Observer agreement in the grading of oral epithelial dysplasia

OBJECTIVES

To determine the extent of observer agreement in diagnosis of oral epithelial dysplasia (OED). Published studies of OED examiner agreement report relatively low agreement levels; however, these studies were limited by the methodologies employed.

METHODS

For this study, 64 slides were each independently examined twice by three oral pathologists. Consistency was assessed by determining intra- and interexaminer agreement. Conformity was assessed by using the modal diagnosis as a gold standard.

RESULTS

The group showed moderate interobserver agreement when grading the presence or absence of OED with a group-simple kappa (Ks) of 0.51 (95% CI = 0.42-0.61), and substantial agreement when using a 5-point ordinal scale with a group-weighted kappa (Kw) of 0.74 (95% CI = 0.64-0.85). The group showed fair to substantial intraexaminer agreement when assessing the presence or absence of OED, with Ks ranging from 0.22 to 0.78, and showing almost a perfect agreement using a 5-point ordinal scale, with Kw ranging from 0.82-0.96. Conformity with the comparison standard modal diagnosis was almost perfect, with pairwise Kw ranging from 0.81 to 0.92.

CONCLUSION

Overall, there was substantial intra- and interobserver consistency and almost perfect conformity in the grading of OED. Appropriate statistical methods are necessary to determine the degree of observer agreement.

Tuberous sclerosis: clinicopathologic features and review of the literature

INTRODUCTION

Tuberous sclerosis is a hamartoneoplastic syndrome, which may involve multiple organ systems. Oral hard tissue manifestations of the syndrome have been described in the literature only as recently as 1955. Patients who presented with clinical manifestations of tuberous sclerosis did not routinely undergo oral surveys to rule out 'lesions', and consequently data on 'lesions' in the maxillofacial complex is scant. Ten cases have been found in the English language literature, which describe maxillofacial 'lesions', which may be tumours, new growths, neoplasms or overgrowths occurring in patients diagnosed with tuberous sclerosis.

PURPOSE

To review the literature for all maxillofacial lesions associated with tuberous sclerosis and to present an eleventh case of a patient with a maxillofacial lesion diagnosed as having tuberous sclerosis.

RESULTS

Eleven cases were found with maxillofacial fibroblastic lesions associated with tuberous sclerosis. These lesions were all fibrous benign neoplasms found in the maxillofacial bony complex.

CONCLUSIONS

Maxillofacial fibroblastic lesions in tuberous sclerosis have various histopathological presentations, some of which may be difficult to differentiate. Consequently, close microscopic examination of these lesions is necessary so that adequate surgical treatment is provided.

Sensory and affective components of orofacial pain: is it all in your brain?

In this paper, we shall review several chronic orofacial pain conditions with emphasis on those that are essentially refractory to treatment. We shall present a review of current and past literature that describes the various pain phenomena as well as their underlying central mechanisms. New data concerning refractory pain will be used to underscore the importance of central processing of pain, with particular emphasis on neuropsychological and cognitive function and capacity that may play important roles in pain processing and maintenance of the pain state. Further, neurophysiological data showing that the anterior cingulate cortex (ACC) and other structures in the brain may play key roles in modulation of chronic pain will also be discussed. Although peripheral triggering events surely play an important role in initiating pain, the development of chronic and, in particular, refractory pain may depend on changes or malfunctions in the central nervous system. These changes may be quite subtle and require sophisticated approaches, such as functional MRI, to study them, as is now being done. New findings obtained therefore may lead to more rational and reliable treatment for orofacial pain.

Epstein-Barr virus detection in non-Hodgkin's lymphoma of the oral cavity: an immunocytochemical and in situ hybridization study

OBJECTIVE

The purpose of this study was to histologically characterize a series of oral non-Hodgkin's lymphomas (NHLs) and to investigate latent and lytic Epstein-Barr virus (EBV) infection in these.

STUDY DESIGN

The revised European-American Lymphoma classification system (41) was used to categorize 58 cases of oral NHL, which included 9 immunosuppression-related NHLs. EBV infection was determined by in situ hybridization for Epstein-Barr virus-encoded RNA and by immunohistochemistry for the EBV antigens latency membrane protein, Epstein-Barr nuclear antigen-2 (EBNA2) and Z EBV replication activator protein.

RESULTS

Most tumors were B-cell lymphomas (78%), but the proportion of T-cell lymphomas was surprisingly high (22%). The most common histologic subtypes were diffuse large B-cell lymphomas (45%), peripheral T-cell lymphomas (19%), and follicle center lymphomas (14%). Two thirds of the known immunosuppression-related NHLs were T-cell lymphomas. All of the immunosuppression-related tumors were EBV-infected, whereas the EBV infection rate in the NHLs of the remaining patients presumed to be immunocompetent was only 9%. Most EBV-positive tumors expressed neither of the latent antigens (ie, latency membrane protein and Epstein-Barr nuclear antigen-2), and coexpression of the 2 was observed only in immunosuppressed patients. Z EBV replication activator protein expression, which is indicative of replicative infection, occurred only in immunosuppressed individuals.

CONCLUSIONS

Diffuse large B-cell lymphomas were the most common histologic subtype of oral NHLs, but T-cell lymphomas were relatively common and frequently occurred in states of immunosuppression. EBV may play a limited role in the initiation of lymphoma in the immunocompetent patient, but the virus may be of importance in progression of the disease in those patients with more aggressive tumors, as immunosuppression occurs.

