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Clinical and Demographic Overlaps Among Immunologically Mediated Oral Diseases: a Challenge for Clinicians

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Clinical and Demographic Overlaps Among Immunologically Mediated Oral Diseases: a Challenge for Clinicians Diagnosis of Oral Pathology Clinical and demographic overlaps among immunologically mediated oral diseases: a challenge for clinicians Maria Auxiliadora Vieira do Carmo, PhD n Frederico Omar Gleber-Netto, MSc n Maria Luisa de Freitas Romano, DDS Patricia Carlos Caldeira, PhD n Maria Cassia Ferreira de Aguiar, PhD This study sought to assess and compare retrospective demographic and symptomatic erythematous ulcers on the buccal mucosa. Painful ulcers clinical data of oral lesions of lichen planus, pemphigus vulgaris, and mu- and/or blisters on the gingiva were the most common presentation for cous membrane pemphigoid from the records of the Department of Oral mucous membrane pemphigoid. Desquamative gingivitis was noted for all Pathology and Surgery, School of Dentistry, Universidade Federal de Minas 3 diseases, but mainly for mucous membrane pemphigoid. Overall, lesions Gerais, Brazil, covering a period of 55 years. Out of 25,435 specimens, were more frequent in white women >50 years. these immunologically mediated diseases accounted for 301 (1.18%) Oral manifestations of immunologically mediated diseases are relatively cases, of which 250 (0.98%) were lichen planus, 27 (0.11%) were rare, and the correct diagnosis can be a challenge for dentists as the pemphigus vulgaris, and 24 (0.09%) were mucous membrane pemphi- lesions often share similar clinical and demographic features. goid. Lichen planus presented mainly as white asymptomatic plaques on Received: June 28, 2012 buccal mucosa. Pemphigus vulgaris was usually characterized by multiple Accepted: February 19, 2013 ichen planus, pemphigus vulgaris, and are raised against cadherin-type cell Materials and methods mucous membrane pemphigoid are adhesion molecules of the squamous Biopsy charts were retrieved from the Lthe most frequent immunologically epithelium, generally desmoglein.3 Oral records of the Department of Oral mediated mucocutaneous diseases with oral lesions are a hallmark of pemphigus vul- Pathology and Surgery, School of involvement. Frequently, the first mani- garis and often herald the disease, being Dentistry, Universidade Federal de festations of these systemic illnesses are detected in almost every patient.12-15 It is Minas Gerais, Brazil. They comprised plaques or vesiculobullous, ulcerative, and/ accepted that it has a fairly strong genetic 25,435 cases from a period of 55 years. or erosive oral lesions. It is noteworthy that background, with a higher prevalence in Cases with a histopathological diag- the lesions in these 3 diseases and others people from the Mediterranean and South nosis of OLP, OPV, or OMMP were (infectious and noninfectious) have similar Asia, and in certain ethnic groups, such as considered for the study. H&E stained clinical and demographic characteristics, Ashkenazic Jews.16 sections were re-examined according to therefore the identification of a disease In mucous membrane pemphigoid, current criteria.5 Conflicting cases were based solely on oral lesions is a challenging the oral mucosa is often the first affected reviewed by 2 experienced oral patholo- issue for dentists, leading to a delay in the site, and it is exclusively involved in 85% gists in order to reach a consensus. Cases establishment of the correct diagnosis and of cases in the literature.5,17,18 In addi- showing clinical and histopathological suitable management of the patient. This tion, some patients may show systemic features suggestive of lichenoid reaction is especially crucial considering that pem- and severe complications, such as ocular were excluded. phigus vulgaris is a life-threatening disease involvement, which may culminate in Demographic data—gender, age, and with poor prognosis, and an early diagnosis symblepharon (adhesion between the skin color (white or nonwhite), along is critical for successful treatment.1-5 eyelid and the eyeball) and blindness.17,18 with the clinical features of the oral In lichen planus, T lymphocytes are The aim of this study was to retro- lesion (site, color, size, number of lesions, activated, leading to the destruction of the spectively assess and compare the demo- recurrence, evolution time, and symp- epithelial basal cell layer by apoptosis.5,6 A