Challenging management of gingival squamous cell carcinoma: a 10 years single-center retrospective study on Northern-Italian patients

Background

Aim of this study was to describe the outcome of patients with gingival squamous cell carcinoma (GSCC), and to recognize aspects affecting clinical course and to consider survival rate.

Material and Methods

The case records of patients, over a 10-year period, were retrospectively examined. Differences in distribution of the potential risk factors by prognosis were investigated through non-parametrical tests (Wilcoxon Rank-Sum and Fisher’s Exact). Survival curves for age, therapy and stage were built by the Kaplan-Meier method and compared with Log-Rank test.

Results

79 patients were analysed. Significant increase in mortality for patients older than 77 and for those with advanced stages was found. Cumulative survival rate 5 years after the diagnosis was 43%, while at 10 years was of 11%.

Conclusions

With a statistical relationship between age and tumour stage with survival rates, and 70% of GSCC cases identified as stage IV, early GSCC diagnosis remains challenging.

Key words:Gingival cancer, clinical appearance, treatment, retrospective study.

Randomized, placebo-controlled, double-blind trial of clobetasol propionate 0.05% in the treatment of oral lichen planus

OBJECTIVE

To perform a randomized, placebo-controlled, double-blind study, with a follow-up period of 6 months, for the use of topical clobetasol in cases of symptomatic oral lichen planus (OLP).

SUBJECTS AND METHODS

Thirty-two participants were analyzed, with the aims of: (I) to compare the usefulness of topically applied clobetasol propionate 0.05% (mixed with 4% hydroxyethyl cellulose gel) and 4% hydroxyethyl cellulose gel alone (considered as placebo) in the management of OLP; (II) to describe which of them is quicker in decreasing signs and reported symptoms, and (III) which is able to give the proper longer remission in the follow-up.

RESULTS

Symptoms improved in all clobetasol-treated patients during the first 2 months of therapy, while only 50% of placebo control group (p = .005) displayed similar results; of the remaining half, 12.5% did experienced a worsening while 37.5% remained stable. Regarding clinical signs, 87.5% of clobetasol-treated patients improved, while only 62.5% of the placebo-treated patients had a positive response (p = .229).

CONCLUSIONS

It is possible to report that clobetasol, at this dosage, has been more effective than a placebo at provoking symptoms improvement in subjects affected by atrophic-erosive oral lesions.

A report on the clinical-pathological correlations of 788 gingival lesion

BACKGROUND

The diagnosis and treatment of a variety of non-plaque related gingival diseases have become an integrated aspect of everyday dentistry. The aim of this study was to analyse the relationship between clinical appearance and histopathological features of gingival lesions in a large Northern Italian population.

MATERIAL AND METHODS

A retrospective study of 788 cases of gingival and alveolar mucosal biopsies was set up. Statistical analysis was performed by calculating the odds ratio and 95% confidence interval (C.I.), in order to assess the degree of association between the clinical parameters considered (primary lesions) and the single pathologies, statistically evaluated by Mantel-Haenszel tests. The correlation between clinical and histological diagnosis was classified as follow: 1) expected data (ED): provisional clinical diagnosis; 2) real data (RD): final histopathology diagnosis; 3) concordant data (CD): correspondence between the expected data and real data. The correlation was calculated as follow: CC (complete concordance) = CD x 100 / ED, this expressing the percentage in which the clinical and the histological diagnosis overlapped.

RESULTS

The most frequently observed and biopsied primary lesions resulted to be exophytic, followed by mucosal colour changes and finally by losses of substance. The statistically significant association between primary lesion and their manifestation in gingival pathologies was reported. Volume increases, for instance, were positively correlated to plasma cell epulis, pyogenic granuloma, fibrous reactive hyperplasia and hemangioma. Verrucous-papillary lesions were most often seen in verrucous carcinoma, verrucous leukoplakia and mild dysplasia. White lesion resulted to be related to leukoplakia or oral lichen planus. Red lesions resulted to be related only oral lichen planus. Erosive vesicle-bullous lesions were linked to disimmune pathologies. Ulcerative lesions were positively associated to oral squamous cell cancer. Finally, potentially malignant disorders have the most percentage high concordance. Among the malignant lesions, the correlation increased up to the squamous cell carcinoma and leukaemia.

