J Oral Pathol Med (2015) 44: 468–474 © 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
doi: 10.1111/jop.12257
wileyonlinelibrary.com/journal/jop
Oral lichenoid lesions and serum antinuclear antibodies in Thai patients Chalakorn Prucktrakul, Pornpan Youngnak-Piboonratanakit, Patnarin Kanjanabuch, Titipong Prueksrisakul, Kobkan Thongprasom Oral Medicine Department, Faculty of Dentistry, Chulalongkorn University, Bangkok, Thailand
OBJECTIVES: The aim of this study was to investigate the presence of serum antinuclear antibodies (ANA) in Thai oral lichenoid drug reaction (OLDR) and oral lichen planus (OLP) patients. MATERIALS AND METHODS: This study comprised 20 patients diagnosed with OLDR, 23 patients with OLP, and 24 healthy control subjects. Participants’ blood samples were assayed for ANA staining patterns and serum ANA titer levels by immunofluorescence using human epithelial type 2 (HEp-2) as a substrate. The serum ANA titer levels were defined as low (1:40–1:80), medium (1:160– 1:320), and high (>1:640). RESULTS: Serum ANA were detected in 73.9%, 70%, and 25% of OLP, OLDR, and control subjects, respectively. There was a statistically significant difference between the number of serum-ANA-positive subjects in the OLP or OLDR groups and the control group (P < 0.01), but no significant difference between the OLP and OLDR groups. The speckled pattern was the most commonly found staining pattern, present in 60.9%, 55.0%, and 20.8% of the OLP, OLDR, and control subjects, respectively. The number of subjects with low ANA titers in the OLP and OLDR groups was significantly higher than that of the control group (P < 0.01). Medium ANA titers were found in 15%, 4.4%, and 4.2% of the OLDR, OLP, and control subjects, respectively, while high ANA titers were not found in any group. CONCLUSIONS: The number of serum-ANA-positive OLP and OLDR patients was significantly higher than the control group. Speckled pattern and low titer levels were the most common findings in both OLP and OLDR groups J Oral Pathol Med (2015) 44: 468–474 Keywords: antinuclear antibodies; oral lichen planus; oral lichenoid drug reaction; Thai
Correspondence: Professor Kobkan Thongprasom, Oral Medicine Department, Faculty of Dentistry, Chulalongkorn University, Bangkok 10330, Thailand. Tel: +6622188942, Fax: +6622188941, E-mail: [email protected] Accepted for publication July 27, 2014
Introduction Oral lichen planus (OLP) is a common chronic inflammatory disease that affected patient’s quality of life due to symptoms, such as a burning sensation or pain, and its low rate of remission (1, 2). Although the etiology of OLP is unclear, it is currently believed to be associated with immunological dysfunction (3, 4). Studies have shown that the immunopathogenesis of OLP involves both antigenspecific and non-specific mechanisms (5–7). Previous studies have investigated the expression of cytokines associated with OLP lesions (4, 8–10). Oral lichen planus and oral lichenoid lesions (OLLs) are similar in their oral presentation and histopathological features, rendering it is difficult to distinguish between these lesions clinically and histopathologically. However, OLLs have distinct causes, including reactions to amalgam restorations or medications. OLLs are classified as oral lichenoid drug reactions (OLDR), oral lichenoid contact lesions (OLCL), and OLLs of graft-versus-host disease (OLLGVHD) (11, 12). OLDR may develop in the oral cavity after administration of certain drugs, for example, oral hypoglycemic agents, angiotensin-converting enzyme inhibitors, and non-steroidal anti-inflammatory drugs (NSAIDs), penicillamine, or gold salts, etc. (13). The most reliable diagnosis of OLDR is when the lesions resolve after withdrawal of the suspected drugs, and the reaction recurs when the patient is rechallenged with the same drug. The distinguishing feature of an OLCL lesion is its emergence near the suspected causative agents, which commonly are amalgam restorations. The majority of OLCLs resolve within several months after removal and replacement of the causative material. An accurate diagnosis is important for the treatment and management of OLP and OLL lesions (14). A study has reported that circulating autoantibodies toward the components of the basal cell membrane, referred to as basal cell cytoplasmic antibodies, were found in patients with a clinical diagnosis of OLLs (15). These antibodies were significantly associated with systemic drug usage, histological diagnosis of a lichenoid reaction, and a unilateral intraoral distribution of the clinical lesion. The authors suggested that the basal cell cytoplasmic phenomenon may be a useful adjunct to clinical and histological
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investigation in diagnosis of oral lesions precipitated by drug therapy. Previous studies have shown the presence of serum autoantibodies in OLP patients, including anti-epithelial cell, antinuclear antibody (ANA), antismooth muscle (SMA), antimitochondrial (AMA), antigastric parietal cell (GPCA), antithyroglobulin (TGA), antithyroid microsomal (TMA), and antidesmoglein 1 and 3 antibodies (16–21). Interestingly, a study has reported that serum ANA was present in 60.9% of Chinese patients with OLP (22). Taken together, this suggests that OLDR that resembles OLP both clinically and histopathologically may be associated with the development of serum ANA. Thus, the objectives of our study were to investigate the relationship between the presence of serum ANA and OLDR and OLP in Thai patients and the association between serum ANA titer levels and staining patterns in OLDR and OLP patients. The information gained in our study concerning the immunopathogenesis of OLDR and OLP can be useful in the differential diagnosis and management of these lesions.
Table 1 Diagnostic criteria of OLP and OLDR using in this study modified from World Health Organization (23) and van der Meij et al. (24) OLP History No systemic diseases No taking medications Clinical criteria Bilateral white striae, plaque and/or ulcerative (erosive), atrophic lesions Histopathological criteria Presence of well-defined bandlike zone of cellular infiltration confined to the superficial part of the connective tissue, consisting mainly of lymphocytes Signs of ‘liquefaction degeneration’ in the basal cell layer Absence of epithelial dysplasia
Patients and methods The study protocol was approved by the Ethics Committee of the Faculty of Dentistry, Chulalongkorn University. The present cross-sectional study comprised patients who had been referred to the Oral Medicine clinic at the Faculty of Dentistry, Chulalongkorn University, Bangkok, Thailand, from May 2013 to January 2014 for the diagnosis and management of OLP or OLDR. All patients enrolled in this study were consecutively recruited. The control group consisted of 24 healthy volunteers who were participated in our study at the same period. The study groups consisted of 20 OLDR patients (atrophic = 10; erosive/ulcerative = 10) and 23 OLP patients (atrophic = 15; erosive/ulcerative = 8). All patients had no skin lesions. The OLDR group comprised 18 women and 2 men whose ages ranged from 23 to 70 years (50.8 11.0 years; mean SD). The OLP group comprised 23 cases, 21 women and 2 men ranging in ages from 26 to 66 years (mean 49.6 12.3 years). The mean duration of the OLP and OLDR lesions were 32.9 56.5 months (range 0.25–351 months) and 42.8 84.1 months (range 1–228 months), respectively. The healthy control subjects consisted of 20 women and 4 men aged 35–59 years (mean 47.2 7.9 years). Inclusion criteria The diagnosis of OLP and OLDR was made based on the clinical and histopathological definitions of the World Health Organization (WHO, 1978) and van der Meij et al. (23, 24). In our study, we modified the diagnostic criteria for OLDR and OLP as shown in Table 1. Symptomatic OLP patients without systemic disease and not taking any medications were included in our study. The patients were diagnosed for OLP both clinically and histopathologically with absence of epithelial dysplasia. The criteria for the patients with OLDR were that they had to have taken medications such as antihypertensive, NSAIDs, hypolipidemic, hypoglycemic, or a combination of medications before the eruption of oral lesions. Healthy control subjects without systemic disease other than dental caries or gingivitis and not taking any
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OLDR History Oral lesions erupted after taking medications Clinical criteriaa Unilateral/bilateral white striae, plaque and/or ulcerative (erosive), atrophic lesions Histopathological criteria Histopathologically typical of OLP or compatible with OLP
Increased amount of plasma cells or eosinophils or perivascular distribution of inflammatory infiltrateb Absence of epithelial dysplasia
OLDR, oral lichenoid drug reaction; OLP, oral lichen planus. a Some cases of OLDR presented as bilateral lesions. b May be found in some cases.
