[Plummer Vinson syndrome]

BACKGROUND

Plummer Vinson syndrome is a rare affection which affects mainly white women. It is characterized by dysphagia, iron deficiency and the presence of superior esophageal web.

AIM

The purpose of this study is to precise the epidemiological, clinical, paraclinical and therapeutical features of the affection.

METHODS

We report 19 cases of Plummer Vinson syndrome collected over 15 years (1990- 2004).

RESULTS

Dysphagia is the main symptom observed in 100% of the cases. 89.4% of the patients had anemia and 15 hyposideremy. All the patients were treated with iron supplementation and endoscopic treatment (dilatation and rupture of esophageal webs). Three patients necessitate multiple sessions of endoscopic dilatation and 15 had favourable evolution. The malignancy was observed in one case.

Risk Factors for Wound Infection After Surgery in Primary Oral Cavity Cancer Patients

OBJECTIVES

Few studies have discussed the predictive factors of surgical wound infection (WI) in primary oral cavity cancer patients. Therefore, we aimed to determine the relevant factors associated with postoperative WI in a large group of patients with oral cavity cancers.

STUDY DESIGN

Retrospective chart review.

METHODS

We retrospectively reviewed 1,693 chart records of oral cavity cancer patients. Twenty variables were obtained from chart review. Statistical methods included descriptive statistics, bivariate analyses, and a multiple logistic regression model for investigating the predictive factors for WI.

RESULTS

Postoperative WI rate was 19.8%. Diabetes mellitus (odds ratio [OR]: 2.511, 95% confidence interval [CI]: 1.409-4.475), perioperative blood transfusion (OR: 4.293, 95% CI: 2.448-7.529), reconstruction with free flap or pectoris major myocutaneous flap (OR: 3.682, 95% CI: 1.909-7.102), and postoperative serum albumin level less than 2.8 g/dL (OR: 2.853, 95% CI: 1.928-4.221) were all independent factors associated with postoperative WI.

CONCLUSIONS

Recognition of relevant factors can help surgeons to identify those at high risk of WI after surgery for primary oral cavity cancer and can enable better management of such cases.

Optimal sampling site for mucosal candidosis in oral cancer patients is the labial sulcus

Traditional sampling methods for the diagnosis of oral candidosis in head and neck cancer patients, i.e. saliva collection or tongue scrapings, are often impossible to perform. The aim was to determine the optimal sampling method. Eighteen oral cancer patients and five control subjects were sampled semi-quantitatively from the labial sulcus, dorsum of the tongue, dental plaque and saliva for cultivation of yeasts. The patients were examined prior to all cancer treatment (n=5), or 2-4 weeks (n=5) or 8-12 weeks (n=8) post-operatively. The incidence of Candida was found to increase from 40 % at the control and pre-operative level up to 73 % 8-12 weeks post-operatively. Candida albicans was found to be the only species until 4 weeks post-operatively. Thereafter, the incidence of species other than C. albicans was 38 %. The most sensitive sampling site was found to be the vestibular sulcus, from which all culture-positive cases could be confirmed. Tongue surface scraping was found to be more sensitive than saliva collection in detecting Candida. All sampling methods and sites were equally sensitive in detecting the different Candida species. Dental plaque was found to have the highest density of Candida colonization, and was thus found to be the most significant source of Candida infection, which emphasizes the role of dental care in these patients.

Mechanical allodynia and thermal hyperalgesia induced by experimental squamous cell carcinoma of the lower gingiva in rats

We developed a rat model of oral cancer pain by inoculating cancer cells into the lower gingiva. A squamous cell carcinoma (SCC) derived from Fisher rats, SCC-158, was inoculated into the subperiosteal tissue on the lateral side of the lower gingiva in male Fisher rats. Inoculation of cancer cells induced marked mechanical allodynia and thermal hyperalgesia in the ipsilateral maxillary and mandibular nerve area. Infiltration of the tumor cells into the mandible and the completely encompassed inferior alveolar nerve was observed. Calcitonin gene-related peptide (CGRP)-, substance P (SP)-, ATP receptor (P2X(3))-, and capsaicin receptor (TRPV1)-immunoreactive cells strikingly increased in the small-cell group of trigeminal ganglia (TGs) after tumor cell inoculation. The TRPV1-immunoreactive cells also increased in the medium- and large-cell groups. Retrograde tracing combined with immunofluorescence techniques revealed the increased expression of peptides and the receptors in maxillary nerve afferent neurons. These results suggest that inoculation of SCC cells into the lower gingiva produces mechanical allodynia and thermal hyperalgesia, indicating the establishment of a novel rat model of oral cancer pain. Increased expression of CGRP, SP, P2X(3), and TRPV1 in the TG may be involved in the behavioral changes in this model.

PERSPECTIVE

To clarify the mechanisms of oral cancer pain, we examined the expression of calcitonin gene-related peptide, substance P, ATP receptor P2X(3), and capsaicin receptor TRPV1 in trigeminal ganglia. Characterizations of these molecular systems which mediate pain perception are important to develop novel clinical tools for promoting relief of oral cancer pain.

Restrictions of food intake in patients with oral cancer

Oral squamous cell carcinoma and its treatment are associated with facial disfigurement and functional inabilities that can lead patients to restrict food intake. The current study examined 80 patients undergoing treatment for the disease in a large Brazilian hospital setting, aiming at the appraisal of covariates with prognostic value for the prevalence of food restriction. Multivariate logistic regression analysis identified tumour size (adjusted odds ratio=19.32) and loss of tongue mobility (adjusted OR=5.51), controlled by the higher odds of females (adjusted OR=7.58) and patients living in crowded households (adjusted OR=4.01), as the most important clinical predictors of food restriction. These results are compatible with the hypothesis that an impaired functional status of the stomatognathic system is caused by large tumours and wide resections. The restriction of food intake in patients with oral cancer is multifactorial, and a complex causal pathway links it to the burden of disease. The knowledge of prognostic factors for nutritional depletion in cancer patients can instruct nutritional interventions in the context of planning treatment protocols aimed at improving quality of life.

