White, red, and mixed lesions of oral mucosa: A clinicopathologic approach to diagnosis

Oral medicine considerations for the older patient

With the proportion of the world population aged over 60 years expected to nearly double to 22% by 2050, health care professionals are faced with the challenge of ensuring they are ready to address this demographic shift. As people age, they are more likely to develop comorbidities which have implications for their oral health. The effects of polypharmacy used to address these underlying health problems can also influence the oral health of older-aged patients. From a clinician's perspective, an awareness of the variety of conditions associated with old age, such as oral-mucosal disease, swellings and manifestations of underlying health conditions, are required to ensure appropriate referral, investigation and management, both in primary and secondary care settings. This article aims to provide the practitioner with an overview of orofacial and oral mucosal conditions commonly encountered with the older patient.

Exploring the Novel Computational Drug Target and Associated Key Pathways of Oral Cancer

Oral cancer (OC) is a serious health concern that has a high fatality rate. The oral cavity has seven kinds of OC, including the lip, tongue, and floor of the mouth, as well as the buccal, hard palate, alveolar, retromolar trigone, and soft palate. The goal of this study is to look into new biomarkers and important pathways that might be used as diagnostic biomarkers and therapeutic candidates in OC. The publicly available repository the Gene Expression Omnibus (GEO) was to the source for the collection of OC-related datasets. GSE74530, GSE23558, and GSE3524 microarray datasets were collected for analysis. Minimum cut-off criteria of |log fold-change (FC)| > 1 and adjusted p < 0.05 were applied to calculate the upregulated and downregulated differential expression genes (DEGs) from the three datasets. After that only common DEGs in all three datasets were collected to apply further analysis. Gene ontology (GO) and pathway analysis were implemented to explore the functional behaviors of DEGs. Then protein−protein interaction (PPI) networks were built to identify the most active genes, and a clustering algorithm was also implemented to identify complex parts of PPI. TF-miRNA networks were also constructed to study OC-associated DEGs in-depth. Finally, top gene performers from PPI networks were used to apply drug signature analysis. After applying filtration and cut-off criteria, 2508, 3377, and 670 DEGs were found for GSE74530, GSE23558, and GSE3524 respectively, and 166 common DEGs were found in every dataset. The GO annotation remarks that most of the DEGs were associated with the terms of type I interferon signaling pathway. The pathways of KEGG reported that the common DEGs are related to the cell cycle and influenza A. The PPI network holds 88 nodes and 492 edges, and CDC6 had the highest number of connections. Four clusters were identified from the PPI. Drug signatures doxorubicin and resveratrol showed high significance according to the hub genes. We anticipate that our bioinformatics research will aid in the definition of OC pathophysiology and the development of new therapies for OC.

Does YouTube™ provide reliable information on oral candidiasis?

OBJECTIVE

To evaluate the quality, source, usefulness and/or reliability, visibility, and popularity of YouTube™ videos on oral candidiasis.

MATERIALS AND METHODS

A YouTube™ search for 'oral candidiasis' was performed, setting the English language. 133 of the 351 videos watched were included in the study. Two periodontologists scored the videos for visibility, popularity, quality, utility, and reliability. Videos' quality was evaluated using the DISCERN and the Global Quality Scale (GQS) tools, by categorizing them through quality assessment, source, duration, views, likes, and dislikes of each video were noted.

RESULTS

82.7% of the videos were moderately or very useful, and the GQS scores were mostly good (41.4%-Score 4) and excellent (42.1%-Score 5). Significant relationships were obtained between Source of Upload, Video Type, Total Discern, and GQS variables and Usefulness scores (p<0.05). The 53.4% of the video sources were Healthcare professionals and their video usefulness scores were mostly "moderately useful" (47.9%) and "very useful" (%42.3). There was a significant positive correlation between the usefulness scores of the videos and the number of likes (p=0.004), comments (p=0.019), and the viewing rate(p=0.006).

CONCLUSIONS

The videos that rank high in searches for oral candidiasis on YouTube™ are mostly useful and comprehensive videos uploaded for educational purposes.

Lichenoid areas may arise in early stages of proliferative verrucous leukoplakia: A long-term study of 34 patients

Background

Proliferative verrucous leukoplakia is considered an uncommon oral potentially malignant disorder with a high malignant transformation rate. The objective of this paper was to define its cancer incidence and related risk factors.

