intralesional steroid injections for osmf

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Intralesional steroid injections for osmf how to beat a steroid urine test

Intralesional steroid injections for osmf


It has been reported that a polymorphism of the promoter region of the matrix metalloproteinase 3 gene is common in OSF and may contribute to development of the disease[ 27 ]. The potential morbidities of OSF are restriction of mouth opening, difficulty with swallowing, mastication, speech, and a burning sensation as well. It has a mortality potential because of the possibility of transformation into squamous cell carcinoma[ 55 ]. Both nonsurgical and surgical treatment options have been suggested.

Nonsurgical options are ISIs, hyaluronidase and interferon gamma. Surgery primarily targets to improve the mouth opening and comprises the excision of the fibrous bands, skin grafts and splitting of the temporalis tendon. Treatment is generally intended to increase the mouth opening and to decrease the burning sensation.

For early-stage submucous fibrosis cases, the results are better with non-surgical methods. In intralesional applications, the triamcinolone acetonide is the most preferred agent but different substances are also applied such as salvianolic acid B SA-B and lycopene.

As far as we know, Gupta and Sharma[ 56 ] were the first who successfully treated the OSF with local injections of chymotrypsin, hyaluronidase, and dexamethasone. Later, sub-mucosal steroid injection and hyaluronidase or topical vitamin A, topical steroid application and oral iron preparations were applied by Borle and Borle[ 57 ] in patients with oral submucous fibrosis. Khanna et al [ 58 ] presented patients in their clinical study in which the author implemented intralesional injection of triamcinolone acetonide in patients with very early and early-stage of OSF cases while they performed surgical intervention in advanced cases.

Satisfactory results were reported in long-term follow up. They reported that positive clinical response was obtained in both study groups when compared with placebo. Singh et al [ 60 ] compared the efficacy of hydrocortisone acetate and hyaluronidase at weekly interval vs triamcinolone acetonide and hyaluronidase at 15 d interval.

They notified no significant differences in symptom or sign scores and any histopathological improvement between the groups. The authors conclude that treatment regimen of triamcinolone acetonide and hyaluronidase was more convenient to the patients because of less number of visits required and of cost efficiency. No side effects were seen[ 60 ].

Rao[ 61 ] treated the patients with OSF using alpha lipoic acid in addition to the ISI of betamethasone and hyaluronidase. He reported that the alpha lipoic acid group exhibited better relief of symptoms as compared to the controls and he concluded that the use of an antioxidant, alpha lipoic acid, along with conventional therapy of ISI is effective in the management of OSF.

Shetty et al [ 62 ] examined the efficacy of spirulina as an antioxidant adjuvant to corticosteroid injection in management of oral submucous fibrosis. They reported that the mouth opening and burning sensation was found to be statistically very highly significant in favor of the spirulina group. Some complications can be seen after the procedure in the OSF cases. Chen et al [ 63 ] observed facial candida albicans cellulitis in a diabetes mellitus patient with oral submucous fibrosis after ISI treatment.

Therefore, it should be noted that some complications can arise due to the predisposing factors such as immunodeficiency HIV , immune-suppression systemic treatments with corticosteroids , chronic illness, obesity, diabetes, malnutrition, vitamin deficiency, alcohol misuse, tobacco smoking and intravenous drugs abuse. According to the hypothesis of Tsai et al [ 64 ], some alkaloids arecoline, arecaidine inhibit fibroblast phagocytosis and this contributes for the development of OSF.

ISIs could cause an enhancement of fibroblast collagen phagocytosis. Juxta-epithelial inflammatory cell infiltration and then progressive hyalinization of the lamina propria and deeper connective tissues are associated with early OSF[ 55 , 65 , 66 ].

Use of ISI have been directed to chronic juxta-epithelial inflammation[ 55 - 57 , 60 ]. The steroids can prevent or suppress inflammatory reactions, so they fight with fibrosis by decreasing fibroblastic proliferation and collagen deposition[ 55 , 65 , 66 ]. Therefore, it can be more successful when the steroid injections administered in the early stages of the disease. According to the literature, triamcinolone acetonide or betamethasone appears to be a suitable choice.

