Surgical management of epidermolysis bullosa: Proceedings of the IInd International Symposium on Epidermolysis Bullosa, Santiago, Chile, 2005

Dental implant considerations in patients with systemic diseases: An updated comprehensive review

BACKGROUND

Various medical conditions and the drugs used to treat them have been shown to impede or complicate dental implant surgery. It is crucial to carefully monitor the medical status and potential post-operative complications of patients with systemic diseases, particularly elderly patients, to minimize the risk of health complications that may arise.

AIM

The purpose of this study was to review the existing evidence on the viability of dental implants in patients with systemic diseases and to provide practical recommendations to achieve the best possible results in the corresponding patient population.

METHODS

The information for our study was compiled using data from PubMed, Scopus, Web of Science and Google Scholar databases and searched separately for each systemic disease included in our work until October 2023. An additional manual search was also performed to increase the search sensitivity. Only English-language publications were included and assessed according to titles, abstracts and full texts.

RESULTS

In total, 6784 studies were found. After checking for duplicates and full-text availability, screening for the inclusion criteria and manually searching reference lists, 570 articles remained to be considered in this study.

CONCLUSION

In treating patients with systemic conditions, the cost-benefit analysis should consider the patient's quality of life and expected lifespan. The success of dental implants depends heavily on ensuring appropriate maintenance therapy, ideal oral hygiene standards, no smoking and avoiding other risk factors. Indications and contraindications for dental implants in cases of systemic diseases are yet to be more understood; broader and hardcore research needs to be done for a guideline foundation.

Phase I/II open-label trial of intravenous allogeneic mesenchymal stromal cell therapy in adults with recessive dystrophic epidermolysis bullosa

BACKGROUND

Recessive dystrophic epidermolysis bullosa (RDEB) is a hereditary blistering disorder due to a lack of type VII collagen. At present, treatment is mainly supportive.

OBJECTIVES

To determine whether intravenous allogeneic bone marrow-derived mesenchymal stromal/stem cells (BM-MSCs) are safe in RDEB adults and if the cells improve wound healing and quality of life.

METHODS

We conducted a prospective, phase I/II, open-label study recruiting 10 RDEB adults to receive 2 intravenous infusions of BM-MSCs (on day 0 and day 14; each dose 2-4 × 10⁶ cells/kg).

RESULTS

BM-MSCs were well tolerated with no serious adverse events to 12 months. Regarding efficacy, there was a transient reduction in disease activity scores (8/10 subjects) and a significant reduction in itch. One individual showed a transient increase in type VII collagen.

LIMITATIONS

Open-label trial with no placebo.

CONCLUSIONS

MSC infusion is safe in RDEB adults and can have clinical benefits for at least 2 months.

Dental implants in patients with epidermolysis bullosa: a systematic review

Purpose

To integrate the available data published on patients with epidermolysis bullosa (EB) rehabilitated with dental implants, as well as to review the recommendations for EB patients receiving implants.

Methods

An electronic search was undertaken in February 2019 in five databases.

Results

Sixteen publications were included, reporting 28 patients with EB, rehabilitated with 161 dental implants. The mean ± SD patients’ age at implant surgery was 34.7 ± 12.1 years (range, 13–56). Only one implant was placed in the molar region, all other implants were placed in the incisor, canine, and premolar regions. Patients received a mean ± SD of 5.8 ± 2.8 implants (range, 2–11). Most of the patients received implant-supported fixed prostheses (fixed partial 14.3%, fixed full-arch 60.7%, overdenture 25%). Implant and prosthesis failure rates were 1.3% and 0%, respectively. The two implant failures were detected before or at the abutment connection. The mean ± SD follow-up time was of 39.2 ± 24.5 months (range, 6–111). The EB patient quality-of-life improved considerably as a result of treatment with dental implants. There is a series of dental care considerations that should be followed to smooth the implant treatment in EB patients.

Conclusions

The dental implant failure rate in EB patients seems to be very low, although the few cases reported in the literature were followed up for a short mean period, i.e., just a little bit longer than 3 years. More cases followed up for a long period are needed in order to be able to make a more reliable prognosis for the long-term oral rehabilitation of EB patients with dental implants.

