Pemphigus vulgaris in prosthodontics ,power point

basic science journal clubs

1. Implant-Supported Oral Rehabilitation of a Patient with Pemphigus Vulgaris: A Clinical Report Altin N, Ergun S, Katz J, Sancakli E, Koray M, Tanyeri H. Implant‐supported oral rehabilitation of a patient with pemphigus vulgaris: A clinical report. Journal of prosthodontics. 2013 Oct;22(7):581-6. DELLA S INDRAN I MDS

2. CONTENTS INTRODUCTION INCIDENCE PATHOGENISIS CAUSES TREATMENT RELATED ARTICLES CONCLUSION LIST OF REFERENCES

3. PEMPHIGUS P emphix - bubble or blister. A utoimmune mucocutaneous diseases. Pemphigus pemphigus vulgaris (PV). pemphigus folacious

4. INCIDENCE Pemphigus vulgaris - 70% of pemphigus cases. 0.5 to 3.2 per 100,000 persons annually. Adults, only occasionally children and adolescents. F ifth and sixth decades.

5. PATHOGENISIS Antibodies- desmoglein 3. Loss of intraepithelial attachment.

6. CAUSE Interaction host’s genetic factors environmental triggering factors such as drugs, diet, UV rays, viruses etc.

7. Implant-Supported Oral Rehabilitation of a Patient with Pemphigus Vulgaris: A Clinical Report PURPOSE The purpose of this article is to report the clinical course of a patient with PV who was treated with an implant retained mandibular overdenture (IRMOD). CLINICAL REPORT A 70-year-old female patient soreness thought to be related to irritations caused by ill-fitting dentures.

8. Medical history revealed PV. ON EXAMINATION Revealed bullae on the hard palate and buccal mucosa bilaterally. An erosive lesion surrounded by yellow crust localized on the lower lip and lower vestibular sulcular area. M ultiple bullae- hairy skin, on the posterior part of the ears, on the occipital area, on the back, and on the pectoral area bilaterally. Post lesional pigmentations- right axillar area and on the skin of the right tibia

9. Positive Nicolsky sign test. Oral mucosal biopsy intraepithelial vesicle formation, acantholysis, Tzanck cells. Direct immunofluorescence (DIF) Immunoglobulin G (IgG) and complement component 3 (C3). Indirect immunofluorescence (IIF) testing IgG .

10. INTRA –ORAL EXAMINATION A trophic mandible with an ill-fitting denture M ucosal lesions in the vestibular sulcus and on the floor of the mouth.

11. TREATMENT PLAN A total prosthesis supported by two implants, which would be placed in the anterior region of the mandible using ball attachment connections. PROCEDURE local anesthesia , full thickness crestal incision, the mucoperiosteal flap buccal and lingual direction. T wo implants ( 1 mm in diameter, 8 mm in length ) were placed at the anterior region of the mandible .

12. Primary wound closure was obtained with difficulty because of the acantholysis . The patient antibiotic (amoxicillin 1 g, 2 × 1, 5 days, orally ), analgesic (naproxen sodium 550 mg, 2 × 1, 5 days, orally), antiseptic mouthwash (4% chlorhexidine gluconate 10 ml, 3 × 1, 5 days). The sutures were removed 1 week postoperatively . The wound healing was uneventful .

13. An interim complete denture relined with a soft-tissue conditioner for a 1-week period. Followed by the application of mouth-cured soft denture liner leaving the implant covered area spaced without any loading to the implants. The soft denture liner was replaced every several weeks, to prevent any microorganisms or fungal growth.

14. The patient was followed up on a 4-week interval until secondary stabilization was achieved . Three months postoperatively, the radiological examination was performed. The undercuts and irregularities were evaluated , and proper gingival healing copings were applied. Primary impressions complete denture perforated trays and irreversible hydrocolloid impression material. The impressions poured by dental plaster, and primary casts were obtained. Special trays were prepared using cold cure acrylic resin materials.

15. Conventional denture fabrication steps were completed, the dentures were fitted, and the spaces for the ball attachments were prepared.

16. The prostheses were delivered, and post-delivery denture maintenance instructions were explained to the patient .

17. The patient was followed up every 6 months. At the 32-month follow-up there was 0.9 mm mean periimplant bone resorption.

