Validation of an Oral Disease Severity Score (ODSS) tool for use in oral mucous membrane pemphigoid.

BACKGROUND: Mucous membrane pemphigoid (MMP) is a rare autoimmune bullous disease predominantly affecting the oral mucosa. Optimal management relies upon thorough clinical assessment and documentation at each visit. OBJECTIVES: The primary aim of this study was to validate the Oral Disease Severity Score (ODSS) for the assessment of oral involvement in MMP. We also compared its inter- and intraobserver reliability with those of the oral parts of the Mucous Membrane Pemphigoid Disease Area Index (MMPDAI), Autoimmune Bullous Skin Disorder Intensity Score (ABSIS) and Physician's Global Assessment (PGA). METHODS: Fifteen patients with mild-to-moderately severe oral MMP were scored for disease severity by 10 oral medicine clinicians from four U.K. centres using the ODSS, the oral sections of MMPDAI and ABSIS, and PGA. Two clinicians rescored all patients after 2 h. RESULTS: In terms of reliability, the interobserver ODSS total score intraclass correlation coefficient (ICC) was 0·97, MMPDAI activity 0·59 and damage 0·15, ABSIS total 0·84, and PGA 0·72. The intraobserver ICCs (two observers) for ODSS total were 0·97 and 0·93; for MMPDAI activity 0·93 and 0·70 and damage 0·93 and 0·79; for ABSIS total 0·99 and 0·94; and for PGA 0·92 and 0·94. Convergent validity between ODSS and MMPDAI was good (correlation coefficient 0·88). The mean ± SD time for completion of ODSS was 93 ± 31 s, with MMPDAI 102 ± 24 s and ABSIS involvement 71 ± 18 s. The PGA took < 5 s. CONCLUSIONS: This study has validated the ODSS for the assessment of oral MMP. It has shown superior interobserver agreement over MMPDAI, ABSIS and PGA, and superior intraobserver reliability to MMPDAI. It is quick and easy to perform. What's already known about this topic? There are no validated scoring methodologies for oral mucous membrane pemphigoid (MMP). Proposed disease activity scoring tools for MMP include the Mucous Membrane Disease Area Index (MMPDAI) and the Autoimmune Bullous Skin Disorder Intensity Score (ABSIS). The Oral Disease Severity Score (ODSS) has been validated for use in oral pemphigus vulgaris (PV). It has been shown to be reliable and sensitive in both lichen planus (LP) and MMP. What does this study add? The ODSS has been shown to be a thorough, sensitive and reproducible, yet quick scoring tool for the assessment of oral involvement in MMP. Its versatility for use in oral PV, MMP and LP is an added advantage over other scoring methodologies. What are the clinical implications of this work? We propose that the ODSS be used as a clinical scoring tool for monitoring activity in oral MMP in clinical practice as well as for use in multicentre studies.

Oral ulcers as a presentation of secondary syphilis.

The incidence of syphilis is increasing, and it typically presents in patients with known risk factors, often to genitourinary physicians. Patients presenting to a dermatologist or ophthalmologist will more likely have secondary syphilis, with the potential for having the associated complications. Early recognition is therefore vital to limit both the disease and risk of further contact spread. In this review, we include two case histories demonstrating the value of recognizing oral signs. Additionally, we review the currently accepted diagnostic and therapeutic recommendations.

Checklists for safe prescribing in oral medicine clinics.

Introduction Prescribing checklists are a means of managing risk related to systemic medications in oral medicine practice.Methods Checklists for workup and monitoring for azathioprine, mycophenolate mofetil (MMF) and dapsone were introduced to an oral medicine clinic. Compliance with the checklists was audited at six and 12-24 months post introduction, and compared to previous clinical practice.Results Azathioprine: compliance with viral serology screening improved from <10% to over 80% at 6 months post checklist introduction, and was 100% at 12 months. Documentation of counselling improved from 48% to 85% at six months, and was 100% at 12 months. Compliance with tuberculosis risk assessment improved from 5% to 50% at six months but declined to 4% at 12 months. Compliance with monitoring blood tests improved slightly. MMF: compliance with viral serology screening increased from nil to 100% at six months. Documented evidence of counselling increased from 20% to 100%. Monitoring blood test compliance for the first six weeks of therapy improved. Dapsone: documentation of patient counselling improved from 25% pre-checklist, to 50% at six months and 60% at 24 months. Monitoring blood test compliance improved at six months but had decreased by 24 months.Discussion and conclusion Clinical checklists led to a modest improvement in prescribing safety in our clinics. The usefulness of checklists depends on cultural changes and clinician engagement. Electronic medication safety programs may be a useful future strategy.

Amiloride, frusemide and urinary kallikrein excretion.

Intravenous administration of the loop diuretic frusemide caused a rapid but short-lived increase in the urinary excretion of kallikrein-like activity in healthy volunteers. Indomethacin alone did not alter urinary electrolyte or kallikrein excretion, but when given concurrently with frusemide it blunted the natriuresis without altering the urinary kallikrein excretion. A single oral dose of amiloride, a distal tubular diuretic, caused a natriuresis but no significant change in urinary kallikrein excretion. The results do not support a direct role for the renal kallikrein-kinin system in mediating the natriuresis induced by diuretics.