Oral lichen planus OLP is a chronic mucocutaneous disease of unknown cause, with oral lesions occurring most commonly in women over 30 years of age. Incidence of OLP is between 0. Different types of OLP have been described as reticular, plaque form, erosive, atrophic, or bullous. Intraorally, the buccal mucosa, tongue and the gingiva are commonly involved although other sites may be rarely affected.

Oral mucosal lesions present alone or with concomitant skin lesions. The most common type is the reticular form which is characterized by numerous interlacing white keratotic lines or striae that produce an annular or lacy pattern[ 27 , 67 ]. The plaque form of OLP tends to resemble leukoplakia clinically but has a multifocal distribution. In the erosive form, the central area of the lesion is ulcerated.

A fibrinous plaque or pseudomembrane covers the ulcer. The erithematous or atrophic type appears as red patches with very fine white striae. It may be seen in conjunction with reticular or erosive variants. Patients complain of pain, burning, sensitivity and generalized discomfort in particularly erosive and atrophic types[ 27 , 67 ]. The risk of malignant transformation varies between 0. A few studies have reported that the malignant potential of OLP and hepatitis C virus infection apparently increased the risk for oral squamous cell carcinoma[ 69 - 71 ].

Patients with reticular and other asymptomatic OLP lesions usually require no active treatment but symptomatic lesions may also need treatment. Nonsurgical treatments are systemic drug therapy, topical corticosteroids-calcineurin inhibitors - retinoids, injection of steroids and ultraviolet irradiation.

The other methods are surgery, laser therapy and cryosurgery[ 67 ]. According to literature, intra- and sublesional treatment of OLP with triamcinolone acetonide was reported by Sleeper[ 72 ] for the first time in In three cases the entire lesion disappeared in two weeks.

In , Randell and Cohen[ 73 ] applied dexamethasone in patients with OLP and they reported successful results. Then Zegarelli[ 74 , 75 ] performed ISI with triamcinolone acetonide and methylprednisolone in patients with erosive or ulcerative OLP. Xia et al [ 76 ] studied with 45 patients with clinical and histologically confirmed ulcerative OLP.

Each participant received 0. The treated areas gave rapid relief of signs and symptoms, while the control areas showed minimal decrease. Thirty-eight No complications were noted with triamcinolone acetonide injections. They concluded that intralesional triamcinolone acetonide injection in ulcerative OLP is effective and safe in achieving lesion and pain regression. They randomly assigned 56 OLP patients receive either intralesional injection of 0.

After the cessation of treatment, patients were followed up for 3 mo. There were no statistical differences between the two groups in erosive areas and pain scores. Lee et al [ 78 ] investigated intralesional injection vs mouth rinse of triamcinolone acetonide in 40 patients with OLP in terms of pain and burning sensation.

They concluded that the efficacies of both treatments were similar. The rate of adverse effects was significantly lower for intralesional injection of triamcinolone acetonide than mouth rinse of TA. In another clinical study, intralesional triamcinolone acetonide plus oral prednisolone was applied by Kuo et al [ 79 ] in 50 patients with erosive OLP. Liu et al [ 80 ] analyzed the efficacy and safety of intralesional betamethasone in the treatment of erosive OLP.

They implemented intralesional betamethasone 1. They found that According to the literature, triamcinolone acetonide is the most preferable agent as intralesional injection in patients with OLP. Recently, betamethasone seems to be also effective. General usage of triamcinolone acetonide is to dilute 10 to 20 mg in 0. Injections are administered into the connective tissue below the erosive lesion from the adjacent normal mucosa.

The treatment is absolutely required in patients with erosive and erythematous types due to the daily life is affected by pain and burning sensation. Generally, patient comfort is provided and the lesions disappeared within one to two weeks after ISI. However, recurrence of the lesions may occur on the long-term follow-up. Disadvantages include mucosal atrophy, difficulty to deposit sufficient quantities into gingival lesions and painful injection[ 82 ].

Other oral diseases treated with ISI are very limited in the literature. Azevedo et al [ 85 ] used intralesional injection of triamcinolone acetonide in patients with oral lichen sclerosis. The authors reported that the patients showed improvement and elasticity of oral tissues enhanced. Luo and Gun[ 86 ] found that intralesional injection of pingyangmycin with triamcinolone acetonide was more effective than pingyangmycin alone for management of lymphatic malformations in oral and maxillofacial region.