Foreign body granuloma following placement of hard tissue replacement material: a case report

The placement of grafting material in extraction sites for ridge preservation is an increasingly common practice among clinicians. This is a case report of a patient presenting with a symptomatic, foreign body granuloma following the placement of hard tissue replacement (HTR) in extraction sockets. The surgical specimen revealed numerous histiocytes and foreign body type giant cells. The grafting material was surgically removed and the patient's symptoms were alleviated. Although biocompatibility of HTR has previously been shown, specific applications may be contraindicated or some patients may exhibit sensitivity to this material.

Physiologic changes in humans subjected to severe, selective calorie restriction for two years in biosphere 2: health, aging, and toxicological perspectives

Biosphere 2 is a closed ecological space of 7-million cubic feet near Tucson, AZ, containing 7 biomes: rain forest, Savannah, ocean, marsh, desert, agricultural station, and habitat for humans and domestic animals. Sealed inside, 4 men and 4 women maintained themselves and the various systems for 2 years. All organic material, all water, and nearly all air was recycled, and virtually all food was grown inside. On the low calorie but nutrient-dense diet available, the men sustained 18% and the women 10% weight loss, mostly within the first 6 to 9 months. The nature of the diet duplicated rodent diets that had been shown to enhance health, lower disease incidence, and retard aging. Using blood specimens frozen at different points during and after the 2 years, determinations were made of a number of biochemical parameters judged to be pertinent based on past studies of rodents and monkeys on similar diets. These included blood lipids, glucose, insulin, glycosylated hemoglobin, renin, and others. The results clearly suggest that humans react to such a nutritional regime similarly to other vertebrates. In addition to these studies, and because this was a tightly closed, isolated environment, the levels of insecticides or pollutants or their derivatives were determined in the sera of 2 crew members. It was found that levels of the lipophilic toxicant DDE and the "total PCB" load increased with the loss of body fat during the first 12-18 months inside Biosphere 2, then decreased.

Odontogenic ghost cell carcinoma: report of four new cases and review of the literature

Only 12 odontogenic ghost cell carcinomas (OGCC) have been reported in the English language literature to date. This article reports four additional cases of this rare odontogenic tumour and examines them in relation to those previously described. Judging from the number of published cases, the OGCC is more prevalent in Asians than other racial groups, occurs more often in the maxilla than the mandible, and is slightly more common in males than females. Histologically, elements of a benign calcifying odontogenic cyst (COC) can be identified in all the malignant variants, either separated or admixed with the malignant epithelial component. The latter can consist of either small basaloid cells or large epithelial cells. Despite the differing histological presentations, the biological behavior of the tumour is unpredictable, with some cases characterized by relatively indolent growth and others by a locally aggressive and potentially fatal course. The tumour apparently arises most often from malignant transformation of a preexisting benign COC, although it may also develop from other odontogenic tumours.

Immunohistochemical and histochemical characterization of the mucosubstances of odontogenic myxoma: histogenesis and differential diagnosis

To discuss the dental origin of odontogenic myxoma and to provide further information for the differential diagnosis between this tumor and myxoid malignant fibrous histiocytoma (MFH) which occasionally occurs in jaw bones, the contents of glycosaminoglycans (GAGs) and proteoglycans (PGs) in the mucosubstances of 15 odontogenic myxomas, 5 myxoid MFH and 3 human fetal tooth germs in the bell stage of development were characterized using histochemical and immunohistochemical methods. Histochemical staining of hyaluronic acid (HA) was undertaken using biotinylated HA binding protein (B-HABP), and immunohistochemical detection was done using a panel of antibodies against chondroitin 6-sulfate (CS-6), chondroitin 4-sulfate (CS-4), dermatan sulfate (DS), keratan sulfate (KS), heparan sulfate (HS), aggrecan, PG-M/versican, decorin and biglycan. In odontogenic myxoma, CS-6, HA and PG-M/versican were observed in the myxomatous matrix of all cases, while KS and HS were seen in none. As for CS-4, DS, aggrecan, decorin and biglycan, only irregular and mild stainings were shown. Consistent and strong positive straining for CS-6, HA and PG-M/versican were seen in dental papilla and provided evidence supporting the origin of this tumor from dental papilla. Except for the constant staining for HA, the myxoid matrix was rarely stained for most GAGs and PGs in myxoid MFH. Immunodetection of CS-6 and PG-M/version with the use of monoclonal antibodies 3-B-3 and 2-B-1 is therefore recommended as a useful tool in differentiating odontogenic myoma from myxoid MFH.

Multiple canalicular adenomas: a case report and review of the literature

The canalicular adenoma is an uncommon, benign salivary gland tumor that most frequently occurs in the upper lip. Rarely, it manifests itself clinically and histologically as a multifocal lesion, a feature not generally seen with other intraoral salivary gland tumors. Here we report a case of canalicular adenoma that manifested itself with 13 clinically discrete tumor masses involving the upper lip and anterior buccal mucosa. In addition to the clinical nodules, there were microscopic foci of tumor cells in the adjacent normal-appearing salivary gland tissue surrounding the tumors. This article also reviews previously reported multifocal canalicular adenomas and discusses their features, emphasizing differences in the reported growth patterns of this unusual tumor.

