Palatal perforations: past and present. Two case reports and a literature review

Oral manifestations of anti-neutrophil cytoplasmic antibody-associated vasculitis: an update and narrative review of the literature

Anti-neutrophil cytoplasmic antibody-associated vasculitis (AAV) is a multisystem disorder of small blood vessels subdivided into granulomatosis with polyangiitis (GPA), microscopic polyangiitis (MPA), and eosinophilic granulomatosis with polyangiitis (EGPA). Oral manifestations (OMs) have been reported to include mucosal ulceration, gingival enlargement, alveolar bone necrosis, tooth loss, oro-antral communication, palatal perforation, parotitis, and candidal infection mainly in GPA. They may appear during the course of the disease, as a disease flare-up, or as the presenting sign. These OMs are often nonspecific and can mimic an array of conditions, therefore formulating a differential diagnosis can be challenging. This review updates the OMs of GPA, and, for the first, time includes OMs of other AAVs. It provides recommendations for the overall assessment and the diagnosis and management of all AAV OMs with considerations for treatment coordination. The role of oral health care providers in multidisciplinary care is highlighted.

Alraqibah M, A. Alharbi B, A. Alyahya R, N. Alrudhayman S, Albisher R. Role of dentist: COVID19 and mucormycosis

Dental practice has evolved over time and has adapted to the challenges that it has faced. The risk of infection spread via droplet and airborne routes poses a significant risk to the dentist who works close to patients. The risk of cross-infection between dental health-care personnel and patients can be very high due to the peculiar arrangements of dental settings. Dental clinics should have air purification systems with high volume excavators and negative pressure rooms for COVID-19 screening. Mucormycosis is a fungal disease that mostly occurs in immunocompromised individuals and those with uncontrolled diabetes. Dental extraction can trigger the occurrence. Increased occurrence of mucormycosis is seen in COVID-affected patients. This article gives a review on the dentistry-related transmission of COVID 19, the relation of COVID and mucormycosis.

Hard Palate Perforation in an Elderly Man With Dementia

A 74-year-old male with a history of mild cognitive impairment presented to the emergency department with failure to thrive and generalized weakness. He was having difficulty swallowing leading to 30 pounds of unintentional weight loss in the last three months. His social history was significant for 12.5 pack-year smoking and drinking (two to three glasses of wine/day). The oral cavity examination revealed a large (3 × 2 cm²) defect with the erythematous border that encompassed the mid-palatal structures and emanated from the hard palate into his nasal cavity. Auto-immune work-up was negative. Palatal biopsy showed squamous cell carcinoma (SCC; well-differentiated). A diagnosis of locally advanced (stage IVa) oral cavity squamous cell carcinoma (OSCC) was made based on PET scan findings. A palatal obturator (prosthesis) was placed to improve his eating, prevent regurgitation. The patient opted for palliative care and did not want to pursue further treatment. He was discharged home with a regular follow-up visit.

Oral changes in cocaine abusers: an integrative review

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Integrative review aiming to detect oral changes in cocaine abusers.

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The main oral changes, methods of diagnosis and treatment were identified.

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Good anamnesis and qualified health professionals are necessary.

Introduction

Cocaine is one of the most often used psychoactive drugs worldwide, being extracted from the leaves of Erytroxylus coca plant. Its abusive use can trigger several consequences for the human body, including the oral cavity.

Objective

To identify the oral disorders that are most commonly found in individuals who abuse cocaine, in addition to the main diagnostic and treatment methods.

Methods

An integrative review was carried out on the databases: LILACS, BBO, LIS, MEDLINE, SciELO, Science Direct and PubMed. The following keywords were used: “Cocaína”, “Boca”, “Palato” and “Odontologia”, together with their synonyms and variations in English, obtained from DeCS and MeSH. The inclusion criteria were original articles, articles in Portuguese, English and Spanish, studies involving individuals, without restriction related to the year of publication. Animal studies, literature reviews, book chapters, theses and dissertations were excluded.