Anjomshoaa et al [ 87 ] performed intralesional injections of triamcinolone acetonide in a patient with follicular lymphoid hyperplasia. In addition, they reported that complete resolution of the lesion was obtained at 7-mo follow-up. It is an uncommon disease, usually presents as recurrent or persistent swelling of the soft tissues in the orofacial region, predominantly on lips, causing significant cosmetic and functional problems[ 88 , 89 ]. The reason of this disease is unknown. However, Mignogna et al [ 91 ] performed small volume, high concentrate, delayed release, intralesional injection of triamcinolone acetonide in patients with OFG.

They reported that all patients remained without recurrences or with cosmetically acceptable slight lip enlargement for a mean time of 19 mo and this method was very affective and it did not require nerve blockage.

The same researchers investigated the long-term outcome in patients treated with intralesional triamcinolone acetonide injections and reported that complete clinical remission were obtained in all patients for a mean time of Several other clinical studies have reported that injections of intralesional steroids are clinically successful method in patients with OFG[ 88 , 89 , 94 ]. Exogenous corticosteroids are usually classified based on their relative glucocorticoid and mineralocorticoid potency as well as duration of their effects.

The most potent glucocorticoids are also the most potent suppressors of the hypothalamic pituitary adrenal axis. While short-acting steroids e. Most prominent properties of corticosteroids are their anti-inflammatory, anti-allergic and analgesic effects.

Glucocorticoids help keeping normal vascular permeability and stabilize lysosomal and cellular membranes. On the other hand, in acute inflammation, they decrease vascular permeability and inhibit the migration of polymorphonuclear lymphocytes into tissues. They also induce apoptosis in normal lymphoid cells; inhibit the clonal expansion of T and B lymphocytes; and reduce the eosinophils, basophils, and monocytes in the circulation.

Glucocorticoids have different effects on neutrophils. They hinder margination of neutrophils and increase the release of mature neutrophils from the bone marrow. However, they may also decelerate wound healing[ 95 ]. Long-term use of corticosteroids can cause osteoporosis, hypertension, electrolyte imbalance, hyperglycemia, delayed wound healing, and a tendency for infections.

There are some contraindications for steroids such as history of allergy, peptic ulcer, Cushing syndrome, uncontrolled diabetes, renal failure, anticoagulation usage, fungal diseases and varicella zoster infection[ 96 ]. Although intralesional injection can be performed easily, several precautions should be taken during the processing.

The injection must always be made using sterile procedures and anatomy of the area should be known. Adjacent nerves should be kept away and intravenous injections should be avoided because of the possibility of systemic effects such as adrenal suppression[ 96 ].

ISI is one of the most preferable non-surgical methods for the treatment of mucosal or bone reactive lesions occurred in oral and maxillofacial region. The accumulating evidence suggests that ISI is well tolerated by patients, the likelihood of postoperative complications is less than those of other methods and patient complaints diminish rapidly.

This method is also minimally invasive and relatively inexpensive. Advanced Search. This Article. Academic Rules and Norms of This Article. Copyright Assignment PDF. Citation of this article. Treatment of mouth and jaw diseases with intralesional steroid injection.

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Published by Baishideng Publishing Group Inc. All rights reserved. World J Stomatol. May 20, ; 4 2 : Published online May 20, Open-Access : This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. Key Words: Intralesional injections , Steroids , Langerhans Cell histiocytosis , Giant cell granuloma , Oral submucous fibrosis , Oral lichen planus , Orofacial granulomatosis.

The effect of a hormone of the adrenal cortex hydroxydehydrocorticosterone; compound E and of pituitary adrenocorticotropic hormone on rheumatoid arthritis. Proc Staff Meet Mayo Clin. Corticosteroids--from an idea to clinical use. Best Pract Res Clin Rheumatol. Hydrocortisone and cortisone injected into arthritic joints; comparative effects of and use of hydrocortisone as a local antiarthritic agent.

