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Diagnostic Utility of Immunofluorescence in Oral Lesions: a Systematic Review J Oral Maxillofac Res 2024;15(3):e2 doi:10.5037/jomr.2024.15302 Abstract | HTML | PDF | XML |
Diagnostic Utility of Immunofluorescence in Oral Lesions: a Systematic Review
1Private practitioner, Virudhachalam, Cuddalore, India.
2Department of Oral and Maxillofacial Pathology and Microbiology, Mahatma Gandhi Postgraduate Institute of Dental Sciences, Puducherry, India.
3Department of Oral and Maxillofacial Pathology and Microbiology, Subbaiah Institute of Dental Sciences, Shimoga, Karnataka, India.
4Department of Medical Oncology, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India.
Corresponding Author:
Virudhachalam - 606001, Cuddalore
India
Phone: 9629245068
E-mail: selvaortho94@gmail.com
ABSTRACT
Objectives: This systematic review aims to evaluate the diagnostic utility of direct and indirect immunofluorescence of oral lesions in comparison with conventional diagnostic aids.
Material and Methods: The diagnostic utility of immunofluorescence in various oral lesions was evaluated. Relevant data from 37 studies, including study characteristics, patient population, test details, and outcomes, were systematically extracted. The search was performed analysing studies across multiple electronic databases including MEDLINE (PubMed), Embase, Scopus and Google Scholar, published from January 15, 2024 until May 15, 2024. Risk of bias was assessed using a modified QUADAS-2 tool.
Results: Most studies demonstrated a low risk of bias in most domains, indicating overall methodological rigor. Comparative analysis showed that direct immunofluorescence (DIF) consistently outperformed indirect immunofluorescence. DIF exhibited high sensitivity and specificity for pemphigus vulgaris (87.8% and 100%), mucous membrane pemphigoid (92% and 98%), and desquamative gingivitis oral ulcers overlapping with oral lichen planus (OLP) (81% and 98.9%). For OLP, DIF showed moderate sensitivity (64.3%) and high specificity (88%).
Conclusions: This review highlights the superior diagnostic utility of direct immunofluorescence over indirect immunofluorescence in evaluating oral lesions. Direct immunofluorescence’s higher performance makes it the preferred technique for conditions requiring direct visualization of tissue-bound immune deposits. The combined use of direct immunofluorescence and indirect immunofluorescence can enhance the evaluation and management of various oral pathologies.
J Oral Maxillofac Res 2024;15(3):e2
doi: 10.5037/jomr.2024.15302
Accepted for publication: 30 September 2024
Keywords: direct immunofluorescence; immunofluorescence techniques; indirect immunofluorescence; oral neoplasms; systematic review.
INTRODUCTION
Oral lesions encompass a wide range of pathological conditions, including benign, premalignant, and malignant entities. Accurate diagnosis of these lesions is crucial for appropriate management and optimal patient outcomes [1]. Conventional diagnostic modalities, such as clinical examination and histopathological analysis, remain the mainstay in the evaluation of oral lesions [2]. However, these techniques can sometimes be limited in their ability to provide a definitive diagnosis, particularly in cases where the clinical presentation is atypical or the histopathological features are ambiguous.
In recent years, the application of advanced diagnostic techniques, such as immunofluorescence (IF), has gained increasing attention in the field of oral pathology. IF is a sensitive and specific laboratory method that utilizes fluorescently labelled antibodies to detect the presence and distribution of specific antigens within tissue samples [3]. This technique has the potential to provide additional information that can complement the findings from clinical and histopathological examinations, leading to more accurate and timely diagnosis of various oral lesions.
The diagnostic utility of IF has been explored in the evaluation of numerous oral pathologies, including autoimmune disorders, infectious diseases, and neoplastic conditions [4]. By identifying the expression patterns of specific biomarkers or molecular targets, IF can aid in the differentiation of similar-appearing lesions, the assessment of disease progression, and the evaluation of treatment responses [5].
