Obstructive sleep apnoea and the need for its introduction into dental curricula

Obstructive sleep apnoea (OSA) is a major health problem which causes blood oxygen desaturation that may initiate a cascade of events via inflammatory cytokines and adrenocorticotrophic hormone that may have impact upon quality of life and lead to potential life-threatening events. Even though OSA affects an increasing number of individuals, the role of dental practitioners in recognition, screening and management has not developed accordingly. The goal of this article was to provide updated information to dental practitioners on pathophysiology, consequences and treatment options of OSA with a focused discussion on oral appliance (OA) therapy, as this topic is not routinely included in current dental curricula of many dental schools. Additionally, we present a template dental curriculum for predoctoral and/or postdoctoral students in education regarding sleep disordered breathing.

Oral health conditions affect functional and social activities of terminally ill cancer patients

PURPOSE

Oral conditions are established complications in terminally ill cancer patients. Yet despite significant morbidity,the characteristics and impact of oral conditions in these patients are poorly documented. The study objective was to characterize oral conditions in terminally ill cancer patients to determine the presence, severity, and the functional and social impact of these oral conditions.

METHODS

This was an observational clinical study including terminally ill cancer patients (2.5–3-week life expectancy). Data were obtained via the Oral Problems Scale (OPS) that measures the presence of subjective xerostomia, orofacial pain, taste change, and the functional/social impact of oral conditions and a demographic questionnaire. A standardized oral examination was used to assess objective salivary hypofunction, fungal infection, mucosal erythema, and ulceration. Regression analysis and t test investigated the associations between measures.

RESULTS

Of 104 participants, most were ≥50 years of age,female, and high-school educated; 45 % were African American, 43 % Caucasian, and 37 % married. Oral conditions frequencies were: salivary hypofunction (98 %), mucosal erythema (50 %), ulceration (20 %), fungal infection(36 %), and other oral problems (46 %). Xerostomia, taste change, and orofacial pain all had significant functional impact; p <.001, p =.042 and p <.001, respectively. Orofacial pain also had a significant social impact (p <.001). Patients with oral ulcerations had significantly more orofacial pain with a social impact than patients without ulcers (p =.003). Erythema was significantly associated with fungal infection and with mucosal ulceration (p <.001).

CONCLUSIONS

Oral conditions significantly affect functional and social activities in terminally ill cancer patients. Identification and management of oral conditions in these patients should therefore be an important clinical consideration.

Efficacy of topical benzydamine hydrochloride gel on oral mucosal ulcers: an in vivo animal study

The aim of this study was to investigate the effect of benzydamine hydrochloride bioadhesive gel on healing of oral mucosal ulceration in an animal model. For in vivo determination of the effects of the bioadhesive gel, 36 rabbits were separated into three groups: the first group was treated with the gel formulation without active agent, the second group with the gel formulation containing benzydamine, and the third group received no treatment. Clinical healing was established by measuring the area of the ulcer in each test group on days 3, 6, 9 and 12. Histological healing was determined on the same days. Benzydamine containing gel applications resulted in a decrease in the ulcer area in 12 days (p=0.000). Histological evaluation showed that the benzydamine group had a higher mean histological score than the base and the control groups during the whole test period, and the difference between the benzydamine group and the control group was significant (p=0.04). The bioadhesive gel formulation of benzydamine hydrochloride showed a statistically significant increased rate of mucosal repair in this experimental standard mucosal wound animal study. It is a candidate for the topical treatment of oral mucosal ulcerative lesions.

The utility of toluidine blue staining and brush cytology as adjuncts in clinical examination of suspicious oral mucosal lesions

The objective of this study was to investigate the utility of toluidine blue and brush cytology in patients with clinically detected oral mucosal lesions. Clinical examination of 35 patients was completed before toluidine blue application, oral brush cytology and scalpel biopsy. Lesions were photographed before and after stain application; followed by brush cytology. All findings were compared with histopathologic results. Severe dysplasia and carcinoma-in-situ were determined as 'positive'; no dysplasia and mild to moderate dysplasia were defined as 'negative'. The sensitivity, specificity, positive and negative predictive values of clinical examination and toluidine blue were the same: 0.923, 0.433, 0.414, and 0.929, respectively. Those of brush cytology were 0.923, 0.517, 0.462, and 0.938. The concordance of all methods was 30% for benign and 61% for malignant lesions. Adjuncts identified 92% of carcinoma-in-situ and squamous cell carcinoma as confirmed by histopathology, in contrast to clinical findings alone in which 62% of these lesions were identified (p=0.046). In conclusion, adjunct diagnostic methods decreased the level of uncertainty for the diagnosis of oral malignancies and lichenoid dysplasias when applied as adjuncts to clinical examination.

Analysis of oral lesion biopsies identified and evaluated by visual examination, chemiluminescence and toluidine blue

Conventional visual examination and palpation remains the gold-standard for the identification of oral mucosal lesions. The purpose of this study was to investigate the adjunctive value of a chemiluminescent light source (ViziLite, Zila Pharmaceuticals, Phoenix, Arizona) and application of pharmaceutical grade toluidine blue (TBlue(630), Zila Pharmaceuticals, Phoenix, Arizona) to further assess lesions identified during the conventional oral soft tissue examination. Lesions deemed clinically suspicious by visual examination under incandescent light were further assessed under chemiluminescence and then application of toluidine blue stain. Differences between the conventional visual examination and chemiluminescent examination were noted on four characteristics which may aid in lesion identification. Tissue retention of toluidine blue stain was documented. Each suspicious lesion was biopsied and diagnosed based upon routine histopathology. Both adjunctive exams were evaluated by comparing the histologic diagnosis. The additive value of toluidine blue stain retention was assessed in lesions diagnosed as "serious pathology" defined as severe dysplasia, carcinoma in situ and squamous cell carcinoma. Ninety-seven clinically suspicious lesions in 84 patients were identified. The chemiluminescent exam improved the brightness and/or sharpness of margin in 61.8% of identified lesions. Biopsied lesions with toluidine blue stain retention reduced the false positive rate by 55.26% while maintaining a 100% negative predictive value (NPV). Chemiluminescence was shown to increase the brightness and margins of mucosal lesions in a majority of cases and therefore may assist in identification of mucosal lesions not considered under traditional visual examination. Toluidine blue stain retention was associated with a large reduction in biopsies showing benign histology (false positive biopsy results), while maintaining a 100% NPV for the presence of severe dysplasia or cancer. Practitioners may consider use of these adjuncts in practice, however the results presented are based upon experienced providers in referral centers for mucosal disease or cancer centers and therefore positive findings may be an indication for referral to experienced providers.