Results

In total, 1373 records were identified. Of these, 22 articles were selected to comprise the review. Several oral alterations caused by cocaine abuse were found, primarily perforation of the palate, predisposition to periodontal diseases, temporomandibular disorders, bruxism, damage to oral tissues, dental caries, destructive lesions of the facial midline, xerostomia and ageusia. Among the diagnostic methods used by the professionals, anamnesis, intraoral examinations and head and neck computed tomography were the most frequently mentioned. As for treatment, in patients with palatal perforation, the reconstruction of the affected area or the use of prosthetic obturators is carried out.

Conclusion

The management of these patients is not an easy task, as many of the users do not even seek professional help. The health professionals must be able to recognize these manifestations and alterations to establish timely and accurate diagnosis and treatment planning.

Cocaine-Induced Midline Destructive Lesions: A Real Challenge in Oral Rehabilitation

Cocaine abuse is associated with severe local effects on mucosal and osteocartilaginous structures, with a centrifugal spreading pattern from the nose, a condition known as cocaine-induced midline destructive lesions (CIMDL). When the soft or hard palate is affected, a perforation may occur, with subsequent oro-nasal reflux and hypernasal speech. Both diagnosis and therapy (surgical or prosthetic) constitute a serious challenge for the physician. The cases of three patients affected by cocaine-induced palatal perforation and treated with a palatal obturator at San Raffaele Dentistry department between 2016 and 2019 are presented. In addition, the literature was reviewed in search of papers reporting the therapeutic management in patients affected by cocaine-induced palatal perforation. All the patients in our sample suffered from oro-nasal reflux and hypernasal speech, and reported a significant impact on interpersonal relationships. The results at the delivery of the obturator were satisfactory, but the duration of such results was limited in two cases, as the progression of the disease necessitated continuous modifications of the product, with a consequent increase in costs and a reduction in patient satisfaction. In conclusion, the therapy for palatal defects in CIMDL includes both reconstructive surgery and prosthetic obturators, the latter being the only possibility in the event of active disease. It successfully relieves symptoms, but the long-term efficacy is strongly related to the level of disease activity.

Cocaïne et lésions destructrices centro-faciales : à propos d'un cas

INTRODUCTION

Cocaine use is associated with multiple complications, some of which can mimic systemic diseases, especially Antineutrophil Cytoplasmic Antibody (ANCA) associated vasculitis. We report a case of Cocaine Induced Midline Destructive Lesions (CIMDL) for which a diagnosis of granulomatosis with polyangiitis (GPA) was discussed.

CASE REPORT

A 42-year-old male, cocaine consumer, was admitted in our department for a centrofacial destructive process. He had no extra ear, nose and throat (ENT) involvement. ANCA were positive with a perinuclear fluorescence pattern and an anti-Proteinase 3 specificity. Regarding this unusual immunologic pattern and in the absence of histological argument for a GPA, a diagnosis of CIMDL was made.

CONCLUSION

CIMDL is a centrofacial destructive process due to intranasal cocaine use. It is frequently associated with the presence of p-ANCA with both anti-HNE and anti-PR3 specificity.

An isotopic case study of individuals with syphilis from the pathological-anatomical reference collection of the national museum in Prague (Czech Republic, 19th century A.D.)

OBJECTIVE

This paper aims at investigating the possible existence of isotopic offsets in δ¹³C_col and δ¹⁵N_col values in relation to tertiary syphilis.

MATERIAL

Based on materials from the 19th c. A.D. deriving from the pathological-anatomical reference collection (the Jedlička collection) of the National Museum in Prague (Czech Republic), a comparative approach of ten individuals with syphilis and nine without the disease was undertaken.

METHODS

Bone powder samples were defatted according to the protocol of Liden et al. (1995). Bone collagen was extracted following the protocol of Bocherens et al. (1991).

