Intermittent parathyroid hormone enhances the healing of medication-related osteonecrosis of the jaw lesions in rice rats

Medication-related osteonecrosis of the jaw (MRONJ) is a potentially severe adverse event in patients treated with antiresorptives. Management of MRONJ is challenging, and no non-antibiotic, established medical treatment exists. Intermittent parathyroid hormone (iPTH) has been used off-label to treat MRONJ with favorable results. However, its medical efficacy has rarely been substantiated in clinical or preclinical experiments. Using a validated rice rat, infection-based model of MRONJ, we evaluated the effects of iPTH on established MRONJ. We hypothesize that iPTH contributes to MRONJ resolution by enhancing alveolar bone turnover and healing oral soft tissues. Eighty-four rice rats began a standard rodent chow diet at age 4 weeks to induce localized periodontitis. Rats were simultaneously randomized to receive saline (vehicle, VEH) or zoledronic acid (ZOL, 80 μg/kg IV) every 4 weeks. Oral exams were conducted bi-weekly to assign a gross quadrant grade (GQG, 0-4) to evaluate any lesion at the lingual aspect of the interdental space between maxillary molar (M2) and M3. 14 of 20 VEH-treated rice rats (70%) developed maxillary localized periodontitis with GQG 2-3 after 30 ± 10 weeks of saline. Additionally, 40 of 64 ZOL-treated rice rats with periodontitis developed MRONJ-like lesions after 30 ± 10 weeks of ZOL treatment. Rice rats with localized periodontitis or MRONJ-like lesions were treated with saline or iPTH (40 μg/kg) subcutaneously (SC) 3 times/week For 6 weeks until euthanasia. We found that iPTH -treated ZOL rats had a lower prevalence of MRONJ (p < 0.001), with lower severity extent of oral lesions (p = 0.003) and percentage of empty osteocyte lacunae (p < 0.001). ZOL rats treated with iPTH displayed a higher osteoblast surface (p < 0.001), more osteoblasts (p < 0.001), higher osteoclast surface (p < 0.001) and more osteoclasts (p = 0.002) at alveolar bone surfaces than ZOL/VEH rats. Greater gingival epithelial thickness and epithelial cell proliferation rate was found in the oral mucosa and gingiva of ZOL/PTH rats than in ZOL/VEH rats (p < 0.001). Our data suggest that iPTH is an efficacious non-operative medicinal therapy that accelerates oral healing and enhances the resolution of MRONJ lesions in ZOL-treated rice rats.

Preventing or controlling periodontitis reduces the occurrence of osteonecrosis of the jaw (ONJ) in rice rats (Oryzomys palustris)

INTRODUCTION

Osteonecrosis of the jaw (ONJ) is an adverse event that requires association of both systemic risk factors, such as powerful anti-resorptives (pARs; e.g. zoledronic acid [ZOL]), and local oral risk factors (e.g. tooth extraction, periodontitis). Whereas optimal oral health prior to initiate pARs is recognized as critically important for minimizing ONJ risk, the efficacy of preventive/maintenance measures in patients who are taking pARs is understudied. Rice rats fed a standard diet (STD), rich in insoluble fiber, develop localized periodontitis. STD-rats with localized periodontitis treated with ZOL for 18-24 wk develop ONJ. Hence, we hypothesized that controlling/preventing localized periodontitis in the ZOL-treated rats, reduces ONJ occurrence.

METHODS

We used two approaches to attempt reducing periodontitis prevalence: 1) periodontal cleaning (PC); and 2) replacing the STD-diet with a nutritionally-equivalent diet high in soluble fiber (SF). 75 four-week-old male rats were weight-randomized into five groups (n = 15) in a 24-week experiment. Three groups ate the STD-diet and two the high SF-diet. STD-diet groups received intravenous (IV) vehicle (VEH) q4wks (STD + VEH), 80 μg/kg ZOL q4wks IV (STD + ZOL), or ZOL plus PC q2wks (STD + ZOL + PC). The SF-diet groups received VEH (SF + VEH) or ZOL (SF + ZOL). Jaws were processed for histopathology and evaluated for ONJ prevalence and tissue-level periodontitis.

RESULTS

1) 40% of STD + VEH rats developed maxillary localized periodontitis with no ONJ; 2) 50% of STD + ZOL rats developed ONJ; 3) 7% of STD + ZOL + PC rats developed ONJ (p < 0.01 vs. STD + ZOL); and 4) one SF + ZOL rat developed localized periodontitis, and no SF + VEH or SF + ZOL rats developed ONJ (p < 0.001 vs. STD + ZOL).

CONCLUSIONS

1) Periodontal cleaning in ZOL-treated rats decreases localized periodontitis severity and reduces ONJ prevalence; and 2) feeding a SF-diet to ZOL-treated rats reduces both incidence of localized periodontitis and ONJ. Our data indicates strong oral microbial community shifts according to oral health condition and trends in the shifts associated with diet.