Oral and oesophageal squamous cell carcinoma--a complication or component of autoimmune polyendocrinopathy-candidiasis-ectodermal dystrophy (APECED, APS-I)

Autoimmune polyendocrinopathy-candidiasis-ectodermal dystrophy (APECED) is an autosomal recessive disease exceptionally common in Finland. It is associated with a limited T lymphocyte defect, an autoimmune response to various tissues, particularly endocrine glands. Most patients have chronic oral candidosis, which has been suggested to be carcinogenic. In Finland 92 patients have been diagnosed with APECED and 66 of them are alive. Our aim was to study the possible association of APECED with oral and oesophageal carcinoma. We evaluated the medical histories of all 92 patients for morbidity, causes of death, and known risk factors for oral cancer. We invited all current patients for a clinical examination of their oral mucosa. Six of the 92 had developed oral or oesophageal squamous cell carcinoma (SCC) by the mean age of 37 (29-44years) and four of them had died from it. The six represent 10% of the patients older than 25years. Five of the six patients had long-lasting oral candidosis. Four of the six had smoked regularly for 15years or more. One patient had been on immunosuppressive therapy for 6years following kidney transplantation when SCC in her mouth occurred. The partial T cell defect of APECED seems to favour the growth of Candida albicans and predispose to chronic mucositis and SCC. Aggressive control of oral candidosis and close follow-up of oral mucosa is a necessity in patients with APECED.

On the natural course of oral lichen lesions in a Swedish population-based sample

OBJECTIVES

The aim was to assess the natural course of oral lichen lesions (OLL) among unselected, non-consulting individuals.

SUBJECTS AND METHODS

A cohort of 327 subjects with OLL, confirmed in 1973-1974 during a population-based survey in two Swedish municipalities, was followed through January 2002 via record linkages with nationwide and essentially complete registers. A sample of 80 drawn from the 194 surviving subjects who still resided in the area in 1993-1995 was invited for interview and oral re-examination.

RESULTS

At the end of follow-up, one case of oral cancer was detected, while 0.4 were expected. The overall mortality among subjects with OLL was not significantly different from that in the 15,817 OLL-free subjects who participated in the initial population based survey in 1973-1974. The lesion had disappeared in 14 (39%) of 36 re-examined subjects with white OLLs in 1973-1974, and four (11%) had transformed into red types. In the corresponding group of 19 with red forms initially, five (26%) had become lesion free and four (21%) had switched to white types. Although the cohort size does not permit firm conclusions regarding oral cancer risk, the natural course over up to 30 years appears to be benign in the great majority.

Pain complaint as the first symptom of oral cancer: a descriptive study

OBJECTIVE

To identify pain as the initial symptom of oral cancer patients.

STUDY DESIGN

Hospital charts of 1412 patients (1977 to 1998) with oral cancer were reviewed (238 female and 1174 male).

RESULTS

Pain was the initial complaint in 19.2% of the sample. Oral cancer (ratio 4:1) and initial pain (ratio 9:1; P= .001) was prevalent in men. There were 12 different complaints of pain: sore throat (37.6%), tongue pain (14.0%), mouth pain (12.9%); pain when swallowing (11.1%), dental pain (5.9%); earache (5.9%); pain in the palate (4.1%); burning mouth (3.3%); gingival pain (2.2%); pain when chewing (1.1%); neck pain (1.1%), and facial pain (0.7%). Pain was associated with advanced TNM staging and location of tumor in the tongue (P= .004) and the tongue/mouth floor (P< .006).

CONCLUSION

There were 12 different descriptions of pain; pain was related to TNM staging in the tongue and the tongue/mouth floor. The data presented reinforce the suggestion that patients with orofacial pain need systematized evaluation and sometimes require an interdisciplinary approach.

Administration of bisphosphonate for hypercalcemia associated with oral cancer

BACKGROUND

The efficacy of treating hypercalcemia with bisphosphonate (BP) in patients with advanced oral cancer has not been fully investigated. This retrospective study evaluated the clinical course of hypercalcemic patients with and without BP treatment.

METHODS

Sixteen hypercalcemic patients, most of whom had uncontrollable locoregional lesions and lung metastases, were studied. Nine patients had been given BP, and the rest had not.

RESULTS

There were significant differences in age and serum ALT between the BP-treated and -untreated groups. The first administration of BP effectively and safely decreased the serum calcium level, but repeated administrations were less effective. Although the patients treated with BP survived significantly longer than the untreated subjects, the difference of the median was only about 2 weeks.

CONCLUSION

The occurrence of hypercalcemia in oral cancer patients apparently implies an extremely poor prognosis, and long-term survival cannot be expected, even with BP treatment.

Dental Considerations in the Management of Head and Neck Cancer Patients

The text has emphasized the need for a timely dental consult early in the process of the head and neck cancer patient's treatment. Nonrestorable diseased teeth should be removed before radiation and chemotherapy. The primary survey of the patient should include an examination of the oral cavity, noting the state of the dentition and periodontal tissues. Complications commonly seen in patient's undergoing radiotherapy,such as xerostomia, mucositis, and trismus, may be reduced and, therefore,improve the patient's quality of life. Optimizing the patient's oral health benefits the patient's postsurgical and postirradiation course. The dental health care professional can serve an important role in the overall outcome of the patient's care.

Diagnosis of aseptic deep venous thrombosis of the upper extremity in a cancer patient using fluorine-18 fluorodeoxyglucose positron emission tomography/ computerized tomography (FDG PET/CT)

We describe a patient with a history of recurrent squamous cell carcinoma of the tongue and abnormal FDG uptake in the left arm during a re-staging FDG PET/CT. After revision of the patient's clinical history, tests and physical exam, the abnormal FDG uptake was found to correspond to an extensive aseptic deep venous thrombosis of the upper extremity.

