Oral cancer awareness in North-Western Spain: a population-based study

Background

An early diagnosis depends greatly on patient awareness. Thus, the aim of this study was to investigate general awareness of oral cancer and knowledge about its risk factors, signs and symptoms.

Material and Methods

Cross-sectional population-based survey of randomly selected respondents conducted from March 1, 2015 to 30 June 2016.

Results

A total of 5,727 people entered the survey (response rate: 53%). When asked what cancers participants had heard about, 20.3% mentioned oral cancer. Regarding risk factors, tobacco was mentioned by 55.3% of the sample (n=3,169), followed by alcohol (12.5%; n=708), poor oral hygiene (10.8%; n=618), diet (6.5%; n=377), and genetics (4.5%; n=248).

Conclusions

General population has low awareness of oral cancer with poor knowledge of risk factors and main alarm signs. In addition, individuals in the risk group scored lower values in the main variables analysed; even those highly educated showed insufficient awareness and knowledge of oral cancer. In these circumstances, there is clear need for educational interventions tailored to the target audience and aimed at increasing knowledge and awareness of oral cancer to promote primary prevention of oral cancer and minimising the time interval of patients with symptomatic oral cancer in their path to treatment.

Key words:Oral cancer, awareness, risk factors, surveys and questionnaires, Spain.

Online audio-visual information on oral cancer for Spanish-speaking laypersons. A cross-sectional study

Background

Lack of knowledge and awareness of oral cancer seem to be the main causes of diagnostic delay. Online resources are often used by patients to obtain health/medical information. However, there are no reports on the quality and usefulness of oral cancer audio-visual resources in Spanish. The aims of this investigation were to disclose the type of information about oral cancer available, and whether it may be useful to shorten the patients’ oral cancer appraisal time-interval.

Material and Methods

Cross-sectional study undertaken at three video-sharing sites on October, 13th 2019. Keywords: “Cáncer oral”; “cáncer de boca”. The first 100 results in each viewing list were retrieved by three reviewers. Demographical data was recorded, and interaction indexes, viewing rates, comprehensiveness, and usefulness were calculated for each video. The presence of non-scientifically supported information was also assessed. A descriptive analysis was undertaken, and relationships between variables were explored using the Spearman correlation test.

Results

A total of 127 videos were selected. They were produced mainly by mass-media (46.5%; n=59) and their length ranged from 0.28 to 105.38 minutes (median 4.15 minutes; IQR: 2.34-9.67). The most viewed video (10,599,765 views; visualization rate 726,508.9) scored 0 both in usefulness and comprehensiveness. The most useful video gathered 44,119 views (visualization rate 2.033.13). A highly significant positive correlation (0.643; p<0.001) could be observed between usefulness and comprehensiveness of the videos, together with negative correlations between the visualization rate and usefulness (-0.186; p<0.05), and visualization rate and comprehensiveness (-0.183; p<0.05).

Conclusions

Online audio-visual material about oral cancer in Spanish is incomplete, of limited usefulness, and often includes non-scientifically supported information. Most of these resources are produced by mass media and healthcare professionals, with minor contributions from educational and healthcare institutions. Visualization rates negatively correlated with the usefulness and comprehensiveness of the contents in these digital objects.

Key words:Oral cancer, diagnostic delay, patient education, internet, audio-visual resources, Spanish.

People would rather see a physician than a dentist when experiencing a long-standing oral ulceration. A population-based study in Spain

BACKGROUND

Primary care physicians have been reported to be the first choice for patients with oral ulcerations. This study investigates the health-seeking behaviour of lay public in Galicia (North-western Spain) if experiencing a long-standing oral ulceration.

MATERIAL AND METHODS

Cross-sectional population-based survey of randomly selected respondents conducted from March 1, 2015 to 30 June 2016.

RESULTS

A total of 5,727 pedestrians entered the study (response rate: 53%), mostly in the 45-64 age group (30.2%; n=1,728), 47.7% of them (n=2,729) were males. Most participants (42.1%; n=2,411) reported to visit their dentist once a year and had secondary or compulsory education as their highest educational achievement (28.18%, n=1,614; 28%, n=1,600 respectively). When questioned what they would do if they had a wound/ulceration lasting longer than 3 weeks, most participants answered they would go to see their primary care physician (62.8%; n=3,597) and less than one quarter of the sample (23.8%; n=1,371) would seek consultation with their dentist.

