A Comparative Randomized, Open-label, Multicenter Study of the Efficacy and Safety of Miconazole Mucoadhesive Tablets and Miconazole Gel in the Treatment of Oropharyngeal Candidiasis [Translated Article]

INTRODUCTION

SO-1105 is an oral mucosal adhesive tablet containing 50 mg of miconazole. It had been shown overseas that a once-daily application of the drug continues antifungal effect in the treatment of oropharyngeal candidiasis. We report the results of the phase 3 clinical study of this drug with miconazole gel as a control in Japan.

METHODS

The study included patients aged 20 years or older with oropharyngeal candidiasis who had oral lesions characterized by oropharyngeal candidiasis and whose fungi was confirmed by direct microscopic examination. The primary efficacy endpoint was the clinical cure rate on Day15 after 14 days of administration. The population analyzed for efficacy was per protocol set (PPS).

RESULTS

120 subjects were included in PPS. In detail, 59 subjects were in the SO-1105 group (SO-1105 group) and 61 subjects were in the miconazole gel group (Gel group). For efficacy, the clinical cure rate on Day15 was 47.5% in SO-1105 group and 47.5% in Gel group, showing the similar efficacy between both groups. For safety, adverse drug reactions were observed in 29.0% of SO-1105 group and 24.6% of Gel group, showing the similar safety between both groups.

CONCLUSION

The efficacy of SO-1105 was shown to be similar to that of miconazole gel. Meanwhile, SO-1105 is an adhesive tablet and is administered once-daily. For this, SO-1105 is expected to better compliance and useful drug for the elderly. Therefore, SO-1105 is considered to be widely used in clinical practice as one of the therapeutic drugs for oropharyngeal candidiasis.

Antimicrobial susceptibility surveillance of bacterial isolates recovered in Japan from odontogenic infections in 2013

We report on the findings of the first antimicrobial susceptibility surveillance study in Japan of isolates recovered from odontogenic infections. Of the 38 facilities where patients representing the 4 groups of odontogenic infections were seen, 102 samples were collected from cases of periodontitis (group 1), 6 samples from pericoronitis (group 2), 84 samples from jaw inflammation (group 3) and 54 samples from phlegmon of the jaw bone area (group 4) for a total of 246 samples. The positivity rates of bacterial growth on culture were 85.3%, 100%, 84% and 88.9%, respectively, for groups 1, 2, 3 and 4. Streptococcus spp. isolation rates according to odontogenic infection group were 22% (group 1), 17.7% (group 3) and 20.7% (group 4). Anaerobic isolation rates were 66.9% (group 1), 71.8% (group 3) and 68.2% (group 4). Drug susceptibility tests were performed on 726 strains excluding 121 strains that were undergrown. The breakdown of the strains subjected to testing was 186 Streptococcus spp., 179 anaerobic gram-positive cocci, 246 Prevotella spp., 27 Porphyromonas spp., and 88 Fusobacterium spp. The isolates were tested against 30 antimicrobial agents. Sensitivities to penicillins and cephems were good except for Prevotella spp. The low sensitivities of Prevotella spp is due to β-lactamase production. Prevotella strains resistant to macrolides, quinolones, and clindamycin were found. No strains resistant to carbapenems or penems were found among all strains tested. No anaerobic bacterial strain was resistant to metronidazole. Antimicrobial susceptibility testing performed on the S. anginosus group and anaerobic bacteria, which are the major pathogens associated with odontogenic infections, showed low MIC₉₀ values to the penicillins which are the first-line antimicrobial agents for odontogenic infections; however, for Prevotella spp., penicillins combined with β-lactamase inhibitor showed low MIC₉₀ values.

Gradient subthalamic neurodegeneration and tau pathology in the hypoglossal nucleus as essential pathological markers of progressive supranuclear palsy - Richardson syndrome

Progressive supranuclear palsy - Richardson syndrome (PSP-RS) was first described in 1964 by Steele et al. Tau pathology has not been reported in the hypoglossal nuclei of PSP-RS patients, whereas Steele et al. described gliosis with no remarkable neuronal losses in the hypoglossal nucleus. This study aimed to investigate the distribution and degree of tau pathology-associated neurodegeneration, with an emphasis on the hypoglossal nucleus, in patients with PSP-RS. Six clinicopathologically proven PSP-RS cases were included in this study. All patients were clinicopathologically and immunohistochemically re-evaluated. This study confirmed the following neuropathological characteristics of PSP-RS: (1) neurodegeneration usually affects the striatonigral system and cerebellar dentate nucleus; (2) the cerebellar afferent system in PSP-RS is affected by absent-to-mild neurodegeneration; and (3) the extent of tau distribution throughout the central nervous system is greater than the extent of neurodegeneration. Furthermore, we found that subthalamic neurodegeneration was more prominent in the ventromedial region than in the dorsolateral region. Nevertheless, the tau pathology showed no remarkable differences between these two sites. Interestingly, the tau pathology was frequently observed in the hypoglossal nuclei of PSP-RS patients. Gradient neurodegeneration of the subthalamus and tau pathology in the hypoglossal nucleus could be regarded as essential pathological features of PSP-RS.

A multicenter retrospective investigation on the efficacy of perioperative oral management in cancer patients

Patients develop a number of oral complications during cancer treatments. Oral bacteria are associated with the onset of dental focal infections and the progression of oral mucositis. Dental focal infections are frequently associated with the systemic onset of bacteremia, sepsis, and pneumonia. The degeneration of oral function with these complications may become an obstacle to cancer treatments. Although comprehensive oral management, including oral care, the removal of dental focal infections, and improvements in oral function with dentures, is conducted for cancer patients in Japan, few studies have assessed its efficacy.The aim of the present study was to investigate the incidence of dental/oral complications in cancer patients with perioperative oral managements (POMs) based on a large number of case series with a multicenter retrospective analysis.The medical records of cancer patients with POMs were retrospectively reviewed and the incidence of oral complications and efficacy of oral management were investigated.A total of 2744 cancer patients with POMs (1684 males and 1080 females, mean age 65.9 ± 13.0 years) were included and investigated in the present study. Among these patients, 2097 (76.4%) started POM before the initiation of cancer treatments, with 2130 (77.6%) receiving oral care only and 391 (14.2%) being subjected to invasive treatments, such as tooth extraction. The incidence of dental focal infections during the period of cancer treatments was 8.2%. The most frequent infection was acute periodontitis, including alveolar abscesses (112 patients, 4.1%). The incidence of grade 2 and 3 oral mucositis was 2.8%. Prolonged fever was observed in 113 patients (4.1%), with 7 having dental focal infections (6.2%). These incidence rates were lower than those reported previously.Based on analyses of a large number of patients, the present results support the efficacy of oral management in cancer patients. However, further studies are needed to establish adequate oral management guidelines for cancer patients.

