Role of medical history and medication use in the aetiology of upper aerodigestive tract cancers in Europe: the ARCAGE study

BACKGROUND

The study aimed to investigate the role of medical history (skin warts, Candida albicans, herpetic lesions, heartburn, regurgitation) and medication use (for heartburn; for regurgitation; aspirin) in the aetiology of upper aerodigestive tract (UADT) cancer.

METHODS

A multicentre (10 European countries) case-control study [Alcohol-Related CAncers and GEnetic susceptibility (ARCAGE) project].

RESULTS

There were 1779 cases of UADT cancer and 1993 controls. History of warts or C. albicans infection was associated with a reduced risk [odds ratio (OR) 0.80, 95% confidence interval (CI) 0.68-0.94 and OR 0.73, 95% CI 0.60-0.89, respectively] but there was no association with herpetic lesions, heartburn, regurgitation or medication for related symptoms. Regurgitation was associated with an increased risk for cancer of the oesophagus (OR 1.47, 95% CI 0.98-2.21). Regular aspirin use was not associated with risk of UADT cancer overall but was associated with a reduced risk for cancer of oesophagus (OR 0.51, 95% CI 0.28-0.96), hypopharynx (OR 0.53, 95% CI 0.28-1.02) and larynx (OR 0.74, 95% CI 0.54-1.01).

CONCLUSIONS

A history of some infections appears to be a marker for decreased risk of UADT cancer. The role of medical history and medication use varied by UADT subsites with aspirin use associated with a decreased risk of oesophageal cancer and suggestive of a decreased risk of hypopharyngeal and laryngeal cancers.

Socioeconomic factors associated with risk of upper aerodigestive tract cancer in Europe

INTRODUCTION

In the European Union, there are 180,000 new cases of upper aerodigestive tract (UADT) cancer cases per year--more than half of whom will die of the disease. Socioeconomic inequalities in UADT cancer incidence are recognised across Europe. We aimed to assess the components of socioeconomic risk both independently and through their influence on the known behavioural risk factors of smoking, alcohol consumption and diet.

PATIENTS AND METHODS

A multicentre case-control study with 2198 cases of UADT cancer and 2141 controls from hospital and population sources was undertaken involving 14 centres from 10 countries. Personal interviews collected information on demographics, lifetime occupation history, smoking, alcohol consumption and diet. Socioeconomic status was measured by education, occupational social class and unemployment. Odds ratios (ORs) and 95% confidence intervals (CIs) were computed using unconditional logistic regression.

RESULTS

When controlling for age, sex and centre significantly increased risks for UADT cancer were observed for those with low versus high educational attainment OR=1.98 (95% CI 1.67, 2.36). Similarly, for occupational socioeconomic indicators--comparing the lowest versus highest International Socio-Economic Index (ISEI) quartile for the longest occupation gave OR=1.60 (1.28, 2.00); and for unemployment OR=1.64 (1.24, 2.17). Statistical significance remained for low education when adjusting for smoking, alcohol and diet behaviours OR=1.29 (1.06, 1.57) in the multivariate analysis. Inequalities were observed only among men but not among women and were greater among those in the British Isles and Eastern European countries than in Southern and Central/Northern European countries. Associations were broadly consistent for subsite and source of controls (hospital and community).

CONCLUSION

Socioeconomic inequalities for UADT cancers are only observed among men and are not totally explained by smoking, alcohol drinking and diet.

The reported prevalence of oral lichen planus: a review and critique

OBJECTIVE

To examine all studies reporting prevalences of oral lichen planus (OLP) for epidemiological validity and to extract prevalence data from the valid papers.

DESIGN

Computer based literature searches were carried out using the MeSH headings 'lichen planus, oral and (prevalence or incidence)' and were supplemented by manual searching.

MAIN OUTCOME MEASURES

Each paper was examined for five criteria: clinic-based or population study, adequate demographic description (by sex and age group) of the population, adequate demographic description of the sample (if the population was sampled), adequate demographic description of the OLP cases identified, and histological confirmation of the clinical diagnosis.

RESULTS

Forty-five relevant papers were identified, 21 clinic-based and 24 population studies. All but one of the population studies was deficient. One study, while having some defects, was probably sufficiently valid to permit the findings to be regarded as useful. An overall age-standardized prevalence of 1.27% (0.96% in men and 1.57% in women) can be calculated from this study.