CONCLUSIONS

General Galician population would seek professional consultation about a long-standing oral ulceration, relying mostly on primary care physicians. Those neglecting these lesions are elderly, less-schooled people and unaware of oral cancer.

Therapeutic approaches for actinic cheilitis: therapeutic efficacy and malignant transformation after treatment

Actinic cheilitis (AC) is a sun-induced premalignant lesion. AC is a clinical term housing a wide pathological spectrum ranging from hyperkeratosis to invasive squamous cell carcinoma. The aim of this systematic review was to examine the therapeutic efficacy of different approaches in clinical, histological, and cosmetic terms, and the malignization rate after treatment. A systematic search was undertaken in October 2016 and updated in April 2019 at MEDLINE (from 1966), Embase (from 1980), and Proceedings Web of Science (Conference Proceedings Citation Index-Science (CPCI-S) from 1990) databases. The search strategy was (("actinic" or "solar") AND ("cheilitis")) using both medical subject headings (MeSH) and freetext. A total of 392 potentially eligible reports were identified. After the selection procedure, 20 articles were included. It was concluded that surgical treatment is the first line of treatment for AC and has proved useful for the clinical and pathological control of the disorder. However, there was no evidence of effective treatment in preventing malignant transformations. Non-surgical procedures showed less consistent results, although drug therapy may improve the results obtained by other therapeutic approaches.

Oral mucosal peeling related to dentifrices and mouthwashes: A systematic review

Background

The aim of this systematic review was to summarise the clinical information available about oral mucosal peeling (OMP) and to explore its aetiopathogenic association with dentifrices and mouthwashes.

Material and Methods

PICOS outline: Population: subjects diagnosed clinically and/or pathologically. Intervention: exposition to oral hygiene products. Comparisons: patients using products at different concentrations. Outcomes: clinicopathological outcomes (primary) and oral epithelial desquamation (secondary) after use. Study design: any. Exclusion criteria: reports on secondary or unpublished data, in vitro studies. Data were independently extracted by two reviewers.

Results

Fifteen reports were selected from 410 identified. Descriptive studies mainly showed low bias risk, experimental studies mostly an “unclear risk”. Dentifrices or mouthwashes were linked to OMP, with an unknown origin in 5 subjects. Sodium lauryl-sulphate (SLS) was behind this disorder in 21 subjects, tartar-control dentifrices in 2, and flavouring agents in 1 case. Desquamation extension was linked to SLS concentration. Most cases were painless, leaving normal mucosa after desquamation. Tartar-control dentifrices caused ulcerations more frequently.

Conclusions

OMP management should consider differential diagnosis with oral desquamative lesions, particularly desquamative gingivitis, with a guided clinical interview together with pathological confirmation while discouraging the use of the product responsible for OMP.

Key words:Systematic review, oral mucosal peeling, dentifrices, sodium lauryl-sulphate, oral hygiene products.

Quality of cross-infection control in dental laboratories. A critical systematic review

Purpose

To identify reported practices for cross-infection control in dental laboratories and to quantify the importance of the flaws encountered.

Data sources

Systematic search (cross-infection AND dental laboratory) at EMBASE, PubMed, SciELO and Scopus databases.

Study selection

Papers reporting on cross-sectional studies providing original data about cross-infection knowledge, practices and attitudes of dental technicians. Papers reporting on a single laboratory or institution were excluded.

Data extraction

Data extraction was undertaken independently by three reviewers using a purpose made form. The outcome of this study was analyzed in five aspects, namely process organization, disinfection, working environment, use of individual protective equipment and vaccination policy.

Results of data synthesis

The systematic search output was 1651 references and 11 papers were finally selected. Flaws were more frequently identified in terms of vaccination policy, biological safety of the working environment and use of individual protective equipment (100%). Slightly better results were found in terms of organization of the cross-infection control process (89.47%) and disinfection practices (85.71%). The application of the formula for disclosing the relative importance of the flaws identified in the literature prioritizes the need for interventions aimed at improving the organization of the cross-infection control procedures, followed by training in item disinfection. The control of the working environment together with the use of individual protective equipments rank closely in importance, followed by the existence of a vaccination policy.

Conclusions

Sub-standard cross-contamination practices seem to be a common finding in dental laboratories, which may well compromise the quality of certain dental treatments.