RESULTS

Our results show that individuals with syphilis have lower δ¹³C_col values than individuals without the disease; the observed difference between the two groups is about 0.3-0.4‰, which is relatively small but still meaningful. However, no difference between δ¹⁵N_col values of the two groups has been noticed.

CONCLUSIONS

Either diets prescribed by physicians to syphilitic patients or nutritional stress caused by cyclic appetite disturbance due to the disease itself or the administered medical treatment appeared to be possible explanations of the observed isotopic pattern. Overall, the response of the two isotopic proxies could argue for relatively limited nutritional restrictions.

SIGNIFICANCE

This is the first study examining bone collagen isotopic response to syphilis based on clinically documented human skeletal materials.

LIMITATIONS

The sample sizes are relatively small and cautiousness must be taken regarding the interpretations of the data.

SUGGESTIONS FOR FURTHER RESEARCH

Compound-specific stable isotope investigations and analysis of mercury content could be helpful to better understand the observed isotopic effects.

Forty cases of acquired oral syphilis and a review of the literature

The aim of this study was to describe 40 cases of acquired oral syphilis (AOS) and to discuss the distribution of demographic characteristics, clinical features, and differential diagnosis of the disease. A retrospective study was conducted covering a 17-year period at a single institution in southern Brazil. Moreover, a literature review was performed through a search of the PubMed database for articles on AOS published between 1955 and March 2018. Data were analyzed descriptively. The predominant group within the case series was male patients in their twenties. The vast majority of cases (92.5%) were in the secondary stage of the disease. The lips were the most commonly affected site, with greyish-white mucous patches and reddish ulcers. In the literature review, the largest number of reported cases came from North America. Male patients in the third and fourth decades of life were most affected. AOS occurred more commonly as mucous patches and ulcers on the tongue and palate. Similarities regarding the distribution by sex, age, and anatomical location were found in the present study when compared to cases reported elsewhere. Clinicians, oral pathologists, and maxillofacial surgeons should familiarize themselves with the variable spectrum of signs and symptoms of AOS in their clinical practice to improve diagnosis and management.

Palatal perforation and chemical ulcers of the tongue in a blind patient

We report a unique case of a potassium aluminum sulfate oral dissolution leading to palatal chemical necrosis and extensive chemical ulcers on the tongue. The patient, a 47-year-old white, blind male, denied using cocaine or other illegal drugs that could cause such lesions. His self-medication started as a treatment for a traumatic ulcerative lesion on the hard palate. After palatal perforation, he started another self-medication routine, mixing corticoid cream and tandrilax tablets with a gauze obturator. Our treatment comprised the removal of all chemical factors, a surgical debridement, and a prosthetic obturator to resolve the communication. The 1-year follow-up showed no complications.

A case of tertiary syphilis manifested with multiple skin gummas

The tertiary cutaneous syphilis has become extremely rare as a result of the effective treatment of early syphilis with penicillin and occasional antibiotic therapy for concomitant infections. We report a case of tertiary gummatous syphilis associated with asymptomatic neurosyphilis that was initially misdiagnosed as basal cell carcinoma of the skin. A 67-year-old woman presented with the 18-month history of multiple, firm, bluish-red asymptomatic nodes on the parietal scalp, chin and lateral part of the trunk that had developed without preceding trauma. One node on the trunk had small central ulceration covered with dry yellowish crust. On the left retroauricular area the brownish-purple atrophic scar was observed. Blood tests revealed reactive VDRL, ELISA and TPHA assays. Skin biopsy has showed endarteritis with endothelial swelling and caseating granulomas along with plasmocytic infiltrate in the dermis and subcutaneous tissue. Increased lymphocyte count and the positive VDRL test with cerebrospinal fluid have confirmed the diagnosis of asymptomatic syphilitic meningitis in this patient. The treatment with aqueous penicillin intravenously has lead to resolution of the skin infiltrates and progressive more than 4-fold reduction of follow-up serum VDRL titers. This case is reported as a reminder of the possibility of tertiary syphilis with misleading clinical patterns in patients infected during the epidemics of 1995-2000. We would like to emphasize the necessity to perform timely serological and pathomorphological study to prevent misdiagnosis and mistreatment.