The impact of highly active antiretroviral therapy and immunodeficiency on human papillomavirus infection of the oral cavity of human immunodeficiency virus-seropositive adults

BACKGROUND

Prevalence of human papillomavirus (HPV)-associated oral condylomas has reportedly increased in HIV-infected individuals since the introduction of highly active antiretroviral therapy (HAART). The relationships between HIV therapy regimen, overall health, and subclinical oral HPV have not been examined.

GOAL

To determine oral HPV genotype prevalence and the impact of HAART and health in the HIV+ population.

STUDY

An L1 consensus-primer polymerase chain reaction and linear array assay were used to examine the prevalence of 27 HPV genotypes in saliva of 98 HIV+ individuals. Risk assessment variables were compared to oral HPV status.

RESULTS

Oral HPV was detected in 37% of HIV+ African American individuals. Caucasians were at greater risk of oral HPV infection than African Americans. Markers of advanced HIV disease did not predict HPV status. Therapy status was associated with HPV detection.

CONCLUSIONS

Treatment of HIV, rather than HIV immunosuppression, appears to play a role in oral HPV infections in HIV+ individuals.

Prevalence of oral lesions in HIV patients related to CD4 cell count and viral load in a Venezuelan population

AIM

To determine the prevalence of oral lesions in a HIV+ group of patients, related to CD4 cell count and viral load in a Venezuelan population.

MATERIALS AND METHODS

In the present study, we evaluated 75 HIV+ adult patients, attended at the Center of Infectious Diseases, at the Faculty of Dentistry, Central University of Venezuela. Each patient was clinically examined for detection of oral mucosal lesions. In addition, CD4 cell count was determined by flow cytometry, as well as viral load by RT-PCR (Amplicor HIV-RNA, TM test 1.5, Roche).

RESULTS

85% (64/75) of HIV/AIDS patients showed associated HIV lesions. Oral Candidiasis constituted the most common lesion representing a 61% (39/64), followed by Oral Hairy Leukoplakia 53% (34/64); Oral Leukoplakia 34% (22/64), Melanic Hyperpigmentation 38% (18/64); Papilloma 13 (6/64), Lineal Gingival Erythema 8% (5/64); Aphtous Recurrent Stomatitis 5% (4/64) and Kaposi's Sarcoma 5% (3/64). Only one case of the following lesions were represented by Non Hodgkin Lymphoma, Multifocal Epithelial Hyperplasia, Recurrent Herpes, Histoplasmosis and Molluscum Contagiosum. The patients with a viral load of 30.000 copies/mm3 exhibited oral lesions related with HIV, independent of CD4 cell count, although patients with CD4+ levels of 200 cel/mm3 were more susceptible to develop these lesions.

CONCLUSIONS

The most common oral lesion was Oral Candidiasis followed by Oral Hairy Leukoplakia, Oral Leukoplakia and Melanic Hyperpigmentation. A high viral load was strongly associated to the oral lesions occurrence independently of CD4+ cell count.

[Dysphagia in oral medicine]

Dysphagia, defined as a difficulty in swallowing of fluids and/or food, is one of the most frequent symptoms of oesophageal, gastrointestinal or ENT diseases. Interestingly, dysphagia can be also the initial or late symptom of several oral diseases: e.g. traumatic ulcerations, immunomediated or infectious lesions, malignant neoplastic disease or mucositis in chemio-radiotherapy. The presence of this frequent symptom, with or without oral evident lesions, can suggest the presence of oral or perioral diseases, promoving adequate diagnostic-therapeutic management. In this paper, authors describe aetiology, pathogenesis and clinical aspects of oral diseases, as being more frequently associated with dysphagia; moreover, they describe the most important clinical and epidemiological features of systemic diseases associated with dysphagia.

[Palatograms and linguograms for studying misarticulation following surgery for tumors of the tongue and oral cavity floor]

This work deals with the mechanism of misarticulation following surgery for malignancies in the oral cavity. The underlying cause was dysfunction of the tongue due to partial or total resection, consequences of the resection of the mandible together with the oral cavity floor, or dysfunkction of the lower lip failing to seal the space of Donders. Anatomic alternations reveal themselves as shifts in the points of contact between structures of the articulation system noticeable on palatograms or linguograms. Limited mobility of tongue tip may affect speech, particularly in the case of sounds of the first and second articulation zone.

Malignant tumours presenting after dental extraction: a case series

OBJECTIVE

To present the clinical spectrum of malignant neoplasms detected after extraction of teeth.

DESIGN

Retrospective study.

SETTING

Department of Oral and Maxillofacial Surgery, University of Benin Teaching Hospital, Nigeria.

MAIN OUTCOME MEASURES

Demographic and clinical data of patients diagnosed with malignant neoplasms related to a history of tooth extraction.

RESULTS

Twelve patients with histopathologically confirmed tumours detected after extraction of teeth were studied. There were 11 males and one female giving a male to female ratio of 11:1. They ranged in age from 15-85 years with a mean age of 53 years. Pain and swelling were the most common presenting complaints. The mandible was more often involved seven (58.3%) cases while five (41.7%) cases occurred in the maxilla. Squamous cell carcinoma (in 9 cases) was the most common malignant neoplasm among these patients.

CONCLUSION

Malignant tumours can mimic periapical infections necessitating a high index of suspicion when faced with toothache of uncertain cause.

Oral malignancies in HIV disease: Changes in disease presentation, increasing understanding of molecular pathogenesis, and current management

Infection with human immunodeficiency virus (HIV) and progression to acquired immune deficiency syndrome (AIDS) are associated with a vide variety of morbidities. Local and systemic diseases can develop in association with HIV infection and may manifest themselves as malignancies of the oropharynx. Advances in HIV management, fueled by increasing understanding of molecular pathogenesis, have resulted in marked changes in the prevalence of oral malignant disease. This paper discusses recent trends in the presentation and treatment of malignancies related to HIV and AIDS with an emphasis on malignancies seen in the oral cavity.

