Case of cheilitis granulomatosa associated with apical periodontitis

NLRP3 Inflammasome in Autoinflammatory Diseases and Periodontitis Advance in the Management

Inflammatory chemicals are released by the immune system in response to any perceived danger, including irritants and pathogenic organisms. The caspase activation and the response of inflammation are governed by inflammasomes, which are sensors and transmitters of the innate immune system. They have always been linked to swelling and pain. Research has mainly concentrated on the NOD-like protein transmitter 3 (NLRP3) inflammasome. Interleukin (IL)-1 and IL-18 are pro-inflammatory cytokines that are activated by the NOD-like antibody protein receptor 3 (NLRP3), which controls innate immune responses. The NLRP3 inflammasome has been associated with gum disease and other autoimmune inflammatory diseases in several studies. Scientists' discovery of IL-1's central role in the pathophysiology of numerous autoimmune disorders has increased public awareness of these conditions. The first disease to be connected with aberrant inflammasome activation was the autoinflammatory cryopyrin-associated periodic syndrome (CAPS). Targeted therapeutics against IL-1 have been delayed in development because their underlying reasons are poorly understood. The NLRP3 inflammasome has recently been related to higher production and activation in periodontitis. Multiple periodontal cell types are controlled by the NLRP3 inflammasome. To promote osteoclast genesis, the NLRP3 inflammasome either increases receptor-activator of nuclear factor kappa beta ligand (RANKL) synthesis or decreases osteoclast-promoting gene (OPG) levels. By boosting cytokines that promote inflammation in the periodontal ligament fibroblasts and triggering apoptosis in osteoblasts, the NLRP3 inflammasome regulates immune cell activity. These findings support further investigation into the NLRP3 inflammasome as a therapeutic target for the medical treatment of periodontitis. This article provides a short overview of the NLRP3 inflammatory proteins and discusses their role in the onset of autoinflammatory disorders (AIDs) and periodontitis.

Alternatives to β-Lactams as Agents for the Management of Dentoalveolar Abscess

Dentoalveolar abscess are localized infections within the tooth or the surrounding alveolar bone, often resulting from untreated dental caries or dental trauma causing alveolar bone resorption or even loss. Serious consequences arising from the spread of a dental abscess can often lead to significant morbidity and mortality. The acute dentoalveolar abscess is a polymicrobial infection comprising strict anaerobes, such as anaerobic cocci i.e., Prevotella fusobacterium species, and facultative anaerobes i.e., Streptococci viridians and Streptococcus anginosus. Moreover, inappropriately managed dental infections can progress to severe submandibular space infections with associated serious complications, such as sepsis and airway obstruction. An audit of the Hull Royal Infirmary between 1999 and 2004 showed an increase in the number of patients presenting to oral and maxillofacial surgery services with dental sepsis. Thus, the scientific community is forced to focus on treatment strategies for the management of dentoalveolar abscess (DAA) and other related dental problems. The current treatment includes antibiotic therapy, including β-lactams and non-β- lactams drugs, but it leads to the development of resistant microorganisms due to improper and wide usage. Furthermore, the currently used β-lactam therapeutics is non-specific and easily hydrolyzed by the β-lactamase enzymes. Thus, the research focused on the non-β-lactams that can be the potential pharmacophore and helpful in the management of DAA, as the appropriate use and choice of antibiotics in dentistry plays an important role in antibiotic stewardship. The newer target for the choice is NLRP inflammasome, which is the major chemical mediator involved in dental problems. This review focused on pathogenesis and current therapeutics for the treatment of dentoalveolar abscesses.

Current treatment modalities in granulomatous cheilitis

BACKGROUND

Granulomatous cheilitis (GC) is a poorly understood disorder of the labial mucosa, which is a subtype under an umbrella term "orofacial granulomatosis." Several treatment modalities have been tried in the management of GC with suboptimal to optimal results.

OBJECTIVE

The objective of this article is to discuss various treatment modalities, whether medical or surgical, that have been tried for the management of GC with success.

METHODS

A comprehensive literature search was performed to screen articles related to the successful treatment of GC. Articles published in journals indexed in PubMed were searched along with those in Google Scholar. There was no availability of systematic review or meta-analysis on treatment of GC in the literature search. Recent data has been collected and consolidated from various case reports and case series to provide a concise overview of various treatments applied in GC.

RESULTS

Various treatment modalities have been used in GC including glucocorticoids, antibiotics, immunomodulatory, and biological agents, surgical debulking, and laser therapy. No treatment modality has provided a predictable success. Intralesional corticosteroid therapy has been used more frequently either alone or in combination with other modalities.