This systematic review aimed to comprehensively evaluate the current evidence on the diagnostic utility of immunofluorescence in the evaluation of oral lesions. By synthesizing the available literature, the review aims to provide a critical appraisal of the performance characteristics, clinical applications, and limitations of this diagnostic modality in the management of various oral pathologies. The findings of this systematic review would contribute to the understanding of the role of immunofluorescence in the enhanced diagnosis and management of oral lesions, ultimately leading to improved patient care and outcomes.
MATERIAL AND METHODS
Protocol and registration
Preferred Reporting Items for Systematic Reviews and Meta Analyses (PRISMA) statement criteria were followed for framing this systematic review [6]. The review adhered to the recent PRISMA guidelines for systematic reviews to ensure transparency and completeness in reporting.
Focus question
The review question for this systematic review on the diagnostic utility of IF in oral lesions was framed in the Primary Immune Regulatory Disorders (PIRD) format (Table 1). In PIRD format, the review question could be stated as: “What is the diagnostic utility of IF (I) compared to conventional diagnostic methods (R) in the evaluation of patients with various types of oral lesions (P), in terms of diagnostic accuracy, sensitivity, specificity, and clinical utility (D)?”
Table 1 Primary Immune Regulatory Disorders (PIRD) framework |
Information sources
To conduct a comprehensive systematic review on the diagnostic utility of IF in oral lesions, a thorough and well-structured search strategy was employed. The search was performed analysing studies across multiple electronic databases, including MEDLINE (PubMed), Embase, Scopus and Google Scholar, published from January 15, 2024 until May 15, 2024, to ensure a broad coverage of the relevant literature.
Search
The search strategy utilized a combination of controlled vocabulary (e.g., MeSH terms in MEDLINE) and free-text keywords related to the key components of the review question: oral lesions, immunofluorescence, and diagnostic performance. Relevant terms such as “oral cavity,” “mouth diseases,” “immunofluorescence,” “diagnostic techniques,” “sensitivity and specificity,” “accuracy”, “prognosis” and “treatment outcome” were used, along with appropriate Boolean operators (e.g., AND, OR) to optimize the search (Table 2).
Table 2 Search and screening Mesh = Medical Subjects Headings; TW = text word. |
The search was limited to studies published in English, without any restrictions on the publication date. This decision was based on the anticipated rapid advancements in the field of IF and the need to capture the most recent evidence. Additionally, the search was restricted to studies involving human participants to ensure the clinical relevance of the included evidence.
To ensure the comprehensiveness of the search, the reference lists of the included studies and relevant review articles were manually screened to identify any additional eligible studies that might have been missed in the initial database searches.
Selection of studies
The selection of articles for inclusion in the systematic review was conducted in a stepwise manner. First, two independent reviewers (S.A. and B.R.) screened the titles and abstracts of all retrieved records to identify potentially relevant studies. Second, the full-text articles of the selected studies were reviewed to determine their eligibility based on the predefined inclusion and exclusion criteria. Title and abstract screenings were performed using an online screening tool Rayyan® (Qatar Computing Research Institute; HBKU, Doha, Qatar [www.rayyan.ai]).
Cohen’s kappa coefficient (κ) values for 10% of the publications were calculated to assess the inter-rater reliability of the reviewers.
Types of publication
This systematic review covered human studies that were published in the English language.
Types of studies
The review included all diagnostic accuracy studies, from inception until July 2024 which reported the diagnostic utility of IF compared to conventional diagnostic methods in the evaluation of patients with various types of oral lesions.
Type of population
Patients with various types of oral lesions (premalignant, malignant, and inflammatory/autoimmune conditions).
Inclusion and exclusion criteria for the selection
Inclusion criteria
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Studies that evaluated the diagnostic utility of IF in the evaluation of oral lesions.
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Studies that compared the performance of IF to conventional diagnostic methods (e.g., clinical examination, histopathological analysis).
