterogeneity.

CONCLUSION

The nature of the oral mucosa biopsied does not influence the rate of DIF + to diagnosis. The choice of biopsy site should only take into account the characteristics of the clinical picture and the benefit/risk balance of the surgical protocol. The sample must be taken in healthy aeras as close as possible of active lesions: on the gingiva if the MMP and PV are strictly gingival, on the alveolar mucosa if the whole gingiva is altered and on any healthy mucosa if a large number of oral sites are affected.

CLINICAL TRIALS

CRD42023392345.

Clinical relevance of interdental papilla biopsy in chronic erosive gingivitis (desquamative gingivitis): retrospective bicentric study of 148 specimens

Background

Chronic erosive gingivitis, also called desquamative gingivitis, defines a clinical picture that can be generated by several inflammatory and immune diseases. Pathology is therefore essential for the differential diagnosis. However, when the gingival lesion is initial, exclusive or predominant, selecting the biopsy site and protocol may be problematic due to tissue fragility. Especially since there are few studies on the subject, the aim of our study was to assess the protocol, diagnostic relevance and tolerance of an original protocol using interdental papilla biopsy.

Methods

We conducted a retrospective bicentric study, from October 2011 to July 2019, including all patients with a chronic erosive gingivitis who had received, for diagnostic purposes, a interdental papilla biopsy.

Results

The contribution levels for the two hospital departments were 94.7% and 97.1%, respectively. No postoperative complication was recorded in the short or long term.

Conclusion

The interdental papilla biopsy protocol is perfectly adapted to the anatomopathological examinations required to establish differential diagnosis of chronic erosive gingivitis. This surgical protocol is simple to perform, non iatrogenic with a very good tolerance and and accessible to all clinicians. It is highly efficient with an excellent contribution level.

ClinicalTrials NCT04293718 (March 3, 2020). Health Data Hub N° F20201109083211 (November 9, 2020).

Supplementary Information

The online version contains supplementary material available at 10.1186/s12903-021-01820-9.

Plaque control improves the painful symptoms of oral lichen planus gingival lesions. A short-term study

BACKGROUND

Lichen planus is a mucocutaneous disease with manifestation in the oral mucosa, the gingiva being one of the most affected regions. In some cases, the lesion may be painful and lead to fragility of the tissues, so that precise diagnosis and adequate treatment are indispensible factors for improving the clinical condition. The aim of this study was to evaluate the effectiveness of plaque control in the improvement of clinical features and painful symptoms of oral lichen planus with gingival involvement.

METHODS

Twenty patients diagnosed with gingival lichen planus confirmed by histopathological examination were selected. The patients were evaluated by a trained examiner, with regard to the clinical features of the lesions [Index of Escudier et al. (Br J Dermatol, 157, 2007, 765)]; painful symptoms (Visual Analog Scale); and periodontally, as regards the visible plaque and gingival bleeding indices. Periodontal treatment consisted of supragingival scaling and oral hygiene instruction, with professional plaque removal afterward for a period of 4 weeks. The entire sample was evaluated at the baseline and at the conclusion of treatment, and the results were analyzed by the Wilcoxon nonparametric test.

RESULTS

The data demonstrated that the majority of patients were women (90%), with a mean age of 55.9 years. Periodontal treatment resulted in statistically significant reduction (P < 0.05) in the periodontal indices, with consequent improvement in the clinical features and painful symptoms of the lesions.

CONCLUSIONS

It was demonstrated that plaque control was effective in improving the clinical features and painful symptoms of oral lichen planus with gingival involvement.

Profiles of dental caries and periodontal disease in individuals with or without psoriasis

BACKGROUND

Psoriasis is a chronic inflammatory disease that is manifested on the skin. Studies of oral health in psoriasis patients are limited. The aim of this study is to assess the experience and risk of caries and periodontal disease in individuals with and without psoriasis.

METHODS

The material consisted of 89 individuals with mild-to-moderate chronic plaque psoriasis and 54 without psoriasis, recruited at the University Hospital in Gothenburg, Gothenburg, Sweden. Psoriatic arthritis (PsoA) was diagnosed in 25 of the individuals with psoriasis. All participants answered questionnaires and were subjected to saliva sampling and oral radiologic and clinical examinations. Two computer applications were used for illustration of oral disease risk profiles.

RESULTS

Individuals with psoriasis had lower salivary pH, fewer remaining teeth, fewer sites with probing depth ≤4 mm, and a lower radiographic alveolar bone level than individuals without psoriasis (P <0.05). Most of the differences remained significant after controlling for confounders. Differences in alveolar bone levels were no longer significant, particularly after introducing the confounder sex into the regression model. Similar numbers of decayed and filled teeth, sites with deep pockets, sites that bled on probing, and risk profiles were observed. Individuals with PsoA exhibited a lower stimulated salivary secretion rate than those without psoriasis (P <0.05).

CONCLUSIONS

There were no differences in profiles of caries and periodontal disease experience and risk between individuals with and without psoriasis. Fewer remaining teeth were observed in individuals with psoriasis. However, the exact reason for tooth loss could not be identified. Meanwhile, the reduced salivary pH in individuals with psoriasis and salivary secretion in individuals with PsoA may pose some risk for future caries.