Characterizing disease manifestations and treatment outcomes among patients with orofacial granulomatosis in China

Background

Racial variation exists in the incidence of orofacial granulomatosis (OFG). The epidemiology and clinical characteristics of OFG in Asian countries are poorly described.

Objective

To describe the epidemiologic and clinical features of OFG in China from data collected on chronic odontogenic infection and studied in actual practice regarding the long-term outcome of OFG patients receiving different treatments.

Methods

Data on demographics, medical history, chronic odontogenic infection, and the extent of disease were collected, and long-term outcomes after the end of treatments were evaluated.

Results

Of the 165 OFG patients, 118 (71.5%; 95% CI 64.6%-78.5%) had a chronic odontogenic infection. There was a variety of difference between OFG with and without chronic odontogenic infection. Approximately 98.3% (95% confidence interval 94.8%-100%) of OFG patients with chronic odontogenic infection who received dental treatment showed a marked response, of whom 31 patients (53.4%; 95% confidence interval 40.2%-66.7%) had complete remission.

Limitations

Endoscopic investigations were not performed for most of the patients, and more detailed data were not collected, which might have demonstrated additional systemic problems.

Conclusions

OFG with chronic odontogenic infection is the major clinical pattern of OFG in China, which may be a subtype of OFG. Dental treatment should necessarily be the preferred first-line therapy for such patients.

Association between cheilitis granulomatosa and odontogenic infections: A case-control study

The association between cheilitis granulomatosa and dental infections (dental caries and apical periodontitis) is still not well understood. Herein, we aimed to investigate the association in large hospital cases with cohort controls. Cheilitis granulomatosa cases (n = 181) were retrieved from Peking University Hospital of Stomatology and age- and sex-matched to controls (n = 181). The χ² -test, Student's t-test, and Mann-Whitney U-test were used to compare the differences between groups. The χ² -test and odds ratio were used to verify if there was an association and risk relationship. The results showed that both dental caries and apical periodontitis were associated with cheilitis granulomatosa (p < 0.001). Individuals with cheilitis granulomatosa had approximately a twofold increased frequency of dental caries than those without cheilitis granulomatosa (104/181, 57.5% vs. 53/181, 29.3%) (p < 0.001). The odds ratio of dental caries occurring in the case group compared to the control group was 3.211. The frequency of apical periodontitis in patients with cheilitis granulomatosa was significantly greater than in those without cheilitis granulomatosa (109/181, 60.2% vs. 28/181, 15.5%) (p < 0.001). The odds ratio was 8.272. Moreover, apical periodontitis was also locationally related to cheilitis granulomatosa (p < 0.001). Collectively, our study showed that the foci of dental infections are associated with cheilitis granulomatosa, suggesting that proper treatment of focal teeth may be important in the management of cheilitis granulomatosa.

A severe case of cheilitis granulomatosa: clinical-pathologic findings and management

INTRODUCTION

Cheilitis granulomatosa is an idiopathic granulomatous disorder which is rare and cosmetically disturbing. It presents with a persistent painless labial swelling which obscure etiology. Diagnosis is mainly based on the histopathological features following biopsy. There is no definitive treatment of this disease, reason being its lack of well-defined etiology. It has been proven largely resistant to most of the treatment options.

CASE DESCRIPTION

A 28-year-old man presented with the labial swelling which was confirmed to be cheilitis granulomatosa following histopathologic examination. We have successfully managed this case using intralesional steroids.

CONCLUSION

Intralesional steroids can be used successfully in management of cheilitis granulomatosa.

Characteristics of the salivary microbiota in cheilitis granulomatosa

Background

Cheilitis granulomatosa (CG) is a disturbing and persistent idiopathic lip swelling. The cause and treatment has not been wholly elucidated. Some reports infer that CG is mainly associated with dental infection but no firm or reliable microbiological evidence has been provided for a causative organism. This study aimed to evaluate whether microorganisms contribute to the etiology of CG in order to inform appropriate treatment options in clinic.

Material and Methods

Unstimulated saliva was collected from 15 CG patients who were diagnosed clinically and pathologically and 15 healthy controls (HC). DNA was extracted from the precipitate of the centrifuged saliva for 16s rRNA high-throughput sequencing using the Miseq PE300 platform. The distribution of the microbiome between the two groups was compared.