J Am Med Assoc. Local injection of prednisolone TBA in the treatment of rheumatic diseases. Ohio Med. Metabolic and antirheumatic activities of 6-methylprednisolone medrol. Ann Rheum Dis. Robinson RC. Treatment of dermatoses with local application of triamcinolone acetonide, a new synthetic corticoid; a preliminary report. Bull Sch Med Univ Md. Kendall PH.

Triamcinolone hexacetonide. A new corticosteroid for intra-articular therapy. Ann Phys Med. The effects of methylprednisolone acetate in the treatment of bone cysts. Results of three years follow-up. J Bone Joint Surg Br. Chir Organi Mov. Savastano AA. The treatment of bone cysts with intracyst injection of steroids.

Injection of steroids will largely replace surgery in the treatment of benign bone cysts. Komp DM. Langerhans cell histiocytosis. N Engl J Med. Lichtenstein L. AMA Arch Pathol. Eosinophilic granuloma: resolution of maxillofacial bony lesions following minimal intervention. Report of three cases and a review of the literature. J Craniomaxillofac Surg. Clinical and radiographic features of eosinophilic granuloma in the jaws: review of 41 lesions treated by surgery and low-dose radiotherapy.

Treatment for solitary eosinophilic granuloma of the mandible by steroid injection: report of a case. J Oral Maxillofac Surg. Eosinophilic granuloma of bone: diagnosis and management. Skeletal Radiol. Spontaneous remission of a solitary eosinophilic granuloma of the mandible after biopsy: a case report. Direct injection of methylprednisolone sodium succinate in the treatment of solitary eosinophilic granuloma of bone: a report of 9 cases.

Multifocal eosinophilic granuloma of the jaw: long-term follow-up of a novel intraosseous corticoid treatment for recalcitrant lesions. Int J Oral Maxillofac Surg. Intralesional corticosteroid therapy for mandibular Langerhans cell histiocytosis preserving the intralesional tooth germ. Oral Maxillofac Surg. Intralesional infiltration of corticosteroids in the treatment of localized Langerhans cell histiocytosis of the mandible: report of two cases.

Percutaneous techniques for the diagnosis and treatment of localized Langerhans-cell histiocytosis eosinophilic granuloma of bone. J Bone Joint Surg Am. Jaffe HL. Giant-cell reparative granuloma, traumatic bone cyst, and fibrous fibro-oseous dysplasia of the jawbones. Oral Pathology: Clinical Pathologic Correlations. Holland: Elsevier Health Sciences ;. Central giant cell lesions of the jaws: a clinicopathologic study. Central giant cell lesions of the jaws. A clinical, radiologic, and histopathologic study.

Prognostic significance of cortical perforation in the recurrence of central giant cell granulomas of the jaws. Treatment of central giant cell granuloma of the jaw with calcitonin. Central giant cell granuloma of the jaw: a review of the literature with emphasis on therapy options.

Jacoway JR. Central giant cell granuloma: An alternative to surgical therapy. Terry B , Jacoway J. Management of central giant cell lesions: an alternative to surgical therapy. Local injection of corticosteroids for central giant cell granuloma.

A case report. Intralesional corticosteroid injection for central giant cell granuloma. Treatment of giant cell granuloma of the maxilla with intralesional injection of steroids. Head Neck. Treatment of a central giant cell lesion of the mandible with intralesional glucocorticosteroids. Carlos R , Sedano HO. Intralesional corticosteroids as an alternative treatment for central giant cell granuloma. Biomed Pharmacol J ; Betel nut chewing: A brief review.

Chole RH, Patil R. Drug treatment of oral sub mucous fibrosis—A review. Int J Contemp Med Res ; Assessment of various treatment modalities for the treatment of oral submucous fibrosis: A comparative study. A review of perioperative corticosteroid use in oral and maxillofacial surgery. Drug Invent Today ; Bansal M. Efficacy of local and systemic corticosteroid and hyaluronidase therapy in oral submucous fibrosis: A histopathological study.

Comparative efficacy of intralesional placental extract and intralesional triamcinolone acetonide in the management of OSMF. Oral submucous fibrosis: A contemporary narrative review with a proposed inter-professional approach for an early diagnosis and clinical management. J Otolaryngol Head Neck Surg ; Management of oral submucous fibrosis with injection of hyaluronidase and dexamethasone in grade III oral submucous fibrosis: A retrospective study. J Int Oral Health ; Oral submucous fibrosis: An update.

