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

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.

The association between smoking cessation and periodontal status and salivary proteinase levels

BACKGROUND

Little information is available about the effects of the cessation of cigarette smoking on oral health, although cigarette smoking has been shown to be associated with a variety of oral diseases. The aim of this study was to compare periodontal status, salivary proteolytic activity, especially collagenase-2 (MMP-8) levels, and oral mucosal status in individuals who had quit smoking for at least 6 months (mean 3.5, SD 1.3 years) and in regular smokers.

METHODS

The subjects were 409 white male smokers aged 55 to 74 years with 15 or more remaining teeth. They had participated in a major cancer prevention study (ATBC Study). Eighty-two of the men had given up smoking and 327 were smokers. The subjects were examined clinically to determine the prevalence of periodontal pockets, gingival bleeding (BOP) and suppuration, and prevalence of keratotic oral mucosal lesions. The loss of alveolar bone was determined radiographically. Candida albicans was cultivated, and lesions showing leukoplakia were examined histopathologically. General proteolytic activity and collagenase-2 or matrix metalloproteinase-8 (MMP-8) levels in saliva, salivary pH, and buffering capacity were measured. Linear regression, logistic regression, or Fisher's exact test were used in statistical analysis.

RESULTS

Salivary general proteolytic activity and MMP-8 levels were lower in current smokers than in ex-smokers (P <0.05 and P <0.05, respectively). The prevalence of > or = 4 mm deep pockets, gingival suppuration, and loss of crestal bone were statistically significantly lower (P = 0.003, P<0.001, and P<0.05, respectively) and salivary buffering capacity higher (P <0.05) in those who had quit smoking compared to current smokers; there was no difference in BOP. The prevalence of oral leukoplakia did not differ significantly between smokers and quitters, but was higher in those who smoked >15 cigarettes per day compared to quitters (odds ratio 3.5, 95% CI, 0.8 to 15.3).

CONCLUSIONS

These data suggest that periodontal status and oral mucosal health are better in those who have quit cigarette smoking compared to current smokers. However, the data further suggest that smoking may significantly lower both general proteolytic enzyme activity and MMP-8 levels in saliva. Thus, care should be taken in interpreting results revealing salivary/mouthrinse proteinases as diagnostic markers for oral/periodontal disease activity.

Prevalence of oral precancerous and cancerous lesions in elderly Malaysians

A house to house survey on elderly subjects aged 60 years old and above was undertaken in a large district in Malaysia. A total of 486 subjects in randomly selected Enumeration Blocks were interviewed and examined. The prevalence of oral precancerous lesions was recorded at 3.3%, of which leukoplakia was the most common. When the ethnic distribution of these oral precancerous and cancerous (OPC) lesions was compared, 72% of those inflicted were Indians. Oral cancer was detected in two subjects (0.4%), both of whom were of Indian origin. Among subjects with OPC lesions, 4.2% were smokers, 12.7% were betelquid chewers, 11.8% had indulged in both habits, whilst one subject had not practised any of the oral habits of interest (0.4%). The findings suggest the occurrence of OPC lesions to be related to betelquid chewing.

Long-term supplementation with alpha-tocopherol and beta-carotene and prevalence of oral mucosal lesions in smokers

OBJECTIVE

To assess the effect of alpha-tocopherol and beta-carotene supplementation on the prevalence of oral mucosal lesions in smokers.

DESIGN

An end-point examination of a random sample of participants in a controlled trial for 5-7 years (Alpha-Tocopherol Beta-Carotene Cancer Prevention Study) in Helsinki, Finland.

SUBJECTS

A total of 409 white male cigarette smokers, aged 55-74 years who received either alpha-tocopherol (50 mg per day) or beta-carotene (20 mg per day) supplementation, both of these or placebo capsules.

METHODS

Clinical examination of oral mucosae, histological examination of lesions showing leukoplakia and cytological examination of buccal epithelium. Statistical analysis using Fisher's exact test.

RESULTS

No statistically significant differences were found between the study groups either in the prevalence of oral mucosal lesions or in the cells of unkeratinized epithelium. Leukoplakia was present in 24 (5.9%) of the subjects. Seven lesions showed dysplasia.

CONCLUSION

The present study on oral health does not support the hypothesis that alpha-tocopherol or beta-carotene supplementation plays an essential role in preventing oral mucosal changes in smokers.

Oral lesions in a Jordanian population

Since there is little information available on the prevalence of oral lesions in the Middle East population generally, and no data on the Jordanian population, this study was undertaken to correct this deficiency in our knowledge. During this investigation 2175 consecutive asymptomatic dental patients attending the Initial Treatment Unit in the Faculty of Dentistry, Jordan University of Science and Technology were examined for the presence of oral lesions. A total of 30 different oral lesions and conditions were diagnosed. Fordyce's granules and tori were the most common conditions diagnosed in 49 per cent and 15.7 per cent of the subjects respectively. Larger scale studies are required on an unselected group of the Jordanian population to assess the overall significance of the findings.