Management of patients with congenital epidermolysis bullosa

Congenital epidermolysis bullosa (EB) is a clinically and genetically heterogeneous group of hereditary skin diseases characterized by the formation of blisters and/or erosions in response to minimal trauma. Etiopathogenetic methods for treating the disease are undergoing various stages of clinical research; therefore, external therapy implying caring for affected and non-affected skin remains to be the main treatment method. Such a therapy aims to reduce the healing period of erosive and ulcerative skin defects, thus improving the overall quality of patients’ life. This review sets out to provide clinical recommendations for the management of EB patients developed by different groups of experts, which generalize methods for treating EB patients, main principles of external therapy and relieving subjective sensations, as well as to describe specific situations entailing this pathology.

An algorithmic approach for the management of hand deformities in dystrophic epidermolysis bullosa

Treatment of hand deformities in epidermolysis bullosa patients represents a challenging field in hand surgery practice, thus a systematic approach by a team is mandatory for a successful result. A simple and practical algorithm for the surgical treatment of hand deformities in EB was employed by the authors where the deformities of each digit in EB patients was categorized according to pseudosyndactyly and interphalangeal joint contracture severity for guidance during the surgical treatment. The current study retrospectively reviewed the medical records and photographic data of 13 EB patients followed in our department, for whom a systematic approach to the management and treatment was used. Mild cases were treated by surgical release and secondary healing with non-adhesive dressing while moderate cases were treated with autologous dermal grafts harvested with a special technique that were fixed on denuded areas on the proximal interphalageal joints after release. The remaining areas were treated similarly to the mild group. Additional K-wires were applied for two weeks in severe cases. A total of 21 procedures were performed on 13 EB patients with hand deformities according to the proposed treatment strategy. Functional recovery was satisfactory for each patient and the outcomes were dependent upon the severity of deformity. A multidisciplinary and conscious approach followed by an algorithmic surgical treatment protocol described in the study has been beneficial in providing consistent and successful long-term results for these patients.

Hand surgery for dystrophic epidermolysis bullosa

BACKGROUND

Epidermolysis bullosa (EB) is a group of inherited, mechanobullous disorders caused by mutations in various structural proteins in the skin. The manifestation of these disorders in the hand is of digital contractures and pseudosyndactyly or "cocoon hands," causing significant functional impairment.Our preferred surgical treatment of these patients involves separation of the digits from the palm by releasing the finger flexion contractures and separating them, primarily the adducted thumb. However, recurrence is common. Our hypothesis was that functional improvement is gained irrespective of recurrence of contractures.

METHODS

We retrospectively evaluated 4 patients, 2 male and 2 female, whose average age was 11 years, treated surgically by the separation of all their digits and by coverage with skin grafts. The follow-up period was between 1 and 3½ years.

RESULTS

Partial recurrence of the deformity was observed in all patients. Recurrence was more pronounced in the nondominant hand, especially between the digits and of flexion contractures, but did not preclude the use of precision or oppositional pinch at final follow-up. The patient with the longest follow-up has been referred for revision surgery to gain further release of contractures.Significant rehabilitation goals were achieved in all 4 patients after surgery. After 6 months, both of the younger patients were measured for finger dexterity, which showed lower scores than the norm, although this was felt to be dependent on which daily manual activities they were more familiar with. These tests could not have been performed before surgery.

CONCLUSIONS

All patients and families felt the effort was worthy. Separating the thumb and straightening the digits was found to be significant, yet the indication for separating all the digits is debatable. The need for revision surgery, to maintain the digit function, is clear.

LEVEL OF EVIDENCE

Level 4, case series.

A Cross Sectional, Observational Survey to Assess Levels and Predictors of Psychological Wellbeing in Adults with Epidermolysis Bullosa

Epidermolysis bullosa (EB) describes a cluster of genetically determined skin disorders. Symptoms can be painful, disabling and disfiguring, yet there is little research on the psychological impact of the disease. The study aim was to measure psychological wellbeing in adults with EB; and to examine the association between psychological wellbeing and self efficacy, health locus of control and adjustment to appearance in an observational, cross sectional survey. Questionnaire packs comprising the General Health Questionnaire (GHQ-12), the General Self Efficacy Scale (GSE), the Multidimensional Health Locus of Control Scale (MHLOC), and the Derriford Appearance Scale (DAS-24), were sent to approximately 385 adults with EB. The data were analysed using SPSS. Eighty-seven participants responded. Scores on the GHQ-12 showed non-problematic psychological health in 36% of the sample; levels bordering on clinical disorder in 32.1% and severe psychological distress in 31.9%. No correlations were found between demographic factors (age and sex) or clinical factors (EB type and perceived severity) and psychological well-being. Scores on the GSE, the internal locus of control sub-scale of the MHLOC and the DAS-24 showed them to be statistically significant correlates of psychological wellbeing (P<0.001; P<0.018; and P<0.001 respectively). In a regression analysis, adjustment to appearance and self efficacy accounted for 24% of the variation in psychological wellbeing. Adults with EB might be at risk of experiencing poor psychological health. Interventions designed to enhance disease self management, self efficacy and improve body image are likely to be beneficial in this clinical group.