Methods

A retrospective audit of 34 patients diagnosed with proliferative verrucous leukoplakia from a university‐based unit, during the period from 1995 to 2019 was performed. The mean number of visits was 23 ± 18.6. The follow‐up was divided into four‐time intervals to evaluate the clinical presentation, number of lesions, dysplasia grade, and malignant transformation rate.

Results

The majority of patients were females 29 (85.3%), with verrucous component (77.8%), with a gingival presentation (31.8%), and with a preceding lichenoid area (44.1%). Eleven patients (32.4%) were affected by oral cancer during the follow‐up, developing a total of 15 carcinomas. The mean age of malignant transformation was 67.2 ± 12.9 years, particularly 8 ± 8.5 from the onset of the lesions. Warty forms presented a higher mean estimate for malignant transformation (15.2 years, 95% confidence interval 4.4–26 years) than nodular forms (1.9 years, 95% confidence interval 1.9–1.9) (p = 0.019). Patients with an initial proliferative verrucous leukoplakia diagnosis suffered a higher risk of malignancy, particularly 15.55 times (95% confidence interval 1.69–143.17; p = 0.015) than those who did present a preceding area with lichenoid morphology.

Conclusion

Proliferative verrucous leukoplakia presented a high malignant transformation rate and sometimes displayed preceding oral lichenoid areas in early stages. Further studies are needed to understand the impact of these lichenoid areas in proliferative verrucous leukoplakia progression.

Expression of Mucin1 in saliva in oral squamous cell carcinoma and oral potentially malignant disorders (case control study)

OBJECTIVES

Overexpression of mucin1 is found in head and neck squamous cell carcinoma tissues compared with adjacent non-neoplastic tissues and higher levels are associated with metastasis and invasion. The expression level of mucin1 in saliva of normal individuals, oral potentially malignant disorders and oral squamous cell carcinoma patients and its correlation to clinical and histological variables was evaluated.

SUBJECTS AND METHODS

Forty oral potentially malignant disorders, 40 oral squamous cell carcinoma subjects, and 20 age matched-controls were included. Stimulated salivary samples were collected from all participants, and mucin1 expression was measured by real-time PCR.

RESULTS

Mucin1 expression in saliva was significantly elevated in oral potentially malignant disorders when compared with controls. Similarly, mucin1 expression was significantly elevated in oral squamous cell carcinoma group when compared with oral potentially malignant disorders and controls. Mucin1 expression in OSCC patient showed significant positive correlations with T classification and distant Metastasis. Mucin1 expression in oral potentially malignant disorders patients showed significant positive correlations with degree of dysplasia.

CONCLUSIONS

The expression level of mucin1 in saliva might be a potential biomarker for diagnosing oral potentially malignant disorders and oral squamous cell carcinoma.

Recognition and management of vitamin B12 deficiency: Report of four cases with oral manifestations

Vitamins are organic compounds present in low concentrations in food, performing vital and specific cell metabolism functions. Vitamin B12 is essential for red blood cell formation in the bone marrow and its deficiency is caused, mainly, by gastrointestinal malabsorption. In addition to systemic manifestations, oral signs and symptoms have also been associated to this condition such as glossitis, papillary atrophy, painful erythema areas, burning sensation, dysgeusia, lingual paresthesia and itching. This study aims to report four cases of oral manifestations caused by vitamin B12 deficiency. All patients presented oral mucosa lesions. Vitamin B12 deficiency was diagnosed based in clinical characteristics and complementary exams. Oral supplementation for vitamin B12 deficiency was conducted/realized in three patients, while one patient was treated with parenteral doses. All of them showed partial or total remission of the signs and symptoms.

The role of non-coding RNAs in drug resistance of oral squamous cell carcinoma and therapeutic potential

Oral squamous cell carcinoma (OSCC), the eighth most prevalent cancer in the world, arises from the interaction of multiple factors including tobacco, alcohol consumption, and betel quid. Chemotherapeutic agents such as cisplatin, 5-fluorouracil, and paclitaxel have now become the first-line options for OSCC patients. Nevertheless, most OSCC patients eventually acquire drug resistance, leading to poor prognosis. With the discovery and identification of non-coding RNAs (ncRNAs), the functions of dysregulated ncRNAs in OSCC development and drug resistance are gradually being widely recognized. The mechanisms of drug resistance of OSCC are intricate and involve drug efflux, epithelial-mesenchymal transition, DNA damage repair, and autophagy. At present, strategies to explore the reversal of drug resistance of OSCC need to be urgently developed. Nano-delivery and self-cellular drug delivery platforms are considered as effective strategies to overcome drug resistance due to their tumor targeting, controlled release, and consistent pharmacokinetic profiles. In particular, the combined application of new technologies (including CRISPR systems) opened up new horizons for the treatment of drug resistance of OSCC. Hence, this review explored emerging regulatory functions of ncRNAs in drug resistance of OSCC, elucidated multiple ncRNA-meditated mechanisms of drug resistance of OSCC, and discussed the potential value of drug delivery platforms using nanoparticles and self-cells as carriers in drug resistance of OSCC.