medications were included in the study. Informed consent was obtained from all patients and control subjects before participating in this study. Exclusion criteria Any subjects in the study groups who did not meet the inclusion criteria were excluded from our study. History takings from the patients with the current medications or medication records were assessed strictly. If the history of oral lesion eruption and medications taken was not clear, those patients were excluded from our study. The patients whose biopsy specimens demonstrated dysplasia were also excluded. Oral lesions contacted with amalgam restorations or metal crowns were excluded from this study. Moreover, patients with severe systemic disease, over 70 years of age, pregnant, non-compliance, or with a questionable diagnosis were excluded. Laboratory assessment Five milliliters of venous blood was taken from the patients and healthy controls in the morning between 10:00 and 12:00 and stored at 4°C. The blood samples were then transported to the laboratory for analysis. Complete blood examination was performed using a Coulter counter (Sysmex Corporation, Kobe, Japan). An indirect immunofluorescence assay (IIF) was performed using human epithelial type 2 (HEp-2) as a substrate (Euroimmunâ from Lubeck, Germany) to determine the ANA staining pattern and positive ANA staining titer. A positive ANA titer is the highest serum dilution where immunofluorescent staining can be observed. The ANA titer levels were defined as follows (25, 26): 1:40–1:80 = low; 1:160–1:320 = medium; >1:640 = high. The ANA staining patterns were classified as speckled, homogeneous, nucleolar, peripheral, centromere, or anticytoplasmic. J Oral Pathol Med
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The number of serum-ANA-positive subjects and ANA titer levels were compared between the groups using the chisquare test or Fisher’s exact test. A P-value 0.05). None of the groups demonstrated a high titer level. Speckled pattern and low ANA titer levels were the most common findings in both the OLP and OLDR groups.
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Hypolipidemic drugs such as the statins were the most commonly used medication in 8/9 patients (88.9%) that were serum ANA positive. Antihypertensive drugs such as amlodipine, atenolol, losartan, and hydrochlorothiazide were also used in eight of the patients positive for serum ANA. ANA positivity was also seen in OLDR patients taking medications such as NSAIDs, hypoglycemic, oral contraceptives, levothyroxine, and muscle relaxant (Table 3).
Discussion The present study investigated the presence of serum ANA in Thai OLDR and OLP patients. We found that the majority of the OLP and OLDR patients in our study were serum ANA positive; however, a portion of the control subjects tested positive as well. The most common findings in the OLP and OLDR groups were speckled ANA staining pattern and low ANA-positive titers. Assaying for serum ANA is a useful tool for making the proper diagnosis and prognosis of lesions in patients who have overlapping oral manifestations. In the present study, we found that the number of serum-ANA-positive subjects was significantly higher in the OLP and OLDR groups compared to the healthy control group. The detection of an abnormal ANA titer is a significant criterion for the diagnosis of systemic lupus erythematosus (SLE) (27, 28), mixed connective tissue disease, Sj€ ogren’s syndrome, scleroderma, and other connective tissue diseases (29). The frequency of presence of ANA is much higher in patients with SLE, mixed connective tissue disease, Sj€ ogren’s syndrome, scleroderma, and other connective tissue diseases compared to normal population (30). However, positive serum ANA results can also be found in the normal population. Several studies have reported that 4–13.8% of the healthy population had positive serum ANA results at a 1:80 dilution (25, 31–33). Positive ANA results among healthy individuals are more commonly found in women and those over 65 years (25, 34). Moreover, a study has shown that 3.3% of the normal population were ANA positive at a 1:320 dilution (25). The majority of the subjects in the groups in our study had a low titer (1:80), and high serum ANA titers (1:640 dilution) were not found in any of the subjects in our study. Positive serum ANA titers at a dilution equal to or greater than 1:160 are usually considered clinically significant (35, 36). When Table 3 Medications in antinuclear antibodies-positive patients with oral lichenoid drug reaction Medicationa Hypolipidemic Antihypertensive Non-steroidal anti-inflammatory drugs Hypoglycemic Oral contraceptives Levothyroxine Muscle relaxant a
One patient took more than one medication.
n (%) 9 (45.0) 8 (40.0) 2 (10.0) 2 1 1 1
(10.0) (5.0) (5.0) (5.0)
a positive ANA titer of more than 1:640 is detected, it is important to monitor the individual for autoimmune diseases, even though the patient may have no significant oral signs or symptoms. Close follow-up in such cases is needed to evaluate the patient’s symptoms and clinical findings because autoantibodies can be detected prior to the clinical manifestation of disease. Various patterns of ANA staining and several different nuclear antigens were found in the serum of patients with various autoimmune diseases and also provided the useful information for diagnosis (30, 32, 37, 38). In the present study, positive serum ANA results were found at a 1:320 dilution in two cases that demonstrated a homogeneous pattern. One of these subjects was taking losartan, an angiotensin II receptor antagonist, and the other was taking amlodipine. In addition, one subject who demonstrated a peripheral pattern was taking oral contraceptives. Interestingly, one subject in the OLP group had a positive ANA at titer of 1:320 with homogeneous and speckled patterns. This individual had a history of oral lesions developed only 4 months, and her serum was ANA positive at a titer of 1:80 with a cytoplasmic pattern. One subject in the healthy control group, a 47-year-old woman, was also serum ANA positive with a speckled pattern at a titer of 1:320. Although a positive result can occur in middle-aged women (32), close long-term follow-up should be carried out with a patient with these findings to monitor for the autoimmune or other connective tissue diseases such as SLE that can develop from high serum ANA titer levels. After follow-up of this case for 1 year, she is still in healthy condition. However, positive autoantibody results alone are insufficient to establish a diagnosis of SLE; the oral medicine specialist should consider the patient’s relevant medical history and oral presentation along with other clinical and laboratory criteria before making a diagnosis. In the present study, positive serum ANA results were detected in 73.9%, 70%, and 25% of the OLP, OLDR, and the control groups, respectively. There was a significant difference in the number of positive ANA results between the OLP or OLDR groups and the control group (P < 0.01), whereas the difference between the OLDR and OLP groups was not significant (P > 0.05). Notably, one patient was serum ANA positive with more than one staining pattern. The speckled pattern was the most commonly found staining pattern present in 60.9%, 55%, and 20.8% of the OLP, OLDR, and control groups, respectively. To the best of our knowledge, the present study is the first report of positive serum ANA results in OLDR patients. In our study, 11 OLDR patients were positive for serum ANA with a speckled pattern, six patients with a homogeneous pattern, two patients with a nucleolar pattern, and one patient each with a peripheral and a centromere pattern. When considering the medications taken by the OLDR patients who presented with positive ANA results, hypolipidemic drugs such as the statin group were the most commonly used in 8/9 patients. Patients taking antihypertensive drugs such as amlodipine, atenolol, losartan, or hydrochlorothiazide were also found to be serum ANA positive. In addition, patients taking medications such as NSAIDs, hypoglycemic drugs, oral contraceptives, levothyroxine, or muscle relaxant were serum ANA positive.