Gingival Fibroma: An Emerging Distinct Gingival Lesion with Well-Defined Histopathology

Gingival growths, barring a few are mostly reactive and seldom exhibit significant true neoplastic potential. The common etiology is local irritation from dental plaque/calculus, trauma as well as medication-related overgrowth. Such lesions are easily distinguishable and categorized into diagnoses such as pyogenic granuloma, peripheral ossifying fibroma, etc. We present a previously undescribed, but commonly encountered, reactive gingival growth with unique histologic features and suggest the diagnostic term "gingival fibroma." An IRB approved retrospective review of the University of Florida Oral Pathology Biopsy Service encompassing years 2010-2019, was performed to select cases. Demographics, clinical data, and microscopic diagnoses were recorded and analyzed. Four board-certified oral and maxillofacial pathologists agreed upon and established the diagnostic criteria. These are: a prominent fibromyxoid stroma, variable cellularity, a whorled or storiform pattern of arrangement of the cellular elements, lack of significant inflammation or vascularity, and complete absence of calcification, and/or odontogenic islands. A total of 60 cases met all criteria and were included in the study. Age range in years was 14-87 with the mean at 45.11 years. A striking female predilection (90%) was noted. Approximately 62% of cases were reported on the maxillary gingiva, followed by 38.3% in the mandibular gingiva. Majority, 66.7% were in the anterior incisor region followed by 11.7% in the canine/first premolar areas. All lesions were submitted as excisional biopsy, and 4 cases recurred within 2-3 years of excision. In all cases, lesional tissue appeared to extend to the surgical base of the specimen. We present 60 cases of a histologically unique entity occurring exclusively on the gingiva and introduce the diagnostic term "Gingival Fibroma" for these lesions. Further studies with adequate clinical follow-up may help understand the exact clinical behavior of these lesions.

Anti-vascular endothelial growth factor antibody monotherapy causes destructive advanced periodontitis in rice rats (Oryzomys palustris)

OBJECTIVE

Angiogenesis inhibitors (AgI) are commonly used in combination chemotherapy protocols to treat cancer, and have been linked to osteonecrosis of the jaw (ONJ). However, it is unknown if AgI therapy alone is sufficient to induce ONJ. We have previously established an ONJ model in rice rats with localized periodontitis that receive zoledronic acid (ZOL). The purpose of this study was to use this model to determine the role of anti-vascular endothelial growth factor A (anti-VEGF) antibody treatment of rice rats with localized maxillary periodontitis. We hypothesized that rice rats with localized maxillary periodontitis given anti-VEGF monotherapy will develop oral lesions that resemble ONJ, defined by exposed, necrotic alveolar bone.

METHODS

At age 4 weeks, 45 male rice rats were randomized into three groups (n = 15): 1) VEH (saline), 2) ZOL (80 μg/kg body weight, intravenously once monthly), and 3) anti-VEGF (5 mg B20-4.1.1/kg body weight, subcutaneously twice weekly). After 24 weeks, rats were euthanized, jaws were excised and a high-resolution photograph of each quadrant was taken to assign a severity grade based on gross appearance. Jaws were then fixed, scanned by MicroCT, decalcified and sectioned for histopathologic and immunohistochemical analyses.

RESULTS

40-80% of the rats in the three groups developed gross oral lesions. 50% of ZOL rats developed ONJ. In contrast, 80% of the anti-VEGF rats developed destructive advanced periodontitis that was characterized by extreme alveolar bone loss and fibrosis. Anti-VEGF rats never developed exposed, necrotic bone. Furthermore, only anti-VEGF rats developed mild to severe mandibular periodontitis. Compared to VEH rats, more T-cells were found in periodontal lesions of anti-VEGF rats and more cells of the monocyte lineage were found in ONJ lesions of ZOL rats.

CONCLUSIONS

Anti-VEGF monotherapy administered to a validated rodent model of ONJ caused a destructive advanced form of periodontitis that differed significantly from ONJ.

An Analysis of Clinical and Histopathologic Features of Fibrous Dysplasia of the Jaws: A Series of 40 Cases and Review of Literature

Fibrous dysplasia (FD) is a rare condition commonly involving the jaws. While FD has a typical clinical and histological presentation, considerable variation exists. Moreover, overlap of features with other disorders is possible. This study serves to characterize the features of a large case series of FD of the jaws. With IRB approval, the University of Florida Oral Pathology Biopsy Service archive was retrospectively searched from 1994 to 2015 for cases of FD. Epidemiological data, location, duration, clinical and radiographic appearance, clinical impression and exact microscopic diagnosis were recorded. The average age was 37.3 years (range 7-87 years) with majority of cases in females (67.5%). The most common ethnicity was Caucasian. Maxillary location was predominant (59%), followed by mandible (38%) and multiple locations (3%). Expansion was reported in 78% of cases. Radiographically, most cases exhibited ground glass opacity, however some presented with a mottled or mixed radiopaque/radiolucent appearance. Histologically, a wide variation in terms of stromal cellularity, presence of osteoblastic rimming, and presence of calcified material mimicking cemento-osseous dysplasia was observed. Clinicians and pathologists should be cognizant of the significant variability in clinical, histopathologic, and radiographic presentation of FD, which may pose a diagnostic challenge.

Clear cell changes in salivary gland neoplasms: A 20-year retrospective study

BACKGROUND

Clear cells are observed histopathologically in both benign and malignant neoplasms but their presence in salivary gland tumors has not been extensively documented.

