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
• Pemphix - bubble or blister.
• Autoimmune 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.
• Fifth 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.
• Multiple 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
• Atrophic mandible with an ill-fitting denture
• Mucosal lesions in the vestibular sulcus and on the floor of the
mouth.

12. 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.
• Two implants ( 1 mm in diameter, 8 mm in length ) were placed at
the anterior region of the mandible.

13. • 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.

14. • 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.

15. • 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.

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

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

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

19. 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

20. RELATED ARTICLES

21. 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.

22. 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.

24. • Difficulties in consuming sour and spicy food.
• Oral mucosa was dry.
• Blisters and gingival inflammation were noticed on gingiva.
• The Nicolsky sign was positive.

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

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

27. • 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.
• All teeth were reprepared with supragingival chamfer margins
where possible.

28. • 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)
• Tooth paste with fluoride was recommended for daily use to promote
remineralization and reduce risk of future caries.

29. • FOLLOW UP
1week.
Every 3 month.
Till 1 year.

30. 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.
• Conical pontics used where there is a knife-edge residual alveolar ridge.

31. 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.

32. • 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.

33. 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.

35. • During the maintenance phase, primary impression with an irreversible
hydrocolloid impression material was prepared, by using a complete
tray.
• Dental 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.

36. 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.

37. 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.
• Prosthetic treatment of patients with acantholytic pemphigus using
removable dentures is promising.

38. • 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.

39. 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.

40. • 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.

41. • 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.

42. 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.

44. CASE 2
• A 39-year-old man with EB, was referred to clinic with complaints
of caries and loose lower teeth.
• Ulcers on the lower buccal mucosa, teeth with caries, and improper
oral hygiene.
• Panoramic 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.

45. 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.

46. 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.

47. 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.

48. 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.

49. 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.

50. •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.

51. 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
remarkable.
• Maxillary and mandibular partial dentures were completed and
inserted in her mouth, the patient returned to the dentist for the
alleviation of “sore spots.”

52. • 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.

53. • 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.

54. • 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.
• Pemphigus lesions, seen at the mandibular ridge just distal to the lower
right premolar and on retromolar pad of the lower right mandible.

55. • On maxillae, two regions of undercut bone seen, each 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.

56. • 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.

57. 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

58. 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.

59. • 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).

60. 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.

61. Results of the research

65. 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.

66. REFERENCES
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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
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• Cetkovska P: Autoimunitnibuloznidermatozy. Ces-slov Derm 2004;81:188-196
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al. Pemphigus and mucous membrane pemphigoid: An update from diagnosis to
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67. THANKYOU