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Syafarina I, Mazaya M, Indrawati A, Akbar SZ, Sukowati C, Sadikin R. Skin Microbial Composition and Genetic Mutation Analysis in Precision Medicine for Epidermolysis Bullosa. Curr Drug Targets 2024; 25:404-415. [PMID: 38566380 DOI: 10.2174/0113894501290512240327091531] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Revised: 02/14/2024] [Accepted: 02/21/2024] [Indexed: 04/04/2024]
Abstract
Epidermolysis bullosa (EB) is an inherited skin disease representing a spectrum of rare genetic disorders. These conditions share the common trait that causes fragile skin, resulting in the development of blisters and erosions. The inheritance follows an autosomal pattern, and the array of clinical presentations leads to significant physical suffering, considerable morbidity, and mortality. Despite EB having no cure, effectively managing EB remains an exceptional challenge due to its rarity and complexity, occasionally casting a profound impact on the lives of affected individuals. Considering that EB management requires a multidisciplinary approach, this sometimes worsens the condition of patients with EB due to inappropriate handling. Thus, more appropriate and precise treatment management of EB is essentially needed. Advanced technology in medicine and health comes into the bioinformatics era. Including treatment for skin diseases, omics-based approaches aim to evaluate and handle better disease management and treatment. In this work, we review several approaches regarding the implementation of omics-based technology, including genetics, pathogenic mutation, skin microbiomics, and metagenomics analysis for EB. In addition, we highlight recent updates on the potential of metagenomics analysis in precision medicine for EB.
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Affiliation(s)
- Inna Syafarina
- Research Center for Computing, National Research and Innovation Agency (BRIN), Jakarta Pusat 10340, Indonesia
| | - Maulida Mazaya
- Research Center for Computing, National Research and Innovation Agency (BRIN), Jakarta Pusat 10340, Indonesia
| | - Ariani Indrawati
- Research Center for Data Science and Information, National Research and Innovation Agency (BRIN), Jakarta Pusat 10340, Indonesia
| | - Sharfina Zahra Akbar
- Department of Nanotechnology Engineering, Airlangga University, Surabaya, Indonesia
| | - Caecilia Sukowati
- Eijkman Research Center for Molecular Biology, National Research and Innovation Agency (BRIN), Jakarta Pusat 10340, Indonesia
- Liver Cancer Unit, Italian Liver Foundation NPO, Fondazione Italiana Fegato ONLUS, Trieste, Italy
| | - Rifki Sadikin
- Research Center for Computing, National Research and Innovation Agency (BRIN), Jakarta Pusat 10340, Indonesia
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El Yacoubi O, Chbicheb S. Recessive dystrophic epidermolysis bullosa (RDEB): Oral manifestation and management rules in oral surgery: A case report. Int J Surg Case Rep 2022; 102:107848. [PMID: 36580730 PMCID: PMC9827050 DOI: 10.1016/j.ijscr.2022.107848] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2022] [Revised: 12/13/2022] [Accepted: 12/20/2022] [Indexed: 12/24/2022] Open
Abstract
INTRODUCTION AND IMPORTANCE The recessive dystrophic epidermolysis bullosa is a severe form of hereditary epidermolysis bullosa characterized by deformities of the skin, blisters and erosions on the mucous membranes. Oral manifestations are frequent and extensive vary from small discrete vesicles to large bullae, associated with microstomia, ankyloglossia and a depapilled tongue. The purpose of this case report is to describe oral health status of patient with recessive-dystrophic epidermolysis bullosa, and the measures that dentists should adopt with the purpose of provide an effective dental treatment. CASE PRESENTATION We present a clinical case of a patient with recessive-dystrophic epidermolysis bullosa who underwent a bone regularization and whose follow-up was carried out until healing. CLINICAL DISCUSSION The management of patients with RDEB in oral surgery requires the adoption of an atraumatic technique and certain precautions to limit the formation of bullae and promote mucosal healing. CONCLUSION We can conclude that oral management of patients with recessive dystrophic epidermolysis bullosa presents a challenge for the oral surgeon and the management is generally multidisciplinary and relies essentially on the adoption of a preventive and atraumatic approach.