Shorter specialist time intervals are associated with advanced stage on symptomatic oral cancer

OBJECTIVES

As longer times from the first symptom to diagnosis and treatment of oral cancers have been linked to poorer outcomes, this study investigates the contribution of the specialist to this time (STI).

SUBJECTS AND METHODS

A series of 228 oral/oropharyngeal squamous cell carcinoma patients were retrospectively studied to determine the STI and its related factors.

RESULTS

Patients were mostly males (n = 170; 74.5%), (50.7% stages I-II), mean age = 61.4 ± 12.5 years. The STI median was 6 days (X±SD:6.8 ± 5.6 days). Time first symptom to diagnosis was 64 days (X±SD:91.0 ± 84.6 days). Univariate regression unveiled a significant association between STI and TNM stage, which was confirmed by multivariate regression.

CONCLUSIONS

Specialist time interval is a short time interval in oral cancer diagnosis, imposing a limited time burden in the context of the whole interval until diagnosis. However, there seems to be room for improvement and a possible target for future interventions to shorten STI particularly for patients at early stages after their disease has been disclosed.

The length of patient and primary care time interval in the pathways to treatment in symptomatic oral cancer. A quantitative systematic review

OBJECTIVES

To examine the relative length of the patient and primary care intervals in symptomatic oral cancer.

DESIGN

Quantitative systematic review.

SEARCH STRATEGY

Oral cancer OR oral squamous cell carcinoma OR oropharyngeal cancer AND time interval OR diagnostic delay.

SETTING

Primary and secondary care.

PARTICIPANTS

Oral and oropharyngeal cancer patients.

MAIN OUTCOME MEASURES

We computed five measures (patient, primary care, diagnosis, total diagnosis and total treatment intervals). Most studies did not provide any dispersion measure. We then used the sample size of each study to compute a weighted average of the mean intervals. When the median was provided, we assumed normality of the distribution of the means and used the median as a proxy of the mean.

RESULTS

A total of 1089 articles were identified, and 22 met the inclusion criteria, reporting on 2710 patients from Europe, USA, India, Australia, Japan, Argentina and Iran. The weighted average of patient interval was 80.3 days. Primary care interval was five times shorter: 15.8 days. The diagnostic interval was appreciably shorter (47.9 days) when compared with the patient interval during symptomatic period.

CONCLUSIONS

Patient interval represents the major component of waiting times since the detection of the first signs/symptoms to the definitive diagnosis of oral cancer. Thus, strategies focused on high-risk patients should be prioritised. Interventions aimed at optimising the health systems should be implemented by monitoring and facilitating diagnostic and treatment pathways of patients with oral cancer.

Assessment of time intervals in the pathway to oral cancer diagnosis in north-westerm Spain. Relative contribution of patient interval

BACKGROUND

Despite continuous advances in diagnosis and therapy, oral cancers are mostly diagnosed at advanced stages with minor survival improvements in the last two decades. Both phenomena have been attributed to delays in the diagnosis. This study aims at quantifying the time elapsed until definitive diagnosis in these patients and the patient interval's contribution.

MATERIAL AND METHODS

A hospital-based, ambispective, observational study was undertaken on incident cases with a pathological diagnosis of oral squamous cell carcinoma recruited during 2015 at the Oral and Maxillofacial Surgery services of CHUAC (A Coruña) and POVISA (Vigo) hospitals.

RESULTS

74 consecutive oral cancer patients (59.5% males; median age: 65.0 years (IQ:57-74)) were studied. Most cases (52.7%; n=39) were at advanced stages (TNM III-IV) at diagnosis. The period since first sign/symptom until the patient seeks health care was the longest interval in the pathway to diagnosis and treatment (median: 31.5 days; IQR= 7.0 - 61.0) and represents >60% of the interval since symptom onset until referral to specialised care (pre-referral interval). The average interval assigned to the patient resulted to be relatively larger than the time elapsed since the patient is seen at primary care until a definitive diagnosis is reached (diagnostic interval). Median of the referral interval for primary care professionals: 6.5 days (IQR= 0.0 - 49.2) and accounts for 35% (19% - 51%) of the diagnostic interval.

CONCLUSIONS

The patient interval is the main component of the pathway to treatment since the detection of a bodily change until the definitive diagnosis. Therefore, strategies focused on risk groups to shorten this interval should be implemented in order to ease an early diagnosis of symptomatic oral cancer.