CONCLUSIONS

There appears to be only one usable prevalence study of OLP. Other large-scale studies are required in other populations. Such studies need to distinguish between OLP and lichenoid reactions.

Policies and practices of European dental schools in relation to smoking; a ten-year follow-up

OBJECTIVE

To investigate the policies and practices of European dental schools in relation to smoking as a ten-year follow-up.

DESIGN

A postal survey questionnaire.

SETTING

European dental schools in 2003.

MATERIALS AND METHODS

Two hundred and one European dental schools were identified from the DentEd database. A postal questionnaire was sent to each with up to three follow-up letters to non-responders.

MAIN OUTCOME MEASURES

Results were tabulated and compared with the previous study (1993).

RESULTS

The effective response rate (allowing for errors in the database) was 149 of 199 schools (72%). Eighty schools (59%) had written tobacco policies, 132 (92%) banned smoking in clinical areas, 127 (89%) in non-clinical areas and 122 (85%) in public access areas. One hundred and seven (76%) expected students to take tobacco histories from all patients, while 79 (69%) and 100 (70%) respectively taught students anti-smoking advice and expected them to give such advice. The number of schools teaching the role of tobacco in oral cancer aetiology was 133 (93%), in periodontal disease was 135 (94%) and in osseointegrated implant failure was 127 (91%). There was considerable regional variation between northern, southern and eastern Europe. Direct comparison of the responses of the 78 schools that replied in both 1993 and 2003 showed some improvements in most of their policies and practices. However, there was some deterioration in the practices of southern European schools.

CONCLUSIONS

While improvements were seen in the practices of most schools, comparison with recent US data suggests that European schools lag behind. However, self-selection of respondents may have introduced bias into the results.

Regional variations in oral cancer incidence in Ireland

Oral cancer has anecdotally been held to have a regional distribution in Ireland, with higher incidence rates in western areas. The first all-Ireland data sets on oral cancer incidence rates were recently published by cancer registries in Northern Ireland and the Republic of Ireland, for the years 1994-1998 and 1994-1997 respectively. The objective of this study was to analyse these rates according to the 12 health administrative regions on the island of Ireland. All rates were standardised to the world population using standard methodology, and were examined separately for lip, intra-oral, salivary and pharyngeal cancers for men and for women. Rates were mapped to highlight any regional variations. In general, the anecdotal evidence for higher incidences in the west of Ireland has not been borne out, except for lip cancers in men, which in turn is reflected in the slight western preponderance in the distribution of all oral cancers. The incidences of intra-oral cancers in both men and women were highest in the regions that include the two large conurbations (Belfast and Dublin). We conclude that the anecdotal evidence for a higher incidence of oral cancer in the west of Ireland was probably based on the distorting effect of the high incidences of lip cancer in men in these regions.

Periapical status and quality of endodontic treatment in an adult Irish population

AIM

To determine the prevalence of apical periodontitis and the quality of root fillings in an adult Irish population using a retrospective analysis of orthopantomograms (OPGs).

METHODOLOGY

A systematic sample of clinical records and OPGs of 302 adult patients attending the Dublin Dental Hospital, Ireland, were screened by two examiners to determine the quality of root canal treatment and the prevalence of apical periodontitis. The operators who carried out the treatment were unknown. Two examiners inspected OPGs after inter-examiner correlation. European Society of Endodontology (ESE) guidelines were used to determine adequacy of root treatment.

RESULTS

Of the 7427 teeth examined 2% had root fillings. Apical periodontitis was evident in 1.6% of all nonroot filled teeth whilst 33.1% of the subjects had at least one tooth with apical periodontitis. Of the root filled teeth, 25% had apical periodontitis and 52.6% were considered technically inadequate by ESE guidelines. There was a statistically significant (P < 0.05) negative correlation between the quality of the root fillings and the prevalence of apical periodontitis. Posterior root filled teeth (premolars and molars) had a greater prevalence of apical periodontitis than anterior root filled teeth.

CONCLUSIONS

The technical quality of root fillings in an adult Irish population was poor and was consistent with a high prevalence of apical periodontitis.