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Sakthivel P, Raveendran S, Panda S, Singh CA. Oral potential malignant disorders - A long list not to be forgotten. Oral Oncol 2021; 116:105244. [PMID: 33662761 DOI: 10.1016/j.oraloncology.2021.105244] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Accepted: 02/17/2021] [Indexed: 10/22/2022]
Affiliation(s)
| | | | - Smriti Panda
- All India Institute of Medical Sciences, New Delhi, India
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Turkyilmaz A, Bulut AC, Hancerliogullari D. Endodontic management of a patient with dystrophic epidermolysis bullosa: A case report. AUST ENDOD J 2020; 47:97-104. [PMID: 33368821 DOI: 10.1111/aej.12480] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Revised: 11/30/2020] [Accepted: 12/08/2020] [Indexed: 11/28/2022]
Abstract
Epidermolysis bullosa is a congenital genetic disease that causes blistering and erosion of the skin and mucosa. The main known forms include simple, junction, dystrophic and mixed subtypes. This case report presents the endodontic management and 1-year follow-up of a 27-year-old female patient with epidermolysis bullosa who was referred to the Faculty of Dentistry, Kırıkkale University, Turkey. An extraoral examination showed that the patient had multiple scars and blisters. The intraoral examination revealed ankyloglossia, microstomia, shallow buccal and vestibular sulci, enamel hypoplasia, gingival inflammation, mouth ulcers, symptomatic and asymptomatic deep caries, a tooth with an apical lesion and a tooth with pulpitis. The dental treatment was divided into four stages: (i) oral hygiene motivation and elimination of gingival bleeding, (ii) restorative and/or endodontic procedures, (iii) extractions and prosthetic treatments and (iv) recall appointments. A 1-year follow-up radiographic examination of the periapical status of the root canal treatments was clear.
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Affiliation(s)
- Ali Turkyilmaz
- Department of Endodontics, Faculty of Dentistry, University of Kirikkale, Kirikkale, Turkey
| | - Ali Can Bulut
- Department of Prosthodontics, Faculty of Dentistry, University of Kirikkale, Kirikkale, Turkey
| | - Dilek Hancerliogullari
- Department of Endodontics, Faculty of Dentistry, University of Kirikkale, Kirikkale, Turkey
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Krämer S, Lucas J, Gamboa F, Peñarrocha Diago M, Peñarrocha Oltra D, Guzmán‐Letelier M, Paul S, Molina G, Sepúlveda L, Araya I, Soto R, Arriagada C, Lucky AW, Mellerio JE, Cornwall R, Alsayer F, Schilke R, Antal MA, Castrillón F, Paredes C, Serrano MC, Clark V. Clinical practice guidelines: Oral health care for children and adults living with epidermolysis bullosa. SPECIAL CARE IN DENTISTRY 2020; 40 Suppl 1:3-81. [PMID: 33202040 PMCID: PMC7756753 DOI: 10.1111/scd.12511] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
BACKGROUND Inherited epidermolysis bullosa (EB) is a genetic disorder characterized by skin fragility and unique oral features. AIMS To provide (a) a complete review of the oral manifestations in those living with each type of inherited EB, (b) the current best practices for managing oral health care of people living with EB, (c) the current best practices on dental implant-based oral rehabilitation for patients with recessive dystrophic EB (RDEB), and (d) the current best practice for managing local anesthesia, principles of sedation, and general anesthesia for children and adults with EB undergoing dental treatment. METHODS Systematic literature search, panel discussion including clinical experts and patient representatives from different centers around the world, external review, and guideline piloting. RESULTS This article has been divided into five chapters: (i) general information on EB for the oral health care professional, (ii) systematic literature review on the oral manifestations of EB, (iii) oral health care and dental treatment for children and adults living with EB-clinical practice guidelines, (iv) dental implants in patients with RDEB-clinical practice guidelines, and (v) sedation and anesthesia for adults and children with EB undergoing dental treatment-clinical practice guidelines. Each chapter provides recommendations on the management of the different clinical procedures within dental practice, highlighting the importance of patient-clinician partnership, impact on quality of life, and the importance of follow-up appointments. Guidance on the use on nonadhesive wound care products and emollients to reduce friction during patient care is provided. CONCLUSIONS Oral soft and hard tissue manifestations of inherited EB have unique patterns of involvement associated with each subtype of the condition. Understanding each subtype individually will help the professionals plan long-term treatment approaches.