Odontogenic tumors. A demographic study of 759 cases in a Chinese population

Seven hundred fifty-nine cases of odontogenic tumors retrieved from the files of College of Stomatology, West China University of Medical Sciences were classified according to the World Health Organization's Histological Classification of Odontogenic Tumors and compared with similar reports from other countries. Among these cases, 93.9% of the tumors were benign and 6.1% were malignant. Ameloblastomas predominated (58.6%) with a predilection for the mandible, while odontomas, generally regarded as the most frequent odontogenic tumor in North America, only accounted for 6.7%, the fourth most common tumor in this series. The mandible and the maxilla were divided into eight anatomic regions, and the distribution of each odontogenic tumor type amongst these regions was recorded. The relative incidence of each tumor type, patient age and gender were also compared with data from other selected large series. Geographic differences were noted in the relative incidence of ameloblastoma, odontoma and malignant odontogenic tumors among the Chinese/African, North American and Turkish/German groups. Ameloblastoma and malignant odontogenic tumors are not considered rare in a Chinese population.

Proliferative activity of calcifying odontogenic cysts as evaluated by proliferating cell nuclear antigen labeling index

The calcifying odontogenic cyst (COC) presents with diverse histological features; thus, several subclassifications have been proposed. To evaluate the significance of the various histological features and subtypes of COC from the perspective of proliferative activity, the proliferating cell nuclear antigen (PCNA) labeling index (LI; the percentage of positive nuclei) was assessed immunohistochemically in 25 cases of COC (21 benign and four malignant). All of the benign cases were of the cystic variety and further subclassified into non-proliferative subtype (NPS; four cases); proliferative subtype (PS; eight cases); and COC associated with odontoma (COCaO, nine cases). The PCNA LI of the malignant COC (65.2+/-5.6) was significantly higher than that of the benign COC (11.6+/-9.0; P = 0.002). Non-proliferative subtype (6.8+/-2.8) showed the lowest PCNA LI and PS (17.2+/-11.2) the highest of among the three subtypes of benign cystic COC (P = 0.028). In nine cases of COCaO, six showed epithelial lining of the non-proliferative type as NPS and the other three had lining with proliferative features as PS. The PCNA LI of the latter COCaO group (14.3+/-6.6) was significantly higher than that of the former (6.1+/-4.3; P = 0.05), as seen between PS and NPS. These results demonstrate that PCNA LI is a possible parameter for differentiating malignant COC from benign COC and, whatever the subtypes, the proliferative features in the lining are the main factor influencing the proliferating activity of COC.

Craniofacial pain: a multidisciplinary approach

Patients with pain involving the head and orofacial complex are among the most challenging both for dentists and physicians. A collaborative approach to diagnosis and management will yield the best possible result for the patient and minimize aggravation and frustration for the clinician. This collaboration must include ongoing discussion between the various clinicians. Ultimately, the various practitioners will develop a deeper comprehension of each others' fields, and the boundaries of the various disciplines will become less definite and a truly transdisciplinary approach will result. The latter is a highly desirable outcome for clinicians and patients. (The patient presenting with an atypical facial pain has been used as an example of just such a situation and the brief dissertation above should not be interpreted as an in-depth discussion of this complex disorder.

Management of gingival vitiligo with the use of a tattoo technique

The purpose of this report is to describe the management of gingival vitiligo in a black female. This patient was referred by her psychiatrist to the Mount Sinai Hospital Dental Department (Toronto) for assessment of progressive loss in gingival pigmentation. According to her psychiatrist this loss of pigmentation, which the patient indicated may be considered in Africa as a hallmark of HIV infection, was a significant exogenous factor in relation to the patient's ongoing clinical depression. After obtaining informed consent, a modification of a tattooing method used for skin was applied to the patient's attached gingival tissues. Test sites were tattooed prior to performing full gingival tattooing under local anaesthesia. The results demonstrate that it was possible to restore this patient's gingival pigmentation in a highly esthetically acceptable manner. The resulting coloration was reminiscent of the patient's natural pigmentation that had been lost ostensibly because of her systemic disorder. Our findings also showed that the artificial pigmentation established via the tattoo method was stable 4 months postoperatively and continues to be stable, as expected. A profound improvement in the patient's mood was noted.

Lumps of the tongue

Lesions of the tongue are often encountered in the process of a dental examination. These can include alterations of the tongue surface texture or colour, ulcers or exophytic lesions (lumps). The latter can represent variations of normal, benign or malignant pathological processes. This article will not provide a detailed list of all possible exophytic tongue lesions but will present a few of the more common conditions to be considered when such lesions are encountered.

Patient satisfaction with a consultation at a cranio-facial pain unit

OBJECTIVE

Patient satisfaction is an important component of the evaluation of the quality of health care and has also been linked to therapeutic outcomes. The objective of this paper was to assess patient satisfaction with an initial consultation at a cranio-facial pain unit located in a large hospital in a major metropolitan centre.

DESIGN

A case series design was used. The study population consisted of new patients referred to the unit. One month before their initial appointment patients were mailed an oro-facial pain questionnaire. Immediately following the consultation they were mailed a satisfaction questionnaire which contained a modified version of the Dental Visit Satisfaction Scale.

RESULTS

Oro-facial pain data were collected from 121 patients and 78 of these returned a completed satisfaction questionnaire. While levels of satisfaction with the consultation were high overall, specific questions about consultation processes and outcomes revealed some sources of dissatisfaction. Just over half reported dissatisfaction with communications and one fifth were dissatisfied with outcomes in terms of diagnosis and treatment. Satisfaction with communication was the only dimension of the consultation process to be associated with satisfaction with outcomes, and satisfaction with outcomes was the main predictor of satisfaction overall.