A national epidemiological survey of oral mucosal lesions in Malaysia

The prevalence of oral mucosal lesions in Malaysia was determined by examining a representative sample of 11,707 subjects aged 25 years and above throughout the 14 states over a period of 5 months during 1993/1994. A two-stage stratified random sampling was undertaken. A predetermined number of enumeration blocks, the smallest population unit in the census publication, was selected from each state. With the selected enumeration block, a systematic sample of living quarters was chosen with a random start. The survey instrument included a questionnaire on sociodemographic characteristics and a clinical examination. The clinical examination was carried out by 16 specially trained dental public health officers and the diagnosis calibrated with a final concordance rate of 92%. The age in the sample ranged from 25 to 115 years with a mean of 44.5+/-14.0. The sample comprised 40.2% males and 59.8% females; 55.8% were Malays, 29.4% Chinese, 10.0% Indians and 1.2% other ethnic groups. Oral mucosal lesions were detected in 1131 (9.7%) subjects, 5 (0.04%) had oral cancer, 165 (1.4%) had lesions or conditions that may be precancerous (leukoplakia, erythroplakia, submucous fibrosis and lichen planus) and 187 (1.6%) had betel chewer's mucosa. The prevalence of oral precancer was highest amongst Indians (4.0%) and other Bumiputras (the indigenous people of Sabah and Sarawak) (2.5%) while the lowest prevalence was amongst the Chinese (0.5%).

Oral status and prosthetic factors related to residual ridge resorption in elderly subjects

Our earlier studies on edentulous elderly subjects have shown associations of severe resorption in the mandibular residual ridge with female gender and systemic diseases. The aim of this study was to examine whether other factors also were related to residual ridge resorption (RRR). Among 177 edentulous elderly subjects effects on RRR were investigated with regard to history of edentulousness and denture-wearing, the condition of the dentures and soft tissues, dental status of the opposing jaw, and oral hygiene habits. No significant association was found between degree of resorption and duration of edentulousness in either the mandible or the maxilla. RRR was related to denture quality (P < 0.05); however, severe resorption was not. In the maxilla previous use of removable partial dentures was a factor contributing to the resorption (odds ratio (OR), 2.4); flabby ridge was related to the severity of the resorption (OR, 2.4). This study showed local factors related to RRR more often in the maxilla than in the mandible, thus suggesting that severe resorption in the mandible is influenced more by systemic factors than by those investigated in this study.

Oral mucosal smokeless tobacco lesions among adolescents in the United States

The presence of oral smokeless tobacco lesions among adolescents may be an early indicator of increased risk for oral cancers. Data from the 1986-1987 National Survey of Oral Health in US School Children were used to examine the cross-sectional relationship between the use of tobacco and alcohol and the presence of white or whitish oral soft-tissue lesions. The sample included 17,027 schoolchildren (aged 12 to 17 years) who provided information on the use of snuff, chewing tobacco, cigarettes, and alcohol and who received oral clinical examinations. Smokeless tobacco lesions were detected in 1.5% of students (projects to about 300,000 nationally), including 2.9% of males and 0.1% of females. These lesions were more prevalent among whites (2.0%) than among African-Americans (0.2%) or Hispanics (0.8%). Modeling with multivariate logistic regression revealed that, among white males, current snuff use was the strongest correlate of lesions [odds ratio (OR) = 18.4; 95% confidence interval (CI) = 8.5-39.8], followed by current chewing tobacco use [OR = 2.5; 95% CI = 1.3-5.0]. Lesions were strongly associated with duration, monthly frequency, and daily minutes of use of snuff and chewing tobacco. These data suggest that snuff may be a stronger risk factor than chewing tobacco for smokeless tobacco lesions, but the use of either of these forms of oral tobacco exhibits a dose-response relationship with the occurrence of lesions. We found little evidence that the use of alcohol or cigarettes may increase the risk of smokeless tobacco lesions. Preventing smokeless tobacco lesions and their possible malignant transformation may be best accomplished among adolescents by preventing the use of snuff and chewing tobacco.

Oral infections in home-living elderly patients admitted to an acute geriatric ward