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Studies that reported at least one of the following outcome measures: diagnostic accuracy, sensitivity, specificity, or clinical utility of IF.
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Study designs including randomized controlled trials, cohort studies, case-control studies, and cross-sectional studies.
Exclusion criteria
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Case reports, case series, letters, editorials and review articles.
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Studies that did not focus on the diagnostic performance of IF in oral lesions.
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Studies with insufficient data or unclear methodology.
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Any discrepancies between the reviewers during the screening and selection process were resolved through discussion and, if necessary, the involvement of a third reviewer to reach a consensus.
Data extraction
Data extraction for this systematic review was carried out systematically to ensure the accuracy and completeness of the gathered information. A standardized data extraction form was developed and piloted before use.
Data items
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Study characteristics: authors, publication year, study design, and sample size.
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Patient (population): demographic details (age, gender), type of oral lesions (benign, premalignant, malignant, inflammatory/autoimmune), and diagnostic context.
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Index test details: type of IF (direct or indirect), specific antibodies used, antigen targets, and methodology (including tissue processing and antigen retrieval techniques).
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Reference test details: conventional diagnostic methods used for comparison, such as clinical examination and histopathological analysis.
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Outcome measures: diagnostic accuracy metrics (sensitivity, specificity, positive predictive value, negative predictive value), clinical utility (impact on diagnosis, treatment planning, and patient outcomes), and any reported adverse effects or limitations of IF.
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Key findings: summary of the main results, including any reported improvements in diagnostic accuracy or clinical decision-making.
Two independent reviewers performed data extraction, and discrepancies were resolved through discussion or consultation with a third reviewer. This approach ensured a high level of reliability and minimized the risk of bias in the data extraction process.
Risk of bias assessment
The risk of bias in the included studies was assessed using a modified version of the Quality Assessment of Diagnostic Accuracy Studies (QUADAS-2) tool [7]. This tool evaluates the risk of bias across four key domains: patient selection, index test, reference standard, and flow and timing. The assessment process involved:
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Patient selection: evaluating whether the study population was representative of the general population with oral lesions, and whether selection criteria were clearly defined and appropriate.
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Index test: assessing the potential for bias in the conduct and interpretation of the IF test, including blinding of the test results and consistency in the application of the test protocol.
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Reference standard: examining the appropriateness and reliability of the reference standard (clinical examination and histopathological analysis) used for comparison, and whether the reference standard results were interpreted independently of the index test results.
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Flow and timing: reviewing whether all patients received the same reference standard, the interval between the index test and reference standard, and the handling of any missing data or patient withdrawals.
Each domain was rated as having a low, high, or unclear risk of bias. Two reviewers independently assessed the risk of bias, with any disagreements resolved through discussion or consultation with a third reviewer. The results of the risk of bias assessment were summarized narratively and presented in a tabular format to provide a clear overview of the quality of the included studies.
Synthesis of the results
Data from the aforementioned studies were systematically collected and tabulated into the following fields: study characteristics, patient population, index test details, reference test details, outcome measures and key findings.
Statistical analysis
The level of agreement between the two raters in selecting abstracts and studies were measured using Cohen’s kappa coefficient (κ). Quantitative synthesis of the results from the included studies was not possible due to high heterogeneity observed across the included studies.
RESULTS
Study selection
In the current systematic review, an extensive search across multiple databases identified a total of 654 records. Prior to screening, 234 duplicate records were removed, resulting in 420 unique records to be screened. Following the initial screening process, 200 records were excluded based on predefined criteria, leaving 220 reports for further assessment. All 220 reports were successfully retrieved and evaluated for eligibility. Out of these, 183 reports were excluded due to various reasons such as not meeting the inclusion criteria or insufficient data quality and unclear methodology. Ultimately, 37 studies were deemed eligible and included in the final review. This process follows the PRISMA 2020 guidelines, ensuring a rigorous and transparent methodology in the selection of studies for the review [7]. The level of agreement between two authors (S.A. and B.R.) in the selection of abstracts was measured at κ = 0.88. The detailed workflow for study selection is presented in Figure 1.