18. CONCLUSION Pemphigus vulgaris typically runs a chronic course, causing blisters, erosions, and ulcers on the mucosa and skin . Oral problems such as blister formation with minimal trauma are usually encountered in patients with PV . Prosthetic rehabilitation with implant-retained prostheses improves stabilization of the prosthesis, resulting in a higher level of patient comfort . IRMOD with ball attachment provided better prosthesis retention with fewer soft-tissue complications, this treatment choice could be considered as a good alternative for removable complete dentures in PV patients

19. RELATED ARTICLES

20. Prosthodontic Rehabilitation of an Oral Pemphigus Vulgaris Patient.   Ates U, Yuzugullu B. Prosthodontic Rehabilitation of an Oral Pemphigus Vulgaris Patient.IntJProsthodontRestorDent2011;1(2 ): 128-131.

21. CASE REPORT A 59-year-old male patient referred to Department of Prosthodontics with a complaint of swelling and pain on his left mandibular second molar tooth along with oral ulcers. Medical and dental history.

22. D ifficulties in consuming sour and spicy food. O ral mucosa was dry. Blisters and gingival inflammation were noticed on gingiva. The Nicolsky sign was positive.

23. All existing restorations were removed and the patient was referred to the dermatology clinic for an examination.

24. Diagnosis of PV was confirmed by histopathological examination and immunofluorescence analysis. SYSTEMIC TREATMENT S ystemic corticosteroid therapy, was administrated for 2 months . Intial dose was100 mg/day, then decreased up to 20 mg/day. PROSTHETIC TREATMENT F ixed partial restorations were constructed with supragingival margins.

25. With the oral PV under control, oral rehabilitation was initiated and an informed consent form was signed by the patient related to his prosthodontic treatment . A ll teeth were reprepared with supragingival chamfer margins where possible.

26. Impressions additional silicone impression material. Then, metal-reinforced porcelain fixed-partial restorations were prepared . The new restorations were temporarily cemented (cement-zinc oxide noneugenol) for 1 week as a try-out period . Afterward, both the restorations and the teeth were cleaned and cemented permanently using zinc polycarboxylate cement. Oral hygiene instructions were given. A nonalcohol - based mouth rinse (Biothene mouthwash) T ooth paste with fluoride was recommended for daily use to promote remineralization and reduce risk of future caries.

27. FOLLOW UP 1week. Every 3 month. Till 1 year.

28. DISCUSSION Fixed prosthesis are preferred wherever possible and great care are taken to create optimal gingival contours to prevent inflammation and facilitate hygiene . Modified ridge-lap pontics for anterior dentition, hygienic or modified hygienic pontics where esthetics is not important. C onical pontics used where there is a knife-edge residual alveolar ridge.

29. CONCLUSION The most important aspect of PV is its early recognition, diagnosis and treatment . The dental clinician and healthcare team play a critical role in the quality of life for these patients. Though the dental problems in PV can be challenging, thoughtful and comprehensive dental treatment planning and execution will result in favorable outcomes .

30. Removable Prosthetic Treatment in Oral Pemphigus Vulgaris: Report of Three Cases Corsalini M, Rapone B, Di Venere D, Petruzzi M . Removable prosthetic treatment in oral pemphigus;Report of three cses . Journal of International Society of Preventive & Community Dentistry. 2019 Jul;9(4): 423.

31. AIM OF THE STUDY The study aimed to evaluate and describe the possibility of rehabilitating three patients who suffered from oral PV with a removable prosthesis. CASE SERIES Three patients of age 64, 62, and 60 years were presented with pemphigus vulgaris. Initial treatment consisted of oral prednisone (1 mg/kg die), the dosage of which was decreased gradually according to clinical improvement .

32. During the maintenance phase , primary impression with an irreversible hydrocolloid impression material was prepared, by using a complete tray. D ental plaster primary cast, and trays acrylic resin material After border moulding, final impressions taken. The patients were treated with total removable upper and lower acrylic prostheses . After insertion, they underwent periodic quarterly check-ups to assess any complications and/or worsening on the diseased oral mucosa by the removable prosthesis.

33. DISCUSSION It is crucial to obtain a very smooth, highly polished denture, to avoid any mechanical irritation of the mucosa . Careful attention to occlusal harmony and smooth, rounded borders which are moulded precisely are vital to successful treatment . Gentle handling of the oral mucosa is necessary so as not to cause further injury.