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Affiliation(s)
- Susanne Krämer
- Facultad de OdontologíaUniversidad de ChileSantiagoChile
| | - James Lucas
- Dental DepartmentRoyal Children's HospitalMelbourneAustralia
| | | | | | | | - Marcelo Guzmán‐Letelier
- Hospital Base ValdiviaValdiviaChile
- Facultad de OdontologiaUniversidad San SebastiánValdiviaChile
| | | | - Gustavo Molina
- Universidad Nacional de CórdobaArgentina
- Universidad Católica de CórdobaArgentina
| | | | - Ignacio Araya
- Facultad de OdontologíaUniversidad de ChileSantiagoChile
- Hospital Santiago OrienteMaxillofacial Surgery UnitChile
| | - Rubén Soto
- Facultad de OdontologíaUniversidad de ChileSantiagoChile
| | | | - Anne W Lucky
- Cincinnati Children's Epidermolysis Bullosa CenterCincinnati Children's HospitalCincinnatiOhioUSA
- The University of Cincinnati College of MedicineCincinnatiOhioUSA
| | - Jemima E Mellerio
- St John's Institute of DermatologyGuy's and St Thomas’ NHS Foundation TrustLondonUK
| | - Roger Cornwall
- Cincinnati Children's Epidermolysis Bullosa CenterCincinnati Children's HospitalCincinnatiOhioUSA
| | - Fatimah Alsayer
- Royal National ENT and Eastman Dental HospitalsUniversity College London HospitalsLondonUK
| | - Reinhard Schilke
- Hannover Medical SchoolDepartment of Conservative DentistryPeriodontology and Preventive DentistryHannoverGermany
| | | | | | - Camila Paredes
- Facultad de OdontologíaUniversidad de ChileSantiagoChile
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Oral and perioral soft tissue lesions and oral functions in patients with dystrophic epidermolysis bullosa. VOJNOSANIT PREGL 2020. [DOI: 10.2298/vsp201010128c] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Background/Aim. Numerous oral manifestations may occur within dystrophic
epidermolysis bullosa (DEB). Aim of the study was to examine oral and
perioral soft tissues and oral functions in DEB patients over a period of
one year. Methods. Twenty-four patients (1 month to 36 years old), were
clinically examined initially (T0), after 6 months (T6) and after 12 months
(T12). Appearance and localization of perioral and oral bullae and scars,
maximum mouth opening, reduced vestibule depth, absence of lingual papillae
and palatal rugae and restricted tongue movement due to scarring were
monitored. The values of maximum mouth opening at the initial examination
were compared to those measured in healthy control group of the same age.
The age of patients and differences between dominant and recessive subtype
of DEB were analyzed. Results. Average maximum mouth opening was
significantly lower in DEB patients compared to healthy individuals. Oral
and perioral bullae and scars, microstomia, and reduced vestibule depth were
very common, with no statistically significant difference among T0, T6, and
T12. The prevalence of restricted tongue movement due to scarring and the
absence of lingual papillae and palatal rugae increased significantly over
one year. Patients with microstomia, vestibule depth, and restricted tongue
movement due to scarring were significantly older than patients without
these characteristics. Lingual papillae and palatal rugae were more
frequently absent in recessive than in dominant DEB. Conclusion. DEB causes
significant changes in oral and perioral soft tissues and oral functions
impairment.
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Mello BZF, Neto NL, Kobayashi TY, Mello MBA, Ambrosio ECP, Yaedú RYF, Machado MAAM, Oliveira TM. General anesthesia for dental care management of a patient with epidermolysis bullosa: 24-month follow-up. SPECIAL CARE IN DENTISTRY 2016; 36:237-40. [PMID: 26936632 DOI: 10.1111/scd.12170] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Epidermolysis bullosa comprises a group of uncommon skin-related diseases, characterized by the formation of blisters on mucocutaneous regions occurring spontaneously, following a trauma, exposure to heat, or as a result of minimal mechanical trauma. The dental treatment of the patient with epidermolysis bullosa raises many questions and discussions, due to the difficulty of carrying out the procedures. This report aimed to detail the clinical considerations of the treatment under general anesthesia of a patient with epidermolysis bullosa. The extraction of all deciduous teeth under general anesthesia was recommended based on the clinical and radiographic examinations. At 24-month follow-up, the patient had great improvement in oral hygiene without new caries lesions. The patient has been followed-up at every month for caries lesion prevention and permanent tooth development. The treatment under general anesthesia provided the ideal safe conditions and was beneficial for the patient.
