Oral Lesions in Autoimmune Bullous Diseases: An Overview of Clinical Characteristics and Diagnostic Algorithm

Proposal of a modified technique of Nikolsky's sign in oral autoimmune vesiculobullous diseases

Nikolsky's sign, originally described for skin lesions, presents challenges when applied to the oral mucosa. To address this, a modified Nikolsky's sign has been proposed specifically for the oral mucosa. In this variant, a gentle breath of air from the air syringe embedded in the dental unit is used to inflate a pre-existing collapsed blister (non-induced technique). Alternatively, in the induced technique, a healthy peri-lesion mucosal site is gently scratched with a blunt dental tool, and after a few minutes, air is blown on the same area to inflate any newly formed blister. The sign is considered positive if a blister is raised from the blown surface. The described modified Nikolsky's sign improves the visualization of oral vesicles and blisters in a cost-effective, easy, and minimally invasive manner. Its elicitation can aid in referring patients to specialized tertiary care units.

Classification-Predictive Model Based on Artificial Neural Network Validated by Histopathology and Direct Immunofluorescence for the Diagnosis of Oral Lichen Planus

The diagnosis of oral lichen planus (OLP) poses many challenges due to its nonspecific clinical symptoms and histopathological features. Therefore, the diagnostic process should include a thorough clinical history, immunological tests, and histopathology. Our study aimed to enhance the diagnostic accuracy of OLP by integrating direct immunofluorescence (DIF) results with clinical data to develop a multivariate predictive model based on the Artificial Neural Network. Eighty patients were assessed using DIF for various markers (immunoglobulins of classes G, A, and M; complement 3; fibrinogen type 1 and 2) and clinical characteristics such as age, gender, and lesion location. Statistical analysis was performed using machine learning techniques in Statistica 13. The following variables were assessed: gender, age on the day of lesion onset, results of direct immunofluorescence, location of white patches, locations of erosions, treatment history, medications and dietary supplement intake, dental status, smoking status, flossing, and using mouthwash. Four statistically significant variables were selected for machine learning after the initial assessment. The final predictive model, based on neural networks, achieved 85% in the testing sample and 71% accuracy in the validation sample. Significant predictors included stress at onset, white patches under the tongue, and erosions on the mandibular gingiva. In conclusion, while the model shows promise, larger datasets and more comprehensive variables are needed to improve diagnostic accuracy for OLP, highlighting the need for further research and collaborative data collection efforts.

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.

Eosinophils in Oral Disease: A Narrative Review

The prevalence of diseases characterised by eosinophilia is on the rise, emphasising the importance of understanding the role of eosinophils in these conditions. Eosinophils are a subset of granulocytes that contribute to the body's defence against bacterial, viral, and parasitic infections, but they are also implicated in haemostatic processes, including immunoregulation and allergic reactions. They contain cytoplasmic granules which can be selectively mobilised and secrete specific proteins, including chemokines, cytokines, enzymes, extracellular matrix, and growth factors. There are multiple biological and emerging functions of these specialised immune cells, including cancer surveillance, tissue remodelling and development. Several oral diseases, including oral cancer, are associated with either tissue or blood eosinophilia; however, their exact mechanism of action in the pathogenesis of these diseases remains unclear. This review presents a comprehensive synopsis of the most recent literature for both clinicians and scientists in relation to eosinophils and oral diseases and reveals a significant knowledge gap in this area of research.

Ocular involvement in oral vesiculobullous diseases: A review on reported cases in the literature

Introduction

Vesiculobullous disorders are a group of autoimmune diseases manifesting as chronic ulcers in the oral cavity. Ocular involvement may accompany oral ulcers and cause various problems for patients. This review summarizes the data regarding ocular involvement in patients with oral vesiculobullous.

Methods

Web of Science, Scopus, PubMed/MEDLINE, and Embase electronic databases were searched according to related keywords. Finally, 58 articles were included, all of which were case reports or series. Characteristics such as the age and sex of patients, location and type of oral lesion, type of ophthalmic injury, the interval between oral and ocular lesion, and treatment of oral and ocular disorders were summarized in tables.

Results

Eye involvement was 1.6 times more prevalent in women, and most patients were between 30 and 60 years old (67.4 %). Pemphigus vulgaris accounted for almost half of the cases (48.4 %), though lichen planus is more prevalent in the general population. The most frequently affected oral site was the buccal mucosa (17.5 %), and oral ulcers usually presented as erythema, erosion, or inflammation (22.7 %). Conjunctivitis was the most common type of eye involvement (18.4 %), and ophthalmic lesions regularly appeared 12-60 months after the development of oral lesions (30.1 %). Blindness was reported in only one case. Corticosteroids and immunosuppressives were the most frequent oral and ocular lesion therapies.