Figure 1 PRISMA flow diagram summarising the search strategy and study selection. |
Exclusion of studies
One hundred and eighty three articles were not included in this review since they were not relevant to the review question of the current systematic review.
Study characteristics
The characteristics of included studies are presented in Tables 3A, 3B and 4A, 4B, 4C, 4D. The included studies [8-44] consist of a mix of prospective and retrospective designs, addressing various aspects of oral mucosal diseases. Among them, fourteen studies were prospective [9,11,13,14,17,18,29-32,34,36,37,42] and twenty three were retrospective [8,10,12,15,16,19-28,33,35,38-41,43,44]. The studies collectively cover a wide range of conditions, with multiple studies focusing on oral lichen planus (OLP) [21,42-44]. Other conditions investigated include cicatricial pemphigoid [13], oral pemphigoid [17], and pemphigus vulgaris [41] (Table 3).
Table 3A Characteristics of included studies ACIF = anti-complement immunofluorescence; ANA = antinuclear antibody; BMZ = basement membrane zone; C3 = complement component 3; DIF = direct immunofluorescence; DLE = discoid lupus erythematosus; DG = desquamative gingivitis; FITC = fluorescein isothiocyanate; H&E = hematoxylin and eosin; IIF = indirect immunofluorescence; IgG = immunoglobulin G; IgA = immunoglobulin A; IgM = immunoglobulin M; LE = lupus erythematosus; MIF = multiplexed immunofluorescence; MMO = maximum mouth opening; OLDR = oral lichenoid dysplasia; OLL = oral lichenoid lesions; OLP = oral lichen planus; OMLP = oral mucosal lichen planus; OSCC = oral squamous cell carcinoma; OSF = oral submucous fibrosis; PV = pemphigus vulgaris; RAS = recurrent aphthous stomatitis; T1 = tumour size classification (smallest); T4 = tumour size classification (largest); WHO = world health organization; IF = immunofluorescence. |
Table 3B Characteristics of included studies ACIF = anti-complement immunofluorescence; ANA = antinuclear antibody; BMZ = basement membrane zone; C3 = complement component 3; DIF = direct immunofluorescence; DLE = discoid lupus erythematosus; DG = desquamative gingivitis; FITC = fluorescein isothiocyanate; H&E = hematoxylin and eosin; IIF = indirect immunofluorescence; IgG = immunoglobulin G; IgA = immunoglobulin A; IgM = immunoglobulin M; LE = lupus erythematosus; MIF = multiplexed immunofluorescence; MMO = maximum mouth opening; OLDR = oral lichenoid dysplasia; OLL = oral lichenoid lesions; OLP = oral lichen planus; OMLP = oral mucosal lichen planus; OSCC = oral squamous cell carcinoma; OSF = oral submucous fibrosis; PV = pemphigus vulgaris; RAS = recurrent aphthous stomatitis; T1 = tumour size classification (smallest); T4 = tumour size classification (largest); WHO = world health organization; IF = immunofluorescence. |
Table 4A Outcome variables of included studies ACIF = anticomplement immunofluorescence; ANA = antinuclear antibody; BMZ = basement membrane zone; C3 = complement component 3; CB = cytoid bodies; DIF = direct immunofluorescence; DG = desquamative gingivitis; Dsg1 = desmoglein 1; Dsg3 = desmoglein 3; H&E = hematoxylin and eosin; HGD = high-grade dysplasia; IIF = indirect immunofluorescence; IgG = immunoglobulin G; IgA = immunoglobulin A; IgM = immunoglobulin M; LE = lupus erythematosus; LGD = low-grade dysplasia; MMP = mucous membrane pemphigoid; MMO = maximum mouth opening; OLDR = oral lichenoid dysplasia; OLL = oral lichenoid lesions; OLP = oral lichen planus; OMLP = oral mucosal lichen planus; OSCC = oral squamous cell carcinoma; OSF = oral submucous fibrosis; PV = pemphigus vulgaris; RAS = recurrent aphthous stomatitis; T1 = tumour size classification (smallest); T4 = tumour size classification (largest); ELISA = enzyme-linked immunosorbent assay; HCV = hepatitis C virus; SCC = squamous cell carcinoma; IF = immunofluorescence. |
