Oral and dental health in alcohol misusing patients

Dental and oral health and their relationship to nutritional status among a group of alcohol misusers (n = 107) from south London is reported. The Alcohol Use Disorders Identification Test (AUDIT) questionnaire was validated as an accurate and reliable screening questionnaire for use in alcohol misuse detection by a dentist. Half of the study population consumed >200 units of alcohol/week, and 80% were heavy smokers. A high incidence of tooth wear and trauma to the dentition was recorded. Eight subjects had oral mucosal lesions, including two previously treated carcinomas. The dental health in alcoholics overall was not compromised, but nutritional impairment (body mass index and reduced midarm muscle circumference) was associated with periodontal lesions. Oral mucosal health of alcoholics is of concern, particularly in heavy smokers. The interrelationships between dental-oral health and alcohol-tobacco usage have implications for preventative counseling in this patient group.

Localised oral histoplasmosis lesions associated with HIV infection

Opportunistic fungal infections account for a significant amount of morbidity associated with HIV disease. We report here a case of localised oral histoplasmosis without evidence of disseminated disease in a patient who lacked stigmata of HIV disease at the time of initial presentation. The diagnosis is based on histology with special stains, complement fixing antibodies in serum, and culture of the organism from fresh tissues. Activation of subclinical disease following an infection in Uganda may explain the development of these exophytic oral lesions in this British resident.

Option-4 algorithm for automated disc probe: reduction in the variance of site-specific relative attachment level measurements

Physical periodontal measurement is plagued by many confounders which result in aberrant values. Replicate measurements can reduce the number of aberrant values, the measurement error, and the variance of site-specific measurements. This study aimed to reduce the variance of site-specific measurements by using a new clinical algorithm (the Option-4 algorithm) for an automated disk probe. A single clinician recorded full-mouth relative attachment levels (RAL) at one visit in 32 patients (mean age 45.5 years) with moderately advanced chronic adult periodontitis. RAL was recorded over two passes at six sites per tooth (4,675 sites). The algorithm accepted the first and second pass RALs (RAL1 and RAL2) if their difference was < or = 1 mm, otherwise a maximum of two further RALs (RAL3 and RAL4) were recorded until the difference between any two RALs was < or = 1 mm (SAL1 and SAL2): 4,048 sites (86.6%) required two recordings, 580 sites (12.4%) required three recordings and 47 sites (1%) required four recordings. Correlation coefficients for RAL1 and RAL2 and SAL1 and SAL2 (4,675 sites) were both > or = 0.91 (P = 0.00). Site-specific variances were calculated for RAL1 and RAL2 and SAL1 and SAL2. The mean of the RAL1/RAL2 site-specific variances (A) was 0.45 mm2 (range 0.00 mm2 to 35.28 mm2) whilst the mean of the SAL1/SAL2 variances (B) was 0.09 mm2 (range 0.00 mm2 to 0.5 mm2): the respective medians were 0.08 mm2 and 0.02 mm2. The study demonstrated high intra-examiner RAL reproducibility. The Option-4 algorithm produced an 80% reduction in the mean site-specific variance of RAL1/RAL2 (Y) and a 75% reduction in the median site-specific variance of RAL1/RAL2 (y = [(A - B)/A] x 100).

Important differences in clinical data from third, second, and first generation periodontal probes

This study compared relative attachment levels (RAL) and probable crevice depths (PCD) from 6 periodontal probes (1 third, 4 second, and 1 first generation). A single clinician recorded RAL and PCD in 6 patients with chronic adult periodontitis (mean age 48.2 years) during two visits (interval: 1 week) using a Latin square examination order. Replicate measurements were recorded at the 4 interproximal sites of the Ramford index teeth to examine intra-probe differences. Additional single measurements were recorded at similar sites of units 11, 26, 31 and 46 to investigate interprobe differences. Intra-probe RAL and PCD reproducibility was < or = 1 mm at > 94% of the sites. All intra-probe Pearson correlation coefficients were > 0.85 (P = 0.00). Inter-probe RAL and PCD agreement was < or = 1 mm at > 49% of the sites for RAL and > 61% of the sites for PCD. All inter-probe Pearson correlation coefficients were > 0.42 (P = 0.00) for RAL and > 0.49 (P = 0.00) for PCD. Analyses of variance showed significant differences in RAL and PCD between the first generation probe and the second generation probes (P < 0.005); in RAL between the third generation probe and the first and second generation probes (P = 0.0354); and in PCD between the third generation probe and the first and second generation probes (P = 0.0475). Inter-probe differences were clinically significant in the recorded percentages of pockets > or = 4 mm and > or = 6 mm. Significant inter-probe differences were found in RAL and PCD which have clinical importance in data interpretation and comparison.