Drug holiday clinical relevance verification for antiresorptive agents in medication-related osteonecrosis cases of the jaw

Treatment strategies of medication-related osteonecrosis of the jaw (MRONJ) are controversial. Recently, surgical treatment has been reported as superior to nonsurgical treatment, but the contribution discontinued antiresorptive agent use during MRONJ treatment remains unclear. This study aimed to evaluate the efficacy of drug holidays and treatment strategies in MRONJ cases. Four-hundred and twenty-seven patients with MRONJ treated at nine hospitals from 2009 to 2017 were included in this multicenter retrospective study. Multivariate Cox regression analysis showed that the primary disease (osteoporosis or malignant tumor), diabetes, serum albumin, and treatment method (surgical or nonsurgical) were significantly correlated with the cure rate. The cumulative 1-year cure rates in the surgical and nonsurgical treatment groups were 64.7% and 18.2%, respectively. However, discontinuing antiresorptive agents did not influence the treatment outcome in the cohort overall, or in 230 patients after performing propensity score matching among the discontinuation and continuation groups. When stratifying by treatment method, antiresorptive agent discontinuation significantly increased the cure rate in patients with osteoporosis who underwent nonsurgical treatment. In patients with malignant tumors undergoing nonsurgical therapy, discontinuing the antiresorptive agent was associated with a better treatment outcome, but not with statistical significance. In contrast, drug holidays showed no effect on improving outcomes in patients with both osteoporosis and malignant tumors who underwent surgical therapy. Thus, regardless of the primary disease, discontinuing antiresorptive agents during treatment for MRONJ may not be necessary and may be helpful in some cases. Future prospective trials should examine this question further.

P254 The differential impact of renal resistive index on future cardiovascular event in the hospitalised cardiovascular patients according to left ventricular ejection fraction: J-VAS study

Introduction

Renal resistive index (RRI) not only reflects renal vascular hemodynamics but also correlates well with systemic arterial stiffness. RRI associated with cardiovascular events in the selected group of cardiovascular patients including heart failure (HF). However, previous study limited only in the preserved ejection fraction (EF) patients.

Purpose

To determine the differential impact of RRI on cardiovascular events among cardiovascular patients according to EF.

Methods

A retrospective analysis of the Jichi Vascular Hemodynamics in Hospitalised Cardiovascular Patients (J-VAS) cohort. EF and RRI were measured in all patients, then categorised into groups of reduced EF (rEF < 40%), mid-range EF (mrEF 41-49%), and preserved EF (pEF≥50%). The latter group was subdivided into RRI≥0.8 and <0.8 to identify the risk of the primary endpoint, which was the composite of cardiac death, HF, acute coronary syndrome (ACS), aortic disease, arterial occlusion, and stroke.

Results

We included 1765 patients (mean age 64.7 years, 76% men). The most common diagnoses were ACS(66%) and HF(25%). During the median follow up of 1.9 years, 252 cardiovascular events occurred, 30.7%, 17.7%, and 10.4% in the rEF, mrEF and pEF group. RRI≥0.8 associated with the primary endpoint in the patients with pEF (Hazard ratio(HR), 1.69; 95%confident interval(CI) 1.11-2.58), but the association was not found in the other EF groups. Multivariate Cox regression analysis putting the pEF with RRI < 0.8 as a reference, pEF with RRI≥0.8 had a comparable risk for the primary endpoint to the mrEF group (HR, 1.55; 95%CI, 1.04-2.30 and HR, 1.92; 95%CI, 1.31-2.80, respectively), while the risk was highest in the rEF group (HR, 3.80; 95%CI, 2.73-5.29).

Conclusions

The risk of cardiovascular events in cardiovascular patients with pEF related to renal vascular hemodynamic alterations justified by RRI. In the patients with pEF, those with high RRI had comparable risk to the mrEF patients.

Risk of RRI≥0.8 for the primary endpoint Preserved EF HR (95%CI); P Mid-range EF HR (95%CI); P Reduced EF HR (95%CI); P Model 1 2.05 (1.39-3.02); P <0.001 1.60 (0.81-3.18); P =0.179 0.94 (0.53-1.67); P =0.838 Model 2 1.86 (1.25-2.78); P =0.002 1.33 (0.65-2.72); P =0.430 0.93 (0.52-1.66); P =0.792 Model 3 1.69 (1.11-2.58); P =0.015 1.10 (0.51-2.36); P =0.810 0.70 (0.38-1.28); P =0.242 Adjusted hazard ratio of RRI≥0.8 for the primary endpoint, RRI≥0.8 associated with a significant risk for the primary endpoint in the pEF group but not in the mrEF and rEF group. Model 1 was adjusted for age, sex and body mass index (BMI). Model 2 was adjusted for age, sex, BMI, smoking, dyslipidemia, and diabetes. Model 3 was adjusted for age, sex, BMI, smoking, dyslipidemia, diabetes, and glomerular filtration rate (GFR).

Abstract P254 Figure. Survival plot of the 4 subgroups

CD163+ macrophages infiltration correlates with the immunosuppressive cytokine interleukin 10 expression in tongue leukoplakia

Objective

Accumulating evidence suggests that macrophages are involved in the immunoediting of oral squamous cell carcinoma but the role of macrophages in oral carcinogenesis is unclear. We aimed to clarify the role of macrophages in oral leukoplakia, which is the most common oral potentially malignant disorder from immunotolerance viewpoint.