Severe comorbidity negatively influences prognosis in patients with oral and oropharyngeal cancer after surgical treatment with microvascular reconstruction

The aim of the study was to investigate the possible impact of comorbidity on survival of patients undergoing composite resection and microvascular reconstruction for oral/oropharyngeal cancer. Patient, tumour and treatment data were recorded. Comorbidity was graded by the Adult Comorbidity Evaluation (ACE-27) test. Survival and statistics were calculated. Comorbidity score ACE-27 grade 2 was present in 47% of patients, for ACE-27 grade 3 this was 13%. The median follow-up was 50 (3-87) months. Thirty-eight patients died, 32 developed a recurrence. Comorbidity score ACE-27 grade 3 turned out to be a clear predictor for overall survival (p<0.05). For ACE-27 grade 3 (n=13) 5-years survival was 29%, for ACE-27 grade 2 (n=87) this was 64%. No multivariate influences on the effects of comorbidity were found. Improved knowledge of the effect of comorbidity on survival may lead to better patient selection and counselling for major surgery and microvascular reconstruction.

The idiosyncratic relationship between diagnostic delay and stage of oral squamous cell carcinoma

Approximately half of patients with oral cancer present with advanced lesions when five-year survival rates are as low as 20%, however, diagnostic delay has repeatedly been found to be unrelated to the stage of oral cancer at diagnosis. The aim of this study was to investigate why diagnostic delay is frequently unrelated to the stage of oral cancer at diagnosis. The odds ratio (OR) of early versus advanced oral squamous cell carcinoma was calculated for 245 consecutive patients with untreated oral squamous cell carcinoma. Being female (OR=0.40; 0.19-0.80; p<0.05) and married (OR=0.27; 0.11-0.66; p<0.01) was predictive of early stage disease. Being non-white (OR=5.42; 1.66-17.67; p<0.01) was predictive of advanced stage disease. There is no evidence that these patient demographics are associated with faster growing tumours, yet it is possible that those who are male, unmarried and non-white may not notice an oral lesion until it is advanced in stage. It is concluded that differences in tumour biology are not a likely explanation for the absence of a delay-stage relationship but instead, a proportion of tumours may be silent until advanced in stage.

Airway management of patients undergoing oral cancer surgery

OBJECTIVE

This retrospective study aims to describe the airway management and benefits of nasotracheal intubation over tracheostomy in 260 patients with oral cancer undergoing surgery.

METHODS AND RESULTS

The medical records of 260 patients undergoing surgery for oral cancer were reviewed for airway management during the perioperative period. Eighteen patients had previous surgery for oral cancer and were scheduled for flap reconstruction, recurrence or other complications. In 28 cases neck movement was restricted and decreased mouth opening was found in 50% of all patients because of a large growth or fixation of tissues of head and neck, oral cavity, pharynx or larynx by tumour, or radiation fibrosis. In 53 patients intubation was undertaken under spontaneous ventilation. In 20 cases the trachea was extubated in the immediate postoperative period. In 220 cases patients were extubated next morning in the intensive care unit. In none of the cases was elective tracheostomy under local anaesthesia performed before surgery for the maintenance of the airway for anaesthesia. Elective tracheostomies were done in 17 cases. Three patients remained intubated for 24-48 h because of a high suspicion of airway obstruction following extubation due to a large pectoralis major flap. These three patients received a tracheostomy because of increased oropharyngeal and laryngeal oedema. In three cases emergency tracheostomies were performed due to upper airway obstruction after extubation and in one case prolonged elective ventilation was required due to severe chest infection.

CONCLUSION

Oral cancer patients have a potentially difficult airway but, if managed properly during perioperative period, morbidity and mortality can be reduced or avoided. Oral cancer patients can be managed safely without the routine use of a tracheostomy. Nasotracheal intubation is a safe alternative to tracheostomy in oral cancer patients except in some selected patients.

DNA identification of the pathogen of candidal aspiration pneumonia induced in the course of oral cancer therapy

Aspiration of oropharyngeal bacteria and fungi is occasionally suspected in patients with pneumonia. A patient with oral carcinoma underwent chemoradioimmunotherapy and, about 4 weeks from the start of the therapy, the patient suffered from severe oral mucositis induced by chemoradiotherapy, and candidal pneumonia was subsequently induced. The candidal pneumonia was insufficiently improved by potent antifungal drugs, taking a lethal course. Randomly amplified polymorphic DNA analysis and DNA sequence examination of strains isolated from the oral cavity 1 week before the onset of pneumonia and autopsied lung revealed the identity of both strains as Candida albicans, and the DNA analysis supported aspiration of oral Candida. These results indicate that the pathogen of the pneumonia, C. albicans, was aspirated from the oral cavity and that oral Candida is easily aspirated and becomes the pathogen of pneumonia.

Congenital sublingual teratoid cyst: a case report and literature review

Head and neck dermoid cysts comprise less than 10% of all dermoid cysts. The sublingual location is very rare. One hypothesis for their etiology is that they arise from entrapment of epithelial debris or rests during the midline fusion of the first 2 branchial arches. They are classified as epidermoid, dermoid, and teratoid cysts. Sublingual cysts are slow-growing lesions generally seen in the second and third decades of life. They are rare in childhood. The cysts may interfere with swallowing and breathing. Rarely, they may show malignant transformation. Surgical extirpation is the treatment of choice.

The prevalence of oral leukoplakia in 138 patients with oral squamous cell carcinoma

OBJECTIVES

To determine the relationship between oral leukoplakia (OL) and oral squamous cell carcinoma (OSCC), and to evaluate possible differences between those carcinomas with and without associated leukoplakia.

MATERIAL AND METHODS

A total of 138 patients were studied at the Stomatology Service of the University General Hospital, Valencia, Spain. These patients were divided into two groups: group 1, patients with oral cancer and leukoplakia, and group 2, patients with OSCC but with no associated premalignant lesions. The relationship between this precancerous lesion and the OSCC was evaluated, as well as the possible clinical and histological differences between the tumours of the two groups.