CONCLUSIONS

Although the relationships between patients and practitioners at the unit were favourable, improvements in communications may be necessary if the full benefits of the consultation are to be realised. This can be difficult with this patient population whose conditions are complex and often poorly understood.

Neuropsychologic deficits and clinical features of posttraumatic temporomandibular disorders

Previous studies have shown that characteristics of posttraumatic temporomandibular disorders (pTMD) differ considerably from those of nontraumatic or idiopathic temporomandibular disorders (iTMD). Both the rate of recovery and the amount of treatment required appear to be different for both groups. In this blinded study, 14 patients with iTMD and 13 patients with pTMD were examined. Patients submitted to a variety of reaction-time tests and neuropsychologic assessments to test their ability to cope with simple and more complex tasks with and without a variety of cognitive interferences. Clinical examination was used to assess signs of TMD. Eleven of the subjects (six iTMD, five pTMD) consented to a second phase of the investigation, whereby the patients were studied with single-photon emission computerized tomography (SPECT) using 99mTc-hexamethylpropyleneamineoxime (HMPAO). For simple and complex reaction-time tests, the pTMD group was significantly slower than the iTMD group (P < .05 to P < .001). Other neuropsychologic assessment tools such as the Consonant Trigram Test and the California Verbal Learning Test indicated that pTMD patients were more affected by both proactive and retroactive interferences and were more likely to perseverate on a single thought. In clinical examination, pTMD patients demonstrated greater reaction to muscle palpation than did iTMD patients (P < .05). The SPECT results suggested that there were mild differences between the two populations, and further ther studies are required to confirm this finding. The results lend support to the concept that there are differences between pTMD and iTMD populations. It is suggested that although patients with pTMD may have some similarities to those with iTMD, the former population may benefit from being handled somewhat differently and should be assessed and treated using a more broad, multidisciplinary treatment paradigm. These results must be confirmed in studies of larger populations.

Effects of salmon calcitonin on patients with atypical (idiopathic) facial pain: a randomized controlled trial

The analgesic properties of salmon calcitonin for the treatment of atypical facial pain (AFP) were investigated. An initial open-label trial of salmon calcitonin in subjects with refractory AFP was followed with a randomized, double-blind, placebo-controlled crossover trial of salmon calcitonin in the management of AFP. Salmon calcitonin (100 IU in 1 mL saline) was administered in an open-label fashion to 13 subjects with refractory AFP five times per week for 6 weeks. In the subsequent randomized investigation, salmon calcitonin (100 IU in 1 mL saline) or placebo (1 mL saline) was delivered three times per week for 3 weeks, with a 1-week washout prior to crossover. The percentage of subjects dropping out (57%) exceeded that reported in other pain studies using calcitonin. Therefore, it was imperative to halt the study for ethical reasons. There was no difference in outcome measures (P > .05) in subjects administered either active drug or placebo, and a high incidence of side effects led to dropout in subjects taking salmon calcitonin. Although salmon calcitonin may have analgesic properties, it is not efficacious for AFP, largely because of the side effects.

Pain and the quality of life in patients referred to a craniofacial pain unit

Although there are reasons to believe that temporomandibular disorders and other facial pain conditions would have a major impact on the quality of patients' lives, only a small number of studies have attempted to address this in a systematic way. In this study, data on pain and its consequences were assessed for 121 patients making their first visit to a craniofacial pain research unit. The extent to which musculoskeletal and neurologically based facial pain compromised the quality of life was measured using the Oral Health Impact Profile, a recently developed index of the functional and psychosocial outcomes of oral conditions. The data indicated that facial pain had a substantial impact on daily life and that its most common outcomes were psychologic. When compared with a nonpain population, the extent of this impact was striking. There was a four-fold increase in functional problems such as difficulty chewing foods and a nine-fold increase in reports of depression. As anticipated, scores on the Oral Health Impact Profile were associated with the characteristics of the pain and diagnostic subgroups.

Factitious injury of the oral mucosa: a case series

Gingival and oral mucosal tissues can be the site of a number of mucocutaneous and ulcerative conditions. Generally, these are not difficult to identify on the basis of clinical characteristics, and diagnosis can be aided by the use of routine histopathological and immunopathological techniques as well as other laboratory investigations. Self-induced or factitious injury (FI) of the oral mucosal tissues may present a confusing clinical picture, and be diagnosed erroneously as a mucocutaneous disorder in spite of the absence of appropriate pathological and immunopathological findings, or a failure to respond to routine treatment. A case series is presented here outlining 4 cases of FI which presented initially as mucocutaneous disease. These cases were investigated to rule out systemic or local causes, in order to establish a diagnosis of FI. Treatment of these conditions was facilitated with placebo or sham procedures which were designed primarily to cover the lesions. In most cases, the self injurious behavior could be linked to secondary gain.

Computer applications in the intensive care unit

Incorporating computers into all aspects of daily ICU operations is a formidable task both technically and logistically. To coordinate a project as complex as this, it is imperative to achieve close cooperation between physicians, nurses, basic scientists, computer specialists, hospital administrators, and equipment manufacturers. In this article, we have provided a blueprint and have discussed the implementation of a COmputational Model of PATient Health Status (COMPATHS) designed to carry out such integration.