Conclusion

Considering the serious burdens of any ocular injury, monitoring the ocular health of patients with oral vesiculobullous diseases is highly recommended in high-risk cases, especially middle-aged women with oral pemphigus vulgaris.

Convolutional neural network misclassification analysis in oral lesions: an error evaluation criterion by image characteristics

OBJECTIVE

This retrospective study analyzed the errors generated by a convolutional neural network (CNN) when performing automated classification of oral lesions according to their clinical characteristics, seeking to identify patterns in systemic errors in the intermediate layers of the CNN.

STUDY DESIGN

A cross-sectional analysis nested in a previous trial in which automated classification by a CNN model of elementary lesions from clinical images of oral lesions was performed. The resulting CNN classification errors formed the dataset for this study. A total of 116 real outputs were identified that diverged from the estimated outputs, representing 7.6% of the total images analyzed by the CNN.

RESULTS

The discrepancies between the real and estimated outputs were associated with problems relating to image sharpness, resolution, and focus; human errors; and the impact of data augmentation.

CONCLUSIONS

From qualitative analysis of errors in the process of automated classification of clinical images, it was possible to confirm the impact of image quality, as well as identify the strong impact of the data augmentation process. Knowledge of the factors that models evaluate to make decisions can increase confidence in the high classification potential of CNNs.

Oral mucous membrane pemphigoid: updates in diagnosis and management

Mucous membrane pemphigoid (MMP) is a rare, immune-mediated, vesiculobullous disease that predominantly affects the oral cavity and conjunctiva. In MMP, autoantibodies are directed against hemidesmosomal proteins in the basement membrane zone, most commonly BP180. Clinical signs and symptoms include gingival desquamation, erosions, and ulcerations. Differential diagnoses include other immune-mediated blistering diseases, such as bullous pemphigoid. Definitive diagnosis is reached through history taking, physical examination, tissue biopsy and/or serology testing. MMP, although not curable, is typically managed with topical or systemic corticosteroids, in addition to immunosuppressive therapies and biologic agents in recalcitrant cases. Untreated MMP can lead to life-threatening complications, such as blindness. As a condition that affects the oral cavity, it is important that dentists understand how to recognise, diagnose and manage the disease.

Topical applications of heterologous platelet rich plasma (PRP) for refractory gingival lesions in autoimmune blistering diseases

BACKGROUND

Recalcitrant gingival erosions, blisters and desquamative gingivitis are common features in oral autoimmune blistering diseases (AIBD). First line treatments include high-dosage corticosteroids and other immunosuppressive drugs, with several side effects and elevated number of recurrences. Autologous platelet-rich plasma (PRP) has been recently introduced as an alternative treatment and its use seems to be promising and safe.

METHODS

In this study we describe the use of topical application of heterologous PRP in nine patients affected by mucous membrane pemphigoid, with gingival lesions refractory to previous treatments. Topical applications of PRP were performed once a week for 2 months and the endpoint for clinical evaluation was set 3 months after the last session. Oral disease severity score (ODSS) and VAS scores for pain measurement were recorded before and after treatment.

RESULTS

The procedure was painless, well accepted, and free from adverse reactions. All patients (100%) reported a reduction in VAS whereas reduction in ODSS was observed in 89% of patients.

CONCLUSIONS

Within the limits of the study, topical heterologous PRP is a safe and promising procedure to be studied in future controlled randomized trials as adjuvant treatment for refractory gingival lesions in patients with AIBDs.

Gingival Manifestations in Oral Chronic Autoimmune Bullous Diseases: A Retrospective Study

Background and Objectives: Desquamative gingivitis (DG) is a clinical term indicating "peeling gums" and is associated with different oral manifestations. In this study, we aimed to assess the association between DG and autoimmune blistering mucocutaneous diseases (ABMD) with oral manifestations. Materials and Methods: A retrospective study including 88 patients diagnosed between 1998 and 2019 with ABMD (intraepithelial and subepithelial autoimmune blistering diseases) was performed at the Oral Medicine Department, Faculty of Dentistry, "Carol Davila" University of Medicine and Pharmacy in Bucharest. For each patient, the sociodemographic and anamnestic data, as well as clinical features of oral lesions (location), histological evaluation, and direct immunofluorescence data were collected. Results: Most of the patients involved in the study were female (78.4%). In total, 34 patients (38.63%) were diagnosed with subepithelial autoimmune diseases (SAD) and 54 (61.36%) had intraepithelial autoimmune diseases (IAD). Differences in the anatomic distribution of oral involvement were found between SAD and IAD. The presence of DG was significantly more common in patients with SAD compared to those with a diagnosis of IAD. Conclusions: Specific anatomical locations of the oral lesions are significantly associated with different subtypes of ABMD, with gingiva and hard palate mucosa being more involved in SAD and the soft palate and buccal mucosa in IAD. Desquamative gingivitis is a clinical sign that raises diagnostic challenges for several conditions in oral medicine.

