|Year : 2009 | Volume
| Issue : 4 | Page : 407-411
|Correlation of " in vivo" microcirculation and degeneration of the basal cells of the epithelium in lingual lichen planus
GA Scardina, A Ruggieri, P Messina
Department of Oral Science, University of Palermo, Palermo, Italy
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|Date of Submission||03-Aug-2007|
|Date of Decision||25-Oct-2007|
|Date of Acceptance||21-Nov-2007|
|Date of Web Publication||29-Jan-2010|
| Abstract|| |
Background: Oral lichen planus is an inflammatory chronic disease with an autimmune pathogenesis and unknown etiology that affects oral mucosa, with or without the involvement of the skin and other mucous membranes. The principal histological characteristics are the degeneration of the basal cell layer and the abnormal infiltration of inflammatory cells into the subepithelial layer of connective tissue.
Objectives: This study is aimed to appraise if lingual lichen planus (LLP) is sustained by alteration of the oral microcirculation and if this abnormal vascularisation increases the degeneration of basal keratinocytes and the disruption of the basement membrane.
Materials and Methods: Fifteen patients with a histological diagnosis of LLP with higher degree of degeneration of the basement membrane, fifteen LLP patients with lower degree of basement membrane (BM) degeneration and fifteen healthy patients were included in the study. The microcirculation of the left margin of the lingual mucosa of all the patients and subjects was analysed with the videocapillaroscopy. The following parameters were analyzed on each capillaroscopic image: c0 apillary loop length, loop diameter, and capillary density. The results obtained by videocapillaroscopy software were subjected to statistical analysis using Mann Whitney U-test (P < 0.001). Statistical analysis was performed using PAST software, v. 1.53.
Results: Capillary density, loop length, and total diameter showed statistically significant differences between LLP patients with histologically lower degree of BM degeneration and healthy subjects and a meaningful significant difference between LLP patients with higher degree of BM degeneration.
Conclusions: A remarkable increase in capillary density was showed by videocapillaroscopic exam. The increased value of the density could be associated with angiogenesis mechanism and it could be an indicator of the evolutionary condition of LLP. Videocapillaroscopy may be useful for the evaluation of the evolution or regression of the disease.
Keywords: Capillaroscopy, lichen planus, oral, tongue
|How to cite this article:|
Scardina G A, Ruggieri A, Messina P. Correlation of " in vivo" microcirculation and degeneration of the basal cells of the epithelium in lingual lichen planus. Indian J Dent Res 2009;20:407-11
Oral lichen planus (OLP) is a chronic mucosal condition that is commonly encountered in clinical dental practice. Lichen planus is believed to represent an abnormal immune response in which epithelial cells are recognized as foreign, secondary to changes in the antigenicity of the cell surface. The principal histological characteristics are the infiltration of inflammatory cells into the subepithelial layer of connective tissue and the degeneration of the epithelium of the basal membrane. In of chronic inflammation microcirculation could have a role that, probably, consists to sustain the process. Besides it is certain that the angiogenesis is implicated in the establishment and maintenance of the chronic inflammation. Such process can be individualized through the analysis of the vascular density that can be investigated using the videocapillaroscopy. Capillaroscopy is a method for studying the microcirculation, whereby small vessels can be observed in vivo with the use of a microscope.  In the diagnostic evaluation and monitoring of lingual lichen planus (LLP), which is a chronic inflammatory condition with immunologic pathogenesis, capillaroscopy has a very important role, since it can reveal any vascular modifications in patients affected by this pathology.  Such modifications in the vascular pattern ,,,,,,, might be useful for monitoring progression of the disease. This study aimed at evaluating the differences in the vascular pattern between healthy patients and patients suffering from LLP with high and low degrees of basement membrane (BM) degeneration.
|How to cite this URL:|
Scardina G A, Ruggieri A, Messina P. Correlation of " in vivo" microcirculation and degeneration of the basal cells of the epithelium in lingual lichen planus. Indian J Dent Res [serial online] 2009 [cited 2015 Mar 6];20:407-11. Available from: http://www.ijdr.in/text.asp?2009/20/4/407/59434
| Materials and Methods|| |
Fourty-five patients were examined with capillaroscopy: 15 patients affected by LLP in the left margin of the lingual mucosa with histological diagnosis of low degree of BM degeneration (group 1: 9 females and 5 male; mean age: 59.8 ± 9.18; range: 45-73 years), 15 LLP patients in the same site with histologically higher degree of BM degeneration (group 2: 8 females and 6 male; mean age: 57.9 ± 8.33; range 42-69) and 15 healthy subjects (control group: 9 females and 5 male; mean age: 56.7 ± 12.65; range: 38-75years) [Table 1]. All participants gave informed consent according to the requirements of Italian law on privacy and treatment of personal data. Patients having white and/or red lesions suspicious of OLP, irrespective of the clinical symptoms, were subjected to incisional biopsy; tissue was taken from well-defined lesions and, if possible, included margins of healthy tissue.  The OLP patients included in the study had to satisfy definite histopathological criteria as given below:
Patients with lesions that did not strictly satisfy the above histological criteria were not included in the study.