[Cystic changes of the skin caused by Dermocystidium koi in koi carp]

Skin infection in koi carp by Dermocystidium koi is described. Symptoms of disease and the parasite are illustrated.

A comparison of low dose methotrexate bioavailability: oral solution, oral tablet, subcutaneous and intramuscular dosing

OBJECTIVE

To compare the relative bioavailability of low dose methotrexate (MTX) administered as tablet, oral solution, and subcutaneous (sc) injection to that of intramuscular (im) injection in patients with rheumatoid arthritis (RA).

METHODS

Twelve patients meeting the American College of Rheumatology criteria for RA had serial blood MTX concentration samples drawn over a 24-h period after receiving their normal weekly MTX dose. Relative bioavailability (F) of the tablet and oral solution formulations was determined by comparison of the area under the time-versus-serum-concentration curves (AUC) for the 2 different oral formulations as a percentage of the AUC for im injection. Also, relative bioavailability of the sc formulation was compared to im in 6 of the patients.

RESULTS

Mean F for the oral tablet was 0.85, while that for the oral solution was 0.87. Both oral formulations showed a statistically significant difference in mean F when compared to im (tablet vs im, p = 0.002, oral solution vs im, p = 0.009). No statistically significant difference, however, was found in mean relative bioavailability between tablet and solution (p = 0.744). The mean F for sc was 0.97; no statistically significant difference existed between the mean F values for the sc and im routes of administration (p = 0.657).

CONCLUSIONS

Our data suggest the oral solution may be substituted for tablet dosing and sc injection substituted for im. Thus, a variety of different dosing methodologies may be considered providing the most appropriate route in each patient, given issues of compliance, medication cost, and preference.

Prosol-chlorhexidine irrigation reduces the incidence of bacteremia during ultrasonic scaling with the Cavi-Med: a pilot investigation

The purpose of this pilot investigation was to determine whether the incidence of bacteremia following subgingival ultrasonic scaling and root planing could be reduced by the use, pre- and intraoperatively, of an irrigant containing 0.12 per cent chlorhexidine (CHX); Prosol. Individuals having evidence of significant periodontal disease (minimum of seven sites per quadrant 4.0 mm and bleeding on probing) were entered into this study. By use of a random number table, patients were assigned to either the experimental or control groups. The procedures, as described below, were carried out in a double blind fashion so that neither the investigator nor the patient was aware of whether Prosol or placebo was being used. The placebo solution was flavored to make it indistinguishable from Prosol. Patients were first anesthetized. Their gingival crevices were then irrigated using the Cavi-Med ultrasonic scaler. At this point, the ultrasonic action was not activated. Ten minutes later, ultrasonic scaling and root planing with the Cavi-Med unit were begun with a continuous flow of either the placebo or control solutions. Blood samples were taken preoperatively, while postoperative samples were taken one minute after completing the scaling of each quadrant and then 10 minutes after scaling the second quadrant. Routine aerobic and anaerobic bacterial culture methods were used to identify viable blood-borne bacteria. The results show that there was no difference in the distribution or presentation of periodontal disease between the experimental and control quadrants.(ABSTRACT TRUNCATED AT 250 WORDS)

Evaluation of temporomandibular joint internal derangement

The incidence of internal derangement of the temporomandibular joint has been documented in patients with temporomandibular disorders. However, the detection and diagnosis of a displacement of the temporomandibular joint disc in relation to internal derangement is not always accurate, and it varies according to the method of examination. A prospective clinical investigation of 26 patients (45 temporomandibular joints) with signs and symptoms of temporomandibular joint pain and dysfunction was completed to examine the accuracy of clinical examination, sagittal recording device tracings, arthrography, and magnetic resonance imaging in detecting internal derangement in the temporomandibular joint. A group of 16 asymptomatic control subjects (32 temporomandibular joints) was examined for the presence of internal derangement by the methods under consideration. Incidence of bilateral internal derangement in the temporomandibular joints of the symptomatic patients was also assessed. Findings obtained through clinical examination and sagittal recording device tracings agreed most often with the arthrographic findings of internal derangement. Magnetic resonance imaging often failed to detect the presence of arthrographically detected internal derangement. Internal derangement was identified bilaterally in a significant number of patients, despite the absence of bilateral symptoms. This incidence varied according to the technique used. In the control group, 9% of the temporomandibular joints that had been assessed as normal according to clinical examination and sagittal recording device tracings were found to have internal derangement according to magnetic resonance imaging.

Symptomatic benign migratory glossitis: report of two cases and literature review

Benign migratory glossitis (geographic tongue) is a common clinical finding in routine pediatric dentistry. The condition usually discovered on routine clinical examination, appearing as an asymptomatic, ulcer-like region on the dorsum of the tongue. The lesion may recur at different sites on the tongue, creating a migratory appearance, and in many cases, will resolve completely. The presentation of symptomatic geographic tongue in children is rare. This article presents two cases of symptomatic geographic tongue. Both children presented with a chief complaint of significant oral pain which was affecting daily activity, eating, and sleeping. Both patients presented with a classical clinical presentation of ulcer-like regions on the dorsum of the tongue in which the filiform papillae were denuded. Successful management was achieved with topical and systemic antihistamine. The clinician should be aware that this condition may be symptomatic in children.