Little is known about the oral health of the frail and home-living elderly. The effects of dentogenic infections on the general condition of the elderly are also unknown. We therefore set out to investigate 191 elderly patients referred to an acute geriatric hospital due to sudden worsening of their general health. The patients' mean age was 81.2 +/- 6.4 years (range, 67 to 96 years), and they had lived at home before hospitalization. The patients were examined and their diagnoses set by a team of physicians. The dentist's examination was also made bedside. Panoramic x-rays were taken for those who were able to stand (n = 148). Particular attention was paid to the occurrence of dental infection foci and systemic infection parameters of blood. Only patients free from other than dental infections were included in the statistical analyses (n = 184). Panoramic x-rays revealed dentogenic infection foci in 71.1% of the dentate patients. Periodontal condition was poor in 96.2% of the patients (CPI score, 2 to 4). All infection parameters were high in patients with high periodontal treatment need, but the differences were not statistically significant. Neither were there statistically significant correlations between the number of dentogenic infection foci recorded from the radiographs and infection parameters of blood. More of the edentulous patients had positive salivary yeast counts than did the dentate patients (84.4% vs. 66.1%; P < 0.05). No correlation was found between the main systemic diagnoses and dental infections. Since the prevalence of dentogenic infection foci in our subjects was high, and they did not cause marked increase in the hematological infection parameters investigated, it seems clear that geriatricians should refer their patients for dental examinations. Although our patients represent the home-living elderly population in a Nordic country with a high standard of living and good medical care, dental care had been neglected regardless of the patients' systemic disease.

Prevalence study of oral white lesions with special reference to a new definition of oral leucoplakia

In this survey, the experiences with and implications of a revised definition of oral leucoplakia are described. One of the new aspects of the revised definition is the distinction between a provisional, clinical diagnosis and a definitive one for which histopathological examination is required. A prevalence study of white lesions of the oral mucosa among a selected population of 1000 consecutive patients from the Netherlands showed a prevalence of a provisional and definitive diagnosis of oral leucoplakia of 0.6 and 0.2%, respectively. For uniform reporting, a recently proposed classification and staging system has been used to stage leucoplakias with a definitive diagnosis. The use of the revised definition of oral leucoplakia, as well as the classification and staging system, seem very suitable for epidemiological studies.

Chemotherapy-associated oral mucosal lesions in patients with leukaemia or lymphoma

In order to determine the incidence rate of oral lesions associated with chemotherapy, as well as well as its association with clinical and laboratory parameters and potential risk factors, 50 in-patients with non-Hodgkin's lymphoma or leukaemia under chemotherapy were followed from January 1993 to May 1994. Basal and weekly oral examinations were performed. Clinical and laboratory data were registered. Wilcoxon's rank sum test, chi square test, univariate and multivariate logistic regression analyses were used, 36 individuals with leukaemia and 14 with non-Hodgkin's lymphoma were followed for 158 weeks; mean age was 33 years (range 15-85). Oral lesion incidence rate was 45/100 patients-week. Exfoliative cheilitis and infections (herpes and candidosis) were the most common oral complications, followed by haemorrhagic lesions and mucositis. Haemorrhagic lesions correlated with thrombocytopenia (RR = 30.5). Etoposide administration (RR = 8.6), alkylating agents (RR = 15.6), a prior course of chemotherapy (RR = 23.2) and neutropenia (RR = 4.16) were predictors of mucositis. Oral lesions were a common complication in this study, and a possible association of mucositis with several factors is suggested.

Betel chewer's mucosa in elderly Cambodian women

A total of 102 rural Cambodian women with a mean age of 60 +/- 8.5 years (range 39 to 80 years) who chewed betel quid were examined for oral mucosal lesions, in particular betel chewer's mucosa. The average duration of betel quid chewing was 15.5 +/- 12.8 years. The average number of daily betel quids was 5.4 +/- 2.9. Forty women (39.2%) used betel quids overnight. Thirty-eight (37.3%) did not show any oral mucosal lesion. Sixty-two (60.8%) showed betel chewer's mucosa. Homogeneous leukoplakia was found in three women (2.9%). Out of 130 sites affected by chewer's mucosa, the buccal mucosa was the most frequently involed (n = 68). In thirty-two subjects (31.4%) more than one location was affected. The presence of a lesion was significantly associated with the duration of the habit (P < 0.01) and the number of betel quids per day (P < 0.001). Betel chewing seems to be prevalent in elderly Cambodian women, while younger people do not seem to have taken up this habit. The risk for oral cancer in the Cambodian population is presently unknown.

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.

An epidemiological survey of oral mucosal lesions among elderly Malaysians

A house to house random survey on elderly subjects was undertaken in the District of Klang in Malaysia. The objective of this study was to investigate the prevalence of oral mucosal lesions (OML) among the elderly in this area. The primary units in the sampling frame were the Enumeration Blocks (EBs) as defined under the population census. All households of the selected EBs were considered as sampling units and members aged 60 and above were considered as respondents. There was a slight preponderance of females, with the Malays comprising the majority of the subjects. Of the 486 respondents, mean aged 69.1 +/- 7.3 yr, 111 had at least one oral mucosal lesion, a prevalence of 22.8%. A total of 145 lesions were detected. The prevalence of OML was highest among Indians and least among the Chinese. The most common finding was tongue lesions, recording a prevalence of 10.7%, followed by oral pigmentation (4.9%) and white lesions (4.3%). Denture related lesions were comparatively low at 2.5%. Two cases of oral cancer if representative would give a relatively high prevalence of 0.4%.