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One limitation in our study was the number of patients enrolled; thus, a causal relationship between medications and ANA development could not be determined with certainty. However, it is possible that these drugs act as neoantigens that lead to the development of ANA. Antigens are processed by the antigen-presenting cells and are presented to the helper/inducer T cells in the oral mucosa, in the regional lymph nodes, and in the circulation. We postulate that cytokines secreted by helper T cells may activate antigen-specific activated B cells to produce ANA in the tissues and circulation of OLDR patients. A study should be conducted to detect serum ANA in a larger group of patients taking medications with oral lesions. The mechanism of ANA development in the sera of OLDR patient remains unclear. Three patients in our study with OLDR who had medium ANA titers took antihypertensive drugs such as amlodipine, losartan, and oral contraceptives for more than 1 year. The oral lesions in one patient taking oral contraceptives might be considered to be drug-induced lupus erythematosus; however, this was ruled out by additional clinical and histopathological findings. This is the first study in Thai patients that would be useful for the basic knowledge, diagnosis, treatment, and prognosis of the oral lesions in the future. Medications used in those patients should be monitored carefully during treatment and considered for long-term observation. It is possible to withdraw the suspected drugs and replace them with another drug in those patients because of the need for treatment of their systemic disease. The mechanisms of ANA development caused by these drugs still remain unclear; therefore, more investigations of these medications should be performed to better clarify the relationship between medications and ANA development. In our study, we used HEp-2 cells as the substrate for blood serum analysis. Indirect immunofluorescence assay (IIF) using HEp-2 cells is the gold standard for determining the presence of ANA. This assay provides information about the cellular localization of autoantigens that is useful for the proper diagnosis (39). When using the HEp-2 substrate for IIF, titers of 1:80 or higher are typically deemed positive (30). We recommend using the other alternative substrates for detection of ANA in OLP and OLDR patients in the future research, so the results might be possibly different from this study. Chronic ulcerative stomatitis (CUS) is a rare chronic condition that affects the oral mucosa causing painful ulcerations. Patients with CUS develop autoantibodies against a 70-kD nuclear protein involved in epithelial cell growth and differentiation. Patients with CUS can have ulcerative lesions of the oral mucosa that are clinically similar to erosive OLP. The differential diagnosis between these two diseases is important because corticosteroid therapy is typically an ineffective treatment for CUS, while antimalarial drugs such as hydroxychloroquine are effective (40, 41). The pathogenesis of CUS is unknown, and many patients are not diagnosed because of the high cost of direct immunofluorescence (DIF) and the need for special processing (42). The diagnosis of CUS requires that a surgical biopsy demonstrates a characteristic DIF immunopathologic pattern, which is a finding that speckled pattern
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in the nuclei of the basal and parabasal epithelial cells, known as the stratified epithelium-specific antinuclear antibody (SES-ANA) (41–43). Recent studies have shown that IIF can detect SES-ANA (41, 43). In our study, we did not perform DIF in our OLP and OLDR patients with positive serum ANA and a speckled pattern to exclude these lesions from CUS because of lacking special technique. However, every time when patients with OLLs and positive ANA test are found, further investigation for SLE/DLE should be made starting with anti-DNA antibodies in all cases. Medical history is also paramount as sometimes relevant information can be retrieved (e.g., history of unexplained hematological disorders, joint pains, previous strokes, etc.). We have to be particularly aware of the diagnosis of SLE/DLE because oral manifestations in most of our patients with OLDR in this study were similar with lupus-like lesions, which were very difficult in diagnosis by oral manifestations and histological and/or ANA appearances. Although there is still a lack of clarity particularly about the diagnosis of SLE or DLE, recent review literature about oral lichenoid tissue reactions (OLTRs) including OLP, OLCL, OLDR, OLL of graft-versus-host disease, oral DLE, oral lesions of SLE, etc. has suggested that molecular techniques may be useful to differentiate OLTRs (44). Regarding OLDR and OLCL, the lesion in OLDR appeared after the patient taking medication and frequently rechallenged the same drug to confirm diagnosis of OLDR was impossible because of ethics consideration. Thus, medical history, report of drugs-induced OLDR, and oral manifestation of OLP-like lesion would be helpful in diagnosis and management. Regarding the diagnosis of OLCL, when the causative material that contacted to the lesions was removed and new material was replaced, the lesion could resolve within several months. Management of OLCL with this method is recommended when the faulty restorations have to be replaced, and then, we could confirm the diagnosis of OLCL. The pathogenesis of OLP has been reported to involve both antigen-specific and non-specific mechanisms (5). OLP is characterized histopathologically by an intraepithelial and subepithelial infiltration predominated by CD8+ T cells and CD4+ T cells in deep lamina propria (7, 45). These findings suggest that OLP is a T-cell-mediated inflammatory disease. A previous study showed a significantly higher number of subjects with serum autoantibodies in Chinese patients with OLP in 60.9% (22). We found a comparable number of subjects positive for serum ANA in the OLP (73.9%) and OLDR (70%) groups. The incidence of serum autoantibodies in the small groups of OLP patients showed different targets location such as antibasal cells, epithelial antigen, and desmoglein 1 and 3 (16–21). Hence, our results imply that ANA may be associated with the immunopathogenesis of OLDR and OLP. In addition, the ANA IIF test using HEp-2 cells as cell substrate should be considered and recommended the ‘gold standard’ assay to screen for autoantibodies in sera from patients with SLE and other systemic autoimmune rheumatic diseases (ARDs) (46). Moreover, the detection of the nuclear dense fine-speckled staining pattern can be used as a biomarker to rule out the diagnosis of SLE and other systemic ARDs (47). Early diagnosis is very important for
OLLs and serum ANAs in Thai patients Prucktrakul et al.
further successful treatment in these autoimmune diseases. Thus, most of OLP and OLDR patients who showed ANA positive with speckled pattern should be concerned carefully with closed follow-up. However, the specific mechanisms of ANA in OLDR and OLP require further study to better understand the role of ANA in the immunopathogenesis of these conditions that may be helpful in their differential diagnosis and management.
Conclusions The number of serum-ANA-positive subjects in the OLP and OLDR groups was significantly higher than in the healthy control group in Thai patients. Speckled pattern and low ANA titer levels were the most common findings in both the OLP and OLDR groups.
References 1. Thongprasom K, Carrozzo M, Furness S, Lodi G. Interventions for treating oral lichen planus. Cochrane Database Syst Rev 2011: CD001168. 2. Thongprasom K, Prapinjumrune C, Carrozzo M. Novel therapies for oral lichen planus. J Oral Pathol Med 2013; 42: 721–7. 3. Thornhill MH. Immune mechanisms in oral lichen planus. Acta Odontol Scand 2001; 59: 174–7. 4. Lu R, Zhang J, Sun W, Du G, Zhou G. Inflammation-related cytokines in oral lichen planus: an overview. J Oral Pathol Med 2013; doi: 10.111/jop.12142 [Epub ahead of print]. 5. Sugerman PB, Savage NW, Walsh LJ, et al. The pathogenesis of oral lichen planus. Crit Rev Oral Biol Med 2002; 13: 350–65. 6. Zhao ZZ, Savage NW, Sugerman PB, Walsh LJ. Mast cell/T cell interactions in oral lichen planus. J Oral Pathol Med 2002; 31: 189–95. 7. Lodi G, Scully C, Carozzo M, Griffiths M, Sugerman PB, Thongprasom K. Current controversies in oral lichen planus: report on an international consensus meeting. Part 1. Viral infections and etiopathogenesis. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2005; 100: 40–51. 8. Rhodus NL, Cheng B, Bowles W, Myers S, Miller L, Ondrey F. Proinflammatory cytokine levels in saliva before and after treatment of (erosive) oral lichen planus with dexamethasone. Oral Dis 2006; 12: 112–6. 9. Thongprasom K, Dhanuthai K, Sarideechaigul W, Chaiyarit P, Chaimusig M. Expression of TNF–a in oral lichen planus treated with fluocinolone acetonide 0.1%. J Oral Pathol Med 2006; 35: 161–6. 10. Youngnak-Piboonratanakit P, Dhanuthai K, Thongprasom K, et al. Expression of IFN-c before and after treatment of oral lichen planus with 0.1% fluocinolone acetonide in orabase. J Oral Pathol Med 2009; 38: 689–94. 11. Lodi G, Scully C, Carrozzo M, Griffiths M, Sugerman PB, Thongprasom K. Current controversies in oral lichen planus; report of an international consensus meeting-Part 2. Management and malignant transformation. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2005; 100: 164–78. 12. Al-Hashimi I, Schifter M, Lockhart P, et al. Oral lichen planus and oral lichenoid lesions: diagnostic and therapeutic considerations. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2007; 103(Suppl): S25.e1–12. 13. Serrano-Sanchez P, Bagan JV, Jimenez-Soriano Y, Sarrion G. Drug-induced oral lichenoid reactions. A literature review. J Clin Exp Dent 2010; 2: e71–5.