Rare periodontal ligament drainage for periapical inflammation of an adjacent tooth: a case report and review of the literature

Aim. To report a case with an unusual drainage route of periapical inflammation exiting through the gingival sulcus of an adjacent vital tooth and review probable factors determining the diversity of the discharge routes of periapical inflammation. Summary. An 18-year-old male patient presented with periodontal abscess of tooth 46, which was found to be caused by a periapical cyst with an acute abscess of tooth 45. During endodontic surgery, a rarely reported drainage route for periapical inflammation via the gingival sulcus of an adjacent vital tooth was observed for the first time. Complete periodontal healing of the deep pocket of tooth 46 and hiding of the periapical cyst of tooth 45 followed after root canal treatment and periapical surgery with Bio-Oss Collagen implantation on tooth 45. The drainage routes of periapical inflammation are multivariate and the diversity of drainage pathways of periapical inflammation is mainly related to factors such as gravity, barriers against inflammation, and the causative tooth itself.

Palatal ulceration

Palatal ulcers are a common presentation and can be conveniently divided into developmental and acquired causes, the latter of which is subdivided into acute and chronic causes. Most commonly seen dermatologic causes have associated skin manifestations. Acute and multiple ulcers are usually infectious or drug induced in origin. Recurrent ulcers are largely dominated by aphthosis, while chronic ulcers are seen in immunocompromised patients and can occasionally be malignant. It is essential to involve the oral and maxillofacial surgeons early in the therapeutic management to tackle the inevitable complications that may ensue in the chronic cases.

A bizarre cause of extensive oronasal fistula

Oronasal fistula is defined as an abnormal duct, connecting the nasal with the oral cavity. We present an extremely rare case of oronasal fistula associated with rhinolithiasis. The particular case presents the unique feature of a palatal defect, being large enough to enable the in toto removal of the rhinolith. A 2-layer closure of the fistula was finally undertaken, by utilizing a vestibular and a palatal mucoperiosteal flap.

Progressive midfacial bone erosion and necrosis: case report and differential diagnosis

A 31-year-old woman presented with a large oro-nasal communication (ONC), loss of vomer and significant nasal cartilage and nose deformity. Physical examination of the patient revealed a typical midline destructive lesion (MDL) with nasal septum and hard/soft palate perforation with a friable granular surface and a large amount of necrotic tissues. Medical history was unremarkable and the patient denied previous local trauma, including surgical procedures or drug assumption. Pathological examination revealed the presence of necrosis and chronic inflammation. MDLs have numerous etiologies. Signs and symptoms of MDLs can be similar and an accurate diagnosis may be elusive. We hereby present detailed clinicopathological findings.

Dental profile of a community of recovering drug addicts: Biomedical aspects. Retrospective cohort study

Objectives: to obtain a biomedical oral profile of a community of adult drug addicts in treatment by analysing their dental health, with a view to determining whether the state of their oral health could be attributed primarily to their lifestyle and the direct consequences of drug abuse on their overall condition, rather than to the effects of the drugs used. Experimental Design: the study was conducted under the terms of an agreement between the Complutense University of Madrid’s (UCM) Odontology Faculty and the City of Madrid’s Substance Abuse Institute. Seventy drug addicts and 34 control group subjects were examined. The study assessed oral hygiene habits, systemic pathology, type of drugs used and the duration of use, oral pathology, oral health indices, risk of caries based on saliva tests, oral candidiasis and periodontal microbiology. Results: statistically significant differences (p<0.05) were found between the test and control groups for practically all the variables analysed. In the drug users group, dental hygiene was wanting, systemic and oral pathology prevailed and the decayed/missing/filled teeth or surface (DMFT/S) indices denoted very poor buccodental health. The saliva tests showed a substantial risk of caries and candidiasis rates were high. By contrast, with a single exception, the microbiological studies detected no statistically significant difference between drug users and control groups periodontal flora. Conclusions: drug-dependent patients had poor oral health and a significant increase in oral pathology, essentially caries and periodontal disease. Their risk of caries was high and the presence of candidiasis was representative of their poor general and oral health. Drug users’ poor buccodental condition was more closely related to lifestyle than to drug abuse itself.