Assessing ST18 gene polymorphisms (rs17315309, rs2304365) in Iraqi patients with Pemphigus vulgaris

Pemphigus vulgaris (PV) is a potentially fatal autoimmune disease characterized by blistering of the skin, mucous membranes, and oral cavity. Genetics are implicated in its etiology, with the ST18 gene identified as a potential risk factor for pemphigus in certain populations, suggesting its role as a novel molecular target for therapeutic intervention. This study aimed to detect single nucleotide polymorphisms (SNPs) rs17315309 A/G and rs2304365 C/G in the ST18 gene among Iraqi/Arabic patients with PV. A total of 90 Iraqi subjects participated in this study, including 45 patients diagnosed with PV and 45 healthy controls. SNP analysis was performed using High-Resolution Melt Analysis (HRMA) with Eva Green I Dye. For SNP rs17315309 A/G, the distribution of heterozygous genotypes showed highly significant differences between the patient and healthy groups (P = 0.005), with the mutant G-allele being significantly more prevalent in patients than in the healthy group (P = 0.001). In contrast, for SNP rs2304365 C/G, the distribution of heterozygous and mutant genotypes did not differ significantly between patients and healthy individuals (P = 0.8 and P = 0.3, respectively), with the mutant G-allele also showing no significant difference (P = 0.4). Our data indicate a significant association between PV and the rs17315309 A/G SNP in the ST18 gene among the Iraqi population of Arabic origin. However, no association was found between patients with PV and the rs2304365 C/G SNP in the same gene.

Optimal biopsy site for the diagnosis of oral pemphigus vulgaris and mucous membrane pemphigoid: a systematic review and meta-analysis

The aim of this study was to critically evaluate the diagnostic yields of direct immunofluorescence (DIF) analysis on perilesional and normal-appearing mucosa biopsy samples, to determine the optimal biopsy site for patients presenting with oral pemphigus vulgaris (PV) or mucous membrane pemphigoid (MMP). Electronic databases and article bibliographies were searched in December 2022. The primary outcome was the rate of DIF positivity. Of 374 records identified after the elimination of duplicates, 21 studies with 1027 samples were ultimately included. Meta-analysis revealed a pooled DIF positivity rate of 99.6% (95% confidence interval (CI) 97.4-100.0%, I2 = 0%) for PV and 92.6% (95% CI 87.9-96.5%, I2 = 44%) for MMP for biopsies from perilesional sites, and of 95.4% (95% CI 88.6-99.5%, I2 = 0%) for PV and 94.1% (95% CI 86.5-99.2%, I2 = 42%) for MMP for biopsies from normal-appearing sites. For MMP, there was no significant difference in the rate of DIF positivity between the two biopsy sites (odds ratio 1.91, 95% CI 0.91-4.01, I2 = 0%). The results suggest that the perilesional mucosa remains the optimal biopsy site for DIF diagnosis of oral PV, while the normal-appearing mucosa biopsy is optimal for oral MMP.

Detection of Abnormal Changes on the Dorsal Tongue Surface Using Deep Learning

Background and Objective: The tongue mucosa often changes due to various local and systemic diseases or conditions. This study aimed to investigate whether deep learning can help detect abnormal regions on the dorsal tongue surface in patients and healthy adults. Materials and Methods: The study collected 175 clinical photographic images of the dorsal tongue surface, which were divided into 7782 cropped images classified into normal, abnormal, and non-tongue regions and trained using the VGG16 deep learning model. The 80 photographic images of the entire dorsal tongue surface were used for the segmentation of abnormal regions using point mapping segmentation. Results: The F1-scores of the abnormal and normal classes were 0.960 (precision: 0.935, recall: 0.986) and 0.968 (precision: 0.987, recall: 0.950), respectively, in the prediction of the VGG16 model. As a result of evaluation using point mapping segmentation, the average F1-scores were 0.727 (precision: 0.717, recall: 0.737) and 0.645 (precision: 0.650, recall: 0.641), the average intersection of union was 0.695 and 0.590, and the average precision was 0.940 and 0.890, respectively, for abnormal and normal classes. Conclusions: The deep learning algorithm used in this study can accurately determine abnormal areas on the dorsal tongue surface, which can assist in diagnosing specific diseases or conditions of the tongue mucosa.