14. Bagan VJ, Thongprasom K, Scully C. Adverse oral reactions associated with the COX-2 inhibitor Rofecoxib. Oral Dis 2004; 10: 401–3. 15. Lamey PJ, McCartan BE, MacDonald DG, MacKie RM. Basal cell cytoplasmic autoantibodies in oral lichenoid reactions. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1995; 79: 44–9. 16. Lundstrom IM. Serum immunoglobulins and autoantibodies in patients with oral lichen planus. Int J Oral Surg 1985; 14: 259–68. 17. Lin SC, Sun A, Wu YC, Chiang CP. Presence of anti-basal cell antibodies in oral lichen planus. J Am Acad Dermatol 1992; 26: 943–7. 18. Sun A, Chiang CP, Chiou PS, Wang JT, Liu BY, Wu YC. Immunomodulation by levamisole in patients with recurrent aphthous ulcers or oral lichen planus. J Oral Pathol Med 1994; 23: 172–7. 19. Lodi G, Olsen I, Piattelli A, D’Amico E, Artese L, Porter SR. Antibodies to epithelial components in oral lichen planus (OLP) associated with hepatitis C virus (HCV) infection. J Oral Pathol Med 1997; 26: 36–9. 20. Carrozzo M, Gandolfo S, Lodi G, et al. Oral lichen planus in patients infected or noninfected with hepatitis C virus: the role of autoimmunity. J Oral Pathol Med 1999; 28: 16–9. 21. Lukac J, Brozovi S, Vucicevi-Boras V, Mravak-Stipeti M, Malenica B, Kusi Z. Serum autoantibodies to desmogleins 1 and 3 in patients with oral lichen planus. Croat Med J 2006; 47: 53–8. 22. Chang JY, Chiang CP, Hsiao CK, Sun A. Significantly higher frequencies of presence of serum autoantibodies in Chinese patients with oral lichen planus. J Oral Pathol Med 2009; 38: 48–54. 23. WHO Collaborating Centre for Oral Precancerous Lesions. Definition of leukoplakia and related lesions: an aid to studies on oral precancer. Oral Surg Oral Med Oral Pathol 1978; 48: 518–39. 24. Van der Meij EH, Schepman KP, van der Waal I. The possible premalignant character of oral lichen planus and oral lichenoid lesions: a prospective study. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2003; 96: 164–71. 25. Tan EM, Feltkamp TE, Smolen JS, et al. Range of antinuclear antibodies in healthy individuals. Arthritis Rheum 1997; 40: 1601–11. 26. Chou IJ, Kuo CF, See LC, et al. Antinuclear antibody status and risk of death in children and adolescents. Scand J Rheumatol 2011; 40: 472–7. 27. Petri M, Orbai AM, Alarc on GS, et al. Derivation and validation of the Systemic Lupus International Collaborating Clinics classification criteria for systemic lupus erythematosus. Arthritis Rheum 2012; 64: 2677–86. 28. Fortuna G, Brennan MT. Systemic lupus erythematosus: epidemiology, pathophysiology, manifestations, and management. Dent Clin North Am 2013; 57: 631–55. 29. Peng X, Tang J, Wu Y, Yang B, Hu J. Novel method for ANA quantitation using IIF imaging system. J Immunol Methods 2013; 404: 52–8. 30. Kavanaugh A, Tomar R, Reveille J, Solomon DH, Homburger HA. Guidelines for clinical use of the antinuclear antibody test and tests for specific autoantibodies to nuclear antigens. American College of Pathologists. Arch Pathol Lab Med 2000; 124: 71–81. 31. Watanabe A, Kodera M, Sugiura K, et al. Anti-DFS70 antibodies in 597 healthy hospital workers. Arthritis Rheum 2004; 50: 892–900. 32. Mariz HA, Sato EI, Barbosa SH, Rodrigues SH, Dellavance A, Andrade LE. Pattern on the antinuclear antibody-HEp-2 test is a critical parameter for discriminating antinuclear antibody-
473
J Oral Pathol Med
OLLs and serum ANAs in Thai patients Prucktrakul et al.
474
33. 34. 35. 36. 37.
38.
39. 40.
41.
positive healthy individuals and patients with autoimmune rheumatic diseases. Arthritis Rheum 2011; 63: 191–200. Satoh M, Chan EK, Ho LA, et al. Prevalence and sociodemographic correlates of antinuclear antibodies in the United States. Arthritis Rheum 2012; 64: 2319–27. De Vlam K, De Keyser G, Verbruggen G, et al. Detection and identification of antinuclear antibodies in the serum of normal blood donors. Clin Exp Rheumatol 1993; 11: 393–7. Malleson P, Sailer M, Mackinnon M. Usefulness of antinuclear antibody testing to screen for rheumatic diseases. Arch Dis Child 1997; 77: 299–304. Weiss JE. Pediatric systemic lupus erythematosus: more than a positive antinuclear antibody. Pediatr Rev 2012; 33: 62–73. Solomon DH, Kavanaugh AJ, Schur PH; American College of Rheumatology Ad Hoc Committee on Immunologic Testing Guidelines. Evidence-based guidelines for the use of immunologic tests: antinuclear antibody testing. Arthritis Rheum 2002; 47: 434–44. Malleson PN, Mackinnon MJ, Sailer-Hoeck M, Spencer CH. Review for the generalist: the antinuclear antibody test in children – when to use it and what to do with a positive titer. Pediatr Rheumatol Online J 2010; 8: 27. Invernizzi P, Lleo A, Podda M. Interpreting serological tests in diagnosing autoimmune liver diseases. Semin Liver Dis 2007; 27: 161. Islam MN, Cohen DM, Ojha J, Stewart CM, Katz J, Bhattacharyya I. Chronic ulcerative stomatitis: diagnostic and management challenges—four new cases and review of literature. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2007; 104: 194–203. Solomon LW. Chronic ulcerative stomatitis. Oral Dis 2008; 14: 383–9.
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42. Carlson MW, Garlick JA, Solomon LW. Chronic ulcerative stomatitis: evidence of autoimmune pathogenesis. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2011; 111: 742–8. 43. Jaremko WM, Beutner EH, Kumar V, et al. Chronic ulcerative stomatitis associated with a specific immunologic marker. J Am Acad Dermatol 1990; 22: 215–20. 44. Khudhur AS, Di Zenzo G, Carrozzo M. Oral lichenoid tissue reactions: diagnosis and classification. Expert Rev Mol Diagn 2014; 14: 169–84. 45. Khan A, Farah CS, Savage NW, Walsh LJ, Harbrow DJ, Sugerman PB. Th1 cytokines in oral lichen planus. J Oral Pathol Med 2003; 32: 77–83. 46. Meroni PL, Schur PH. ANA screening: an old test with new recommendations. Ann Rheum Dis 2010; 69: 1420–2. 47. Fritzler MJ. The antinuclear antibody test: last or lasting gasp? Arthritis Rheum 2011; 63: 19–22.