MATERIAL AND METHODS

With IRB approval, the archive of the University of Florida College of Dentistry oral pathology biopsy service was retrospectively searched from 1994-2014 for all benign and malignant salivary tumors. Epidemiological data, tumor location and duration, and type of tumor were recorded. A four reviewer panel examined the original slides. Reviewers scaled each case as 0 (no clear cells present), 1 (few to focal clear cells), 2 (less than 50% clear cells), and 3 (greater than 50% clear cells).

RESULTS

A total of 535 cases were included of which 48% of tumors displayed 0 clear cells (257/535), 31.4% (168/535) scored 1, 13.6% (73/535) scored 2, and 7% (37/535) scored 3. Of the 251 (47%) malignant neoplasms, 64% (160/251) demonstrated 0-1 clear cell change, while 36% (91/251) showed a score of 2-3. For the total 284 (53%) benign tumors, 93% (265/535) scored 0-1 and 7% (19/535) scored a 2-3 range. No statistical difference was noted for gender, age, or duration of time present in regards to presence or absence of clear cells. Statistically significant differences in clear cell presence were found between location groups, between benign and malignant diagnosis, and between specific diagnostic groups.

CONCLUSIONS

This study demonstrates the frequent presence of increased numbers of clear cells in oral salivary malignancies and highlights salivary gland differential diagnoses when presented with clear cell changes.

Desmoplastic fibroma of the mandible: a series of three cases and review of literature

The desmoplastic fibroma (DF) is a rare, fibroblastic lesion of bone that histologically resembles the desmoid tumor of soft tissue. Although classified as benign, it frequently demonstrates aggressive behavior, often causing tooth mobility, extensive bone destruction, and has a moderate to high recurrence rate. We present three cases of DF in the mandible: the first in a 13 year old female involving the mandibular body in the region of teeth #s 27-#28, the second in a 57 year old female with a lesion apical to tooth #30, and the third in a 20-year-old female involving the left posterior mandible. Clinical, histologic, immunohistochemical (IHC) and radiographic features of this rare neoplasm are discussed. The challenges encountered in establishing an accurate diagnosis due to significant microscopic overlap with other spindle cell lesions are also detailed. Additionally, the findings of IHC stains including vimentin, smooth muscle actin, S-100 protein, β-catenin, HHF-35 and proliferation marker, Ki-67 on 3 cases are reported. The potential for misdiagnosis is high, especially in early lesions, since immunohistochemistry has been reported in literature to be inconsistent when differentiating DFs from other spindle cell lesions. A comparative review of DF and similar entities in the jaws with current considerations in treatment and prognosis is presented.

Intraoral basal cell carcinoma, a rare neoplasm: report of three new cases with literature review

Intraoral basal cell carcinoma (IOBCC) is an extremely rare entity that bears close microscopic resemblance to and is often confused with the peripheral ameloblastoma (PA). Basal cell carcinomas are thought to arise from pluripotential basal cells present within surface epithelium and adnexal structures, so theoretically they can arise within the oral cavity. Many of the early cases reported as IOBCC actually represent PA. Most of the well documented cases arise from the gingiva. The histologic features of basal cell carcinoma that help separate it from a PA include: tumor arising from surface epithelium, scattered mitotic figures and apoptotic cells, presence of mucoid ground substance and tumor infiltrating widely throughout the connective tissue and often exhibiting a prominent retraction artifact. Clinically IOBCC resemble carcinomas, compared to the benign and innocuous appearance of the PA and typically presents as surface ulcerations varying from rodent ulcer to an ulcerated erythroplakia appearance. This contrasts with the classic "bump on the gum" appearance of PAs with usually intact surface and appearing as small discrete, sessile, exophytic lesions. Importantly, the proliferative basaloid epithelium demonstrates positive immunoreactivity for the anti-epithelial antibody, Ber-EP4, a cell surface glycoprotein. The IOBCC has the potential for local recurrence and aggressive behavior and should be treated with wide surgical excision and close clinical follow up. We present 3 rare cases of IOBCC and discuss the salient histologic, immunohistochemical and clinical features.

Bis-enoxacin inhibits bone resorption and orthodontic tooth movement

Enoxacin inhibits binding between the B-subunit of vacuolar H(+)-ATPase (V-ATPase) and microfilaments, and also between osteoclast formation and bone resorption in vitro. We hypothesized that a bisphosphonate derivative of enoxacin, bis-enoxacin (BE), which was previously studied as a bone-directed antibiotic, might have similar activities. BE shared a number of characteristics with enoxacin: It blocked binding between the recombinant B-subunit and microfilaments and inhibited osteoclastogenesis in cell culture with IC50s of about 10 µM in each case. BE did not alter the relative expression levels of various osteoclast-specific proteins. Even though tartrate-resistant acid phosphatase 5b was expressed, proteolytic activation of the latent pro-enzyme was inhibited. However, unlike enoxacin, BE stimulated caspase-3 activity. BE bound to bone slices and inhibited bone resorption by osteoclasts on BE-coated bone slices in cell culture. BE reduced the amount of orthodontic tooth movement achieved in rats after 28 days. Analysis of these data suggests that BE is a novel anti-resorptive molecule that is active both in vitro and in vivo and may have clinical uses.

