Oral Lesions of Immune-Mediated and Autoimmune Diseases: A 12-year Experience at a Single Brazilian Referral Center.

BACKGROUND: Oral lesions of immune-mediated and autoimmune diseases have been well-documented, but studies from Brazil are limited. The varied spectrum of oral lesions within this demographic group poses challenges to clinicians, particularly when they occur in isolation. This study aimed to evaluate the occurrence, clinical characteristics, and management of patients with oral lesions of immune-mediated and autoimmune diseases at a single center in Brazil. METHODS: A retrospective cross-sectional study was conducted from 2010 to 2022. Clinicodemographic data, histopathological features, and treatment modalities were analyzed descriptively and analytically. RESULTS: Of the 3,790 oral and maxillofacial lesions diagnosed, 160 (4.2%) were confirmed as immune-mediated or autoimmune diseases. The population surveyed predominantly consisted of women (73.7%), with a mean age of 60.2 years. Oral lichen planus (51.3%), mucous membrane pemphigoid (MMP) (23.7%), and pemphigus vulgaris (PV) (19.4%) were the most prevalent lesions. The buccal mucosa (59.4%) was predominantly affected, with pain reported in 46.2% of cases, notably in individuals with PV and MMP. The average time to disease stabilization post-local and/or systemic corticosteroid therapy was 15.8 months for systemic lupus erythematosus, 8.7 months for MMP, and 6.5 months for PV. CONCLUSION: Although oral lesions related to immune-mediated and autoimmune diseases are uncommon, their diverse clinicopathological aspects require multidisciplinary management.

Mandibular bone imaging assessment in chronic kidney disease: a systematic review and meta-analysis.

OBJECTIVE: This systematic review and meta-analysis sought to assess the published research on mandibular cortical and trabecular bone patterns (TBPs) in individuals with chronic kidney disease (CKD) assessed by radiomorphometric index (RMI) analysis on dental radiographs. STUDY DESIGN: The review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. Observational studies that radiographically evaluated cortical and TBPs were analyzed. Risk of bias was assessed according to the Joanna Briggs Institute Critical Appraisal Checklists. Quality of evidence was evaluated using the Grading of Recommendations, Assessment, Development, and Evaluation approach. Meta-analysis was performed for studies using dichotomous models or verifying mean differences according to RMI type. RESULTS: Thirteen papers were included. Mandibular cortical index (MCI) and mental index (MI) were the most frequently evaluated RMIs. For MCI, the estimated risk ratio for decreased bone mineral density indicated by greater porosity in the cortices was 13.7% in CKD patients (95% confidence interval: 0.04-0.24; P = .008) when compared to healthy individuals. MI mean differences in CKD compared to control groups ranged from -0.5100 to -0.2000 mm. However, risk of bias was generally high and quality of evidence was very low. CONCLUSIONS: MCI and MI are useful screening tests in assessing bone patterns but must be evaluated with caution due to the risk of bias and low quality of evidence in the published literature.

Prevalence of human herpesvirus in plasma and saliva of cirrhotic patients: A pilot study.

AIMS: The objective of this study was to identify the presence of human herpesvirus (HHV) in the plasma and saliva of hepatic-cirrhosis patients and correlate it with clinical data and laboratory tests. This is a pilot, observational, and cross-sectional study. METHODS AND RESULTS: Specimens of plasma and saliva from 72 cirrhotic individuals were analyzed by means of polymerase chain reaction. The patient population had a mean age of 54.84 years old (SD ± 10) and was 70% males (51/72). Approximately 47% (n = 34) of the patients had leukopenia and HHV was not identified in the plasma specimens. The main species of HHV identified in the saliva were HHV-7 (n = 42, 62%) and Epstein-Barr virus (EBV) (n = 30, 41%). Moreover, there was a significant decrease in the total number of leukocytes and lymphocytes in saliva containing EBV (P = .038 and P = .047, respectively). CONCLUSION: The results show that the presence of EBV in the saliva of cirrhotic patients was correlated with their circulating immune status. It may be possible that the immune dysfunction displayed by the cirrhotic patients plays a role in the shedding of EBV into saliva.

Oral lesions of systemic lupus erythematosus: A collaborative Latin American study.