Diameter of alveolar antral artery in the lateral sinus wall: study of related factors

To identify the variables that influence the diameter of the artery in the lateral sinus wall, we studied 240 sinuses, focusing on sex, pattern of tooth loss, type of residual crest, thickness of the lateral wall, height and width of the ridge, and width of the sinus.

Distance of the alveolar antral artery from the alveolar crest. Related factors and surgical considerations in sinus floor elevation

Background

In a variable proportion of maxillary sinuses alveolar antral artery is located close to the residual ridge, increasing the chances for haemorrhagic complications during sinus floor elevation procedures.

Material and Methods

Retrospective observational study of CBCT explorations performed for implant-treatment planning. The upper first molar area was selected for this study. The relative uncertainty (standard deviation of the measurement divided by its mean and expressed as a percentage from 0% to 100%) was chosen for determining the observational errors. For modeling the chances of AAA detection, the generalized additive models (GAM) approach was chosen.

Results

A total of 240 maxillary sinuses were studied (46.25% males) whose median median age was 58 years old (IQR: 52-66). Univariate models showed that the chances for an AAA-alvelar crest distance ≤15mm increase in wider sinuses with lower, subsinusally edentulous crests. When distance is considered as a continuous variable, the best mutivariate model showed an explained deviance of 67% and included AAA diameter, distance AAA-sinus floor, sinus width, and shape, height and width of the residual ridge. Thinner AAAs are found closer to the crest (within the ≤15mm safe distance).

Conclusions

Bearing in mind the inclusion criteria and the limitations of this investigation, it is concluded that there is a high proportion of maxillary sinuses where AAA describes a course close to the alveolar crest (≤15mm), which was classically considered a safe distance for SFE. This position is related to the presence of atrophic crests (depressed ridge form) and wide maxillary sinuses where the distance of the vessel to the floor of the sinus is small. This information may permit a better surgical planning of SFE procedures.

Key words:Cone-beam computed tomography, blood vessels, sinus floor augmentation, intraoperative complications.

Key points and time intervals for early diagnosis in symptomatic oral cancer: a systematic review

The aim of this study was to identify key points and time intervals in the patient pathway to the diagnosis of oral cancer, from the detection of a bodily change to the start of treatment. A systematic search of three databases was performed by two researchers independently. Articles reporting original data on patients with symptomatic primary oral or oropharyngeal squamous cell carcinoma that was pathologically confirmed were included. These articles had to include an outcome variable of 'diagnostic delay', 'time interval', or 'waiting time to diagnosis', or report time intervals from first symptom to treatment. Furthermore, the outcome variable had to have a clearly defined start point and end point, with the time measurement presented as a continuous or categorical variable. A total of 1175 reports were identified; 28 articles on oral cancer studies and 13 on oral and oropharyngeal cancer studies were finally included. These papers showed poor quality in terms of questionnaire validation, acknowledgement of biases influencing time-point measurements, and strategies for verification of patient self-reported data. They also showed great heterogeneity. The review findings allowed the definition of key points and time intervals within the Aarhus framework that may better suit the features of the diagnostic process of this neoplasm, particularly when assessing the impact of waiting time to diagnosis.

[Update in family medicine: Periodontal disease]

About 85-94% of the Spanish adults older than 35 experience gum problems, and about 15-30% suffer from periodontitis, being severe in up to 5-11% of them. Unlike other inflammatory conditions, periodontal disease rarely causes discomfort, or limits life or causes functional limitations until its advanced stages, when clinical signs and symptoms arise (gingival recession, pathological teeth migration, or mobility). Lack of knowledge about the disease, together with the idea that tooth loss is linked to ageing, frequently results in a late diagnosis, requiring extensive treatments with a worse prognosis. At Primary Care level, there is series of drugs have been related to periodontal disease (anticonvulsants, immunosuppressive drugs, and calcium channel blockers) as secondary effects, which vary as regards their frequency and severity depending of the amount of accumulated plaque. Stress and depression have also been reported to alter the immune response and to increase the inflammatory response as well as periodontal susceptibility. Certain systemic conditions, such as diabetes mellitus, cardiovascular disorders, respiratory diseases, as well as low-weight pre-term birth, have also been linked to periodontitis.