Clin Cosmetic Investig Dermatol ; Int J Dent Clin Prevalence of oral submucous fibrosis in patients visiting dental college in rural area of Jaipur, Rajasthan. Efficacy of lycopene in the management of oral submucous fibrosis. Oral submucous fibrosis — A hospital based retrospective study.

Journal of Pearldent ; Lycopene in the management of oral submucous fibrosis. Asian J Pharm Clin Res ; Molecular pathways regulated by areca nut in the etiopathogenesis of oral submucous fibrosis. Ultrastructural changes of collagen in different histopathological grades of oral submucous fibrosis. Oral submucous fibrosis in Asian countries. J Oral Pathol Med

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J Contemp Dent Pract , 20 3 , 01 Mar Cited by: 1 article PMID: Ingle E. Oral Dis , 24 5 , 22 Aug Cited by: 4 articles PMID: Europe PMC requires Javascript to function effectively. Recent Activity. Recent history Saved searches. Search articles by 'Leena James'. James L 1 ,. Search articles by 'Akshay Shetty'.

Shetty A 2 ,. Search articles by 'Diljith Rishi'. Rishi D 3 ,. Search articles by 'Marin Abraham'. Abraham M 4. Affiliations 1 author 1. Share this article Share with email Share with twitter Share with linkedin Share with facebook. Abstract Background Oral submucous fibrosis OSMF is a chronic debilitating and potentially malignant condition of the oral cavity. Materials and methods A total of 28 patients diagnosed with OSMF were treated in Sri Rajiv Gandhi College of Dental Sciences for a time period of 9 months, by obtaining the patient's consent and with the approval of the institution's research ethical committee.

Conclusion Injection of hyaluronidase with dexamethasone is an effective method of managing Grade III OSMF and can possibly eliminate the morbidity associated with surgical management. Free full text. J Int Oral Health. PMID: Author information Article notes Copyright and License information Disclaimer.

Correspondence: Dr. Shetty A. Email: moc. Received Feb 15; Accepted May This is an open-access article distributed under the terms of the Creative Commons Attribution-Noncommercial-Share Alike 3. This article has been cited by other articles in PMC. Go to:. Background: Oral submucous fibrosis OSMF is a chronic debilitating and potentially malignant condition of the oral cavity. Conclusion: Injection of hyaluronidase with dexamethasone is an effective method of managing Grade III OSMF and can possibly eliminate the morbidity associated with surgical management.

Keywords: Dexamethasone, hyaluronidase, oral submucous fibrosis. Open in a separate window. Figure 1. Hyaluronidase in OSMF Hyaluronidase by breaking down hyaluronic acid the ground substance in connective tissue lowers the viscosity of intercellular cement substance. Dexamethasone in OSMF Acts as an immune suppressive agent by its antagonistic activity on the soluble factors released by the sensitized lymphocytes succeeding the activation by nonspecific antigens.

Graphs 1. Table 1 Percentage of relief of symptoms post-treatment. Table 2 Average mouth opening in four grouped patients before and after treatment. Clinical aspects of oral submucous fibrosis. Acta Odontol Scand. Joshi SG. Submucous fibrosis of palate and pillars. Indian J Otolaryngol. Etiology of oral submucous fibrosis with special reference to the role of areca nut chewing.

J Oral Pathol Med. Failure of hyaluronidase to increase in invasiveness of neoplasms. Cancer Res. Pathak AG. Fibrin producing factor in OSMF. Oralsubmucous fibrosis-treatment with hyaluronidase. J Indian Dent Assoc. Ultrastructural findings of muscle degeneration in oral submucous fibrosis. J Oral Pathol. Management of oral submucous fibrosis: a conservative approach. J Oral Maxillofac Surg. Martin H, Koop EC. Preceancerous mouth lesions of avitaminosis B Am J Surg.

Gupta D, Sharma SC. Oral submucous fibrosis--a new treatment regimen. Oral stent as treatment adjunct for oral submucous fibrosis. Oral submucous fibrosis. Occurrence of epithelial atypia in 51 Indian villagers with oral submucous fibrosis.