Orofacial pain in cancer: part II--clinical perspectives and management

Cancer-associated pain is extremely common and is associated with significant physical and psychological suffering. Unfortunately, pain associated with cancer or its treatment is frequently under-treated, probably due to several factors, including phobia of opioids, under-reporting by patients, and under-diagnosis by healthcare workers. The most common etiology of cancer pain is local tumor invasion (primary or metastatic), involving inflammatory and neuropathic mechanisms; these have been reviewed in Part I. As malignant disease advances, pain usually becomes more frequent and more intense. Additional expressions of orofacial cancer pain include distant tumor effects, involving paraneoplastic mechanisms. Pain secondary to cancer therapy varies with the treatment modalities used: Chemo-radiotherapy protocols are typically associated with painful mucositis and neurotoxicity. Surgical therapies often result in nerve and tissue damage, leading, in the long term, to myofascial and neuropathic pain syndromes. In the present article, we review the clinical presentation of cancer-associated orofacial pain at various stages: initial diagnosis, during therapy (chemo-, radiotherapy, surgery), and in the post-therapy period. As a presenting symptom of orofacial cancer, pain is often of low intensity and diagnostically unreliable. Diagnosis, treatment, and prevention of pain in cancer require knowledge of the presenting characteristics, factors, and mechanisms involved.

Oral mucositis (OM) related morbidity and resource utilization in a prospective study of head and neck cancer (HNC) patients

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Background: Few studies have reported the burden of oropharyngeal mucositis (OM) as well as the downstream resource consumption and risk of complications due to OM following standard therapy in head and neck cancer patients. This study was a prospective, multi-center, single-arm observational study of patients receiving radiation with or without chemotherapy for head and neck cancer. Methods: Over a 6-week period, the severity and impact of OM were assessed 5 times with the oral mucositis weekly questionnaire (OMWQ-HN) and patient resource use was collected bi-weekly. Seventy-five patients were enrolled from 6 centers in the United States. Hospitalization costs are reported from the Healthcare Utilization Project Nationwide Inpatient Sample (HUPNIS). Results: Sixty-seven percent (95% CI: 55%–77%) of the patients received concurrent chemoradiation. Seventy-six percent (95% CI: 65%–85%) of patients reported severe mouth and throat soreness. Eighty-five percent (95% CI: 75%-92%) were prescribed opioid analgesics. Mouth pain and throat pain accounted for 78% (95% CI: 68%–86%) of opioid uses. During weeks 1 and 2, 38% (95% CI: 26%-50%) of patients reported severe difficulty swallowing (59% by week 6); 67% (95% CI: 46%-83%) of these patients were taking opioids (84% by week 6). Over half of the patients (38/75; 51% [95% CI: 39%–62%]) had a feeding tube placed. Twenty-eight patients (37% [95% CI: 26%–49%]) were hospitalized, 30% (95% CI: 16%–49%) of hospitalizations were considered related to mucositis. Mean length of stay was 4.9 days (range: 1–16, SE: 0.72). National average cost for a 5-day hospitalization during this study period was approximately $23,000 (SE: $565.00 [HUPNIS]). Conclusions: Mucositis is a frequent, severe, and costly complication of treatment for head and neck cancer. Effective interventions may not only relieve patient suffering but also reduce healthcare consumption and downstream costs.

[Table: see text]

RK-0202 for radiation-induced oral mucositis

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Background: This study evaluated the effect of RK-0202, administered as an oral rinse, on the incidence of severe oral mucositis in patients being treated with of radiation therapy (RT) for tumors of the head and neck. Methods: This was a prospective, randomized, placebo-controlled, double-blind study that compared the effect of 2 concentrations of RK-0202 with placebo on the incidence of severe oral mucositis at a cumulative RT dose of 60 Gy in 110 subjects. Twenty-seven subjects received RK-0202 5%, 38 received RK-0202 10%, 29 received placebo and 16 received standard of care. Subjects began dosing just prior to RT and continued dosing six times daily throughout RT. Oral mucositis was assessed twice weekly throughout RT by trained oral evaluators. Results: The higher dose of RK-0202 (10%) successfully attenuated severe oral mucositis as measured by WHO or NCI-CTC v.3 criteria. The incidence of WHO grade 3 or 4 oral mucositis by a cumulative RT dose of 60 Gy was 35% in the RK-0202 group vs. 54% in the placebo group (p = NS). By 50 Gy the incidences in the RK-0202 and placebo groups were 25% and 54%, respectively (p = 0.053). Similarly, the incidence of NCI grade 3 or 4 oral mucositis by 60 Gy was 64% in the RK-0202 cohort vs. 92% for subjects being treated with placebo (p = 0.005). Subjects treated with RK-0202 required less feeding tube placement compared to placebo recipients (3% vs. 22%, p = 0.037) and less opiate analgesia. The median percent of time on opiates was 6% on RK-0202 vs. 21% on placebo. The overall incidence of serious adverse events was significantly lower in subjects treated with RK-0202 (8% vs. 31%, p = 0.024). In general, there was no benefit noted among subjects who received RK-0202 as a 5% solution. Conclusions: RK-0202 significantly reduced the incidence of severe mucositis in subjects treated with radiotherapy for head and neck cancer and was not associated with significant adverse events.

[Table: see text]

Preliminary results of the validation of a patient (pt) self-administered questionnaire (Oral Mucositis Weekly Questionnaire-Head and Neck [OMWQ-HN]) to assess the impact of OM on pain and functioning in head and neck cancer (HNC)

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Background: Pt self-reported questionnaires measuring acute and specific effects of OM are needed to assess effects of interventions and guide patient care. We evaluated the feasibility, validity, and reliability of the OMWQ-HN on OM and its impact on pts’ abilities to perform alimentary and other routine functions. Methods: Validity and reliability of the OMWQ-HN was assessed in 75 pts from a prospective multicenter study receiving radiotherapy ± chemotherapy (RTCT). Assessments included test-retest reliability, internal consistency reliability, and cross-sectional validity. The OMWQ-HN’s sensitivity to detect change was demonstrated by using the changes in the Performance Status Scale for HNC (PSS-HN) and the Functional Assessment of Cancer Therapy (FACT-HN) to form 3 independent groups (better, no change, worse) for comparison. Effect sizes (ES) were calculated for group comparisons to measure the clinical significance of differences. Results: Compliance rates were >90% throughout the study. The OMWQ-HN demonstrated good test-retest reliability (r = 0.89). Cronbach’s alpha was >0.85 and mouth, throat, and pain-related items correlated highly with each other (r>0.7). Cross-sectional analyses to assess validity showed that OMWQ-HN scores were different across levels of pain, with those in the worst pain category reporting the most severe OMWQ-HN scores (ES >0.5 for all comparisons). The OMWQ-HN was sensitive to change in FACT-HN and PSS-HN (p < 0.001 and p = 0.013, respectively). Patients reported increases in mouth and throat soreness (MTS) that corresponded with a steady decline in oral function. Conclusions: These results indicate the OMWQ-HN is a feasible, valid, and reliable instrument for assessing the impact of mucositis on patients receiving RTCT in the HNC patient care setting.

[Table: see text]

Clinical evaluation of chemiluminescent lighting: an adjunct for oral mucosal examinations

OBJECTIVE

The purpose of this study was to describe the utility of oral chemiluminescent lighting (FDA-cleared ViziLite) as an adjunct to standard visual examination (SVE) to enhance visualization of mucosal lesions, particularly those "clinically suspicious" for oral pre-cancer or cancer. Subjects were considered at risk for oral cancer or pre-cancer if they have no a priori knowledge of the presence or absence of an oral lesion at the time of examination.

