Cancer prevention in the dental practice: oral cancer screening and tobacco cessation advice

OBJECTIVES

In this paper we describe the proportion of US adults who report receiving oral cancer screening and tobacco cessation counseling and assistance from dentists and other health professionals.

METHODS

Data from the 1992 National Health Interview Survey (NHIS) Cancer Control Supplement, a nationally representative sample of 12,035 adults 18 years of age and older, are analyzed.

RESULTS

In 1992, less than 10 percent of adults reported oral cancer screening by a dentist or hygienist within the past three years. White adults (10.1%, 95% CI = 9.3, 10.9) reported an oral cancer screening three times more frequently than black (3.2%, 95% CI = 1.9, 4.5) or Hispanic (3.4%, 95% CI = 2.1, 4.7) adults. About half of adult current smokers had seen a dentist within 12 months, and of those only 24.1 percent (95% CI = 21.7, 26.5) had been advised to quit smoking. Heavy smokers (two or more packs a day) were more likely to have been advised to quit than light (pack or less per day) or occasional smokers. A similar proportion (24.3%, 95% CI = 17.6, 31.0) of white adult men who reported using smokeless tobacco products had been told by a dentist to quit using tobacco.

CONCLUSIONS

Results from this population-based survey indicate that cancer screening and tobacco cessation advice are underutilized in the dental practice. Increased patient awareness and implementation of screening and tobacco cessation interventions could improve oral cancer incidence and mortality and have a public health benefit for other tobacco-related morbidity and mortality as well.

Rapid orthodontics with alveolar reshaping: two case reports of decrowding

Two case reports demonstrate a new orthodontic method that offers short treatment times and the ability to simultaneously reshape and increase the buccolingual thickness of the supporting alveolar bone. A 24-year-old man with a Class I severely crowded malocclusion and an overly constricted maxilla with concomitant posterior crossbites and a 17-year-old female with a Class I moderately to severely crowded malocclusion requested shortened orthodontic treatment times. This new surgery technique included buccal and lingual full-thickness flaps, selective partial decortication of the cortical plates, concomitant bone grafting/augmentation, and primary flap closure. Following the surgery, orthodontic adjustments were made approximately every 2 weeks. From bracketing to debracketing, both cases were completed in approximately 6 months and 2 weeks. Posttreatment evaluation of both patients revealed good results. At approximately 15 months following surgery in one patient, a full-thickness flap was again reflected. Visual examination revealed good maintenance of the height of the alveolar crest and an increased thickness in the buccal bone. The canine and premolars in this area were expanded buccally by more than 3 mm, and yet there had actually been an increase in the buccolingual thickness of the overlying buccal bone. Additionally, a preexisting bony fenestration buccal of the root of the first premolar was covered. Both of these findings lend credence to the incorporation of the bone augmentation procedure into the corticotomy surgery because this made it possible to complete the orthodontic treatment with a more intact periodontium. The rapid expansive tooth movements with no significant apical root resorption may be attributed to the osteoclastic or catabolic phase of the regional acceleratory phenomenon. Instead of bony "block" movement or resorption/apposition, the degree of demineralization/remineralization might be a more accurate explanation of what occurs in the alveolar bone during physiologic tooth movement in these patients.

Orofacial considerations for pediatric, adult, and elderly victims of abuse

Health care providers must take the time to educate themselves about domestic violence, its signs and symptoms, and the proper care of victims of child, spouse, or elder abuse. It is not enough to treat the immediate injuries without offering necessary and appropriate intervention on behalf of the victim. No one deserves to be beaten, sexually abused, or emotionally mistreated. If abuse is suspected, report it to the proper authorities. By focusing attention on this major health problem, physicians can provide a leadership role in using health care response to reduce the incidence of abuse and, ultimately, to save lives.

Intraosseous salivary tissue: jawbone examples of choristomas, hamartomas, embryonic rests, and inflammatory entrapment: another histogenetic source for intraosseous adenocarcinoma

PROBLEM

Hundreds of primary salivary neoplasms have been found to be completely enclosed within the marrow spaces of the maxilla and mandible, yet nonneoplastic salivary tissue has never been convincingly identified within marrow, either separately or adjacent to such neoplasms. This situation has forced the acceptance of an inherently awkward odontogenic origin for all intramedullary salivary carcinomas and adenomas.