- Signs of keratinocyte alteration of the basal layer of the squamous epithelium, with a saw-toothed epithelium-connective tissue interface;
- Absence of dysplastic phenomena;
- Hyperparakeratosis with thickening of the granular cell layer;
- Degeneration of the basal cell layer of low and high level;
- Infiltration of inflammatory cells into the sub-epithelial layer of connective tissue.
The subjects in the control group had no systemic pathology that could alter microcirculation of the oral mucosa (e.g., diabetes, hypertension, Sjögren syndrome, rheumatoid arthritis, etc.). Patients who were on systemic drugs (e.g., antihypertensives, oral hypoglycemic drugs, anti-inflammatory drugs, etc.) or those with amalgam or composite fillings in direct contact with the lesions were not included in the study.
Oral videocapillaroscopy is a simple, repeatable, non- invasive, panoramic technique that is performed in vivo and is well-tolerated by the patient. This computerized technique is used with specific software (DS Medigroup, Milan Italia) that allows the acquisition and the elaboration of the data. The videocapillaroscope is made up of a central unit, a fibre optic probe with video-optic terminal and a high resolution colour monitor. The central body includes a light source consisting of a cold halogen light emitted by a 100 W lamp fitted with an automatic or manual control device to regulate the luminosity. The probe is made up of a flexible cable containing a bundle of optic fibres, and a cable which connects the unit that elaborates the video signal contained in the central unit to the video-optic terminal. The terminal itself is made up of a colour micro television camera and a support for holding different lenses. The lens has a focal spot of 1.811mms and zoom which vary from 10 to ×1000. For the study in question, a ×200 zoom was be used. The morphofunctional evaluation of microcirculation is based on specific parameters: Length of the capillary loop, diameter of the loop, diameter of afferent and efferent loops, capillary tortuousness and density. The videocapillaroscopic investigation will always be performed with the same light source, at the same room temperature (23°C), in the morning, with the same operator and repeated many times for every area under investigation. . The statistical analysis of the data collected in the various phases of the study was analysed using the Mann-Whitney U test and PAST software, v. 1.53, a freeware developed in 1995 by Ryan PD, Harper DAT, and Whalley JS (the latest version was released in September 2006). ,
In all the groups, the mucosa of the left margin of the tongue was examined [Figure 1] and [Figure 2]. Loop visibility is a morphological parameter which gives an indication of the difficulty of capillary focusing. It was evaluated as follows:
This was followed by a morpho-functional evaluation of the microcirculation, with particular attention to the following parameters:
- Mark 1: Simple focusing (less than 30 s from the beginning of the examination)
- Mark 2: Medium focusing (from 30 s to 2 min from the beginning of the examination)
- Mark 3: Difficult focusing (more than 2 min from the beginning of the examination)
- Mark 4: Impossibility of focusing
Capillary density (number of loops per square millimeter) was calculated for every patient and for each image obtained by videocapillaroscopy. Following this, an average value was calculated for every patient. Capillary density, assessed with the use of videocapillaroscopy, is the parameter which permits evaluation of the angiogenesis process in LLP patients.
- Capillary loop length
- Loop diameter
- Capillary density 
A minimum of 6 capillary loops were examined for every image, and the following measurements were carried out on each of them: Capillary loop length and total loop diameter. A qualitative investigation was also carried out, aimed at evaluating the level of discomfort felt by the patients during the clinical procedure of videocapillaroscopy.
| Results|| |
The lingual mucosa in LLP patients was characterized by a microcirculation with an arrangement referable to type III of Curri's classification (with capillaries lying parallel to the mucosal surface). The loop pattern was consistently parallel to the surface. This particular pattern of the capillaries belonging to what is called the 'subepithelial plexus' proved very useful for determining capillary density, which is the most important parameter since it is related to the neoangiogenetic phenomenon.
Microcirculation architecture in healthy subjects and in LLP patients was characterized by a network of capillaries arranged in a polygonal mesh and oriented parallel to the surface. The microvessels were located mainly just underneath the epithelium. After counting these microvessels, we determined values of the microvessel density:
The microvessel density in LLP was significantly higher than in normal tissues in any level of BM disruption. It must be stressed that there was no sharp distinction between the control group and the pathological groups (LLP group 1 and 2); however, borderline conditions were frequently observed.
- Mean ± SD (35.4 ± 2.99) in LLP patients with low degree of BM degeneration;
- Mean ± SD (47.9 ± 2.33) in LLP patients with high degree of BM degeneration;
- Mean ± SD (27.75 ± 4.79) in healthy patients [Table 2].