Acknowledgements This study was supported by the Faculty of Dentistry Grant, Chulalongkorn University Fiscal year 2013, and the Research Unit in Oral Diseases. We would like to thank Assistant Prof. Kanokporn Bhalang, Dr Paswach Wiriyakijja, Assistant Prof. Pratanporn Arirachakaran, Dr Chanwit Prapinjumrune for providing specimens for this study, and the Oral Medicine Department staff for their assistance. Our thanks also go to Associate Prof. Kittipong Dhanuthai and Dr Ekarat Phattarataratip, Oral Pathology Department, Faculty of Dentistry, Chulalongkorn University for histopathological reports. We thank Mr Wasan Punyasang, Faculty of Medicine for his assistance with statistical analysis. We also thank Dr Kevin Tompkins for editing this manuscript.
doi: 10.1111/jop.12257
wileyonlinelibrary.com/journal/jop
Oral lichenoid lesions and serum antinuclear antibodies in Thai patients Chalakorn Prucktrakul, Pornpan Youngnak-Piboonratanakit, Patnarin Kanjanabuch, Titipong Prueksrisakul, Kobkan Thongprasom Oral Medicine Department, Faculty of Dentistry, Chulalongkorn University, Bangkok, Thailand
OBJECTIVES: The aim of this study was to investigate the presence of serum antinuclear antibodies (ANA) in Thai oral lichenoid drug reaction (OLDR) and oral lichen planus (OLP) patients. MATERIALS AND METHODS: This study comprised 20 patients diagnosed with OLDR, 23 patients with OLP, and 24 healthy control subjects. Participants’ blood samples were assayed for ANA staining patterns and serum ANA titer levels by immunofluorescence using human epithelial type 2 (HEp-2) as a substrate. The serum ANA titer levels were defined as low (1:40–1:80), medium (1:160– 1:320), and high (>1:640). RESULTS: Serum ANA were detected in 73.9%, 70%, and 25% of OLP, OLDR, and control subjects, respectively. There was a statistically significant difference between the number of serum-ANA-positive subjects in the OLP or OLDR groups and the control group (P < 0.01), but no significant difference between the OLP and OLDR groups. The speckled pattern was the most commonly found staining pattern, present in 60.9%, 55.0%, and 20.8% of the OLP, OLDR, and control subjects, respectively. The number of subjects with low ANA titers in the OLP and OLDR groups was significantly higher than that of the control group (P < 0.01). Medium ANA titers were found in 15%, 4.4%, and 4.2% of the OLDR, OLP, and control subjects, respectively, while high ANA titers were not found in any group. CONCLUSIONS: The number of serum-ANA-positive OLP and OLDR patients was significantly higher than the control group. Speckled pattern and low titer levels were the most common findings in both OLP and OLDR groups J Oral Pathol Med (2015) 44: 468–474 Keywords: antinuclear antibodies; oral lichen planus; oral lichenoid drug reaction; Thai
Correspondence: Professor Kobkan Thongprasom, Oral Medicine Department, Faculty of Dentistry, Chulalongkorn University, Bangkok 10330, Thailand. Tel: +6622188942, Fax: +6622188941, E-mail: [email protected] Accepted for publication July 27, 2014
Introduction Oral lichen planus (OLP) is a common chronic inflammatory disease that affected patient’s quality of life due to symptoms, such as a burning sensation or pain, and its low rate of remission (1, 2). Although the etiology of OLP is unclear, it is currently believed to be associated with immunological dysfunction (3, 4). Studies have shown that the immunopathogenesis of OLP involves both antigenspecific and non-specific mechanisms (5–7). Previous studies have investigated the expression of cytokines associated with OLP lesions (4, 8–10). Oral lichen planus and oral lichenoid lesions (OLLs) are similar in their oral presentation and histopathological features, rendering it is difficult to distinguish between these lesions clinically and histopathologically. However, OLLs have distinct causes, including reactions to amalgam restorations or medications. OLLs are classified as oral lichenoid drug reactions (OLDR), oral lichenoid contact lesions (OLCL), and OLLs of graft-versus-host disease (OLLGVHD) (11, 12). OLDR may develop in the oral cavity after administration of certain drugs, for example, oral hypoglycemic agents, angiotensin-converting enzyme inhibitors, and non-steroidal anti-inflammatory drugs (NSAIDs), penicillamine, or gold salts, etc. (13). The most reliable diagnosis of OLDR is when the lesions resolve after withdrawal of the suspected drugs, and the reaction recurs when the patient is rechallenged with the same drug. The distinguishing feature of an OLCL lesion is its emergence near the suspected causative agents, which commonly are amalgam restorations. The majority of OLCLs resolve within several months after removal and replacement of the causative material. An accurate diagnosis is important for the treatment and management of OLP and OLL lesions (14). A study has reported that circulating autoantibodies toward the components of the basal cell membrane, referred to as basal cell cytoplasmic antibodies, were found in patients with a clinical diagnosis of OLLs (15). These antibodies were significantly associated with systemic drug usage, histological diagnosis of a lichenoid reaction, and a unilateral intraoral distribution of the clinical lesion. The authors suggested that the basal cell cytoplasmic phenomenon may be a useful adjunct to clinical and histological
OLLs and serum ANAs in Thai patients Prucktrakul et al.
investigation in diagnosis of oral lesions precipitated by drug therapy. Previous studies have shown the presence of serum autoantibodies in OLP patients, including anti-epithelial cell, antinuclear antibody (ANA), antismooth muscle (SMA), antimitochondrial (AMA), antigastric parietal cell (GPCA), antithyroglobulin (TGA), antithyroid microsomal (TMA), and antidesmoglein 1 and 3 antibodies (16–21). Interestingly, a study has reported that serum ANA was present in 60.9% of Chinese patients with OLP (22). Taken together, this suggests that OLDR that resembles OLP both clinically and histopathologically may be associated with the development of serum ANA. Thus, the objectives of our study were to investigate the relationship between the presence of serum ANA and OLDR and OLP in Thai patients and the association between serum ANA titer levels and staining patterns in OLDR and OLP patients. The information gained in our study concerning the immunopathogenesis of OLDR and OLP can be useful in the differential diagnosis and management of these lesions.
Table 1 Diagnostic criteria of OLP and OLDR using in this study modified from World Health Organization (23) and van der Meij et al. (24) OLP History No systemic diseases No taking medications Clinical criteria Bilateral white striae, plaque and/or ulcerative (erosive), atrophic lesions Histopathological criteria Presence of well-defined bandlike zone of cellular infiltration confined to the superficial part of the connective tissue, consisting mainly of lymphocytes Signs of ‘liquefaction degeneration’ in the basal cell layer Absence of epithelial dysplasia
Patients and methods The study protocol was approved by the Ethics Committee of the Faculty of Dentistry, Chulalongkorn University. The present cross-sectional study comprised patients who had been referred to the Oral Medicine clinic at the Faculty of Dentistry, Chulalongkorn University, Bangkok, Thailand, from May 2013 to January 2014 for the diagnosis and management of OLP or OLDR. All patients enrolled in this study were consecutively recruited. The control group consisted of 24 healthy volunteers who were participated in our study at the same period. The study groups consisted of 20 OLDR patients (atrophic = 10; erosive/ulcerative = 10) and 23 OLP patients (atrophic = 15; erosive/ulcerative = 8). All patients had no skin lesions. The OLDR group comprised 18 women and 2 men whose ages ranged from 23 to 70 years (50.8 11.0 years; mean SD). The OLP group comprised 23 cases, 21 women and 2 men ranging in ages from 26 to 66 years (mean 49.6 12.3 years). The mean duration of the OLP and OLDR lesions were 32.9 56.5 months (range 0.25–351 months) and 42.8 84.1 months (range 1–228 months), respectively. The healthy control subjects consisted of 20 women and 4 men aged 35–59 years (mean 47.2 7.9 years). Inclusion criteria The diagnosis of OLP and OLDR was made based on the clinical and histopathological definitions of the World Health Organization (WHO, 1978) and van der Meij et al. (23, 24). In our study, we modified the diagnostic criteria for OLDR and OLP as shown in Table 1. Symptomatic OLP patients without systemic disease and not taking any medications were included in our study. The patients were diagnosed for OLP both clinically and histopathologically with absence of epithelial dysplasia. The criteria for the patients with OLDR were that they had to have taken medications such as antihypertensive, NSAIDs, hypolipidemic, hypoglycemic, or a combination of medications before the eruption of oral lesions. Healthy control subjects without systemic disease other than dental caries or gingivitis and not taking any
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OLDR History Oral lesions erupted after taking medications Clinical criteriaa Unilateral/bilateral white striae, plaque and/or ulcerative (erosive), atrophic lesions Histopathological criteria Histopathologically typical of OLP or compatible with OLP
Increased amount of plasma cells or eosinophils or perivascular distribution of inflammatory infiltrateb Absence of epithelial dysplasia
OLDR, oral lichenoid drug reaction; OLP, oral lichen planus. a Some cases of OLDR presented as bilateral lesions. b May be found in some cases.