METHODOLOGY

Five-hundred and one consecutive consenting subjects, over 40 years of age and with a positive tobacco history, received a standard visual examination with conventional incandescent lighting, followed by chemiluminescent lighting. All lesions were recorded, and for lesions detected by both screening modalities, comparisons were made of the subjective parameters of lesion brightness, sharpness, surface texture, and relative size.

RESULTS

A total of 410 epithelial lesions were detected in 270 subjects by standard visual examination, of which 127 were clinically "suspicious" for oral cancer and pre-cancer. Ninety-eight lesions were also visualized by chemiluminescent lighting as "aceto-white" (CL+), in addition to six lesions not previously seen by standard visual examination. Seventy-seven of the CL+ lesions (78.5%) were clinically suspicious; all "suspicious" lesions with an ulcerative component and ulcerated lesions consistent with trauma were CL+. Leukoplakias were significantly more likely to be CL+ than erythroplakias (p < 0.01). Overall, those lesions illuminated by chemiluminescent lighting appeared brighter, sharper, and smaller compared to incandescent illumination.

CONCLUSION

The results of this study suggest that oral chemiluminescent lighting, when used as a screening adjunct following the standard visual oral examination, provides additional visual information. Leukoplakias may be more readily visualized by chemiluminescence. Studies are underway to explore the clinical significance and predictive value of oral chemiluminescent lighting.

Permanent vision loss in one eye following administration of local anesthesia for a dental extraction

Prilocaine Plain, an amide local anesthetic (LA), is somewhat less potent than lidocaine and considerably less toxic after injection into peripheral tissues. Clinically, it produces less vasodilation and is similar to other amide LA in relative freedom from allergic reactions. It is reliably used in a plain solution for cardiac patients receiving short procedures. In this report a patient with a known diagnosis of bacterial endocarditis suffered permanent visual loss in the left eye immediately following dental extraction surgery prior to mitral valve surgery. The clinical implications indicate that the delivery of LA must be done with aspiration before and during the injection. This will possibly prevent intravascular injection, which can lead to fluid emboli occluding the ophthalmic artery with the devastating result of vision loss.

The relationship between mucosal cyclooxygenase-2 (COX-2) expression and experimental radiation-induced mucositis

Although cycloooxygenase-2 (COX-2) is upregulated by factors associated with oral mucositis, its role in the pathogenesis of mucositis has not been studied. We investigated the kinetics of mucosal COX-2 expression following radiation exposure, and assessed its relationship to the development of oral mucositis in an established animal model using immunohistochemical endpoints. While little or no COX-2 expression was observed in unirradiated mucosa or in tissue taken 2 days after radiation, COX-2 expression was dramatic on days 10 and 16, especially in submucosal fibroblasts and endothelium. The kinetics of COX-2 expression paralleled mucositis severity. A burst of angiogenic activity was seen on day 21 following peak COX-2 expression. The kinetics of COX-2 expression relative to mucositis progression suggests that COX-2 is not a primary driver of radiation injury, but instead plays an amplifying role.

Quality of life, taste, olfactory and oral function following high-dose chemotherapy and allogeneic hematopoietic cell transplantation

Multiple oral complaints develop following high-dose chemo/radiotherapy and hematopoietic cell transplantation (HCT) which can influence quality of life. The purpose of this investigation was to assess quality of life, oral function, taste and smell in a cohort of patients following HCT. A general quality of life survey (the European Organization for Research and Treatment of Cancer (EORTC)) Quality of Life (QOL) questionnaire (QLQ-C30), with an added oral symptom and function scale and assessment of taste and smell was administered to a consecutive series of patients at day 90-100 post HCT. General QOL was impacted by fatigue, affecting physical, social emotional and cognitive function. While oral function scales appeared to be little affected at day 90-100 post HCT, abnormalities of taste were reported. Reports of changes in taste and smell appeared to parallel each other and changes remained at the time of the survey post-HCT. Change in taste appeared to be closely associated with dry mouth. Patients appeared to have difficulty in differentiating sour and bitter, which had been more affected than salt and sweet taste. Females appeared to report greater changes in taste than males. Increased smell sensitivity and taste change resulted in changes in food preparation in some cases, as did reported increase in sensitivity to sour and bitter taste. Acute complications are well known to affect QOL during the early period following HCT, but little assessment of long-term changes in oral QOL and taste has been conducted following transplant. The EORTC QLQ C-30 questionnaire with the oral addendum provides a measure of the quality of life and oral function, and may provide useful outcome measures for assessment of oral care prevention and management in HCT patients.

Comparison of HPV infection, p53 mutation and allelic losses in post-transplant and non-posttransplant oral squamous cell carcinomas

BACKGROUND

Oral squamous cell carcinoma (SCC) is increasingly found in transplant recipients, although little is known of the natural history of the disease or the mechanism underlying this increase.

METHODS

In this article we describe the history of development of 5 oral post-transplant SCCs (PSCCs) and compare their genetic profiles to 34 non-posttransplant SCCs (NPSCCs).

RESULTS

Of the five patients with PSCCs, 3 had bone marrow transplants and two, kidney. All three PSCCs from bone marrow recipients were preceded locally by graft-vs.-host disease (GVHD). Two of the GVHD were biopsied and demonstrated dysplasia. Similar frequencies of loss of heterozygosity (LOH) occurred in PSCCs and NPSCCs at 3p, 9p, 17p and 8p, with lower frequencies in PSCCs at 4q (39% vs. 0%), 11q (53% vs. 20%) and 13q (45% vs. 20%), although the latter were not significantly different. Only 1 PSCC had a p53 mutation, compared to historical values of 40-60% for NPSCC. Interestingly, human papillomavirus (HPV) DNA was detected in 3 (60%) PSCCs, in comparison to only 4 (12%) of the 34 NPSCCs (P = 0.0346).

CONCLUSIONS

Dysplasia in oral GVHD may be a strong indicator of cancer risk and should not be regarded as reactive changes to lichenoid mucosites. The low level of p53 mutation and increased HPV infection support the involvement of HPV in the development of PSCC, while the similarity in LOH patterns suggests that other aspects of carcinogenesis may be comparable in these two types of SCCs.

The use of bone scintigraphy in temporomandibular joint disorders

INTRODUCTION

The use of bone scintigraphy (bone scan) in the diagnosis of temporomandibular joint (TMJ) disease has been infrequent, as compared with traditional radiographic techniques. Bone scans have the potential to detect active bone remodeling whereas corresponding radiographs may be normal or document past structural change in the joint. Traditional radiographic findings and relevant clinical signs and symptoms correlated with bone scans may aid in the diagnosis of TMJ disease and possibly affect treatment and prognosis of individual cases. The use of bone scans as an additional tool in diagnosing TMJ disease was assessed in this series of patients.

METHODS

Thirty consecutive subjects with TMJ tenderness were selected for bone scintigraphy using technetium diphosphonate 99 mTc and single photon emission computerized tomography. These subjects received bone scans as well as other selected imaging modalities for diagnostic purposes.