Development of glutathione S-transferase placental form (GST-P) stained foci during hamster buccal pouch mucosa carcinogenesis

The expression of the placental form of glutathione S-transferase (GST-P) using anti-rat liver GST-P antibody was investigated in hamster buccal pouch mucosa (HBPM) treated with 0.5% dimethylbenz[a]anthracene (DMBA) biweekly for 12 weeks. This preliminary study showed that the anti-rat liver GST-P antibody is applicable to the HBPM model and that DMBA treatment induced GST-P positive foci. These foci are randomly distributed and frequently involved the hyperplastic and dysplastic segments of the epithelium, as well as squamous cell carcinoma. Further study is needed to explore the kinetics of these GST-P positive foci.

Effect of benzoyl peroxide on two-stage oral carcinogenesis and gamma-glutamyl transpeptidase in hamsters

Hamster buccal pouches were treated with 7,12-dimethylbenz(a)anthracene (DMBA) triweekly for 3 wk and subsequently with 40% benzoyl peroxide (BP) in acetone for up to 27 wk. BP treatment resulted in a marked hyperplasiogenic effect and a weak tumor promoting effect. Whereas most carcinogens and tumor promoters induce gamma-glutamyl transpeptidase (GGT) activity, BP diminished its activity as compared to controls. Comparable results have also been noted in the liver, where a group of newly isolated hepatocarcinogens, peroxisome proliferators (PP), also characteristically deplete the GGT activity and placental glutathione S-transferase (GST-P), another tumor marker.

Pleomorphic Adenoma: A Preliminary Histopathologic Comparison between Tumors Occurring in the Deep and Superficial Lobes of the Parotid Gland

Twenty-four cases of pleomorphic adenoma of the parotid gland were retrospectively reviewed. The histopathological features of capsular thickness, penetration and completeness, tumoral cell population and mitotic activity were analyzed in twelve superficial lobe and twelve deep lobe tumors. The capsules were found to be significantly thicker and less likely to be penetrated by tumor in the deep lobe group. No significant differences in completeness of encapsulation, cell population or mitotic activity were found between the two groups. This may explain the clinical suggestion that the less aggressive surgical approach which is often performed does not compromise the prognosis for recurrence in the deep lobe lesions.

Pleomorphic adenoma: a preliminary histopathologic comparison between tumors occurring in the deep and superficial lobes of the parotid gland

Twenty-four cases of pleomorphic adenoma of the parotid gland were retrospectively reviewed. The histopathological features of capsular thickness, penetration and completeness, tumoral cell population and mitotic activity were analyzed in twelve superficial lobe and twelve deep lobe tumors. The capsules were found to be significantly thicker and less likely to be penetrated by tumor in the deep lobe group. No significant differences in completeness of encapsulation, cell population or mitotic activity were found between the two groups. This may explain the clinical suggestion that the less aggressive surgical approach which is often performed does not compromise the prognosis for recurrence in the deep lobe lesions.

Characteristics and response to treatment of posttraumatic temporomandibular disorder: a retrospective study

Temporomandibular disorders (TMDs) are likely the most common cause of persistent pain in the head and neck. Treatment for TMDs can be quite varied although, in general, favorable treatment outcome is reported to be on the order of 75-80%, regardless of treatment approach. However, it has been reported that patients suffering from posttraumatic TMDs, and, in particular, patients who have been involved in motor vehicle accidents (MVAs), do not respond as well to therapy. Therefore, this study was undertaken to elucidate some of the historical and clinical features of posttraumatic TMDs and to compare this with the features of TMDs that developed independent of identifiable trauma. Furthermore, a comparison between recovery rates in the two populations was undertaken as well as a comparison of the treatment modalities used in the two groups. Fifty-two posttraumatic TMD patients were compared to an age- and sex-matched population of "routine" TMD patients whose conditions developed independent of trauma. Treatment, consisting of various accepted modalities, ranged from 3 to 5 years after the MVA, with progress assessed at each visit. The data indicate that 48% of posttraumatic TMD and 75% of TMD patients reported recovery with treatment (p less than 0.001). The posttraumatic TMD patients required significantly more treatment than the control TMD population. The findings suggest further that 60% of MVA TMD patients suffer from symptoms suggestive of affective disorder compared to only 14% of TMD patients. In view of the above, it appears that posttraumatic TMD patients do not respond to therapy as well as the control subjects. While the mechanisms underlying this finding are not clear, it could be related to a difference in underlying pathophysiology. The data showing that posttraumatic TMD patients develop significantly more symptoms suggestive of affective disorders than control TMD patients could imply that there is a relationship between these findings that requires further study.

Alteration in glutathione level during carcinogenesis of hamster buccal pouch mucosa

This study examined the level of glutathione (GSH)--a tripeptide that may have an important role in detoxification of carcinogens--in the hamster buccal pouch mucosa (HBPM) by a 12-week regimen of tri-weekly topical application of 7,12-dimethylbenz[a]anthracene (DMBA) in mineral oil. GSH was quantified periodically and shown to be doubled in carcinogen-treated vs. control pouch mucosa. In the tumors that developed, the level of GSH was three times that of the controls. Previous studies showed that gamma-glutamyl transpeptidase (GGT), one of the enzymes that may be responsible for the detoxification of carcinogens, was increased in the hamster mucosa pre-neoplastic foci, but decreased with the formation of overt neoplasia. GGT and GSH are intimately related, since GGT is the only enzyme that can cleave the intact GSH molecule. The increase in both GSH and GGT levels may be responsible for the increased resistance of the pre-neoplastic pouch epithelium to the toxic effects of the carcinogen.