Prevalence of immune mediated vesiculobullous lesions among patients visiting a private dental hospital with special emphasis on gingival manifestation

Background and Aim

Vesiculobullous lesions are a group of mucocutaneous lesions that are predominantly immune-mediated but may also have a genetic or viral origin. The most common site of occurrence is buccal mucosa, whereas the number of cases involving gingiva is comparatively low. Based on the literature, although numerous studies have reported the prevalence of vesiculobullous lesions in the nonkeratinized epithelium, there is a dearth of knowledge about its occurrence in keratinized oral mucosa, especially gingiva. The objective of the study was to assess the prevalence of immune-mediated oral vesiculobullous lesions emphasizing the occurrence in keratinized mucosa, especially the gingiva, among patients visiting a private dental hospital.

Materials and Methods

The study was conducted in a private teaching dental institute and hospital setting. Out of 615 incisional biopsies received in the department of oral pathology, between June 2019 and April 2021, n = 22 samples were immune-mediated vesiculobullous lesions confirmed by clinical and histopathological diagnosis after eliminating lesions of viral origin. Patient details including age, gender, site, duration, and systemic illness were collected from the digital information archiving software and analyzed by appropriate statistics using SPSS software.

Results

Based on the results, 95.5% of the patients had histopathological features of intraepithelial clefting and only 4.5% of them showed subepithelial clefting. Female predilection was 6.3:1. The most common site of involvement was nonkeratinized mucosa (36.36%) and 59.09% of the patients presented with systemic illness.

Conclusion

The study shows most of the features of pemphigus is consistent in gingiva and other parts of oral mucosa. The dental practitioners should be aware of the various oral manifestations of such lesions to ensure accurate diagnosis and adequate treatment.

S2k guidelines on the management of paraneoplastic pemphigus/paraneoplastic autoimmune multiorgan syndrome initiated by the European Academy of Dermatology and Venereology (EADV)

BACKGROUND

Paraneoplastic pemphigus (PNP), also called paraneoplastic autoimmune multiorgan syndrome (PAMS), is a rare autoimmune disease with mucocutaneous and multi-organ involvement. PNP/PAMS is typically associated with lymphoproliferative or haematological malignancies, and less frequently with solid malignancies. The mortality rate of PNP/PAMS is elevated owing to the increased risk of severe infections and disease-associated complications, such as bronchiolitis obliterans.

OBJECTIVES

These guidelines summarize evidence-based and expert-based recommendations (S2k level) for the clinical characterization, diagnosis and management of PNP/PAMS. They have been initiated by the Task Force Autoimmune Blistering Diseases of the European Academy of Dermatology and Venereology with the contribution of physicians from all relevant disciplines. The degree of consent among all task force members was included.

RESULTS

Chronic severe mucositis and polymorphic skin lesions are clue clinical characteristics of PNP/PAMS. A complete assessment of the patient with suspected PNP/PAMS, requiring histopathological study and immunopathological investigations, including direct and indirect immunofluorescence, ELISA and, where available, immunoblotting/immunoprecipitation, is recommended to achieve a diagnosis of PNP/PAMS. Detection of anti-envoplakin antibodies and/or circulating antibodies binding to the rat bladder epithelium at indirect immunofluorescence is the most specific tool for the diagnosis of PNP/PAMS in a patient with compatible clinical and anamnestic features. Treatment of PNP/PAMS is highly challenging. Systemic steroids up to 1.5 mg/kg/day are recommended as first-line option. Rituximab is also recommended in patients with PNP/PAMS secondary to lymphoproliferative conditions but might also be considered in cases of PNP/PAMS associated with solid tumours. A multidisciplinary approach involving pneumologists, ophthalmologists and onco-haematologists is recommended for optimal management of the patients.

CONCLUSIONS

These are the first European guidelines for the diagnosis and management of PNP/PAMS. Diagnostic criteria and therapeutic recommendations will require further validation by prospective studies.

Identification of Six microRNAs as Potential Biomarkers for Pemphigus Vulgaris: From Diagnosis to Pathogenesis

BACKGROUND

Pemphigus vulgaris (PV) is a potentially fatal autoimmune bullous disease. The role of microRNA (miRNA, miR) in the diagnosis and pathogenesis of PV remains unknown. This study aims to provide potential miRNA biomarkers for PV diagnosis and therapy options.

METHODS

Serum samples were obtained from 22 PV patients, 15 mucous membrane pemphigoid (MMP) patients, and 10 normal controls (NC). Total RNA was extracted from the serum samples, and 12 selected miRNAs were detected by quantitative real-time polymerase chain reaction (qRT-PCR). Bioinformatic analyses including target gene prediction and enrichment analysis were performed.