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Affiliation(s)
- Bianca Zeponi Fernandes Mello
- PhD Student, Department of Pediatric Dentistry, Orthodontics and Public Health, Bauru School of Dentistry, University of São Paulo, Bauru, São Paulo, Brazil
| | - Natalino Lourenço Neto
- Postdoctoral Student, Department of Pediatric Dentistry, Orthodontics and Public Health, Bauru School of Dentistry, University of São Paulo, Bauru, São Paulo, Brazil
| | - Tatiana Yuriko Kobayashi
- Postdoctoral Student, Department of Pediatric Dentistry, Hospital of Rehabilitation of Craniofacial Anomalies, University of São Paulo, Bauru, São Paulo, Brazil
| | - Marina Barbosa Almeida Mello
- MSc Student, Department of Stomatology, Bauru School of Dentistry, University of São Paulo, Bauru, São Paulo, Brazil
| | - Eloá Cristina Passucci Ambrosio
- MSc Student, Department of Pediatric Dentistry, Orthodontics and Public Health, Bauru School of Dentistry, University of São Paulo, Bauru, São Paulo, Brazil
| | - Renato Yassutaka Faria Yaedú
- Professor, Department of Stomatology, Bauru School of Dentistry and Hospital of Rehabilitation of Craniofacial Anomalies, University of São Paulo, Bauru, São Paulo, Brazil
| | - Maria Aparecida Andrade Moreira Machado
- Full Professor, Department of Pediatric Dentistry, Orthodontics and Public Health, Bauru School of Dentistry, University of São Paulo, Bauru, São Paulo, Brazil
| | - Thais Marchini Oliveira
- Associate Professor, Department of Pediatric Dentistry, Orthodontics and Public Health, Bauru School of Dentistry and Hospital of Rehabilitation of Craniofacial Anomalies, University of São Paulo, Bauru, São Paulo, Brazil
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Mortazavi H, Baharvand M, Mehdipour M. Oral potentially malignant disorders: an overview of more than 20 entities. J Dent Res Dent Clin Dent Prospects 2014; 8:6-14. [PMID: 25024833 PMCID: PMC4091702 DOI: 10.5681/joddd.2014.002] [Citation(s) in RCA: 66] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2013] [Accepted: 08/07/2013] [Indexed: 12/13/2022] Open
Abstract
Cancer of the oral cavity accounts for approximately 3% of all malignancies diagnosed annually in 270,000 patients world-wide. Oral cancer is the 12th most common cancer in women and the 6th in men. Many oral squamous cell carcinomas develop from potentially malignant disorders (PMDs). Lack of awareness about the signs and symptoms of oralPMDs in the general population and even healthcare providers is believed to be responsible for the diagnostic delay of these entities. The aim of this article is to update and improve the knowledge of healthcare providers about oral PMDs.
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Affiliation(s)
- Hamed Mortazavi
- 1Associate Professor, Department of Oral and Maxillofacial Medicine, Faculty of Dentistry, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Maryam Baharvand
- 1Associate Professor, Department of Oral and Maxillofacial Medicine, Faculty of Dentistry, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Masoumeh Mehdipour
- 1Associate Professor, Department of Oral and Maxillofacial Medicine, Faculty of Dentistry, Shahid Beheshti University of Medical Sciences, Tehran, Iran
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Sari E, Eryilmaz T, Tetik G, Ozakpinar HR, Eker E. Suprathel(®) -assisted surgical treatment of the hand in a dystrophic epidermolysis bullosa patient. Int Wound J 2014; 11:472-5. [PMID: 24517465 DOI: 10.1111/iwj.12226] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2013] [Accepted: 01/03/2014] [Indexed: 11/30/2022] Open
Abstract
Epidermolysis bullosa (EB) is a progressive familial disorder composed of dermal mucosal blisters, flexion contractures and pseudosyndactylies. Flexion contractures and pseudosyndactyly can be treated with surgery but usually require skin grafting. Because of poor wound healing, skin graft harvesting is a challenge in these patients. In order to prevent donor-site morbidities due to skin graft harvesting some alloplastic materials were introduced. In this study, we focused on Suprathel(®) as a new allograft material for covering the skin defects of a patient with dystrophic EB.
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Affiliation(s)
- Elif Sari
- Plastic, Reconstructive and Aesthetic Surgery Department, Kirikkale University Faculty of Medicine, Yahsihan-Kirikkale, Turkey
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Javed AP, Shenai P, Chatra L, Veena KM, Rao PK, Prabhu R. Occurrence of epidermolysis bullosa along with Amelogenesis imperfecta in female patient of India. Dent Res J (Isfahan) 2013; 10:813-6. [PMID: 24379873 PMCID: PMC3872636] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Epidermolysis bullosa (EB) is an inherited disorder, which is characteristically presented as skin blisters developing in response to minor injury. Junctional variety of EB is also associated with enamel hypoplasia. Amelogenesis imperfecta presents with abnormal formation of the enamel both in deciduous and permanent dentition. This article describes a previously unreported case of Amelogenesis imperfecta with complete loss of enamel in a young female patient with EB.