Periodontitis as an early presentation of HIV infection

OBJECTIVE

To determine whether the presence of rapidly progressive periodontitis (RPP) in people at high risk for acquired immunodeficiency syndrome (AIDS) may be the first symptom of previously unrecognized human immunodeficiency virus (HIV) infection.

DESIGN

Case series.

SETTING

Dental clinic.

PATIENTS

Twenty patients who presented or were referred to the dental clinic over 6 months for the treatment of unexplained RPP and were at high risk for AIDS.

OUTCOME MEASURES

Diagnosis of HIV infection: identification of candidal organisms in cytologic smears, determination of complete and differential blood counts and of ratio between T4 (helper) and T8 (suppressor) lymphocytes, and performance of HIV antibody assays.

MAIN RESULTS

All of the patients were men, although sex was not an inclusion criterion. Sixteen (80%) of the 20 patients were found to have HIV infection. Four had been aware that they were HIV positive: two admitted it only when their T4:T8 ratio was known and the other two when the T4:T8 test was explained or requested. Fifteen of the patients were homosexual, three came from AIDS-endemic areas, and two had hemophilia. The RPP was responsible for alveolar bone loss in all of the patients. One patient lost bone in one site because of localized osteomyelitis. Only five patients had concurrent candidal overgrowth, and three had Kaposi's sarcoma. The mean T4:T8 ratio was 0.57 (standard deviation 0.52).

CONCLUSIONS

These findings suggest that periodontal disease may be one of the first clinical presentations of previously undiagnosed HIV infection. Thus, patients at high risk for AIDS who present with aggressive periodontal disease should be investigated for possible HIV infection. However, further, prospective studies are required to confirm the contention that RPP is one of the first signs of HIV infection or AIDS.

Temporal arteritis with normal erythrocyte sedimentation rates presenting as occipital neuralgia

A retrospective review of 46 patients with biopsy-proven giant cell (temporal) arteritis revealed 8 (17%) whose initial presentation was occipital pain. The most likely etiology of occipital pain in these patients was occipital artery inflammation. A Westergren erythrocyte sedimentation rate less than 40 mm/hour was noted at presentation in 6 of these 8 patients. Giant cell arteritis should be considered in the differential diagnosis of elderly patients who present with occipital pain and demonstrate a normal erythrocyte sedimentation rate.

In vitro study on the impact of fish sera on the survival and fine structure of the eel-pathogenic acanthocephalan Paratenuisentis ambiguus

The effects of fish sera on the growth and fine structure of infective larvae of the eel-pathogenic acanthocephalan Paratenuisentis ambiguus (Eoacanthocephala: Tenuisentidae) were studied under in vitro conditions using sera from the final host Anguilla anguilla and from two accidental fish hosts as well as fetal calf serum. As controls larvae were also kept in medium in the absence of serum and in experimentally infected eels. Sera from the accidental fish hosts carp and rainbow trout exerted toxic effects on the acanthocephalans. Worms maintained in medium containing sera from these two fish were contracted and displayed inverted probosces. Moreover, the tegument exhibited vacuolization and the formation of necrotic areas, including lysis of the mitochondria. Due to these effects, the parasites died at 21 (rainbow trout) or 21-50 days (carp) post-incubation. Eel sera had no toxic effect on the infective larvae. The growth of the larvae in medium depended on the composition of the latter, but was reduced as compared with that in the natural final host. Based on these results, we conclude that components of the hosts' blood sera play a role in the determination of the host specificity of P. ambiguus.

Chronic ethanol feeding and acute ethanol exposure in vitro: effect on intestinal transport of biotin

This study examined the effects of chronic ethanol feeding and acute ethanol exposure in vitro on biotin transport in rat intestine. Transport studies were performed with intestinal everted sacs. Ethanol was fed to rats for 6-7 wk. Compared with pair-fed controls, ethanol feeding significantly decreased plasma biotin concentrations and transport at physiological concentrations (0.01, 0.1, and 0.3 mumol/L) but not at pharmacological concentration (100 mumol/L). When added to the incubation medium of everted jejunal sacs from dry-food-fed rats, ethanol (2% vol:vol) significantly inhibited the transport of biotin at a physiological concentration (0.1 mumol/L) but not at a pharmacological concentration (100 mumol/L). The inhibitory effect of ethanol on the transport of 0.1 mumol biotin/L increased with increasing concentration of ethanol in the incubation medium [0.5% to 5% (vol:vol)]. Acetaldehyde, the major ethanol metabolite, also significantly inhibited biotin transport at 0.2% (vol:vol). These data demonstrate that chronic ethanol feeding and acute ethanol exposure in vitro inhibit the intestinal transport of biotin by the carrier-mediated process. Chronic ethanol feeding is also associated with a significant decrease in plasma biotin concentrations. The ethanol-induced inhibition in intestinal transport of biotin may be a contributing factor in reducing plasma biotin concentrations.

Aggressive osteoblastoma of the temporal bone: a case report

Osteoblastoma is a rare tumor of bone which is usually present in the long bones and vertebrae. Occasionally, they present in the head and neck, and only very rarely will they have a locally aggressive clinical course. We report a case of the aggressive subtype of benign osteoblastoma and its histologic and radiologic presentation.