Key words:Buccal, dental, drug addicts.

The manifestation of cocaine-induced midline destructive lesion in bone tissue and its identification in human skeletal remains

Cocaine-induced midline destructive lesion (CIMDL) is a condition that may arise in response to chronic insufflation ("snorting") of cocaine. It is clinically diagnosed when the nasal septum, lateral nasal walls, and/or hard palate show signs of destruction in association with cocaine use. Although its true incidence is unknown, CIMDL is not an uncommon clinical finding amongst intranasal cocaine abusers and is likely to be encountered by forensic anthropologists and medical examiners working worldwide. Given the preponderance of drug abusers amongst the subjects of forensic casework, the ability to diagnose CIMDL in dry bone may provide crucial insight into an investigation and even help confirm an individual identification. This paper aims to make practicing forensic anthropologists aware of CIMDL. Through the analysis of existing clinical literature, patient CT scans, and histology sections, it works toward the establishment of formal diagnostic criteria for identifying CIMDL in human skeletal remains. Lytic destruction regularly involves the vomer and frequently extends to the perpendicular plate of the ethmoid, the palatal process of the maxillae or the palatine bones, and the inferior nasal conchae. The middle nasal conchae, medial walls of the maxillary sinuses, ethmoid sinuses, and cribriform plate are often damaged. Destruction may also implicate the superior nasal conchae, the orbit, and the sphenoid. Bones affected by CIMDL may contain necrotic lesions or may be absent entirely. Lesions show minimal, if any, signs of repair. The author proposes that this lack of new bone formation may be mediated by potentially elevated leptin levels in cocaine abusers and CIMDL patients and may be the key to differentiating CIMDL from other lytic processes of the midface.

Observance of Kassowitz law-late congenital syphilis: Palatal perforation and saddle nose deformity as presenting features

Late congenital syphilis refers to the people with syphilis from the age of 2 to 30 years. We report a case of late congenital syphilis in a 9 year old girl with perforation of palate and saddle nose deformity. Kassowitz law was also observed (if a woman with untreated syphilis has series of pregnancies, the likelihood of infection of the fetus in later pregnancies becomes less). Venereal Disease Research Laboratory (VDRL) and Treponema pallidum hemagglutination (TPHA) were reactive. Computed tomography (CT) scan of paranasal sinus showed maxillary and nasal polyps. The case reported here is a rare presentation of late congenital syphilis with perforation of palate and saddle nose deformity.

Cocaine-induced midline destructive lesions - an autoimmune disease?

In Europe it is estimated that around 13million of adults (15-64years) have used cocaine at least once in their lifetime. The most frequently used route of administration for the drug is intranasal inhalation, or "snorting", and thus the adverse effects of cocaine on the nasal tract are very common. Habitual nasal insufflations of cocaine may cause mucosal lesions, and if cocaine use becomes chronic and compulsive, progressive damage of the mucosa and perichondrium leads to ischemic necrosis of septal cartilage and perforation of the nasal septum. Occasionally, cocaine-induced lesions cause extensive destruction of the osteocartilaginous structures of nose, sinuses and palate that can mimic other diseases such as tumors, infections, and immunological diseases. Thorough diagnostic workup, including endoscopic, radiologic, histopathologic and serologic testing is imperative to arrive at the proper diagnosis and to initiate appropriate local and systemic treatment. Positive antineutrophil cytoplasmic antibody (ANCA) test results may be found in an unexpectedly large proportion of patients with CIMDL. In several instances their lesions are clinically indistinguishable from granulomatosis with polyangiitis (Wegener's) limited to the upper respiratory tract. CIMDL seem to be the result of a necrotizing inflammatory tissue response triggered by cocaine abuse in a subset of patients predisposed to produce ANCA, particularly those reacting with HNE. The presence of these HNE-ANCA seems to promote or define the disease phenotype. CIMDL do not respond well to immunosuppressive therapy. Only the consistent removal of persistent stimuli of autoantibody production (cocaine, bacterial superinfections) can halt the disease process, prevent the progression of the lesions and promise success of surgical repair procedures.