Evaluation of multiple micronutrient supplementation in the management of oral submucous fibrosis in Karachi, Pakistan

Oral submucous fibrosis (OSF) is an oral precancerous condition characterized by symptoms such as intolerance to spicy food, altered salivation, progressive difficulty in opening the mouth, and signs like vesiculation, ulceration, blanching, rigidity, and stiffening of the oral mucosa and depapillation and altered mobility of the tongue. It is seen mostly among people of Indian subcontinent origin. The major structural change is extensive fibroelastic scarring of the lamina propria and deeper connective tissues. A combination of micronutrients (vitamins A, B complex, C, D, and E) and minerals (iron, calcium, copper, zinc, magnesium, and others) was evaluated for its efficacy in controlling the symptoms and signs of OSF in 117 compliant subjects in Karachi, Pakistan, in a single-arm preliminary study. The subjects received supplementation for one to three years. Significant improvement in symptoms, notably intolerance to spicy food, burning sensation, and mouth opening, was observed at exit. The interincisor distance deteriorated in 11 subjects (10%) at exit; it was stable in 56 subjects (49%) and improved in 48 (41%). The mean interincisor distance was 19.1 +/- 10.8 (SD) mm at exit compared with 16.2 +/- 7.5 mm at baseline. A significant proportion of concomitant lesions like leukoplakia also regressed at exit. The major outcome from this study was a beneficial clinical response in subjects with OSF to multiple micronutrient intervention, which justifies its further evaluation in well-designed randomized controlled trials in other settings in South Asia.

Increased titre and avidity of IgG antibodies to Porphyromonas gingivalis whole cells and a cell surface protein in subjects with adult periodontitis

The titre and avidity of IgG antibodies to Porphyromonas gingivalis whole cells and a 47 kDa cell surface protein were determined in serum samples taken from 20 subjects with adult periodontitis and 20 controls, matched for age, gender, ethnic origin and oral hygiene status. Antibody titres were measured by ELISA and antibody avidity was determined by a chaotrope-dissociation ELISA. Avidity was defined as the molarity of chaotrope required to reduce absorbance by 50% (ID50). The mean IgG antibody log titre to whole cells (8.29 vs. 6.92; p < 0.01) and to the 47 kDa antigen (7.61 vs. 6.77; p < 0.05) were higher in cases than in controls. Mean IgG antibody avidity to whole cells (4.59 vs. 2.47; p < 0.001) and to the surface protein (2.54 vs. 1.67; p < 0.001) were also higher in cases than in controls. In cases, IgG antibody titre was highly correlated with avidity for both whole cells (r = 0.878; p = < 0.001) and the 47 kDa protein (r = 0.683; p < 0.001). There was a weaker positive correlation between the titre and the avidity of antibody to whole cells (r = 0.591; p < 0.01) in the control population but antibody titre and avidity for the 47 kDa sonicate antigen were not correlated in the controls (r = 0.104). We conclude that many patients with adult periodontitis have effective humoral immunity to P. gingivalis. However, in up to half the patients with adult periodontitis, antibody titres and avidities were low and similar to control values, indicating either susceptibility due to poor host response or that disease is not associated with this particular pathogen.

