Off-label use of biologicals in the management of inflammatory oral mucosal disease

World Workshop on Oral Medicine VII: Oral adverse effects to biologic agents in patients with inflammatory disorders. A scoping review

BACKGROUND

Biologic agents are rapidly emerging as an effective therapy to treat autoimmune and other chronic diseases. The use of these agents is poorly characterized, resulting in a lack of guidance for dental practitioners. Case reports of oral adverse events have begun to emerge. However, their scope and frequency have not been summarized and analysed to date. The objective of this review was to characterize the literature on oral adverse effects associated with biological therapy when used for autoimmune and inflammatory disorders.

METHODS

This review was developed in accordance with scoping review recommendations. Search strategies were developed and employed for six databases. Studies were selected using a systematic search process but with broad inclusion of study types given the paucity of information available. Reports of oral adverse events were analysed descriptively according to agent, mechanism of action, underlying disease, and oral adverse effect observed.

RESULTS

Our search returned 2080 articles and 51 met our inclusion criteria, of which most were case reports. The most frequent adverse effects included angioedema, oral lichenoid lesions, osteonecrosis of the jaw, and oral infections. There were also cases of oral malignancies associated with use of biologic agents. Less common effects such as pigmentation were also described.

CONCLUSIONS

Oral adverse events have been reported in patients on biologic therapy, albeit in small numbers to date. This limits the generalizability of these results, which should not be used to generate a clinical guideline as they are based primarily on case reports. However, this study presents the first review characterizing the adverse effects observed. Large multi-center studies will be necessary to further define the oral and dental complications caused by biologic agents.

Advancement in therapeutic strategies for immune-mediated oral diseases

BACKGROUND

Immune-mediated diseases are a diverse group of conditions characterized by alteration of cellular homeostasis and inflammation triggered by dysregulation of the normal immune response. Several immune-mediated diseases exhibit oral signs and symptoms. Traditionally, these conditions are treated with corticosteroids or immunosuppressive agents, including azathioprine, cyclophosphamide, and thalidomide. Recent research into the developmental pathways of these diseases has led to the exploration of novel approaches in treatment. This review examines newer treatment modalities for the management of immune-mediated diseases with oral presentations. Topical calcineurin inhibitors (TCIs) such as tacrolimus and pimecrolimus have been employed successfully in managing oral lichen planus and pemphigus vulgaris. Biologic agents, comprising monoclonal antibodies, fusion proteins, and recombinant cytokines, can provide targeted therapy with fewer adverse effects. Neutraceutical agents comprising aloe vera, curcumin, and honey are commonly used in traditional medicine and offer a holistic approach. They may have a place as adjuvants to current standard therapeutic protocols. Photodynamic therapy (PDT) and low-level laser therapy (LLLT) utilize a specific wavelength of light to achieve desired cellular change. While the use of PDT in immune-mediated diseases is contentious, LLLT has shown positive results. Newer therapeutic modalities involve kinase inhibitors, S1P₁ receptor modulators, MSCs, and iRNA providing targeted treatment of specific diseases.

Role of biologics in refractory recurrent aphthous stomatitis

Refractory recurrent aphthous stomatitis (RRAS) manifests as severe ulcerative lesions of the oral mucosa with poor healing and a poor response to conventional therapy, with or without systemic diseases. Its treatment remains a clinical challenge owing to the lack of effective therapies. Recently, biologics have emerged as promising targeted therapies for RRAS. The biologics targeting specific inflammatory pathways involved in the pathogenesis of RRAS, including tumor necrosis factor-alpha inhibitors and interleukin inhibitors, offer a more precise and promising therapeutic approach for RRAS. These targeted therapies have been shown to promote healing and decrease recurrence frequency in, and improve the quality of life of patients with RRAS. Herein, the types and mechanisms of biologics currently used to treat RRAS have been reviewed; furthermore, the dose, duration, therapeutic efficacy, and adverse effects of RRAS with or without certain associated systemic diseases, and the current problems and future directions have been discussed.

