Guide to epidemiology and diagnosis of oral mucosal diseases and conditions. World Health Organization

Malignant transformation of oral potentially malignant disorders in males: a retrospective cohort study

Background

Oral squamous cell carcinoma could be preceded by clinically evident oral potentially malignant disorders (OPMDs). Transformation of OPMDs to cancer has been studied in several population groups. It is difficult to undertake comparisons across populations due to variations in the methods of computation of malignancy rates among different studies. The aim of our study was to estimate the rate of malignant transformation of OPMDs taking into account the duration of follow-up and to identify the significant factors indicative of malignant potential.

Methods

A total of 148 male patients with OPMDs were included. They were selected among all consecutive subjects registered at the maxillofacial clinic at a medical hospital in Kaohsiung, Taiwan. The mean follow up period was 37.8 months.

Results

The malignant transformation rate was highest in subjects diagnosed with oral epithelial dysplasia. In this group the transformation rate was 7.62 per 100 persons-year. The rate in the group with verrucous hyperplasia (VH) was 5.21 per 100 persons-year, and in those with hyperkeratosis or epithelial hyperplasia was 3.26 per 100 persons-year. The anatomical site of OPMDs was the only statistically significant variable associated with malignancy. The hazard rate ratio (HRR) was 2.41 times for tongue lesions when compared with buccal lesions.

Conclusion

The reported discrepancies of malignant transformation of OPMDs involve the follow-up time to cancer development and hence it is preferable to use a time-to-event estimation for comparisons. We found that malignant transformation of OPMDs involving the tongue was significantly higher than in other anatomical subsites after adjusting for the clinicopathological type or lifestyle factors at diagnosis.

The effect of smoking on periodontal health of 15- to 16-year-old adolescents

BACKGROUND

Smoking is a severe risk factor for periodontal health in adults, but data on the effect of smoking on periodontal health in teenage populations are sparse. The aim of this study was to investigate the effect of duration and quantity of smoking on periodontal health in teenagers and possible differences between genders.

METHODS

The oral health of 501 adolescents (15- to 16-year-old boys [n = 258] and girls [n = 243]) was examined. A structured questionnaire about self-reported smoking and health habits was filled out, and bitewing x-rays were taken. Clinical examinations included measuring periodontal indexes, such as visible plaque index, bleeding on probing, root calculus (RC), probing depth, and attachment loss. Results were analyzed by generalized linear logistic regression.

RESULTS

Twenty-five percent of boys and 27% of girls were smokers. The boys and girls who smoked had higher RC values than non-smokers (P <0.001). The adjusted scores for smoking boys and girls were 17.3 (95% confidence interval [CI]: 8.6 to 31.7) and 13.6 (95% CI: 5.5 to 29.7), respectively. The adjusted scores for non-smokers were 10.4 (95% CI: 5.7 to 18.3) and 7.7 (95% CI: 3.3 to 17.3), respectively. Smoking boys and girls also had more periodontal pockets > or =4 mm than non-smokers: the score for boys was 4.6 (95% CI: 2.2 to 9.1), and the score for girls was 5.4 (95% CI: 1.1 to 23.2; P <0.001).

CONCLUSION

Smoking significantly impaired periodontal health in teenagers.

Species distribution and in vitro antifungal susceptibility of oral yeast isolates from Tanzanian HIV-infected patients with primary and recurrent oropharyngeal candidiasis

Background

In Tanzania, little is known on the species distribution and antifungal susceptibility profiles of yeast isolates from HIV-infected patients with primary and recurrent oropharyngeal candidiasis.

Methods

A total of 296 clinical oral yeasts were isolated from 292 HIV-infected patients with oropharyngeal candidiasis at the Muhimbili National Hospital, Dar es Salaam, Tanzania. Identification of the yeasts was performed using standard phenotypic methods. Antifungal susceptibility to fluconazole, itraconazole, miconazole, clotrimazole, amphotericin B and nystatin was assessed using a broth microdilution format according to the guidelines of the Clinical and Laboratory Standard Institute (CLSI; M27-A2).

Results

Candida albicans was the most frequently isolated species from 250 (84.5%) patients followed by C. glabrata from 20 (6.8%) patients, and C. krusei from 10 (3.4%) patients. There was no observed significant difference in species distribution between patients with primary and recurrent oropharyngeal candidiasis, but isolates cultured from patients previously treated were significantly less susceptible to the azole compounds compared to those cultured from antifungal naïve patients.

Conclusion

C. albicans was the most frequently isolated species from patients with oropharyngeal candidiasis. Oral yeast isolates from Tanzania had high level susceptibility to the antifungal agents tested. Recurrent oropharyngeal candidiasis and previous antifungal therapy significantly correlated with reduced susceptibility to azoles antifungal agents.

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.

Lesions of the oral mucosa: an epidemiological study of 23785 Mexican patients

This study is a cross-sectional report of oral mucosal lesions in 23785 patients more than 15 years of age who requested elective dental care in a dental school. Among the patients examined, the general lesion rate was 356.60 lesions per 1000 patients. Sixty-eight entities were identified, the lesions being more common among males. White, red, and ulcerated lesions were seen to predominate, associated mostly with chronic irritative causative factors. The prevalence rates of individual oral mucosal lesions ranged from 0.55 to 105.36 per 1000 patients examined. Age and sex assessment showed some differences in the type and presentation rates of the lesions. These and other epidemiological aspects are discussed.

Prevalence of oral cancer and pre-cancer and associated risk factors among tea estate workers in the central Sri Lanka

BACKGROUND

To screen for oral cancer or not is being debated, but for high-risk populations with minimal access to regular dental care systematic oral examinations could provide some benefit.

METHODS

We undertook oral mucosal examinations of labourers employed in tea estate plantations in Sri Lanka. In a two-stage screening procedure, first by estate medical officers and then by visiting specialists, we examined 12 716 persons at their workplaces achieving a coverage of one-sixth of the total workforce.

RESULTS

Fourteen oral cancers and 848 subjects with oral pre-cancer (6.7%) were detected giving population prevalences of 46.1 per 1000 for leukoplakia and 16.4 per 1000 for oral submucous fibrosis. Among subjects with any oral mucosal disorder (n = 1159) proportions of current users of betel quid, smokers and alcohol use was recorded at 92%, 31% and 61% respectively. The synergistic effect of these three risk habits on the development of oral leukoplakia was evident in mixed habit groups.

CONCLUSIONS

The prevalence of oral pre-cancer in tea estate labourers was higher than estimates reported in previous studies. In the absence of state-sponsored preventive activities, it is necessary to improve the capacity of individual health practitioners and small medical centres to participate in oral health promotion and oral cancer/pre-cancer screening.

Profile of the oral health among ambulant older Greek and Italian migrants living in Melbourne

BACKGROUND

Over the last 50 years an increasing number of migrants have settled in Australia. These immigrants now constitute a large proportion of the Australian population, and some research suggests that they may be at high-risk for oral diseases.

METHODS

This paper presents data on the oral health status of a convenience sample of 721 ambulant Greek- (n = 367) and Italian-born (n = 354) adults aged 55 years or older. The volunteer participants were recruited through ethnic social clubs located in Melbourne, Australia.

RESULTS

The sample was largely a dentate one (83.6 per cent); with a mean DMFS score of 67.5 (s.d. 37.4). Dentate participants had 13 per cent of their restorative care unmet, and 57.3 per cent needed oral hygiene instruction plus removal of stain and hard deposits on their teeth. Almost 8 per cent required complex periodontal therapy and 30 per cent of those fully edentulous were in need of full dentures.

CONCLUSIONS

Comparing these findings with existing data on oral health of older adults in Australia, the participants in this study appear to have lower DMFS scores and a higher prevalence of gingivitis, but less need for complex periodontal treatment. Inequalities were apparent in the proportion of unmet restorative and prosthetics needs.

Investigation of functional gene polymorphisms: IL-1B, IL-6 and TNFA in benign migratory glossitis in Brazilian individuals

BACKGROUND

Benign migratory glossitis (BMG) is a very common immunological oral disease of unknown aetiology.

METHODS AND SUBJECTS

Fifty-three consecutive subjects affected by BMG and 53 age- and sex-matched control subjects were genotyped for IL-1B, IL-6 and TNFA polymorphisms. Binary logistic regression models were fitted and values of P < 0.05 were considered significant.