CONCLUSIONS

This article presented the frequency and the clinico-pathological concordance of all primary lesions and the histopathological diagnosis of gingival lesions. For every primary lesion, it is possible to correlate a specific histopathological diagnosis in a statistical manner. This can be a valuable aid for not specialist clinicians who daily observe mucosae and have the opportunity to intercept major diseases.

Can atrophic-erosive oral lichen planus promote cardiovascular diseases? A population-based study

OBJECTIVE

Lichen planus has been recently associated with an increased risk of cardiovascular diseases (CVDs). The oral manifestations can be divided into white hyperkeratotic lesions (WL) and atrophic and erosive lesions (RL). The aim of this report was to compare the presence of CVDs between patients affected by WL or RL, to test the hypothesis that RL are associated with an increased incidence of CVDs.

SUBJECTS AND METHODS

Patients were analysed through a complete collection of all the risk factors for CVDs. The primary endpoint was the occurrence of a cardiovascular event-acute coronary syndrome (ACS), any revascularization or stroke/TIA. A multivariable logistic regression model, adjusted for age at diagnosis, body mass index, smoking, alcohol consumption, diabetes, hypertension, CVDs familiarity and periodontitis, was performed.

RESULTS

A prospective cohort of 307 patients has been evaluated; 185 (60.3%) had WL and 122 RL (39.7%). Twenty-four patients had a CVD. ACS occurred more frequently in RL (adjusted odds ratio 5.83; 95% CI: 1.16-29.39), mainly due to the higher risk of it after the histological diagnosis of Oral lichen planus OLP (odds ratio 4.23; 95% CI: 0.66-27.23).

CONCLUSION

Patients with RL could possibly have a higher risk of developing ACS. Further analysis on larger cohort is however warranted.

Describing the gingival involvement in a sample of 182 Italian predominantly oral mucous membrane pemphigoid patients: A retrospective series

BACKGROUND

The oral cavity has been frequently described as the only site of involvement or as the first manifestation of mucous membrane pemphigoid (MMP), being the gingival tissues often involved, but usually this has been effusively detailed in limited case series. This is a retrospective evaluation of the gingival involvement in 182 Italian patients with oral MMP.

MATERIAL AND METHODS

The diagnosis of MMP was established by both clinical morphology and direct immunofluorescence finding. Patient information (age, gender, risk factors and medical status) and parameters of manifestation (lesions' distribution, site and type) were detailed.

RESULTS

The mean age was 62 years for women (n=137) and 67 years for men (n=45). Patients had several sites of oral involvement; the gingiva was the most common one, affecting 151 patients (82.96%; 119 f - 32 m). Female subjects had more possibilities to develop gingival lesions than male patients (P = 0.005). Sixty-five patients (35.7%; 58 f - 7 m) had pure gingival involvement. Patients with lower gingival involvement statistically had more complaints (P = 0.006).

CONCLUSIONS

This report is one of the largest about predominantly oral MMP cases, detailing the very frequent gingival involvement; this could be crucial not only for oral medicine specialists but also for primary dental healthcare personnel and for periodontists.

Favourably effective formulation of sodium iodide and salicylic acid plus professional hygiene in patients affected by desquamative gingivitis

The aim of this prospective pilot study was to evaluate the efficiency of an oral hygiene protocol, in combination with a solution of sodium iodide associated to salicylic acid (SISA), in patients affected by desquamative gingivitis (DG). Twenty patients not totally responding to conventional topical therapies, were selected. They received oral hygiene instructions with non-surgical periodontal therapy in a 21-day cohort study (during 3 weekly appointments). The SISA was used at the end of each session, with an impregnated gauze (with 5 ml of the solution) applied for 15 minutes for the upper jaw, and for a further 15 minutes with a new gauze for the lower. Evaluated clinical outcome variables included the full mouth plaque (FMPS) and bleeding (FMBS) scores, probing depth, patient related outcome and clinical gingival signs. Two months after concluding the planned protocol, a statistically significant reduction was observed for FMPS (P=0.032), FMBS (P=0.038), reported pain (P=0.000) and gingival clinical improvement (P=0.005). Topical application of SISA and professional oral hygiene procedures are connected with improvement of gum status, and decrease of related pain in subjects affected by severe DG.