RESULTS

Twelve miRNAs were increased in the serum of the PV group compared with the NC group, in which six miRNAs had good efficacy to diagnose PV from MMP with the area under the receiver operator characteristic curves of 0.970 to 0.988. A series test for the combination of miR-584-5p and miR-155-5p reached the sensitivity and specificity of 95.5% and 100%. Bioinformatic analysis revealed target gene enrichment in the cell adhesion pathways, immune-relating pathways, and P38 mitogen-activated protein kinases signaling pathway.

CONCLUSION

The study provides new insights and targets of miRNAs for the precise diagnosis and the exploration of pathogenesis for PV, which may serve as a reference for further research into autoimmune bullous diseases.

Immunoglobulin Disorders and the Oral Cavity: A Narrative Review

The oral mucosa is a mechanical barrier against the penetration and colonization of microorganisms. Oral homeostasis is maintained by congenital and adaptive systems in conjunction with normal oral flora and an intact oral mucosa. Components contributing to the defense of the oral cavity include the salivary glands, innate antimicrobial proteins of saliva, plasma proteins, circulating white blood cells, keratinocyte products of the oral mucosa, and gingival crevicular fluid. General disturbances in the level of immunoglobulins in the human body may be manifested as pathological lesions in the oral mucosa. Symptoms of immunoglobulin-related general diseases such as mucous membrane pemphigoid (MMP), pemphigus vulgaris (PV), linear IgA bullous dermatosis (LABD), Epidermolysis Bullosa Aquisita (EBA), and Hyper-IgE syndrome (HIES) may appear in the oral cavity. In this review, authors present selected diseases associated with immunoglobulins in which the lesions appear in the oral cavity. Early detection and treatment of autoimmune diseases, sometimes showing a severe evolution (e.g., PV), allow the control of their dissemination and involvement of skin or other body organs. Immunoglobulin disorders with oral manifestations are not common, but knowledge, differentiation and diagnosis are essential for proper treatment.

Desquamative Gingivitis in the Context of Autoimmune Bullous Dermatoses and Lichen Planus-Challenges in the Diagnosis and Treatment

Desquamative gingivitis (DG) is a clinical term that describes erythema, desquamation and erosions of the gingiva, of various etiologies. Although the clinical aspect is not specific for a certain disease, an accurate diagnosis of the underlying disorder is necessary because the disease course, prognosis and treatment vary according to the cause. DG may inflict significant oral discomfort, which is why patients typically present to the dentist for a first consultation, rendering it important for these specialists to be informed about this condition. Our paper aims to review the ethiopatogenesis and diagnostic approach of DG, focusing on the most common underlying disorders (autoimmune bullous dermatoses and lichen planus) and on the management of these patients. Potential etiological agents leading to an inflammatory immune response in the oral mucosa and DG appearance include genetic predisposition, metabolic, neuropsychiatric, infectious factors, medication, dental materials, graft-versus-host reaction and autoimmunity. A thorough anamnesis, a careful clinical examination, paraclinical explorations including histopathological exam and direct immunofluorescence are necessary to formulate an appropriate diagnosis. Proper and prompt management of these patients lead to a better prognosis and improved quality of life, and must include management in the dental office with sanitizing the oral cavity, instructing the patient for rigorous oral hygiene, periodic follow-up for bacterial plaque detection and removal, as well as topical and systemic therapy depending on the underlying disorder, based on treatment algorithms. A multidisciplinary approach for the diagnosis and follow-up of DG in the context of pemphigus vulgaris, bullous pemphigoid, cicatricial pemhigoid or lichen planus is necessary, including consultations with dermatologists, oral medicine specialists and dentists.

Oral Pemphigoid Recalcitrant Lesion Treated with PRGF Infiltration. Case Report

Mucous membrane pemphigoid (MMP) is a heterogeneous group of chronic autoimmune subepithelial blistering diseases. Oral involvement is present in almost all patients, may represent the onset of the disease, and causes different degrees of pain, dysphagia, soreness, and bleeding. Treatment is based on systemic and/or oral corticoids, or other immunosuppressants. Occasionally, oral lesions can show a poor response to standard treatments. We present the case of a 61-year-old female patient with a painful extensive MMP oral ulcerative lesion recalcitrant to previous systemic azathioprine and local triamcinolone treatment, which was successfully treated in a novel way using PRGF infiltrations as adjuvant. After four weekly infiltrations, pain was reduced from 10 to 0 in a VAS and the lesion was completely healed. The patient continued with a low dose maintenance immunosuppressive treatment (prednisone 5 mg/day PO), and after 13 months of follow-up, there was no relapse of the lesion and no side effects. Although future research is necessary to confirm these observations, PRGF could be a useful adjuvant for the management of extensive mucous membrane pemphigoid oral lesions.