34. CONCLUSION If patients follow rigorous and periodic follow‑up , along with a corticosteroid immunosuppressive therapy, there is no deterioration of their clinical symptoms by using removable acrylic resin prosthesis. P rosthetic treatment of patients with acantholytic pemphigus using removable dentures is promising.

35. Treatment of Epulis Fissuratum with CO2 Laser and Prosthetic Rehabilitation in Patients with Vesiculobullous Disease Işeri U, Özçakır-Tomruk C, Gürsoy-Mert H. Treat . Treatment of Epulis Fissuratum with CO2 Laser and Prosthetic Rehabilitation in Patients with Vesiculobullous Disease Photomedicine and laser surgery. 2009 Aug 1;27(4):675-81.

36. AIM The purpose of this article is the clinical presentation of the treatment of epulis fissuratum with CO2 laser and prosthetic rehabilitation of three patients with vesiculobullous diseases. CASE 1 A 43-year-old woman with EB was referred to clinic with the complaint of hyperplasia and a demand for prosthetic rehabilitation .

37. No cervical or submandibular adenopathy . Ulcers on the lower buccal mucosa, the tongue and elongated rolls of tissue in the maxillary muco -labial fold area.

38. Patient lost all the upper teeth due to caries and periodontitis , was wearing a chronically ill-fitting denture which caused inflammatory fibrous hyperplasia . The hyperplasia appeared to be split apparently by the overextended labial flange of the denture . Mandibular lateral incisors, canines, and premolar teeth with increased dental plaque and periodontitis were present .

39. TREATMENT PLAN The fibrous tissues were excised with CO2 laser with standard hand piece, with power settings ranging from 2 to 5 W in super pulse mode under local anaesthesia. The dental plaque was cleaned with ultrasonic scalers. Oral hygiene instructions on effective brushing were demonstrated.

40. CASE 2 A 39-year-old man with EB, was referred to clinic with complaints of caries and loose lower teeth. U lcers on the lower buccal mucosa, teeth with caries, and improper oral hygiene. P anoramic radiography showed that the mandible was very atrophic and all the teeth were very loose , floating in the soft tissues. He had been wearing a chronically ill-fitting lower partial denture for 10 year.

41. TREATMENT PLAN Extraction of teeth. The fibrous tissues, were excised with a CO2 laser. A well formed acrylic denture for the maxilla and a partial denture for the mandible were fabricated after a month of wound healing.

42. CASE 3 A 52 year-old man with a complaint of inflammatory papillary hyperplasia in anterior maxilla. The patient’s history revealed that he had previously visited a dentist due to painful oral lesions . Suspecting that the lesions might be PV, the dentist referred the patient to a dermatologist for further consultation. A mucosal punch biopsy from lesional and perilesional tissues revealed PV.

43. TREATMENT Systemic corticosteroids Oral candidiasis –side effect of corticoid therapy –anti-fungal drugs. CO2 laser Dentures were reconstructed and the patient has been stable for 6 months without any symptoms. Recalled every 3 months.

44. DISCUSSION Early diagnosis and treatment can improve the quality of life. The CO2 laser has become a favoured instrument in the treatment of soft tissue pathologies because of its affinity for water-based tissues . Laser application did not result in blister formation and patients showed significantly less postoperative pain .

45. CONCLUSION The CO2 laser may be a convenient instrument in the treatment of soft tissue pathologies in VBDs due to its minimal surrounding tissue damage. Use of complete or partial dentures has been considered a practical, economic, and nonsurgical treatment option for VBD patients.

46. Prosthetic management of patient with pemphigus vulgaris. case report. Tolenito AT. Prosthetic management of patient with pemphigus vulgaris. J Prosthet Dent 1977;38:255-38.

47. CASE HISTORY A 66-year-old woman was approached for a complete upper denture and a removable partial lower denture . The patient had small bleeding crack on the roof of mouth that elicited a sharp pain. Upon examination, dentist saw nothing r emarkable . Maxillary and mandibular partial dentures were completed and inserted in her mouth, the patient returned to the dentist for the alleviation of “sore spots .”

48. Severe hoarseness of voice accompanied by xerostomia . After 2 weeks, “white patches” appeared on her tongue and buccal mucosa . The next day, tongue appeared to be “getting whiter,” and her mouth was extremely sore, even though she had not worn her dentures for weeks.