OBJECTIVE

The purpose of this study was to microscopically evaluate a large number of maxillofacial marrow samples for the presence of intramedullary salivary tissue.

STUDY DESIGN

We microscopically reviewed 5034 maxillofacial bone samples from the Latvala Inflammatory Bone Registry for evidence of heterotopic salivary inclusions within the marrow tissues. Contributing surgeons were contacted for each identified case of intraosseous salivary tissue to assure that all submitted tissue was removed from within the marrow spaces rather than from overlying soft tissue.

RESULTS

Thirteen of 5034 marrow samples (0.3%) contained heterotopic acinic hamartomas, salivary choristomas, embryonic salivary rests, or entrapped surface glands. Four additional hamartomas of the condyle are described. We report also the chance finding of incipient odontogenic epithelial neoplasms (n = 6) and odontogenic epithelial rests (n = 84) within the fatty marrow and outside the periodontal ligament spaces, confirming that not all odontogenic neoplasms are necessarily of periodontal ligament origin.

CONCLUSION

The frequency rate for salivary choristomas, hamartomas, embryonic rests, and displaced surface glands within alveolar bone is no less than 2.6 of 1000 biopsied marrow samples. This provides an additional and quite logical histogenetic explanation for the presence of intraosseous salivary neoplasms.

Maxillofacial osteonecrosis in a patient with multiple "idiopathic" facial pains

Previous investigations have identified focal areas of alveolar bone tenderness, increased mucosal temperature, abnormal anesthetic response, radiographic abnormality, increased radioisotope uptake on bone scans, and abnormal marrow within the quadrant of pain in patients with chronic, idiopathic facial pain. The present case reports a 53-year-old man with multiple debilitating, "idiopathic" chronic facial pains, including trigeminal neuralgia and atypical facial neuralgia. At necropsy he was found to have numerous separate and distinct areas of ischemic osteonecrosis on the side affected by the pains, one immediately beneath the major trigger point for the lancinating pain of the trigeminal neuralgia. This disease, called NICO (neuralgia-inducing cavitational osteonecrosis) when the jaws are involved, is a variation of the osteonecrosis that occurs in other bones, especially the femur. The underlying problem is vascular insufficiency, with intramedullary hypertension and multiple intraosseous infarctions occurring over time. The present case report illustrates the extreme difficulties involved in the diagnosis and treatment of this disease.

Ischemic osteonecrosis under fixed partial denture pontics: radiographicand microscopic features in 38 patients with chronic pain

STATEMENT OF PROBLEM

Previous studies have identified focal areas of alveolar tenderness, elevated mucosal temperature, radiographic abnormality, and increased radioisotope uptake or "hot spots" within the quadrant of pain in most patients with chronic, idiopathic facial pain (phantom pain, atypical facial neuralgia, and atypical facial pain).

PURPOSE

This retrospective investigation radiographically and microscopically evaluated intramedullary bone in a certain subset of patients with histories of endodontics, extraction, and fixed partial denture placement in an area of "idiopathic" pain.

MATERIAL AND METHODS

Patients from 12 of the United States were identified through tissue samples, histories, and radiographs submitted to a national biopsy service. Imaging tests, coagulation tests, and microscopic features were reviewed. Of 38 consecutive idiopathic facial pain patients, 32 were women.

RESULTS

Approximately 90% of subpontic bone demonstrated either ischemic osteonecrosis (68%), chronic osteomyelitis (21%), or a combination (11%). More than 84% of the patients had abnormal radiographic changes in subpontic bone, and 5 of 9 (56%) patients who underwent radioisotope bone scan revealed hot spots in the region. Of the 14 patients who had laboratory testing for coagulation disorders, 71% were positive for thrombophilia, hypofibrinolysis, or both (normal: 2% to 7%). Ten pain-free patients with abnormal subpontic bone on radiographs were also reviewed.