Lichen Planus

Lichen planus (LP) is a T cell-mediated disease affecting the stratified squamous epithelia of the skin and/or mucus membrane. Histologically, the disease is characterized by a lichenoid inflammatory infiltrate and vacuolar degeneration of the basal layer of the epidermis. LP has three major subtypes: Cutaneous, mucosal and appendageal LP. Rarely, it may affect the nails in the absence of skin and/or mucosal changes. LP may also be induced by several drugs, typically anti-hypertensive medication or be associated with infections, particularly viral hepatitis. The diagnosis is based on the clinical presentation and characteristic histological findings. Although the disease is often self-limiting, the intractable pruritus and painful mucosal erosions result in significant morbidity. The current first-line treatment are topical and/or systemic corticosteroids. In addition, immunosuppressants may be used as corticosteroid-sparing agents. These, however are often not sufficient to control disease. Janus kinase inhibitors and biologics (anti-IL-12/23, anti-IL17) have emerged as novel future treatment options. Thus, one may expect a dramatic change of the treatment landscape of LP in the near future.

Refractory Oral Ulcer Responsive to Infliximab: A Case Report

PURPOSE

Some oral ulcers are refractory to treatment. Recently, anti-tumor necrosis factor-alpha (anti-TNF-α) agents have been shown to induce relatively long remissions of refractory oral ulcers.

METHODS

A 69-year man presented with a sore throat caused by a pharyngeal ulcer in the soft palate and subsequently repeatedly developed oropharyngolaryngeal ulcers and an ulcer in the ileocecal region. Intestinal Behçet disease was suspected, but he did not meet the diagnostic criteria for this condition. Seven months after the initial presentation, he developed a lingual ulcer that did not resolve despite treatment with prednisolone. Given the suspicion of intestinal Behçet disease, 300 mg of infliximab was administered intravenously.

RESULTS

After the third dose of infliximab with prednisolone, the ulcer began to improve. He received infliximab every 8 weeks thereafter and developed no new oropharyngolaryngeal ulcers during the 17 months after the first infusion of infliximab.

CONCLUSIONS

When a patient has refractory oral ulcers, attention must be paid to digestive symptoms and whether the patient has a systemic disease such as Behçet disease investigated. Furthermore, administration of infliximab to patients with refractory ulcers can be considered even when they do not fulfill the clinical criteria for a systemic disease.

The Measurement of Serum Tumor Necrosis Factor-alpha Levels in Patients with Lichen Planus

Background:

Lichen planus is a common mucocutaneous inflammatory skin disease with a multifactorial etiology. Cytokines have a key role in its pathogenesis. In our study, we aimed to investigate the relationship between the disease severity and levels of the tumor necrosis factor alpha (TNF-α) cytokine which was considered as a primary cytokine that initiates the cytotoxicity.

Materials and Methods:

A total of 34 patients with lichen planus who were 18 year or older and gender-matched healthy controls were included in the study. Serum TNF-α levels were measured by human TNF-α enzyme-linked immunosorbent assay test kits and the values in the two groups were statistically compared.

Results:

The mean serum TNF-α levels were higher in the patient group than that in the control group. Serum TNF-α levels were not associated with oral mucosal involvement and gender. However, it was observed that the level of TNF-α was higher in older ages, both in patient and in control groups.

Conclusion:

It is thought that TNF-α, a proinflammatory cytokine, may have an important role in the pathogenesis of lichen planus.

The measurement of serum TNF-α levels in patients with lichen planus

BACKGROUND

Lichen planus is a common mucocutaneous inflammatory skin disease with a multifactorial etiology. Cytokines play a key role in lichen planus pathogenesis. This study investigates the relationship between disease severity and levels of tumor necrosis factor-α (TNF-α), which is considered a primary cytokine that initiates cytotoxicity.

MATERIAL AND METHODS

Serum TNF-α levels were compared between a patient group (n = 34) and a control group (n = 20). TNF-α serum levels were measured using human TNF-α Enzyme-Linked Immunosorbent Assay (ELISA) test kits, and the two groups were statistically compared to each other.

RESULTS

Mean serum TNF-α levels were found to be significantly higher in the patient group than in the control group (p < 0.005). However, no significant association was observed between TNF-α levels and oral mucosal involvement (p > 0.005). No relationship was detected between TNF-α levels and patients' sex.

CONCLUSION

It is thought that TNF-α, a proinflammatory cytokine, may play an important role in the pathogenesis of lichen planus. TNF-α may be a simple and effective predictor to illustrate the inflammatory status in patients with lichen planus.