Angiomatoid fibrous histiocytoma on the hard palate: case report

BACKGROUND

Angiomatoid fibrous histiocytoma (AFH) is a rare, soft tissue sarcoma, which is slow growing with low metastatic potential. We recently had a patient present with AFH, which had a palatal perforation and it looked like a cyst in the occlusal view. Therefore, the radiological and histological features of AFH are reported herein. In addition, the differential diagnosis for this lesion is also discussed with a review of the literature.

CASE REPORT

A 23-year-old woman presented with a spontaneous perforation of the palate. Clinically, a painless and ulcerative lesion was shown on the mid-palate area. Radiological findings revealed a well-demarcated, homogeneous, oval-shaped radiolucent lesion in the occlusal view. Histological examination with incisional biopsy, showed a relatively well-defined cystic-like mass including tumor cells. Taking into consideration the histological and immunohistochemical findings, the presented lesion was diagnosed as AFH. Under general anesthesia, the patient underwent a modified cylindrical partial maxillectomy including safety margins.

DISCUSSION

In the present case, clinically differential diagnosis can be made with various diseases that have palatal perforations such as trauma, infection, neoplasia, collagen vascular disease, and idiopathic conditions. The treatment recommended in the literature has been radial excision. The prognosis of the tumor has been favorable.

Repair of the cocaine-induced cleft palate using the modified double-opposing z-plasty

Cocaine is a potent vasoconstrictor, and long-standing use can result in an acquired palatal cleft. Similar to congenital cases, this palatal defect can cause nasal emission and hypernasal speech. The goals of palate repair include optimizing palatal function for speech and feeding while avoiding dehiscence or postoperative fistulae. The modified double-opposing Z-plasty is an effective technique for cleft palate repair. We describe the first reported case using this technique to repair a palatal defect resulting from chronic cocaine use. Recommended requirements for using this technique include absence of future or ongoing ischemic insults to the tissue (cocaine abstinence) for at least 1 year, an intact vascular pedicle demonstrated by greater palatine dimples, presence of sufficient vascularized soft tissue with preserved pharyngeal arches, small to medium defect sizes within 10 cm(2), and extensive flap mobilization with tension-free closure. The advantages of this technique include preservation and reorientation of functional muscle, single-stage repair, and obviated requirement for distant donor sites.

Cocaine-induced encephalocele: case report and literature review

BACKGROUND AND IMPORTANCE

The abuse of cocaine can lead to significant destruction of midline craniofacial structures. This process occurs secondary to myriad mechanisms, including ischemic necrosis, irritation by chemical adulterants, and direct trauma during its administration. Coupled with a prolonged chronic infection of intranasal and anterior skull base regions, an encephalocele can be formed. We report a case of an encephalocele secondary to cocaine use and its associated complications.

CLINICAL PRESENTATION

A 56-year-old man presented with altered mental status and cerebritis secondary to the presence of an intranasal encephalocele. On computed tomography, extensive destruction of the anterior cranial fossa was observed. The patient had a 30-year history of intranasal cocaine abuse, and his urine tested positive for the presence of cocaine on admission. The patient was treated with intravenous antibiotics and underwent a repair of his cranial defect and resection of the encephalocele. The patient made a good recovery after treatment.