CONCLUSIONS

Intraosseous ischemia and chronic inflammation were suggested as a pathoetiologic mechanism for at least some patients with atypical facial pain. These conditions were also offered as an explanation for poor healing of extraction sockets and positive radioisotope scans.

Oral cancer in a tobacco-chewing US population--no apparent increased incidence or mortality

OBJECTIVE

Smokeless tobacco use is an accepted risk factor for oral cancer in the United States, but the major proof of this is based largely on a single epidemiologic (case-control) comparison of women, whereas the chewing of tobacco is predominantly a habit of men. The present investigation sought to compare gender-specific oral cancer mortality and incidence rates in West Virginia, the state with the highest per capita consumption of smokeless tobacco, with rates from other states and with the US average rates. It was hypothesized that the cancer rates for West Virginia males would be significantly greater than the US average and greater than the rates for states with less smokeless tobacco consumption.

STUDY DESIGN

Data from the West Virginia Cancer Registry for the years 1993 through 1995 were compared with data from contemporary Surveillance and Epidemiology End Results for the US (with respect to incidence) and from the Center for Disease Control and Prevention's National Center for Health Statistics (with respect to mortality).

RESULTS

The average annual incidence rates (per 100,000 population) for oral/pharyngeal cancer in West Virginia males and females were 13.4 and 5.1, respectively; these compared with rates of 15.4 and 5.7 for the US. The average annual mortality rates (per 100,000 population) for the disease in West Virginia males and females were 4.2 and 1.6, respectively; these compared with 4.4 and 1.5 for the US. West Virginia oral/pharyngeal mortality rates for both genders were statistically significantly lower than US rates throughout the years 1950 through 1980. Among other potential oral cancer etiologic factors, the very low prevalence of alcohol abuse in West Virginia seemed to be relevant.

CONCLUSIONS

The hypothesis was not confirmed by data analysis. West Virginia is the state with the highest per capita consumption of smokeless tobacco, yet it has less oral/pharyngeal cancer than the US average. The authors strongly urge additional and improved epidemiologic evaluation of the oral cancer risk of smokeless tobacco use in US males.

Oral verrucous carcinoma. Incidence in two US populations

Much is known about the clinical appearance, biological behavior, and treatment of verrucous carcinoma of the oral cavity. However, the epidemiologic characteristics are completely unknown. This cancer is considered to be rare in Western cultures because it is not common in oral pathology biopsy services, but there is no epidemiologic evidence for this belief. To provide this evidence, 2 population-based incidence investigations were carried out, one in Rochester, Minn., and the other in the state of West Virginia. The results were as follows: the age-adjusted average annual incidence rate for oral verrucous carcinoma among Rochester residents was 0.1/100,000 person-years (0.2 for males, 0.0 for females), whereas the incidence rate for all intraoral carcinomas was 3.6/100,000 person-years (5.4 for males, 2.1 for females). Among men over 64 years of age, the incidence rate for verrucous carcinoma was increased to 3.2/100,000 person-years. Verrucous carcinoma was among the least common of the oral carcinomas in this population, representing only 3% of the total. The age-adjusted incidence rate for oral and pharyngeal verrucous carcinoma among West Virginia residents was somewhat greater, 0.3/100,000 person-years, and showed an even gender predilection (0.28 for males, 0.29 for females). The incidence rate for all oral/pharyngeal cancers in West Virginia was 8.8/100,000 person-years (13.4 for males, 5.7 for females), which was below the US average. The conclusion is that oral verrucous carcinoma is a rare tumor of older people, diagnosed in only 1 to 3 of every 1,000,000 persons each year.