RESULTS AND DISCUSSION

The findings on bone scan were evaluated and a change in preliminary clinical diagnosis or treatment was made in 60% of cases because of the findings on bone scintigraphy. Bone scintigraphy may be valuable to assess progress of TMJ inflammation or remodeling, and may affect diagnosis and treatment of patients with TMJ tenderness.

Periodontal disease and periodontal management in patients with cancer

Periodontal infection may exacerbate during cancer therapy and may result in oral pain and infection, and systemic infection, which may cause morbidity and can lead to mortality in neutropenic cancer patients. Periodontal disease in head and neck cancer patients treated with radiation therapy may lead to acute and chronic complications. The literature was reviewed by a search of Medline of the National Library of Medicine. The search was conducted to identify publications assessing periodontal disease in cancer patients. In addition, a review of papers referenced in the retrieved papers was conducted to identify additional publications for review. Periodontal disease should be assessed and managed prior to medical treatment of cancer for those with oropharyngeal cancer, and for patients in whom neutropenia may develop during treatment. Pretreatment assessment and management, and maintenance of oral hygiene have been shown to be effective in preventing oral and systemic complications during treatment. A complete oral and periodontal examination is appropriate for all patients planned to receive head and neck radiation therapy and those to be treated with medical protocols that are anticipated to result in neutropenia. Oral and periodontal care must continue following cancer therapy, and requires that the health care provider have an understanding of the malignant disease, oral manifestations of the disease, medical management of the disease, and of the oral complications that may develop.

Oral topical doxepin rinse: analgesic effect in patients with oral mucosal pain due to cancer or cancer therapy

Oral mucositis is a treatment limiting toxicity of cancer therapy. The purpose of this study was to assess the impact of doxepin oral rinse in the management of oral mucosal pain in cancer patients. Forty-one cancer patients with oral mucosal pain were provided a solution of doxepin (0.5%) for oral rinsing. Oral pain was assessed prior to rinsing, and following rinsing for 4 h using a visual analogue scale (VAS). Adverse effects were recorded. Doxepin rinse resulted in a reduction of pain intensity of more than 50%, with pain relief extending for more than 3 h with pain not returning to baseline 4 h after rinsing. The rinse was tolerated by patients with mucosal damage, and had acceptable taste, and infrequent mucosal stinging with use. Some patients reported sedation after use, likely due to systemic absorption. The results of this single dose trial suggest that topical doxepin rinse has significant ability to provide clinically significant pain relief in patients with mucosal damage with an extended duration of effect.

Taste and smell dysfunction in patients receiving chemotherapy: a review of current knowledge

Disorders of taste are prevalent in patients undergoing chemotherapy and often have a negative impact on quality of life and nutrition. We now present a review of the physiology of taste and smell and a discussion of the multiple causes of disturbances in these senses in patients undergoing standard- and high-dose chemotherapy. A better understanding of the complex and often multifactorial etiology of taste dysfunction should enable the clinician to institute measures to minimize the impact of these disturbing changes.

Understanding "alternative" dental products

Alternative, complementary, integrative, and holistic health care are matters of public interest and include oral and dental care products. There are a variety of dental products promoted as "alternatives" to the standard commercial dental products that most dentists recommend and most patients use. These alternative products can be categorized as standard dental products made with natural ingredients, herbal products, homeopathic products, and synthetic alternative products. Dental health care providers should be aware of the range of "alternative" dental products and be able to counsel their patients to understand the type of support and evidence needed to determine safety and efficacy of treatment. The use of dental care products should be based upon sound basic science and sufficient clinical evidence of safety and efficacy.

Characteristics of oral and paraoral malignant lymphoma: a population-based review of 361 cases

BACKGROUND

Lymphoma is the second most common neoplasm of the head and neck; almost 50% of all lymphomas occur in this region. Waldeyer's ring is the most common site of lymphomas involving the oral region. The purpose of this study was to review the characteristics of a large series of malignant lymphoma of the oral region.

METHODS

Three hundred sixty-one consecutive cases of malignant lymphoma of the oral region were identified in the Tumor Registry between 1969 and 1998.

RESULTS

The 361 cases (200 males and 161 females) of malignant lymphoma of the oral region accounted for 3.5% of all oral malignancies. The mean age was 62.5 years and the most prevalent site of involvement was the tonsil (32.7%), followed by the parotid gland (16.1%). Sixty-five percent of the lesions were diagnosed as large-cell (38%) or small-cell (27%) lymphoma. One quarter of the patients died of the disease in a mean of 2.78 years after diagnosis. Of a total 26 patients who died from other causes, 12 died because of other cancers, including 7 (27%) with leukemia and 5 (19%) with oral carcinoma. The prognosis is based, at least partially, on the histologic grading (low, intermediate, or high) and the anatomic stage of the disease. Localized low-grade lymphomas have a more favorable prognosis compared with those that are disseminated and/or have high-grade cellular changes.

CONCLUSION

Lymphoma is the second most common malignant oral disease. Thorough head and neck and oral examination is necessary to identify lesions that may represent lymphoma.

Impact of localized treatment in reducing risk of progression of low-grade oral dysplasia: molecular evidence of incomplete resection

Currently, there is no consensus on the appropriate treatment for low-grade oral dysplasia. This is mainly due to the difficulty in predicting outcome for this heterogeneous group of lesions. In this study, we constructed a detailed clinical history of 66 mild and moderate dysplasias in order to determine how treatment affected outcome, and to evaluate the effect of treatment on lesions with different genetic profiles, which are defined by patterns of loss of heterozygosity (LOH) associated with low, intermediate and high risk of progression [Clin. Cancer Res., 6, 357-62, 2000]. The results showed that although treatment guided by clinical removal of leukoplakia reduced cancer progression risk in all three risk groups, the amount of reduction in our study group did not reach statistical significance. To assess whether completeness of lesion removal was a major factor in recurrence, repeat biopsies at the primary sites were analyzed for persistent LOH status on chromosomes 3p, 4q, 8p, 9p, 11q, 13q and 17p. Strikingly, eight of 17 cases judged clinically removed contained the same molecular clones in the initial and subsequent biopsies, suggesting incomplete removal. When molecular information was included in the assessment of lesion removal, treatment significantly reduced the risk of progression for cases with intermediate (P=0.043) and high risk (P=0.001) genetic profiles, but not cases with low-risk profiles. A 9.1-fold decrease in progression risk was observed for those with high-risk profile. Altogether, these data suggest the use of molecular profiles to guide the treatment of low-grade dysplasia. Our data also suggest that currently an inadequate margin may in part be responsible for the high rate of recurrence, especially in high-risk lesions.

Benzydamine HCl for prophylaxis of radiation-induced oral mucositis: results from a multicenter, randomized, double-blind, placebo-controlled clinical trial

BACKGROUND

Benzydamine was evaluated in patients with head and neck carcinoma for treatment of radiation-induced oral mucositis, a frequent complication of radiation therapy (RT) for which there is no predictable therapy or preventive treatment currently available.