The microvessel density showed significant differences between the two groups. The differences were meaningful between the control group and the LLP patients with high degree of BM degeneration [Table 2].
| Discussion|| |
The oral mucosa is a window through which we can observe the vascular bed in vivo. This study uses oral capillaroscopy to investigate the morphology of the microcirculation in LLP. The importance of the pattern of the microcirculation, even from a clinical point of view, is due to the fact that the capillaries represent a vascular area where trophic-metabolic exchanges between blood and tissue take place; thus it has a critical role in organ function. Oral capillaroscopy is an imaging method allowing the in vivo and atraumatic assessment of the morphology and some functional aspects of oral capillaries. Although it is mainly indicated for the early detection of scleroderma microangiopathy and in connective tissue diseases, it is also used in those diseases whose pathogenesis is due to an anatomical or functional anomaly of the microcirculation. Its noninvasiveness, reproducibility, low cost, and considerable sensitivity make this technique very useful in the early diagnosis and monitoring of microangiopathies.
Lichen planus is a relatively common disorder, estimated to affect 0.5-2.0% of the general population. It is a chronic inflammatory disease that affects mucosal and cutaneous tissues. The mucosal form occurs more frequently than the cutaneous form and tends to be more persistent and more resistant to treatment. 
The study of the microcirculation in LLP could provide useful information to individualize at the right moment the evolution of LLP.  Although many steps are associated with the progression of the disease, neoangiogenesis is an essential factor. Neoangiogenesis-the formation of new microvasculature-is an important component in many biological processes, both in physiological conditions such as proliferating endometrium, corpus luteum formation, and embryogenesis, and in pathological conditions such as rheumatoid arthritis, diabetic retinopathy, inflammation diseases, and neoplastic disease. The process of angiogenesis involves several sequential steps, including degradation of the basement membrane of the parent vessel and extracellular matrix, locomotion of endothelial cells toward a tumor implant, mitosis, lumen formation, development of sprout loops and of a new basement membrane and, finally, recruitment of pericytes. Each of these distinct steps is regulated by different factor of induction. The induction of angiogenesis depends on a balance between positive and negative angiogenic factors. A prognostic factor in the evaluation of angiogenesis process is the microvascular density that consists in the counting of the new formed vessels. This value is proportional to the increase of the inflammatory elements and results a greater destruction of the basement membrane. Capillaroscopy is a good method to analyze microvessel density. The difficulty in studying angiogenesis in humans is the lack of direct methods for measuring angiogenic activity. A commonly used indirect method consists of measuring the density of the microvasculature in histological sections and considering this measurement to represent the angiogenic status of the lesions. ,
To the best of our knowledge, the present study is the first scientific study in which videocapillaroscopy was used for the morphological evaluation of the vascular density of the microcirculation in LLP patients. In this study we used it to investigate the oral mucosa of LLP patients in two different histological level: In LLP with low and high degeneration of basement membrane. Capillaroscopy applied to the lingual mucosa is a reliable method, useful for studying and monitoring OLP, if combined with the conventional methods.
The principal result of the present study is the increase in the capillary density in LLP. This increase is significant between control group and LLP with lower degree of BM degeneration and meaningful between control group and LLP with higher degree of BM degeneration. There is a correlation between the chronic inflammation that is characteristic of this disease and the increased capillary density in the two different histological groups analysed in the present study. The loops examined showed a variable pattern; besides the typical stirrup shape, there were loops with hairpin, comma, and corkscrew shapes. Occasional microhemorrhages in the form of reddish spots were also seen, which could be traced back to possible microtraumas.
A pathological condition is characterized by an apparent disorder of the normal architecture and/or by the presence of morphological anomalies. Capillaroscopy might also be useful to check the effectiveness of the selected therapeutic protocol.  It could permit a comparison of the characteristics of pre- and post-treatment local microcirculation as well as an objectification or parameterization of an aspect of the program which would otherwise have to rely on patient information (symptoms) or on clinician evaluation. 
The capillaroscopic patterns give us a snapshot of the lingual mucosa in vivo, showing all alterations, whether significant or not, especially for parameters like capillary density. The choice of this form of examination in the diagnostic evaluation and monitoring of LLP (a chronic inflammatory condition with immunologic pathogenesis) is fundamental, since it reveals the changes that occur in the vascular pattern in patients affected by this pathology. These variations in the vascular pattern might play an important role in clarifying the evolutionary mechanism of OLP and, moreover, might be useful for monitoring of the disease process. The angiogenesis and inflammatory aspect of OLP can be observed through the in vivo observation of subepithelial plexus. Capillaroscopy showed that loop density increased significantly in the microcirculation in LLP. These parameters could be monitored for the evaluation of different treatment modalities in these patients. The lingual mucosa may soon become a reliable indicator of the evolutionary condition of inflammatory pathologies such as LLP. This method would allow the oral physician to evaluate in vivo the effectiveness of ongoing pharmacological therapies, the patient's state of health, the evolution or regression of a certain pathology, and all those microstructure alterations of the vascular system that are useful for predicting and monitoring the progress of a systemic and/or topical pathological condition based on an angiogenesis process.  We believe that oral capillaroscopy may represent a useful additional tool in the follow-up of LLP.
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G A Scardina
Department of Oral Science, University of Palermo, Palermo
[Figure 1], [Figure 2]
[Table 1], [Table 2]
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