ABBREVIATIONS

BE, bis-enoxacin; V-ATPase, vacuolar H(+)-ATPase; TRAP, tartrate-resistant acid phosphatase; αMEM D10, minimal essential media, alpha modification with 10% fetal bovine serum; SDS-PAGE, sodium dodecyl sulfate-polyacrylamide gel electrophoresis; RANKL, receptor activator of nuclear factor kappa B-ligand; NFATc1, nuclear factor of activated T-cells; ADAM, a disintegrin and metalloprotease domain; OTM, orthodontic tooth movement.

Characterization of bilateral trigeminal constriction injury using an operant facial pain assay

In order to better understand and treat neuropathic pain, scientific study must use methods that can assess pain processing at the cortical level where pain is truly perceived. Operant behavior paradigms can accomplish this. We used an operant task to evaluate changes following chronic constriction injury to the trigeminal nerves. We also relate these behavioral changes to immunohistochemistry of transient receptor potential channels vanilloid 1 and melastatin 8 (TRPV1 and TRPM8) in the trigeminal ganglia. Following nerve injury, successful performance of the operant task was reduced and aversive behaviors were observed with 10 and 37 °C stimulation, indicating cold allodynia and mechanical allodynia respectively. In contrast, while aversive behaviors were observed with 48 °C stimulation, successful performance of the operant task was not substantially hindered following injury. These behavioral changes were accompanied by an increase in TRPV1 positive cells and an increased intensity of TRPM8 staining at 2 weeks post-injury, when cold allodynia is maximal. These findings suggest that the incorporation of operant behavioral assessment in the study of pain may provide insight into the relationship among peripheral changes, motivational drive, and pain. Understanding this relationship will allow us to better treat and prevent chronic neuropathic pain.

Polymicrobial periodontal pathogen transcriptomes in calvarial bone and soft tissue

Porphyromonas gingivalis, Treponema denticola, and Tannerella forsythia are consistently associated with adult periodontitis. This study sought to document the host transcriptome to a P. gingivalis, T. denticola, and T.forsythia challenge as a polymicrobial infection using a murine calvarial model of acute inflammation and bone resorption. Mice were infected with P. gingivalis, T. denticola, and T. forsythia over the calvaria, after which the soft tissues and calvarial bones were excised. A Murine GeneChip(®) array analysis of transcript profiles showed that 6997 genes were differentially expressed in calvarial bones (P < 0.05) and 1544 genes were differentially transcribed in the inflamed tissues after the polymicrobial infection. Of these genes, 4476 and 1035 genes in the infected bone and tissues were differentially expressed by upregulation. Biological pathways significantly impacted by the polymicrobial infection in calvarial bone included leukocyte transendothelial migration (LTM), cell adhesion molecules, adherens junction, major histocompatibility complex antigen, extracellular matrix-receptor interaction, and antigen processing and presentation resulting in inflammatory/cytokine/chemokine transcripts stimulation in bone and soft tissue. Intense inflammation and increased activated osteoclasts were observed in calvarias compared with sham-infected controls. Quantitative real-time RT-PCR analysis confirmed that the mRNA level of selected genes corresponded with the microarray expression. The polymicrobial infection regulated several LTM and extracellular membrane pathway genes in a manner distinct from mono-infection with P. gingivalis, T. denticola, or T. forsythia. To our knowledge, this is the first definition of the polymicrobially induced transcriptome in calvarial bone and soft tissue in response to periodontal pathogens.

Tannerella forsythia infection-induced calvarial bone and soft tissue transcriptional profiles

Tannerella forsythia is associated with subgingival biofilms in adult periodontitis, although the molecular mechanisms contributing to chronic inflammation and loss of periodontal bone remain unclear. We examined changes in the host transcriptional profiles during a T. forsythia infection using a murine calvarial model of inflammation and bone resorption. Tannerella forsythia was injected into the subcutaneous soft tissue over calvariae of BALB/c mice for 3 days, after which the soft tissues and calvarial bones were excised. RNA was isolated and Murine GeneChip (Affymetrix, Santa Clara, CA) array analysis of transcript profiles showed that 3226 genes were differentially expressed in the infected soft tissues (P < 0.05) and 2586 genes were differentially transcribed in calvarial bones after infection. Quantitative real-time reverse transcription-polymerase chain reaction analysis of transcription levels of selected genes corresponded well with the microarray results. Biological pathways significantly impacted by T. forsythia infection in calvarial bone and soft tissue included leukocyte transendothelial migration, cell adhesion molecules (immune system), extracellular matrix-receptor interaction, adherens junction, and antigen processing and presentation. Histologic examination revealed intense inflammation and increased osteoclasts in calvariae compared with controls. In conclusion, localized T. forsythia infection differentially induces transcription of a broad array of host genes, and the profiles differ between inflamed soft tissues and calvarial bone.

Virulence of major periodontal pathogens and lack of humoral immune protection in a rat model of periodontal disease

OBJECTIVE

This study was designed to test the hypothesis that periodontal pathogens Tannerella forsythia and Porphyromonas gingivalis are synergistic in terms of virulence potential using a model of mixed-microbial infection in rats.

