Trends in Diversity Related to Gender and Race in the Surgical Specialties and Subspecialties Inclusive of Oral and Maxillofacial Surgery

Medical training in the United States has undergone multiple evolutions and maturations. The Flexner Report and its effects, written in 1910, still has significant impact on modern professional education in the medical and dental arenas. The National Academy of Medicine (Institute of Medicine) in 2003 documented the need for diversity in the health care workforce, and the Association of American Medical Colleges additionally looked at Medical Education and health care through the lens of Academic Medicine. Both these reports reflected that health care institutions, providers, educators, students, and surgical residents are mandated to improve the health of the nation.

Role of Oral Microbial Infections in Oral Cancer

The role of bacterial and viral carcinogenesis in the oral cavity is increasingly of interest, as a means to provide more methods of cancer prevention. There may be relationships between bacteria and multiple strains of viruses in the progression of malignancy. Cancer cause is closely related to the type of carcinogen, as well as the synergistic or additive actions of combined risk factors, the susceptibility of the host, and duration of interaction between host and exposure to risk factor. Much research is underway to further define the role of microbial and bacterial agents in the progression of malignancy.

Phosphatase and Tensin Homolog Hamartoma Tumor Syndrome: A Case Report

INTRODUCTION

Phosphatase and tensin homolog (PTEN) hamartoma tumor syndrome (PHTS) may manifest as one of four distinctive disorders: 1) Cowden syndrome; 2) Bannayan-Riley-Ruvalcaba syndrome; 3) Proteus syndrome; or 4) Proteus-like syndrome. Clinical features of PHTS commonly include multiple benign hamartomas of the skin and mucous membranes as well as macrocephaly. Despite the benign nature of the characteristic lesions, patients diagnosed with PHTS are at increased risk of certain cancers, most notably carcinomas of the breast, thyroid, and endometrium.

CASE PRESENTATION

A 28-year-old African-American female presented with generalized gingival overgrowth that involved the palate, gingival margins, and retromolar areas. The dorsal tongue also exhibited a generalized tissue hyperplasia. Based on clinical presentation, biopsies were performed for histology and genetic testing. Although histology revealed non-specific fibroepithelial hyperplasia, genetic testing revealed a novel heterozygous mutation of the PTEN gene (c.158_164dupTAGTAAG), believed to result in premature termination of the protein. The patient did not exhibit macrocephaly or extraoral skin lesions and did not have any obvious cognitive deficit.

CONCLUSIONS

This presentation of a Cowden syndrome-like scenario demonstrates that intraoral lesions may be the first symptom leading to a diagnosis of PHTS. Furthermore, the case shows that communication with and referral from the general dentist to specialists (e.g., oral pathologist, oral surgeon, or periodontist) can facilitate the establishment of a definitive diagnosis and allow for preventive screening and genetic counseling to aid in the treatment of secondary diseases, most notably associated cancers.

Oral Kaposi Sarcoma Associated with Severe Alveolar Bone Loss: Case Report and Review of the Literature

BACKGROUND

In AIDS patients who present with an oral neoplasm, Kaposi sarcoma is the tumor most frequently encountered, comprising 50% to 80% of all tumor occurrences. However, oral Kaposi sarcoma associated with erosion of underlying bone is a relatively rare finding. This report and review of the literature documents a case of AIDS-related oral Kaposi sarcoma exhibiting severe bilateral erosion of the maxillary alveolar ridges.

METHODS

An HIV-seropositive male with extensive maxillary Kaposi sarcoma and associated bilateral alveolar bone erosion presented for dental evaluation subsequent to radiation therapy. Clinical and radiographic examinations were performed. Medical and dental histories were procured and supplemented with consultations from the patient's primary physician and radiation oncologist. Maxillary edentulation with surgical revision for primary closure was the treatment of choice for management of the dentoalveolar pathology. A maxillary immediate treatment denture was designed to obturate anticipated antral communications with the maxillary sinus.

RESULTS

Surgical and prosthetic treatments were completed, but complicated by an oral-antral perforation that subsequently healed without complication. Soft tissue biopsies obtained during surgery revealed no evidence of residual Kaposi sarcoma.

CONCLUSIONS

Although AIDS-related oral Kaposi sarcoma is a relatively common finding, erosion of subjacent alveolar bone is uncommon. Treatment of the tumor with subsequent dental reconstruction can be complicated by the severe lack of bone, surgical perforation of the maxillary sinus, and lack of stable teeth to serve as abutments. Significant advances in understanding the pathogenesis of AIDS-related Kaposi sarcoma have occurred in the last decade. HHV-8 and various inflammatory cytokines have been implicated in the pathogenesis and are likely to become the primary targets for therapeutic intervention.