Prevalence study of oral mucosal lesions in a selected Cambodian population

The aim of this study was to investigate the epidemiology of oral mucosal lesions in a selected Cambodian population to obtain pilot data useful in planning an oral health data base for the country. Due to unstable conditions in Cambodia, the validity of population data related to present census information is highly questionable. Therefore, prior to this investigation a census registration was carried out using local health workers as registrars in nine villages of a commune. In the period July 4-31, 1991, a total of 1319 individuals (953 women, 366 men, 15-99 yr) were examined by one oral surgeon in the nine villages of Kok Trop Commune, Kandal Stung District, southwest of the capital Phnom Penh. Clinical diagnoses were based on WHO criteria. Information on smoking habits, betel nut chewing habits, and alcohol use was collected by 4 Khmer dental personnel. In total, 71 lesions were recorded in 64 (4.9%) individuals. Leukoplakia was found in 1.1%, lichen lesions in 1.8%, candidosis in 1.4%, submucous fibrosis in 0.2%, cancer in 0.1% and other diagnoses in 0.8%. The prevalence of leukoplakia was 2.2% and 0.6% among men and women respectively, a statistically significant difference (P < 0.05). There were significantly more smokers (P < 0.01) among subjects with leukoplakia (64.3%) than among those without this lesion (28.6%). All subjects with lichen lesions were women. The age-adjusted relative risk for developing lichen among betel nut chewers as compared to non-chewers was 3.3.(ABSTRACT TRUNCATED AT 250 WORDS)

Oral and dental manifestations in gastroesophageal reflux disease

One hundred seventeen patients with reflux disease were examined with respect to the severity of their disease and oral, dental, and salivary findings. Twenty-eight patients had dental erosion, whereas the remaining 89 patients did not. No mucosal changes could be observed to be linked with the reflux disease. In the mean, the patients with erosion were older (54 versus 49 years), and the mean duration of their reflux disease was longer in comparison to those without erosion (17 versus 11 years, respectively). The severity of the reflux disease was more marked among patients with erosion than in those without as assessed by esophagogastroduodenoscopy, the Maratka classification, histologic examination of gastric and esophageal biopsy specimens, and 24-hour esophageal pH monitoring. No statistically significant differences were observed between the groups in any salivary parameters studied, although the number of patients with low salivary-buffering capacity was higher among those with erosion than among those without. Patients taking beta-blocking agents or tranquilizers had more erosion than those who did not take these medications. The severity of the reflux disease was not associated with any subjective symptoms in the mouth or pharynx. The frequency of consumption of acidic drinks and foodstuffs as determined by a questionnaire did not differ between the patients with and without dental erosion. Thus severe reflux disease of long duration was found to be potentially detrimental to the teeth, whereas milder forms of the disease need not cause dental side effects.

Oral mucosal lesions in 65-74-year-old Hong Kong Chinese

There have been no reported surveys of oral mucosal lesions among the elderly in Asian countries. Therefore, the purpose of this study was to determine the prevalence of oral mucosal lesions among 65-74-yr-old, community-dwelling elderly Chinese in Hong Kong and to determine the prevalence of lesions in denture wearers, tobacco smokers, and alcohol drinkers. A total of 537 noninstitutionalized 65-74-yr-olds were interviewed and clinically examined in an oral health survey conducted in 1991. In the survey, the elderly underwent a systematic examination of their oral mucosa by one of the three examiners with the aid of an overhead light. The examiners were trained and calibrated before and during the survey, and a specially prepared colour atlas of oral mucosal lesions was used for lesion recognition. No mucosal lesions were detected in 64% of the elderly. In the 193 elderly subjects with lesions, 80% exhibited only one lesion. There was no difference in prevalence between men and women. The more common lesions, each being found in 5-7% of the elderly, were lingual varicosities, frictional keratosis on the buccal mucosa, denture stomatitis on the palatal mucosa, and denture-induced hyperplasia in the maxillary and mandibular buccal sulcus. Denture wearers had a higher prevalence of lesions (40%) than nonwearers (32%). There was no difference in the prevalence or number of oral mucosal lesions between those defined as users of tobacco and alcohol and those defined as nonusers in this study. No confirmed oral malignancies were found.

Smoke signals: an alert for oral disease

Since the early 1600s, questions have been raised about the ill effects of smoking. Tobacco has long been linked to oral cancer and leukoplakia, but research in the last 20 years suggests an association with other oral diseases as well. Studies concerning the effects of smoking on the periodontal diseases--and the mechanisms involved--are reviewed.