Comprehensive review on the pathophysiology, clinical variants and management of pemphigus (Review)

Pemphigus represents a group of chronic inflammatory disorders characterized by autoantibodies that target components of desmosomes, leading to the loss of intercellular adhesion between keratinocytes and causing intraepithelial blistering. The pemphigus group consists of four main clinical types with several variants: pemphigus vulgaris (with pemphigus vegetans and pemphigus herpetiformis as variants), pemphigus foliaceus, paraneoplastic pemphigus and IgA pemphigus (with two clinical variants: intraepidermal neutrophilic IgA dermatosis and subcorneal pustular dermatosis). Genetic factors are involved in the pathogenesis, with HLA-DR4 (DRB1*0402) and HLA-DRw6 (DQB1*0503) allele more common in patients with pemphigus vulgaris, HLA class II DRB1*0344 and HLA Cw*1445 correlated with paraneoplastic pemphigus, and HLA-DRB1*04:01, HLA-DRB1*04:06, HLA-DRB1*01:01, HLA-DRB1*14, associated with a higher risk of developing pemphigus foliaceus. Autoantibodies are conducted against structural desmosomal proteins in the skin and mucous membranes, mainly desmogleins, desmocollins and plakins. Cell-mediated immunity may also play a role, especially in paraneoplastic pemphigus. Patients may present erythema, blisters, erosions, and ulcers that may affect the skin, as well as mucosal surfaces of the oral cavity, eyes, nose, leading to severe complaints including pain, dysphagia, and fetor. Oral mucosal postbullous erosive lesions are frequently the first sign of disease in pemphigus vulgaris and in paraneoplastic pemphigus, without skin involvement, making the diagnosis difficult. Treatment options classically include immunosuppressive agents, such as corticosteroids and corticosteroid-sparing agents such as azathioprine, mycophenolate mofetil, cyclophosphamide, methotrexate or dapsone. Newer therapies focus on blocking cell signaling events induced by pathogenic autoantibodies and/or targeting specific autoantibodies. The disease evolution is conditioned by the treatment with maximum doses of corticosteroids and the side effects associated with long-term immunosuppressive therapy, which is why patients need a multidisciplinary approach in following the treatment. In this review, we provide a comprehensive overview of the epidemiology, pathophysiology, clinical aspect, diagnosis and management of the main intraepidermal blistering diseases from the pemphigus group.

Direct immunofluorescence analysis of oral Tzanck smears for pemphigus vulgaris: A diagnostic test

BACKGROUND

Pemphigus vulgaris (PV) is a rare and potentially fatal autoimmune blistering disease. Direct immunofluorescence (DIF) and histopathological analysis are crucial methods for PV diagnosis, but oral tissue biopsy is difficult to perform because of the fragile characteristics of the oral mucosa. However, no well-designed diagnostic studies addressing the validity of DIF analysis of oral Tzanck smears for the diagnosis of PV exist. We aimed to design a diagnostic test based on DIF analysis combined with oral Tzanck smears and evaluate its diagnostic accuracy for PV.

METHODS

We enrolled 81 patients with oral erosive lesions, of whom 41 patients had PV and 40 were non-PV controls. Oral Tzanck smears were obtained from oral mucosal lesions and observed under a fluorescence microscope after fixing and fluorescence staining. The diagnostic efficacy indexes including sensitivity, specificity, predictive value, Youden index, diagnostic odds ratio, and likelihood ratio were calculated.

RESULTS

Of the 41 PV patients, 36 showed DIF-positive findings for oral Tzanck smears, and all 36 DIF-positive PV patients showed IgG and/or C3 deposition, with seven also showing IgA and/or IgM positivity. None of the non-PV controls showed DIF positivity. The sensitivity and specificity of DIF analysis with oral Tzanck smears were 87.80% and 100%, respectively. The area under the receiver operator characteristic curve (ROC) was 0.939, with the test demonstrating significantly high diagnostic efficacy.

CONCLUSION

DIF analysis of oral Tzanck smears is a minimally invasive and easy-to-operate technique that can assist the rapid and accurate diagnosis of PV in dental clinic.

Diagnostic Concordance between Optical Coherence Tomography and Histological Investigations for Immune-Mediated Desquamative Gingivitis: Observational Study