Radiographic assessment of photodynamic therapy as an adjunctive treatment on induced periodontitis in immunosuppressed rats

Objective

The aim of this study was to assess radiographically the effect of photodynamic therapy (PDT) as an adjunctive treatment to scaling and root planing (SRP) on induced periodontitis in dexamethasone-induced immunosuppressed rats.

Material and Methods

The animals were divided into 2 groups: ND group (n=60): saline treatment; D group (n=60): dexamethasone treatment. In both ND and D groups, periodontal disease was induced by the placement of a ligature in the left first mandibular molar. After 7 days, ligature was removed and all animals received SRP, being divided according to the following treatments: SRP: saline and PDT: phenothiazinium dye (TBO) plus laser irradiation. Ten animals per treatment were killed at 7, 15 and 30 days. The distance between the cementoenamel junction and the height of the alveolar bone crest in the mesial surface of the mandibular left first molars was determined in millimeters in each radiograph. The radiographic values were analyzed statistically by ANOVA and Tukey's test at a p value <0.05.

Results

Intragroup radiographic assessment (ND and D groups) showed that there was statistically significant less bone loss in the animals treated with PDT in all experimental periods compared to those submitted to SRP. Intergroup radiographic analysis (ND and D groups) demonstrated that there was greater bone loss in the ND group treated with SRP compared to the D group treated with PDT at 7 and 30 days.

Conclusion

PDT was an effective adjunctive treatment to SRP on induced periodontitis in dexamethasone-induced immunosuppressed rats.

Desquamative gingivitis as a manifestation of chronic mucocutaneous disease

Desquamative gingivitis (DG) is a clinical descriptive term indicating "peeling gums". DG is usually the result of a disease process that causes separation of the epithelium from the underlying connective tissue in the oral masticatory mucosa. DG may be a manifestation of several mucocutaneous diseases, most commonly cicatricial pemphigoid, pemphigus vulgaris and lichen planus. Correct diagnosis of the underlying disease in DG patients requires careful clinical observation, detailed examination of medical history, biopsy and histopathological examination of the lesions as well as more specialized tests such as direct and indirect immunofluorescence. Treatment of DG consists of treating the underlying disease and often requires the use of immunosuppressive agents, such as corticosteroids. Elimination of local gingival irritants, such as dental plaque and calculus, can significantly improve the treatment outcome.

Pseudolymphomatous tumid lupus erythematosus of the oral mucosa

Oral lesions are frequent complications of systemic lupus erythematosus, but only ulceration is included in the 1982 American College of Rheumatology revised criteria. Because the lack of a uniform classification, a range of ulcerative and keratotic lesions are typically described. In this report we describe a unique progressive irregularly cobblestoned and vegetating plaque of the oral mucosa with clinical and histological features mimicking a cutaneous lymphoma. Despite the papillomatous and extensive nature of the lesions and the dense lymphoid infiltrate with follicle formation suggesting a malignant lymphoproliferative process, the slow progression coupled with a mixed cell infiltrate and polyclonality supported a diagnosis of pseudolymphoma. Recognition of this entity is important to prevent diagnosing them as a malignant lymphoma. As well as with the other mucosal lesions in lupus erythematosus, this pseudolymphomatous variant should be added to the disease spectrum.

Mercury sensitisation: review, relevance and a clinical report

Eczematous eruptions may be produced through topical contact with mercury and by systemic absorption in mercury sensitive individuals. Mercury is considered a weak sensitiser and contact with mercury salts such as chloride or ammonium chloride may cause hypersensitivity leading to contact dermatitis or Coomb's Type IV hypersensitivity reactions. The typical manifestation is an urticarial or erythematous rash, and pruritus on the face and flexural aspects of limbs, followed by progression to dermatitis. True allergy to mercury is rare but is more common in females. Exposure to mercury vapour produced in operating rooms is the main concern for dentists. Every effort should be made to avoid contact with mercury vapour if possible by using barrier techniques, reducing the temperature of the operating room and of the amalgam restoration. Air conditioning and proper ventilation of the operating room, the use of coolant sprays, good suction and proper handling of amalgam waste is recommended. Various reports show the use of MELISA (memory lymphocyte immunostimulation assay) and patch tests in determining mercury sensitivity. Topical application of glucocorticoids and dimethisone is helpful.

Drug delivery strategies for common orofacial diseases

There are many types of diseases associated with the oral cavity. As an adjunct to professional oral dental care, various drug delivery systems have been developed to improve the treatment or prevention of these diseases. In this manuscript, the current status of drug delivery strategies for these common orofacial diseases is reviewed. Biomineral-binding drug delivery and on-demand drug release are suggested to be considered in the future design of drug delivery systems for orofacial diseases. Apparently, this research field deserves much more attention from both pharmaceutical scientists and dental health professionals.