Materials and methods

The study included 24 patients who underwent surgical resection for tongue leukoplakia. The relationships between macrophage markers and clinicopathological factors were assessed. Conditioned medium was harvested from the CD163+ human monocytic leukaemia cell line, THP-1. The phenotypic alteration of human oral keratinocytes by the conditioned medium treatment was assessed using quantitative reverse transcription-polymerase chain reaction and enzyme-linked immunosorbent assay. Moreover, the clinical samples were evaluated using immunohistochemistry.

Results

Tongue leukoplakia tissues with high CD163+ macrophage infiltration were associated with significantly higher degrees of epithelial dysplasia, abnormal Ki-67 expression and cytokeratin13 loss when compared with the tissues with low CD163+ macrophage infiltration. In vitro, CD163+ THP-1 conditioned medium induced immunosuppressive molecules, especially interleukin-10 (IL-10) in human oral keratinocytes. The IL-10 expression levels showed significant positive correlations with not only the numbers of FOXP3+ regulatory T cells but also that of CD163+ macrophages.

Conclusions

In tongue leukoplakia, CD163+ macrophages infiltration correlates with immunosuppressive cytokine IL-10 expression.

Dental intervention against osteoradionecrosis of the jaws in irradiated patients with head and neck malignancy: a single-arm prospective study

BACKGROUND

The purpose of this study was to investigate the effectiveness of dental intervention before and after radiation therapy (RT) for head and neck malignancy on prevention of osteoradionecrosis (ORN) of the jaws.

METHODS

This is a single-arm prospective study according to intervention protocol of prophylactic dental extraction before RT and routine follow-up after RT. The primary endpoint was the occurrence of jawbone exposure during the first 2 years after RT.

RESULTS

Sixty-seven patients were assessed. Before RT, 144 teeth among 39 patients (58%) were prophylactically extracted. The occurrence of transient jawbone exposure during the first 2 years after RT was 7%. Because those jawbone exposures healed with intervention after RT, no jawbone exposure was found at 2 years after RT.

CONCLUSIONS

Dental intervention both before and after RT seemed to be important to prevent ORN development. Further studies in larger cohorts are necessary.

Effect of low-intensity pulsed ultrasound after intraoral vertical ramus osteotomy

OBJECTIVE

The present study investigated the effect of low-intensity pulsed ultrasound (LIPUS) on long-term osseous healing of the cleavage space between bone fragments after intraoral vertical ramus osteotomy (IVRO).

STUDY DESIGN

Patients undergoing IVRO were randomly assigned to the LIPUS group (n = 12) or the control group (n = 9) after surgery. LIPUS treatments were applied daily to the cleavage space between bone fragments for 3 weeks. We observed 3-dimensional quantitative color mapping of the whole mandible created by computed tomography (CT) data at 1 month, 6 months, and 1 year postoperatively. On the basis of CT values, the color grades were classified as D1 to D5 by using the Misch criteria. We then calculated mean CT values and rated each color grade in different selection ranges.

RESULTS

The mean CT values of the LIPUS group were significantly higher than those of the control group at 1 month, 6 months and 1 year postoperatively (P < .01). The color grades of the cleavage between bone fragments increased from D5 to D1 over time.

CONCLUSIONS

Our results indicated that LIPUS promoted osseous healing after IVRO, thus improving bone density and offering clinical benefits.

Factors associated with severe oral mucositis and candidiasis in patients undergoing radiotherapy for oral and oropharyngeal carcinomas: a retrospective multicenter study of 326 patients

PURPOSE

The present retrospective multicenter study intended to investigate the factors associated with severe oral mucositis and candidiasis in patients undergoing radiotherapy for oral and oropharyngeal carcinomas.

METHODS

A total of 326 patients who underwent radiotherapy for oral and oropharyngeal cancers were enrolled in the study. The patients' age, sex, body mass index, primary site, diabetes, serum albumin, creatinine, hemoglobin, leukocyte and lymphocyte, concurrent cisplatin or cetuximab, method of radiation, total radiation dose, feeding route, use of spacers, pilocarpine hydrochloride, and corticosteroid ointment were examined, and the associations of each variable with oral mucositis and candidiasis were analyzed by multivariate Cox regression analysis.

RESULTS

Grade 3 oral mucositis occurred in 136 (41.7%) patients. Male sex, oropharyngeal cancer, low hemoglobin levels, low leukocytes or lymphocytes, concurrent cisplatin or cetuximab, and oral feeding were found to be significantly associated with a higher incidence of severe oral mucositis. Oral candidiasis occurred in 101 (31.0%) patients. Oropharyngeal cancer, low leukocyte count, and oral mucositis of grade 2 or higher were found to be significantly associated with a higher incidence of oral candidiasis. The use of a topical steroid ointment was not found to be a risk factor for oral candidiasis.

CONCLUSIONS

The present retrospective study demonstrated that certain factors may predispose patients with oral and oropharyngeal cancers receiving radiotherapy to develop severe oral mucositis and oral candidiasis. A preventive strategy for severe oral mucositis needs to be established in the future for high-risk cases.

A radiologic evaluation of the incidence and morphology of maxillary sinus septa in Japanese dentate maxillae

PURPOSE

Evaluation of the inner aspect of the maxillary sinus is important for the success of a sinus lift procedure. The most common surgical complication is perforation of the Schneiderian membrane, which is thought to occur because of the presence of maxillary sinus septa. Therefore, we retrospectively investigated the incidence and morphology of maxillary sinus septa using multiplanar reformatted computed tomographic (CT) images from dentate Japanese patients.

METHODS

A total of 276 patients and 552 maxillary sinus segments were evaluated. The maxillary sinus septa were divided into four locations: forefront, anterior, middle, and posterior. The heights of the septa were measured at three sites from the deepest point of the sinus floor: lateral, mid-point, and medial.

RESULTS

Sinus septa were identified in 191 of 552 (34.6%) maxillary sinus segments obtained from 111 of 276 (40.2%) patients. One unilateral septum was most commonly detected, and the sinus septa were most often located in the middle of the maxillary sinus. The average height of the identified septa was 8.69 ± 4.68 mm (mean ± standard deviation).