Oral health in alcohol misusers

One hundred and seven chronic alcohol misusers (mean age 42.9 years; range 21-65 years; 80 males) attending four centres in South East London were interviewed on their current and past alcohol consumption. Their nutritional status (body mass index (BMI) and mid arm muscle circumference) was also recorded. Each subject completed a dental and oral mucosal examination. Ninety four per cent of the sample consumed greater than 50 units of alcohol per week and 80 per cent greater than 100 units of alcohol per week. Smoking and alcohol misuse were found to be related, 81 per cent reporting both habits. Neither plaque index scores or mean subject pocket depths were correlated with alcohol consumption but both were positively correlated with the frequency and duration of smoking. Overall mean DMFT was 15.4; age specific mean DMFT and tooth loss of the sample were closely similar to the 1988 United Kingdom adult dental health survey data. The prevalence and severity of tooth wear and attrition were greater in the sample than levels described in the literature and these dental features may prove useful markers to the practitioner. Trauma to teeth and oral mucosae was noted in 25 per cent of the sample. Seven oral mucosal lesions (including one treated carcinoma) were detected; mucosal trauma could have acted as a co-factor. Furthermore, 21 per cent of the alcoholics were malnourished (BMI < 20). It is concluded that, unlike several reports from the United States, dental health in this sample of alcoholics is not compromised; however mucosal health is a cause for concern.

Risk factors associated with Epstein-Barr virus replication in oral epithelial cells of HIV-infected individuals

OBJECTIVE

To examine risk factors associated with Epstein-Barr virus (EBV) replication in the oral epithelium of an HIV-infected cohort.

DESIGN

Longitudinal study of behavioural, medication and immunological parameters of HIV-1-seropositive outpatients attending a genitourinary clinic. Outcome measure was EBV DNA positivity in curetted oral squames, as detected by in situ hybridization. Logistic regression for repeated observations of the same individuals was used to analyse how risk changed over time.

RESULTS

Fifty six individuals were studied; 158 patient-visits were made in total (mean, 2.8). Of 137 samples curetted from the tongue, 36 were positive for EBV DNA. Recreational drug use, oral sexual practices, therapy with zidovudine and aciclovir, and changes in CD4 and total lymphocyte counts were not associated with changes in risk. Alcohol drinking, elevated CD8 lymphocyte counts and fluconazole therapy were associated with a decreased risk, and cigarette smoking with increased risk.

CONCLUSION

Behavioural and HIV-specific immunological changes may play important roles in promoting and affecting the course of oral EBV replication. Rigorous anticandidal therapy and avoidance of cigarette smoking may retard the development of oral hairy leukoplakia.

Toombak-associated oral mucosal lesions in Sudanese show a low prevalence of epithelial dysplasia

Clinical (n = 281) and histopathological (n = 141) characteristics of toombak-associated oral mucosal lesions detected in an epidemiological study in northern Sudan in 1992/93 are described. The lesional site in the majority of toombak users was the anterior lower labial groove and the lower labial mucosa. 4 degrees (1-4) of clinical severity of lesions, similar to those used to characterise Swedish snuff-dipper's lesion, were applied. An association between the severity of mucosal lesions and a longer lifetime duration (> 10 years) of toombak use was found, but the severity was not related to the daily frequency of the habit. Parakeratosis, pale surface staining of the epithelium and basal cell hyperplasia were commonly observed, but epithelial dysplasia was infrequent (10/141). The most significant observation was a PAS-positive amorphous deposit between the lamina propria and the submucosa, found in 25/141 biopsies. The clinical and histopathological features of toombak lesions are closely similar to Swedish moist snuff-dipper's lesions and this may reflect the high alkalinity of these products, resulting in an alkaline burn on the oral mucosa following chronic exposure. The low prevalence of epithelial dysplasia implies a low risk of malignant transformation. Nevertheless, the high concentrations of tobacco-specific nitrosamines present in toombak, and the high prevalence of oral cancer in Sudan, mandate biopsy and careful histopathological analysis of any such lesions detected in habitues.

Strengths and weaknesses of screening programmes for oral malignancies and potentially malignant lesions

Screening for oral cancer is in an early stage of development. No randomized controlled trials have been undertaken to determine the impact of screening on mortality or even on interim outcomes such as incidence or down-staging. Until such data are available, mass screening for oral cancer is not recommended as public health policy. Case finding studies to identify individuals at risk because of life-style, and to detect potentially malignant oral mucosal changes followed by appropriate intervention may, however, reduce the future incidence of oral cancer. Where manpower is available, opportunistic screening focused on high-risk subjects may be beneficial.