Oral lichen planus

Lichen planus is an inflammatory mucocutaneous disease that can affect the skin, hair, nails, and mucosal surfaces. Mucosal sites of involvement include oral, genital, ocular, otic, esophageal, and, less commonly, bladder, nasal, laryngeal, and anal surfaces. Oral lichen planus is a mucosal variant of lichen planus, which tends to affect women more often than men, with a typically more chronic course and potential for significant morbidity. Treatment can be challenging, and there is potentially a low risk of malignant transformation; however, therapeutic benefits can be obtained with various topical and systemic medications. Clinical monitoring is recommended to ensure symptomatic control. Increasing awareness and recognition of this entity have continued to fuel advances in therapy and in our understanding of the disease.

Orofacial adverse effects of biological agents

Biological agents (BA) are increasingly used effectively in the treatment of a range of disorders, but to date, their application in diseases affecting the orofacial region has been fairly limited. Several orofacial adverse effects related to BA have been recently reported. However, the evidence for such adverse reactions is not always strong, and some of the adverse effects of BA have only been reported in case reports or case series. Most reactions to BA reported thus far have been in association with antitumor necrosis factor-α agents, which is not surprising, as these are the most widely-used BA. In the present study, the orofacial adverse effects are reported with various BA in order to sensitize clinicians to the possibilities. In addition, we briefly summarize the mode of action and indications of these BA. As the use and range of BA increases, the number and diversity of adverse effects might well increase. Despite the adverse effects of biological agents, these may often be less serious than the adverse effects of the more traditional immunosuppressive agents.

Remission of severe aphthous stomatitis of celiac disease with etanercept

Celiac disease is a common autoimmune disease triggered by gluten-containing foods (wheat, barley and rye) in genetically predisposed individuals. We present a patient with celiac disease complicated by severe aphthous stomatitis resulting in impairing swallowing, chewing and speaking. This led to weight loss, psychosocial problems as well as inability to perform her work. A variety of topical and systemic medications used resulted in either no improvement or only partial alleviation of the patient’s symptoms. After informed consent, etanercept was initiated and resulted in complete remission of aphthous stomatitis, decrease in arthralgia and fatigue and considerable improvement in her quality of life. The use of newer biological agents for selected and severe manifestations of celiac disease may lead to improved morbidity in these patients, but more studies are needed to determine long-term efficacy as well as safety of these drugs in the mucosal and/or systemic complications of this disease.

Inflammation-related cytokines in oral lichen planus: an overview

Cytokines are powerful mediators which play a central role in both innate and adapted immune responses. Aberrant productions of cytokines may lead to the onset of immune deficiency, allergy or autoimmunity, which are involved in the mechanisms of various immune-mediated inflammatory diseases. Oral lichen planus (OLP) is a chronic inflammation disease affecting the oral mucosa with unknown aetiology. Previous studies have described the abnormal expression patterns of various inflammation-related cytokines, such as IL-1, 2, 4, 5, 6, 8, 10, 12, 17, 18, TGF-β, IFN-γ and TNF-α, in lesions, saliva, serum and peripheral blood mononuclear cells from patients with OLP, which may reflect the immune dysregulation status and emerge as central players in the immunopathogenesis of OLP. Besides, the gene polymorphisms of several cytokines such as IFN-γ, TNF-α, IL-4, IL-10 have been found to be involved in the susceptibility of OLP. In this review, we gave a brief introduction of the characteristics and biological functions of these inflammation-related cytokines and summarized for the first time the current knowledge on the involvement of inflammation-related cytokines in OLP. Further research on the exact roles of these cytokines will aid the understanding of the pathogenesis and the identification of novel therapeutic approaches of OLP.

Mucous membrane pemphigoid

Mucous membrane pemphigoid (MMP) is chronic and frequently associated with exacerbations and remissions of clinical signs and symptoms. Clinicians should use pathologic and immunonologic techniques to help diagnose patients. Multidisciplinary collaboration is often necessary for the diagnosis and proper treatment of MMP. Systemic adjuvant immunosuppressive therapy is necessary for patients with progressive disease. In spite of the advances in available immunosuppressive medications and biologics, scarring is a significant complication in many cases. Surgical intervention is not curable; however, it may be necessary for restoring function and improving quality of life.