BACKGROUND: Systemic lupus erythematosus (SLE) is a multifactorial autoimmune disease that may affect the oral mucosa. The variable spectrum of oral lesions observed in SLE can pose challenges in diagnosis, particularly when the lesions occur in isolation. The aim of this study was to describe the oral lesions occurring in patients with SLE from Latin America. METHODS: This collaborative record-based study involving 11 oral and maxillofacial pathology and medicine services across Venezuela, Argentina, Chile, Brazil, and Mexico describes the clinicopathological profile of SLE-related oral lesions. RESULTS: Seventy patients with SLE and oral lesions were included in the study. The majority were females (75.7%; female/male ratio: 3.1:1) and white (62.1%), with a mean age of 38.4 years (range: 11-77 years). The most common site of oral lesions was the hard/soft palate (32.0%). Clinically, oral lesions predominantly presented as ulcers (26.6%), erosions (26.6%), and white lesions (23.4%). Isolated oral lesions occurred in 65.2% of individuals, while cutaneous manifestations occurred in 80.3%. The main clinical diagnostic hypothesis in 71.4% of cases was an immune-mediated disease. Oral biopsies followed by histopathological analysis were performed in 50 cases. CONCLUSION: Oral lesions of SLE exhibit a variety of clinical and histopathological features. A key point in diagnosis is that unusual oral changes without an obvious local cause may indicate a possible systemic condition presenting with oral lesions. A multidisciplinary approach, which includes regular oral examination, is warranted to identify oral lesions and provide treatment.

What are the main oral manifestations in heart transplant patients? A scoping review.

OBJECTIVE: The purpose of this scoping review is to evaluate the oral manifestations (OM) of heart transplant (HT) patients undergoing immunosuppressive therapy (IT). MATERIAL AND METHODS: A literature search was performed using keywords and MeSH terms related to OM and HT in the Medline/PubMed, Web of Science, Cochrane Library, Scopus, LILACS/BBO databases and in gray literature without language or date restrictions until June 2023. Studies that evaluated HT individuals who used any IT and who reported the occurrence of OM were considered eligible. The results from the search were imported to EndNote Web, and duplicates were removed followed by title/abstract and full-text analysis. RESULTS: A total of 402 nonduplicated studies were found and 13 fulfilled the criteria and were included in the present review: 10 cross-sectional, 2 cohorts, and 1 clinical trial. The most reported OM were periodontal diseases, including drug-induced gingival enlargement (DIGE), gingival bleeding, gingivitis, and periodontitis. Reported in a minority of studies are oral cancer, opportunistic infections (oral hairy leukoplakia and erythematous candidiasis), enamel defects, and burning mouth. CONCLUSION: Considering the methodological heterogeneity of the studies analyzed, DIGE is the most commonly observed oral manifestation in HT individuals.

Lesions in the oral mucosa associated with the use of checkpoint inhibitors: A bibliometric and critical review.

AIMS: Immune-related adverse events (irAEs) linked to the use of immune checkpoint inhibitors (ICIs) have become increasingly frequent. To perform a bibliometric and critical review of the general panorama of publications on oral mucosal lesions (OML) associated with ICIs. METHODS AND RESULTS: Systematized searches were performed in four databases. The included studies were organized and bibliometric and clinical data were extracted and analyzed using VantagePoint and Microsoft Excel. Most of the 35 included studies were reports or case series (n = 33/94.2%). The American authors stood out (n = 17/48.5%), with the majority presenting only one publication. Independent groups carried out most of the publications (n = 31/88.5%). Over the years, publications have increased for users of nivolumab and pembrolizumab. In 21 studies (60%), OML were more common in men, between the 6th and 9th decades of life and who had lung carcinoma (n = 13/37.1%). Pembrolizumab (n = 17/48.5%) was the most used ICI. The patients were affected by one or more OML, including: ulcers (n = 28/80%) and erythema (n = 11/31.4%). Systemic corticosteroids (n = 24/68.5%) and the discontinuation of ICI use (n = 18/51.4%) were the main approaches used. CONCLUSION: OML related to the use of ICIs have become increasingly common. More accurate data need to be published.

Diagnosis and management of exuberant palatal pyogenic granuloma in a systemically compromised patient - Case report.

AIM: To discuss the diagnosis and treatment of an exuberant oral pyogenic granuloma (OPG) in the palatal region in a systemically compromised patient. METHODS AND RESULTS: A 50-year-old woman presented with extensive and painless nodular mass that extended throughout the palatal region, with difficulty speaking, swallowing and spontaneous bleeding for 6 months. Her medical history showed poorly controlled type II diabetes mellitus and hypertension. The intraoral physical examination also revealed poor oral hygiene and periodontal disease. After clinical and radiographic evaluation, the presumptive diagnosis of OPG was made and complete excision of the lesion was performed. Local hemostatic measures were employed to control bleeding. Microscopic evaluation showed a lobulated lesion composed of many blood capillaries confirming the diagnostic hypothesis. CONCLUSIONS: In summary, individuals with severe periodontal disease and systemic disorders may present exacerbated clinical presentations of OPG.

Orofacial Manifestations in a Middle-Aged Woman with Cowden Syndrome: A Case Image.