CONCLUSION

Multiplanar reformatted CT images can identify maxillary sinus septa in any plane. The height of maxillary sinus septa in the dentate maxillae was higher than detected in previous studies. Appropriate treatment planning using CT images should be considered to prevent surgical complications.

Clinical Evaluation of CO2 Laser Vaporization Therapy for Oral Lichen Planus: A Single-Arm Intervention Study

Objective: The purpose of this study is to evaluate the efficacy of CO₂ laser vaporization therapy for oral lichen planus (OLP) refractory to conservative treatments. Methods: The study group comprised 16 patients with clinically and histologically diagnosed OLP. They underwent conservative treatment for 3 months using an adrenal cortex hormone ointment and azulene sulfonate sodium hydrate gargle. Patients who showed no improvement with conservative treatment underwent CO₂ laser vaporization therapy (3 W, continuous-wave mode). The assessment was performed using the numerical rating scale (NRS) as a subjective indicator and the Thongprasom sign score (TSS) as an objective indicator of OLP. These two scales were recorded during examinations performed before treatment and then at 7 days, 1, 3, and 6 months, and 1 year after irradiation. Differences between preirradiation and each point of time after irradiation were tested by Wilcoxon's signed-rank tests. Results: Laser irradiation was administered to 9 patients with 11 sites. The NRS score and TSS decreased at all 11 sites (100%) and 10 sites (90.9%) at 1 year after irradiation compared with preirradiation scores. The NRS score and TSS were statistically lower (p < 0.05) at 1 and 3 months (short-term) and 6 months and 1 year (mid-long-term) after irradiation than the preirradiation scores. There were no patients with malignant transformation during the study period. Conclusions: These single-arm clinical trial results show the efficacy of CO₂ laser vaporization therapy for OLP refractory to conservative treatment.

Effect of size difference between hemiglossectomy and reconstruction flap on oral functions: A retrospective cohort study

BACKGROUND AND OBJECTIVE

Forearm free flaps are used after hemiglossectomy. However, no investigation has been performed on whether oral functions are better preserved when sizes of the resection and reconstruction flap are exact matches, or whether the size of the resection should be changed. We aimed to retrospectively examine whether size differences between the resection and reconstruction flap affect speech and swallowing functions postoperatively, and to determine whether there are more favorable flap size ratios.

METHODS

This is a retrospective cohort study of patients undergoing hemiglossectomy using a forearm free flap between 2006 and 2016 at Kobe University Hospital, Japan. The effect of size difference between the resection and reconstruction flap on maintained oral function was assessed. Speech and swallowing functions were assessed, and their correlation with the ratio of the flap size to that of the resected area was determined. With these data, distribution maps of the relationship between the functional level and reconstructed dimension ratio were prepared. The more suitable reconstructed dimension ratio was examined and evaluated. The Fisher exact test, Kruskal-Wallis test, and Scheffe test were used in statistical analyses.

RESULTS

Eighty-eight patients underwent hemiglossectomy using a forearm free flap during a 10-year period. Of these cases, 66 patients were included in this study, while 22 were excluded. The ratio of the area of the reconstruction flap to that of the resection site was 0.59-2.79 (median: 1.61). Sixty patients had flaps greater than the resection area, whereas 6 had smaller flaps. Significant differences were found in speech intelligibility and swallowing function when the reconstructed dimension ratio was categorized as follows: ≤1.3, 1.3-1.8, and ≥1.8.

CONCLUSION

Our findings suggest that postoperative deterioration of oral functions after hemiglossectomy could be reduced if reconstruction is performed using a forearm free flap with a surface area 1.3 to 1.8 times greater than that of the resection area.

Induced Pluripotent Stem Cell-related Genes Correlate With Poor Prognoses of Oral Squamous Cell Carcinoma

BACKGROUND/AIM

We recently investigated the contribution of the iPS-related genes SOX2, OCT4, and Nanog to de-differentiation by assaying for their mRNA levels. Given that mRNA expression does not always correlate with the protein levels, the aim of this study was to retrospectively determine the expression of these four iPS-related factors in human OSCC specimens by immunohistochemistry and examine their association with patient prognosis.

MATERIALS AND METHODS

iPS cell-related gene expression in 89 OSCC patients by tissue microarray, and its correlation with clinicopathological factors, differentiation, metastasis, and poor prognoses were investigated.

RESULTS

No evidence of statistically significant relationships was found between the expression of iPS cell-related genes and clinicopathological parameters. However, our data indicated that KLF4 expression was associated with survival, and poor tumor differentiation. In addition, high expression of KLF4 was an independent poor prognostic factor (p=0.004) for OSCC patients.

CONCLUSION

In preoperative biopsies, higher KLF4 and poor differentiation may be clinically effective predictors for the prognosis of oral cancer.

Multicenter retrospective study of the prognosis and treatment outcomes of Japanese oral squamous cell carcinoma patients with level IV/V metastasis

BACKGROUND

The purpose of this study was to retrospectively describe the characteristics and outcomes of patients with oral squamous cell carcinoma and level IV/V metastasis and to compare patients who underwent no postoperative therapy with those who underwent postoperative radiotherapy (RT) and concomitant chemoradiotherapy (CCRT).

METHODS

We evaluated 669 patients. Clinicopathological data, postoperative therapy, and clinical course were investigated.

RESULTS

Sixty-one patients (9.1%) developed level IV/V metastasis. The 3-year cumulative overall survival rates of patients with and without level IV/V metastasis were 47.3% and 64.3%, respectively. Tongue tumors, pN2 or N3 classification, and moderate or poor differentiation were significantly associated with the development of level IV/V metastasis. The surgery+RT/CCRT group was associated with better 3-year cumulative disease-specific survival and overall survival rates than the surgery only group.

CONCLUSION

Adjuvant therapy (RT alone or CCRT) after surgery is recommended for patients with level IV/V metastasis.