medications were included in the study. Informed consent was obtained from all patients and control subjects before participating in this study. Exclusion criteria Any subjects in the study groups who did not meet the inclusion criteria were excluded from our study. History takings from the patients with the current medications or medication records were assessed strictly. If the history of oral lesion eruption and medications taken was not clear, those patients were excluded from our study. The patients whose biopsy specimens demonstrated dysplasia were also excluded. Oral lesions contacted with amalgam restorations or metal crowns were excluded from this study. Moreover, patients with severe systemic disease, over 70 years of age, pregnant, non-compliance, or with a questionable diagnosis were excluded. Laboratory assessment Five milliliters of venous blood was taken from the patients and healthy controls in the morning between 10:00 and 12:00 and stored at 4°C. The blood samples were then transported to the laboratory for analysis. Complete blood examination was performed using a Coulter counter (Sysmex Corporation, Kobe, Japan). An indirect immunofluorescence assay (IIF) was performed using human epithelial type 2 (HEp-2) as a substrate (Euroimmunâ from Lubeck, Germany) to determine the ANA staining pattern and positive ANA staining titer. A positive ANA titer is the highest serum dilution where immunofluorescent staining can be observed. The ANA titer levels were defined as follows (25, 26): 1:40–1:80 = low; 1:160–1:320 = medium; >1:640 = high. The ANA staining patterns were classified as speckled, homogeneous, nucleolar, peripheral, centromere, or anticytoplasmic. J Oral Pathol Med
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The number of serum-ANA-positive subjects and ANA titer levels were compared between the groups using the chisquare test or Fisher’s exact test. A P-value 0.05). None of the groups demonstrated a high titer level. Speckled pattern and low ANA titer levels were the most common findings in both the OLP and OLDR groups.
OLLs and serum ANAs in Thai patients Prucktrakul et al.
Hypolipidemic drugs such as the statins were the most commonly used medication in 8/9 patients (88.9%) that were serum ANA positive. Antihypertensive drugs such as amlodipine, atenolol, losartan, and hydrochlorothiazide were also used in eight of the patients positive for serum ANA. ANA positivity was also seen in OLDR patients taking medications such as NSAIDs, hypoglycemic, oral contraceptives, levothyroxine, and muscle relaxant (Table 3).
Discussion The present study investigated the presence of serum ANA in Thai OLDR and OLP patients. We found that the majority of the OLP and OLDR patients in our study were serum ANA positive; however, a portion of the control subjects tested positive as well. The most common findings in the OLP and OLDR groups were speckled ANA staining pattern and low ANA-positive titers. Assaying for serum ANA is a useful tool for making the proper diagnosis and prognosis of lesions in patients who have overlapping oral manifestations. In the present study, we found that the number of serum-ANA-positive subjects was significantly higher in the OLP and OLDR groups compared to the healthy control group. The detection of an abnormal ANA titer is a significant criterion for the diagnosis of systemic lupus erythematosus (SLE) (27, 28), mixed connective tissue disease, Sj€ ogren’s syndrome, scleroderma, and other connective tissue diseases (29). The frequency of presence of ANA is much higher in patients with SLE, mixed connective tissue disease, Sj€ ogren’s syndrome, scleroderma, and other connective tissue diseases compared to normal population (30). However, positive serum ANA results can also be found in the normal population. Several studies have reported that 4–13.8% of the healthy population had positive serum ANA results at a 1:80 dilution (25, 31–33). Positive ANA results among healthy individuals are more commonly found in women and those over 65 years (25, 34). Moreover, a study has shown that 3.3% of the normal population were ANA positive at a 1:320 dilution (25). The majority of the subjects in the groups in our study had a low titer (1:80), and high serum ANA titers (1:640 dilution) were not found in any of the subjects in our study. Positive serum ANA titers at a dilution equal to or greater than 1:160 are usually considered clinically significant (35, 36). When Table 3 Medications in antinuclear antibodies-positive patients with oral lichenoid drug reaction Medicationa Hypolipidemic Antihypertensive Non-steroidal anti-inflammatory drugs Hypoglycemic Oral contraceptives Levothyroxine Muscle relaxant a
One patient took more than one medication.
n (%) 9 (45.0) 8 (40.0) 2 (10.0) 2 1 1 1
(10.0) (5.0) (5.0) (5.0)
a positive ANA titer of more than 1:640 is detected, it is important to monitor the individual for autoimmune diseases, even though the patient may have no significant oral signs or symptoms. Close follow-up in such cases is needed to evaluate the patient’s symptoms and clinical findings because autoantibodies can be detected prior to the clinical manifestation of disease. Various patterns of ANA staining and several different nuclear antigens were found in the serum of patients with various autoimmune diseases and also provided the useful information for diagnosis (30, 32, 37, 38). In the present study, positive serum ANA results were found at a 1:320 dilution in two cases that demonstrated a homogeneous pattern. One of these subjects was taking losartan, an angiotensin II receptor antagonist, and the other was taking amlodipine. In addition, one subject who demonstrated a peripheral pattern was taking oral contraceptives. Interestingly, one subject in the OLP group had a positive ANA at titer of 1:320 with homogeneous and speckled patterns. This individual had a history of oral lesions developed only 4 months, and her serum was ANA positive at a titer of 1:80 with a cytoplasmic pattern. One subject in the healthy control group, a 47-year-old woman, was also serum ANA positive with a speckled pattern at a titer of 1:320. Although a positive result can occur in middle-aged women (32), close long-term follow-up should be carried out with a patient with these findings to monitor for the autoimmune or other connective tissue diseases such as SLE that can develop from high serum ANA titer levels. After follow-up of this case for 1 year, she is still in healthy condition. However, positive autoantibody results alone are insufficient to establish a diagnosis of SLE; the oral medicine specialist should consider the patient’s relevant medical history and oral presentation along with other clinical and laboratory criteria before making a diagnosis. In the present study, positive serum ANA results were detected in 73.9%, 70%, and 25% of the OLP, OLDR, and the control groups, respectively. There was a significant difference in the number of positive ANA results between the OLP or OLDR groups and the control group (P < 0.01), whereas the difference between the OLDR and OLP groups was not significant (P > 0.05). Notably, one patient was serum ANA positive with more than one staining pattern. The speckled pattern was the most commonly found staining pattern present in 60.9%, 55%, and 20.8% of the OLP, OLDR, and control groups, respectively. To the best of our knowledge, the present study is the first report of positive serum ANA results in OLDR patients. In our study, 11 OLDR patients were positive for serum ANA with a speckled pattern, six patients with a homogeneous pattern, two patients with a nucleolar pattern, and one patient each with a peripheral and a centromere pattern. When considering the medications taken by the OLDR patients who presented with positive ANA results, hypolipidemic drugs such as the statin group were the most commonly used in 8/9 patients. Patients taking antihypertensive drugs such as amlodipine, atenolol, losartan, or hydrochlorothiazide were also found to be serum ANA positive. In addition, patients taking medications such as NSAIDs, hypoglycemic drugs, oral contraceptives, levothyroxine, or muscle relaxant were serum ANA positive.