MATERIALS AND METHODS

Three groups of rats were infected orally with either T. forsythia or P. gingivalis in mono-bacterial infections or as mixed-microbial infections for 12 weeks and a sham-infected group were used as a control. This study examined bacterial infection, inflammation, immunity, and alveolar bone loss changes with disease progression.

RESULTS

Tannerella forsythia and P. gingivalis genomic DNA was detected in microbial samples from infected rats by PCR indicating their colonization in the rat oral cavity. Primary infection induced significantly high IgG, IgG2b, IgG1, and IgG2a antibody levels indicating activation of mixed Th1 and Th2 immune responses. Rats infected with the mixed-microbial consortium exhibited significantly increased palatal horizontal and interproximal alveolar bone loss. Histological examinations indicated significant hyperplasia of the gingival epithelium with moderate inflammatory infiltration and apical migration of junctional epithelium. The results observed differ compared to uninfected controls.

CONCLUSION

Our results indicated that T. forsythia and P. gingivalis exhibit virulence, but not virulence synergy, resulting in the immuno-inflammatory responses and lack of humoral immune protection during periodontitis in rats.

Molecular characterization of Treponema denticola infection-induced bone and soft tissue transcriptional profiles

Treponema denticola is associated with subgingival biofilms in adult periodontitis and with acute necrotizing ulcerative gingivitis. However, the molecular mechanisms by which T. denticola impacts periodontal inflammation and alveolar bone resorption remain unclear. Here, we examined changes in the host transcriptional profiles during a T. denticola infection using a murine calvarial model of inflammation and bone resorption. T. denticola was injected into the subcutaneous soft tissue over the calvaria of BALB/c mice for 3 days, after which the soft tissues and the calvarial bones were excised. RNA was isolated and analysed for transcript profiling using Murine GeneChip arrays. Following T. denticola infection, 2905 and 1234 genes in the infected calvarial bones and soft tissues, respectively, were differentially expressed (P <or= 0.05). Biological pathways significantly impacted by T. denticola infection in calvarial bone and calvarial tissue included leukocyte transendothelial migration, cell adhesion (immune system) molecules, cell cycle, extracellular matrix-receptor interaction, focal adhesion, B-cell receptor signaling and transforming growth factor-beta signaling pathways resulting in proinflammatory, chemotactic effects, and T-cell stimulation. In conclusion, localized T. denticola infection differentially induces transcription of a broad array of host genes, the profiles of which differed between inflamed calvarial bone and soft tissues.

Porphyromonas gingivalis infection-induced tissue and bone transcriptional profiles

Porphyromonas gingivalis has been associated with subgingival biofilms in adult periodontitis. However, the molecular mechanisms of its contribution to chronic gingival inflammation and loss of periodontal structural integrity remain unclear. This investigation aimed to examine changes in the host transcriptional profiles during a P. gingivalis infection using a murine calvarial model of inflammation and bone resorption. P. gingivalis FDC 381 was injected into the subcutaneous soft tissue over the calvaria of BALB/c mice for 3 days, after which the soft tissues and calvarial bones were excised. RNA was isolated from infected soft tissues and calvarial bones and was analysed for transcript profiles using Murine GeneChip((R)) arrays to provide a molecular profile of the events that occur following infection of these tissues. After P. gingivalis infection, 6452 and 2341 probe sets in the infected soft tissues and calvarial bone, respectively, were differentially expressed (P </= 0.05). Biological pathways significantly impacted by P. gingivalis infection in tissues and calvarial bone included cell adhesion (immune system) molecules, Toll-like receptors, B-cell receptor signaling, transforming growth factor-beta cytokine family receptor signaling, and major histocompatibility complex class II antigen processing pathways resulting in proinflammatory, chemotactic effects, T-cell stimulation, and downregulation of antiviral and T-cell chemotactic effects. P. gingivalis-induced inflammation activated osteoclasts, leading to local bone resorption. This is the first in vivo evidence that localized P. gingivalis infection differentially induces transcription of a broad array of host genes, the profiles of which differed between inflamed soft tissues and calvarial bone.

Chronic ulcerative stomatitis: Diagnostic and management challenges—four new cases and review of literature

Chronic ulcerative stomatitis (CUS) is a recently described mucocutaneous disease characterized by involvement of mucosal surfaces and skin. The disease usually presents in the form of painful oral ulcers and has been seen predominantly among older women. Clinically, CUS patients may exhibit erosive or ulcerative lesions of oral mucosa resembling erosive lichen planus and/or other vesiculobullous lesions. Routine histology may exhibit features of lichenoid mucositis and is often nondiagnostic. Direct immunofluorescence studies of mucosal or skin biopsies usually reveal a unique pattern of IgG bound to nuclei of keratinocytes of the basal and parabasal cell layers. Chronic ulcerative stomatitis exhibits a unique resistance to standard treatments available, including topical and systemic corticosteroids and immunomodulatory medications. However, long-lasting favorable clinical responses may be achieved with hydroxychloroquine pharmacotherapy. We present the clinicoimmunopathologic findings of four cases of CUS and discuss the varied clinical, microscopic spectrum, and treatment for this chronic, debilitating, and often recalcitrant condition. A systematic review of the literature, including 35 previously reported cases, is presented.