RESULTS

A significant difference in the distribution of IL-1B genotypes was observed in the group with BMG in univariate analyses (P = 0.01). The multivariate analyses showed that the CT genotype of the IL1-B gene was significantly associated with a high risk to develop BMG (P = 0.02, OR 2.76). The combined presence of IL-1beta high and intermediate producers genotypes was also associated with BMG in multivariate analyses (P = 0.01, OR 3.05). IL-6 and TNFA polymorphisms were not associated with BMG in the univariate and multivariate analyses.

CONCLUSION

Our findings demonstrate that the polymorphism +3954 IL-1B is associated with an increased risk of BMG development and suggest a genetic basis for disease development.

Oral lichen planus and chronic hepatitis C: a controversial association

Our aim was to study the possible association between oral lichen planus and chronic hepatitis C in patients from the state of Minas Gerais, Brazil. Two groups of patients were studied: group 1, 50 patients with oral lichen planus evaluated for the presence of chronic hepatitis C; and group 2, 215 patients with chronic hepatitis C examined for evidence of oral lichen planus. Diagnosis of oral lichen planus in both groups was based on clinical and histologic findings. One case of chronic hepatitis C was diagnosed in group 1 (2.0%), which was not considered statistically significant (P = .464). In group 2, the prevalence of oral lichen planus was 2.3% (5 cases), which showed statistical significance (P = .002). Although our results suggest oral lichen planus as an extrahepatic manifestation of chronic hepatitis C in the studied population, the association between these two entities should be further investigated.

Relationship between cognitive impairment and oral health: results of the Health 2000 Health Examination Survey in Finland

OBJECTIVE

The aim was to study oral health in relation to cognitive impairment in the general population.

MATERIAL AND METHODS

The study population comprised 2320 persons aged 55 years or older who participated in a nationally representative Health 2000 Health Examination Survey in Finland. The data were collected by interviews and clinical oral examinations. Cognition was assessed using a shortened version of the Mini-Mental State Examination (score 0-16). Poisson regression models were used to estimate the relative risk (RR) for continuous variables and logistic regression models to estimate the odds ratio (OR) for dichotomized variables.

RESULTS

The results show that individuals with cognitive impairment have more carious teeth (MMSE 11-10: RR: 1.3, CI: 0.9-1.7, MMSE 9-0: RR: 1.5 CI: 1.0-2.4) than healthy persons. Furthermore, compared to cognitively healthy subjects, those with MMSE 9-0 more often have no teeth and no dentures (OR: 5.2, CI: 1.0-26.6) and less often good denture hygiene (OR: 0.4, CI: 0.2-0.7).

CONCLUSION

Cognitively impaired subjects among older adults in Finland have more carious teeth, are more often edentulous without using a denture, and have poorer denture hygiene than cognitively healthy persons.

Prevalence of oral cancer and potentially malignant lesions among shammah users in Yemen

The purpose of this study was to assess the prevalence of oral precancerous lesions and squamous cell carcinoma (OSCC) in Yemeni users of shammah, a traditional smokeless tobacco habit known in the Arabian Peninsula. The study group comprised 199 male and one female shammah users who were interviewed via a standardised questionnaire and clinically examined in 48 Yemeni villages and cities. Cases with oral leukoplakia (OL) or mucosal burns (MB) were compared with users without any lesion. MB were detected in 31%, of which 46.8% were located on the tongue or floor of the mouth, and OL in 27%, of which 59.2% were located in the same region. In addition, two cases (1%) of apparent OSCC were identified. Statistically significant increased OR (95% CI) of OL were (a) 6.91 (2.66-17.95) for an average duration of the respective shammah application >5min.; (b) 4.90 (1.99-12.08) for a daily frequency of those applications >10; and (c) 4.22 (1.43-12.43) for a daily duration >6h of chewing qat, also a traditional habit in Yemen. Likewise, decreased OR were (a) 0.39 (0.18-0.85) for rinsing the mouth after the shammah application; (b) 0.36 (0.17-0.78) for successful attempts to stop the use in the past; and (c) 0.26 (0.09-0.72) for existing knowledge about the carcinogenicity of shammah that was present in only 19% overall. In conclusion, evidence was shown for a significant association between the prevalence of OL and the daily duration of shammah application in a dose-dependent manner. An appropriate public health program might help to reduce this potential OSCC burden in shammah users.

Oral Mucosal Conditions and Risk Factors among Elderly in a Turkish School of Dentistry

BACKGROUND

Prevalence studies are important to determine the oral health status and treatment needs of elderly people. Our aim was to obtain data for the prevalence of oral mucosal conditions (OMC) in a Turkish elderly sample and to compare our results with different geographic regions.

OBJECTIVE

The purpose of this clinical-based study was to determine the prevalence of OMC and associated risk factors in a clinical-based Turkish elderly sample.

METHODS

The study sample consisted of 700 patients >60 years old. The clinical examination of patients was performed by both authors. All participants were questioned about their general health status, medication use, oral hygiene habits, tobacco or alcohol use, use of dentures, and the length of denture use. Chi2 Pearson's test with Fisher's exact probability test was used to analyze the data. Logistic regression models were used to assess the influence of independent variables; odds ratios were calculated with 95% confidence intervals. Statistical significance was defined as p <0.05.

RESULTS

OMC were recorded in 40.7% of the study sample. The logistic regression model revealed that male gender, length of denture use, smoking habit, and being a former smoker increased the probability of having an OMC. Smoking habit also increased the risk of having leukoplakia. The denture-related lesions accounted for 36.4% with the length of denture use and diabetes mellitus being significant risk factors for denture stomatitis and denture hyperplasia. The model for traumatic ulcer included medication use as a significant risk factor.

CONCLUSIONS

Our results regarding an elderly Turkish sample support the studies of other populations where the prevalence of OMC was related to length of denture use, smoking, and gender. We also observed some important associations between denture-related lesions, systemic diseases, and medication use which require further investigation.

Prevalence of oral lesions in 13- to 16-year-old students in Duzce, Turkey

OBJECTIVE

The aim of this study was to determine the prevalence of oral lesions in 13- to 16-year-old students.

METHODS

A cross-sectional survey was carried out on students in Duzce, a province in the western Black Sea region of Turkey. A total of 993 children aged between 13 and 16 from eight secondary schools were examined. Oral lesions with recurrent behavior, if observed, were recorded at the time of examination. Venous blood samples were obtained for detecting hemoglobin levels.

RESULTS

Two hundred sixty adolescents (26.2%) were diagnosed with at least one oral mucosal lesion at the time of the examination. Thirteen different mucosal alterations were diagnosed, and the most common lesions were angular cheilitis (9%), linea alba (5.3%), and aphthous ulceration (3.6%). The correlation between occurrence of mucosal lesions and sex was not statistically significant (P > 0.05). Statistical evaluation of the data revealed a significant relationship only between the presence of angular cheilitis and anemia (P < 0.05).

CONCLUSION

This study is the first epidemiologic study of oral mucosal lesions in adolescents in Turkey. Angular cheilitis was the only oral mucosal lesion that had a significant correlation with anemia.

Oral manifestations of HIV infection in children and adults receiving highly active anti-retroviral therapy [HAART] in Dar es Salaam, Tanzania

BACKGROUND

The aim of the study was to compare the prevalence and types of HIV-related oral lesions between children and adult Tanzanian patients on HAART with those not on HAART and to relate the occurrence of the lesions with anti-HIV drug regimen, clinical stage of HIV disease and CD4+ cell count.

METHODS

Participants were 532 HIV infected patients, 51 children and 481 adults, 165 males and 367 females. Children were aged 2-17 years and adults 18 and 67 years. Participants were recruited consecutively at the Muhimbili National Hospital (MNH) HIV clinic from October 2004 to September 2005. Investigations included; interviews, physical examinations, HIV testing and enumeration of CD4+ T cells.