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One limitation in our study was the number of patients enrolled; thus, a causal relationship between medications and ANA development could not be determined with certainty. However, it is possible that these drugs act as neoantigens that lead to the development of ANA. Antigens are processed by the antigen-presenting cells and are presented to the helper/inducer T cells in the oral mucosa, in the regional lymph nodes, and in the circulation. We postulate that cytokines secreted by helper T cells may activate antigen-specific activated B cells to produce ANA in the tissues and circulation of OLDR patients. A study should be conducted to detect serum ANA in a larger group of patients taking medications with oral lesions. The mechanism of ANA development in the sera of OLDR patient remains unclear. Three patients in our study with OLDR who had medium ANA titers took antihypertensive drugs such as amlodipine, losartan, and oral contraceptives for more than 1 year. The oral lesions in one patient taking oral contraceptives might be considered to be drug-induced lupus erythematosus; however, this was ruled out by additional clinical and histopathological findings. This is the first study in Thai patients that would be useful for the basic knowledge, diagnosis, treatment, and prognosis of the oral lesions in the future. Medications used in those patients should be monitored carefully during treatment and considered for long-term observation. It is possible to withdraw the suspected drugs and replace them with another drug in those patients because of the need for treatment of their systemic disease. The mechanisms of ANA development caused by these drugs still remain unclear; therefore, more investigations of these medications should be performed to better clarify the relationship between medications and ANA development. In our study, we used HEp-2 cells as the substrate for blood serum analysis. Indirect immunofluorescence assay (IIF) using HEp-2 cells is the gold standard for determining the presence of ANA. This assay provides information about the cellular localization of autoantigens that is useful for the proper diagnosis (39). When using the HEp-2 substrate for IIF, titers of 1:80 or higher are typically deemed positive (30). We recommend using the other alternative substrates for detection of ANA in OLP and OLDR patients in the future research, so the results might be possibly different from this study. Chronic ulcerative stomatitis (CUS) is a rare chronic condition that affects the oral mucosa causing painful ulcerations. Patients with CUS develop autoantibodies against a 70-kD nuclear protein involved in epithelial cell growth and differentiation. Patients with CUS can have ulcerative lesions of the oral mucosa that are clinically similar to erosive OLP. The differential diagnosis between these two diseases is important because corticosteroid therapy is typically an ineffective treatment for CUS, while antimalarial drugs such as hydroxychloroquine are effective (40, 41). The pathogenesis of CUS is unknown, and many patients are not diagnosed because of the high cost of direct immunofluorescence (DIF) and the need for special processing (42). The diagnosis of CUS requires that a surgical biopsy demonstrates a characteristic DIF immunopathologic pattern, which is a finding that speckled pattern
J Oral Pathol Med
in the nuclei of the basal and parabasal epithelial cells, known as the stratified epithelium-specific antinuclear antibody (SES-ANA) (41–43). Recent studies have shown that IIF can detect SES-ANA (41, 43). In our study, we did not perform DIF in our OLP and OLDR patients with positive serum ANA and a speckled pattern to exclude these lesions from CUS because of lacking special technique. However, every time when patients with OLLs and positive ANA test are found, further investigation for SLE/DLE should be made starting with anti-DNA antibodies in all cases. Medical history is also paramount as sometimes relevant information can be retrieved (e.g., history of unexplained hematological disorders, joint pains, previous strokes, etc.). We have to be particularly aware of the diagnosis of SLE/DLE because oral manifestations in most of our patients with OLDR in this study were similar with lupus-like lesions, which were very difficult in diagnosis by oral manifestations and histological and/or ANA appearances. Although there is still a lack of clarity particularly about the diagnosis of SLE or DLE, recent review literature about oral lichenoid tissue reactions (OLTRs) including OLP, OLCL, OLDR, OLL of graft-versus-host disease, oral DLE, oral lesions of SLE, etc. has suggested that molecular techniques may be useful to differentiate OLTRs (44). Regarding OLDR and OLCL, the lesion in OLDR appeared after the patient taking medication and frequently rechallenged the same drug to confirm diagnosis of OLDR was impossible because of ethics consideration. Thus, medical history, report of drugs-induced OLDR, and oral manifestation of OLP-like lesion would be helpful in diagnosis and management. Regarding the diagnosis of OLCL, when the causative material that contacted to the lesions was removed and new material was replaced, the lesion could resolve within several months. Management of OLCL with this method is recommended when the faulty restorations have to be replaced, and then, we could confirm the diagnosis of OLCL. The pathogenesis of OLP has been reported to involve both antigen-specific and non-specific mechanisms (5). OLP is characterized histopathologically by an intraepithelial and subepithelial infiltration predominated by CD8+ T cells and CD4+ T cells in deep lamina propria (7, 45). These findings suggest that OLP is a T-cell-mediated inflammatory disease. A previous study showed a significantly higher number of subjects with serum autoantibodies in Chinese patients with OLP in 60.9% (22). We found a comparable number of subjects positive for serum ANA in the OLP (73.9%) and OLDR (70%) groups. The incidence of serum autoantibodies in the small groups of OLP patients showed different targets location such as antibasal cells, epithelial antigen, and desmoglein 1 and 3 (16–21). Hence, our results imply that ANA may be associated with the immunopathogenesis of OLDR and OLP. In addition, the ANA IIF test using HEp-2 cells as cell substrate should be considered and recommended the ‘gold standard’ assay to screen for autoantibodies in sera from patients with SLE and other systemic autoimmune rheumatic diseases (ARDs) (46). Moreover, the detection of the nuclear dense fine-speckled staining pattern can be used as a biomarker to rule out the diagnosis of SLE and other systemic ARDs (47). Early diagnosis is very important for
OLLs and serum ANAs in Thai patients Prucktrakul et al.
further successful treatment in these autoimmune diseases. Thus, most of OLP and OLDR patients who showed ANA positive with speckled pattern should be concerned carefully with closed follow-up. However, the specific mechanisms of ANA in OLDR and OLP require further study to better understand the role of ANA in the immunopathogenesis of these conditions that may be helpful in their differential diagnosis and management.
Conclusions The number of serum-ANA-positive subjects in the OLP and OLDR groups was significantly higher than in the healthy control group in Thai patients. Speckled pattern and low ANA titer levels were the most common findings in both the OLP and OLDR groups.
References 1. Thongprasom K, Carrozzo M, Furness S, Lodi G. Interventions for treating oral lichen planus. Cochrane Database Syst Rev 2011: CD001168. 2. Thongprasom K, Prapinjumrune C, Carrozzo M. Novel therapies for oral lichen planus. J Oral Pathol Med 2013; 42: 721–7. 3. Thornhill MH. Immune mechanisms in oral lichen planus. Acta Odontol Scand 2001; 59: 174–7. 4. Lu R, Zhang J, Sun W, Du G, Zhou G. Inflammation-related cytokines in oral lichen planus: an overview. J Oral Pathol Med 2013; doi: 10.111/jop.12142 [Epub ahead of print]. 5. Sugerman PB, Savage NW, Walsh LJ, et al. The pathogenesis of oral lichen planus. Crit Rev Oral Biol Med 2002; 13: 350–65. 6. Zhao ZZ, Savage NW, Sugerman PB, Walsh LJ. Mast cell/T cell interactions in oral lichen planus. J Oral Pathol Med 2002; 31: 189–95. 7. Lodi G, Scully C, Carozzo M, Griffiths M, Sugerman PB, Thongprasom K. Current controversies in oral lichen planus: report on an international consensus meeting. Part 1. Viral infections and etiopathogenesis. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2005; 100: 40–51. 8. Rhodus NL, Cheng B, Bowles W, Myers S, Miller L, Ondrey F. Proinflammatory cytokine levels in saliva before and after treatment of (erosive) oral lichen planus with dexamethasone. Oral Dis 2006; 12: 112–6. 9. Thongprasom K, Dhanuthai K, Sarideechaigul W, Chaiyarit P, Chaimusig M. Expression of TNF–a in oral lichen planus treated with fluocinolone acetonide 0.1%. J Oral Pathol Med 2006; 35: 161–6. 10. Youngnak-Piboonratanakit P, Dhanuthai K, Thongprasom K, et al. Expression of IFN-c before and after treatment of oral lichen planus with 0.1% fluocinolone acetonide in orabase. J Oral Pathol Med 2009; 38: 689–94. 11. Lodi G, Scully C, Carrozzo M, Griffiths M, Sugerman PB, Thongprasom K. Current controversies in oral lichen planus; report of an international consensus meeting-Part 2. Management and malignant transformation. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2005; 100: 164–78. 12. Al-Hashimi I, Schifter M, Lockhart P, et al. Oral lichen planus and oral lichenoid lesions: diagnostic and therapeutic considerations. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2007; 103(Suppl): S25.e1–12. 13. Serrano-Sanchez P, Bagan JV, Jimenez-Soriano Y, Sarrion G. Drug-induced oral lichenoid reactions. A literature review. J Clin Exp Dent 2010; 2: e71–5.