METHODS

The safety and efficacy of 0.15% benzydamine oral rinse in preventing or decreasing erythema, ulceration, and pain associated with oral mucositis during RT were evaluated in a randomized, placebo-controlled trial conducted in patients with head and neck carcinoma. Subjects were to rinse with 15 mL for 2 minutes, 4-8 times daily before and during RT, and for 2 weeks after completion of RT; study evaluations were conducted before RT and routinely thereafter up to 3 weeks after RT.

RESULTS

During conventional RT, regimens up to cumulative doses of 5000 centigrays (cGy) benzydamine (n = 69) significantly (P = 0.006) reduced erythema and ulceration by approximately 30% compared with the placebo (n = 76); greater than 33% of benzydamine subjects remained ulcer free compared with 18% of placebo subjects (P = 0.037), and benzydamine significantly delayed the use of systemic analgesics compared with placebo (P < 0.05). Benzydamine was not effective in subjects (n = 20) receiving accelerated RT doses (> or = 220 cGy/day). The incidence of adverse events between treatment groups was comparable without significant differences. Early discontinuation because of adverse events occurred in 6% of benzydamine subjects and 5% of placebo subjects, and there was 1 death (related to the primary diagnosis) in a placebo subject.

CONCLUSIONS

Benzydamine oral rinse was effective, safe, and well tolerated for prophylactic treatment of radiation-induced oral mucositis.

The utility of panoramic imaging of the temporomandibular joint in patients with temporomandibular disorders

OBJECTIVE

The objective of this study was to evaluate the utility of panoramic imaging in assessment of patients with temporomandibular disorders (TMDs).

STUDY DESIGN

Fifty-five consecutive patients referred for diagnosis and management of facial pain and jaw dysfunction were included. A single examiner completed the history and clinical examination on all patients. All patients received panoramic imaging. On the basis of clinical and radiographic findings, a subset of patients received advanced imaging modalities. The panoramic radiographs were interpreted by 2 examiners; if any disagreement was noted, a third examiner interpreted the radiographs.

RESULTS

Seventy-five percent of the patients had complaints of facial pain, and 75% exhibited tenderness in masticatory muscles. Tenderness was present in TM joint regions in 62%. Altered bony anatomy was seen in 43.6% of panoramic radiographs. Panoramic imaging did not lead to changes in clinical diagnosis in any of the patients seen, although the findings on the radiographs did lead to requests for additional imaging studies in 3 cases, one of which was later referred for surgical intervention because of radiographic findings.

CONCLUSION

Clinical findings may be of greater relevance leading to the diagnoses associated with TMD and to determination of the need for additional imaging rather than the use of panoramic imaging in all patients with facial pain and TMD.

Quality of life and oral function in patients treated with radiation therapy for head and neck cancer

BACKGROUND

Multiple oral complaints develop during radiation therapy for head and neck cancer, and quality of life is affected after treatment. The purpose of this investigation was to assess the quality of life, oral function, and oral symptoms in a cohort of patients during and after radiation therapy.

METHODS

A general quality of life survey (the European Organization for Research and Treatment of Cancer (EORTC) Quality of Life Questionnaire (QLQ-C30), with an added oral symptom and function scale was administered to a consecutive series of patients who received radiation therapy for head and neck malignant disease. Patients completed surveys at the beginning of radiation therapy, immediately after, and 6 months after treatment.

RESULTS AND DISCUSSION

The questionnaire used in this study provides increased information regarding the oral and dental function that is frequently affected by radiation therapy. Results of this study indicate the need to determine oral dysfunction after head and neck cancer therapy, so that the most predictable cure or best palliation of the malignancy with the least impact on oral function and quality of life is chosen. Oral complications during and after radiation therapy for head and neck cancer are common and affect quality of life. Oral QOL does not return to pretreatment levels by 6 months after radiation therapy. This study supports the use of a general function scale such as the EORTC questionnaire with the addition of disease/site-specific scales to provide data on outcomes of therapy and on the complications associated with therapy. The EORTC QLQ 30 questionnaire with the oral assessment addendum provides a measure of the quality of life and oral function in head and neck cancer patients and may provide useful outcome measures for assessment of oral care prevention and management strategies in these patient populations. The results show that the questionnaire is responsive to change throughout the course of radiation therapy for head and neck cancer.

Oral mucositis and the clinical and economic outcomes of hematopoietic stem-cell transplantation

PURPOSE

To explore the relationship between oral mucositis and selected clinical and economic outcomes in blood and marrow transplant patients.

PATIENTS AND METHODS

Subjects consisted of 92 transplant patients from eight centers who participated in a multinational pilot study of a new oral mucositis scoring system (Oral Mucositis Assessment Scale [OMAS]). In the pilot study, patients were evaluated for erythema and ulceration/pseudomembrane formation beginning on the first day of conditioning and continuing for 28 days. We examined the relationship between patients' peak OMAS scores and days with fever (body temperature > 38.0 degrees C), the occurrence of significant infection, days of total parenteral nutrition (TPN), and days of injectable narcotic therapy (all over 28 days), days in hospital (over 60 days), total hospital charges for the index admission, and vital status at 100 days.

RESULTS

Patients' peak OMAS scores spanned the full range of possible values (0 to 5) and were significantly (P <.05) correlated with all of the outcomes of interest except days with fever (P =.21). In analyses controlling for type of graft (autologous v allogeneic) and study center, a 1-point increase in peak OMAS score was associated with (1) 1.0 additional day with fever (P <.01), (2) a 2.1-fold increase in risk of significant infection (P <.01), (3) 2.7 additional days of TPN (P <.0001), (4) 2.6 additional days of injectable narcotic therapy (P <.0001), (5) 2.6 additional days in hospital (P <.01), (6) $25,405 in additional hospital charges (P <.0001), and (7) a 3.9-fold increase in 100-day mortality risk (P <.01). Mean hospital charges were $42,749 higher among patients with evidence of ulceration compared with those without (P =.06).

CONCLUSION

Oral mucositis is associated with significantly worse clinical and economic outcomes in blood and marrow transplantation.

Classifications of oral lesions in HIV infection

BACKGROUND

Manifestations of immunosuppression may take the form of opportunistic infection, and neoplasia. While this paper has focused on gingival and periodontal manifestations. these tissues cannot be evaluated in isolation. The presence of involvement of other oral tissues such as the cheek or tongue with manifestations associated with HIV such as hairy leukoplakia, Kaposi's sarcoma at these sites, and candidiasis in addition to periodontal manifestations may further increase the clincal suspicion of underlying immunosuppression and/or progression of the immunosuppressive state.

DISCUSSION

The periodontist plays an essential r le in identifying the periodontal status of an individual and has an important r le to play in early recognition of signs and symptoms of HIV disease or progression of the medical condition.

CONCLUSION

Only through such recognition can appropriate definitive diagnostic testing be conducted, and appropriate therapeutic intervention for the oral condition and the systemic condition be considered.