RESULTS

A total of 237 HIV-associated oral lesions were observed in 210 (39.5%) patients. Oral candidiasis was the commonest (23.5%), followed by mucosal hyperpigmentation (4.7%). There was a significant difference in the occurrence of oral candidiasis (chi2 = 4.31; df = 1; p = 0.03) and parotid enlargement (chi2 = 36.5; df = 1; p = 0.04) between children and adults. Adult patients who were on HAART had a significantly lower risk of; oral lesions (OR = 0.32; 95% CI = 0.22-0.47; p = 0.005), oral candidiasis (OR = 0.28; 95% CI = 0.18-0.44; p = 0.003) and oral hairy leukoplakia (OR = 0.18; 95% CI = 0.04-0.85; p = 0.03). There was no significant reduction in occurrence of oral lesions in children on HAART (OR = 0.35; 95% CI = 0.11-1.14; p = 0.15). There was also a significant association between the presence of oral lesions and CD4+ cell count < 200 cell/mm3 (chi2 = 52.4; df = 2; p = 0.006) and with WHO clinical stage (chi2 = 121; df = 3; p = 0.008). Oral lesions were also associated with tobacco smoking (chi2 = 8.17; df = 2; p = 0.04).

CONCLUSION

Adult patients receiving HAART had a significantly lower prevalence of oral lesions, particularly oral candidiasis and oral hairy leukoplakia. There was no significant change in occurrence of oral lesions in children receiving HAART. The occurrence of oral lesions, in both HAART and non-HAART patients, correlated with WHO clinical staging and CD4+ less than 200 cells/mm3.

Prevalence and risk factors associated with geographic tongue among US adults

OBJECTIVE

To characterize the prevalence of geographic tongue (GT) among US adults.

DESIGN

Population-based case-control study.

MAIN OUTCOME MEASURES

The presence or absence of GT.

SUBJECTS AND METHODS

Data from 16 833 adults examined during The Third National Health and Nutrition Examination Survey, 1988-1994 (NHANES III), a study based on multistage probability sampling were analyzed using SAS-callable SUDAAN 9.0.1.

RESULTS

Geographic tongue point prevalence was 1.8% (95% CI: 1.4, 2.3). Multivariate logistic regression showed significant effects of race-ethnicity, with Whites (AOR = 1.8; 1.3, 2.5) and Blacks (AOR = 1.6; 1.2, 2.1) having greater odds of GT than Mexican-Americans; current corticosteroid therapy (AOR = 3.7; 1.54, 8.6). Cigarette smokers had lower GT prevalence (AOR = 0.4; 0.3, 0.6). Fissured tongue (FT) was strongly associated with GT among non-smokers: AOR = 17.5 (7.8, 39.5). We did not find significant associations with age, gender, oral contraceptive use, diabetes mellitus, allergy or atopy, psychological or dermatological conditions as previous research has suggested.

CONCLUSIONS

Geographic tongue was more prevalent among Whites and Blacks compared with Mexican-Americans, positively associated with FT, and inversely associated with cigarette smoking.

Effective management of smoking in an oral dysplasia clinic in London

BACKGROUND

Precancerous lesions precede the development of oral cancer; of several clinical types the most common is leukoplakia. The risk factors include tobacco and excess alcohol use and diets low in antioxidants. Studies concerning the management of risk factors related to oral precancer are meager.

OBJECTIVES

We investigated the effectiveness of smoking cessation at a dysplasia clinic among patients followed up for at least for 12 months.

METHODS

Data from case notes relating to 180 patients with white and red patches of oral mucosa (excluding other benign disorders confirmed by biopsy findings) attending a dysplasia clinic at a teaching hospital in London and seen by one consultant between 1993 and 2003 were transcribed. Effect of referring to a smoker's clinic to receive specialist help was evaluated against brief advice given at the dysplasia clinic +/- medications.

RESULTS

The mean age at the first visit was 48.5 years (+/-12.5), 65% were male, and 88% were white European. One hundred and sixty-two patients (90%) had used tobacco and 83% were current smokers. Of the smokers 95% had smoked over 10 years, the majority smoking over 10 cigarettes per day. Nine were alcohol misusers including two binge drinkers. One hundred and forty-six were diagnosed with oral leukoplakia, 16 with non-homogeneous types (speckled or nodular). Three patients were diagnosed with an erythroplakia. Nineteen per cent exhibited the presence of dysplasia and one subject had in situ carcinoma. Five patients in the sample quit smoking prior to arrival in the dysplasia clinic. Twenty-seven cases (20%) with oral leukoplakia quit smoking while registered as a patient at the dysplasia clinic: 17 of 100 subjects quit with brief advice +/- medications and 10 of 30 following referral to the smoker's clinic. The difference between the two groups was significant for point prevalence abstinence at the last visit to the clinic (minimum 12 months follow up). Out of a total of 180 precancer cases managed in the dysplasia clinic (mean follow up 4.2 years) three patients subsequently developed invasive carcinoma during follow up.

CONCLUSIONS

Smoking cessation needs to be an integral component of management of cases attending a dysplasia clinic and referring to smoker's clinics could help to improve the effectiveness of managing patients with oral precancer to quit smoking.

Differences in methodologies of measuring the prevalence of oral mucosal lesions in children and adolescents

AIM

This review offers a brief summary of three of the more commonly surveyed and reported oral mucosal conditions found in children, and an appraisal of the variation between selected elements of prevalence study methodologies.

DESIGN

Searches of electronic databases (i.e. MEDLINE, CINAHL, EMBASE and EBM Reviews) were conducted to find publications related to oral mucosal conditions in children. Studies were included and reviewed if they contained data on the prevalence of any of the following oral mucosal conditions: geographical tongue, oral ulceration and herpes labialis in children or adolescents (up to the age of 19 years).

RESULTS

A total of 29 articles out of 333 met the inclusion criteria and were reviewed. Of these 29 reports, 18 considered geographical tongue, 12 herpes labialis and 10 oral ulceration, although a number of the surveys reported on more than one condition. The approaches used in these studies varied on a number of the potentially important areas associated with validity, comparability, and whether or not the findings may be extrapolated beyond the study population, such as the sampling frame, diagnostic criteria, training and calibration, and examination features.

CONCLUSION

Although there were a number of surveys relating to the prevalence of geographical tongue, herpes labialis and oral ulcers in children and adolescents, reported prevalences varied and few studies were directly comparable in terms of the methodology applied. In particular, there was substantial variation between surveys in terms of the diagnostic criteria and method of detection employed although, in many instances, there was inadequate detail to allow full appraisal of the methodology. There is a need for more good-quality epidemiological studies in this area.

Incidence rates for oral leukoplakia and lichen planus in a Japanese population

BACKGROUND

Data on the incidence rates of potentially malignant diseases of the oral cavity in different populations is meagre. This is the first study to report on the age-specific incidence of oral leukoplakia and oral lichen planus from an industrialized country.

METHODS

Annual screening for oral cancer and pre-cancer was undertaken in Municipal Health Centres in Tokoname city, Japan from 1995 to 1998. A total of 9536 volunteers aged 40-95 years participated in this programme. A cohort of 6340 (67%) subjects attended annual mouth examinations following a negative screen result at entry, allowing 13 072 person-years of observations. Some associated risk factors (tobacco and alcohol misuse) and health-related variables were also evaluated.

RESULTS

Over a 4-year follow-up period, 18 new oral leukoplakias (all homogenous; 11 idiopathic and seven tobacco-associated) and 24 oral lichen planus (22 reticular, one erythematous and one ulcerative) were detected at screening and confirmed by re-examination at specialist units. The age-adjusted incidence rate for leukoplakia was 409.2 (95% CI: 90.6-727.9) in male and 70.0 (95% CI: 17.9-121.8) in female per 100,000 person-years observations. For lichen planus, the corresponding rates were 59.7 (95% CI: 7.4-112.1) and 188.0 (95% CI: 96.0-280.1). The age-adjusted incidence rate for tobacco-associated leukoplakia in males was almost 12 times compared with female (560.3 vs. 45.2 per 100,000). Age-specific incidence rates for oral leukoplakia varied by age groups. New oral leukoplakias were more prevalent on gingival/alveolar ridge (33.3%) than in other oral sites, and lichen planus at buccal site (33.3%). Prevalence of smoking habits among those positive for leukoplakia (38.9%) was higher compared with the screen-negatives (26.4%) but these differences did not reach statistical significance (P = 0.232). Regular drinking was not related to occurrence of either oral leukoplakia or oral lichen planus. In cases with diabetes mellitus, relative risk for oral lichen planus adjusted by logistic regression was 6.4 (95% CI: 2.4-17.6), suggesting an association.