14. Bagan VJ, Thongprasom K, Scully C. Adverse oral reactions associated with the COX-2 inhibitor Rofecoxib. Oral Dis 2004; 10: 401–3. 15. Lamey PJ, McCartan BE, MacDonald DG, MacKie RM. Basal cell cytoplasmic autoantibodies in oral lichenoid reactions. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1995; 79: 44–9. 16. Lundstrom IM. Serum immunoglobulins and autoantibodies in patients with oral lichen planus. Int J Oral Surg 1985; 14: 259–68. 17. Lin SC, Sun A, Wu YC, Chiang CP. Presence of anti-basal cell antibodies in oral lichen planus. J Am Acad Dermatol 1992; 26: 943–7. 18. Sun A, Chiang CP, Chiou PS, Wang JT, Liu BY, Wu YC. Immunomodulation by levamisole in patients with recurrent aphthous ulcers or oral lichen planus. J Oral Pathol Med 1994; 23: 172–7. 19. Lodi G, Olsen I, Piattelli A, D’Amico E, Artese L, Porter SR. Antibodies to epithelial components in oral lichen planus (OLP) associated with hepatitis C virus (HCV) infection. J Oral Pathol Med 1997; 26: 36–9. 20. Carrozzo M, Gandolfo S, Lodi G, et al. Oral lichen planus in patients infected or noninfected with hepatitis C virus: the role of autoimmunity. J Oral Pathol Med 1999; 28: 16–9. 21. Lukac J, Brozovi S, Vucicevi-Boras V, Mravak-Stipeti M, Malenica B, Kusi Z. Serum autoantibodies to desmogleins 1 and 3 in patients with oral lichen planus. Croat Med J 2006; 47: 53–8. 22. Chang JY, Chiang CP, Hsiao CK, Sun A. Significantly higher frequencies of presence of serum autoantibodies in Chinese patients with oral lichen planus. J Oral Pathol Med 2009; 38: 48–54. 23. WHO Collaborating Centre for Oral Precancerous Lesions. Definition of leukoplakia and related lesions: an aid to studies on oral precancer. Oral Surg Oral Med Oral Pathol 1978; 48: 518–39. 24. Van der Meij EH, Schepman KP, van der Waal I. The possible premalignant character of oral lichen planus and oral lichenoid lesions: a prospective study. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2003; 96: 164–71. 25. Tan EM, Feltkamp TE, Smolen JS, et al. Range of antinuclear antibodies in healthy individuals. Arthritis Rheum 1997; 40: 1601–11. 26. Chou IJ, Kuo CF, See LC, et al. Antinuclear antibody status and risk of death in children and adolescents. Scand J Rheumatol 2011; 40: 472–7. 27. Petri M, Orbai AM, Alarc on GS, et al. Derivation and validation of the Systemic Lupus International Collaborating Clinics classification criteria for systemic lupus erythematosus. Arthritis Rheum 2012; 64: 2677–86. 28. Fortuna G, Brennan MT. Systemic lupus erythematosus: epidemiology, pathophysiology, manifestations, and management. Dent Clin North Am 2013; 57: 631–55. 29. Peng X, Tang J, Wu Y, Yang B, Hu J. Novel method for ANA quantitation using IIF imaging system. J Immunol Methods 2013; 404: 52–8. 30. Kavanaugh A, Tomar R, Reveille J, Solomon DH, Homburger HA. Guidelines for clinical use of the antinuclear antibody test and tests for specific autoantibodies to nuclear antigens. American College of Pathologists. Arch Pathol Lab Med 2000; 124: 71–81. 31. Watanabe A, Kodera M, Sugiura K, et al. Anti-DFS70 antibodies in 597 healthy hospital workers. Arthritis Rheum 2004; 50: 892–900. 32. Mariz HA, Sato EI, Barbosa SH, Rodrigues SH, Dellavance A, Andrade LE. Pattern on the antinuclear antibody-HEp-2 test is a critical parameter for discriminating antinuclear antibody-
473
J Oral Pathol Med
OLLs and serum ANAs in Thai patients Prucktrakul et al.
474
33. 34. 35. 36. 37.
38.
39. 40.
41.
positive healthy individuals and patients with autoimmune rheumatic diseases. Arthritis Rheum 2011; 63: 191–200. Satoh M, Chan EK, Ho LA, et al. Prevalence and sociodemographic correlates of antinuclear antibodies in the United States. Arthritis Rheum 2012; 64: 2319–27. De Vlam K, De Keyser G, Verbruggen G, et al. Detection and identification of antinuclear antibodies in the serum of normal blood donors. Clin Exp Rheumatol 1993; 11: 393–7. Malleson P, Sailer M, Mackinnon M. Usefulness of antinuclear antibody testing to screen for rheumatic diseases. Arch Dis Child 1997; 77: 299–304. Weiss JE. Pediatric systemic lupus erythematosus: more than a positive antinuclear antibody. Pediatr Rev 2012; 33: 62–73. Solomon DH, Kavanaugh AJ, Schur PH; American College of Rheumatology Ad Hoc Committee on Immunologic Testing Guidelines. Evidence-based guidelines for the use of immunologic tests: antinuclear antibody testing. Arthritis Rheum 2002; 47: 434–44. Malleson PN, Mackinnon MJ, Sailer-Hoeck M, Spencer CH. Review for the generalist: the antinuclear antibody test in children – when to use it and what to do with a positive titer. Pediatr Rheumatol Online J 2010; 8: 27. Invernizzi P, Lleo A, Podda M. Interpreting serological tests in diagnosing autoimmune liver diseases. Semin Liver Dis 2007; 27: 161. Islam MN, Cohen DM, Ojha J, Stewart CM, Katz J, Bhattacharyya I. Chronic ulcerative stomatitis: diagnostic and management challenges—four new cases and review of literature. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2007; 104: 194–203. Solomon LW. Chronic ulcerative stomatitis. Oral Dis 2008; 14: 383–9.
J Oral Pathol Med
42. Carlson MW, Garlick JA, Solomon LW. Chronic ulcerative stomatitis: evidence of autoimmune pathogenesis. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2011; 111: 742–8. 43. Jaremko WM, Beutner EH, Kumar V, et al. Chronic ulcerative stomatitis associated with a specific immunologic marker. J Am Acad Dermatol 1990; 22: 215–20. 44. Khudhur AS, Di Zenzo G, Carrozzo M. Oral lichenoid tissue reactions: diagnosis and classification. Expert Rev Mol Diagn 2014; 14: 169–84. 45. Khan A, Farah CS, Savage NW, Walsh LJ, Harbrow DJ, Sugerman PB. Th1 cytokines in oral lichen planus. J Oral Pathol Med 2003; 32: 77–83. 46. Meroni PL, Schur PH. ANA screening: an old test with new recommendations. Ann Rheum Dis 2010; 69: 1420–2. 47. Fritzler MJ. The antinuclear antibody test: last or lasting gasp? Arthritis Rheum 2011; 63: 19–22.
Acknowledgements This study was supported by the Faculty of Dentistry Grant, Chulalongkorn University Fiscal year 2013, and the Research Unit in Oral Diseases. We would like to thank Assistant Prof. Kanokporn Bhalang, Dr Paswach Wiriyakijja, Assistant Prof. Pratanporn Arirachakaran, Dr Chanwit Prapinjumrune for providing specimens for this study, and the Oral Medicine Department staff for their assistance. Our thanks also go to Associate Prof. Kittipong Dhanuthai and Dr Ekarat Phattarataratip, Oral Pathology Department, Faculty of Dentistry, Chulalongkorn University for histopathological reports. We thank Mr Wasan Punyasang, Faculty of Medicine for his assistance with statistical analysis. We also thank Dr Kevin Tompkins for editing this manuscript.