Detection of the posterior superior alveolar artery in the lateral sinus wall using computed tomography/cone beam computed tomography: a prevalence meta-analysis study and systematic review

A systematic search of MEDLINE, Embase, and Proceedings Web of Science was undertaken to assess the prevalence of the posterior superior alveolar artery (PSAA) in the lateral sinus wall in sinus lift patients, as identified using computed tomography (CT)/cone beam computed tomography (CBCT). For inclusion, the article had to report PSAA detection in the bony wall using CT and/or CBCT in patients with subsinus edentulism. Studies on post-mortem findings, mixed samples (living and cadaveric), those presenting pooled results only, or studies performed for a sinus pathology were excluded. Heterogeneity was checked using an adapted version of the DerSimonian and Laird Q test, and quantified by calculating the proportion of the total variance due to between-study variance (Ri statistic). Eight hundred and eleven single papers were reviewed and filtered according to the inclusion/exclusion criteria. Ten studies were selected (1647 patients and 2740 maxillary sinuses (study unit)). The pooled prevalence of PSAA was 62.02 (95% confidence interval (CI) 46.33-77.71). CBCT studies detected PSAA more frequently (78.12, 95% CI 61.25-94.98) than CT studies (51.19, 95% CI 42.33-60.05). Conventional CT revealed thicker arteries than CBCT. It is concluded that PSAA detection is more frequent when CBCT explorations are used. Additional comparative studies controlling for potential confounding factors are needed to ascertain the actual diagnostic value of radiographic explorations for assessing the PSAA prior to sinus floor elevation procedures.

Er,CR:YSGG lasers induce fewer dysplastic-like epithelial artefacts than CO2 lasers: an in vivo experimental study on oral mucosa

Our aim was to assess wounds made by lasers (CO(2) and Er,Cr:YSGG) for their epithelial architectural changes and width of damage. We allocated 60 Sprague-Dawley(®) rats into groups: glossectomy by CO(2) laser at 3 different wattages (n=10 in each); glossectomy by Er,Cr:YSGG laser at two different emissions (n=10 in each), and a control group (n=10). Histological examination assessed both prevalence and site of thermal artefacts for each group. Both lasers (CO(2) and Er,Cr:YSGG) caused the same type of cytological artefacts. The 3W Er,Cr:YSGG laser produced the fewest cytological artefacts/specimen, and was significantly different from the other experimental groups: 3W CO(2) laser (95% CI=0.8 to 1.0); the 6W CO(2) laser (95% CI=0.1 to 2.0) and the 10W CO(2) laser (95% CI=1.1 to 3.0). CO(2) lasers (3-10W) generate epithelial damage that can simulate dysplastic changes with cytological atypia that affects mainly the basal and suprabasal layers. Irradiation with Er,CR:YSGG laser (2-4W) produces significantly fewer cellular artefacts and less epithelial damage, which may be potentially useful for biopsy of oral mucosa.

Stomatology and odontology: perspectives of Spanish professors and senior lecturers in dentistry

The curricula of dental faculties in many countries of the European Union can be described as odontological. The faculties of some of the countries who have become and are becoming members of the European Community have traditionally educated dentists in the stomatological tradition. In 1987, the Spanish dental education system initiated movement from the stomatological model to the odontological. Both models have their respective strengths and weaknesses. This study surveyed professors and senior lecturers in Spain's public dental faculties to assess their perspectives on 10 items related to the tension between the odontological and the stomatological approach to preparing dentists. Amongst other things, the results of the study indicate that the respondents believe the odontological model, with its emphasis on strengthening technical qualifications, may not prepare individuals for dental practice better than the stomatology tradition; and that the odontological model results in the loss of the strength of the stomatological model, that is, the strong foundation in clinical medicine. The suggestion is advanced that European dental educators consider revising the odontology curriculum to strengthen the education of dental students in clinical medicine. A curriculum in which dental and medical students share the first 3 years of study could accomplish this. It is further suggested that subsequent years in the curriculum be flexible enough for students to earn degrees in both dentistry and medicine, if desired. Such an approach is not inconsistent with the accepted profile and competencies of the European dentist.

Oral cancer: experiences and diagnostic abilities elicited by dentists in North-western Spain

BACKGROUND

Opinions, knowledge, behaviours and attitudes of general dental practitioners on oral cancer prevention and detection have been reported from many countries. However, experiences and skills of oral cancer detection have not been evaluated systematically.

OBJECTIVE

To obtain information on behaviours of screening and ability to correctly detect oral cancer and precancer among general dentists (GDP) in North-western Spain.