A 56-year-old Brazilian woman sought dental care, presenting with multiple asymptomatic papillomatous lesions with a coalescent pattern and intermingled cobblestone-like clefts along the alveolar ridge and marginal and attached gingivae. Multiple whitish papules were also observed on the face, neck, and limbs. Incisional biopsies of these lesions were performed. Microscopically, the skin lesion revealed epithelial clear cells and intraepithelial keratinization with areas of orthokeratosis, while the gingival lesions showed a parakeratinized stratified squamous epithelium with collagenous connective tissue. These features were consistent with those of a trichilemmoma and fibroepithelial hyperplasia, respectively. This article illustrates a case of Cowden syndrome (CS), a rare multisystem genetic condition in which both cutaneous and mucosal tissues were affected. Fewer than 40 cases of CS with oral involvement affecting middle-aged adults have been documented hitherto.

Orofacial manifestations in Brazilian people living with HIV/AIDS under long-term antiretroviral therapy: a cross-sectional study.

OBJECTIVE: The aim of this study was to assess the prevalence of orofacial manifestations in a Brazilian cohort of people living with HIV/AIDS (PLWHIV) using long-term combined antiretroviral therapy (cART) and to correlate the presence of these manifestations with clinical and laboratory characteristics. STUDY DESIGN: A cross-sectional observational study evaluated 101 Brazilian PLWHIV. Demographic characteristics, medical history, and laboratory data were collected. Physical examination and measurement of stimulated salivary flow were performed. RESULTS: The study included 101 participants who were mainly male (61%) and White (73%), with an average age of 48 years, using long-term cART. The most common oral manifestations were facial lipoatrophy (33%), xerostomia (30%), and salivary gland enlargement (12%). Facial lipoatrophy was linked to a longer duration of cART use (P = .002), whereas hairy leukoplakia was linked to a detectable viral load (P = .031). The salivary flow of <0.7 mL/min was associated with an HIV infection time >20 years (P = .023). CONCLUSIONS: People living with HIV/AIDS who use cART often experience facial lipoatrophy, xerostomia, and bilateral enlargement of the parotid glands. Although opportunistic infections and malignant neoplasms are not frequent occurrences, they can still arise.

Recurrent chronic suppurative osteomyelitis in the maxilla of a patient with diabetes mellitus and glucose-6-phosphate dehydrogenase deficiency.

AIMS: To report the case of chronic osteomyelitis of a maxilla in a woman with uncontrolled diabetes mellitus (DM), glucose-6-phosphate dehydrogenase (G6PD) deficiency and mental illness, in an attempt to clarify its pathogenesis and treatment. METHODS AND RESULTS: A case of a woman with moderate G6PD deficiency (Class III) who developed bilateral and asynchronous chronic suppurative osteomyelitis (CSO) of her maxilla with extensive bone sequestra, fistulae and whose management was performed by local surgery for bony sequestra and fistulae removal; closure communication under 4 weeks antibiotic cover. CONCLUSIONS: CSO of the jaw may be a complication of the G6PD deficiency and DM and its severity depends on patient's medical status.

Oral manifestations of autoimmune polyglandular syndrome type 1.

AIMS: Autoimmune polyglandular syndrome type I (APS-I) is a rare condition of autosomal recessive and monogenic inheritance, which is characterized clinically by at least two signs of the classic triad: mucocutaneous candidosis, hypoparathyroidism, and Addison's disease. This study aims to report the oral manifestations of APS-I in a 42-year-old woman, who attended the Special Care Dentistry Center. METHODS AND RESULTS: The patient presented with hypoparathyroidism, diabetes mellitus, and autoimmune hepatitis. Chronic hyperplastic candidosis (CHC) was the main oral manifestation and it was diagnosed based on clinical and cytologic characteristics. Microstomia, angular cheilitis, xerostomia, enamel hypoplasia, and microdontia were also present. CONCLUSIONS: CHC was treated with topical nystatin and oral fluconazole, resulting in a significant improvement of the lesions.

Nitrogenous compounds in the saliva and blood of cirrhotic patients: a cross-sectional study.

OBJECTIVES: Serum increase of nitrogenous compounds (NC) in cirrhotic patients has been associated with the development of hepatic encephalopathy (HE). However, the relation between NC in saliva and HE is unclear. The objective of this study is to measure the levels of nitric oxide and urea in the blood and saliva in 38 cirrhotic patients and correlate them with clinical characteristics and presence and grades of HE. MATERIAL AND METHODS: Automated enzymatic colourimetric assays were performed to determine the levels of NC. Diagnosis and severity of HE were determined based on the West Haven criteria and by using the inhibitory control test. RESULTS: HE was diagnosed in 89.47% of the patients, with the majority (60.50%) presenting covert HE. With regard to the measurement of NC, although nitric oxide is moderately correlated with its amount in blood and saliva (r = 0.630; P < 0.001), only salivary levels were associated with the presence of ascites and ecchymosis (P = 0.013 and P = 0.030, respectively). In patients with HE, the serum levels of urea were higher (P = 0.013) than those in patients without HE or minimal HE. CONCLUSIONS: Nitrogenous compounds in the saliva were correlated with neither the presence nor grades of HE, whereas in the blood, only urea was positively correlated with the severity and presence of HE. CLINICAL RELEVANCE: Saliva is an excellent fluid for diagnosing several diseases, but it does not seem to be able to collaborate with the identification of HE.