CONCLUSIONS

The reported incidence rates for oral leukoplakia in this Japanese population are somewhat higher to those reported from India, the risk habits of the two groups being markedly different. The reported rates for oral leukoplakia and lichen planus allow estimation of service needs in specialist oral medicine clinics and for the training of primary care dentists. A high incidence of idiopathic leukoplakia found in this study raises challenges to the strategy of screening high-risk populations aimed at conserving resources.

Oral precancerous disorders associated with areca quid chewing, smoking, and alcohol drinking in southern Taiwan

OBJECTIVE

To investigate the prevalence and the associated risk factors of oral precancerous disorders in southern Taiwan.

METHODS

We conducted a cross-sectional community survey interviewing 1075 adult subjects, 15 years of age and over, gathered from randomly selected 591 households, and spanning five villages in southern Taiwan. The study protocol included a visual oral soft tissue examination and a questionnaire-based interview. The chi-square test was used to test the differences in prevalence of oral precancerous lesions and conditions by different "life styles" relating to current risk habits of current areca quid chewing, smoking, and alcohol drinking. To control for possible confounding, a logistic regression model was used to estimate the Odds Ratios (OR) for leukoplakia and oral submucous fibrosis (OSF).

RESULTS

136 precancerous lesions and conditions were detected among 1075 subjects (12.7%). The analysis of the spectrum of oral precancerous disorders detected, leukoplakia (n = 80), OSF (n = 17) and verrucous lesions (n = 9), demonstrated an association with gender (P < 0.001). There were statistically significant associations among leukoplakia (P < 0.01), OSF (P < 0.0001), and verrucous lesions (P < 0.0001) and the life style of current areca quid chewing, smoking, and alcohol drinking. The synergistic effect of smoking and areca quid chewing habit on leukoplakia and OSF was demonstrated.

CONCLUSION

This study reinforces the association of current areca quid chewing without tobacco, cigarette smoking, and alcohol drinking to leukoplakia, OSF, and verrucous lesions in Taiwan.

Oral Candida species and betel quid-associated oral lesions in Padaung women of Northern Thailand

Purpose of the present investigation was to study the association between the betel quid chewing (BQC) habits, the oral yeast flora and oral lesions in female Padaung of northern Thailand. Oral swabs were taken from the tongue and palate of 50 Padaung women with and 50 control individuals without BQC habit. The spectrum of oral Candida species in both groups was determined microbiologically. In addition, oral mucosal lesions were registered in both groups. Mean age of BQ chewers was 35.4 years, of non-chewers was 19.2 years. Candida parapsilosis was the most common Candida spp. isolated both in BQ chewers (46%) and non-chewers (44%). Candida albicans was revealed in 24% of BQ chewers and 18% of non-chewers. There was no significant difference in carriage of Candida spp. isolated between both groups. Forty-four per cent of BQ chewers revealed betel chewers mucosa, 10% showed leukoedema. Isolated populations such as the Padaung may reveal different patterns of candidal flora, in this case a predominance of Candida parapsilosis.

Risk factors associated with denture stomatitis in the United States

BACKGROUND

This study reports denture stomatitis (DS) prevalence from a large USA probability sample from the National Health and Nutrition Examination Survey, 1988-1994 (NHANES III).

METHODS

Oral examinations were performed on 3450 individuals 18-90+ years of age (mean: 59.2; SD: 0.50 years), 57.7% male and 42.3% female. Multivariable logistic regression models were fitted for DS using sociodemographic, denture quality, blood analytes, alcohol and tobacco use, history of diabetes, and current antibiotic use as covariates. Odds ratios (OR), adjusted for other covariates in each model (AOR) are presented.

RESULTS

Of 3450 removable denture wearers, 963 (27.9%) had DS. DS prevalence was associated with wearing maxillary (AOR: 6.20) and mandibular (AOR: 5.21) complete dentures continuously; smoking >/=15 cigarettes day (maxillary complete: AOR = 1.31; mandibular complete: AOR = 1.50; maxillary partial: AOR = 2.04); vitamin A deficiency (mandibular complete: AOR = 5.97; maxillary partial: AOR = 5.67; mandibular partial: AOR = 24.42). Maxillary dentures with inadequate relines had approximately half the OR of DS than those with adequate relines (maxillary complete: AOR = 0.42; mandibular complete: AOR = 0.50).

CONCLUSIONS

Denture stomatitis prevalence is associated with the amount of tissue covered by dentures, low vitamin A levels, cigarette smoking, and constant denture wear.

Prevalence of oral mucosal lesions in children and youths in the USA

INTRODUCTION

There is a dearth of studies of oral lesions in children and youths using probability samples of a general population. The present paper describes the results of the Third National Health and Nutrition Examination Survey, 1988-1994 (NHANES III), and compares them to those of the National Survey of Oral Health in US Schoolchildren, 1986-1987.

METHODS

The NHANES III was a large US study based on a multistage probability sample. Dentist examiners were trained to recognize, classify and record, in a standard manner, the clinical characteristics of each of the 48 conditions of interest using procedures based on the World Health Organization's Guide to Epidemiology and Diagnosis of Oral Mucosal Diseases.

RESULTS

Examinations were performed on 10,030 individuals (10.26%) aged between 2 and 17 years, 914 of whom had a total of 976 lesions. The lip was the most frequent site of lesions (30.7%), followed by the dorsum of the tongue (14.7%) and the buccal mucosa (13.6%). Lesions were more prevalent in males (11.76%) than females (8.67%). The most prevalent lesions were lip/cheek bite (1.89%), followed by aphthous stomatitis (1.64%), recurrent herpes labialis (1.42%) and geographic tongue (1.05%). The prevalence of recurrent aphthous stomatitis in the NHANES III child and youth survey was substantially higher than that for adults, while the NHANES III adult estimates for geographic tongue (1.85%; 95% CI 1.42, 2.28) and cheek/lip bite (3.05%; 95% CI 2.36, 3.74) were substantially greater than those for children and youths (0.97% and 2.05%, respectively).

CONCLUSION

Reported prevalences for rare conditions in other studies employing more selected samples (especially if standard errors or confidence intervals are not provided) should be interpreted with caution. Studies of adult populations, however valid, may have limited applicability to children.

The association of tobacco and other factors with recurrent aphthous stomatitis in an US adult population

OBJECTIVE

To determine point and annual prevalence of recurrent aphthous stomatitis (RAS).

SETTING

Reported prevalence of RAS in textbooks and much of the literature varies according to study location, patient selection and whether point prevalence (presence of lesions at examination) or period prevalence (history of lesions during a specified period) is reported. Many studies are based on non-probability samples and this may contribute to significant variation in reported prevalence and factors presumed to be associated with RAS.

METHODS

We analyzed data from the Third National Health and Nutrition Examination Survey, 1988-1994, a large United States probability sample, for RAS and covariates suggested in the literature using bivariate and multivariate logistic regression.

RESULTS

Oral mucosal examinations were performed on 17 235 adults 17 years and older. Of these, 146 (0.89%) had at least one clinically apparent aphthous lesion. For annual (reported) prevalence, Whites (20.87%) and Mexican-Americans (12.88%) had several fold higher prevalence of RAS than Blacks (4.96%). Adults younger than 40 years of age had almost twice the prevalence (22.54%) of those older than 40 years (13.42%).

CONCLUSION

Annual prevalence was significantly higher in whites and Mexican-Americans (compared with blacks), individuals 17-39 years of age, cigarette non-smokers, and those with recurrent herpes labialis history; while it was lower in males. Point prevalence was significantly higher in whites, Mexican-American, individuals 17-39 years of age, cigarette non-smokers, and males.

Recurrent herpes labialis in US children and youth

OBJECTIVE

This study reports data from the Third National Health and Nutrition Examination Study, 1988-1994 (NHANES III).

METHODS

NHANES III was a complex, multistage sample of 33 994 civilian, non-institutional individuals from 19 528 households. Dentist examiners were trained to recognize, classify oral mucosal lesions to include recurrent herpes labialis (RHL). Subjects >or=8 years of age were asked if they had cold sores in the past year and serologic tests for herpes virus type 1 (HSV-1) and type 2 (HSV-2) were performed on blood of youth >12 years of age.

RESULTS

Examinations were performed on 10 032 individuals 2-17 years of age. Overall point prevalence was 1.42% (0.69-2.15); annual prevalence in individuals 8-17 years of age was 14.77% (12.74-16.80); and serologic prevalence of HSV-1 in youth 12-17 years of age was 43.18% (38.88-47.48). When the data were subset to youth 12-17, annual prevalence for seropositives was 24.13% (20.44-27.82) compared with 16.87 (14.16-19.57) for all subjects. Approximately 25% of the seropositive youth had at least one recurrence in the past year.