Occurrence of corrugated white patch lesions on lateral border of tongue in lymphoma patients during cytostatic treatment

The question of whether or not there was an association between immunosuppression and occurrence of corrugated white patch lesions on the lateral border of the tongue was studied in 79 patients being treated for non-Hodgkin lymphoma or Hodgkin's disease. The mouths of 55 patients (mean age 47.8 years, 34 males, 21 females) were examined during periods of chemotherapy. All patients were HIV-seronegative. White non-removable lesions on the lateral margins of the tongue were noted in 27 patients (42.8%) 74 days after commencement of chemotherapy and 10 days after termination of medication. In 12 cases (44.4%) the lesions were bilateral. Epstein-Barr virus (EBV) DNA was found by gene amplification using polymerase chain reaction (PCR) in one of the two biopsy samples taken. No white lesion on the lateral border of tongue had been seen in any patient before treatment, nor were any evident 1 year after treatment. Leucocyte counts were significantly (P = 0.001) lower when the lesion was present than when it was not detected. Before chemotherapy, 70.4% of patients with lesions and 47.6% of patients without lesions had positive salivary yeast cultures. Yeasts could be cultured from the saliva of 80.5% of patients when the lesions were present. In 2 patients clinical oral candidiasis was diagnosed at the time of the lesion. The study revealed a correlation between the occurrence of corrugated white, non-removable lesions of the lateral borders of the tongue, high salivary yeast counts and leucocytopenia.(ABSTRACT TRUNCATED AT 250 WORDS)

Lesions of the oral mucosa in lymphoma patients receiving cytostatic drugs

The 1-year incidence of oral mucosal lesions during cytostatic therapy was investigated in 67 patients [34 men and 33 women (mean age 49 years)] out of 79 original patients, being treated for non-Hodgkin lymphoma or Hodgkin's disease. The incidence of lesions during examinations was 43.4%. Recurrent lesions were observed in 19.4% of cases. Mean leukocyte counts were statistically significantly lower (P < 0.01) during lesion periods than before cytostatic therapy in all lesion groups. Leukocytopenia was found in 85.4% of patients with hairy leukoplakia-like lesions (HLL), and in 81.8% of the patients with angular cheilitis. 5 out of 14 patients with oral ulcers (35.7%) had episodes of septicaemia. Mean thrombocyte counts of patients in various lesion groups were normal (< 140 x 10/1). However, low thrombocyte counts were more statistically significant (P < 0.05), when haemorrhages or HLL were present. Clinical candidiasis was diagnosed in 28.4% of patients during the treatment. However, cultivation revealed that 62.3% of salivary yeast cultures were positive. The study reported here shows a correlation between mucosal ulcers and septicemia, and between leukocytopenia, angular cheilitis and HLL. The disparity between clinically diagnosed candidiasis and the occurrence of salivary yeast counts suggests that antifungal drugs might be of prophylactic value during cytostatic therapy.

Prevalence of tongue lesions in 1013 Jordanian dental outpatients

Over a period of 10 months, 1013 consecutive dental outpatients attending the Screening Clinic in Faculty of Dentistry, Jordan University of Science and Technology, in the city of Irbid were investigated for the presence of tongue lesions. All subjects were seeking treatment for caries and periodontal diseases and none was complaining of oral mucosal disorder. The results showed that 240 subjects (23.7%) had one or more tongue lesions. Geographic tongue and fissured tongue were detected in 6.8% and 11.4% of the examined population respectively, and an association of the two conditions was observed in 2.9% of the subjects. Hairy tongue was diagnosed in 3.4% of the subjects with significantly higher prevalence in males (P < 0.0005). A strong correlation was found between hairy tongue and smoking.

One-year trial of the effect of rinsing with an amine fluoride-stannous-fluoride-containing mouthwash on gingival index scores and salivary microbial counts in lymphoma patients receiving cytostatic drugs

This double-blind study was undertaken to evaluate the effect of twice-daily use of a mouthwash containing 0.025% of fluoride as amine fluoride-stannous fluoride (AmF + SnF) or 0.05% of fluoride as sodium fluoride (NaF) on visible plaque index (VPI) and gingival bleeding index (GBI) and on some salivary micro-organisms in patients suffering from non-Hodgkin or Hodgkin lymphomas. 79 patients were allocated at random to the two mouthwash groups. Mouthwashing began at the start of cancer chemotherapy. Results relating to 45 patients who completed a 1-year rinsing protocol showed a significant decrease in VPI and GBI in the AmF + SnF group. An increase was found in the NaF group. Mean values for stimulated salivary secretion rates and buffering capacities mostly did not differ significantly from baseline values during the study. In both groups, mutans streptococci counts decreased significantly after the study began and remained low in the AmF + SnF group. No corresponding effect was seen in relation to lactobacilli and yeast counts. In the NaF group, lactobacilli counts increased significantly over a year. Significantly more patients reported adverse or unpleasant effects in the AmF + SnF group (52%) than in the NaF group (6%), although both solutions had the same colour and taste. However, all patients continued with rinsing.