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Affiliation(s)
- A. P. Javed
- Department of Oral Medicine and Radiology, Annoor Dental College, Muvattupuzha, Kerala, India
| | - Prashanth Shenai
- Department of Oral Medicine and Radiology, Yenepoya Dental College, Yenepoya University, Deralakatte, Mangalore, Karnataka, India,Address for correspondence: Prof. Prashanth Shenai, Professor, Department of Oral Medicine and Radiology, Yenepoya Dental College, Yenepoya University, Deralakatte, Mangalore - 575018, Karnataka, India. E-mail:
| | - Laxmikanth Chatra
- Department of Oral Medicine and Radiology, Yenepoya Dental College, Yenepoya University, Deralakatte, Mangalore, Karnataka, India
| | - K. M. Veena
- Department of Oral Medicine and Radiology, Yenepoya Dental College, Yenepoya University, Deralakatte, Mangalore, Karnataka, India
| | - Prasanna Kumar Rao
- Department of Oral Medicine and Radiology, Yenepoya Dental College, Yenepoya University, Deralakatte, Mangalore, Karnataka, India
| | - Rachana Prabhu
- Department of Oral Medicine and Radiology, Yenepoya Dental College, Yenepoya University, Deralakatte, Mangalore, Karnataka, India
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Bascones-Martínez A, Muñoz-Corcuera M, Bascones-Ilundain C. [Immunological diseases of buccal localisation]. Med Clin (Barc) 2012; 140:88-92. [PMID: 22989674 DOI: 10.1016/j.medcli.2012.06.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2012] [Revised: 06/04/2012] [Accepted: 06/14/2012] [Indexed: 11/16/2022]
Affiliation(s)
- Antonio Bascones-Martínez
- Departamento de Medicina y Cirugía Bucofacial, Facultad de Odontología, Universidad Complutense de Madrid, Madrid, España.
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Krämer SM, Serrano MC, Zillmann G, Gálvez P, Araya I, Yanine N, Carrasco-Labra A, Oliva P, Brignardello-Petersen R, Villanueva J. Oral health care for patients with epidermolysis bullosa--best clinical practice guidelines. Int J Paediatr Dent 2012; 22 Suppl 1:1-35. [PMID: 22937908 DOI: 10.1111/j.1365-263x.2012.01247.x] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
OBJECTIVE To provide the users with information on the current best practices for managing the oral health care of people living with EB. METHODS A systematic literature search, in which the main topic is dental care in patients with Epidermolysis Bullosa, was performed. Consulted sources, ranging from 1970 to 2010, included MEDLINE, EMBASE, CINAHL, The Cochrane Library, DARE, and the Cochrane controlled trials register (CENTRAL). In order to formulate the recommendations of the selected studies the SIGN system was used. The first draft was analysed and discussed by clinical experts, methodologists and patients representatives on a two days consensus meeting. The resulting document went through an external review process by a panel of experts, other health care professionals, patient representatives and lay reviewers. The final document was piloted in three different centres in United Kingdom, Czech Republic and Argentina. RESULTS The guideline is composed of 93 recommendations divided into 3 main areas: 1) Oral Care--access issues, early referral, preventative strategies, management of microstomia, prescriptions and review appointments 2) Dental treatment: general treatment modifications, radiographs, restorations, endodontics, oral rehabilitation, periodontal treatment, oral surgery and orthodontics, and 3) Anaesthetic management of dental treatment. CONCLUSIONS A preventive protocol is today's dental management approach of choice.
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Affiliation(s)
- Susanne M Krämer
- Department of Paediatric Dentistry, Facultad de Odontología, Universidad de Chile, Santiago, Chile.
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Abstract
Epidermolysis Bullosa (EB) is a form of severe skin adhesion defect due to the disruption of the dermal- epidermal junction. It is classified into simplex and dystrophic forms depending on the level at which the junction is compromised. Repeated ulcerations and bullae formation in the mouth lead to scarring that brings about various changes in the oral cavity. These include loss of sulcular depth, ankyloglossia, limited mouth opening and other dentoalveolar changes. At present while there is no cure for EB, the therapeutic approaches are essentially aimed at controlling the infections and maintaining an acceptable quality of life. Dental management should aim at maintaining a functional dentition that would help in mastication and favour nutrition. Oral manifestations and dental management in a child diagnosed with dystrophic EB since birth are presented here.
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Affiliation(s)
- Uma Eswara
- Department of Pedodontics, the Oxford Dental College and Research Center, Bommanahalli, Hosur Road, Bangalore, India
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