Sensitivity and specificity of OraScan (R) toluidine blue mouthrinse in the detection of oral cancer and precancer

The efficacy of 1% toluidine blue in the identification of oral malignancies and potentially malignant oral lesions was evaluated among a group of Asian patients (n = 102) with undiagnosed oral mucosal lesions and conditions (n = 145). The trial, utilising a ready-to-use kit, was controlled by histopathologic evaluation of a total of 87 dye-retained or dye-negative lesions. Eighteen oral carcinomas all retained the dye and there were no false negatives, yielding a test sensitivity of 100%. Eight of 39 oral epithelial dysplasias were toluidine blue-negative, giving a false negative rate of 20.5% and a sensitivity of 79.5% for oral epithelial dysplasias. The specificity of the technique was low (62%). Five dysplastic lesions were detected solely by the kit and this suggests that the method is valuable for surveillance of high-risk subjects in addition to its remarkable sensitivity in the detection of invasive carcinoma.

Hereditary and environmental risk factors; clinical and laboratory risk matters for head and neck, especially oral, cancer and precancer

The continuing high incidence and mortality of squamous cell carcinoma of the upper aerodigestive tract in South Asia, parts of France and central Europe, together with a rising incidence and mortality from a lower base elsewhere in the Western world, stimulates continuing research on risk factors and risk markers. Tobaccos (smoked and smokeless), heavy alcohol consumption, and areca nut remain the dominant risk factors, with confirmation of the protective effects of diets rich in antioxidants. There is emerging evidence of a small, but real, risk associated with occupational and other air pollution, and with family, part of which may be hereditary. Markers in peripheral blood and saliva are underexploited. Clinical staging and histological grading methods continue to be refined, with improved prognostic value, much aided by newer and simpler methods for estimating cell proliferation and apoptosis. Data on the significance of viral genes are still inadequate, but there is good progress describing the epidemiology of chromosomal abnormalities and abberations of a growing list of oncogenes and tumour suppressor genes. Unfortunately, as yet, these have only limited longitudinal or prognostic data.

Management of potentially malignant oral mucosal lesions by consultant UK oral and maxillofacial surgeons

This paper describes the results of a recent survey carried out under the auspices of the Professional Education and Evaluation Subgroup of the UK Working Group on Screening for Oral Cancer and Precancer. The aim of this survey was to assimilate information regarding currently used management options of potentially malignant oral lesions as a basis from which to rationalise our future approach to their management. The survey has confirmed that variation exists among oral and maxillofacial consultants in their approaches and a more formal approach to management may therefore be indicated.

Elevated conversion of alpha-2-macroglobulin to the complexed form in gingival crevicular fluid from adult periodontitis patients

The broad spectrum protease inhibitor, alpha 2-macgrolobulin (alpha 2M), is one of the host's principal regulators of both endogenous and exogenous proteases and is likely to have an important role in the regulation of proteolytic activity at inflammatory sites. We have determined the amount of complexed (com alpha 2M) and total alpha 2M (tot alpha 2M) in gingival crevicular fluid (GCF) harvested from shallow and deep sites in adult periodontitis (AP) patients (n = 21). An ELISA technique was developed to measure both forms of alpha 2M in the same sample utilizing a monoclonal antibody (MAb) specific for the complexed form. In addition, protease activity towards human serum albumin (Prot1), transferrin (Prot2) and N alpha-benzoyl-L-arginine 7-amido-4-methylcoumarin-hydrochloride (BAAMc; Prot3) were determined in a second GCF sample from the same site. Plasma alpha 2M concentrations were only positively correlated (p = 0.0163) with GCF tot alpha 2M from highly inflamed sites. We observed a significant positive correlation between tot alpha 2M and proteolytic activity in GCF from deep sites but not from shallow sites (Prot1: p = 0.002; Prot2: p = 0.005). A similar correlation between tot alpha 2M and proteolytic activity was found at highly inflamed sites (Prot1: p = 0.014; Prot2: p = 0.002). A very high proportion of the tot alpha 2M in GCF was in the complexed form at both shallow (71.14% +/- 29.13) and deep sites (68.17% +/- 28.5) Com alpha 2M was positively correlated with proteolytic activity only in deep sites (Prot1: p = 0.015; Prot2: p = 0.031). Our results suggest that the concentration of tot alpha 2M in the gingival crevice is positively associated with the amount of proteolytic activity at the site and that protease activities in GCF may only partly explain the high percentage conversion alpha 2M to the complexed form. The high level of alpha 2M inactivation in GCF from AP patients reported here may have significance not only in view of its role as a broad spectrum protease inhibitor but also through the differential effects of native vs complexed alpha 2M on the regulation of immune responses.