Personality of dental students in two dental schools in the United Kingdom and in Ireland

The personality characteristics of students from two dental schools, one in the United Kingdom which admitted students using interviews, and one in Ireland which accepted students solely on examination results, were assessed using the short form of the Eysenck Personality Questionnaire. Results were compared with norms for age and sex. Personality scores of students from the Irish dental school were not significantly different from normal scores. Female and male students from the United Kingdom school scored higher than would be expected on extraversion, and male students from the same school scored lower than would be expected on neuroticism. The differences in personality between the two schools may be explained by the different methods of admission.

Patient satisfaction in an emergency dental clinic

OBJECTIVES

Attendance at emergency clinics may be accompanied by extensive waiting times and frustration and may not result in patients obtaining the treatment which they expected. The objective of the study was to ascertain patient satisfaction with the overall provision of day time emergency services in a university dental teaching hospital, for quality assurance purposes.

METHODS

Patients (or persons accompanying child patients) attending the clinic, selected according to a sampling frame designed to identify approximately 10 per cent of attendees, completed a questionnaire.

RESULTS

High levels of patient satisfaction were found; 17 of 24 questions scoring satisfaction on a scale 1-5 had median scores of 5, six had median scores of 4 and one had a median score of 3. The lower scores related mostly to patient facilities rather than treatment.

CONCLUSIONS

Overall patient satisfaction with their dental A & E experience has been extremely positive, probably attributable to a well motivated staff using a team approach.

Patients' pain experience following oral mucosal biopsy under local anaesthesia

OBJECTIVE

To examine the incidence and severity of post-operative pain and use of analgesics following biopsy of oral mucosal lesions.

DESIGN

A patient survey using a self-completed pain diary.

SUBJECTS AND METHODS

Seventy-six patients attending an oral medicine clinic for investigation of oral mucosal disease recorded overall and worst pain experiences and analgesic usage over 7 post-operative days following biopsy using visual analogue scales in patient completed diaries.

RESULTS

One third of patients reported no post-operative pain on any day. Most patients recorded no pain or mild pain. The percentage experiencing pain dropped from the first day (61%) to the seventh day (21%). Most patients did not use any analgesics. Analgesic use was not related to the presence of pain. Only a small minority of patients recorded severe pain.

CONCLUSION

Biopsy of oral mucosal lesions does not cause undue pain in most patients.

Lichen planus--specific antigen in oral lichen planus and oral lichenoid drug eruptions

OBJECTIVE

To investigate the usefulness of lichen planus-specific antigen as a marker to distinguish idiopathic oral lichen planus from oral lichenoid drug eruptions.

STUDY DESIGN

Biopsy samples were taken from 6 patients with oral lichenoid drug eruptions and 6 patients with idiopathic oral lichen planus. Each biopsy sample was examined for the presence of lichen planus-specific antigen by using a modification of a previously described immunofluorescence method that uses autologous serum and also allogenic sera from the remaining 11 cases.

RESULTS

All autologous and allogenic immunofluorescence tests showed negative findings for lichen planus-specific antigen.

CONCLUSIONS

Lichen planus-specific antigen is not a useful marker to distinguish oral lichenoid drug eruptions from idiopathic lichen planus. This finding is in contrast with our findings in an earlier study of basal cell cytoplasmic autoantibodies.

Clinical management of oral lichen planus

Oral lichen planus is a relatively common chronic disease of the mucous membranes which may have more transient cutaneous manifestations. It has a number of well-recognized clinical signs and a wide range of symptoms from none through mild discomfort to severe debilitating intra-oral erosions and ulceration. It often does not respond to treatment and, in a small proportion of cases, undergoes malignant transformation to squamous cell carcinoma. Although there is an array of treatments, they are palliative rather than curative. Corticosteroids in various forms remain the mainstay of treatment but newer immunomodulatory agents have an increasing role. In this paper, we review current thinking about the management of oral lichen planus and summarize a recent European consensus protocol.

Patient attitudes to glove use by dentists

OBJECTIVE

To evaluate the attitudes of patients on the importance of glove wearing by dentists.

DESIGN

A patient survey using a self-completed patient questionnaire.

SETTING

Ireland.

SUBJECTS AND METHODS

164 consecutive patients attending a dental accident and emergency department were asked to participate. All the patients were aged 16 years or over. Of the surveyed patients, 157 completed a questionnaire designed to elucidate the patients' attitudes to the wearing of gloves by dentists.