CONCLUSION

As RHL is a recurrent infection, prevalence in a population will be related to the proportion of the population that has been infected with herpes simplex virus. When lesion-specific prevalences are cited in the literature, they should be stratified by covariates known to be associated with them. Future studies should examine RHL prevalence in infected individuals.

The prevalence of oral mucosal lesions in U.S. adults: data from the Third National Health and Nutrition Examination Survey, 1988-1994

BACKGROUND

Most reports of oral lesion prevalence are based on studies of atypical populations. There are no published studies on oral mucosal lesion prevalence in U.S. adults that are based on a national probability sample.

METHODS

The Third National Health and Nutrition Examination Survey, or NHANES III, employed a complex, multistage sample of 33,994 civilian, noninstitutionalized people from 19,528 households. Dentist examiners were trained to recognize, classify and record in a standardized manner the clinical characteristics of each of the 48 conditions of interest to include diagnosis, size, location, surface morphology, color consistency, pain, duration and history using procedures based on the World Health Organization's Guide to Epidemiology and Diagnosis of Oral Mucosal Diseases.

RESULTS

Examinations were performed on 17,235 people aged 17 years and older, of whom 4,801 (27.9 percent) had a total of 6,003 lesions. Denture-related lesions (stomatitis, hyperplasia, ulcers, inflammation and angular cheilitis) composed 8.4 percent and tobacco-related lesions (smokeless tobacco-related and nicotinic stomatitis) composed 4.7 percent of all lesions. Discounting denture-related lesions, amalgam tattoos were the most prevalent lesions (3.30 percent), followed closely by cheek/lip bites (3.05 percent) and frictional white lesions (2.67 percent). Smokeless-tobacco users (odds ratio, or OR, = 3.90) and removable denture wearers (OR = 3.57) had the highest odds of having a lesion.

CONCLUSION

Lesion prevalences differed significantly by age, sex, race/ethnicity, denture wearing and tobacco use. When lesion-specific prevalences are cited in the literature, they should be stratified by covariates known to be associated with them.

Oral lichen planus, hepatitis C virus, and HIV: No association in a cohort study from an area of high hepatitis C virus endemicity

OBJECTIVES

We sought to assess the age-specific prevalence of oral lichen planus (OLP) in Mediterranean patients with chronic hepatitis C virus (HCV) and to evaluate the features of OLP in relation to sex, smoking, HCV genotype, HIV-1 coinfection, and antiviral treatments.

METHODS

In all, 178 anti-HCV-positive adults (60 women and 118 men; age range 20-66 years) recruited from two cohorts (104 HIV-negative patients and 74 patients with HIV coinfection) underwent oral examination.

RESULTS

Overall prevalence of OLP was 2.8% (5 of 178) (male/female ratio 0.2; odds ratio=0.119; 95% confidence interval=0.013-1.106), only among HIV-negative participants, always in the reticular pattern, and in the adult age. HCV genotype, tobacco smoking, and treatment (interferon alfa/ribavirin) were not significantly associated to OLP.

CONCLUSIONS

Among HCV-infected patients, we found a low prevalence of OLP. The absence of OLP in HIV-coinfected patients suggests immunosuppression secondary to defective CD4 functions.

Annual screening for oral cancer detection

Most oral cancer and oral mucosal screening programs initiated in the past 20 years have been limited to a single examination of the population under study. Age specific, annual oral mucosal screening examination as a part of general health screening has been in operation in Tokonama city, Japan, from 1986. From 1996 the same target population aged 40 years and older has been invited for screening. The program coverage extended to 26% of the city population. During 1995-1998, out of 9536 attendees who participated in a general health and oral mucosal screening program in Tokoname city 6340 subjects (66.5%) re-attended at least for one further screening examination. There was no difference in the attendance for two annual mucosal examinations between male (67.0%) and female (66.2%) subjects. Three thousand nine hundred thirty-five subjects attended oral screening all 3 years (1996-1999) and the overall show-up rate for three consecutive examinations was 61%. During September-October 1996, 42 volunteer dentists carried out 6705 mouth examinations among those aged 40 years and older at the Municipal Center. One oral cancer was detected in 1996, in a subject free of any mucosal disease in the previous year. Among the screen-negative cases in 1996, 78% re-attended for screening in 1997 and 79% re-attended in the subsequent year. In the cohort that re-attended screening (1996-1998), oral mucosal pathology detected in three consecutive screenings included 18 leukoplakias, 24 with oral lichen planus and 343 other benign mucosal lesions. The number of subjects who complied to return and who remained disease-free over the 3-year period amounted to 3860, 59% of the disease-free subjects seen in 1996. A regular smoker was less likely to attend oral cancer screening in the three consecutive years of follow-up (odds ratio: 0.832, 95% CI 0.701-0.988). Satisfactory participation can be obtained for annual oral mucosal screening in Japan: this allows detection of new lesions, including oral cancer and leukoplakia (a surrogate marker of cancer risk). The number of new oral cancers detected in the program was too low to determine the optimal frequency for oral cancer screening but new oral leukoplakias were found on annual re-screening: the data indicate that the interval between two screens for this population should not be greater than 12 months.

Odontogenic ghost cell tumour with clear cell components: clear cell odontogenic ghost cell tumour?

A case of odontogenic ghost cell tumour (OGCT) with clear cell components was encountered in the mandible of a 63-year-old man. The tumour revealed ameloblastomatous-type epithelial components accompanied by clusters of ghost cells and dentinoid juxtaposed to the odontogenic epithelium. In addition, some areas of the tumour tissue showed sheets and islands of clear, glycogen containing epithelial cells, which were separated by a thin fibrous connective tissue stroma. Both ameloblastic and clear cells exhibited positive immunoreactivities for cytokeratin 19 and AE1/3. It is not known whether this tumour represents a clear cell change of a pre-existing OGCT or a separate and distinct neoplasm derived de novo from the odontogenic epithelium. This tumour was given the term 'clear cell OGCT' because it captures the clear cell components, which is one of the most prominent distinguishing features of the tumour.

Relationship of Oral Lichen Planus to Hepatitis C Virus in Southern Taiwan

Oral lichen planus (OLP) is a relatively common skin and oral disease that manifests as a mucous reaction to a variety of etiologic factors, including autoimmune disease, drug reaction, diabetes mellitus (DM), hypertension, hepatitis C virus (HCV), urolithiasis, psychogenic factors, and bacterial infection. The purpose of this study was to investigate the relationship between HCV infection and OLP as there is a high prevalence of HCV infection in Taiwan. A total of 1,075 subjects aged at least 15 years participated in the study. The total prevalence of OLP was 3% (32/1,075). OLP was significantly associated with DM (odds ratio, OR, 3.09) and HCV (OR, 2.05). Atrophic-erosive OLP (13/32) and reticular OLP (21/32) were significantly associated with HCV and DM, respectively. Logistic regression analysis showed that elevation of alanine aminotransferase (ALT) significantly increased the risk of atrophic-erosive OLP. We concluded that OLP is significantly associated with HCV and DM in southern Taiwan, particularly in HCV patients with elevated serum ALT levels and atrophic-erosive OLP.

Pooled estimate of world leukoplakia prevalence: a systematic review

This study was aimed at estimating the pooled global leukoplakia prevalence using both well-designed studies, which were too few to be representative of the world situation, and less valuable studies. The inverse variance weighting and the random effect methods were used. The latter is based on the principle that if primary studies are heterogeneous, the between-study variance is higher than zero, and its effect must be taken into account in choosing the weighting scheme. The robustness of the estimates was assessed by means of sensitivity analyses. Including 23 primary studies from all over the world published between 1986 and 2002, the point estimates were 1.49% (inverse variance, 95% confidence interval 1.42%-1.56%) and 2.60% (random effect, 95% confidence interval 1.72%-2.74%). The high between-study heterogeneity and the sensitivity analyses suggested that the second estimate was more reliable. Leukoplakia was significantly more prevalent among males (prevalence ratio 3.22), but no difference was found between geographical areas and between younger and older adults. Using these data, the crude annual oral cancer incidence rate attributable to leukoplakia would be between 6.2 and 29.1 per 100000, thus suggesting that the global number of oral cancer cases is probably underreported.