Table 4B Outcome variables of included studies ACIF = anticomplement immunofluorescence; ANA = antinuclear antibody; BMZ = basement membrane zone; C3 = complement component 3; CB = cytoid bodies; DIF = direct immunofluorescence; DG = desquamative gingivitis; Dsg1 = desmoglein 1; Dsg3 = desmoglein 3; H&E = hematoxylin and eosin; HGD = high-grade dysplasia; IIF = indirect immunofluorescence; IgG = immunoglobulin G; IgA = immunoglobulin A; IgM = immunoglobulin M; LE = lupus erythematosus; LGD = low-grade dysplasia; MMP = mucous membrane pemphigoid; MMO = maximum mouth opening; OLDR = oral lichenoid dysplasia; OLL = oral lichenoid lesions; OLP = oral lichen planus; OMLP = oral mucosal lichen planus; OSCC = oral squamous cell carcinoma; OSF = oral submucous fibrosis; PV = pemphigus vulgaris; RAS = recurrent aphthous stomatitis; T1 = tumour size classification (smallest); T4 = tumour size classification (largest); ELISA = enzyme-linked immunosorbent assay; HCV = hepatitis C virus; SCC = squamous cell carcinoma; IF = immunofluorescence. |
Table 4C Outcome variables of included studies ACIF = anticomplement immunofluorescence; ANA = antinuclear antibody; BMZ = basement membrane zone; C3 = complement component 3; CB = cytoid bodies; DIF = direct immunofluorescence; DG = desquamative gingivitis; Dsg1 = desmoglein 1; Dsg3 = desmoglein 3; H&E = hematoxylin and eosin; HGD = high-grade dysplasia; IIF = indirect immunofluorescence; IgG = immunoglobulin G; IgA = immunoglobulin A; IgM = immunoglobulin M; LE = lupus erythematosus; LGD = low-grade dysplasia; MMP = mucous membrane pemphigoid; MMO = maximum mouth opening; OLDR = oral lichenoid dysplasia; OLL = oral lichenoid lesions; OLP = oral lichen planus; OMLP = oral mucosal lichen planus; OSCC = oral squamous cell carcinoma; OSF = oral submucous fibrosis; PV = pemphigus vulgaris; RAS = recurrent aphthous stomatitis; T1 = tumour size classification (smallest); T4 = tumour size classification (largest); ELISA = enzyme-linked immunosorbent assay; HCV = hepatitis C virus; SCC = squamous cell carcinoma; IF = immunofluorescence. |
Table 4D Outcome variables of included studies ACIF = anticomplement immunofluorescence; ANA = antinuclear antibody; BMZ = basement membrane zone; C3 = complement component 3; CB = cytoid bodies; DIF = direct immunofluorescence; DG = desquamative gingivitis; Dsg1 = desmoglein 1; Dsg3 = desmoglein 3; H&E = hematoxylin and eosin; HGD = high-grade dysplasia; IIF = indirect immunofluorescence; IgG = immunoglobulin G; IgA = immunoglobulin A; IgM = immunoglobulin M; LE = lupus erythematosus; LGD = low-grade dysplasia; MMP = mucous membrane pemphigoid; MMO = maximum mouth opening; OLDR = oral lichenoid dysplasia; OLL = oral lichenoid lesions; OLP = oral lichen planus; OMLP = oral mucosal lichen planus; OSCC = oral squamous cell carcinoma; OSF = oral submucous fibrosis; PV = pemphigus vulgaris; RAS = recurrent aphthous stomatitis; T1 = tumour size classification (smallest); T4 = tumour size classification (largest); ELISA = enzyme-linked immunosorbent assay; HCV = hepatitis C virus; SCC = squamous cell carcinoma; IF = immunofluorescence. |
The demographic details of the study populations varied, reflecting a broad spectrum of age groups and gender distributions. For example, Kulthanan et al. [21] included patients aged 6 to 76 years with an equal male-to-female ratio, while Hansen et al. [43] involved an older population with a mean age of 61.9 years, predominantly female. The sample sizes ranged from small cohorts, such as 10 patients in Fine et al. [13], to larger groups, such as 136 patients in Korkitpoonpol et al. [44]. These studies also covered diverse geographic regions, adding to the generalizability of the findings (Table 3).