Exogenous estrogen may exacerbate thrombophilia, impair bone healing and contribute to development of chronic facial pain

A 32 year old white female, in apparently good health, failed to respond to conservative wound care for alveolar osteitis after a routine mandibular first molar extraction. Curettage and biopsy of necrotic alveolar bone from the #30 socket escalated her pain such that hospitalization was necessary for pain management with intravenous morphine. Twelve months prior to admission she had been placed on exogenous estrogen (Premarin, 0.625 mg/day) after a partial oophorectomy. While hospitalized, she was found to have resistance to activated protein C (APCR). Premarin was discontinued. After discharge, weekly changes of an antibiotic impregnated dressing allowed for progressive regeneration of bone and epithelium with gradual reduction in her pain. She was found to be heterozygous for the mutant Factor V Leiden, a heritable factor for increased tendency to form thrombi, so-called thrombophilia. We speculate that the exogenous estrogen administration exacerbated the thrombophilia associated with the Factor V Leiden mutation by compounding the patient's resistance to activated protein C thereby contributing to her development of osteonecrosis and severe alveolar neuralgia.

A preliminary pilot study of treatment of thrombophilia and hypofibrinolysis and amelioration of the pain of osteonecrosis of the jaws

OBJECTIVES

In a preliminary pilot study of 30 treatments in 26 patients with osteonecrosis of the jaws and chronic disabling facial pain, our specific aim was to determine whether, to what degree, and how safely therapy of hypofibrinolysis and thrombophilia would ameliorate the chronic pain associated with osteonecrosis of the mandible and maxilla.

STUDY DESIGN

Thrombophilia was treated with Coumadin (DuPont) in 10 patients; hypofibrinolysis was treated with Winstrol (Sanofi-Winthrop) in 20 patients, including 4 who had mixed thrombophilia and hypofibrinolysis and had previously been treated with Coumadin. The initial treatment period was targeted to be 4 months. Each patient was asked to keep a daily written pain-relief numeric rating score and side-effects diary and to provide a summary pain-relief numeric rating score and side effects compilation for the total treatment period.

RESULTS

There were 4 men and 22 women in the study group; their mean age was 49 +/- 11 years. The mean onset of their osteonecrosis pain was at age 45 +/- 12 years, and the mean duration of their facial pain prior to therapy was 4.5 +/- 4.2 years. Ten patients had one or more thrombophilic traits (there were two patients with protein C deficiency, five with resistance to activated protein C and/or the mutant Factor V Leiden gene, and four with high anticardiolipin antibodies). The 10 patients who were thrombophilic were treated with Coumadin (the international normalized ratio was targeted to 2.5-3.0) for 22 +/- 9 weeks. By self-reported pain-relief numeric rating scores, 6 of the 10 patients with thrombophilia (60%) had > or = 40% pain relief, 2 (20%) had no change, and 2 (20%) had increased pain (30% and 80% worse). Nine of the 10 patients with thrombophilia (90%) had no Coumadin-related side effects; 1 patient (10%) stopped Coumadin therapy (after 28 weeks) because of nosebleeds. Winstrol (6 mg per day) was used for 16 +/- 9 weeks in 20 patients with hypofibrinolysis, some of whom had one or more hypofibrinolytic traits (10 had high levels of plasminogen activator/inhibitor activity, usually accompanied by low stimulated tissue plasminogen activator activity; 13 had high Lp[a] lipoprotein). Of these 20 patients with hypofibrinolysis, 9 patients (45%) had > or = 40% pain relief, 3 patients (15%) had 20% to 30% relief, 5 patients (25%) had no improvement, and 3 patients (15%) had increased pain (30% worse, 60% worse, and 70% worse). Six of the 20 patients with hypofibrinolysis (30%) had no Winstrol-related side effects, while 14 (70%) had side effects that could be attributed to Winstrol, including weight gain, peripheral edema, increased facial and body hair, and acne--all of which were reversed within 6 weeks of stopping Winstrol therapy.

CONCLUSIONS

We postulate that thrombophilia and hypofibrinolysis lead to impaired venous circulation and venous hypertension of the mandible/maxilla with subsequent development of osteonecrosis and chronic facial pain. In many patients, facial pain can be ameliorated by treating the pathogenetic coagulation defects with Coumadin or Winstrol. Large, double-blind, placebo-controlled crossover studies will be required in the future to validate these preliminary results and to determine whether pain relief with Coumadin or Winstrol justifies the risks and side effects associated with these medications, especially for long-term use, in osteonecrosis of the jaws.