Preventive and therapeutic effects of Smad7 on radiation-induced oral mucositis

We report that K5.Smad7 mice, which express Smad7 transgene by a keratin-5 promoter, were resistant to radiation-induced oral mucositis, a painful oral ulceration. In addition to NF-κB activation known to contribute to oral mucositis, we found activated TGF-β signaling in oral mucositis. Smad7 dampened both pathways to attenuate inflammation, growth inhibition and apoptosis. Additionally, Smad7 promoted oral epithelial migration to close the wound. Further analyses revealed that TGF-β signaling Smads and their co-repressor CtBP1 transcriptionally repressed Rac1, and Smad7 abrogated this repression. Knocking down Rac1 in mouse keratinocytes abrogated Smad7-induced migration. Topically applying Smad7 protein with a cell permeable Tat-tag (Tat-Smad7) to oral mucosa showed preventive and therapeutic effects on radiation-induced oral mucositis in mice. Thus, we have identified novel molecular mechanisms involved in oral mucositis pathogenesis and our data suggest an alternative therapeutic strategy to block multiple pathological processes of oral mucositis.

Lichen planus of the esophagus: what dermatologists need to know

BACKGROUND

Esophageal lichen planus (ELP) is a rare manifestation of mucocutaneous lichen planus (LP).

OBJECTIVES

We aimed to report our experience and review all cases of ELP reported in the English-language literature.

METHODS

We report our experience with 4 cases and reviewed PubMed for reports of ELP. Cases were evaluated for age of onset, sex, location of LP, relationship of the onset of ELP to extra-ELP, endoscopic findings, whether biopsy was performed, histopathology of esophageal biopsy specimens, medical history (including gastrointestinal history), development of esophageal squamous cell carcinoma, therapies tried, and response to treatment.

RESULTS

A total of 72 cases of ELP were studied. In all, 87% of patients were female, with a median age of 61.9 years at time of diagnosis. Dysphagia was present in 81% and odynophagia was present in 24%. Oral LP was present in 89%, anogenital/vulvar LP in 42%, and cutaneous LP in 38%. Fourteen patients developed ELP as the sole or first manifestation of LP. Proximal esophageal lesions were present in 64%, distal in 11%, and both proximal and distal in 26%. Histology was "consistent with" LP in 71%. Four patients developed squamous cell carcinoma in association with ELP.

LIMITATIONS

This is a review of our cases and others reported in the literature.

CONCLUSIONS

ELP is underrecognized and underreported. There is often a significant delay between the onset of symptoms and the diagnosis. Malignant transformation of ELP to squamous cell carcinoma has been reported.

Diagnosis and management of vulvar ulcers

The diagnosis and management of the following non-infectious vulvar ulcers are reviewed: vulvar aphthae in adult and pediatric patients, aphthae associated with Behçet's disease, vulvar ulcers resulting from Crohn's disease, and vulvar ulcers associated with human immunodeficiency virus infection. There are many resources providing excellent reviews of infectious ulcers; therefore this topic will not be covered here.

The patient with recurrent oral ulceration

This paper discusses the range of recurrent oral ulceration which affects the oral mucosa. Types of ulceration covered in this paper include traumatic, infective, aphthous, ulceration related to the oral dermatoses, drug-induced, ulceration as a manifestation of systemic disease and ulceration indicating malignancy. Aspects of the aetiology, diagnosis and management of common oral recurrent ulcerative conditions are reviewed from a clinical perspective as an aid to practising dentists.

Alefacept: where it stands today

IMPORTANCE OF THE FIELD

The use of biologics that target a subset of immune cells in the treatment of immune-mediated ailments is an emerging field. Alefacept is one of the first biologics in the treatment of psoriasis. It selectively reduces CD45RO(+) memory T cells and inhibits T-cell activation. Clinical data support its safety and efficacy in a substantial subset of patients with psoriasis.

AREAS COVERED IN THIS REVIEW

This article reviews the mechanism of action and the pharmacokinetic and pharmacodynamic properties of alefacept. It also presents the available data about its effectiveness, modes of treatment as well as safety and efficacy in the treatment of psoriasis and other immune-based dermatologic disorders.

WHAT THE READER WILL GAIN

An overview of the published data about the clinical and adverse effects of alefacept in the treatment of psoriasis and a myriad of immunologically-based disorders.

TAKE HOME MESSAGE

Ongoing literature supports that alefacept is a safe alternative for the treatment of psoriasis. However, it remains the least prescribed medication in this group of drugs, mainly because it is only effective in a small proportion of patients. Nonetheless, its long-lasting effects and tolerability make it an excellent choice for those who do respond.