Subcutaneous spreading squamous cell carcinoma in a patient with epidermolysis bullosa

Epidermolysis Bullosa (EB) is a complex group of genetic disorders characterised by mechanical fragility in the basement membrane zone. Affected individuals experience significant morbidity and mortality, most commonly from cutaneous malignancies. In fact, 90.1% of EB patients develop Squamous Cell Carcinoma (SCC) before the age of 55, 80% of whom die within 5 years of diagnosis. Furthermore, the management of cutaneous malignancies in EB is fraught with challenges given the atypical presentations of malignancies and the co-existence of systemic co-morbidities. To illustrate the common pearls and pitfalls of managing EB in the perioperative setting, we present a case of SCC of the left forefoot which spread through a natural plane of weakness in the dermal-epidermal junction as a complication of the congenital weakness in the area resulting from EB.

Fluoroscopically guided dilation of esophageal strictures in patients with dystrophic epidermolysis bullosa: long-term results

OBJECTIVE

The purpose of this study was to investigate the immediate and long-term outcomes after fluoroscopically guided balloon dilation of esophageal strictures in a series of patients with dystrophic epidermolysis bullosa (DEB).

MATERIALS AND METHODS

Between 2005 and 2011, the medical records of all patients with DEB treated with fluoroscopically guided balloon dilation of esophageal strictures were included in the study and retrospectively analyzed. The indication for treatment was dysphagia attributed to at least one radiologically verified esophageal stricture. The primary endpoints of the study included procedural technical success, clinical improvement assessed with a 0-4 dysphagia score, and major complication rate. Secondary endpoints were patient survival and reintervention rates.

RESULTS

Nineteen consecutively registered patients with DEB (age range, 10-51 years; mean, 30 ± 12.2 years) and dysphagia due to esophageal strictures were treated with fluoroscopically guided balloon dilation. In total, 90 procedures and 121 dilations were performed to manage 28 lesions. Balloon diameter ranged from 8 to 18 mm. The mean follow-up time was 47.51 ± 16.64 months (range, 17-73 months). The technical success rate was 96.7% (87/90). There were no major complications. The mean reintervention rate was 1.19 dilations per patient per year, and the postprocedural dysphagia score (0.72 [95% CI, 0.56-0.87]) was significantly lower than baseline (2.50 [95% CI 2.35-2.65]) (p < 0.001).

CONCLUSION

Repeated fluoroscopically guided balloon dilation is safe and effective for the management of dysphagia caused by esophageal strictures in DEB. Use of this technique was associated with marked clinical improvement in dysphagia and satisfactory long-term reintervention rates with no major complications.

Inherited epidermolysis bullosa: an update and suggested dental care considerations

BACKGROUND

Epidermolysis bullosa (EB) is a skin disease characterized by epithelial fragility that leads to blistering and erosion of the skin and mucosae. The authors conducted a literature review to provide an update on oral manifestations and dental care of patients with EB. Literature Search. The authors reviewed the dental literature on EB in relation to clinical findings and provision of dental care. They searched textbooks and three databases: MEDLINE, Cochrane Library and Embase. The authors did not impose any date or publication status restrictions. They searched all databases up to August 2010.

RESULTS

The literature review revealed that four major groups and 32 subtypes of EB can be distinguished on the basis of the ultrastructural characteristics of skin cleavage, genetic mode of transmission and clinical phenotype. Oral manifestations differ in frequency and severity according to the disease subtype, but the most common are bullae, which leave painful ulcers on rupture, followed by scarring and tissue contraction. Although good oral health status is essential to maintaining oral function, dental treatment can induce new lesions and be hindered by the sequelae of existing lesions.

CLINICAL IMPLICATIONS

Dental treatment in patients with EB requires a multidisciplinary approach. Dental procedures must be minimally traumatic, and the effectiveness of treatment is determined mainly by the patient's general health, cooperation in the dental office and at home, oral hygiene and diet.