Diagnostic pathways and clinical significance of desquamative gingivitis

The term desquamative gingivitis (DG) refers to a clinical manifestation that can be caused by several disorders. Many of them are immunologically mediated; in addition to the oral cavity, they can affect extraoral mucocutaneous sites, e.g., larynx, conjunctiva, esophagus, nasal and genital mucosa, and the skin. The degree of oral, periodontal, and systemic involvement determines the overall morbidity and, sometimes, the mortality of these disorders. We comprehensively review disorders commonly associated with DG and highlight diagnostic pathways, guidelines for differential diagnosis, and oral, periodontal, and systemic implications. More rare conditions are reviewed as well. Mucous membrane pemphigoid, oral lichen planus, and pemphigus vulgaris are responsible for the majority of cases of DG. In addition, other uncommon disorders should be considered. Accurate clinical, histologic, and serologic investigations are often required to differentiate among DG-associated disorders, provide adequate therapy, and improve the prognosis of patients.

Novel biomineral-binding cyclodextrins for controlled drug delivery in the oral cavity

A biomineral-binding alendronate-beta-cyclodextrin conjugate (ALN-beta-CD, Fig. 1) was developed as a novel drug delivery system. "Click" chemistry was used in conjugation of alendronate (ALN) to beta-cyclodextrin (beta-CD). The delivery system shows very strong binding to hydroxyapatite (HA, main component of tooth enamel). Its ability in forming molecular inclusion complex with dexamethsone (Dex, model drug) was investigated independently with phase solubility experiments, isothermal titration calorimetry (ITC), Job plot and (1)H NMR. The stoichiometry of ALN-beta-CD/Dex molecular complex was determined as 1:1, and the binding constant of the complex obtained from ITC study is 3.8 x 10(3) M(-1), which is similar to the binding constant of beta-CD/Dex. In vitro data indicate that the ALN-beta-CD/Dex complex bound to HA could gradually release Dex upon repeated extraction with phosphate buffer saline (PBS). This novel drug delivery system may have great potential in improving treatment of diseases in the oral cavity.

A combined treatment regimen for desquamative gingivitis in patients with oral lichen planus

BACKGROUND

Chronic desquamative gingivitis (DG) is a condition characterized by erythema, ulceration, and desquamation of the free and attached gingiva, usually expression of a district-systemic disease, such as oral lichen planus (OLP).

METHODS

A combined protocol of oral hygiene and topic corticosteroid therapy was applied in 30 patients with DG associated with OLP. Plaque index (PI) and bleeding on probing (BoP) were evaluated at baseline and after 3 months.

RESULTS

PI scoring was significantly lower after treatment in anterior, posterior, and all sites (P < 0.0001) as well as in vestibular and lingual ones (P < 0.0001 and P = 0.0001, respectively). BoP measures were found to be reduced significantly to 22.94% in a full-mouth evaluation (P < 0.0001; OR = 2.633; 95% CI: 2.2685-3.0561) as well as in each specific site (P < 0.0001).

CONCLUSION

This clinical trial validated the efficacy, in patients with DG associated with OLP, of a protocol based on professional oral hygiene and self-performed plaque control measures in improving of gingival health status.

Periodontal Status in Patients With Gingival Mucous Membrane Pemphigoid

BACKGROUND

Mucous membrane pemphigoid (MMP) describes an autoimmune disease with a range of variants, including those with oral, ocular, and cutaneous lesions. Persistent oral lesions, lack of effective oral hygiene, and plaque accumulation may increase the risk of long-term periodontal disease. However, to our knowledge, no studies have evaluated the relationship between the presence of gingival MMP and periodontal health. The purpose of this study was to evaluate the possible impact of gingival pemphigoid lesions on the human periodontium.

METHODS

Twenty patients with histologic confirmation of subepithelial separation with or without direct immunofluorescence testing were randomly chosen to participate in a study evaluating their periodontal status. Parameters evaluated included plaque score, gingival index, bleeding index, probing depths, recession, clinical attachment level, mobility, furcation involvement, number of missing teeth, and Machtei criteria, a previously defined criteria for periodontitis. Individuals matched with respect to age, gender, and smoking history were selected and evaluated for the same parameters.

RESULTS

MMP patients had statistically significant larger mean gingival index scores than age, gender, and smoking history matched controls. Plaque scores, bleeding index, mobility, furcations, clinical attachment level, recession, and periodontal status did not show statistically significant differences between MMP and control patients. A statistically significant difference in plaque index was found when patients with MMP in treatment were compared to patients with MMP in remission. Among patients with MMP, those diagnosed >5 years in the past had statistically significantly greater Class I furcation involvement and recession on facial and lingual surfaces of teeth.

CONCLUSIONS

A relationship was found to suggest that patients with MMP exhibit more gingival inflammation than a control population. Among patients with MMP, patients currently in treatment have higher plaque indices than those in remission and not receiving treatment. Furthermore, when comparing patients with MMP who received a diagnosis>5 years in the past to those with a diagnosis in the past 5 years, statistically significantly greater Class I furcation and facial and lingual recession were measured. Long-term follow-up in this population may provide additional information as to periodontal progression in MMP versus control patients.