In terms of diagnostic methodologies, various IF techniques were employed. direct immunofluorescence (DIF) was the most commonly used, featured in studies by Fine et al. [13], Kulthanan et al. [21], Mao et al. [42], and Hansen et al. [43]. Indirect immunofluorescence (IIF) was used in studies such as Lodi et al. [15] and Bhol et al. [17], while de Freitas Silva et al. [23] utilized double-IF (Table 3).
Outcome characteristics
Outcome antibody targets included human IgG, IgA, and complement components (C3), circulating antibodies against epithelial antigens [15], monoclonal antibodies to human α6 integrin [17], and antibodies against Twist and E-cadherin [23] (Table 4).
Antigen targets were also a significant focus. The study by Bhol et al. [17] specifically identified α6 integrin as a key antigen in oral pemphigoid. In total, three studies assessed epithelial antigens [15,17,21], while Fine et al. [13] and He et al. [41] examined various antigens at the basement membrane zone, such as IgG, IgA, IgM, and C3. The study by de Freitas Silva et al. [23] evaluated the expression of Twist and E-cadherin in oral leukoplakia and oral squamous cell carcinoma, adding another layer to the understanding of antigen targets (Table 4).
Conventional diagnostic methods were prominently assessed in the studies. Kulthanan et al. [21] and Hansen et al. [43] emphasized the importance of combining clinical examination with histopathological and IF techniques for a more accurate diagnosis of OLP. Fine et al. [13] used immunoelectron microscopy along with IF to examine cicatricial pemphigoid, demonstrating the value of advanced imaging techniques in enhancing diagnostic precision (Table 4).
Quality assessment of the included studies
The risk of bias assessment of included studies in this systematic review was conducted using the QUADAS-2 tool, which evaluates bias across four domains: patient selection, index test, reference standard, and flow and timing (Figure 2). The majority of studies demonstrated a low risk of bias in most domains, indicating overall methodological rigor. However, some studies exhibited concerns, particularly in patient selection and flow and timing. Specifically, while domains such as the index test and reference standard consistently showed low risk, variability was noted in patient selection, with a few studies showing potential biases. Despite these concerns, the comprehensive assessment indicates that the included studies largely adhere to robust methodological standards, ensuring the reliability of the synthesized findings. This careful evaluation underscores the credibility of the evidence base, supporting its use in clinical and research settings.
Figure 2 Risk of bias plot using QUADAS-2 tool. + = low; - = some concerns; D1 = patients selection; D2 = index test; D3 = reference standard; D4 = flow and timing. |
DISCUSSION
The findings of this systematic review underscore the growing utility of IF in the diagnostic evaluation of various oral lesions. The included studies collectively demonstrate the ability of this technique to complement and enhance the diagnostic capabilities of conventional clinical and histopathological assessments.