RESULTS

Leukoplakia was detected in 27 (19.56%) patients with OSCC. No differences were found between the two groups regarding age and tumour location. However, statistically significant differences were observed with respect to the form, tumour stage and the presence of adenopathies in the cancers with and without leukoplakia; in that the tumours associated with leukoplakia were diagnosed as being at a more initial stage.

CONCLUSIONS

Those patients with OL associated with oral cancer presented with tumours at a less advanced stage than those where no associated leukoplakia existed.

High Prevalence of Obstructive Sleep Apnea among Patients with Head and Neck Cancer

OBJECTIVES

To determine the prevalence of obstructive sleep apnea (OSA) in patients with cancer of the oral cavity and oropharynx scheduled for primary surgical resection. To correlate the presence of OSA and the occurrence of postoperative morbidities in this patient population.

METHODS

This was a prospective study involving 17 patients with malignancies of the oral cavity and oropharynx scheduled for primary surgical resection. Consecutive patients were approached to undergo overnight polysomnography to determine the apnea-hypopnea index (AHI). OSA was defined by an AHI value > or = 20 events per hour. Postoperative morbidities were evaluated in a blinded fashion for the patients completing surgery.

RESULTS

OSA was present in 13 of 17 patients, yielding a striking prevalence of 76% in this patient group. The mean AHI for patients with OSA was 44.7 +/- 3.5 (standard error) events per hour, with a mean nadir oxygen saturation of 88.2 +/- 1.8%, consistent with moderate to severe sleep-disordered breathing. The OSA and non-OSA patients were similar with respect to age and body mass index. The mean size of the primary tumour was 3.3 cm in patients with an AHI < 20 and 3.5 cm in those with an AHI > or = 20 (p = not significant). Overall, postoperative complications, defined as prolonged intensive care unit stay (> 24 hours), need for mechanical ventilation, and cardiopulmonary morbidities, were observed in 67% of OSA and 25% of non-OSA patients.

CONCLUSIONS

These findings point to a strong association between OSA and malignancies of the oral cavity and oropharynx. This relationship was independent of the size of the primary malignancy in this patient population with tumours ranging from 1 to 7 cm (p = not significant). When comparing the two groups (AHI < 20 and AHI > or = 20), there was a tendency for the group with OSA to have an increase in postoperative morbidities. Further research is warranted to further evaluate the postoperative morbidities and mortalities associated with OSA in this patient population and to determine the potential roles for preoperative treatment with continuous positive airway pressure and tracheotomy.

Syndrome of inappropriate antidiuretic hormone secretion due to recurrent oral cancer

Hyponatremia is a common metabolic disorder in clinical practice and is associated with significant morbidity and mortality, especially among the elderly. Hyponatremia resulting from the syndrome of inappropriate secretion of antidiuretic hormone (SIADH) has been reported in association with neoplasia (including a few reports in patients with head and neck malignancies) and may represent a paraneoplastic condition. Patients with SIADH present with signs and symptoms that cannot be explained by the primary tumour mass effect or its metastases. We describe a 67-year-old male patient with oral squamous-cell carcinoma of recent recurrence admitted because of symptomatic severe hyponatremia resulting from SIADH and discuss the principles of the diagnostic approach and appropriate management.

Evaluation of pain in patients with oral squamous cell carcinoma

In this study we have developed and tested a novel pain questionnaire to measure the pain experienced by patients with oral squamous cell carcinoma. The questionnaire consisted of 8 questions rated by the patient on a visual analog scale. Patients completed the questionnaire at the time of initial presentation before surgical treatment. None of the patients were taking analgesics. The responses were then scored and compiled with patient data and pathology reports. Of the 15 completed questionnaires, 14 patients reported some level of functional restriction from pain (mean, 46.6 +/- 25.2, scale of 0 to 100 mm). On average, patients experienced significantly higher function-related, rather than spontaneous, pain intensity and sharpness. Men (n = 8) had a significantly higher level of function-related pain intensity and sharpness than women had (n = 7). There was a strong correlation between nodal disease and increased levels of spontaneous intensity, sharpness, throbbing, and overall functional restriction.

PERSPECTIVE

The results of this study indicate the heterogeneous nature and function dependence of oral cancer pain. The questionnaire we have developed in this study will allow for correlations between pain parameters and specific tumor biology in future studies.

Familial occurrence of oral submucous fibrosis: report of eight families from northern Kerala, south India

BACKGROUND

Oral submucous fibrosis (OSF) is an archetype of pathological fibrosis due to possibly its presence for centuries amongst people of Indian ethnic extraction. The WHO criteria for a precancerous condition accords well with this disease. The fact that the disease has been reported in at least few subjects who do not practice the habit of areca nut chewing and the inability to prove a dose-effect relationship in almost all cases, the question arose whether there is a predisposition for the disease.

METHODS

A house- to-house survey was carried out in northern Kerala, South India, for the detection of early and advanced OSF from June 2003 through May 2004. An analysis of the family pedigrees of all patients with a positive history of fibrosis has been carried out.

RESULTS

Preliminary analysis of the family survey revealed that OSF tends to aggregate in families. The pedigrees of eight (8) such families presented here and the concept of OSF having a genetic predisposition to its occurrence revisited.

CONCLUSION

The view that OSF having a family predilection, at least in a proportion of cases, and its tendency for familial linkage seems to be apparent by this study. This rather denovo observation of a trend relationship between OSF risk and the number of putative high-risk genotypes should be separately evaluated for the collagen metabolizing and cross-linking pathways. Establishing familial linkage of the disease seems to be an initial step in deciphering further the molecular pathways involved in its causation and biologic progression.