RESULTS

Most patients (93.6%; n = 147) considered that dentists should routinely wear gloves, while 1.9% (n = 3) thought the wearing of gloves was unnecessary. 94.9% (n = 149) considered that gloves were worn to protect both the dentist and the patient, with 1.9% (n = 3) feeling that only the dentist was protected. 72% of patients (n = 113) would not attend a dentist who did not wear gloves. 87.2% (n = 138) of patients thought that the dentist should change gloves between patients, while 1.3% (n = 2) considered glove washing to be sufficient. The remaining 11.4% (n = 17) felt that this decision should be left to the dentist.

CONCLUSION

The majority of surveyed individuals indicated that dentists should wear gloves while treating patients. The results suggest that many patients refuse to have dental treatment carried out by a dentist who does not wear gloves.

Levels of dangerousness: an analysis of Irish dentists' clinical responses to HIV-seropositive patients

Work conducted in the mid-1980s suggested that dentists in the Republic of Ireland felt uncomfortable about treating patients who were HIV-seropositive. It seemed that with greater understanding of the behaviour of the virus, dentists' attitudes would be modified accordingly. The aim of this study was to assess the reactions of Irish dentists to the treatment of HIV-positive patients. All dentists currently on the register were sent a questionnaire to assess their knowledge, attitudes and clinical behaviours. Over 60% of dentists responded. The study highlights dentists' responses to HIV infection suggesting that they are fearful of the virus. They perceive HIV as dangerous to themselves, their other patients and their practice. The findings indicate that attitudes relating to dangerousness remain a significant obstacle in the treatment of this patient group.

Oral lichenoid drug eruptions

OBJECTIVES

To identify, from amongst drugs reported as causing lichenoid drug eruptions, those affecting the oral mucous membranes and to review the clinical, histological and immunological features of such oral lichenoid drug eruptions in comparison to oral lichen planus, amalgam contact lesions and lichen planus-like eruption in graft-versus-host disease (GVHD).

DATA SOURCES

Ovid Medline data searches on CD-Rom were carried out for the years 1966-1996 to identify reports of oral lichenoid drug eruptions and their clinical, histological and immunological features. Articles retrieved were examined for further appropriate references in the period 1940-1996.

DATA EXTRACTION AND SYNTHESIS

Each paper was critically examined for evidence of a clinically verifiable lichenoid drug-eruption affecting the oral mucous membranes and the effects of subsequent drug withdrawal. Available clinical, histological and immunological features were recorded. The papers examined were too diverse in nature to permit a structured criticism. The extracted data have been tabulated where appropriate.

CONCLUSIONS

The reports of oral lichenoid drug eruptions are considerably fewer than those of cutaneous eruptions and fewer drugs have been reported as causing oral rather than cutaneous lichenoid eruptions. Histology and immunology cannot be used reliably to differentiate lichenoid drug eruptions from idiopathic lichen planus, amalgam contact lesions and lichen planus-like eruption in GVHD. Lichenoid drug eruptions may also show some histological characteristics of oral discoid lupus erythematosus. An accepted protocol agreed by a number of international centres would permit the gathering of substantial information on LDE and could lead to a greater understanding of the mechanisms involved.

Expression of CD1 and HLA-DR by Langerhans cells (LC) in oral lichenoid drug eruptions (LDE) and idiopathic oral lichen planus (LP)

Numbers of Langerhans cells (LC) expressing the common thymocyte antigen (T6/CD1) are similar in oral lichen planus (LP) and in normal oral epithelium; however, expression of class II major histocompatibility antigens (HLA-DR/Ia) by Langerhans cells is greater in lichen planus than in normal epithelium, a phenomenon believed to be associated with activation and antigen presentation. This study quantified the numbers of T6+ve and HLA-DR + ve Langerhans cells in oral lichen planus and lichenoid drug eruptions (LDE) to investigate whether differences may reflect differing routes of antigen presentation. Six patients with oral lichenoid drug eruptions and six control idiopathic oral lichen planus patients had lesional biopsies. An immunoperoxidase technique was used to demonstrate binding of T6 and HLA-DR antibodies to identify dendritic intraepithelial cells as Langerhans cells and activated Langerhans cells, respectively. In lichenoid drug eruptions, the number of HLA-DR + ve LC was significantly lower than the number of T6 + ve LC (P < 0.05), whereas in idiopathic lichen planus the numbers of T6 + ve and HLA-DR + ve LC did not differ significantly (P = 0.20). The results provide evidence for differences in the routes of antigen presentation in lichenoid drug eruptions and idiopathic lichen planus.