A study on body mass index (BMI) and some biochemical parameters of the medicos with family history of diabetes mellitus, hypertension and coronary heart disease

Increasing prevalence of diabetes mellitus (DM), hypertension (HT), coronary heart disease (CHD) is alarming; risk factors are fairly stable, passing fairly well from childhood to adulthood; genetic factors play a role. This is important to know the status of some biochemical parameters viz, fasting plasma glucose level, fasting serum insulin (FI), serum triglyceride (STG), total cholesterol (TC), low density lipoprotein (LDL), high density lipoprotein (HDL) among the medicos with family history (FH) of DM, HT or CHD and the relationship of biochemical parameters with body mass index (BMI). Mean age of the sample (n=67) was 22 years with 76.12% males and 23.88% females; 44.78%, 29.85% and 19.40% had FH of DM, HT and CHD respectively; 8.96% had the FH of three diseases. High BMI was seen in 62.69% cases; it was significantly high among those with FH of DM (p<0.05) but not significant against HT (p>0.05) or CHD (p>0.05). All had normal fasting plasma glucose level. Positive association existed (a) between BMI with FI, LDL and HDL, FI with LDL and HDL, TG with TC, TC with LDL and HDL, LDL with HDL among those with FH of DM; (b) between BMI with FI, STG and HDL, FI with LDL and HDL, TC with LDL and HDL, LDL with HDL among those with FH of HT; (c) between BMI with FI, STG and HDL, FI with TC, LDL and HDL, TC with LDL and HDL, LDL with HDL among those with FH of CHD. Multiple correlation coefficients (R) also indicated moderate association.

Expression of the receptor of advanced glycation end products in gingival tissues of type 2 diabetes patients with chronic periodontal disease: a study utilizing immunohistochemistry and RT-PCR

OBJECTIVES

Relationship between diabetes and periodontal disease is well established. It has been shown that advanced glycation end-products (AGEs) might exert noxious effects on gingival tissues through its receptor. Evidence for the role of receptors of AGE (RAGE) in periodontal disease was verified in a murine model for diabetes. However, the presence of RAGE in human gingival tissues has not been demonstrated previously. In this study we demonstrate the presence of RAGE in human periodontium in patients with chronic periodontitis with and without type 2 diabetes.

MATERIAL AND METHODS

Gingival biopsies from eight patients with both type 2 diabetes and chronic periodontitis and 14 healthy control subjects with chronic periodontitis were immunohistochemically stained for RAGE. Five samples from the study groups and four controls were subjected to reverse transcriptase coupled to polymerase chain reaction (RT-PCR) for quantitative determination of mRNA for RAGE.

RESULTS

On immunohistochemistry, positive staining for RAGE was seen in the endothelium and the basal and spinous layer of the inflamed gingival epithelium in both type 2 diabetes and non-diabetes tissue with no statistically significant difference between both groups. RT-PCR, however, showed a 50% increase in mRNA for RAGE in the gingiva of diabetic patients when compared with controls (p<0.05).

CONCLUSIONS

Although there was no change in the staining intensity for RAGE between both groups, the increase in the mRNA for RAGE in the type 2 diabetes gingival epithelium may indicate a possible involvement of this receptor in the periodontal destruction in type 2 diabetes.

Receptor of advanced glycation end product (RAGE) expression in the minor salivary glands of patients with Sjögren's syndrome: a preliminary study

OBJECTIVE

Receptor for advanced glycation end product (RAGE) is a cell-surface receptor with ligands capable of inducing proinflammatory responses in autoimmunity. We investigated the immunohistochemical expression and immunoblotting of RAGE in labial salivary glands from Sjögren's syndrome (SS) patients.

MATERIAL AND METHODS

Ten minor salivary glands from SS and 15 from normal salivary tissue adjacent to mucocele were stained immunohistochemically using an antibody to RAGE. Immunoblotting was performed on four SS biopsies and four controls from normal gland.

RESULTS

Immunohistochemistry showed all sections positive for RAGE. The SS sections did not statistically differ from controls. In immunoblotting, SS samples expressed approximately 100% more RAGE than controls [probability (p)<0.03, Student's t-test].

CONCLUSIONS

RAGE is present in the labial salivary glands of both normal and SS patients, with preliminary data suggesting over-expression in SS tissues. The role of RAGE in the pathogenesis of SS has yet to be determined.