Oral findings in patients with active or inactive Crohn's disease

The frequency and type of oral mucosal lesions, dental infections, and salivary constituents were evaluated in 53 patients with Crohn's disease, who were divided into inactive, mildly active, and severely active groups on the basis of clinical and endoscopic criteria. Buccal biopsies from nine patients with active disease showed morphologic changes that suggested Crohn's disease-related lesions. Panoramic radiographs revealed more infectious foci in the teeth of patients with active Crohn's disease than in patients with inactive disease. Salivary flow rate, buffering capacity, total protein, amylase, and IgA and IgG concentrations did not differ with respect to the activity of Crohn's disease. The observed mucosal inflammation in patients with active Crohn's disease, although high in frequency, was mild and did not need therapy, but the great number of dental infections in association with the activity of Crohn's disease should be taken into account in the treatment of these patients.

Effects of cannabis smoking on oral soft tissues

The oral effects of cigarette smoking have been well documented but the effects of cannabis smoke on the oral environment have been poorly documented. Three-hundred cannabis/tobacco/methaqualone smokers were examined. Two control groups consisting of 152 tobacco- and 189 non-smokers respectively were examined similarly. Health of the oral tissues and oral dryness was recorded. Lesions present included leukoedema, leukoplakia and numerous others. The only significant differences between lesions and conditions noted in cannabis users and controls occurred with respect to leukoedema, dry mouth and traumatic ulcer.

Silver-binding nucleolar organizer region proteins as a possible prognostic indicator in oral submucous fibrosis

Silver-binding nucleolar organizer region proteins (AgNORs) were counted in sections from formalin-fixed, paraffin-embedded tissue blocks of oral submucous fibrosis (OSMF) and oral squamous cell carcinoma (SCC). Moderately advanced and advanced cases OSMF, and well-differentiated and poorly differentiated cases of SCC, were studied with respect to the relation between AgNOR counts and histologic grading. Normal oral mucosa collected from age- and sex-matched subjects constituted the control group. The pooled mean (+/- SD) AgNOR counts were as follows: normal mucosa, 2.50 +/- 0.52 (n = 5); moderately advanced OSMF, 5.24 +/- 1.23 (n = 10); advanced OSMF, 7.26 +/- 1.12 (n = 10); well-differentiated SCC, 8.29 +/- 1.47 (n = 5); and poorly differentiated SCC, 9.49 +/- 0.74 (n = 5). The pooled mean AgNOR counts in advanced OSMF were higher than in moderately advanced cases (t = 3.84; p < 0.005) and those in poorly differentiated SCC were higher than those of well-differentiated SCC, although the comparison was not significant in the latter (t = 1.63, p > 0.10). AgNOR counts could hold promise for predicting the biologic behavior of OSMF because this study demonstrated a correlation with clinical and histologic grading.

Oral infection as a reason for febrile episodes in lymphoma patients receiving cytostatic drugs

56 patients receiving chemotherapy for non-Hodgkin lymphoma or Hodgkin's disease with curative intent were monitored for up to one year after initiation of treatment. During chemotherapy (mean duration 5.2 months), 26 of the patients (46%) suffered from 38 febrile episodes. In only 16 instances was an extraoral cause for the septicaemia found. However, severe dental infection, reflected in an elevated radiological index for the jaws, was found more frequently in patients suffering febrile episodes than in those without (P = 0.02). Moderate to severe gingival inflammation was observed during 22 (58%) of episodes. During 71% of the episodes various pathological findings were also recorded in the oral mucosa. No source of infection other than an oral one was found in 42% of the patients. Our results emphasise the importance of oral foci as the possible infection source in patients receiving intensive chemotherapy.

Effect of antiseptic mouthwashes on some clinical and microbiological findings in the mouths of lymphoma patients receiving cytostatic drugs

51 patients suffering from Hodgkin's disease or non-Hodgkin's lymphoma participated in this double-blind, cross-over study in which 2 antiseptic mouthwashes were tested for their effects on various periodontal index scores and salivary microbial counts. All patients were receiving combination cytostatic treatment based on methotrexate and doxorubicin. The patients (49 +/- 14 years old, 28 men, 23 women) were allotted at random to 2 groups. One rinsed with a 0.12% chlorhexidine gluconate (CHX) solution, the other with a 0.025% amine-stannous fluoride (AmF + SnF) solution 2x daily for 2 weeks. Both groups then continued rinsing with a 0.05% sodium fluoride (F) solution for 2 weeks, before switching over to AmF + SnF or CHX, respectively. All solutions had been prepared in such a way that they had the same colour and taste. Visible plaque index and gingival bleeding index scores were significantly reduced after periods of rinsing with CHX solution (P less than 0.001) and AmF + SnF solution (P less than 0.05). Microbiological cultivations of saliva specimens revealed significant reductions in mutans streptococci immediately after commencing rinsing, while lactobacilli and yeast counts were not affected.