Uremic stomatitis mimicking oral hairy leukoplakia: report of a case

Report on an unusual case of uremic stomatitis mimicking oral hairy leukoplakia. The similarities of the two lesions are discussed, and the differential diagnosis reviewed.

Salivary cortisol and anxiety in recurrent aphthous stomatitis

Anxiety and salivary cortisol were measured in two groups of patients with recurrent aphthous ulceration. One group of patients had persistent aphthae (Group 1) and the others had been relieved of their aphthae following correction of detected haematinic deficiency states (Group 2). Anxiety was measured using the Hospital Anxiety and Depression scale and radioimmunoassay of salivary cortisol. There was a statistically significant increased proportion of borderline or clinically anxious patients in Group 1 compared to Group 2 (P < 0.05). Median salivary cortisol levels also showed a statistically significant elevation in Group 1 (P < 0.01). It is concluded that stress may play a role in the aetiology of recurrent aphthous stomatitis, particularly in patients who have an underlying anxiety trait.

Proliferating cell nuclear antigen staining in syndrome and nonsyndrome odontogenic keratocysts

OBJECTIVES

The relatively aggressive behavior of the odontogenic keratocyst might be expected to correlate with the degree of proliferation of the cyst epithelium. The proliferation rate of odontogenic keratocyst epithelium was studied with the use of an antibody to the proliferating cell nuclear antigen, a nuclear protein expressed in cycling cells.

STUDY DESIGN

We used the monoclonal antibody PC10 to examine 41 odontogenic keratocysts (21 associated with the nevoid basal cell carcinoma syndrome, 20 nonsyndrome), and assessed the number of positive nuclei in 1000 cells. Statistical analysis was carried out with analysis of variance and correlation analysis.

RESULTS

Positive staining with proliferating cell nuclear antigen was seen in all keratocysts; in addition, there was a significant difference in proliferating cell nuclear antigen positivity between the syndrome and nonsyndrome keratocysts.

CONCLUSIONS

The findings support the view that epithelial proliferation plays a significant role in the behavior of odontogenic keratocysts and suggest that the more aggressive behavior in nevoid basal cell carcinoma syndrome may correlate with a higher rate of epithelial proliferation.

Policies and practices of European dental schools in relation to smoking: the place of tobacco education in the undergraduate dental curriculum

A postal questionnaire was used to ascertain policies and practices of European dental schools in relation to smoking and the teaching of the relationship of smoking to the aetiology and primary prevention or oral cancer. A majority of responding schools taught the role of smoking in the aetiology of oral cancer. A majority expected students to take smoking histories from patients. Half of schools taught anti-smoking advice to students and half expected students to impart such advice to patients. A majority banned smoking in clinical and non-clinical teaching facilities and associated public access areas. There is scope for considerable improvement in curricula in relation to anti-smoking counselling and in the practices of schools in expecting students to act as tobacco counsellors.

Psychological factors associated with oral lichen planus

50 patients with oral lichen planus (LP) were investigated for current anxiety and depression and for related personality factors. Anxiety levels, as measured on the Hospital Anxiety and Depression (HAD) Scale, were elevated in 50% of cases while depression scores, measured on the same scale, were low in all but a few. The sample profile showed a slight tendency towards anxiety, as measured by the Cattell 16 PF Questionnaire, but did not confirm previous reports of high intelligence and intellectual orientation. There were no statistically significant associations between erosive oral LP and either anxiety or depression, as measured on the HAD Scale, or anxiety as measured by the Cattell 16 PF Questionnaire.

Basal cell cytoplasmic autoantibodies in oral lichenoid reactions

One hundred sixty-one patients with a clinical diagnosis of an oral lichenoid reaction were evaluated serologically for circulating autoantibodies toward basal cell membrane components. The study group comprised 119 women and 42 men with a median age of 59 and 55 years, respectively. Most patients (n = 144) had an oral mucosal biopsy undertaken. Serologic investigation aimed to identify an IgG antibody that, under immunofluorescent staining, produced an annular fluorescence of basal cells and that has been referred to as basal cell cytoplasmic antibody. These basal cell cytoplasmic antibodies were significantly associated with systemic drug usage, histologic diagnosis of a lichenoid reaction, and a unilateral intraoral distribution of the clinical lesion. In the diagnosis of oral lichenoid reactions precipitated by drug therapy, the basal cell cytoplasmic phenomenon may be a useful adjunct to clinical and histologic investigation.