Lymphoid and mesenchymal tumors in transgenic mice expressing the v-fps protein-tyrosine kinase

src, abl, and fps/fes are prototypes for a family of genes encoding nonreceptor protein-tyrosine kinases. The oncogenic potential of the v-fps protein-tyrosine kinase was investigated by introduction of the gag-fps coding sequence of Fujinami sarcoma virus into the mouse germ line. Transgenic mice with v-fps under the transcriptional control of a 5' human beta-globin promoter (GF) or with both 5' and 3' beta-globin regulatory sequences (GEF) were viable. Unexpectedly, both GF and GEF transgenes were expressed in a wide variety of tissues and induced a spectrum of benign and malignant tumors. These tumors, which included lymphomas, thymomas, fibrosarcomas, angiosarcomas, hemangiomas, and neurofibrosarcomas, developed with various frequencies after latent periods of 2 to 12 months. The majority of lymphoid neoplasms appeared to be of T-cell origin and were monoclonal, as judged by rearrangements of the T-cell receptor beta or immunoglobulin genes. Some tissues that expressed the v-fps oncogene, such as heart, brain, lung, and testes, developed no malignant tumors. The v-fps protein-tyrosine kinase therefore has a broad but not unrestricted range of oncogenic activity in cells of lymphoid and mesenchymal origin. The incomplete penetrance of the neoplastic phenotype and the monoclonality of lymphoid tumors suggest that tumor formation in v-fps mice requires genetic or epigenetic events in addition to expression of the P130gag-fps protein-tyrosine kinase.

High incidence of lung, bone, and lymphoid tumors in transgenic mice overexpressing mutant alleles of the p53 oncogene

We have investigated the role of the p53 gene in oncogenesis in vivo by generating transgenic mice carrying murine p53 genomic fragments isolated from a mouse Friend erythroleukemia cell line or BALB/c mouse liver DNA. Elevated levels of p53 mRNA were detected in several tissues of two transgenic lines tested. Increased levels of p53 protein were also detected in most of the tissues analyzed by Western blotting (immunoblotting). Because both transgenes encoded p53 proteins that were antigenically distinct from wild-type p53, it was possible to demonstrate that overexpression of the p53 protein was mostly, if not entirely, due to the expression of the transgenes. Neoplasms developed in 20% of the transgenic mice, with a high incidence of lung adenocarcinomas, osteosarcomas, and lymphomas. Tissues such as ovaries that expressed the transgene at high levels were not at higher risk of malignant transformation than tissues expressing p53 protein at much lower levels. The long latent period and low penetrance suggest that overexpression of p53 alone is not sufficient to induce malignancies and that additional events are required. These observations provide direct evidence that mutant alleles of the p53 oncogene have oncogenic potential in vivo and that different cell types show intrinsic differences in susceptibility to malignant transformation by p53. Since recent data suggest that p53 may be a recessive oncogene, it is possible that the elevated tumor incidence results from functional inactivation of endogenous p53 by overexpression of the mutant transgene. The high incidence of lung and bone tumors suggests that p53 transgenic mice may provide a useful model to investigate the molecular events that underlie these malignancies in humans.

Cardiac and neurological abnormalities in v-fps transgenic mice

Transgenic mice that widely express the v-fps protein-tyrosine kinase develop several independent pathological conditions, in addition to a high tumor incidence. v-fps expression and protein-tyrosine kinase activity in the heart were directly correlated with cardiac enlargement. This cardiomegaly was accompanied by severe myocardial and endocardial damage, which was concentrated in the left ventricular wall, and characterized by a progressive atrophy and necrosis of cardiac muscle fibers with concomitant fibrosis. This pathology was associated with congestive heart failure. Mice from five lines developed a marked trembling, correlated with expression of the v-fps transgene in the brain, and two lines showed a striking bilateral enlargement of the trigeminal nerves. Unlike tumor formation, these cardiac and neurological phenotypes were evident shortly after birth and showed 100% penetrance. The pleiotropic effects of the v-fps transgene suggest the involvement of protein-tyrosine kinases in mammalian neural development and cardiac function.

Gamma-glutamyl transpeptidase activity in superficial exfoliated cells during hamster buccal pouch carcinogenesis

The study of gamma-glutamyl transpeptidase (GGT) activity in transformed tissues has conventionally involved the killing of an animal or excision of the lesion, preventing longitudinal study. Oral exfoliative cytology allows longitudinal examination; however, it has been shown to be an unreliable criterion of malignancy. GGT activity has been demonstrated histochemically to involve the full thickness of the epithelium, including the keratin layer during carcinogenesis of hamster buccal pouch epithelium. This study correlates the GGT-stained foci in tissue sections and the proportion of GGT-positive cells in a superficial smear during a 13-week regime of tri-weekly topical application of 7,12-dimethylbenz[a]-anthracene (DMBA) in mineral oil. GGT-positive cells were detected in smears 3 weeks after application of the carcinogen, coincident with GGT-positive foci in tissue sections involving the keratin layer. The proportion of GGT-positive cells in each experimental period increased during the first 7 weeks of the experiment and plateaued thereafter. The number of GGT-positive foci in tissue sections in each experimental period also increased during the experiment. GGT activity was not detected in either smears or tissue sections of untreated or mineral oil treated mucosa. The correlation between the proportion of GGT-positive cells in smears and GGT-positive foci in tissue sections suggest the possibility of studying the GGT activity in an experimentally induced lesion without its elimination. Furthermore, oral exfoliative cytology using GGT staining may be useful in detecting precancerous lesions clinically.