Effects of locally-delivered human macrophage products and estrogen on murine inflammatory bone resorption

The objective of this study was to use an in vivo model of periodontitis (mouse calvaria) to quantify the effects of local release of secreted human macrophage products, 17beta-estradiol (E2), and proinflammatory lipopolysaccharide (LPS) on histologic bone resorption. Human THP-1 monocytes (106) were converted to macrophage phenotype by 500 ng/ml phorbol 12-myristate- 13-acetate (PMA) and treated as follows: no stimulation or Escherichia coli LPS (10 microg/ml) alone or in combination with a physiologic dose of E2 (100 pg/ml) for 24 h in RPMI/10% FBS, washed extensively, then incubated for 24 h in serum-free media. Supernatant products were concentrated and incorporated into a 4% (w/v) methylcellulose gel. Separate gels were incorporated with the following: LPS (500 microg/animal) alone, high dose of E2 (10 ng/animal) alone, a combination of LPS + E2, or gel only (controls). Loaded or control gels were placed into a polylactic acid occlusive dome, inserted subcutaneously over the calvaria of mature ovariectomized ICR Swiss mice (8 mice x 7 groups x 2 times [5/14 days] = 112 animals), then calvaria were evaluated histologically. Macrophage stimulation with LPS alone, but not LPS in combination with E2, produced supernatants which upregulated osteoclast numbers in the suture area compared to gel controls at 5 days (p = 0.009). The addition of LPS directly to the local delivery gels significantly upregulated osteoclasts in endosteal surfaces compared to gel controls at 5 days (p = 0.024) and at 14 days (p = 0.025). The addition of E2 to LPS down-regulated resorption to a level not different from gel controls at 14 days. This in vivo model appears effective in studying inflammatory bone resorption, which may be inhibited by E2 directly or through its influence on secreted macrophage products.

Humoral immune responses in different clinical forms of tuberculosis

To assess the antibody responses in different clinical forms of tuberculosis in an attempt to ascertain the specificity of such a response, so that it may be used as a diagnostic tool, 93 tuberculosis cases and 62 normal healthy controls were included in the study. All the cases were diagnosed as tuberculosis by clinical picture including radiological findings, blood picture, fine needle aspiration cytology (FNAC) or histopathological features, sputum examination or urine culture for acid-fast bacilli. IgM and IgG antibodies in the cases and controls were detected by ELISA using A60 antigen from M. bovis and compared with common diagnostic parameters of tuberculosis like presence of acid-fast bacilli in smear and tuberculin response. Antibody responses with A60 antigen has not been found to be specific and often failed to detect a new case.

Chemistry of metal-bound anion radicals. A family of mono- and bis(azopyridine) chelates of bivalent ruthenium

The reaction of the dihydride [RuII(H)2(CO)(PPh3)3], 3, with excess azo-2,2'-bipyridine (abp) in boiling dry benzene has afforded the diradical bischelate [RuII(abp.-)2(CO)(PPh3)], 4, and the hydridic monochelate monoradical [RuII(abp.-)(H)(CO)(PPh3)2], 5. A similar reaction between 3 and 2-(p-chlorophenylazo)pyridine (Clpap) did not yield a bischelate, but the hydridic monoradical [RuII(Clpap.-)(H)(CO)(PPh3)2], 6, has been isolated. Upon treatment of 4-6 with NH4PF6 in a wet dichloromethane-acetonitrile medium, the one-electron-oxidized salts 4+PF6-, 5+PF6-, and 6+PF6- are isolated, H+ being the oxidizing agent. The X-ray structures of 4+PF6-.CH2Cl2, 5+PF6-.H2O, and 6+PF6- have been determined. In the monoradical 4+ the azo N-N bond lengths in the two chelate rings are 1.284(6) and 1.336(6) A, showing that the radical electron is localized in the latter ring. The half-filled extended Hückel HOMO is indeed found to be so localized, and it has a large azo character. Complexes 4-6 display radical redox couples with E1/2 in the range -0.5 to +0.10 V vs SCE. The E1/2 values qualitatively correlate with corresponding vco values (1900-2000 cm-1). The monoradicals (S = 1/2) 4+, 5, and 6 uniformly display a strong EPR signal near g = 2.00. Metal-mediated magnetic interaction makes the EPR-silent diradical 4 strongly antiferromagnetic with J = -299 cm-1. Crystal data are as follows: (4+PF6-.CH2Cl2, C40H33Cl2F6N8-OP2Ru) monoclinic, space group P2(1)/c (no. 14), a = 14.174(6) A, b = 16.451(4) A, c = 18.381(4) A, beta = 98.00(3) degrees, Z = 4; (5+PF6-.H2O, C47H41F6N4O2P3Ru) monoclinic, space group P2(1)/n (no. 14), a = 9.433(2) A, b = 38.914(17) A, c = 13.084(3) A, beta = 103.47(2) degrees, Z = 4; (6+PF6-, C48H39ClF6N3OP3Ru) monoclinic, space group P2(1)/n (no. 14), a = 10.496(5) A, b = 22.389(8) A, c = 19.720(6) A, beta = 90.53(3) degrees, Z = 4.

Cinnamon-induced oral erythema multiformelike sensitivity reaction

BACKGROUND

Erythema multiforme, or EM, is a hypersensitivity reaction to agents such as herpes virus, drugs or foods. Oral EM-like reactions may be induced by cinnamon. It is important for dentists to recognize this condition.

CASE DESCRIPTION

The authors report an unusual case of cinnamon-induced oral EM-like reaction in an older female patient. The disease manifested itself as chronic extensive surface ulcerations and lip swelling. The patient was treated repeatedly with topical and systemic steroids but responded to them only temporarily. The patient was cured when the offending agent--cinnamon--was eliminated from her diet.