One key advantage of IF is its potential to improve the differentiation of similar-appearing oral lesions. Several studies have reported the successful application of IF in distinguishing between clinical mimics, such as pemphigus vulgaris and mucous membrane pemphigoid, or between different subtypes of OLP [45]. For instance, Fine et al. [13] used DIF to identify specific antibody deposits in cicatricial pemphigoid, facilitating accurate differentiation from other similar conditions. Kulthanan et al. [21] demonstrated that DIF was critical in differentiating lichen planus from lupus erythematosus based on unique deposition patterns of immunoreactants. This ability to identify specific expression patterns of various molecular markers and antigens aids clinicians in reaching more accurate and definitive diagnoses, which is crucial for appropriate management and treatment.
Another important aspect of the diagnostic utility of IF is its ability to assess disease progression and treatment response. The reviewed studies have demonstrated the usefulness of IF in monitoring the expression of biomarkers associated with malignant transformation, such as p53 and Ki-67, in premalignant oral lesions. For example, de Freitas Silva et al. [23] utilized double-IF to evaluate the co-expression of Twist and E-cadherin in oral squamous cell carcinoma, providing insights into tumour progression and potential therapeutic targets. Additionally, IF has been employed to evaluate the effects of therapeutic interventions, offering a method to assess treatment efficacy by monitoring changes in the expression of biomarkers.
The comparative analysis of diagnostic parameters reveals notable differences in performance between DIF and IIF across various oral lesions. DIF generally exhibits higher diagnostic performance metrics across conditions such as pemphigus vulgaris, OLP, and desquamative gingivitis oral ulcers overlap with OLP [46].
For pemphigus vulgaris, DIF’s high sensitivity (87.8%) and specificity (100%) are attributed to its ability to detect tissue-bound autoantibodies directly in lesional skin or mucosa, providing precise localization of immune deposits. According to He et al. [41] this high level of specificity indicates that DIF is highly reliable in correctly identifying patients without the disease, while its sensitivity ensures most cases are detected. IIF, however, shows slightly lower diagnostic performance due to its reliance on circulating autoantibodies, which may fluctuate based on disease activity and treatment status.
In mucous membrane pemphigoid, DIF is particularly effective in identifying linear deposits of IgG, IgA, or C3 along the basement membrane zone, which are critical for accurate diagnosis. Studies such as those by Genovese et al. [47] emphasize the importance of these specific immune deposits for distinguishing mucous membrane pemphigoid from other blistering disorders. IIF’s lower sensitivity in this condition is due to the occasional absence of circulating autoantibodies, as noted in the study by Challacombe et al. [48].
For OLP, DIF effectively detects fibrinogen deposits and colloid bodies. The study by Mao et al. [42] reports a sensitivity of 64.3%, indicating a moderate ability to identify true positive cases. In contrast, Hansen et al. [43] reports a sensitivity of 32% and specificity of 88%, with positive predictive value and negative predictive value of 68% and 61% respectively, suggesting a lower sensitivity but a higher specificity, making DIF more reliable for confirming the disease rather than detecting it. IIF’s limited ability to detect specific immunoreactant patterns results in lower sensitivity, as it often fails to identify the fibrinogen deposits characteristic of OLP, leading to lower diagnostic performance.
For desquamative gingivitis oral ulcers overlapping with OLP, the study by Bresler et al. [33] demonstrates a high sensitivity of 81% and specificity of 98.9%, with a positive predictive value of 97.9% and negative predictive value of 88.9%. This high sensitivity and specificity can be explained by the precise localization of immune complexes in tissue samples, which is strength of DIF.
In chronic erosions blistering exudation of the oral mucosa, the IIF study by Zhou et al. [28] shows a sensitivity of 84.8% and specificity of 60%, suggesting a good ability to detect true positive cases but a moderate rate of false positives. This variability in sensitivity and specificity reflects the challenges of relying on circulating autoantibodies, which can vary in concentration and presence.
Donatsky et al. [9] found that patients with recurrent aphthous stomatitis had higher antibody titres to adult human oral mucosa compared to controls, supporting an autoimmune aetiology for Recurrent Aphthous Stomatitis. However, this did not directly improve diagnostic accuracy or clinical decision-making.