Alcohol content of proprietary mouthwashes

The use of mouthwashes with high ethanol content has been linked to excess risks of mouth cancer, as have prolonged and frequent use of mouthwashes with lower ethanol contents. Twenty two proprietary mouthwashes available without prescription in Ireland were analysed by gas chromatography and their ethanol contents (w/v) at manufacturers' recommended dilutions for use were calculated. The ethanol contents of diluted mouthwashes ranged from < 0.01-23.40% w/v. 27% had ethanol contents > 10% w/v; 9% had ethanol contents > 20% w/v. As the use of the higher ethanol content mouthwashes may be a possible risk factor for oral cancer in frequent or constant users, we believe that the attention of the statutory regulatory authorities should be drawn to this situation.

Oral cancer in Ireland, 1984-1988

Age standardised oral cancer incidence rates were calculated for the Republic of Ireland from data collected by the Southern Tumour Registry for the years 1984-1988. The annual incidence rates (per 100,000) for men were lip 3.8, tongue 1.2 and mouth 1.8 while the corresponding rates for women were lip 0.2, tongue 0.7 and mouth 0.5. The incidence of lip cancer is shown to be much lower than indicated by previously published Irish rates. In general, oral cancer incidence rates in Ireland are comparable to those reported for Denmark. The vast majority (94%) of cases were histologically verified. The results, along with recent findings on mortality, contradict the view that Ireland has a very high rate of oral cancer by west European standards.

The association of menstrual cycle, pregnancy, and menopause with recurrent oral aphthous stomatitis: a review and critique

OBJECTIVE

To examine critically the postulated associations between recurrent aphthous stomatitis and the menstrual cycle, pregnancy, and menopause, and to determine why such associations had been accepted previously in the absence of convincing evidence.

DATA SOURCES

We used MEDLINE data base searches in 1988 and 1991 to identify all articles since 1966 referring to estrogen, progesterone, menstruation, menstrual cycle, menopause, or pregnancy, and to aphthous stomatitis. Similar searches were carried out in the Index to Dental Literature for the period 1942-1991, and in MEDLINE on CD-ROM in 1991. Articles uncovered were examined for further appropriate references in the 50-year period 1942-1991. We excluded letters, abstracts, and articles in journals that are not peer-reviewed.

METHODS OF STUDY SELECTION

We discovered one retrospective study on aphthous ulceration and ovarian hormones, eight prospective studies, three uncontrolled trials on the use of hormones in aphthous stomatitis, one controlled trial, and four review papers.

DATA EXTRACTION AND SYNTHESIS

Each paper was carefully read, in translation where necessary, and opinions and findings were critically examined for source, authenticity, and statistical analysis. Each paper was also examined critically in terms of its review and acceptance of previous papers. The papers were too diverse in nature to permit a structured criticism.

CONCLUSIONS

No associations have been established between aphthous stomatitis and the premenstrual period, pregnancy, or menopause. No properly designed study has shown a therapeutic effect of ovarian hormones on aphthous stomatitis. Reasons for this lack and the need for large-scale studies are identified.

Validity of a patient self-completed health questionnaire in a primary care dental practice

1500 patient medical histories derived from self-completed health questionnaires alone and from a combination of questionnaire, structured interview by a dentist, and selective reference to family doctors were compared. In 4.25% of cases, the questionnaire medical history was significantly deficient. Such questionnaires yield an inadequate medical history when used on their own.

Gliadin antibodies identify gluten-sensitive oral ulceration in the absence of villous atrophy

This study demonstrates gluten-sensitive recurrent oral ulceration (ROU) in the absence of gastrointestinal abnormalities which is associated with a humoral response to wheat protein. Ten patients with severe ROU were investigated; all had normal small intestinal biopsies. Four patients had raised levels of antibodies to alpha gliadin, a wheat protein fraction; in three of these four, the ulceration remitted on treatment with a gluten-free diet (G.F.D.) and relapsed on gluten challenge. None of the remaining six patients had raised alpha gliadin antibody (AGA) levels and none responded to G.F.D. Thus raised AGA levels can be used to identify patients with ROU who are likely to respond to a GFD.