Results

CG patients had a greater microbial flora that was more diverse than the HC. Prevotella, Alloprevotella, Porphyromonas, Actinomyces, Rothia, Fusobacterium, Haemophilus, and Aggregatibacter had a significantly higher abundance in CG patients. In contrast, Streptococcus and Campylobacter were the most abundant genera in HC with a mean relative abundance of 63% and 2%, respectively. The microbiological network indicated that most of the bacteria that were enriched at greater levels in CG patients were likely to be Prevotella, Actinomyces, and Rothia. These have been shown to co-exist with other bacteria.

Conclusions:

The composition and structure of bacterial communities in CG patients were different from HC. Most of the genera observed in CG patients were associated with periodontitis and pulp infection. These findings might be helpful in understanding the etiology of CG. Further study will be needed to confirm these findings and explore the underlying pathological mechanism.

Key words:Cheilitis granulomatosa, 16s rRNA high-throughput sequencing, salivary microbiota.

Buccal localization of Crohn's disease with long-term infliximab therapy: a case report

INTRODUCTION

Cheilitis granulomatosa causes persistent idiopathic lip swelling and ulceration and it can sometimes be recognized as a unique or early manifestation of Crohn's disease. Spontaneous remission is rare and with the lack of controlled trials, different therapeutic approaches have been used. Some cases have been treated with an exclusion diet in the attempt to rule out diet allergens, while the most popular treatments include antibiotics such as tetracycline and clofazimine tranilast, benzocaine topical or intralesional steroids, and cheiloplasty, with different outcomes.

CASE PRESENTATION

We describe the case of a 23-year-old Caucasian man, primarily diagnosed with cheilitis granulomatosa for a severe lower lip swelling, and then with Crohn's disease of the terminal ileum and anus. Treatment of Crohn's disease with an anti-tumor necrosis factor alpha agent (infliximab) successfully induced remission of both the gastrointestinal disease and the oral lesion.

CONCLUSIONS

Our recommendation is that physicians should be able to recognize cheilitis granulomatosa as a possible marker of a more complex systemic disease and proceed first with an accurate physical examination, and further suggest investigations of the bowel. In cases of Crohn's disease, a therapy with biological agents can be successful.

Intralesional injection of Pingyangmycin plus corticosteroids may be an effective treatment for cheilitis granulomatosa

Cheilitis granulomatosa is a rare disease characterised by the recurrent labial swelling of one or both lips with the possibility of the condition to remain on a permanent basis. This kind of granulomatous, inflammatory disease may appear independently or be linked to a paralysis such as the facial and lingua plicata which then characteristic of the Melkersson-Rosenthal syndrome. Classically, a non-necrotizing granulomatous inflammation is seen at histologic examination. Many treatments have been tried. But as its high recurrence rate, the results were often disappointing. The major active component of Pingyangmycin is bleomycin A5. Currently, bleomycin has been proved to be a widely accepted treatment protocol for hemangiomas and lymphangioma. It has been proved that bleomycin could infiltrate prominently into lymphocytes and other inflammatory cells. Stromal connective tissue would proliferate markedly as the result of sclerotherapy. Oedema, lymphangiectasia and perivascular lymphocytic infiltration are always seen in cheilitis granulomatosa histologically. Therefore, we hypothesize that intralesional injection of Pingyangmycin plus corticosteroids may be a safe and effective treatment for cheilitis granulomatosa. The efficacy of this treatment modality is worthy of further investigation.

Cheilitis granulomatosa: a case report with review of literature

Cheilitis granulomatosa (CG) is a chronic swelling of the lip due to granulomatous inflammation. It is a rare inflammatory disorder first described by Miescher in 1945. It is a monosymptomatic form or an incomplete variant of Melkersson-Rosenthal syndrome; a triad of recurrent orofacial edema, recurrent facial nerve palsy and fissuring of the tongue. As the etiology remains unknown, treatment of CG is challenging. We present a case of CG in a 43-year-old female patient secondary to allergy to certain food items. The present case highlights the importance of thorough investigations in the diagnosis of this lesion as the findings mimic many other granulomatous conditions.

Improvement of Cheilitis granulomatosa after Dental Treatment

A 38-year-old male suffered from swelling of the lower lip for 3 months. Neither facial nerve palsy nor fissuring of the tongue was present. Histological examination of a biopsy taken from the lower lip revealed non-caseous epithelioid cell granulomas, suggestive of cheilitis granulomatosa. Patch testing revealed positive reactions to mercury chloride and amalgam. His symptoms markedly improved 3 months after treatment of the apical periodontitis and replacement of dental crowns. As his dental crowns did not contain mercury, we believe that the cheilitis granulomatosa may have been related to the focal dental infection.