Br J Cancer. Intraoral injection of hydrocortisone and placental extract in oral submucous fibrosis. Clinical evaluation of different treatment methods for oral submucousfibrosis. Oral submucous fibrosis is a chronic, progressive, potentially malignant oral disorder which results in rigidity and stiffness of the oral mucosa with loss of tissue mobility and eventual inability to open the mouth. An enormous number of medications are being employed in the treatment of this disease.

Nevertheless, no single medication could control the signs and symptoms in all the patients. Intralesional steroid injection is one of the modalities for the symptomatic relief of burning and may also be combined with hyaluronidase and placental extract intralesional injections to improve mouth opening. The main aim of this case report is to highlight the unusual complication of intralesional steroid in the form of abscess formation in a patient with oral submucous fibrosis.

This is the first case reported in the literature, where bilateral buccal space infection developed following steroid injection, given for the symptomatic treatment of burning sensation in a year young patient suffering from oral submucous fibrosis. A year-old otherwise healthy male, with a habit of chewing gutkha for past three years, presented with pain and swelling in the bilateral cheek region of two weeks duration Fig1.

The pain was dull, aching and continuous in nature, which posed difficulty in chewing. His past dental history revealed that he had reduced mouth opening since six months and burning sensation in oral cavity while eating hot and spicy food. He had consulted with a private dental clinic for the same complaint and was diagnosed with oral submucous fibrosis. Following which, he developed swelling associated with dull, aching continuous pain. Click here to View figure Extraoral examination revealed a diffuse swelling on the bilateral cheek region measuring 4X4.

The swelling was soft, fluctuant and compressible, associated with tenderness. Mouth opening was reduced with interincisal distance measuring 13mm Fig2 due to oral submucous fibrosis. Intraoral examination exhibited blanching of bilateral buccal mucosa Fig3 and soft palate with shrunken uvula. Fibrous bands on the bilateral buccal mucosa and in the circumoral region were palpable.

Movements of the tongue were restricted. Click here to View figure. Click here to View figure Hard tissue examination exhibited full complement of teeth in the maxillary and mandibular arch. Routine radiographic examination by taking orthopantomogram and vitality test of all the teeth ruled out any odontogenic cause for the swelling.

Correlating history, clinical and radiographic examination, a provisional diagnosis of bilateral buccal space infection due to intralesional corticosteroid injections in buccal mucosa was hypothesized. To confirm the diagnosis, ultrasonography of the bilateral cheek area was done using a 7. Hence abscess in bilateral buccal space was considered as a final diagnosis. CT is the gold standard for soft tissue infection but due to its high cost, time taking scanning procedure and radiation hazards, ultrasound has emerged as the next most suitable and cost-effective imaging modality.

Click here to View figure With aseptic precautions, aspiration of the swelling was carried out intraorally for decompression under local anesthesia Fig5. Thereafter intraoral incision was given in bilateral buccal mucosa and the abscess was drained. The patient was empirically recommended antibiotic amoxicillin in combination with clavulanic acid mg and metronidazole mg.

The pus was sent for a culture which had no growth of microorganisms even after 72 hours. The extraoral swelling completely resolved within one week and no recurrence has been reported in last six months. Click here to View figure Discussion. Oral submucous fibrosis is a potentially malignant disorder of oral mucosa that has received considerable debate in the recent years because of its progressive incapacitating and resistant nature.

Burning sensation of the oral cavity and mucosal ulcerations are the initial symptoms of OSMF. As the disease progresses, the manifestations include blanching and stiffening of the oral mucosa leading to restricted mouth opening, along with palpable fibrous bands in the buccal mucosa, circumoral bands in upper and lower labial mucosa, shrunken uvula along with restricted tongue movements.

Numerous treatment modalities are currently employed for OSMF, ranging from medical and surgical interventions, physiotherapy after cessation of the habit, and usually, a combination of these are used in clinical practice. With multiple treatment options being used, no single modality can provide complete cure of the disease. In many centers, intralesional injection of corticosteroids is being implemented as the first line therapy for patients stage II and III OSMF with mouth opening less than 20mm.