Non-alcoholic steatohepatitis (NASH) and oral lichen planus: a rare occurrence

Oral lichen planus (OLP) is frequently associated with hepatitis C virus infection but uncommonly with other causes of liver disorder. The authors report the case of a 41-year-old male patient with a clinical and histological diagnosis of OLP who presented with a marked alteration of the transaminase values, with no signs of past or present HBV, HCV, HGV or TTV infection. The patient did not consume alcohol and no exposure to hepatotoxic substances was reported. All autoantibodies were negative. Hepatic fine needle biopsy showed macrovesicular steatosis with a slight chronic portal inflammatory infiltrate and signs of siderosis. Iron metabolism was slightly altered. Genetic tests showed a heterozygotic mutation for hereditary haemochromatosis gene (HLA-H C282Y) but not for HLA-H63D. The patient presented slight insulin resistance but had normal glycaemic values. The results are consistent with a diagnosis of non-alcoholic steatohepatitis (NASH). This is the first reported case of NASH associated with OLP.

Course of oral lichen planus: a retrospective study of 808 northern Italian patients

OBJECTIVES

To undertake a retrospective inspection of the general features, clinical presentation and outcome of 808 Italian patients with oral lichen planus (OLP), followed up from 6 months to 17 years.

RESULTS

The mean age was 61 years for women (n = 493) and 58 years for men (n = 315). More than 20% of the total cases had liver abnormalities (n = 164) of which 83.5% infected with hepatitis C virus (n = 137). The reticular and plaque form were the predominant type, affecting almost 60% of patients. 12.3% of patients had also extraoral manifestation, taking into account the skin (n = 63) and genital (n = 24). Symptoms were present in 40% of the total patients. Only less than 2.47% of patients underwent remission, whereas 78% still had oral lesions at the end of the follow-up period. Treatment was directed towards almost 42% of the patients, mainly using topical corticosteroids. Oral squamous cell carcinoma developed in 15 patients, commonly arising on the lateral border of the tongue.

CONCLUSION

This is one of the largest groups of OLP patients with such long a follow-up ever reported. We confirm the chronic nature of this disorder, rarely remissive and the treatment intend for alleviating symptoms. OLP is established to be a disease with small frequency of malignant transformation.

Topical clobetasol in the treatment of atrophic-erosive oral lichen planus: a randomized controlled trial to compare two preparations with different concentrations

Oral lichen planus (OLP) is a chronic inflammatory disease that can be painful, mainly in the atrophic and erosive forms. Numerous drugs have been used with dissimilar results, but most treatments are empirical and do not have adequate control groups or correct study designs. However, to date, the most commonly employed and useful agents for the treatment of LP are topical corticosteroids. A randomized, double-blind, placebo-controlled trial has been designed to compare the efficacy and safety of two different formulations of clobetasol, a very potent topical steroid, in the topical management of OLP and to evaluate which gives the longest remission from signs and symptoms. Thirty-five consecutive patients were divided into two groups: the first received clobetasol propionate 0.025% and the second was given clobetasol propionate 0.05%. Both drugs were placed in 4% hydroxyethyl cellulose bioadhesive gel. Anti-mycotic prophylaxis was also added. After the end of therapy, patients received a 2-month follow-up. In all, 14 of the 15 clobetasol 0.025% patients (93%) and 13 of the 15 clobetasol 0.05% patients (87%), had symptoms improvement after 2 months of therapy (P = 0.001 in both groups). Also, 13 of the 15 clobetasol 0.025% patients (87%) and 11 of the 15 clobetasol 0.05% patients (73%) had clinical improvement after 2 months of therapy (P < 0.05 in both groups). No statistical differences were found in comparing the two different formulations. A larger concentration of the active molecules cannot further improve the therapeutic findings or optimize the obtained results in a significant manner.