Medication-related osteonecrosis of the jaw after tooth extraction in cancer patients: a multicenter retrospective study

Root amputation, immunosuppressive therapy, mandibular tooth extraction, pre-existing inflammation, and longer duration of treatment with bone-modifying agents were significantly associated with an increased risk of medication-related osteonecrosis of the jaw. Hopeless teeth should be extracted without drug holiday before the development of inflammation in cancer patients receiving high-dose bone-modifying agents.

INTRODUCTION

No studies have comprehensively analyzed the influence of pre-existing inflammation, surgical procedure-related factors such as primary wound closure, demographic factors, and drug holiday on the incidence of medication-related osteonecrosis of the jaw (MRONJ). The purpose of this study was to retrospectively investigate the relationships between these various factors and the development of MRONJ after tooth extraction in cancer patients receiving high-dose bone-modifying agents (BMAs) such as bisphosphonates or denosumab.

METHODS

Risk factors for MRONJ after tooth extraction were evaluated with univariate and multivariate analyses. The following parameters were investigated in all patients: demographics, type and duration of BMA use, whether BMA use was discontinued before tooth extraction (drug holiday), the duration of such discontinuation, the presence of pre-existing inflammation, and whether additional surgical procedures (e.g., incision, removal of bone edges, root amputation) were performed.

RESULTS

We found that root amputation (OR = 22.62), immunosuppressive therapy (OR = 16.61), extraction of mandibular teeth (OR = 12.14), extraction of teeth with pre-existing inflammation, and longer duration (≥ 8 months) of high-dose BMA (OR = 7.85) were all significantly associated with MRONJ.

CONCLUSIONS

Tooth extraction should not necessarily be postponed in cancer patients receiving high-dose BMA. The effectiveness of a short-term drug holiday was not confirmed, as drug holidays had no significant impact on MRONJ incidence. Tooth extraction may be acceptable during high-dose BMA therapy until 8 months after initiation.

Tumor budding and adjacent tissue at the invasive front correlate with delayed neck metastasis in clinical early-stage tongue squamous cell carcinoma

Background and Objectives

Some patients with early‐stage oral cancer have a poor prognosis owing to the delayed neck metastasis (DNM). Tumor budding is reportedly a promising prognostic marker in many cancers. Moreover, the tissue surrounding a tumor is also considered to play a prognostic role. In this study, we evaluated whether tumor budding and adjacent tissue at the invasive front can be potential novel predictors of DNM in early tongue cancer.

Methods

In total, 337 patients with early‐stage tongue squamous cell carcinoma were retrospectively reviewed. The patient characteristics and histopathological factors were evaluated for association with DNM. DNM rates were calculated; items which were significant in the univariate analysis were used as explanatory variables, and independent factors for DNM were identified by the multivariate analysis.

Results

The univariate analysis identified T classification, depth of invasion, tumor budding, vascular invasion, and adjacent tissue at the invasive front as significant predictors of DNM; the multivariate analysis using these factors revealed all the above variables except vascular invasion, which are independent predictors of DNM.

Conclusion

In addition to conventional predictors, high grade tumor budding and adjacent tissue at the invasive front can serve as useful predictors of DNM in early tongue cancer.

A Multicenter Retrospective Study of Elective Neck Dissection for T1-2N0M0 Tongue Squamous Cell Carcinoma: Analysis Using Propensity Score-Matching

Background

This multicenter retrospective study aimed to determine whether elective neck dissection (END) can be performed for T1-2N0M0 tongue cancer.

Methods

Patients with T1-2N0M0 tongue squamous cell carcinoma who received treatment between January 2000 and December 2012 were enrolled at 14 multicenter study sites. The 5-year overall survival (OS) and 5-year disease-specific survival (DSS) were compared between the propensity score-matched END and observation (OBS) groups.

Results

The results showed that the OS rates among the 1234 enrolled patients were 85.5% in the END group and 90.2% in the OBS group (P = 0.182). The DSS rates were 87.0% in the END group and 94.3% in the OBS group (P = 0.003). Among the matched patients, the OS rates were 87.1% in the END group and 76.2% in the OBS group (P = 0.0051), and the respective DSS rates were 89.2% and 82.2% (P = 0.0335).

Conclusion

This study showed that END is beneficial for T1-2N0M0 tongue cancer. However, END should be performed for patients with a tumor depth of 4–5 mm or more, which is the depth associated with a high rate of lymph node metastasis. The use of END should be carefully considered for both elderly and young patients.

A literature review of perioperative antibiotic administration in surgery for medication-related osteonecrosis of the jaw

PURPOSE

Few studies exist that focus on the details of perioperative antibiotic administration for surgery to treat medication-related osteonecrosis of the jaw (MRONJ). The regime and duration of perioperative antibiotics applied in published studies were reviewed to clarify appropriate perioperative antibiotic use in MRONJ surgery.

METHODS

A literature search was conducted using the MEDLINE database via PubMed.

RESULTS

The search resulted in 453 hits on PubMed. After reading the downloaded full-text articles, 17 articles met the inclusion and exclusion criteria. The most common perioperative antibiotic used for MRONJ surgery was a combination of penicillin-based antibiotics and β-lactamase inhibitor (52.9%), and the second most common regime was penicillin-based antibiotics with metronidazole (17.6%). The duration of administration was 2 weeks postoperatively in nine studies, whereas four studies applied long-term administration (2-6 weeks postoperatively).

CONCLUSIONS

Oral and maxillofacial surgeons mostly prefer penicillin-based antibiotics plus β-lactamase inhibitor or metronidazole for MRONJ surgery. The duration of administration of these medications may be based on empirical experience.

Perioperative intervention by oral medicine team in cardiovascular surgery patients

In brief, perioperative oral intervention consists of elimination of odontogenic foci and maintenance of oral hygiene in patients undergoing surgery. The importance of oral intervention before, during, and after medical treatments is well-known, especially in cancer patients, because odontogenic foci such as untreated deep dental caries or periodontitis can cause systemic infection in patients with myelosuppression resulting from chemotherapy. Although perioperative oral intervention is currently recommended for patients with cardiovascular disease, its efficacy in this population has not been established. This article consists of three sections: first, we review the current knowledge about the association between dental disease and cardiovascular disease to show the importance of oral hygiene maintenance and the risks of invasive dental procedures in patients with cardiovascular disease; second, we introduce pertinent, but limited evidence concerning the effect of oral care in preventing postoperative pneumonia; and finally, we present the optimal strategy for perioperative oral intervention in cardiovascular surgery patients.