Keratosis follicularis of the oral mucosa with oral squamous cell carcinoma

Darier's disease or keratosis follicularis is a genodermatosis which may involve the oral mucosa. Malignant degeneration is rare. We report the first case of the combined manifestation of oral keratosis follicularis and oral squamous cell carcinoma and discuss the possible involvement of ATP2A2 (located in 12q23-24.1) which encodes the sarco/endoplasmic reticulum Ca(2+)-ATP isoform 2 (SERCA2), in the pathogenesis.

[Manifestations of HIV infection in the oral cavity]

Affections in the oral cavity are important clinical markers of HIV infection and may, in fact, be the first clinical manifestation of undiagnosed HIV positivity. These affections include infections, tumours, conditions caused by direct HIV activity, as well as adverse side-affects of antiretroviral and other antimicrobial drugs. The paper lists disorders of the mouth that can complicate HIV infection and manifestations of HIV infection in the oral cavity. Accompanied by photographs of the oral cavity of patients treated at the Dept of infectious diseases.

Dental and oral lesions in HIV infected patients: a study in Brazil

AIM

To determine the prevalence of dental and oral lesions, as well as treatment need, in a group of HIV sero-positive Brazilians. In addition, to test the association between oral manifestation of HIV infection and age, sex, mode of transmission and drug therapy.

METHOD

All HIV seropositive patients attending a dedicated dental clinic in Recife were invited to participate in the study. They were all examined by one trained and calibrated examiner and interviewed by one trained interviewer.

RESULTS

161 of 204 patients (78.9%) agreed to participate in this study. Most of the participants were male (76%), had acquired HIV sexually (74.5%), and were taking some form of antiretroviral therapy (70.8%). 33.5% had one or more oral manifestation of HIV. Candidiasis was the most common (28.6%), followed by hairy leukoplakia (9.3%), Kaposi sarcoma (2.5%), ulceration (2.5%), herpes simplex (1.2%), papiloma (0.6%), and 4.4% had periodontal disease. Only 1.2% reported xerostomia. There were no differences in the prevalence of oral manifestations of HIV infection between age groups, sexes, modes of transmission and types of drug therapy (P>0.05). The mean DMF-T score was 19 (SD 8) and 78.9% needed some form of dental treatment.

CONCLUSIONS

While the prevalence of oral manifestations of HIV/AIDS was low in this sample of HIV seropositive Brazilians, dental status was poor and need for dental treatment was high.

Colour Doppler ultrasound in preoperative assessment of the neck vessels in patients with tumours of the oral cavity and the neck region

BACKGROUND

The aim of the study was not only to establish the applicability of color Doppler ultrasound of the neck vessels in patients with tumors of the oral cavity and the neck region but also to check whether the coexistence of sclerotic changes in the carotid arteries is essential in determination of the sequence of surgical procedure.

MATERIAL/METHODS

Color Doppler ultrasound was performed on 110 patients, aged 15 -71 years with tumors of the oral cavity and the neck. The localization, size, echogenicity, as well as the tumor relationship to the surrounding structures and big vessels of the neck region was analyzed.

RESULTS

Compression of the veins was observed in 27 cases, and of the arteries only in 20 cases. Infiltration of the jugular vein was observed in 8 patients, whereas infiltration of the carotid artery were seen only in 6 patients. Severe internal carotid artery stenosis, due to arteriosclerosis, was observed in 10 patients. Three persons were suggested to be operated on, first due to carotid artery stenosis, later on, due to the oral cavity tumor.

CONCLUSIONS

It was found that color Doppler ultrasound is useful in deciding upon the method of treatment, while the examination of the neck vessels is helpful in establishing the sequence of surgical procedures in patients with tumors and coexisting arteriosclerosis.

Knowledge and behaviors of primary care physicians on oral cancer in Italy

We investigated the knowledge and behaviors of a random sample of 500 primary care physicians (PCPs) regarding oral cancer in Calabria (Italy). 87.6% and 64% indicated tobacco and alcohol use as risk factors, only 31.5% and 2.8% having a prior oral cancer lesion and older age. 60.9% knew that squamous-cell carcinoma is the most common form; 68.8% and 37.1% that the tongue and floor of the mouth were the two most common sites. Respectively 91.5% and 41.7% knew that leukoplakia and erythroplakia were the two conditions most likely to be associated with oral cancer. 17.6% of PCPs recognized that an early oral lesion usually is small and painless red area and 26.8% knew how to examine the tongue. PCPs who learned about oral cancer from scientific journals were more likely to indicate tobacco use as a risk factor for oral cancer and those who do not need additional information to indicate alcohol use as a risk factor. Oral examination was provided by 63.8% and 37.1% to those 40 years of age and older. Half of respondents asked about the personal patient's experience of oral cancer and about the patient's family, most about patients' tobacco and alcohol use. The odds of asking about patients' tobacco and alcohol use and of performing oral cancer examination were significantly higher for those who practiced medicine for a longer period. Additional training and continuing educational programs on prevention and early detection of oral cancer for PCPs are strongly needed.

Cancer-related oral health care services and resources: a survey of oral and dental care in Canadian cancer centres

PURPOSE

Prevention and management of oral complications of cancer and cancer therapy will improve oral function and quality of life, and reduce morbidity and the cost of care. Oral assessment, and oral and dental care have been strongly recommended before cancer therapy and should be continued during and after cancer therapy. The purpose of this survey was to assess the resources available for oral care in Canadian cancer centres.

METHODS

Provincial cancer centres were assessed by questionnaire to determine the resources available for oral care in these facilities.

RESULTS

Wide variability in oral and dental care of patients with cancer across Canada and a lack of documented standards of care were reported. Very few cancer centres had institutionally supported dental staff to support the oral care of patients with cancer, and few had dental treatment capability on site. The majority of centres managed oral care needs in the community with the patient's prior dentist.

CONCLUSIONS

We recommend that national guidelines be developed for medically necessary oral and dental care for patients with cancer.