Ciclosporin vs. clobetasol in the topical management of atrophic and erosive oral lichen planus: a double-blind, randomized controlled trial

BACKGROUND

Oral lichen planus (OLP) is a chronic inflammatory disease that can be painful, especially in the atrophic and erosive forms. Several drugs have been used with varying results, but most treatments are empirical, and do not have adequate control groups or correct study designs.

OBJECTIVES

To compare the effectiveness of clobetasol and ciclosporin in the topical management of OLP and to evaluate which is more cost-effective and which gives the longest remission from signs and symptoms.

METHODS

A randomized, comparative, double-blind study was designed. Forty consecutive patients were divided into two groups to receive clobetasol propionate or ciclosporin for 2 months. Both drugs were placed in 4% hydroxyethyl cellulose bioadhesive gel. Antimycotic prophylaxis was also given. After the end of therapy, patients underwent a 2-month follow-up.

RESULTS

Eighteen of 19 clobetasol-treated patients (95%) improved after 2 months of therapy, while 13 of 20 ciclosporin-treated patients (65%) had a clinical response (P = 0.04). Symptomatology improved in 18 clobetasol-treated patients (95%) and in 17 ciclosporin-treated patients (85%) (not statistically significantly different). Two months after the end of therapy, 33% of clobetasol-treated patients and 77% of ciclosporin-treated patients were stable (P = 0.04). Clobetasol produced significantly more side-effects than ciclosporin (P = 0.04). The daily cost of ciclosporin treatment was 1.82 compared with 0.35 for clobetasol therapy.

CONCLUSIONS

Clobetasol is more effective than ciclosporin in inducing clinical improvement, but the two drugs have comparable effects on symptoms. Conversely, clobetasol gives less stable results than ciclosporin when therapy ends and has shown a higher incidence of side-effects. The daily cost of ciclosporin is more than five times higher than clobetasol.

Localized oral amyloidosis of the palate

BACKGROUND

Amyloidosis is a rare disease with multifactorial pathogenesis. Localized amyloidosis affecting the head and neck region is an uncommon and benign process, which has almost no clinical consequences. The most reported characteristic features of localized oral amyloidosis appear as multiple soft nodules of the tongue, lip and cheek.

METHODS

We report the case of a 68-year-old woman suffering from a primary localized amyloidosis presenting as a purple patch on the palate.

CONCLUSIONS

The presence of systemic amyloidosis or underlying plasma cell dyscrasia have to be ruled out in patients presenting with a diagnosis of amyloidosis of the oral mucosa. If a primary localized amyloidosis is proven, the surgical therapy may be useful to eliminate a functional impairment.

Systemic and topical corticosteroid treatment of oral lichen planus: a comparative study with long-term follow-up

BACKGROUND

Topical corticosteroids are the mainstay treatment for oral lichen planus (OLP), but some authors suggest that systemic corticosteroid therapy is the only way to control acute presentation of OLP.

METHODS

Forty-nine patients with histologically proven atrophic-erosive OLP were divided into two groups matched for age and sex. The test group (26 patients) was treated systemically with prednisone (50 mg/day), and afterwards with clobetasol ointment in an adhesive medium plus antimicotics, whereas the control group (23 patients) was only treated topically with clobetasol plus antimycotics.

RESULTS

Complete remission of signs was obtained in 68.2% of the test group and 69.6% of the control group, respectively (P = 0.94). Similar results were obtained for symptoms. Follow-up showed no significant differences between the two groups. One-third of the patients of the test group versus none in the control group experienced systemic side-effects (P = 0.003).

CONCLUSIONS

The most suitable corticosteroid therapy in the management of OLP is the topical therapy, which is easier and more cost-effective than the systemic therapy followed by topical therapy.