Topical azathioprine in the treatment of immune-mediated chronic oral inflammatory conditions: a series of cases

OBJECTIVES

After hematopoietic cell transplantation, a variety of complications can occur, including chronic graft-versus-host disease (GVHD), with 25% to 70% of these involving the oral cavity. Those lesions, as well as oral involvement of autoimmune mucocutaneous diseases, might present as painful, erythematous, and ulcerative oral lesions. Management includes topical and systemic immunosuppressive agents, including systemic azathioprine (AZA). The purpose of this study was to evaluate the efficacy of topical AZA in chronic oral GVHD and in oral autoimmune diseases in a series of patients.

METHODS

Four men and 2 women with GVHD and 2 men with autoimmune vesiculo-ulcerative oral lesions were treated with topical AZA. A rinse of 5 mL of 5 mg/mL AZA in methylcellulose were rinsed 3 to 4 times daily for over 1 minute and expectorated, or a gel in the same concentration in 3% methylcellulose was topically applied. The outcome was evaluated separately for total ulcer size, assessment of the erythema, and severity of pain by using a visual analogue scale. Global estimated improvements represented a proportional combined improvement of ulcers, erythema, and pain.

RESULTS AND CONCLUSIONS

The mean estimated global improvement for 6 patients with GVHD who used AZA rinse was 60% in a mean of 16.67 weeks. Ulcers improved by 58%, erythema by 55%, and pain was reduced by 63%. Two patients with oral lesions of vesiculo-ulcerative diseases (1 AZA rinse and 1 topical gel) improved by 95% and 96%, respectively, in 3 months. One patient with GVHD applied topical AZA gel in addition to mouthrinses, and a 29% estimated global improvement was achieved in addition to 50% of improvement achieved with AZA mouthrinses. The observed effect of topical AZA suggests that it can be used for management of oral immune-mediated inflammatory conditions, and for patients who are provided with systemic immunosuppressives it can allow control of oral findings with lower systemic dosing. The therapeutic potential of topical AZA as mouthrinse versus topical applications and the most effective concentration should be further investigated.

Changing oral care needs in the United States: the continuing need for oral medicine

OBJECTIVE

The purpose of this article is to provide oral care providers evidence of oral conditions and medical compromise that is impacting the oral health and oral health needs of the public.

DESIGN

Data were analyzed based on current epidemiologic data, derived in large part from the Health and Nutrition Examination Surveys, the National Center for Health Statistics, National Health Interview Survey Series 1994-1997; American Cancer Society, National Cancer Institute Surveillance Examination and End Results data base, Morbidity and Mortality Weekly Reports, peer-reviewed publications, and surveys of oral medicine-related disorders.

RESULTS

Millions of Americans have medical conditions that complicate their oral health care. Oral health problems associated with age, medical health and treatment, and institutional setting are increasing. Chronic orofacial pain, persistent oral soft tissue lesions, and salivary gland and chemosensory disorders are common problems of modern society.

CONCLUSIONS

Evidence suggests that the next decade will bring a significantly increased demand for diagnosis and management of patients with oral conditions and patients with oral manifestations of systemic conditions, and an increase in general oral care needs of patients who are medically compromised. These increasing demands should be reflected in dental education and continuing education.

Assessment of various topical oral formulations by bone marrow transplant recipients

Topical approaches to management of oral mucositis have the advantages of high local concentration and limited or no systemic absorption, reducing the risk of systemic complications. The acceptability of topical therapies in cancer patients has not been evaluated. Thirty-eight transplant patients assessed the acceptability of three formulations (rinse, thin gel, thick gel) of a new compound developed to prevent oral mucositis. The rinse was selected as the most acceptable formulation. The thick gel received the lowest rating. Consistency was a major determinant of overall acceptability. A neutral taste was desirable for most participants. Room temperature of the formulation was rated as completely acceptable. Most participants would be willing to use the rinse or thin gel several times per day, to retain each dose in the oral cavity for up to 5 min, and to swallow it. The support of caregivers may be needed to achieve compliance with such regimens.

The correlation between epidermal growth factor levels in saliva and the severity of oral mucositis during oropharyngeal radiation therapy

BACKGROUND

Epidermal growth factor (EGF) is present in biologic fluids, including saliva, and plays a role in maintenance of the epithelial barrier and in healing of damaged mucosa. The purpose of this study was to assess the relation between salivary EGF and the severity of oral mucositis in patients with carcinoma of the head and neck during radiation therapy.

METHODS

Whole resting saliva (WRS) and whole stimulated saliva (WSS) were collected prior to radiation and each week during radiation treatment for 11 men and 7 women. Oral mucositis was evaluated using the National Cancer Institute (NCI) scale of 0-4 and the Oral Mucositis Assessment Scale (OMAS), which evaluates the extent of erythema (scale of 0-2) and ulcerations (scale of 0-3) in nine oral sites. The overall OMAS score of 0-45 reflected the mucosal condition. EGF was assayed in the saliva specimens.

RESULTS

The total mean radiation dose delivered to the head and neck was 5667 centigrays (cGy) in a mean of 24 fractions. Ulcerative oral mucositis occurred in 94% of patients. The mean OMAS score ranged from 2.83 in the first week of treatment to 14.77 in the fifth week. The mean WRS and WSS volumes decreased significantly from pretreatment to the first week of radiation treatment and then remained stable. A similar pattern was seen for the mean total output of EGF. A significant and negative correlation was found between higher levels of EGF in stimulated saliva and low OMAS score, reflecting less severe erythema and ulceration. A general trend showing that less tissue damage was associated with a higher EGF level in resting saliva also was illustrated. EGF levels were correlated with the OMAS score; however, no correlation was found when assessing the NCI score, which combines tissue damage with function and symptoms in a single score.

CONCLUSIONS

Radiation-induced mucositis appeared to be modified by saliva volume, total EGF, and concentration of EGF in the oral environment. Saliva volume and total EGF output decreased significantly in the first weeks of treatment and remained reduced throughout radiation therapy. The findings suggest that higher levels of EGF in saliva, particularly in stimulated saliva, prior to and during radiation treatment may be associated with less severe mucosal damage due to radiation therapy. It is also postulated that human EGF may affect the development and healing of radiation-damaged mucosa.

A survey of antibiotic use in dentistry

BACKGROUND

Antibiotics are important in the management and prophylaxis of infection in patients at risk of experiencing microbial disease. As a result of the increase in antimicrobial resistance, the authors conducted a survey to assess current antibiotic use in dental practice.

METHODS

The authors mailed a two-page, pretested survey to all licensed dental practitioners in British Columbia, Canada. A total of 2,542 surveys were mailed; 19.9 percent were returned by fax or mail. The authors examined an association between factors analyzed using a chi 2 test.

RESULTS

Respondents were demographically consistent with all registered dentists in British Columbia. They reported writing an average of 4.45 prescriptions per week. Antibiotics prescribed after treatment primarily were penicillin and its derivatives. Recommended adult doses of penicillin were prescribed by 59.2 percent of respondents; recommended daily doses of amoxicillin were prescribed by 72.2 percent of respondents. The average prescription duration was 6.92 days. Respondents prescribed prophylactic antibiotics an average of 1.15 times per week for prophylaxis of bacterial endocarditis; 17.5 percent reported postoperative dosing for prophylaxis, ranging from a one- to seven-day prescription with an average of 6.91 postoperative doses. Preoperative antibiotics were prescribed for patients with a history of rheumatic fever or any heart murmur or prosthetic hip. Antibiotics were prescribed more frequently for surgical procedures and patients with acquired immunodeficiency syndrome than for other circumstances.