Simultaneous nonparotid cranial mucosa-associated lymphoid tissue lymphoma and common variable immunodeficiency

Common variable immunodeficiency (CVID) is a condition characterized by low levels of immunoglobulin (Ig) G and either IgA or IgM in the presence of recurrent infections. This disorder is associated with an increased risk of malignancy. Mucosa-associated lymphoid tissue (MALT) lymphoma is a recently recognized form of non-Hodgkin's lymphoma that is not often present in the head. MALT lymphoma in patients with CVID is rare, and until now, it has not been reported in a cranial location outside of the parotid gland. We report the cases of 2 patients who had CVID and cranial MALT lymphoma outside of the parotid gland, and we describe their successful treatment with chemotherapy.

Oral solid form of primary effusion lymphoma mimicking plasmablastic lymphoma

Primary effusion lymphoma (PEL) is a rare large cell lymphoma subtype that usually is associated with human immunodeficiency virus infection. Features facilitating PEL identification are its clinical presentation, cytologic findings, immunophenotypic profile, and particularly, relation to human herpesvirus 8 (HHV8) infection. Uncommonly, PEL may present as a solid form that predominantly involves the distal digestive tract and poses major diagnostic problems, especially when unassociated with body cavity effusions. We herein report the case of an HIV-positive 42-year-old male with synchronous presentation of a pleural cavity PEL and a tongue-based lesion, both displaying plasmablastic features. Demonstration of HHV8 presence in the lingual lesion excluded a plasmablastic lymphoma and established the diagnosis of an oral solid form of PEL. This case illustrates the need for investigating HHV8 in any plasmablastic-looking lymphoma, especially in HIV-infected patients.

Application of a mandibular nerve block using an indwelling catheter for intractable cancer pain

We report a case in which a mandibular nerve block using an indwelling catheter was employed for pain management in a terminal case of orofacial cancer. The patient was a 74-year-old female weighing 27 kg. She had a 27-month history of mouth floor and tongue cancer. The cancer recurred and spread to bilateral face and neck. The severest pain mainly originated from the right mandibular region. Two steps of pain relief were performed for the patient. First, pain control using 1% lidocaine or 0.25% bupivacaine administered intermittently or continuously through an indwelling catheter in the mandibular nerve was performed for 1 week to estimate the amount of pain relief thereby obtained. Second, a neurolytic block was applied to the mandibular nerve through the catheter. After the neurolytic block, the total dosage of morphine and diclofenac remained unchanged for 2 months. We conclude from the present case that this technique is an excellent means of obtaining long-term pain control in patients with intractable orofacial cancer pain.

Oral diseases and conditions throughout the lifespan. II. Systemic diseases

Oral diseases may affect general health and many systemic disorders have oral manifestations and implications for dental treatment. This article reviews examples of the oral manifestations of systemic diseases, including oral cancer, diabetes mellitus, and infection from HIV. In addition, the plausible link between periconceptional use of folic acid by the mother and the risk of facial clefts is reviewed. The possible associations between oral infections, specifically periodontal diseases, and both cardiovascular disease and the delivery of preterm low birthweight infants also are reviewed. These and other associations present challenges to dentists, who must evaluate the scientific evidence supporting the associations or alleged causality and select effective treatment options. Both of these challenges require in-depth knowledge of the scientific method, criteria to establish causality, and evaluation of the merit of possible treatment options; in turn, these requirements identify dentists as medical professionals who utilize prevention as the first option in health care, use oral tissues and saliva to diagnose systemic diseases, rely on medical facilities to order laboratory tests, and diagnose and treat patients in close collaboration with their medical colleagues.

Chronic lingual ulceration caused by lipoma of the oral cavity. Case report

Although lipomas are among the most frequent tumors in the human body, their presentation in the oral cavity is not common. Oral cavity lipomas usually show a slow painless and assymptomatic growing. When these tumors reach big sizes, they can cause compressive symptons and deformities. In this paper we present the case of a patient in whom oral lipoma was the final finding in the differential diagnosis of a chronic mucosal ulcer. CT scan and MRI images and microscopical examination after fine-needle aspiration were the clue for the final diagnosis. The surgical excision of the tumor was the basis for the healing of the ulcer. We also review the most relevant and recent literature about clinic, diagnosis and treatment for these tumors.

Quantitative sensory testing in trigeminal nerve damage assessment

Evaluating sensory nerve damage is a challenging and often frustrating process. Diagnosis and follow-up is usually based on the patient's history and gross physical evaluation in addition to simple sensory tests such as brushing or pin prick. Based on evidence accumulated from clinical and animal experiments, quantitative sensory testing (QST) has emerged as a useful tool in the assessment of sensory nerve damage. QST has demonstrated diagnostic capabilities in temporomandibular disorders, burning mouth syndrome, oral malignancies, numb chin syndrome, posttraumatic pain, and whiplash injuries, and in elucidating mechanisms of central sensitization. In this article specific clinical uses of QST are described and its clinical applicability is demonstrated. Future studies should be directed at exploring the use of QST in the diagnosis and classification of further nerve pathologies.

Fanconi's anemia and clinical radiosensitivity report on two adult patients with locally advanced solid tumors treated by radiotherapy

BACKGROUND

Patients with Fanconi's anemia (FA) may exhibit an increased clinical radiosensitivity of various degree, although detailed clinical data are scarce. We report on two cases to underline the possible challenges in the radiotherapy of FA patients.

CASE REPORT AND RESULTS

Two 24- and 32-year-old male patients with FA were treated by definitive radiotherapy for locally advanced squamous cell head and neck cancers. In the first patient, long-term tumor control could be achieved after delivery of 67 Gy with a-in part-hyperfractionated split-course treatment regimen and, concurrently, one course of carboplatin followed by salvage neck dissection. Acute toxicity was marked, but no severe treatment-related late effects occurred. 5 years later, additional radiotherapy was administered due to a second (squamous cell carcinoma of the anus) and third (squamous cell carcinoma of the head and neck) primary, which the patient succumbed to. By contrast, the second patient experienced fatal acute hematologic toxicity after delivery of only 8 Gy of hyperfractionated radiotherapy. While the diagnosis FA could be based on flow cytometric analysis of a lymphocyte culture in the second patient, the diagnosis in the first patient had to be confirmed by hypersensitivity to mitomycin of a fibroblast cell line due to complete somatic lymphohematopoietic mosaicism. In this patient, phenotype complementation and molecular genetic analysis revealed a pathogenic mutation in the FANCA gene. The first patient has not been considered to have FA until he presented with his second tumor.