CONCLUSION

Alternative causes of an encephalocele, including trauma, surgery, and congenital malformation, were ruled out in this patient. Histopathological analysis of the necrotic tissue and the absence of renal or pulmonary disease also indicated that the patient did not suffer from Wegener granulomatosis, a known cause of spontaneous intranasal lesions. To the best of our knowledge, this is the first report of an encephalocele likely induced solely by cocaine abuse.

A case of successfully treated rhinocerebral mucormycosis: dental implications

This paper presents a case of rhinocerebral mucormycosis in a 22-year-old female patient with type I diabetes mellitus, who was successfully treated with surgery and long-term antifungal medication. The patient had initially been submitted to extraction of an upper third molar by a general dental practitioner but was referred to our department three days postoperatively because of double vision. Immediately following histopathological confirmation of the infection, the patient was administered Amphotericin B and Posaconazole intravenously. Surgical excision of the affected site was relatively conservative. The patient was free of the disease 15 months after initial admission to the hospital and has recently returned for reconstruction. The aim of this paper is to increase the awareness of general dental practitioners regarding uncommon serious conditions in diabetic patients, which may be confused with periodontal or dental diseases.

Naso-oral fistula due to rhinolithiasis: a rare presentation

Naso-oral fistula, as the name suggests, is an abnormal communication between the nasal and oral cavities. It is an extremely rare clinical entity encountered in routine rhinology clinics across the world. The occurrence of this fistula due to rhinolithiasis is much rarer. We present one such case in a 40-year-old man, who came to us for assessment of a "hole" in his palate. The cause of this naso-oral fistula was found to be a rhinolith in the right nasal cavity. This report emphasizes that trainee rhinologists should be vigilant about this little recognized and rare condition.

Hard palate perforation in cocaine abusers: a systematic review

Cocaine abuse has increased in the past decade, with a rise in the reported cases of midpalatine perforations produced as a result. The vasoconstrictive and caustic effect of the drug can produce direct irritation and ischemia of the nasal and palatine mucosa, leading over the long term to the creation of an oronasal perforation secondary to maxillary bone destruction. The present study offers a systematic review of all the clinical cases of necrotic nasopalatine perforations attributed to inhaled cocaine documented in the PubMed literature database. The main clinical characteristics of the disorder and its different management options are examined. Likewise, emphasis is placed on the importance of a correct differential diagnosis with respect to other conditions also characterized by midfacial necrotic destruction. Of the 36 cases included in the study, 21 corresponded to females and 15 to males. Most of the lesions were located in the hard palate (77.7%) with only 5.5% being found in the soft palate. Combined hard and soft palate presentations in turn accounted for 16.6% of the cases. The mean diameter of the perforation was 19.32 ± 16.94 mm (95%CI: 11.81-26.83). The most frequent clinical manifestation was rhinolalia together with the regurgitation of solid food and liquids through the nares. Management consists of a combination of antibiotics, analgesics, prostheses (obturators), and surgical reconstructions of the defect.

Cocaine and oral health

In the UK almost one million individuals use cocaine on a regular basis, implying that dentists are likely to encounter individuals that use cocaine. Regular use of this drug may have several orofacial effects, such as perforation of the nasal septum and palate, gingival lesions and erosion of tooth surfaces. In addition, recent use of cocaine increases the risk of a medical emergency during dental treatment, especially when epinephrine-containing local anaesthetics or retraction cords are used. Therefore, dental treatment should be postponed for 6 to 24 hours after the use of cocaine.

Congenital syphilis, still a reality in 21st century: a case report

Congenital syphilis is a preventable disease and its presence reflects a failure of prenatal care delivery systems, as well as syphilis control programmes. The procedure to prevent congenital syphilis through antenatal screening and treatment is well established. But implementation of effective programmes has proved very difficult especially in resource constrained countries.