CONCLUSIONS

More than 80 percent of respondents reported that they followed current American Heart Association prophylaxis guidelines. The authors, however, noted discrepancies in prophylactic use of antibiotics for bacterial endocarditis and for patients with large joint prostheses, as well as in prescribing antibiotics in the presence of clinical infection. In therapeutic use, approximately 85 percent of respondents followed appropriate prescription guidelines for dosing and duration of therapy.

CLINICAL IMPLICATIONS

Appropriate and correct use of antibiotics is essential to ensure that effective and safe treatment is available and that practices that may enhance microbial resistance are avoided. To improve standards of care, dentists need up-to-date pharmacology in dental education, as well as continuing education, further outcome studies and continuous assessment of dental practices.

A case series of acquired immunodeficiency syndrome patients with initial neoplastic diagnoses of intraoral Kaposi's sarcoma

BACKGROUND

Oral Kaposi's sarcoma (KS) may represent the initial clinical manifestation of immunosuppression in human immunodeficiency virus disease. This article reviews the treatment provided to these patients and the outcome of the disease and provides the opportunity to assess the impact of improvements in the medical therapy of acquired immunodeficiency syndrome on disease outcome.

METHODS

A tumor registry was examined to identify patients in whom oral KS was the first neoplastic diagnosis.

RESULTS AND CONCLUSIONS

Thirty-seven cases of oral KS representing 1.9% of all cases of KS were identified as the first malignant diagnosis in patients with acquired immunodeficiency syndrome. Patients with oral KS have limited survival; the cause of death is either infection or malignancy. In our study, the palate was the most common site of primary involvement in the oral cavity. Recently diagnosed patients remained alive longer than those diagnosed earlier, and the patients with the most recently diagnosed cases were alive at the completion of the study, suggesting that medical management of human immunodeficiency virus has improved with new therapies.

Unconventional dentistry: Part IV. Unconventional dental practices and products

This is the fourth in a series of 5 articles providing a contemporary overview and introduction to unconventional dentistry (UD) and its correlation to unconventional medicine (UM). Several common UD and UM practices are described to familiarize practitioners with a variety of theories, practices, products and treatments that specifically apply to dentistry. This brief review is not intended as an in-depth resource.

Nasopharyngeal carcinoma: the role of the dentist in assessment, early diagnosis and care before and after cancer therapy

Nasopharyngeal carcinoma (NPC) may present first to the dental profession as facial pain, neck masses, difficulty in speech and swallowing, ear, nose and throat symptoms, or as symptoms of temporomandibular disorders (TMD). Recognition of the signs and symptoms are essential in order to lead to the correct diagnosis, and to avoid inappropriate intervention that may further delay diagnosis and initiation of treatment of the cancer. Differentiation between NPC and TMD may be facilitated by specific questioning of other symptoms that are not frequently associated with TMD such as neck masses, nasal obstruction, recent unilateral hearing deficit and epistaxis. The general dentist can become involved at three stages of a patient's experience with NPC: Stage 1, recognition of signs and symptoms; Stage 2, pre-treatment dental assessment; and Stage 3, post-treatment support. This paper is intended to: (1) alert the general dentist of the signs and symptoms associated with NPC, such that timely and appropriate treatment may ensue; (2) provide a basic outline for assessment, preparation, palliation and continuing care of a patient diagnosed with NPC; and (3) underline the significant role of the general dentist in achieving an optimal quality of life for these patients

Assessment of objectives of post-doctoral general dentistry programs in Canada

Objectives of hospital-based post-doctoral general dentistry programs in Canada were assessed by questionnaire. Seventy percent (14 of 20) of the program directors responded. Educational goals and objectives were assessed in professional skills and practice management, public health and preventive dentistry, oral medicine and pathology, special needs patient care, trauma and emergency care, restorative/prosthodontic care, endodontics, orthodontics/pediatric dentistry, oral surgery, periodontics, pharmacology, and functioning in a hospital. High rankings of proficiency were related to primary care, restorative/prosthodontic, endodontic, and surgical care. Emergency care, sedation, and pharmacology were also ranked highly. Lower rankings of proficiency were reported in orthodontics, aspects of public health dentistry, practice management, and advanced oral and maxiliofacial surgery. When the results of the Canadian survey were compared with those of a survey of US post-doctoral general dentistry programs, substantial similarity was seen. The findings support continuing reciprocity in accreditation standards between the Canadian and American Commissions on Dental Education and Dental Accreditation.

Topical azathioprine in the combined treatment of chronic oral graft-versus-host disease

This paper presents the first report of the use of topical azathioprine in the management of persistent symptomatic chronic oral graft-versus-host disease (GVHD). Topical azathioprine suspension was used as an oral rinse and was swallowed, maintaining the previously prescribed systemic dose of azathioprine, and resulted in improvement in a case of oral GVHD that was resistant to other approaches to management. Topical azathioprine may provide additional therapy in the management of immune-mediated oral mucosal disease. Clinical trials appear warranted based upon the results of topical azathioprine use as presented in this case report.

Use of allelic loss to predict malignant risk for low-grade oral epithelial dysplasia

One of the best approaches to identifying genetic changes critical to oral cancer progression is to compare progressing and nonprogressing oral premalignant lesions. However, such samples are rare, and they require long-term follow-up. The current study used the large archive network and clinical database in British Columbia to study loss of heterozygosity (LOH) in cases of early oral premalignancies, comparing those with a history of progression to carcinoma in situ or invasive cancer and those without a history of progression (referred to as nonprogressing cases). Each of 116 cases was analyzed for LOH at 19 microsatellite loci on seven chromosome arms (3p, 4q, 8p, 9p, 11q, 13q, and 17p). The progressing and nonprogressing cases showed dramatically different LOH patterns of multiple allelic losses. An essential step for progression seems to involve LOH at 3p and/or 9p because virtually all progressing cases showed such loss. However, LOH at 3p and/or 9p also occurred in nonprogressing cases. Individuals with LOH at 3p and/or 9p but at no other arms exhibit only a slight increase of 3.8-fold in relative risk for developing cancer. In contrast, individuals with additional losses (on 4q, 8p, 11q, or 17p), which appeared uncommon in nonprogressing cases, showed 33-fold increases in relative cancer risk. In conclusion, analysis of LOH at 3p and 9p could serve as an initial screening for cancer risk of early premalignancies. Follow-up investigation for additional losses would be essential for predicting cancer progression.