Prevalence of oral mucosal lesions in elderly people in Santiago, Chile

BACKGROUND

Oral prevalence studies are important to know the state of health and the needs of treatment. Our aim was to determine the prevalence of oral mucosal lesions and associated factors among aging Chileans.

METHODS

A random sample by age, gender, and socioeconomic status was obtained, comprising 889 individuals older than 65 years. Individuals were interviewed and examined in Santiago, the capital of Chile, according to the World Health Organization guidelines.

RESULTS

The prevalence of one or more oral mucosal lesions in the sample was 53%. Logistic regression model revealed that denture use increased the probability of one or more oral mucosal lesions by threefold, while age, gender, smoking, medication use, xerostomia, and social or cultural factors had no effect. The most common lesion was denture stomatitis (22.3%), followed by irritative hyperplasia (9.4%), oral mucosal varicosities (9%), solitary pigmented lesions (4%), traumatic ulcer (3.5%), angular cheilitis (2.9%), multiple pigmented lesions (2.8%), hemangioma (2.3%), lichen planus (2.1%), leukoplakia (1.7%), recurrent aphthous stomatitis (1.4%), nicotine stomatitis (1.3%), median rhomboid glossitis (0.9%), actinic cheilitis (0.9%), pyogenic granuloma (0.7%), oral squamous papiloma (0.6%), and mucocele (0.2%). One case of oral cancer was observed. Different factors increased the probability of specific oral mucosal pathologies.

CONCLUSIONS

We can conclude that oral mucosal lesions are common in elderly people in Santiago, suggesting the necessity for improved standards of prevention, and diagnostic and opportune treatment of these lesions.

Low prevalence of oral leukoplakia in a representative sample of the US population

Recent studies reported a tendency towards a lower prevalence of oral leukoplakia (OL), compared with the past. To assess the prevalence of OL in a representative sample of the US population, data from the oral mucosal tissue assessment and some other covariates of 16128 participants in the US National Health and Nutrition Examination Survey (NHANES III) were included. The clinical definition of OL was applied according to the WHO criteria. The weighted prevalence estimates of OL were 0.66+/-0.14% in males, 0.21+/-0.05% in females and 0.42+/-0.08% in total. The age peaks were at 40-49 years in males and at >or=70 years in females. The prevalence estimates were 0.37% for homogeneous OL and 0.06% for non-homogeneous OL. Gingiva (38.8%) and buccal mucosa (30.9%) were the most frequent locations. Compared to previous studies in the USA, a substantial decline of the prevalence of OL was shown.

Oral health status, C-reactive protein and mortality--a 10 year follow-up study

BACKGROUND

Epidemiological studies have reported a strong association between C-reactive protein (CRP) and cardiovascular diseases (CVD). Elevated CRP levels have been observed both in dentate individuals with chronic dental infections like periodontal disease and in those edentulous. The mechanisms behind these observations, especially the reasons for the elevation of CRP in the edentulous, are poorly understood. The comparative data on the importance of these inflammatory conditions in the oral cavity as causes of elevated CRP levels and CVD risk factors are also limited.

OBJECTIVE

To determine if edentulism is associated with increased levels of CRP and investigate the possible mechanism for this association; and to study the influence of periodontal disease and edentulism on 10-year mortality.

SUBJECTS

Of the 364 subjects aged 76, 81, and 86 years in 1990, 196 were dentate and 168 edentulous. By December 1999, 179 had died, almost half (n = 87) of them due to cardiovascular disease.

RESULTS

Significantly more of the edentulous subjects had elevated (> or = 3 mg/L) CRP levels as compared to those with at least 20 teeth (p < 0.01). They also had high salivary microbial counts (p < 0.05), and more mucosal lesions (p < 0.0001) than those with at least 20 teeth. In multivariate analysis, high microbial counts (OR 2.3, CI 1.06-5.05) and mucosal lesions (OR 2.18, CI 1.03-4.61) were significantly associated with elevated CRP levels. The risk for all-cause mortality was non-significantly elevated among the edentulous (RR 1.48, CI 0.95-2.31) and dentate with periodontal disease (RR 1.58, CI 0.96-2.61). CVD mortality was significantly higher among the dentate with periodontal disease (RR 1.97, CI 1.01-3.85) when compared with dentate without periodontal disease.

CONCLUSION

Among the edentulous, chronic infections like denture-related mucosal lesions are important determinants of elevated CRP, comparable to periodontal disease in the dentate. Elevated CRP per se and edentulism were not significantly associated with increased mortality. Periodontal disease was, however, still associated with a two-fold CVD mortality in this very old population.

Oral pre-cancer and the associated risk factors among industrial workers in Japan's overseas enterprises in the UK

BACKGROUND

Screening at industries has been advocated as a method of early detection for cancer. This study describes the prevalence of oral pre-cancerous lesions and other mucosal diseases following oral mucosal screening, and associated risk factors among Japanese industrial workers in the UK.

METHODS

Oral mucosal screening was by invitation at 51 industrial locations in the UK. A self-administered questionnaire was used to record socio-behavioural factors and frequency of daily intake of fruits and vegetables.

RESULTS

Four hundred and eighty-four subjects attended for oral mucosal screening (mean age 39.9 +/- 8.3 years) and their mean period of residence in UK was 5.3 +/- 4.5 years. 63.4% examined were male. 31.3% of males and 26.6% of females smoked daily. The gender differences were striking compared with Japan's national rates. A higher proportion of managerial staff was regular heavy (20+ per day) smokers. The intake of more than five portions per day of vegetables and/or fruits during the weekend was significantly higher in females than in males (P = 0.022). One hundred and six subjects (22%) were detected with oral mucosal lesions, including 16 leukoplakia lesions (3.3%) and three with oral lichen planus (1%). The rate of positive detections was higher in managers (7.5%). Odds ratios were estimated by socio-behavioural variables. Among subjects positive for oral leukoplakia, managers accounted for 68.8% (OR 5.26; 95% CI, 1.24-22.29). 87.5% of subjects detected with oral leukoplakia smoked daily and had done so for the past 10 years (OR 28.40; 95% CI, 5.63-143.28). Though regular alcohol drinking was a common feature among male leukoplakia cases, heavy alcohol misuse was not encountered. None reported an intake of five or more portions of fruits or vegetables.

CONCLUSIONS

The Japanese nationals working in managerial positions in the UK and daily regular smokers in the industries visited were found to be at a high risk of oral pre-cancer. Regular dental/oral check up and tobacco education programmes are encouraged for oral cancer/pre-cancer control in industrial settings.

Prevalence of oral leukoplakia

Introduction This paper reviews epidemiologic studies on prevalence of oral leukoplakia. Special emphasis is placed on population selection, diagnostic criteria, type and training of examiners and risk factor assessment. Prevalence of leukoplakia in these studies has ranged from 0.6% to 4.6%. Variations in prevalence among the studies could depend on methodology, especially studied populations and diagnostic criteria. Most investigations have investigated the entire available adult population in a geographic region or a random sample. Others have comprised selected populations, such as hospital or clinic patients. Our study has shown that prevalence of oral leukoplakia was 2.2% in a relatively small and highly selected population. Age and gender The onset of leukoplakia usually takes place after the age of 30 years. Our study showed that oral leukoplakia occurred in men over 40 years of age and in women over 50 years of age. These results are supported most previous findings. Gender distribution varies in most studies, ranging from a strong male predominance (4:1), to almost 1:1 in the Netherlands. Smoking and prevalence of oral leukoplakia Tobacco smoking is the most important known etiological factor in development of oral leukoplakia. Smokers have a six-fold increase in the risk of developing leukoplakia of the oral mucosa in regard to non-smokers. Six European studies, including our study, found a prevalence of smoking between 56 and 97 percent in leukoplakia patients. Our study also showed that the majority of smokers with leukoplakia (74.0%) smoked more than 20 cigarettes per day compared to 34.5 % of those without leukoplakia. Alcohol and prevalence of oral leukoplakia Smoking and alcohol consumption are often coexistent factors making it difficult to assess the effects of these factors individully. In our study the higest prevalence of leukoplakia (33.3%) was established in subjects who smoked cigarettes and consumed alcohol, compared to those who smoke tobacco only (18.2%).