CONCLUSION

FA has to be considered in patients presenting at young age with squamous cell carcinoma of the head and neck or anus. The diagnosis FA is of immediate importance for guiding the optimal choice of treatment. Radiotherapy or even radiochemotherapy seems to be feasible and effective in individual cases.

Cytogenetic characteristics of oral squamous cell carcinomas in Fanconi anemia

Fanconi anemia (FA) is an autosomal recessive syndrome with a marked predisposition to malignancies, in particular acute myeloid leukemia and squamous cell carcinoma of the oral cavity. We examined oral squamous cell carcinoma tissue from two FA patients (FA-A and FA-C) by comparative genomic hybridization. Both tumors, which were negative for human papilloma as well as Epstein-Barr viral sequences, showed multiple alterations with a high proportion of whole-arm chromosomal gains and losses. This combination of features as well as the sites involved in chromosomal breakage are very similar to what is typically observed in non-FA oral tumors. These results suggest that the process leading to early occurrence of oral cancer in FA patients follows a similar pathway as in non-FA cancer patients, which would support a caretaker function for FA genes in the protection against oral carcinogenesis. Since FA patients are uniquely hypersensitive to DNA cross-linking agents, while oral cancer in the general population is thought to be environmentally induced, these results also suggest that environmental DNA cross-linkers may be causally involved in oral carcinogenesis.

Evaluation of quality of life of patients with oral cavity cancer in three counties of south Bulgaria

AIM

To evaluate the quality of life of patients with oral cavity cancer in three counties of South Bulgaria.

MATERIALS AND METHODS

A standard questionnaire was developed to evaluate the social status. Twenty two patients with oral cancer were interviewed (diagnoses by ICD 9th Revision 141-149). SPSS statistical software version 8.0 was used for statistical analysis employing the alternative analysis and ANOVA.

RESULTS AND DISCUSSION

Oral cancer affects 1) mostly men-68.2%, 2) smokers-59.1% (of the people we interviewed, smoking regularly twenty and more cigarettes daily), and 3) people who consume alcohol on regular basis - 40.9% of the interviewees. The life quality of the interviewed people was evaluated on a specially developed five-degree scale. 22.7% of the interviewed people were classified as first scale group characerised with speaking and alimentary disorders, impaired aesthetics and pains in the oral cavity. 36.4% were scored as the second scale group--these had speaking disorders and disorders of the alimentary tract, oral cavity pain without impairment of the orofacial aesthetics. 27.3% were classified as third scale group in which the patients had only two functions impaired. Group five contained 4.5% of all patients with no manifest disorders.

CONCLUSIONS

The results suggest that oral cancer patients need a lot of prosthetic care to mend their oral defects and a lot of rehabilitation to restore their ability to function socially, a task which must be realized by a rehabilitation team including the general dental practitioner.

[Stomato-oncological screening in diabetic patients]

The data of the literature suggest that studies have not been performed to date on possible correlations between diabetes and precancerous states and tumors in the oral cavity. Internationally, only one investigation appears to have dealt with the incidence of leukoplakia among diabetics. In the present work, stomato-oncological screening was performed on 200 treated diabetics. Precancerous lesions were found in 8%, and benign lesions in 14.5%. Comparison with earlier Hungarian screening studies indicated that benign and precancerous lesions occur with greater frequency among diabetics than in the average population. The proportion of oral cavity lesions is higher among diabetics of type 2 than among those of type 1. The combination of diabetes mellitus and smoking means an enhanced risk from the aspect of precancerosis of the oral cavity.

Lymphoma in the infraorbital region

BACKGROUND

B-cell lymphomas are rare neoplasms in the oral cavity. They are significant to dentists because the oral complications associated with treatment mean that dentists can play an important role in their detection.

CASE DESCRIPTION

The authors describe the case of a 55-year-old man with nonhealing ulcers, swelling and pain six months after maxillary left canine extraction. As it occurred in the infraorbital region after canine tooth extraction, the authors suspected B-cell lymphoma. Clinical examination revealed infraorbital edema with regional submandibular lymphadenopathy. Intraoral examination revealed a nonhealing ulceration with ill-defined borders in the surrounding mucosa. It was 5- x 5-centimeters in diameter and gray-white. The histopathologic examination showed diffuse, atypical, lymphoid cell infiltration and immuno-histochemically positive staining. After the histopathologic examination, the authors referred the patient to a medical center for treatment.

CLINICAL IMPLICATIONS

Dentists should look for signs of B-cell lymphoma when a patient has extended pain and swelling after an extraction.

[Mouth dryness and burning sensation of the oral mucosa: causes and possibilities for treatment]

Both sets of complaints, mouth dryness and a burning sensation of the oral mucosa, can have a variety of causes. Local and regional as well as systemic causes can be responsible for burning mouth syndrome. Diseases of the oral mucosa can have genetic, inflammatory, or neoplastic origins. Autoimmune diseases and allergies as well as different afflictions relating to internal medicine can be accompanied by a burning sensation in the oral mucosa. Neurological and psychiatric illnesses must be clarified during interdisciplinary diagnostics in order to identify idiopathic forms. The causes of mouth dryness are similarly complex. In addition to inadequate fluid intake, particularly in elderly patients, drug side effects or systemic diseases are frequently also responsible. Treatment is directed at the underlying disease; in ambiguous cases, symptomatic therapy can provide relief for medical complaints.