CLINICAL IMPLICATIONS

Oral EM or EM-like reactions pose a diagnostic dilemma due to their varied etiologies and clinical manifestations. Correct diagnosis is essential for effective treatment. A negative skin test does not rule out an allergic reaction to food.

Recalcitrant oral ulcers caused by calcium channel blockers: diagnosis and treatment considerations

BACKGROUND

Oral ulcers often pose a dilemma in diagnosis and treatment. Patients seen routinely in dental practices are frequently receiving multiple medications. The authors discuss the pathogenesis, clinical appearance and treatment of drug-induced oral ulcers.

CASE DESCRIPTIONS

Two patients with recalcitrant painful oral ulcers caused by calcium channel blockers are described. These ulcers failed to heal despite repeated interventions, including surgery, laser ablation, and topical and systemic steroid therapy. Results of the histopathologic examinations were nonspecific. The patients were in a great deal of pain because of the initial failure to recognize the cause of these ulcers.

CLINICAL IMPLICATIONS

A careful medical history, including a detailed list of medications received, is critical in identifying drug-induced oral ulcerations, especially when the ulcer is resistant to treatment and of indeterminate cause. To date, calcium channel blockers have not been reported to cause oral ulcerations.

Metastatic neuroblastoma with ganglioneuromatous differentiation and mandibular involvement

Neuroblastic tumors comprise neuroblastoma (NB), ganglioneuroblastoma, and ganglioneuroma (GN). NBs have shown remarkable differentiation capabilities, which include spontaneous regression. In the last 3 decades, the prognosis for metastatic NB has improved significantly. The ability to distinguish prognostic subtypes based on clinical and biologic features allows for understanding of this disease process and development of management procedures. NBs are often asymptomatic and remain undetected until a large abdominal mass or metastasis is found. GN, the most differentiated variant, is a benign neoplasm with significant growth potential and ability to cause clinical complications. GN of the mandible has seldom been reported in the literature in English. We present a case of NB metastatic to the mandible exhibiting ganglioneuromatous differentiation. We discuss the current understanding of the biology, grading, classification, and prognostic implications of NB.

Linear IgA disease histopathologically and clinically masquerading as lichen planus

In each of 2 cases reported, the patient presented with features of erosive lichen planus or lichenoid drug eruptions and an incisional biopsy taken from the patient was diagnosed histologically as lichen planus. Subsequent recurrences or exacerbations were associated with vesiculobullous lesions. Simultaneous or subsequent direct immunofluorescence studies--from the same tissue sample in one case and from a similar site in the other case--demonstrated classic features of linear IgA disease. Both patients were originally treated for lichen planus with systemic and/or topical corticosteroids with limited success. One patient was treated with sulfapyridine with minimal improvement. Both patients were subsequently treated with dapsone and demonstrated significant clinical improvement. We propose that linear IgA disease may be more common than reported in the oral cavity, inasmuch as many cases of recalcitrant lichen planus, erosive lichen planus, and lichenoid drug eruptions, especially those with a vesiculobullous component, may in reality represent linear IgA disease. We recommend that direct immunofluorescence be done in any case in which bullous lichen planus is suspected.

Bilateral inverse Duane's retraction syndrome--a case report

Duane's retraction syndrome is a well known congenital musculo-facial anomaly. Various explanations have been given for the aetiology of this syndrome. Inverse Duane's retraction syndrome is a condition with reverse clinical features. Abduction of the affected eye is possible to some extent and is accompanied by retraction of the eyeball, narrowing of the palpebral fissure and pseudoptosis. There may be some restriction of movement on adduction. The primary lesion is suspected to be in the medial rectus muscle. Frequently the muscle is found to be entrapped following trauma to the medial wall of the orbit. A case of bilateral inverse Duane's retraction syndrome and convergent squint along with left-sided perceptive deafness is reported. As is usually the case there was no structural abnormality or entrapment of the muscle from trauma.

Functional heterogeneity of sialic acid binding agglutinins of rat uteri towards in vitro lymphocyte transformation

The sialic acid binding agglutinins (SAS) are purified from three different stages (proestrus [P], estrus [E], diestrus [D]) of rat uterine homogenate. All three proteins are capable of inhibiting the in vitro phytohemagglutinin (PHA)-induced blastogenic response of lymphocytes and thymocytes as manifested by inhibition of 3H-thymidine incorporation into cells. The lymphocytes isolated from pregnant female rats were found to be more susceptible to inhibition. In resting lymphocyte cultures (RLC), however, the P- and E-SAS proteins acted differently from the D-SAS by stimulating lymphocyte proliferation in the cultures initiated from normal rat lymphocytes. At the same dose these proteins were inhibitory to the RLC, where cultured lymphocytes were isolated from the pregnant female. Reverse hemolytic plaque formation assay results also indicated functional heterogeneity between these proteins. P-SAS induced a potent polyclonal activation of the B cell, whereas E- and D-SAS did not show much activation. SAS proteins do not have any complement-like activity. These results, corroborated by cell viability count and 51Cr uptake tests, suggest that D-SAS has genuine lymphoblastogenesis-suppressive properties whereas P- and E-SAS-induced suppression in the presence of PHA is probably due to an increased cell-density-dependent cytotoxicity.