Long-Term Effects on Volume Change in Musculocutaneous Flaps after Head and Neck Reconstruction

Objective Musculocutaneous flap reconstruction surgery is one of the standard procedures following head and neck cancer resection. However, no previous studies have classified flaps in terms of muscle and fat or examined them after long-term follow-up. The purpose of this study was to estimate the fat and muscle volume changes in musculocutaneous flaps during long-term follow-up.

Methods We conducted a retrospective analysis of 35 patients after musculocutaneous flap reconstruction. The total, fat, and muscle volumes of the musculocutaneous flaps were measured using 3-dimensional images. Changes in flap volumes over time (1 month, 1 year [POY1], and 5 years [POY5] postoperatively) were assessed. Flap persistence was calculated using flap volumes at 1 month after reconstruction for reference.

Results Flap persistence at POY5 was 42.0% in total, 64.1% in fat, and 25.4% in muscle. Muscle persistence was significantly decreased (p < 0.0001). In a multiple regression analysis, decreased body mass index (BMI) of ≥ 5% influenced fat persistence less than muscle persistence at POY1; however, there was no significant difference at POY5. Postoperative radiation therapy was associated with a significant decrease in total flap persistence at POY1 (p = 0.046) and POY5 (p = 0.0097). Muscle persistence significantly decreased at POY5 (p = 0.0108). Age significantly influenced muscle volume at POY1 (p = 0.0072).

Conclusion Reconstruction flaps are well-preserved with high fat-to-muscle ratios. Recommendations for weight maintenance are necessary for patients less than 2 years after surgery due to the influence of BMI on fat persistence. Radiation therapy is necessary for some patients based on their disease state. Intensity-modulated radiation therapy can be offered to reduce scattering irradiation to normal tissues.

Gold nanoparticles enhance X-ray irradiation-induced apoptosis in head and neck squamous cell carcinoma in vitro

Enhancing the antitumor effect of radiation, while reducing damage to organs, is a significant challenge in radiation therapy for head and neck malignancies. One promising radiosensitizer is gold. The present study aimed to determine whether gold nanoparticles (AuNPs) have the potential to enhance the effects of X-ray irradiation on head and neck cancer cells. The human head and neck carcinoma cell line HSC-3 was used. Total cell number and the levels of cell proliferation and apoptosis were compared between control cells and cells treated with 5-nm AuNPs alone at four concentrations (0.1, 0.4, 1.0 and 10.0 nM), X-ray irradiation alone at three doses (2, 4 and 8 Gy), or a combination of 4 Gy X-ray irradiation and 1.0 nM AuNPs. Analysis of variance and Tukey-Kramer testing were performed to compare the different groups. The total number of cells significantly decreased following 4 and 8 Gy X-ray irradiation, compared with in the control group (control vs. 4Gy, P=2.19×10^-4; control vs. 8Gy, P=1.28×10^-6). The combination of 4 Gy X-ray irradiation and 1.0 nM AuNPs significantly reduced the total number of cells compared with 4 Gy X-ray irradiation alone (P=2.95×10^-4). Cell proliferation was not affected by AuNP treatment alone, 4 Gy X-ray irradiation alone or the combination of X-ray irradiation and AuNPs. The combination of 4 Gy irradiation and 1.0 nM AuNPs significantly increased the number of apoptotic cells compared with 4 Gy irradiation alone (P=0.0261). In conclusion, AuNPs combined with X-ray irradiation enhanced the cytotoxic effect on human head and neck cancer cells in vitro, through the induction of apoptosis, but not inhibition of cell proliferation.

Effect of local application of transcutaneous carbon dioxide on survival of random-pattern skin flaps

INTRODUCTION

Skin flap procedures are widely used to reconstruct skin and soft tissue defects. Skin flap necrosis is a serious postoperative complication. Many researchers have introduced pharmacological agents to improve flap ischemia in experimental studies. However, outcomes of these studies remain controversial. We previously demonstrated that transcutaneous CO₂ application improves hypoxia in fracture repair. In this study, we hypothesized that improving hypoxia by transcutaneous CO₂ application can improve the blood flow in skin flaps and increase angiogenesis. We investigated whether transcutaneous CO₂ application can increase the survival of random-pattern skin flaps.

MATERIALS AND METHODS

Six-week-old male Sprague-Dawley rats were divided into two equal groups: the control group (n = 6) and CO₂ group (n = 6). A random-pattern skin flap was constructed in these rats. Topical CO₂ was applied using a hydrogel every day for 5 days in the CO₂ group. The flap survival area was measured on postoperative days 1, 3, and 5. The vessel density and expression of vascular endothelial growth factor (VEGF), basic fibroblast growth factor (bFGF), and hypoxia-inducible factor-1α (HIF-1α) were evaluated on postoperative day 5.

RESULTS

A statistically significant difference was found in the percentage of the flap survival area between the two groups on postoperative days 3 and 5 (p < 0.05). Furthermore, the expression of VEGF and bFGF was significantly higher and that of HIF-1α was significantly lower in the CO₂ than in the control group (p < 0.05).

CONCLUSIONS

Transcutaneous CO₂ application can improve the blood flow in skin flaps and increase angiogenesis, thus increasing the survival of random-pattern skin flaps.

Delayed Socket Healing After Dental Extraction in Patients Undergoing Myelosuppressive Chemotherapy for Hematological Malignancy: Incidence and Risk Factors

PURPOSE

The purpose of this study was to measure the frequency and identify factors associated with delayed socket healing after dental extraction in patients undergoing myelosuppressive chemotherapy for hematologic malignancy.

MATERIALS AND METHODS

This prospective cohort study focused on delayed healing after extraction in patients with hematologic malignancy. Sockets with delayed healing were defined as those with intense pain and bone exposure 1 week postoperatively. Patients with and without delayed socket healing were compared using the Fisher exact test and Mann-Whitney U test with some variables. Receiver operating characteristics curve analysis was conducted to define cutoff values for delayed healing.