Heterozygosity for the Leiden mutation of the factor V gene, a common pathoetiology for osteonecrosis of the jaw, with thrombophilia augmented by exogenous estrogens

We assessed whether heterozygosity for the thrombophilic Leiden mutation of the factor V gene (MFV) was pathogenetic for alveolar osteonecrosis of the jaw and chronic facial pain (neuralgia-inducing cavitational osteonecrosis (NICO)) in 89 patients with NICO. A second specific aim was to assess for thrombophilic synergism between exogenous estrogens and MFV for development of osteonecrosis of the jaw. MFV was found in 24% of the patients, 16 (21%) of 76 women and 5 (39%) of 13 men. The mutation was much less common in healthy normal controls: 3 (3%) of 101 women (chi2 = 14.8, p = 0.001) and 4 (3.7%) of 108 men (chi2 = 20.4, p = 0.001). Patients with and without MFV did not differ in tissue plasminogen activator activity, plasminogen activator inhibitor activity, proteins C and S, lipoprotein (a), or anticardiolipin antibodies (p > 0.05). Use of standard-dose oral contraceptives and/or postmenopausal estrogens before the development of NICO was more common in female patients with MFV (13 (81%) of 16) than in those without it (23 (38%) of 60; chi2 = 9.33, p = 0.002). When the thrombophilic effects of such exogenous estrogens were superimposed on the familial resistance to activated protein C associated with MFV, thrombophilia was augmented and the risk of osteonecrosis was increased. Since heterozygosity for this mutation occurs in at least 3% of unselected, healthy women, measurement of resistance to activated protein C and MFV would identify women at high risk for venous thrombosis and osteonecrosis, in whom use of oral contraceptives or postmenopausal estrogens might be contraindicated, while identifying a much larger group of women (approximately 97%) without the mutation whose risk from exogenous estrogens would be low.

Bulimia nervosa: dental perspectives

Bulimia nervosa and bulimic behavior are among the most common eating disorders, affecting up to 13% of female college students. Most health professionals are aware of the compulsive overeating, self-induced vomiting, and laxative abuse associated with this disease; yet, only a small proportion of affected patients are ever diagnosed, generally only after years of abuse. Since the dental changes observed in most bulimics are recognizable and usually undeniable, the clinician should be aware of the oral and maxillofacial changes of this disease in order to arrive at an early diagnosis. Without successful treatment, an estimated 1 in 300 bulimic cases will have a fatal outcome. Even with treatment, one-third of affected individuals suffer early relapse and half of them do not consider themselves cured after 5 years of psychologic therapy. The learning objective of this article is to discuss the dental and psychologic features of this disorder, with focus on the differential diagnosis and treatment of the oral manifestations.

Papillary (pebbled) masses of the oral mucosa: more than simple papillomas

Soft tissue masses are found in almost 4% of adult dental patients, and most of these will never be biopsied. Clinical evaluation, therefore, is of paramount importance. Oral mucosal masses with irregular or nodular surface alterations are of special concern. These alterations may appear to be papillomas, but there are several type of papillomas, and among the lesions which present with a papilloma-like appearance are diverse malignancies, contagious infections, sexually transmitted diseases, vascular and reparative lesions, and viral proliferations associated with a wide range of different types of human papillomavirus. The learning objective of this article is to present a clear, clinically oriented approach to the diagnosis and management of pebbled and lobulated intraoral masses, enabling the clinician to provide a more meaningful clinical diagnosis and prognosis. For the differential diagnosis discussion, the authors have selected only those entities with the preliminary diagnosis of "papilloma."

Erythroplakia: the dangerous red mucosa

Erythroplakia is an uncommon and subtly innocuous change of the oral mucosa, but it has very specific and identifiable clinical characteristics, therapies, and prognostic features. It is the most dangerous of all the oral cancer precursor lesions, and a search for erythroplakia should be a part of every oral soft tissue examination in persons aged 35 years and older. No erythroplakia lesions should ever be left untreated. Much has been written about the malignant potential of oral leukoplakia, but too often the dental profession has ignored the more dangerous discoloration, erythroplakia, which carries a much greater cancer risk than the white lesions. A clear understanding of this lesion may save lives by identifying oral cancers prior to invasion or at an early stage, thereby avoiding extensive surgery and spread of the disease to other parts of the body. The learning objective of this article is to review and familiarize the reader with the terminology, diagnosis, etiology, treatment, and the prognosis of this disease.