From Simple Mouth Cavities to Complex Oral Mucosal Disorders-Curcuminoids as a Promising Therapeutic Approach

Oral diseases are among the most common encountered health issues worldwide, which are usually associated with anomalies of the oral cavity, jaws, and salivary glands. Despite the availability of numerous treatment modalities for oral disorders, a limited clinical response has been observed because of the inefficacy of the drugs and countless adverse side effects. Therefore, the development of safe, efficacious, and wide-spectrum therapeutics is imperative in the battle against oral diseases. Curcumin, extracted from the golden spice turmeric, is a well-known natural polyphenol that has been extensively studied for its broad pleiotropic attributes and its ability to modulate multiple biological processes. It is well-documented to target pro-inflammatory mediators like NF-κB, ROS, COX-2, IL-1, IL-2, TGF-β, growth factors, apoptotic proteins, receptors, and various kinases. These properties make curcumin a promising nutraceutical in the treatment of many oral diseases like oral submucous fibrosis, oral mucositis, oral leukoplakia, oral erythroplakia, oral candidiasis, aphthous stomatitis, oral lichen planus, dental caries, periodontitis, and gingivitis. Numerous in vitro and in vivo studies have shown that curcumin alleviates the symptoms of most of the oral complications, including the inhibition of the progression of oral cancer. In this regard, many clinical trials have been completed, and many are ongoing to investigate the "curcumin effect" in oral maladies. Therefore, the current review delineates the mechanistic framework of curcumin's propensity in curbing oral diseases and present outcomes of the clinical trials of curcumin-based therapeutics that can provide a breakthrough in the clinical management of these diseases.

Oral potentially malignant disorders: A consensus report from an international seminar on nomenclature and classification, convened by the WHO Collaborating Centre for Oral Cancer

Oral potentially malignant disorders (OPMDs) are associated with an increased risk of occurrence of cancers of the lip or oral cavity. This paper presents an updated report on the nomenclature and the classification of OPMDs, based predominantly on their clinical features, following discussions by an expert group at a workshop held by the World Health Organization (WHO) Collaborating Centre for Oral Cancer in the UK. The first workshop held in London in 2005 considered a wide spectrum of disorders under the term "potentially malignant disorders of the oral mucosa" (PMD) (now referred to as oral potentially malignant disorders: OPMD) including leukoplakia, erythroplakia, proliferative verrucous leukoplakia, oral lichen planus, oral submucous fibrosis, palatal lesions in reverse smokers, lupus erythematosus, epidermolysis bullosa, and dyskeratosis congenita. Any new evidence published in the intervening period was considered to make essential changes to the 2007 classification. In the current update, most entities were retained with minor changes to their definition. There is sufficient evidence for an increased risk of oral cancer among patients diagnosed with "oral lichenoid lesions" and among those diagnosed with oral manifestations of 'chronic graft-versus-host disease'. These have now been added to the list of OPMDs. There is, to date, insufficient evidence concerning the malignant potential of chronic hyperplastic candidosis and of oral exophytic verrucous hyperplasia to consider these conditions as OPMDs. Furthermore, due to lack of clear evidence of an OPMD in epidermolysis bullosa this was moved to the category with limited evidence. We recommend the establishment of a global research consortium to further study the natural history of OPMDs based on the classification and nomenclature proposed here. This will require multi-center longitudinal studies with uniform diagnostic criteria to improve the identification and cancer risk stratification of patients with OPMDs, link them to evidence-based interventions, with a goal to facilitate the prevention and management of lip and oral cavity cancer.

Oral Medicine Considerations for Older Patients

With the projected increase to 1.3 billion people aged 65 years or older by 2040, healthcare professionals are faced with significant challenges in managing this population of patients. In the oral cavity, oral mucosal disease is a significant problem found in older populations. Several facial pain conditions are more likely to be seen in this cohort of patients. Although management of this group of patients may not always be appropriate in general practice, an awareness of the range of oral medicine conditions that may be encountered in older patients is essential to allow prompt referral and treatment.

