International Expert-Based Consensus Definition, Staging Criteria, and Minimum Data Elements for Osteoradionecrosis of the Jaw: An Inter-Disciplinary Modified Delphi Study

Purpose

Osteoradionecrosis of the jaw (ORNJ) is a severe iatrogenic disease characterized by bone death after radiation therapy (RT) to the head and neck. With over 9 published definitions and at least 16 diagnostic/staging systems, the true incidence and severity of ORNJ are obscured by lack of a standard for disease definition and severity assessment, leading to inaccurate estimation of incidence, reporting ambiguity, and likely under-diagnosis worldwide. This study aimed to achieve consensus on an explicit definition and phenotype of ORNJ and related precursor states through data standardization to facilitate effective diagnosis, monitoring, and multidisciplinary management of ORNJ.

Methods

The ORAL Consortium comprised 69 international experts, including representatives from medical, surgical, radiation oncology, and oral/dental disciplines. Using a web-based modified Delphi technique, panelists classified descriptive cases using existing staging systems, reviewed systems for feature extraction and specification, and iteratively classified cases based on clinical/imaging feature combinations.

Results

The Consortium ORNJ definition was developed in alignment with SNOMED-CT terminology and recent ISOO-MASCC-ASCO guideline recommendations. Case review using existing ORNJ staging systems showed high rates of inability to classify (up to 76%). Ten consensus statements and nine minimum data elements (MDEs) were outlined for prospective collection and classification of precursor/ORNJ stages.

Conclusion

This study provides an international, consensus-based definition and MDE foundation for standardized ORNJ reporting in cancer survivors treated with RT. Head and neck surgeons, radiation, surgical, medical oncologists, and dental specialists should adopt MDEs to enable scalable health information exchange and analytics. Work is underway to develop both a human- and machine-readable knowledge representation for ORNJ (i.e., ontology) and multidisciplinary resources for dissemination to improve ORNJ reporting in academic and community practice settings.

Radiographic Orofacial Findings of Systemic Diseases

This article discusses the orofacial clinicoradiographic features of systemic diseases that manifest in the orofacial region. The systemic diseases discussed are grouped into the following: autoimmune diseases, endocrine diseases, bone diseases, hematologic diseases, syndromes, and malignancies. The radiographic manifestation ranges from radiolucent bony destruction, increased bone density, calcification, thinning of cortical plate, loss of trabeculation, missing teeth, and supernumerary teeth. It is imperative for clinicians to be cognizant of these findings, as they may be the first manifestation of these systemic diseases.

A Patient Presents for Dental Extraction and Goes into Sickle Cell Crisis in the Dental Chair

Sickle Cell Disease is an inherited autosomal recessive hemoglobinopathy associated with multiorgan damage. This single gene disorder involves one DNA base pair alteration, producing HbS. The sickle-shaped cells form when deoxygenated in the capillaries. The resulting RBC stasis leads to ischemia and pain, and acute and chronic organ damage. Patients with SCD presenting to a dental office need careful examination to rule out any current infections, neurologic deficits, or other organ involvement before formulating a dental treatment plan to avoid prolonged and complicated procedures. Early intervention and dental anxiety management are key to the dental treatment of patients with SCD.

The Global Need for Easy and Valid Assessment Tools for Orofacial Pain

The World Health Organization recently adopted a historic resolution (WHA74.5) on the urgent need for global oral health improvement. This resolution is particularly relevant in the perspective of the high prevalence of untreated oral diseases. However, one important aspect has been mentioned only in passing, namely that poor oral health often leads to orofacial pain, which is the most common reason for emergency dental visits worldwide. Therefore, an evidence-based decision-making process on oral health should include data related to orofacial pain complaints. To that end, the availability of reliable and valid assessment tools of orofacial pain and related treatment outcomes is essential. INfORM (International Network for Orofacial Pain and Related Disorders Methodology) of the International Association for Dental Research has been one of the driving forces behind the development and implementation of comprehensive sets of tools for such assessments. However, as a prerequisite for the desired global implementation, reliable and valid tools that are also brief, easy to translate, and culturally adaptable need to be further developed and tested. Some of the groundwork to facilitate this process has already been carried out. In addition, a working group within INfORM has developed a short clinical assessment tool for orofacial pain diagnostics that is near completion and will soon be ready for dissemination. Ultimately, reliable and valid orofacial pain assessment is a necessary step toward the development and implementation of appropriate "best buy" interventions that address this major driver of need for oral health care worldwide.

Detection of medial arterial calcification on CBCT images of a patient with undiagnosed type 2 diabetes mellitus: a case report

The finding of medial arterial calcification (MAC) on cone beam computed tomographic scans is more common than many clinicians realize. Medial arterial calcification is a specific pattern of vascular calcification that has been associated with diabetes mellitus. When MAC is identified on a scan, the clinician must refer the patient for evaluation of cardiovascular accident risk and for serologic evaluation to detect undiagnosed type 2 diabetes mellitus. This case report describes a patient with undiagnosed type 2 diabetes mellitus that was later confirmed by hemoglobin A_1c levels after incidental detection of MAC on cone beam computed tomography. The article also reviews the literature on MAC and its relationship with diabetes and discusses radiographic features of MAC that are often unrecognized by clinicians.

The Digital Clone: Intraoral Scanning, Face Scans and Cone Beam Computed Tomography Integration for Diagnosis and Treatment Planning

The purpose of this article is to synthesize different technologies that are available for the creation of a virtual patient, "the digital clone" because the data can be used for diagnosis as well as treatment planning. The role of facial scans, 3-dimensional intraoral scans as well as the cone beam computed tomography in the creation of a digital clone is discussed in detail. A step-by-step guide is created for the reader for integration of the intraoral scan data with the cone beam computed tomography Dicom data to create a digital clone.

Comparison of photothermal radiometry and modulated luminescence, intraoral radiography, and cone beam computed tomography for detection of natural caries under restorations

OBJECTIVES

The aim of this ex vivo study was to measure the sensitivity, specificity, and receiver operating characteristic (ROC) area under the curve (AUC) of a caries diagnostic system based on photothermal radiometry and modulated luminescence (PTR/LUM) and compare them with the values for digital intraoral radiography (IR) and cone beam computed tomography (CBCT) in detecting recurrent decay.

STUDY DESIGN

Class 2 composite restorations were prepared on 70 proximal surfaces: 35 with caries and 35 without caries. The gingival floor of the restored surfaces was assessed for caries under the restorations using each of the 3 modalities. Statistical calculations and analysis were performed using the R statistical computing environment.

RESULTS

The average scores for sensitivity among the 6 observers were 0.89 for PTR/LUM, 0.38 for IR, and 0.40 for CBCT. Sensitivity for PTR/LUM was significantly greater than sensitivity for IR and CBCT. Average scores for specificity were 0.83, 0.80, and 0.70 for PTR/LUM, IR, and CBCT, respectively. CBCT had significantly lower specificity. The AUC was 0.65 for IR and 0.59 for CBCT, which were significantly different. PTR/LUM had moderate intraobserver agreement.

CONCLUSIONS

PTR/LUM, which involves non-ionizing radiation, can serve as a sensitive adjunct in early caries detection and monitoring.