Patient reports of complications of bone marrow transplantation

In recent years, significant improvements have been made in the management of neutropenia and thrombocytopenia and other potentially life-threatening complications of ablative chemotherapy. While these complications are of particular concern to physicians, patients receiving ablative therapy for bone marrow or blood stem cell transplants are often troubled by other side effects such as nausea, vomiting, diarrhea and mouth sores. The purpose of the study was to gain a better understanding of patients' experiences while undergoing a transplant. The same professional medical interviewer conducted in-depth interviews with 38 subjects (10 men, 28 women; mean age 46.9 years) who had received ablative therapy for bone marrow and/or peripheral blood stem cell transplants. Participants were consecutively identified through physician and patient referrals, cancer and BMT patient support groups, and newspaper advertisements. Twenty-eight patients (74%) received autologous stem cell transplants and 10 patients (26%) received allogeneic transplants. Participants reported mouth sores, nausea and vomiting, diarrhea, and fatigue as the most troubling side effects of their transplants. Mouth sores were selected as the single most debilitating side effect (42%), followed by nausea and vomiting (13%). Many patients mentioned that mouth sores made it difficult or impossible to eat (n = 23), swallow (n = 21), drink (n = 17), and/or talk (n = 8). Twenty patients reported pain in the mouth, throat, and/or esophagus. Two-thirds (66%) of patients reported receiving opioid analgesics, most frequently morphine, to relieve oral pain. For many, opioids caused incapacitating side effects, including hallucinations, a feeling of loss of control and a decrease in mental acuity. Patients receiving ablative chemotherapy identify oral mucositis as a significant cause of suffering and morbidity. Effective interventions to alleviate this complication are urgently needed.

Craniofacial osseous and chondromatous sarcomas in British Columbia--a review of 34 cases

Head and neck sarcomas are very rare diseases. The aim of this study was to assess the prevalence and presentation of hard tissue sarcomas in the head and neck and jaws. A search of the British Columbia Tumor Registry identified 34 craniofacial hard tissue sarcomas (11 chondrosarcomas, 23 osteosarcomas) over a period of 29 years. A male predominance (1.8:1) and a mean age of 40.4 years at diagnosis were seen. Of the 23 patients with osteosarcoma, one-third survived for 5 years and 12 (52%) died within a mean of 20 months. Of the 11 patients with chondrosarcoma, 45% survived for 5 years and two (18%) of the patients died within a mean of 6 months. In nine of the osteosarcoma patients (39%) the jaws were involved, and in six of those cases (67%) there was mandibular involvement. Swelling was the first sign in all jaw patients, with a mean age of 41.1 years at diagnosis and a male predominance with a ratio of 8:1. Three of the eight male patients with osteosarcoma of the jaw (38%) died within a mean of less than 1 year. Improved prognosis is related to early recognition and diagnosis to allow for adequate surgical resection. The benefit of a combination of surgery with irradiation or chemotherapy continues to be investigated.

The oral effects of smokeless tobacco

Smokeless tobacco use has increased rapidly in North America. This form of tobacco use has many oral effects including leukoplakia, oral cancer, loss of periodontal support (recession), and staining of teeth and composite restorations. Systemic effects such as nicotine dependence, transient hypertension and cardiovascular disease may also result from smokeless tobacco use. This paper aims to guide dental practitioners in identifying oral lesions that occur due to the use of smokeless tobacco and also offer guidelines on how to counsel patients who express a desire to stop using smokeless tobacco products.

Oral complications associated with immunosuppression and cancer therapies

The oral manifestations of oropharyngeal infection in immunocompromised patients present a particular challenge for both medical and dental professionals because clinical signs and symptoms may be minimal and accurate diagnosis and appropriate treatment may be difficult. Effective control of infection and management of oral symptoms are important and may be achieved by the judicious use of topical and systemic agents and by maintaining good oral hygiene. Prevention of mucosal breakdown, suppression of microbial colonization, control of viral reactivation, and effective management of severe xerostomia are all critical steps to reduce the overall morbidity and mortality of oromucosal infections in the severely immunocompromised patient.

Topical application of vitamin A to oral leukoplakia: A clinical case series

BACKGROUND

Due to the possibility of malignant transformation of oral leukoplakia, these lesions must be assessed and managed closely and, if not resolved, must be reassessed on a regular basis.

METHODS

This study evaluated the use of topical 0.05% vitamin A (tretinoin) acid gel for the treatment of oral leukoplakia. Tretinoin was applied topically 4 times a day for the management of nonmalignant oral white lesions in 26 patients. The clinical response was evaluated in all patients and posttreatment biopsies were performed in ten patients.

RESULTS

The mean age of the patients at the time of diagnosis was 62 years. Of the 26 patients, 50% were tobacco users. Patients were followed for a mean of 23 months. Approximately 27% of the patients had a complete clinical remission. Recurrence of leukoplakia was observed in approximately 40% of patients in whom complete clinical remission occurred if topical applications were discontinued. A 50% reduction in the clinical grade of leukoplakia from a mean of 2.8 to 1.4 on a scale ranging from 0 (no leukoplakia) to 4 (speckled leukoplakia) was observed. When the pretreatment and posttreatment biopsies from 10 patients were evaluated, no change in the mean histologic grade (between mild and moderate dysplasia) was noted; however, some reduction in the histologic grade was noted in 3 of these patients (30%).

CONCLUSIONS

The use of topical vitamin A acid showed a limited effect in controlling oral leukoplakia. Further studies are needed to establish the appropriate indication, efficacy, and best choice for chemoprevention agents. Close follow-up of all patients with oral leukoplakia is required.

Oral mucositis in myelosuppressive cancer therapy

Because the etiology of mucositis is multifactorial , approaches to prevention and management have also been multifactorial. Effective prevention and management of mucositis will reduce the pain and suffering experienced during cancer treatment. Oropharyngeal pain in cancer patients frequently requires systemic analgesics, adjunctive medications, physical therapy, and psychologic therapy in addition to oral care and topical treatments. Good oral hygiene reduces the severity of oral mucositis and does not increase the risk of bacteremia. Current approaches to management include frequent oral rinsing with saline or bicarbonate rinses, maintaining excellent oral hygiene, and using topical anesthetics and analgesics. Cryotherapy is a potential adjunctive approach in some cases. There are a number of approaches that appear to represent viable candidates for further study. Biologic response modifiers offer the potential for prevention and for acceleration of healing. Various cytokines will enter clinical trials in the near future; these offer the potential for reduction of epithelial cell sensitivity to the toxic effects of cancer therapy or for stimulation of repair of the damaged tissue. Other approaches include the use of medications to reduce exposure of the oral mucosa to chemotherapeutic drugs that are secreted in saliva. Antimicrobial approaches have met with conflicting results, little effect being seen with chlorhexidine and systemic antimicrobials in the prevention of mucositis in radiation patients. In patients with BMT and patients with leukemia, chlorhexidine may not be effective in preventing mucositis, although there may be reduction in oral colonization by Candida. Initial studies of topical antimicrobials that affect the gram-negative oral flora have shown reductions in ulcerative mucositis during radiation therapy but have not been assessed in leukemia/BMT. Among other approaches that require further study are low-energy lasers and anti-inflammatory medications. These approaches to management have undergone initial study, but additional investigation is needed to determine their effectiveness with respect to the prevention of mucositis and symptom management and to determine appropriate doses and frequencies of intervention. Current studies and our increasing understanding of the pathogenesis of oral mucositis will lead to new approaches to management and improved quality of life for these patients.