Increased frequency of HLA-DR6 allele in Italian patients with hepatitis C virus-associated oral lichen planus

BACKGROUND

Recent controlled studies have confirmed that hepatitis C virus (HCV) is the main correlate of liver disease in patients with lichen planus (LP), mainly in southern Europe and Japan. However, a low prevalence of HCV infection has been found in LP patients in England and northern France, and significant differences in serum HCV RNA levels or HCV genotypes have not been found between LP patients and controls. Thus host rather than viral factors may be prevalent in the pathogenesis of HCV-related LP. The HLA-DR allele may influence both the outcome of HCV infection and the appearance of symptoms outside the liver.

OBJECTIVES

To assess whether major histocompatibility complex class II alleles play a part in the development of HCV-related LP.

METHODS

Intermediate-resolution DRB typing by hybridization with oligonucleotide probes was performed in 44 consecutive Italian oral LP (OLP) patients with HCV infection (anti-HCV and HCV RNA positive), in an age, sex and clinically comparable disease control group of 60 Italian OLP patients without HCV infection (anti-HCV and HCV RNA negative), and in 145 healthy unrelated Italian bone marrow donors without evidence of liver disease or history of LP and with negative tests for HCV.

RESULTS

Patients with exclusive OLP and HCV infection possessed the HLA-DR6 allele more frequently than patients with exclusive OLP but without HCV infection (52% vs. 18%, respectively; Pc (Pcorrected) = 0.028, relative risk = 4.93). We did not find any relationship between mucocutaneous LP, HCV infection and HLA-DR alleles.

CONCLUSIONS

HCV-related OLP therefore appears to be a distinctive subset particularly associated with the HLA class II allele HLA-DR6. This could partially explain the peculiar geographical heterogeneity of the association between HCV and LP.

[Oral lupus erythematosus. Description and analysis of 11 cases]

BACKGROUND

The aim of this study is to evaluate all the cases of lupus erythematosus with oral involvement coming to the Department of Oral Medicine in the last 15 years (1984-1998).

METHODS

The files of the Oral Medicine Department of the University of Turin have been reviewed to search oral manifestations of lupus erythematosus according to international accepted diagnostic criteria.

RESULTS

A total of eleven patients 7 women (64%) and 4 men (36%) with a mean age of 46 years were included. Three patients (27%) had discoid lupus erythematosus (LED) whereas 8 (73%) had systemic lupus erythematosus (LES). In four patients the diagnosis of lupus was made after oral diagnosis, whereas 7 patients (64%) had a previous diagnosis of lupus. Clinical aspect was typical in 8 cases (73%) while one patient had leukoplakia-like white patches and two patients (18%) had lichen-like oral lesion.

CONCLUSIONS

This study suggest that primitive oral lesion of lupus are quite rare but frequently may have atypical features often difficult to differentiate from lichen planus.

Topical corticosteroids in association with miconazole and chlorhexidine in the long-term management of atrophic-erosive oral lichen planus: a placebo-controlled and comparative study between clobetasol and fluocinonide

OBJECTIVE

To evaluate the efficacy of a combination of topical corticosteroids with topical antimycotic drugs in the therapy of atrophic-erosive forms of oral lichen planus (OLP).

PATIENTS AND METHODS

The study population consisted of 60 patients with OLP subdivided into three groups matched for sex and age. The first group (25 patients) and the second group (24 patients) received respectively 0.05% clobetasol propionate ointment or 0.05% fluocinonide ointment in an adhesive medium (4% hydroxyethyl cellulose gel) plus in each case antimycotic treatment consisting of miconazole gel and 0.12% chlorhexidine mouthwashes. The third group (11 patients), placebo group, received only hydroxyethyl cellulose gel and antimycotic treatment as above. All the treatment regimens were carried out for 6 months. Each patient was examined every 2 months during the 6-month period of active treatment and for a further 6 months of follow-up. Objective and subjective clinical progress was scored and compared between the three groups. Plasma cortisol levels were monitored in half the patients using the topical corticosteroids.