SUBJECTS AND METHODS

Thirty-two randomly selected GDPs completed questionnaires and then classified 50 projected images of clinical lesions, into cancer, precancer or benign lesions.

RESULTS

87.5% reported conducting routine oral examinations, 84.4% provided routine advice to their subjects for risk modifications and 84.4% claimed to biopsy a suspected oral mucosal lesion that they detected in practice. In a quasi research setting using clinical slides, the sensitivity of visual diagnosis of a cancerous lesion was 61.4% and precancer 59.5%. The diagnostic accuracy reported here is lower than what is already reported by evaluation of published screening programmes by dentists.

CONCLUSIONS

Our data from Spain suggest a need for improving the diagnostic ability of GDPs in the visual detection of oral cancer/precancer by strengthening continuing professional education.

"Scheduling delay" in oral cancer diagnosis: a new protagonist

Diagnostic delays in oral cancer have been classified as "patient delay" and "delay by the clinicians". However, the influence of the accessibility (scheduling delay) to the health care system in oral cancer diagnosis has not been studied before. To assess scheduling delay, a descriptive, cross-sectional study was designed. This study was based upon role-play telephone conversations with two standardised patients (lingual ulceration-SP1 and patient seeking fixed prosthodontics-SP2). that followed a structured script. The variables considered in the study were days to go until the arranged appointment, professional degree of the contacted person and referral to other provider of care. The scheduling delay for SP1 reached a median value of 1 day, and for SP2 was 6 days. When the professional degree (receptionist vs GDP) of the person arranging the appointment for the patient with lingual ulceration was considered, the scheduling delay was significantly shorter when the appointment was fixed by the GDP (X approximately i-X approximately j=4.5; 95%CI=-7.48,-1.51). GDPs gave priority to the patients with lingual ulcerations over those demanding fixed bridgework (X approximately i-X approximately j=6.48; 95%CI=-9.46,-3.50). The GDPs showed a high level of awareness of the oral cancer, however, educational interventions seem to be necessary for dental surgery receptionists.

Expression of heat shock protein (HSP70) in oral lichen planus and non-dysplastic oral leucoplakia

The purpose of this study was to investigate the expression of heat shock protein (HSP70) in oral non-dysplastic leucoplakia and in relation to the clinical and pathological features of oral lichen planus. The expression of HSP70 was assessed in the epithelial compartment of normal mucosa (n = 5), oral lichen planus (n = 28) and benign leucoplakia (n = 11) using an immunohistochemical method. The immunostaining intensity distribution (IID) index was used to quantify the positivity of the staining. There was no association between HSP70 overexpression and clinical presentation of oral lichen planus. Oral lichen planus patients showed no statistically significant differences in the depth of the inflammatory infiltrate when expression of HSP70 was considered (X(i)- X(j) = 42.30; 95% confidence interval (95% CI) = -120.87-205.48). No statistically significant differences were identified in terms of HSP70 expression between oral lichen planus and normal buccal mucosal specimens (X(i)- X(j) = 4.07; 95% CI = -0.53-8.67). The IID index score for HSP70 expression in leucoplakia specimens was significantly higher than the one of the oral lichen planus group (X(i) - X(j)= 5.11; 95% CI = 1.73-8.48). It is concluded that there are no statistically significant differences in HSP70 expression between oral lichen planus and normal buccal mucosal specimens, suggesting that HSP70 does not play an obvious part in the pathogenesis of oral lichen planus. The expression of HSP70 was significantly higher in oral leucoplakia than in oral lichen planus, possibly because of differences in cellular activity or cell proliferation.

Artefacts produced by suture traction during incisional biopsy of oral lesions

The aim of this study is to compare the artefacts ascribed to the technique of incisional biopsy using a punch or scalpel and the influence of suture use for traction and delivery of the specimen. A total of 160 samples were obtained from 10 fresh pig tongues by four experienced oral surgeons. Handling artefacts (squeeze artefacts): crush, splits, fragmentation and pseudocysts were assessed. No differences were identified in terms of crush, fragmentation or pseudocysts between samples obtained with a punch or scalpel. Splits were more frequent in those biopsies taken with a scalpel (chi2 = 9.26; P= 0.0023). Artefacts in the punch biopsy group were significantly less than in the group that combined punch and suture traction (P < 0.01). The scalpel and suture traction group showed significantly more artefacts than the group without suture. It is concluded the use of a stitch for traction in small incisional biopsies causes squeeze artefacts, so its use should be restricted to specimen orientation.