RESULTS

One hundred ninety-four dental extractions in 93 patients (median age, 64 yr; range, 20 to 85 yr) were analyzed. The incidence of delayed socket healing was 7.5% (7 of 93 patients). There was no postoperative bleeding. Older age, type of hematologic malignancy (acute leukemia), shorter time from dental extraction to initiation of chemotherapy, low platelet count or hemoglobin level, requirement for red blood cell concentrate or platelet transfusion, and use of an absorbable hemostatic agent were statistically associated with the occurrence of delayed socket healing. Platelet and hemoglobin cutoffs were 4.6 × 10⁴/μL and 7.7 g/dL, respectively.

CONCLUSIONS

Although dental extraction can be safely performed in patients undergoing myelosuppressive chemotherapy for hematologic malignancy, oral surgeons should understand the potential risk for delayed socket healing. When considering dental extraction, patients with hematologic malignancy and low hemoglobin or platelet levels should be informed about the possibility of delayed socket healing.

Ionizing Radiation Enhances Paracellular Permeability Through Alteration of Intercellular Junctions in Cultured Human Lymphatic Endothelial Cells

BACKGROUND

A problematic complication after radiation therapy is lymphedema. Development of lymphedema is associated with an increase in lymphatic paracellular permeability. The current study investigated the effects of radiation on intercellular junctions and paracellular permeability in cultured human dermal lymphatic endothelial cells (HDLECs).

METHODS AND RESULTS

Double immunofluorescence staining with vascular endothelial (VE)-cadherin and actin immediately after X-ray irradiation (5 or 20 Gy) was performed. Morphological changes induced by irradiation were assessed. Cell viability and paracellular permeability after irradiation were also evaluated. Broad junctions in which VE-cadherin was accumulated at cell-cell contacts and almost colocalized with actin were significantly decreased in a dose-dependent manner in confluent and sparse irradiated HDLECs. Irradiation shortened the width of VE-cadherin-positive areas at the cell-cell contacts. Actin filaments did not colocalize with VE-cadherin after 20 Gy irradiation. Although cell viability was not affected by irradiation, paracellular permeability significantly increased in a dose-dependent manner.

CONCLUSIONS

A dose of 5 or 20 Gy irradiation in HDLECs does not affect cell viability, but changes VE-cadherin mediated intercellular junctions and actin structure, resulting in an increase of paracellular permeability. Further investigations on the regulatory proteins involved in radiation-induced changes, which were observed in the current study, may contribute to development of lymphedema therapy.

Transcutaneous carbon dioxide enhances the antitumor effect of radiotherapy on oral squamous cell carcinoma

Radiotherapy (RT) is one of the main treatment modalities for oral squamous cell carcinoma (OSCC), however, radioresistance is a major impediment to its clinical success and poses as a concern that needs to be addressed. Tumor hypoxia is known to be significantly associated with radioresistance in various malignancies, hence, resolving the hypoxic state of a tumor may improve the antitumor effect of RT on OSCC. We have previously revealed that transcutaneous CO2 induced mitochondrial apoptosis and suppressed tumor growth in OSCC by resolving hypoxia. Considering the previous study, we hypothesized that transcutaneous CO2 may enhance the antitumor effect of RT on OSCC by improving intratumoral hypoxia, thereby overcoming radioresistance. In the present study, the combination of transcutaneous CO2 and RT significantly inhibited tumor growth compared with other treatments. This combination therapy also led to decreased expression of HIF-1α in parallel with increased expression of the cleaved forms of caspase-3-8-9 and PARP, which play essential roles in mitochondrial apoptosis. Additionally, the combination therapy increased the expression of ROS modulator 1 and subsequent mitochondrial ROS production, compared to RT alone. These results indicated that transcutaneous CO2 could potentially improve the antitumor effect of RT by decreasing the intratumoral hypoxia and increasing the mitochondrial apoptosis. Our findings indicated that CO2 therapy may be a novel adjuvant therapy in combination with RT for OSCC.

Multi-center retrospective study of the prognosis and treatment outcomes of Japanese oral squamous cell carcinoma patients with single lymph node metastasis and extra nodal extension

BACKGROUND

Oral squamous cell carcinoma (OSCC) containing single lymph node metastasis (pN1) with extra nodal extension (ENE) is a rare clinical situation. Therefore, it is unclear whether pN1 with ENE is at high risk of recurrence among the OSCC population, or whether postoperative radiotherapy (RT)/concomitant chemoradiotherapy (CCRT) is effective in these cases.

OBJECTIVES

The purpose of this retrospective study was to investigate the prognosis and compare between no postoperative therapy and postoperative RT/CCRT in pN1 with ENE OSCC patients.

METHODS

Clinicopathological data and treatment modalities were investigated. The evaluated endpoints were overall survival (OS) and type of recurrence.

RESULTS

The 3-year cumulative OS rates for the pN1 only, multiple lymph node metastasis (MLM) only, ENE + MLM, and ENE + pN1 groups were 77.2%, 66.8%, 43.3%, and 66.6%, respectively. In the ENE + pN1 group, the most common cause of death in the surgery only group was from regional failure. The surgery + RT/CCRT group was associated with better disease-specific survival and OS rates than the surgery only groups (P < 0.05).

CONCLUSIONS

The prognosis of ENE + pN1 was not as poor as that of ENE + MLM, although both these groups feature ENE. Adjuvant therapy (RT/CCRT) after surgery is recommend for cases of ENE + pN1.

Association between pain severity and clinicohistopathologic findings in the mandibular canal and inferior alveolar nerve of patients with advanced mandibular osteoradionecrosis

OBJECTIVE

Pain is one of the most problematic symptoms in patients with osteoradionecrosis of the jaws. This study investigated the associations between pain severity and morphologic alterations of the mandibular canal and inferior alveolar nerve, in respective computerized tomography images and resected specimens of mandibular osteoradionecrosis.