Desquamative gingivitis (DG) denotes a heterogeneous immune-mediated disease for which early diagnosis represents a great challenge. The main aim of this study is to validate diagnostic concordance between specific Optical Coherence Tomography (OTC) patterns for DG related to oral Lichen Planus (OLP), Pemphigus Vulgaris (PV), and Mucous Membrane Pemphigoid (MMP) and definitive histological diagnosis. Forty-three patients with suspected immune-mediated DGs, were progressively recruited. Before biopsy, an OCT preliminary evaluation was performed using specific pre-determined OCT diagnostic patterns (i.e., morphology and localization of blisters, status of the basal membrane, epithelial thickness, presence/absence of acantholytic cells into blister and/or inflammatory infiltrate) related to OLP, PV and MMP. After histological confirmation, OCT and histological diagnoses were compared. Using pre-determined patterns, OCT diagnoses of DGs were: 22 (51%) OLP, of which 11 (26%) were with the bullous variant, 4 (9%) PV and 6 (14%) MMP. The same diagnoses were found by histological investigations (with the main OCT discriminatory potential for the bullous variant of OLP). The concordance between the two diagnostic methods was confirmed by the Fisher exact test (p-value < 0.01). These specific OCT patterns show a diagnostic reliability in 100% of the cases investigated, suggesting their accuracy to support the complex diagnosis and management of immune-mediated DGs.

Immune-Mediated Desquamative Gingivitis and Optical Coherence Tomography Diagnostic Patterns: Clinical Implication from a Systematic Review

Desquamative Gingivitis (DG) comprises heterogeneous clinical manifestations of numerous immune-mediated muco-cutaneous diseases. Optical Coherence Tomography (OCT) has been proposed as a valuable diagnostic support even if, to date, there are no standardized OCT-diagnostic patterns applicable to DGs. A systematic review was performed to detect existing data on in vivo OCT diagnostic patterns of the most common immune-mediated DGs (i.e., pemphigus vulgaris, mucous membrane pemphigoid and oral lichen planus). It has been found that OCT exhibits specific patterns that address the diagnosis of DG by pemphigus vulgaris (i.e., intraepithelial unilocular blister, reduced epithelial thickness, presence of acantholytic cells in the blister) and by mucous membrane pemphigoid (i.e., subepithelial multilocular blister, presence of inflammatory infiltrate), but not by oral lichen planus. These patterns could offer an attractive diagnostic OCT framework to support the clinical preliminary assessment and monitoring of these complex pathological conditions.

Noninvasive in vivo imaging of oral mucosa: state-of-the-art

Technological development has interested most of the dentistry's branches leading to the use of other medical technologies non previously involved in dental practice. This study aims to evaluate the potential role of non-invasive imaging techniques in oral pathology workflow. Optical coherence tomography has been described by several authors as a promising aid for differential diagnosis of autoimmune diseases and to detect epithelial subversion of the oral mucosa before the clinical manifestation of oral mucositis. High-frequency ultrasound offers the chance to assess lesional dimensions both in benign and malignant lesions with a high dimensional reliability compared with histopathology. Reflectance confocal microscopy seems to be helpful in the early detection of cytological changes due to its high resolution, suggesting a more interesting role in the analysis of malignant lesions. The study presented highlighted the potential role of noninvasive in vivo imaging although further studies are needed for the further validation of these techniques.

Risk Factors for Mucosal Involvement in Bullous Pemphigoid and the Possible Mechanism: A Review

Bullous pemphigoid (BP) is the most common type of autoimmune bullous disease and is characterized by the presence of circulating anti-BP180 and/or anti-BP230 autoantibodies. Patients with BP often present with tense blisters and erythema, mainly on the trunk and limbs, but a few patients also have mucosal involvement. In this article, we discuss the fact that BP patients with mucosal involvement tend to have more serious conditions and their disease is more difficult to control. Potential risk factors for mucous involvement include earlier age at onset, drugs such as dipeptidyl peptidase-4 inhibitors, cancer, and blood/serum biomarkers, including lower eosinophil count, higher erythrocyte sedimentation rate, IgG autoantibodies against both the NH₂- and COOH-termini of BP180, and the absence of anti-BP230 antibodies. IgA and C3 deposition at the dermo-epidermal junction may also be present. Understanding these risk factors may benefit earlier diagnosis of these patients and promote the development of novel treatments. What's more, it's helpful in deeper understanding of BP development and the relationship between BP and mucous membrane pemphigoid (MMP).

Comprehensive management of major aphthous ulcer

Recurrent aphthous ulcers are the most prevalent oral mucosal disease, but the subset major aphthous ulcer is a less frequent type. These ulcers are refractory, may persist for several weeks to months, and interfere with the normal state of health. The aetiology is multifactorial and so is the treatment. We present a case of an adolescent male patient reported with multiple oral ulcers. He developed three ulcers simultaneously and suffered for 10 months despite using topical medications prescribed by different dental practitioners. We executed a multidisciplinary treatment approach that resulted in a long-term disease-free state. The treatment methods followed in our case could be a successful model to implement by medical practitioners and oral physicians when the situation demands.