Epidemiologic studies of oral mucosal conditions--methodologic issues

The methods used in the international English-language literature of epidemiologic investigations of oral mucosal conditions were reviewed. Methods used to study leukoplakia, lichen planus, recurrent herpes labialis, recurrent aphthous ulcers, geographic tongue and candidiasis are highlighted. In addition, studies of the full range of pathologies documented in a population were reviewed. The methodologic issues raised by the epidemiologic literature as well as those to be considered for future studies of oral mucosal conditions are presented. Emphasis is placed on study population selection, diagnostic criteria development, type and training of examiners, risk factor assessment and issues related to data collection, analysis and reporting.

Epidemiological study of oral leukoplakia based on mass screening for oral mucosal diseases in a selected Japanese population

The purpose of this study was 1) to show the epidemiological status of oral leukoplakia in a selected population of 3131 Japanese (504 women, 2627 men, aged 18-63 yr, mean age 35.9 yr), and 2) to estimate of the validity of the diagnosis of oral leukoplakia by general practitioners. Seventy-seven individuals were detected as having leukoplakia, a prevalence of 2.5%; 2.7% and 1.0% for men and women, respectively, a difference that is statistically significant (P less than 0.001). The percentage of smokers was 75.3% for patients with leukoplakia and 47.8% for individuals detected as not having leukoplakia, a difference which is statistically significant (P less than 0.001). Of 77 leukoplakia patients, 37 cases (48.1%) received a clinically confirmed diagnosis and 27 patients were diagnosed in further examination as having leukoplakia. These results can also be expressed by a positive predictive value of 0.73 and a false positive ratio of 0.27 for the diagnosis of leukoplakia in the primary mass screening by general practitioners. The results of this study suggest that in order to carry out an efficient oral health program in Japan, the objects for mass screening for leukoplakia might be better limited to men over 30 and women over 40 yr of age.

Oral disease prevention technologies for community use

Dentistry is perhaps the most prevention oriented of the many disciplines in health care. This article examines technologies for the prevention of caries (including the use of fluoride, oral hygiene and prophylaxis, sealants, and dietary modifications), periodontal disease, and soft-tissue lesions that can be used in community-oriented programs.

Clinical oral test for the assessment of oral symptoms of glossodynia and glossopyrosis

Subjective oral symptoms of a burning sensation and pain in the tongue may exist in the absence of any pathological changes in the oral mucosa. Owing to different treatment approaches and the lack of any specific therapy, it appeared potentially useful to identify these subjective symptoms by means of a test for an improved therapy evaluation. In this study, we have attempted to develop a method for the objective assessment of oral symptoms of glossodynia and glossopyrosis, by recording the local temperature. The temperature of the tongue was determined using a DT-1 electron thermoesthesiometer, that was highly sensitive to temperatures between 36 degrees C and 38 degrees C. Measurements were performed in topographic areas recommended by the World Health Organization in 1980. The study sample consisted of a group of 50 patients with glossopyrosis and glossodynia, without any clinically manifest pathological changes in the oral cavity, who were compared with a group of 50 age- and sex-matched subjects free of these oral symptoms and with normal oral mucosa. Statistically significant temperature differences were observed between the patients and the controls, as measured in seven different areas. The lowest temperatures (33 degrees C) were measured in the apex linguae area. The minimum temperature was significantly lower in the study group. Significant differences in temperature were also observed between the sexes. It was concluded that glossodynia and glossopyrosis, both inflammation and diminished circulation without any visible clinical signs, can be diagnosed using the thermoesthesiometry test. Such an objective test allows appropriate therapeutic treatment to be selected for patients with the above-mentioned symptoms.

Oral findings in elderly nursing home residents in selected countries. 2. Soft tissue lesions and denture wearing habits

This paper demonstrated that 38% of the 610 examinees at seven institutions in four countries have soft tissue lesions. Seventy to eighty percent of the detected lesions were of the erythematous type. This incidence was found at institutions with and without attending dentists, in denture and non-denture users, in dependent and independent patients. Tissue lesions in denture wearers were four times as many as in non-denture wearers. The percentage of inflammatory lesions in both denture and non-denture wearers was considerably higher at institutions with no attending dental personnel when compared with those with dental care facilities. Where patients depended on the staff and/or their relatives for their personal hygiene, a sharp increase in pathological findings was seen when compared to independent dwellers. The nursing staff and the relatives know very little about the oral problems of the elderly residents. There was no uniform policy about telling patients when to wear their removable dentures and patients did not always follow instructions when they were given. Many patients sleep with their upper denture while the lower one is removed for the night. Patients sometimes sleep in the dentures and sometimes remove one or both dentures for varying periods of time. The high percentage of soft tissue lesions and erratic denture wearing habits point to neglect and insufficient oral care toward the geriatric population studied.