RESULTS

All patients treated with clobetasol and 90% of the patients treated with fluocinonide witnessed some improvement, whereas in the placebo group only 20% of patients improved (P < 0.0001 and P = 0.00029, respectively. However, when considering complete responses, only clobetasol gave significantly better results than placebo. Clobetasol resolved 75% of the lesions whereas fluocinonide was effective in 25% of cases and placebo in none. Clobetasol achieved better results statistically than did fluocinonide (P = 0.00442) and placebo (P = 0.00049) whereas there was no statistical difference among fluocinonide and placebo (P = 0.140). Similar results were obtained for symptoms. Both drugs were shown to be effective in the treatment of erosive lesions, but clobetasol was considerably more efficacious than fluocinonide in the atrophic areas (75% vs 25% of total response, respectively) (P = 0.00442). None of the treated patients contracted oropharyngeal candidiasis. After 6 months of follow-up, 65% of the clobetasol-treated group and 55% of the fluocinonide group were stable. Estimation of plasma cortisol levels showed no significant systemic adverse effects of clobetasol or fluocinonide.

CONCLUSIONS

Our results suggest that a very potent topical corticosteroid such as clobetasol may control OLP in most cases, with no significant adrenal suppression or adverse effects. Moreover, a concomitant antimycotic treatment with miconazole gel and chlorhexidine mouthwashes is a useful and safe prophylaxis against oropharyngeal candidiasis.

Systemic corticosteroid therapy of oral vesiculoerosive diseases (OVED). An open trial

BACKGROUND

We report the preliminary findings from our open study on how to optimize the doses and the response times to systemic corticosteroid therapy for three forms of oral vesiculoerosive diseases (OVED).

METHODS

All twenty-one patients enrolled in the study were affected with OVED (10 OLP, 6 MMP, 5 EM) and received different doses of prednisone in relation to the type of disease and its severity. Daily mouthwashes with 0.12% chlorhexidine and application of miconazole gel were added to the therapy; its response time to treatment varied individually, the doses were reduced only after 75% of lesions had cleared.

RESULTS

The average response time to treatment was 28 days. Clinical assessment showed that 95% of the patients had improved, whereas 71% had complete remission of oral signs and 48% experienced side effects. The degree of clinical resolution was: 70% complete remission after 26 days of therapy in patients with OLP, 33% complete remission after 38 days in patients with MMP, and 100% complete remission after ten days in patients with EM.

CONCLUSIONS

Although a preliminary study, initial results showed different types and times of response to systemic corticosteroid treatment for the three diseases. Our findings strongly suggest that a unified therapeutic protocol for different OVED is not advisable, nor can systemic treatment be considered the first therapeutic approach.

[Topical treatment of atrophic-erosive oral lichen planus with clobetasol in bioadhesive gel as well as chlorhexidine and miconazole in oral gel]

The study was performed to evaluate the efficacy of the combination of a topical corticosteroid with topical antimicrobic drugs in the therapy of the atrophic-erosive forms of oral lichen planus. Clobetasol propionate, a very potent corticosteroid in the Miller and Munro classification, was used in a 4% hydroxy ethylcellulose bioadhesive gel and applied twice daily for the first four months and once daily for the last two months. Because of the high frequency of candidal infections during corticosteroid therapy, chlorhexidine 0.12%, 3 mouthwashes daily, and miconazole gel, once daily, were added for the whole period of the treatment. Twenty-five patients (17 female, 8 male) participated in the study; 20 concluded the six months of therapy and the six months of follow-up. All 20 patients (100%) had an improvement, while 75% had a complete remission of oral signs. No cases of oral candidiasis were seen. After six months from therapy suspension, 65% of patients were stable in their oral conditions. Our study confirms the efficacy of the combination of a topical corticosteroid with topical antimicrobic drugs in the therapy of the atrophic-erosive forms of oral lichen planus. The stability of our results suggests that, extending the therapy, control of the disease is better.