Salivary albumin and other constituents and their relation to oral and general health in the elderly

OBJECTIVE

Our objective was to study salivary albumin concentrations in the elderly. We expected higher albumin values in the frail and diseased elderly in comparison to the more fit elderly. This was thought to be due to the eventually decreased mucosal integrity in the diseased patients.

STUDY DESIGN

Paraffin wax-stimulated saliva was collected for 5 minutes from 131 hospitalized elderly, mean age of 82 years, and 252 elderly outpatients, mean age of 77 years. Forty-seven of the hospitalized elderly died during the 2-year follow-up. Albumin was analyzed spectrophotometrically from the saliva specimens, and values were studied statistically between the groups and regarding a number of background variables.

RESULTS

The following mean salivary albumin concentrations were observed: outpatients, 200 +/- 157 microg/mL; hospitalized surviving patients, 401 +/- 247 microg/mL; patients who later died, 501 +/- 417 microg/mL. The respective albumin output values were 439.7 +/- 432.8 microg/min in outpatients, 684.3 +/- 396.8 microg/min in hospitalized patients who survived, and 700.0 +/- 481.9 microg/min in the hospitalized patients who died. The differences were significant between the groups. The strongest explanatory factors for higher than median albumin concentrations were the use of analgesics in the hospitalized patients (odds ratio, 4.2; confidence interval, 1.5 to 11.4) and retaining own teeth in the outpatients (odds ratio, 4.3; confidence interval, 1.9 to 4.3). Frequency of mucosal pathologic condition did not appear as an explanatory factor in this respect.

CONCLUSIONS

Our study hypothesis was confirmed, showing significantly higher salivary albumin concentrations in the frail elderly. The present results may also be used as reference data for salivary albumin in the elderly.

Betel quid-associated oral lesions and oral Candida species in a female Cambodian cohort

BACKGROUND

Betel quid chewing (BQC) is still prevalent among elderly Cambodian women and is associated with a wide variety of oral mucosal lesions. BQC has also been associated with a reduced rate of dental caries and changes in the oral microbiological flora.

METHODS

Since no studies were available on the impact of BQC on the oral carriage of Candida species, in this study oral swabs (Fungiquick, Hain Diagnostika, Germany) were taken from the tongue and palate of 48 Cambodian women with BQC habit (study group) and 13 control subjects without BQC habit (control group) to determine the spectrum of Candida species in these two groups. In addition, we investigated lesions of the oral mucosa likely to be associated with BQC habit in both study and control groups.

RESULTS

The median duration of BQC was 10 years (range 10 months-30 years). The following oral lesions were found in the study group: betel chewer's mucosa (85.4%), oral leukoplakia (8.3%), leukoedema (37.5%) and oral lichen planus (4.2%). Oral candidiasis was seen neither in BQ-chewers nor in controls. Candida spp. were found in 70.8% of the cases (controls 69.2%). Whilst C. albicans was isolated from 27.1% of the study cohort, C. tropicalis was the second most common isolate. One control case was colonised by C. dubliniensis--the first report of this organism from a Cambodian population. There was no significant difference in the candidal carriage rate or the Candida species isolated between the study and the control group.

CONCLUSIONS

Mycological findings from the present study do not indicate that BQC has a significant effect on oral colonisation by Candida species.

Risk factors for oral soft tissue lesions in an adult Spanish population

OBJECTIVES

The aims of this study were (i) to determine the prevalence of oral lesions in adults over 30 years old in the city of Oviedo (Spain), and (ii) to analyze the relationship between the prevalence of oral lesions, toxic habits (tobacco and alcohol) and denture wearers in these patients.

METHODS

A representative sample of the adult population in Oviedo (Spain) was obtained through randomized sampling (n = 753); a total of 308 (41%) subjects were finally included in the study. The observed oral pathology was classified according to the WHO criteria and earlier epidemiological studies.

RESULTS

A little over half of all patients (51.1%) had oral lesions. The most frequent lesions were frictional lesion (7.5%), traumatic ulcer (7.1%), denture stomatitis and pseudomembranous candidosis (6.5%), followed by melanin pigmentation (5.8%) and denture-induced hyperplasia (5.2%), plicated tongue (3.9%), lichen planus and hemangioma (3.2%), angular cheilitis and cheek biting (2.9%), fibrous hyperplasia and coated tongue (2.6%), recurrent aphthae (1.9%) and oral leukoplakia (1.6%). In relation to leukoplakia, the odds ratio (OR) of heavy drinkers was 15.98 and the OR of heavy smokers was 12.37. The OR of heavy smokers or heavy drinkers diagnosed of frictional lesion was four times greater than that of nonsmokers or nondrinkers. The OR of heavy smokers with melanic pigmentations was 4.08. The OR of complete denture wearers with candidosis was 11.38. The OR of partial removable denture wearers with hemangioma was 5.01.

CONCLUSIONS

This study shows the relation of heavy tobacco and heavy alcohol to traumatic keratosis and leukoplakia, and of complete dentures to pseudomembranous candidosis, fibrous hyperplasia and stomatitis. Programs designed to eradicate toxic factors (alcohol and tobacco) should, therefore, be implemented with adequate maintenance of dentures.

Oral mucosal conditions in elderly dental patients

OBJECTIVES

The goals of this study were as follows: to obtain baseline information on the incidence of oral mucosal conditions in a population of elderly Thai patients and to investigate differences in the presentation of these findings in relation to age, sex and the wearing of dentures.

SUBJECTS AND METHODS

The incidence of oral mucosal conditions was determined by the clinical examination of a sample of 500 Thai patients aged 60 years and older.

RESULTS

The overall incidence of oral mucosal conditions was 83.6% with no significant difference between men (81.4%) and women (85%). The incidence of oral mucosal conditions indicated a significant increase with advancing age. Varices (59.6%), fissured tongue (28%) and traumatic ulcer (15.6%) were the three most common conditions; and the incidence increased with age. Leukoplakia and smoker's melanosis were more common in men whereas lichen planus was seen more frequently in women. Three cases of oral cancer were detected, representing an incidence of 0.6%. Denture wearers (62.7%) exhibited a significantly higher prevalence of oral mucosal conditions than subjects who had no dentures (28.5%) and subjects with crowns and/or bridges (8.8%). The three most common denture-related problems were traumatic ulcer (22.6%), denture stomatitis (14.3%) and angular cheilitis (4.8%). In addition, the incidence of denture-related conditions among complete denture wearers (46.3%) was higher than in those wearing partial dentures (40.8%).

CONCLUSION

The current results regarding an elderly Thai population support the studies of other populations whereby the incidence of oral mucosal conditions in the elderly is related to age, sex and the wearing of dentures.

Cigarette smoking as a risk factor associated with oral leukoplakia

BACKGROUND: It is well known that oral leukoplakia is the most common precancerous lesion of the oral mucosa. Although tobacco and alcohol are known to be major risk factors for oral leukoplakia worldwide, there are no data on risk factors for oral leukoplakia in our country. The aim of our study was to analyze the association between oral leukoplakia and smoking habit, with attention to the duration and quantity of smoking. METHODS: The study population consisted of 352 patients aged 40-70 years. Prior to the clinical examination, each subject answered a standardized questionnaire regarding tobacco-smoking habits. Oral leukoplakia was diagnosed and grouped according to internationally accepted criteria. Chisquare test was used for statistical analysis. RESULTS: Of the entire sample, 279 were smokers and 73 non-smokers. Oral leukoplaka was found in 53 subjects and among them 50 were smokers and 3 were nonsmokers. All smokers had only used cigarettes. The relative risk of developing oral leukoplakia increased with duration of cigarette smoking habit. The majority of smokers with leukoplakia (74.0%) smoked more than 20 cigarettes per day compared to 34.5% of those without leukoplakia. The highest prevalence of leukoplakia (33.3%) was found in subjects who used cigarettes and alcohol. CONCLUSION: In view of these results, cigarette smoking is significantly related to the etiology of oral leukoplakia.

Gastroesophageal reflux disease: New oral findings

OBJECTIVE

The objective of this study was to investigate the effects of gastroesophageal reflux disease (GERD) on dentition, salivary function, and oral mucosa.