Oral lichen planus and HCV infection.

Chronic infection by hepatitis C virus (HCV) can lead not only to the development of hepatic cirrhosis, but also to the emergence of extra-hepatic manifestations (EHMs), such as oral lichen planus (OLP). Here, we describe a clinical presentation of massive, erosive OLP in an HCV-positive patient whose clinical management was difficult. Full remission was achieved after sustained virological response by using direct-acting anti-retrovirals. This case report demonstrates not only the importance of diagnosing EHMs for identification of HCV infection, but also the importance of controlling it for management of OLP and EHMs.

Diagnosis and management of oral ulcerations associated with mycophenolate mofetil in kidney transplantation.

AIMS: The final diagnosis of oral mucosal ulcerations in solid organ transplant recipients represents a challenge. We describe a unique case of oral ulceration related to mycophenolate mofetil (MMF) toxicity, 11 years after kidney transplantation, whose dose reduction was sufficient to resolve it. METHODS AND RESULTS: A 54-year-old female patient, who underwent kidney transplantation 11 years ago, presents multiple ulcers on the buccal mucosa bilaterally, soft palate and tongue dorsum, for 8 months, with moderate pain. The diagnosis of oral ulcerations associated with MMF therapy was assumed by excluding infection and malignancy diagnosis. After MMF dose reduction, the oral ulcers healed utterly. CONCLUSIONS: MMF toxicity manifested as oral ulcers. Reduction or discontinuation of MMF therapy should be considered in a patient with refractory oral ulcers and a negative workup for other causes.

Can immunohistochemical biomarkers distinguish epithelial dysplasia degrees in actinic cheilitis? A systematic review and meta-analysis

BACKGROUND: Actinic cheilitis (AC) is a potentially malignant disorder of the lip, characterized by epithelial and connective tissue alterations caused by chronic exposure to ultraviolet radiation. In the past decades, diverse studies have been conducted in lip carcinogenesis and many biomarkers have been identified in lip lesions, yet there is no scientific evidence that determines its usefulness in the clinical setting or in histopathological routine. Therefore, we conducted the first systematic review in this field to summarize the results of published studies on immunohistochemical biomarkers in lip carcinogenesis, to evaluate if there is a marker than can distinguish the different histological grades of AC. MATERIAL AND METHODS: Retrospective studies that investigated immunohistochemical biomarkers in AC defined on standardised histological assessment were gathered from five databases and evaluated. Each study was quali-tatively evaluated using the Critical Appraisal Tools from SUMARI. RESULTS: The proliferation marker Ki-67 was the most studied biomarker and we observed, through meta-analysis, that it was differently expressed between AC and lip cancer, but not in AC subgroups. Most articles had a high risk of bias. CONCLUSIONS: In summary, the literature lacks quality follow up studies in actinic cheilitis. Multi-centre cohort studies, with patients stratified by treatment type and the use of image analysis software, could be the solution to further address the issues of investigating potentially malignant lesions and help change clinical practice, in terms of individualizing patients' treatment and prognosis prediction

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Oral lichen planus and HCV infection

Chronic infection by hepatitis C virus (HCV) can lead not only to the development of hepatic cirrhosis, but also to the emergence of extra-hepatic manifestations (EHMs), such as oral lichen planus (OLP). Here, we describe a clinical presentation of massive, erosive OLP in an HCV-positive patient whose clinical management was difficult. Full remission was achieved after sustained virological response by using direct-acting anti-retrovirals. This case report demonstrates not only the importance of diagnosing EHMs for identification of HCV infection, but also the importance of controlling it for management of OLP and EHMs.

Supernumerary teeth in a patient with Turner syndrome: An unusual finding.

AIMS: Turner syndrome (TS) is a genetic disorder associated with abnormalities of the X-chromosome, occurring in about 1 in 2000 to 1 in 3000 live-born girls. We present a case of a 14-year-old girl with TS, who was referred to our outpatient clinic in 2016 because of an ectopic eruption. METHODS AND RESULTS: Dental clinical examination and radiographic investigation revealed eight supernumerary teeth, short roots, enamel hypoplasia, increased overjet, rotation and displacement of teeth, moderate gingivitis and morphological alteration of the upper right central incisor. Dental treatment included extraction of erupted supernumerary teeth, composite resin restoration, supragingival scaling and oral hygiene for plaque control. CONCLUSIONS: The unpublished finding of supernumerary teeth in our patient has led us to suggest the investigation of this dental developmental anomaly in other patients with Turner syndrome.