Incompleteness of oral cancer registration in south-east England, 1971-87

Our objective was to examine the accuracy of reporting oral cancer cases to the cancer registry system. We examined a series of 583 patients with oral malignancies treated at several institutions and reported by our laboratory during 1971-87. Using patient details and pathology diagnosis, we traced the entries for these patients in the Thames Cancer Registry (TCR). Of the 583 patients identified 351 were eligible for entry in TCR. Of these, 255 were traced in the Registry and 96 were not (27%). The data, when separated for the period 1971-80 and post-1980, showed that for the earlier period under-reporting was 21% and for the later period 36%: Underascertainment was particularly marked in the mid-1980s while regional registration in the North Thames Regions was being discontinued and taken over by TCR. The major factors contributing to under-reporting are thought to be the fact that many specialised dental units and oral pathology laboratories may fail to be included in the cancer registration process and possible inconsistencies in death-initiated registrations related to this site. Similar levels of under-reporting were observed in another regional registry (South Western), suggesting that this may be a national problem. If this is the case, national incidence rates for mouth cancer may have been underestimated by about 25% during this period. This contrasts with over 90% completeness of registration for cancers as a whole.

Preventive therapy for periodontal diseases

Rational approaches to the prevention of destructive periodontitis should be based on a clear understanding of etiology and pathogenesis. However, we are dealing with a heterogeneous family of diseases in which different factors operate. It is an oversimplification to regard poor oral hygiene, and hence an accumulation of non-specific dental bacterial plaque, as the major risk factor. Epidemiological evidence indicates that host factors are likely to be of overriding importance for the most severe forms. The limitations of nonspecific plaque control are therefore discussed. Specific inhibitors of virulence factors provide a logical approach, but their clinical application awaits improved knowledge. Improvement of general health and resistance to disease by proper nutrition, the avoidance of intercurrent disease, and elimination of smoking and stress-induced risk are encouraged. The genetic basis of susceptibility to periodontitis is increasingly understood, and, while gene therapy is not likely to be a practicable approach to prevention, genetic markers of risk are emerging.

Association of overexpression of p53 oncoprotein with the state of cell proliferation in oral carcinoma

p53 is a nuclear phosphoprotein recognised as important in the regulation of normal cell growth and proliferation, the wild-type protein suppressing cell division. Expression of presumptive mutant protein, detected by immunohistochemistry, is used increasingly as a diagnostic and prognostic marker in human neoplasms. A question arises as to whether or not p53 (over)expression in a lesion is any more or less informative than other markers of cell proliferation. Twenty well-differentiated oral squamous cell carcinomas which had earlier been examined for immunoreactivity against a panel of p53 antibodies were examined for the status of cell proliferation--both in islands of invading neoplastic cells and in the non-malignant epithelial margins. The status of epithelial cell proliferation was found to be significantly higher in p53-positive tumours when enumerated by Ki-67 antibody, both within the tumour as well as its margins. This may confer a growth advantage to these neoplasms and reflect a status of inactivated p53 protein, although the actual cause of the rapid proliferation may lie in activation/inactivation of other genes. The PCNA labelling indices, on the other hand, were closely similar in both p53-positive and -negative groups, suggesting that stabilisation of p53 protein does not influence the proliferative advantage in these carcinomas via a deregulation step of PCNA-related gene products.