STUDY DESIGN

Thirty-one patients with esophagitis underwent medical evaluation, which included taking their medical history, performing both an esophagogastroduodenoscopy and esophagus biopsy, and conducting a stomatologic examination. The latter consisted of an extraoral and intraoral physical examination, saliva tests (flow, buffer capacity, and pH), and biopsy and morphometry of the palatal mucosa, as well as taking a history of the patients' habits. Fourteen healthy volunteers from the same population were used as a control group.

RESULTS

No relationship between GERD and changes in the oral cavity was shown by saliva tests, oral clinical examination, or histopathologic examination of the palatal mucosa. However, morphometric analysis of the palatal epithelium showed a statistically significant difference between the patients with GERD and the control group.

CONCLUSIONS

GERD is associated with microscopic alterations in the palatal mucosa (epithelial atrophy and increased fibroblast number), which are only detected by morphometry.

Oral symptoms and signs in elderly patients with type 2 diabetes mellitus. A focus on diabetic neuropathy

OBJECTIVE

We investigated oral disorders and compared the findings with the occurrence of neuropathy in type 2 diabetes mellitus.

STUDY DESIGN

Mucosal diseases, tooth loss, and temporomandibular joint dysfunction were examined in 45 patients with long-term type 2 diabetes mellitus and in 77 control subjects. The occurrence of neuropathy was evaluated by neurophysiologic tests.

RESULTS

Of patients with diabetes, 56% suffered from dry mouth and 18% from glossodynia; of controls, correspondingly, 36% and 7% (P <.05); 2 or more mucosal lesions were detected in 42% and 20%, respectively (P =. 008). Temporomandibular joint dysfunction was found in 27% of subjects with diabetes and in 16% of control subjects. Peripheral neuropathy was present in 42% of patients with diabetes and in none of the controls (P <.01), and autonomic parasympathetic neuropathy in 54% and 31%, respectively (P =.02). Peripheral and autonomic parasympathetic neuropathies were independent risk factors for tooth loss and temporomandibular dysfunction.

CONCLUSIONS

Diabetic neuropathy was found to be associated with tooth loss and temporomandibular joint dysfunction.

Serum antioxidant micronutrients and the risk of oral leukoplakia among Japanese

A population-based case-control study was designed for the investigation of any association between serum micronutrient levels and oral leukoplakia. Out of a total of 9536 subjects over the age of 40 years who participated in the oral mucosal screening programme in Tokoname city, 48 cases detected with oral leukoplakia (38 male:10 female) were recruited. For each case, four controls matched by age and sex were selected from the same cohort. We examined the fasting serum levels of retinol, alpha-tocopherol, zeaxanthin and lutein, cryptoxanthin, lycopene and carotenoids (alpha-carotene and beta-carotene) by high-performance liquid chromatography. Among males with leukoplakia mean serum lycopene and beta-carotene levels (0.175+/-0.202, 0.357+/-0.295 micromol/l) were significantly lower than those of controls (0.257+/-0.252, 0.555+/-0.408 micromol/l) (P<0.05, P<0.005). Logistic regression analysis with leukoplakia as the dependent variable showed that high serum levels of beta-carotene were related to low risk of oral leukoplakia (odds ratio 0.160, 95% C.I.: 0.029-0.866, P<0.05). There were no significant differences in any of the serum nutrients estimated in female subjects. Our results suggest for the first time that high serum levels of beta-carotene may provide protection against oral precancer for the Japanese male.

Changes in the edentulous maxilla in persons wearing implant-retained mandibular overdentures

STATEMENT OF PROBLEM

It has been suggested that risk for severe resorption in the anterior maxilla is increased in persons wearing mandibular implant-retained overdentures. However, little information is available about the changes in the edentulous maxilla after mandibular implant treatment.

PURPOSE

This study determined the possible changes in the width of the maxillary residual ridge 6 years after receiving mandibular implant-supported or implant-mucosa-supported overdentures and evaluated the association between the anatomic changes and subjective complaints with maxillary complete dentures.

METHODS AND MATERIAL

The subjects for this study (n = 55), enrolled among the participants of a prospective clinical trial, were randomly assigned into 3 groups treated with: (a) implant-supported overdentures on a transmandibular implant system (n = 21); (b) implant-mucosa-supported overdentures on 2 IMZ implants (n = 20); or (c) conventional complete dentures (n = 14). A lingual contact occlusion concept with anterior open bite was used for tooth arrangement in all subjects. Diagnostic casts were made at baseline, and again at the 6-year follow-up. Most prominent points perpendicular to the crest of residual ridge were located in the incisor, canine, and premolar regions, after which the width of the ridge was recorded at these points with a Boley gage. Subjects' opinions on their dentures were evaluated with a questionnaire.

RESULTS

Significant reduction in the width of the ridge was found in all measurement areas (mean difference = 0.4 to 0.6 mm; P <.0001). However, changes were small and not associated with the type of prosthetic restoration in the mandible. In subjects with implant-mucosa-supported overdentures, complaint of loose maxillary denture correlated with the decrement of residual ridge width.

CONCLUSION

The width of residual ridge decreases with time, despite the type of mandibular prosthetic restoration.

Occurrence of oral lesions in relation to clinical and immunological status among HIV-infected adult Tanzanians

OBJECTIVE

To determine the association, if any, between the presence of oral lesions and clinical and immunological status of untreated HIV-infected adults in Tanzania.

DESIGN

A cross-sectional study.

SETTING

AIDS Clinical Trial Clinic (ATCC) at Muhimbili Medical Centre in Dar-es-Salaam, Tanzania.

SUBJECTS

192 HIV-infected individuals not receiving treatment; 156 individuals confirmed to be HIV-seronegative acted as a control group.

METHODS

Examination of oral structures, determination of HIV serostatus, clinical status, and peripheral CD4+ T cell and total lymphocyte counts.

MAIN OUTCOME MEASURE

Presence of oral lesions.

RESULTS

Intra-oral lesions were seen among 7.7% of the HIV-seronegative, 10.4% of the HIV-seropositive and 36.8% of the AIDS groups, respectively. Enlarged parotid glands were seen in 20% of the AIDS patients, 11.9% of the HIV-seropositives, and 5.1% of the HIV seronegatives. Enlargement of submandibular salivary glands was seen in 29.6% of the AIDS patients, 31.3% of the HIV-seropositives compared with 14.7% among the HIV-seronegatives. Multiple regression analysis was used to calculate adjusted odds ratio (OR) for presence of oral lesions. OR for an intra-oral lesion was 1.6 (95% CI = 0.5; 5.0) among the HIV-seropositives and 8.2 (95% CI = 3.5; 19.7) among the AIDS patients using the HIV-seronegatives as reference. OR for an intra-oral lesion was 0.9 (95% CI = 0.3; 2.9) in HIV-infected patients with peripheral CD4+ T cell count of between 200-500 cells mm-3 and 2.7 (95% CI = 0.9; 7.7) in patients with less than 200 cells mm-3. OR for an intra-oral lesion was 0.4 (95% CI = 0.2; 0.9) for patients with peripheral total lymphocyte counts of between 1000-2000 cells mm-3 and 0.9 (95 CI = 0.4; 2.0) for patients with less than 1000 cells mm-3.

CONCLUSION

The association of oral lesions with the clinical stage of HIV infection and to a lesser extent peripheral CD4+ T cell count does suggest that these lesions could be used as additional markers of immunosuppression and AIDS.

An index of clinical oral disorder in elders (CODE)

Attempts to construct an index of oral health or disorder suitable for older adults have been limited in clinical scope or based on the judgement of very few individuals. Consequently, we present here a multidimensional index of Clinical Oral Disorder in Elders (CODE) based on a breadth of clinical measures relevant to elders. The data for the index are derived from a clinical examination of jaw function, dentures, mucosa, teeth, and periodontium. Weighting or ranking for each disorder within the context of an elderly person was established as mild, moderate or severe by experienced dental clinicians and dental hygienists. Subsequently, the index was constructed by transforming the weights into a numerical value for each clinical measure. Individual scores can relate to the heaviest weight identified during the examination or to the sum of the weights assigned throughout the examination, and the average score during a series of examinations will reflect the clinical status of a particular population. Clinical applications in elderly residential-care populations indicate that the index can be constructed efficiently and with reasonable reliability. We suggest, therefore, that the CODE index is suitable for descriptive and comparative research by providing a clinical format for measuring oral disorder in disabled elders, and, when combined with a psychosocial index, it should be very comprehensive indicator of oral dysfunction in older adults.