graphic data and clinical manifestations toms)—were retrieved from the charts. possible association between lichen planus of oral lichen planus (OLP), oral pem- Symptoms in oral lesions were defined and infectious diseases, such as chronic phigus vulgaris (OPV), and oral mucous as pain or a burning/itching sensation. hepatitis C, has been reported.7 While still membrane pemphigoid (OMMP) from The capacity in recognizing clinical a matter of debate, lichen planus is consid- the Oral and Maxillofacial Pathology presentations of OLP, OPV, or OMMP ered as at risk for malignant transforma- reference center of Minas Gerais, Brazil. was evaluated comparing the clinical tion, according to the latest World Health The authors intended to provide relevant diagnostic hypotheses described in the Organization classification of tumors.8-11 information about the similarities and charts with the final histopathological Pemphigus vulgaris is a severe and differences among these diseases, allow- diagnosis. Descriptive statistical analy- life-threatening autoimmune chronic ing dentists to improve their ability to sis was performed, and the study was mucocutaneous disorder. In this condi- properly recognize the main clinical approved by the Institutional Committee tion, mainly IgG serum autoantibodies presentations of each. of Ethics in Research. www.agd.org General Dentistry January/February 2014 67 Diagnosis of Oral Pathology Clinical and demographic overlaps among immunologically mediated oral diseases Table. Demographic and clinical data in number (%) regarding oral lesions of lichen planus (OLP), pemphigus vulgaris (OPV), and mucous membrane pemphigoid (OMMP). OLP OPV OMMP Total OLP OPV OMMP Total 250 (83.1) 27 (8.9) 24 (8.0) 301 (100) 250 (83.1) 27 (8.9) 24 (8.0) 301 (100) Gender Oral presentation Female 156 (62.4) 19 (70.4) 16 (66.7) 191 (63.5) Plaque 157 (62.8) 2 (7.4) 3 (12.5) 162 (53.8) Male 93 (37.2) 8 (29.6) 8 (33.3) 109 (36.2) Ulcer 37 (14.8) 16 (59.2) 11 (45.8) 64 (21.3) NA 1 (0.4) 0 0 1 (0.3) Macule 25 (10.0) 0 4 (16.6) 29 (9.6) Age (years) Papule 5 (2.0) 1 (3.7) 0 6 (2.0) 10-19 7 (2.8) 0 0 7 (2.3) Blister 1 (0.4) 8 (29.6) 11 (45.8) 20 (6.7) 20-29 23 (9.2) 2 (7.4) 4 (16.6) 29 (9.6) Tumor 1 (0.4) 0 0 1 (0.3) 30-39 56 (22.4) 7 (25.9) 3 (12.5) 66 (21.9) NA 35 (14.0) 5 (18.5) 1 (4.2) 41 (13.6) 40-49 63 (25.2) 7 (25.9) 3 (12.5) 73 (24.3) Desquamative gingivitis 50-59 50 (20.0) 6 (22.2) 5 (20.8) 61 (20.3) Yes 13 (5.2) 4 (14.8) 5 (20.8) 22 (7.3) 60-69 25 (10.0) 4 (14.8) 5 (20.8) 34 (11.3) No 0 0 0 0 70-79 8 (3.2) 0 3 (12.5) 11 (3.7) NA 237 (94.8) 23 (85.2) 19 (79.1) 279 (92.7) 80-89 1 (0.4) 0 0 1 (0.3) Symptomatic NA 17 (6.8) 1 (3.7) 1 (4.2) 19 (6.3) Yes 37 (14.8) 21 (77.7) 16 (66.7) 74 (24.6) Skin color No 172 (68.8) 0 5 (20.8) 177 (58.8) White 109 (43.6) 12 (44.4) 12 (50.0) 133 (44.2) NA 41 (16.4) 6 (22.3) 3 (12.5) 50 (16.6) Nonwhite 127 (50.8) 14 (51.8) 11 (45.8) 152 (50.5) Lesion color NA 14 (5.6) 1 (3.7) 1 (4.2) 16 (5.3) Whitish 161 (64.4) 1 (3.7) 2 (8.3) 164 (54.5) Site Erythematous 13 (5.2) 16 (59.2) 13 (54.2) 42 (14.0) Buccal mucosa 183 (73.2) 18 (66.6) 5 (20.8) 206 (68.4) Whitish and 45 (18.0) 0 4 (16.7) 49 (16.3) Tongue 60 (24.0) 8 (29.6) 0 68 (22.6) erythematous Gingiva 31 (12.4) 6 (22.2) 13 (54.1) 50 (16.6) Pink 3 (1.2) 1 (3.7) 2 (8.3) 6 (2.0) Lips 17 (6.8) 8 (29.6) 2 (8.3) 27 (9.0) Blackened 7 (2.8) 0 0 7 (2.3) Retromolar area 12 (4.8) 4 (14.8) 0 16 (5.3) Purple 0 1 (3.7) 0 1 (0.3) Alveolar mucosa 10 (4.0) 3 (11.1) 3 (12.5) 16 (5.3) NA 21 (8.4) 8 (29.6) 3 (12.5) 32 (10.6) Vestibular mucosa 7 (2.8) 2 (7.4) 1 (4.1) 10 (3.3) Abbreviation: NA, data not available. NA 4 (1.6) 1 (3.7) 3 (12.5) 8 (2.7) Results orthokeratinization, showing a typical Of the 250 cases diagnosed with OLP, Autoimmune diseases accounted for 301 degeneration of the basal layer, along the most affected site was the buccal (1.18%) of the total (25,435) cases: OLP with exocytosis. Immediately subjacent mucosa, followed by the tongue and 250 (0.98%), OPV 27 (0.11%), and to the epithelium was a dense, band-like gingiva. Multiple lesions were noticed OMMP 24 (0.09%). Considering only inflammatory infiltrate, composed pre- in 117 (46.8%) cases. Lesions were the 301 autoimmune disease cases, 83.1% dominantly of lymphocytes. Saw-toothed described as plaques in 157 (62.8%) of the cases were OLP, 8.9% were OPV, rete ridges and colloid (civatte) bodies cases, with a whitish color in 161 (64.4%) and 8.0% were OMMP. Demographic and could be seen in some cases (Fig.
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