A TEM/SEM study of the microbial plaque overlying the necrotic gingival papillae of HIV-seropositive, necrotizing ulcerative periodontitis

The purpose of this study was to examine by transmission (TEM) and scanning electron microscopy (SEM) the supragingival microbial plaque overlying the ulcerated gingival papillae of necrotizing ulcerative periodontitis (NUP) lesions in HIV-seropositive patients. The microbiota of NUP and HIV-seropositive patients with periodontitis has been reported to be similar to that of conventional periodontitis in non-infected subjects, although several investigators have also reported high recovery rates of microbes not generally associated with the indigenous oral microbial flora. Light and electron microscopic observations and microbial culture studies indicate a similar high prevalence of spirochetes in both necrotizing ulcerative gingivitis (NUG) and NUP. In addition, several studies have reported more frequent isolation of Candida albicans from diseased periodontal sites in HIV-seropositive patients than from non-diseased sites. Ten male and six female patients, each HIV-seropositive and exhibiting NUP, constituted the study population. Two biopsies of involved gingival papillae from between posterior teeth were obtained from each patient and processed for examination by both TEM and SEM. Microscopic examination revealed a surface biofilm comprised of a mixed microbial flora of various morphotypes in 81.3% of biopsy specimens. The subsurface flora featured dense aggregations of spirochetes in 87.5% of specimens. Zones of aggregated polymorphonuclear leukocytes and necrotic cells were also noted. Yeasts were observed in 65.6% of specimens and herpes-like viruses in 56.5% of the specimens. Collectively, except for the presence of yeast and viruses, the results suggest that the microbial flora and possibly the soft tissue lesions of NUP and necrotizing ulcerative gingivitis are very similar.

How does time-dependent dental unit waterline flushing affect planktonic bacteria levels?

The purpose of this study was to evaluate how time-dependent waterline flushing affects the presence of biofilm in otherwise-untreated dental unit waterlines (DUWLs). Water samples were obtained from twelve highspeed handpiece DUWLs located in the undergraduate treatment clinic at the University of Missouri-Kansas City, School of Dentistry. Baseline water samples (50 cc) were collected prior to the start of continuous flushing. Additional 50 cc samples were collected after two-, three-, and four-minute flushing intervals from the baseline. The levels of planktonic bacteria in DUWLs were quantified by counting colony forming units (CFUs). In addition, segments of water tubing from each of the highspeed handpiece waterlines were examined by scanning electron microscopy, which confirmed the presence of a residual biofilm in the lumen of each dental unit waterline. A one-factor repeated measures ANOVA showed a statistically significant (p<0.01) reduction in CFUs at all intervals compared to baseline and between each successive time interval. Indeed, after four minutes of continuous flushing, all waterlines still harbored CFU levels that exceed current American Dental Association (ADA) recommendations. It was concluded that water flushing of DUWLs produced a statistically significant reduction in planktonic bacteria at each time interval compared to the baseline and between each successive time interval. However, the level of CFUs after four minutes of continuous water flushing still exceeds the current ADA recommendations for acceptable levels of microorganisms.

Alcohol withdrawal syndrome: current management strategies for the surgery patient

PURPOSE

As advances in the therapeutic management of alcohol withdrawal syndrome occur, oral and maxillofacial surgeons should be aware of the current treatment philosophies and modalities. This article provides a comprehensive review of alcohol withdrawal syndrome and presents some of the current management strategies that can be used for these patients, whether it be in the office or in the hospital.

Determination of the disulfide bond arrangement of human respiratory syncytial virus attachment (G) protein by matrix-assisted laser desorption/ionization time-of-flight mass spectrometry

The attachment protein or G protein of the A2 strain of human respiratory syncytial virus (RSV) was digested with trypsin and the resultant peptides separated by reverse-phase high-performance liquid chromatography (HPLC). One tryptic peptide produced a mass by matrix-assisted laser desorption/ionization (MALDI) time-of-flight (TOF) mass spectrometry (MS) corresponding to residues 152-187 with the four Cys residues of the ectodomain (residues 173, 176, 182, and 186) in disulfide linkage and absence of glycosylation. Sub-digestion of this tryptic peptide with pepsin and thermolysin produced peptides consistent with disulfide bonds between Cys173 and Cys186 and between Cys176 and Cys182. Analysis of ions produced by post-source decay of a peptic peptide during MALDI-TOF-MS revealed fragmentation of peptide bonds with minimal fission of an inter-chain disulfide bond. Ions produced by this unprecedented MALDI-induced post-source fragmentation corroborated the existence of the disulfide arrangement deduced from mass analysis of proteolysis products. These findings indicate that the ectodomain of the G protein has a non-glycosylated subdomain containing a "cystine noose."

Use of 2,6-dihydroxyacetophenone for analysis of fragile peptides, disulphide bonding and small proteins by matrix-assisted laser desorption/ionization

Several peptides were shown to undergo fragmentation during matrix-assisted laser desorption/ionization time-of-flight mass spectrometry to a degree which complicated their analysis using alpha-cyano-4-hydroxycinnamic acid (CHCA) as a matrix, even at threshold laser irradiance. These peptides included synthetic peptides, peptides isolated from viral proteins and a phosphopeptide from beta-casein (residues 33-48). The excessive fragmentation occurred usually as a post-source phenomenon; however, in-source fragmentation was also observed. The combined effects of in-source and post-source fragmentation of one peptide studied led to a failure to observe the protonated molecule of this peptide in reflector mode analysis. The phosphopeptide studied exhibited a high degree of beta-elimination of phosphate. It was demonstrated that the fragility exhibited by these peptides in CHCA, including beta-elimination of phosphate from serine, was not evident with a matrix comprising 2,6-dihydroxyacetophenone (DHAP) and di-ammonium hydrogen citrate (DAHC). The DHAP/DAHC matrix was also adapted for direct analysis of peptides from an acidic reducing milieu containing tris(2-carboxyethyl)phosphine. The molecular weight of equine cytochrome c was determined with a relatively high degree of accuracy (experimental M(r) = 12360.2 +/- 1.4 Da compared to the theoretical M(r) = 12360.09 Da) using DHAP/DAHC as a matrix for reflector mode analysis.