Clinico-Pathological Profile and Outcomes of 45 Cases of Plasma Cell Gingivitis

Plasma cell gingivitis (PCG) is an infrequent inflammatory disease of the gingiva of unknown etiology, characterized by a dense polyclonal proliferation of plasma cells in the connective tissue. The aim of this study was to present a case series of patients affected by PCG, analyzing demographic, clinical, histopathological, and therapeutic data. A group of 36 females and 9 males with a mean age of 60.3 years was evaluated. Clinically, 25 cases were bullous, a clinical phenotype never reported to date, 4 erythematous, 4 keratotic, 4 verruciform, and 3 ulcerative. On histological examination, pure polyclonal plasma cell infiltrate was detected in 20 specimens, while in 25 specimens it was associated with a mixed infiltrate. The first-line therapy consisted of oral hygiene and topical corticosteroids in all patients. In 25 patients, doxycycline and sulfasalazine were added; in 10 of these patients, the disease persisted, and it was necessary to resort to systemic steroids. This study presented the clinico-pathological profile and outcomes of a case series of PCG. This could be an aid for clinicians to be aware of the heterogeneous clinical phenotype and of the possible pure bullous phenotype of PCG. Further studies are needed to improve the knowledge about this disorder.

Ultra-high frequency ultrasound in the differential diagnosis of oral pemphigus and pemphigoid: An explorative study

OBJECTIVES

Intraoral ultra-high frequency ultrasound (UHFUS) is an emerging technique in oral medicine, due to its possibility to provide submillimeter resolution imaging of superficial mucosal structures. In this study, the potential role of UHFUS in the diagnosis of oral pemphigus vulgaris (PV) and mucous membrane pemphigoid (MMP) is assessed.

MATERIALS AND METHODS

Consecutive patients with suspected oral PV or MMP were enrolled. All patients underwent clinical examination, laboratory tests, intraoral UHFUS scan, and biopsy. Histology and direct immunofluorescence were set as benchmark for diagnosis confirmation. The sensitivity and specificity of UHFUS compared to histology were assessed. Mann-Whitney test was performed to evaluate the presence of differences in the echogenicity of PV and MMP. P-value was set at P < 0.05.

RESULTS

Twenty-five patients were included. Thirteen patients were diagnosed with PV, and twelve with MMP. The UHFUS features of PV and MMP lesions were described. Image analysis showed statistically significant differences between the echogenicity of PV and MMP lesions (P < 0.05). Good concordance between UHFUS and histology was found. UHFUS showed 75% sensitivity in the diagnosis of PV and 66.7% in the diagnosis of MMP.

CONCLUSIONS

UHFUS appears a valuable tool in the diagnosis of PV and MMP. Although histology and immunofluorescence remain the gold standard, UHFUS role in the diagnostic algorithm of PV and MMP seems promising as a chair-side tool consistently enhancing clinical evaluation of oral bullous lesions.

Dental Considerations in Patients with Oral Mucosal Diseases

Oral mucosal diseases represent a significant health care burden, rendering a complex patient population in which interdisciplinary care among dermatologists, primary dental providers, and dental specialists is required for optimal care. Oral mucosal diseases often cause painful ulceration and blistering which can impede a patient's ability to perform dental home care and the dental professional's ability to deliver routine and complex treatment. It is crucial to consider the environment of the oral cavity. It is paramount to be aware of the potential side effects that certain medications may cause and the possible interactions with other medications the patient is using.

Oral Biopsy Techniques

Squamous cell carcinoma makes up 90% of cases of oral cancer. However, a myriad of premalignant, inflammatory, and immune-based conditions can manifest as oral mucosal lesions. Biopsy of these lesions shares many of the principles of cutaneous lesions. Biopsy of oral mucosal lesions is a procedure that is safely performed in most cases in the outpatient ambulatory setting using local anesthesia. Special considerations should be taken depending on the presumed diagnosis based on physical examination. Its clinical relevance depends on a sound clinicopathologic assessment of the patient's condition. This article reviews specific considerations for biopsy of oral mucosal lesions.

Saliva and Oral Diseases

Saliva is a fascinating biological fluid which has all the features of a perfect diagnostic tool. In fact, its collection is rapid, simple, and noninvasive. Thanks to several transport mechanisms and its intimate contact with crevicular fluid, saliva contains hundreds of proteins deriving from plasma. Advances in analytical techniques have opened a new era-called "salivaomics"-that investigates the salivary proteome, transcriptome, microRNAs, metabolome, and microbiome. In recent years, researchers have tried to find salivary biomarkers for oral and systemic diseases with various protocols and technologies. The review aspires to provide an overall perspective of salivary biomarkers concerning oral diseases such as lichen planus, oral cancer, blistering diseases, and psoriasis. Saliva has proved to be a promising substrate for the early detection of oral diseases and the evaluation of therapeutic response. However, the wide variation in sampling, processing, and measuring of salivary elements still represents a limit for the application in clinical practice.