Torabinejade et al. [10] used an anticomplement immunofluorescence (ACIF) technique to detect immune complexes in 23 out of 25 periapical lesions, suggesting the role of immune complexes in the pathogenesis of these lesions. This technique proved to be more sensitive than DIF used in previous studies, enhancing the understanding of periapical lesion pathogenesis.
Acosta et al. [11] highlighted that DIF on oral cytological smears could be a useful diagnostic tool for pemphigus vulgaris, providing a specific and less invasive method compared to traditional histology and IIF. The study by Hansen et al. [43] demonstrated that IF could confirm diagnoses in cases where clinical presentations were ambiguous. This technique was able to differentiate between pemphigus vulgaris and bullous pemphigoid, which are conditions that often present similarly in clinical settings.
The observed diagnostic performance values can be explained by the inherent methodological differences between DIF and IIF. DIF involves direct visualization of immune deposits in tissue biopsies, providing higher sensitivity and specificity due to precise localization of immune complexes [49]. Conversely, IIF relies on detecting circulating autoantibodies in the patient’s serum, which can exhibit variability in sensitivity and specificity. The presence and levels of circulating antibodies can fluctuate based on disease activity and treatment status, leading to lower diagnostic performance in some conditions [50].
Limitations
Despite these advantages, the review also underscores the potential limitations and challenges associated with the use of IF in the diagnosis of oral lesions. Optimal tissue processing, antigen retrieval, and antibody selection are crucial for ensuring the reliability and reproducibility of IF results. The interpretation of IF findings can be subjective, requiring experienced pathologists to minimize the risk of false-positive or false-negative interpretations. Additionally, the availability and cost-effectiveness of IF testing may pose practical challenges in certain healthcare settings, particularly in resource-limited regions.
A meta-analysis was not possible due to the heterogeneity of the included studies. Differences in study design, patient populations, diagnostic criteria, and IF methodologies resulted in significant variability in reported diagnostic metrics, precluding a quantitative synthesis of the data. Additionally, variations in antibody selection, tissue processing techniques, and reporting standards across studies further contributed to the difficulty in aggregating results.
Future research should focus on further validating these findings in larger, prospective cohorts, developing standardized protocols, and exploring cost-effective methods to integrate IF into routine clinical practice. The integration of IF with emerging technologies such as digital pathology and artificial intelligence holds promise for further enhancing diagnostic capabilities and improving patient outcomes. The judicious use of DIF and IIF, guided by the specific clinical context and the nature of the suspected oral lesion, can significantly enhance diagnostic accuracy, guide targeted treatment strategies, and ultimately improve patient care in the field of oral pathology.
CONCLUSIONS
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Direct immunofluorescence shows higher sensitivity, specificity, area under the curve, positive predictive value, and negative predictive value across multiple conditions.
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Direct immunofluorescence is effective for diagnosing autoimmune and inflammatory oral conditions by visualizing immune deposits in tissues.
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Indirect immunofluorescence varies in performance due to reliance on circulating autoantibodies, which can fluctuate with disease activity and treatment.
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Direct immunofluorescence is preferred when precise localization of immune complexes in tissue is essential.
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Indirect immunofluorescence is valuable in conditions where circulating autoantibodies play a significant role.
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Both techniques complement each other in diagnosing oral lesions.
ACKNOWLEDGMENTS AND DISCLOSURE STATEMENTS
The authors declare that there was no conflict of interest related to this study.
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To cite this article: Diagnostic Utility of Immunofluorescence in Oral Lesions: a Systematic Review J Oral Maxillofac Res 2024;15(3):e2 URL: http://www.ejomr.org/JOMR/archives/2024/3/e2/v15n3e2ht.htm |
Received: 12 July 2024 | Accepted: 30 September 2024 | Published: 30 September 2024
Copyright: © The Author(s). Published by JOMR under CC BY-NC-ND 3.0 licence, 2024.