Long-term effects of jawbone curettage on the pain of facial neuralgia

PURPOSE

To evaluate the dimension and duration of pain reduction in patients with facial neuralgias after localization, decortication, and curettage of histologically confirmed inflammatory jawbone lesions of the newly identified form of alveolar avascular osteonecrosis called neuralgia-inducing cavitational osteonecrosis (NICO).

MATERIALS AND METHODS

One hundred ninety patients who could be located retrospectively and who had histories of jawbone curettage for chronic "idiopathic" facial pain, either trigeminal neuralgia (TN) or atypical facial neuralgia/pain (AFN), were identified through surgical pathology reports from four institutions. To assess pain reduction after jawbone surgery, these patients were mailed a modified McGill Pain Survey by investigators with whom they had had no previous professional contact. Patient demographics and clinicopathologic characteristics were also reviewed through surgical pathology specimens and reports.

RESULTS

More than two thirds of the respondents to whom the questionnaire was mailed experienced complete or almost complete disappearance of neuralgic pain immediately or shortly after curettage of jawbone osteonecrosis (NICO), regardless of whether they had previously been diagnosed with TN or AFN. Thirty percent, however, experienced local recurrence of jaw inflammation and facial pain, and one third developed at least one and as many as 12 additional foci of histologically confirmed osteonecrosis. Despite this, however, the long-term (average, 4.6 years) abatement of neuralgic pain was total or almost total in 74% of treated patients.

CONCLUSIONS

Neuraglia-inducing cavitational osteonecrosis appears to be associated with at least some cases of facial neuralgia, or with a pain so similar as to be clinically indistinguishable. Decortication and curettage dramatically reduces or eliminates this intense pain in two of every three patients, although multiple surgeries may be required, and additional sites of osteonecrosis may occur. It is recommended that NICO be included in the differential diagnosis of idiopathic facial pain syndromes.

Identification and semiquantification of estrogen and progesterone receptors in pyogenic granulomas of pregnancy

Cases of pyogenic granuloma in pregnant women, nonpregnant women, and men were evaluated for the detection of estrogen and progesterone receptor proteins by immunoperoxidase staining. Immunostaining for estrogen receptors revealed a marked immunoreactivity of the endothelium within lesional tissue and in the overlying mucosal epithelium in many cases. Progesterone receptor immunoreactivity was only present within the epithelium, where it was much less than that of estrogen receptor immunoreactivity in both quantity (proportion of positive cells) and intensity. No characteristic staining pattern or significant quantitative difference among the three study groups could be discerned. These findings suggest that the quantity of estrogen or progesterone receptors in pyogenic granuloma is not the determining factor in the pathogenesis of this lesion. Rather, such a role may be attributed to the levels of circulating hormones. The levels of estrogen and progesterone are markedly increased in pregnancy and could therefore exert a greater effect on the endothelium of the pyogenic granuloma.

The beginning of oral pathology. Part I: First dental journal reports of odontogenic tumors and cysts, 1839-1860

Literature reviews of oral lesions frequently lack an appropriate historic perspective, presuming that the mid- to late-twentieth century reports are the first valid reports available. The mid-nineteenth century dental journals, however, are replete with clinical, surgical, and microscopic descriptions of oral tumors and cysts. Most of these have never been referenced during the present century. The purpose of this article is to report the earliest dental journal references for a variety of odontogenic tumors and cysts. These references are derived from a canvass of all dental journals published from the first journal (American Journal of Dental Science) in 1839 to the appearance of Dental Cosmos and the organization of the American Dental Association in 1860.