STUDY DESIGN

We assessed 14 lesions in 13 patients who underwent segmental mandibulectomy for surgical debridement and simultaneous reconstruction with free fibula flap (1 patient exhibited bilateral lesions). The extent of the mandibular canal bone defect on preoperative coronal computerized tomography images and the number of inferior alveolar nerve fascicles in resected specimens were evaluated. Comparisons were made between the slight pain and extreme pain groups. In most of the patients in the extreme pain group, either mandibular canal bone defects were absent or entire circumferential defects were present; inferior alveolar nerve fascicles were either distinguishable or completely absent in the resected specimens.

RESULTS

Although there was no statistically significant association between extreme pain and computerized tomography or histopathologic findings, the histopathologically indistinguishable inferior alveolar nerve fascicles was significantly associated with slight pain.

CONCLUSIONS

The degree of degeneration of mandibular canal and inferior alveolar nerve may be associated with pain severity in patients with mandibular osteoradionecrosis.

Differences between osteoradionecrosis and medication-related osteonecrosis of the jaw

PURPOSE

The appearance of osteoradionecrosis (ORN) and medication-related osteonecrosis of the jaw (MRONJ) is similar, but clinically important differences between ORN and MRONJ exist. The aim of this study was to compare the clinical data between ORN and MRONJ and to reveal the critical differences between these diseases.

METHODS

We retrospectively reviewed the epidemiological data, clinical findings, and treatment in 27 ORN and 61 MRONJ patients. Radiographic signs before the initiation of treatment were also assessed.

RESULTS

The median age (P = 0.0474) and the ratio of female to male patients (P < 0.0001) were significantly higher in MRONJ patients. There were significantly more MRONJ patients who reported a history of pain when compared with ORN patients (P = 0.0263). As an aetiological factor, tooth extraction was significantly more relevant to MRONJ than ORN (P = 0.0352). When assessing the radiographic signs on computed tomographic images, periosteal reaction was found only in MRONJ patients (P = 0.0158). Minimal debridement was performed significantly more frequently for MRONJ (P = 0.0093), and by contrast, surgical resection was performed more frequently for ORN (P = 0.0002).

CONCLUSIONS

Understanding the clinical and underlying pathological differences between ORN and MRONJ probably contributes to the selection of appropriate treatment for each patient.

Changes regarding Age and Correlations between Serum Lipids and Body Mass Index in Humankind

Objectives: To improve insight into age and gender related distributions of serum lipids and their correlation with body mass index (BMI).

Methods: Serum lipids embracing atherogenic index (AI) and BMI were analyzed from the results obtained in 19,823 men and 14,788 women undergoing a health examination between 1986 and 1996.

Results: The changes in total cholesterol (TC), triglyceride (TG), AI and BMI differed regarding gender. Although high-density lipoprotein-cholesterol (HDL-C) showed a flat pattern for all ages in both genders, its level in women was higher than in men. The ratio of the number in the unsuitable range to those in the suitable range increased with age as to TC in both sexes, then more than half of the population have an unsuitable level in the sixth decade. As for the correlation between serum lipids and BMI: TC, TG and AI correlated positively, but HDL-C correlated negatively. There were significant gaps between both age and gender.

Conclusions: We suggest that the normal range of values of serum lipids needs to be revised according to gender and age to evaluate the risk status for a cardio-cerebrovascular disease more precisely in the field of preventive medicine. Simpler guidelines are preferable in specialized care as well as in general practice, particularly since computer technology is not yet universally adapted. In the near future, when computed information technology will be as common as the electricity and the telephone are current on the whole earth, all guidelines will have to be computed on the spot and personally.

Potential role of post-treatment follow-up FDG-PET CT to detect mandibular osteoradionecrosis: A case report

It was hypothesized that fluorodeoxyglucose (FDG) uptake on post-treatment follow-up positron emission tomography with computed tomography (PET CT; using PET CT to monitor and rule out recurrence and metastasis of head and neck carcinoma) would be useful for detecting and understanding the disease state of osteoradionecrosis (ORN) of the jaw. The present study included 14 patients who developed mandibular ORN following radiation therapy (RT) for head and neck cancer and underwent follow-up PET CT several times following RT. Areas exhibiting FDG uptake were retrospectively assessed on post-treatment follow-up PET CT images and were classified into three types: Spot type: Only spot accumulation of FDG; localized type: Accumulation of FDG restricted to within the bone resorption area; extensive type: Accumulation of FDG extending into surrounding soft tissue. PET classification at the time of clinical diagnosis of mandibular ORN in the 14 patients demonstrated the extensive type in 43%, localized type in 36% and spot type in 21%. An increased area of FDG uptake around the ORN was revealed retrospectively on post-treatment follow-up FDG PET-CT images in 50% of patients. Alterations in PET classification included spot type to localized type in 36% and localized type to extensive type in 14%. A significantly increased number of patients with extensive-type ORN (P=0.026) required surgery. Post-treatment follow-up FDG-PET CT may be useful for early detection and better understanding of ORN.

Expression of Ror2 Associated with Fibrosis of the Submandibular Gland

The submandibular gland (SMG) is one of the major salivary glands that play important roles for variety of physiological functions, such as digestion of foods, prevention of infection, and lubrication of the mouth. Dysfunction of the SMG, often associated with a salivary inflammation, adversely influences a person's quality of life. However, the mechanism underlying inflammation-driven dysfunction of the SMG is largely unknown. Here, we used a mouse model in which the main excretory duct of the SMG is ligated unilaterally to induce inflammation of the gland and examined the expression of Wnt5a, Ror1 and Ror2 genes, encoding Wnt5a ligand and its cognate receptors, which have been implicated in tissue damage or inflammatory responses in variety of tissues. We show that expression levels of Ror1, Ror2, and Wnt5a are increased in the ligated SMG undergoing interstitial fibrosis, which is accompanied by robust expression of fibrosis-associated genes, such as TGF-β1, TNF-α, IL-1β, and MMP-2. Increased immunostaining signal of Ror2 was detected in the fibrotic tissues with abundant accumulation of fibroblasts and collagen fibers in the ligated SMG, suggesting that Ror2-mediated signaling might be activated in response to tissue damage and associated with progression of fibrosis in the SMG.Key words: submandibular gland, Ror2, Wnt5a, fibrosis, inflammation.