Patients complaining about amalgam-related symptoms suffer more often from illnesses and chronic craniofacial pain than their controls

All patients who during the academic year 1987-88 had come or were referred for investigation to the Institute of Dentistry, University of Oulu, because of their anticipated amalgam-related symptoms were included in the study. The group comprised 20 patients, 7 men and 13 women, 41.6 +/- 11.1 yr old. For paired controls, 20 age and sex matched subjects were randomly selected among other patients at the Institute. The subjects' medical and dental history was taken, they were all examined clinically, and saliva analyses were done. The subjects were tested with standard patch test series of 25 common dental allergens. All patients were given the possibility to give a blood test for mercury concentration analysis, but only five were willing to do so. The results showed that the group of 20 patients suffered significantly more often from medical illnesses than the controls (P less than 0.05). Chronic craniofacial pain was diagnosed significantly more often among the patients than in the controls (P less than 0.01). The controls had more caries than the patients, but there was no difference in any other clinical, salivary chemical or microbiological findings between the groups. In the five patients who gave blood samples, both inorganic and organic mercury levels were below threshold values. No difference was observed between the patients and controls in the allergy test reactions.

Dental erosion and upper gastrointestinal disorders

The orodental status, particularly dental erosions, of 109 patients with upper gastrointestinal symptoms was examined. In 44 patients, the underlying pathosis was associated with increased acid output in the stomach (reflux esophagitis or duodenal ulcer), while in 48 patients who underwent cholecystectomy, the duodenogastric reflux was alkaline. In 17 patients with gastric ulcer, the gastric secretion was usually normal. The diagnoses were made with gastroscopy. Seven patients with dental erosion were found, and they all came from the group of 35 dental patients with reflux esophagitis or duodenal ulcer. No erosions were seen in the other diagnostic groups (F = 0.02). Thus, gastrointestinal disorders with increased output of gastric acid may be linked with dental erosions. The finding emphasizes the need for accurate diagnosis and appropriate treatment of patients with upper gastrointestinal symptoms in order to avoid irreversible lesions in the teeth.

Precancerous and other oral mucosal lesions related to chewing, smoking and drinking habits in Thailand

In a field study (1979-1984) four out of six major hilltribes of Northern Thailand, namely the Lahu, Karen, Lisu and Meo, as well as a group of rural Thai, were examined. Chewing, smoking and drinking habits and lesions of the oral mucosa (leukoedema, preleukoplakia, leukoplakia and chewer's mucosa) were recorded. 1866 individuals were examined. Considerable differences in the chewing and smoking habits among the various tribes were recorded and some of them were considered tribe-specific. Chewing of betel and miang was more prevalent among older people; these habits seem to have lost their attraction for the younger people. Cigarette smoking was more prevalent among middle-aged individuals. Leukoedema was observed in 12.4%, preleukoplakia in 1.8%, leukoplakia in 1.1% and chewer's mucosa in 13.1%. Men and the older generation were affected more often, except that more women (Karen and Thai) revealed chewer's mucosa. A positive correlation could be demonstrated between some mucosal lesions (leukoedema, chewer's mucosa) and some smoking and chewing habits.

ORPAMS: a data-management system for oral pathology

Oral pathology diagnostic services accumulate considerable clinicopathologic information on oral diseases/conditions. The authors describe an Oral Pathology Data-Management System (ORPAMS) designed for an oral tissue diagnostic program. Various features of data entry, manipulation, retrieval, and storage are outlined, and the research potential of the system is discussed.

The prevalence of oral mucosal lesions in an elderly population

In a population of 629, 145 elderly subjects had at least one mucosal lesion; 27% of denture wearers had a denture-related lesion. Lesions were found most commonly on the palate, followed by the lips. Increasing age was the only significant factor in the risk of soft tissue enlargement.

Oral mucosal lesions among elderly in Israel

The prevalence of ulcerative or proliferative oral mucosal lesions (OML) is an important parameter in evaluating the oral health of an elderly population. This paper relates the prevalence of OML in an elderly population to possible risk factors and defined high-risk groups. The second objective was to examine whether effective prediction of OML was possible from interview data alone. The elderly population of a Jerusalem neighborhood was surveyed in 1981: 456 elderly were interviewed by trained interviewers, and their oral cavities were examined by an oral epidemiologist. Specific diagnoses were confirmed by an independent senior clinician. Almost 40% of the elderly presented ulcerative or proliferative oral mucosal lesions. The prevalence of these OML was strongly related to the condition and age of dentures. The association between these OML and oral hygiene disappeared after controlling for the condition of the denture. Two variables ascertained by interview--age of denture and self-reported suitability of denture--turned out to be strong predictors of denture condition.

Epidemiologic study of 600 villagers of oral precancerous lesions in Bilugyun: preliminary report

A house-to-house survey of 11 villages selected by random sampling was carried out in Bilugyun. Chaung-zone township. Mon State of South Eastern Burma to study the prevalence of oral precancerous lesions and smoking and chewing. A total of 6000 villagers who were above 15 years at the time of this study were examined. The prevalence of preleukoplakia was 0.3%, leukoplakia 1.7%, lichen planus 0.4%, leukokeratosis nicotina palati 2.3, erythroplakia 0.1%, submucous fibrosis 0.1%, and cancer 0.03%. A correlation was done between habits and lesions.