Evaluation of PD-L1, PD-L2, PD-1 and cytotoxic immune response in oral lichen planus

OBJECTIVE

To investigate the expression of programmed death-ligands 1 and 2 (PD-L1, PD-L2), programmed death-1 (PD-1), CD8 and granzyme B (GrB), as well as its correlation with the severity of oral lichen planus (OLP).

MATERIALS AND METHODS

In a collaborative study, 33 cases of OLP were evaluated according to the latest criteria proposed by the American Academy of Oral and Maxillofacial Pathology (AAOMP/2016) and were submitted to immunohistochemistry. Positivity was measured semiquantitatively (PD-L1, PD-L2) and quantitatively (PD-1, CD8, GrB). The severity of OLP was assessed according to clinical subtype, symptomatology and response to corticosteroid therapy.

RESULTS

Most OLPs were considered to be negative for PD-L1 (66.6%), but high expression of PD-L2 (96.9%) by keratinocytes and immunoinflammatory cells was observed. PD-1⁺ cell density/mm² was reduced compared to CD8⁺ cells. A low cytotoxic immune response (CD8:GrB ratio) was also demonstrated. Interestingly, there were fewer GrB⁺ cells in the intraepithelial region in reticular OLP compared to erosive/bullous OLP.

CONCLUSIONS

PD-L1/PD-1 pathways appear to be compromised in OLP due to low PD-L1 expression in most samples. In contrast, PD-L2 overexpression associated with a possible regulation of the cytotoxic immune response suggests an immune tolerance that may contribute to the chronic profile of OLP.

Malignant transformation of oral leukoplakia: a follow-up study

OBJECTIVE

The main objective of the study was to identify the determinants that contribute to the malignant transformation of oral leukoplakia in a group of patients managed in secondary care. A secondary objective was to compare two dysplasia grading systems to determine their utility in assessing the prognosis.

MATERIAL AND METHODS

The cohort consisted of 93 patients diagnosed during the period 2009-2013. The variables recorded and analysed included age and sex, clinical presentation (colour) and severity of oral epithelial dysplasia (OED) scored by the WHO (2005) and the binary grading systems. The planned management included excision of high-grade dysplasia and observation of low-grade dysplasia lesions based on the WHO grading system. Patient factors were transcribed from the pathology records and updated using a questionnaire sent out to the whole group of patients. Data were analysed using χ² test and Kaplan-Meier analysis (P < 0.05).

RESULTS

Complete follow-up data were available for 93 patients. Malignant transformation occurred in 7 patients (7.5%) during a mean follow-up period of 30 months. Among the surgically excised group (n = 51), a recurrence of oral leukoplakia was noted in 16 patients (31%). WHO OED grading (P = 0.02) and the presence of red areas (P = 0.012) were useful in predicting malignant transformation with severe epithelial dysplastic lesions and red and white mixed lesions showing higher rates.

CONCLUSION

Leukoplakias (7.5%) transformed over a mean follow-up period of 30 months. Dysplasia grading and the clinical appearance by colour (mixed white and red) were significant predictors of malignant transformation CLINICAL SIGNIFICANCE: Patients with erythroleukoplakia and those diagnosed with moderate or severe epithelial dysplasia require more intensive interventions as such lesions have a higher risk of developing a malignancy.

Sensitivity to antifungals by Candida spp samples isolated from cases of chronic atrophic candidiasis (CAC)

The treatment of choice for chronic atrophic candidiasis (CAC), also known as denture stomatitis, is topical antifungal therapy. This study aimed to isolate, identify, and assess the antifungal susceptibility of Candida species from mucosal sites in denture wearers with a diagnosis of CAC and determine the prevalence of associated variables. The sample consisted of 44 patients wearing complete or partial dentures who had a clinical diagnosis of CAC. Using sterile cotton swabs, specimens were collected from the oral mucosa of all patients and grown at 30ºC for 48 h in CHROMagar Candida, as a means of isolating and screening the species. The complementary identification of the species was performed using the VITEK 2 automated system (BioMérieux), as well as the determination of their susceptibility to antifungal agents. Data were analyzed using the chi-square test. STATA 13.1 was used for statistical analysis (α = 5%). Of 44 patients with CAC, 33 (75%) had lesions classified as Newton type II. Yeasts were isolated in 38 cases. The most prevalent species was Candida albicans. None of the isolates were resistant to the antifungals tested. Our findings suggest that current indications for antifungal agents are appropriate. Also, antifungal susceptibility testing and proper fungal identification can help dentists to determine the optimal course of treatment for CAC.