Concordance between undergraduate dental students and their lecturers in their attitudes towards difficult patients

The 'difficult' patient syndrome is caused by an imbalance in the dentist-patient relationship which may be influenced by human, cultural and psychosocial factors. The aim of this study was to compare the concordance between undergraduate dental students and lecturers in the degree of difficulty assigned to vignettes describing 'difficult' patients and to describe the extent to which ratings are influenced by gender, place of study and experience of specific 'difficult' patients. A questionnaire with 21 patient-stereotypes identified as difficult from the specialized literature was prepared. Both students and lecturers had to determine the degree of difficulty of each stereotype on a Likert-like scale. The students selected were in the final 2 years before graduation in Santiago de Compostela (Spain) and Porto (Portugal) Dental Schools. Lecturers were selected by simple random sampling method. Both lecturers and undergraduate students found more difficulty in those patients classified as aggressive, manipulative help-rejecters or patients with invasive companions. On the other hand, drug abusers and HIV-positive patients were ranked as presenting low levels of difficulty. Our results seem to point to the need of improving undergraduate teaching and learning of specific procedures for the management of aggressive or stubborn patients and those with invasive companions.

Prevalence of diabetes mellitus amongst oral lichen planus patients. Clinical and pathological characteristics

OBJECTIVES

The aim of this study has been to define the prevalence of DM (considered according to the ADA-97 criteria) in OLP patients and also to investigate the existence of clinical and pathological differences between OLP patients with or without DM.

STUDY DESIGN

Sixty-two patients suffering from OLP according to clinical and pathological criteria were selected to enter the study and classified after the DM diagnosis guidelines suggested by The American Diabetes Association (ADA-1997). The variables considered for each patient were: age, sex, clinical presentation, extension of the lesions, location of the lesions, number of locations, Candida albicans colonization, and density of subepithelial inflammatory infiltrate.

RESULTS

Up to 27.4% of OLP cases were associated to type 2 DM (DM2) and 17.7% were related to an impaired fasting glucose (IFG). The mean age of the DM2-associated OLP group was significantly higher than the non-diabetic group's. No significant differences could be observed in terms of clinical and pathological features between diabetic and non-diabetic OLP patients.

CONCLUSION

The high prevalence of hydrocarbonate metabolism disorders observed in OLP patients justify the use of FPG for screening of DM2 in these patients.

Clinical and pathological characteristics of oral lichen planus in hepatitis C-positive and -negative patients

The reported prevalence rate of anti-hepatitis C virus (HCV) antibodies in patients with oral lichen planus shows wide geographical variation and ranges from 0 to 65%. Certain characteristic clinical features have been attributed to oral lichen planus associated to HCV infection. The purpose of this investigation has been to assess hypothetical clinical differences, as well as differences in the intensity of the subepithelial inflammatory infiltrate between oral lichen planus-HCV +ve patients and oral lichen planus-HCV -ve patients. A total of sixty-two patients entered the study. Their mean age was 63.5 +/- 14.49 years, and 48.4% of them were men and 51.6% women. Patients were classified according to their serum HCV positivity. Age, sex, clinical presentation (reticular or atrophic-erosive), extension of the lesions, location of the lesions, number of locations affected, intensity of the inflammatory infiltrate and Candida albicans colonization were recorded for each patient. Reticular lichen planus was the most frequent clinical presentation in both HCV +ve (57.1%) and HCV -ve patients (63.6%). C. albicans colonization ranged from 42.8% in HCV +ve and 41.7% in HCV -ve patients. HCV + ve patients showed certain oral locations more frequently affected than HCV -ve ones: lip mucosa, 28.6% versus 7.3%; tongue, 57.1% versus 29.1%; and gingiva, 71.4% versus 23.6%. The number of affected intraoral locations was higher in HCV +ve patients (71.4%) than among HCV -ve ones (20.4%; chi2 = 8.34; P < 0.011). No statistically significant differences could be established in terms of density of subepithelial inflammatory infiltrate between the groups. Our results reinforce the need for liver examination in all patients with oral lichen planus, particularly those showing lesions on the gingiva with multiple intraoral locations affected, as no pathological differences could be identified between HCV + ve and HCV -ve patients.