'You're whatever the patient needs at the time': the impact on health and social care professionals of supporting people with epidermolysis bullosa

OBJECTIVES

Professionals working with people who encounter pain and suffering can experience adverse emotional effects themselves. However, to provide effective support it is necessary to understand specific work-related experiences and contexts. This study investigated the impact on professionals of supporting people with the skin condition 'epidermolysis bullosa'.

METHODS

A two-part mixed methods design was utilized. Part one comprised interviews with specialist nursing and social care professionals (n = 7). Part two comprised a survey administered to a range of EB specialist professionals (n = 26).

RESULTS

The interview data were analysed inductively and informed the survey design. The survey data were analysed deductively and compared to the interview findings. Three integrated themes were subsequently depicted: the intensity and depth of involvement; managing with limited resources; and the need to look after yourself.

DISCUSSION

Findings show the ways in which the work can affect well-being and how the impact is intensified by the low numbers of specialist professionals in the field. But the support of team members, access to effective supervision and the rewards of working with a remarkable population make the professional role worthwhile. Adequate clinical supervision, skills training and access to multi-disciplinary expertise were all highlighted as beneficial for well-being.

A review of the obstetric management of patients with epidermolysis bullosa

Epidermolysis bullosa (EB) is a rare inherited skin condition characterized by the development of blisters after minor mechanical friction or trauma. There are few reported pregnancies in the literature in these women. We describe a pregnancy we recently managed. The collated series of pregnancies show that there are no additional antenatal or postnatal problems and that the skin itself does not worsen during pregnancy. Vaginal delivery is most favourable, but if a caesarean section is required, regional anaesthesia should be attempted. A multidisciplinary team should be active throughout the pregnancy of these women and a well-documented labour plan should be made in advance.

Pain management in epidermolysis bullosa

Pain is an unfortunate constant in the lives of most patients with epidermolysis bullosa (EB), especially for those with the more severe types of EB. Patients with EB have a broad spectrum of need for pain treatment, varying with the type of EB, the severity within that type, and the particular physical, emotional, and psychological milieu of each individual. Prevention of situations that precipitate trauma to the skin or exacerbate other pain-inducing complications of this multifaceted disorder is the primary goal of the treating physician. The approach to pain management is different in daily life, during intermittent exacerbations or injuries, or when hospitalizations or operative procedures occur.

Surgical management of infantile cataracts in dystrophic epidermolysis bullosa

Epidermolysis bullosa describes a group of mechanobullous skin diseases that result in the formation of blisters with little or no trauma. In dystrophic epidermolysis bullosa, the eyelid skin and ocular surface are commonly affected; however, infantile cataracts are a rare occurrence. A 7-month-old boy with dense bilateral cataracts and nystagmus underwent cataract extraction, lens implantation, and limited vitrectomy with the use of specialized techniques to reduce iatrogenic skin and ocular surface complications. No iatrogenic skin or ocular surface complications were observed postoperatively. At 24 months of age, the child demonstrated improved visual function.

Non-endoscopic percutaneous gastrostomy placement in children with recessive dystrophic epidermolysis bullosa

Recessive dystrophic epidermolysis bullosa (RDEB) is associated with high nutritional demands, esophageal strictures and dysphagia. About one quarter of the patients require gastrostomy tube placement to maintain adequate nutritional status. To minimize trauma to the skin and pharyngoesophageal mucosa caused by commonly used gastrostomy tube insertion techniques, we used a non-endoscopic, percutaneous, image-guided approach. This approach combines the use of ultrasound for mapping of the liver and spleen, water-soluble contrast enema to visualize the colon, and gastric insufflation to define the stomach. The gastrostomy tube is replaced by a low-profile button gastrostomy tube 10-12 weeks postoperatively. The five female patients reported in this series ranged in age from 6 to 9 years. They all tolerated the procedure well and no perioperative complications were encountered. All were able to tolerate feedings on postoperative day 1 and all underwent successful replacement of gastrostomy tubes by low-profile button tubes. Our experience suggests that a non-endoscopic, image-guided approach to gastrostomy tube placement offers a safe, effective, and minimally traumatic alternative to more commonly used approaches. It minimizes the risk of procedure-related morbidity and leads to overall improvement in the quality of life. As such, we strongly recommend that it be included in the treatment armamentarium for patients with epidermolysis bullosa and nutritional failure.