49. Referred a dermatologist. Biopsy and immunologic studies confirmed the diagnosis of pemphigus vulgaris. Administration of prednisone was begun, but cutaneous lesions began to appear and bullae developed over her trunk and upper extremities. These conditions worsened as did the mouth lesions.

50. The patient was then hospitalized. Initially, doses of prednisone given were high; then were subsequently lowered. After a 2 month of hospital stay, the patient was discharged. DENTURE TREATMENT The remaining maxillary teeth extracted, and the healing was uneventful . P emphigus lesions, seen at the mandibular ridge just distal to the lower right premolar and on retromolar pad of the lower right mandible.

51. On maxillae, two regions of undercut bone seen, e ach at the site of the left and right canines . Since surgical intervention to correct the bone defects was avoided, a prosthesis of soft denture liner was fabricated. A soft liner of good resilience, colour stability, chemical resistance, good bonding to the denture , low water sorption, and resistance to dimensional change was selected. For the fabrication of the maxillary and mandibular dentures, standard clinical techniques were employed in which the tissues were gently manipulated.

52. The patient was recalled 1 week after insertion of the completed prostheses . Two regions of the lower partial denture covering the lesions required slight adjustments. Upon examination 16 months later, no adjustments were necessary. The patient was comfortable with the new prostheses . The dentures provided a protective covering to the delicate mucosa, especially over the two regions which had bony defects.

53. DISCUSSIONS The decision to use a soft liner material was based on the fact that there would be fewer problems for the patient in the undercut regions on the maxillae, since additional surgery could be avoided . The denture was smoothened and highly polished to avoid the risk of mechanical irritation to the mucosa. Occlusal harmony and smooth rounded borders are prerequisites to successful treatment

54. CONCLUSION The mortality rate of patients with pemphigus vulgaris has been greatly reduced. The painful mouth condition at the time of the disease results in a lack of good oral hygiene which, in turn, increases the need for prosthetic services .

55. Study of the State of Denture-Supporting Tissues in Patients with Pemphigus Vulgaris. Henyk BL, Rozko MM. The study of the state of denture supporting tissues in patients with pemphigus vulgaris. Archive of Clinical Medicine. 2017 Jun 12;23(1).

56. Objective The objective of the research was to describe the effect of acantholytic pemphigus on the state of denture-supporting tissues. Materials and methods of the research Group 1 20 patients with acantholytic pemphigus. Group 2 20 persons with partial loss of teeth without any somatic pathology having indications for orthopedic treatment. Examination Method clinical examination methods - questioning of patients with acantholytic pemphigus objective methods of examination - visual examination, examination of the oral cavity.

57. Results of the research

58. CONCLUSION Acantholytic pemphigus as well as glucocorticosteroid therapy has a significant impact on the state of the OM and periodontal tissues . The damage to the oral mucosa due to the acantholysis process was found in 100.0% of cases. A sharp deterioration of periodontal status may be caused by corticosteroid therapy.

59. REFERENCES Pradeep AR, Thorat MS, Raju A: Pemphigus vulgaris associated with significant periodontal findings: a case report. Int J Med Med Sci 2009;1:297-301 2. Harman KE, Gratian MJ, Seed PT, et al: Diagnosis of Pemphigus by ELISA: a critical evaluation of two ELISAs for the detection of antibodies to the major pemphigus antigens, desmoglein 1 and 3. Clin Exp Dermatol 2000;25:236-240 3 . Cetkovska P: Autoimunitnibuloznidermatozy. Ces-slov Derm 2004;81:188-196 4. Weinberg MA, Insler MS, Campen RB: Mucocutaneous features of autoimmune blistering diseases. Oral Surg Oral Med Oral Pathol 1997;84:51-534.   Buonavoglia A, Leone P, Dammacco R, Di Lernia G, Petruzzi M, Bonamonte D, et al. Pemphigus and mucous membrane pemphigoid: An update from diagnosis to therapy.  Autoimmun Rev.  2019;18:349–58.   Robinson JC, Lozada-Nur F, Frieden I. Oral pemphigus vulgaris: A review of the literature and a report on the management of 12 cases.  Oral Surg Oral Med Oral Pathol Oral Radiol Endod .  1997;84:349–55. 

60. THANKYOU