Oral leukoplakia and erythroplakia: a review and update

Soft tissue health in the oral cavity is essential for overall dental and medical health and a successful maintenance of any restoration. This article reviews the clinical, etiologic, and prognostic features of oral leukoplakia, the most common of all chronic mucosal lesions, affecting 3% of all adults. The newest definitions for leukoplakia, erythroplakia, and smokeless tobacco keratosis are offered, along with a rationale for predicting malignant transformation and for treatment planning of these most important precancers. The learning objective of this article is to update the information for the clinician for early diagnosis and treatment of these lesions.

Estrogen and progesterone receptor status of central giant cell lesions of the jaws

It is well known that the central giant cell lesion (granuloma) of the jaws has a distinct female predilection. In addition, occasional cases of central giant cell lesion have been reported to have undergone marked proliferation in pregnant patients and in those undergoing hormonal therapy. As such, we have evaluated 10 central giant cell lesions for the detection of estrogen and progesterone receptor proteins with the use of immunoperoxidase staining. Surprisingly, however, immunostaining for estrogen receptor protein was essentially negative in all cases examined. Although an occasional mononuclear cell stained weakly positive for estrogen receptor protein, these findings suggest that in most cases, factors other than a direct influence of the ovarian hormones, estrogen and progesterone, are responsible for the development and growth of these lesions.

Identification and semi-quantification of estrogen and progesterone receptors in peripheral giant cell lesions of the jaws

Cases of peripheral giant cell lesions of the jaws (PGCL) were evaluated for the detection of estrogen and progesterone receptor proteins (ERS/PRS) utilizing immunoperoxidase staining. Staining for ERS was strongly positive in three cases when examining the mononuclear cell population. Another two cases were weakly positive. In addition, an occasional ER + multinucleated giant cell could be observed in three of the cases examined. PRS immunoreactivity was essentially negative in all cases. It is well known that the PGCL has a marked female predilection. This, coupled with the present findings, gives further evidence that some PGCL may be at least partially under hormonal influence.

Oral leukoplakia--rationale for diagnosis and prognosis of its clinical subtypes or "phases"

The precancerous nature of the most common of chronic oral mucosal lesions, leukoplakia, is much better understood now than at any time since it was first brought to professional attention by Sir James Paget 143 years ago. Clinical research from the past decade now allows confident identification of high-risk features of oral leukoplakias and of those persons affected by them. This paper summarizes current understanding of this important disease and provides practical suggestions for appropriate management and classification of its various subtypes or "phases."

Neuralgia-inducing cavitational osteonecrosis (NICO). Osteomyelitis in 224 jawbone samples from patients with facial neuralgia

A somewhat obscure etiologic theory for facial neuralgias presumes a low-grade osteomyelitis of the jaws that produces neural degeneration with subsequent production of inappropriate pain signals. Animal investigations and treatment successes with human patients based on this theory lend it credence. The present study examined 224 tissue samples removed from alveolar bone cavities in 135 patients with trigeminal neuralgia or atypical facial neuralgia. All tissue samples demonstrated clear evidence of chronic intraosseous inflammation. The most common microscopic features included dense marrow fibrosis or "scar" formation, a sprinkling of lymphocytes in a relative absence of other inflammatory cells (especially histiocytes), and smudged, nonresorbing necrotic bone flakes. Very little healing or new bone formation was visible. These lesions were able to burrow several centimeters to initiate distant cavities. The present preliminary investigation cannot prove etiology, but the presence of intraosseous inflammation in every single jawbone specimen in these patients and certain clinical and treatment aspects of these lesions (to be reported later) has led the authors to recommend the term neuralgia-inducing cavitational osteonecrosis or NICO for these lesions.

Laryngeal precancer: a review of the literature, commentary, and comparison with oral leukoplakia

Laryngeal keratosis (LK) is a precancerous mucosal change with great similarity to oral leukoplakia. Its malignant transformation rate varies from 1% to 40%, with the highest rates being found in patients microscopically diagnosed as "keratosis with atypia" (KWA). Recent evidence indicates that even cases with only mild or moderate epithelial dysplasias are at increased risk for malignant transformation, with the highest rates occurring in patients with more severe dysplasia or carcinoma in situ. Approximately 81% of LK patients are men and the average age at diagnosis is 50 years, a decade younger than that for laryngeal carcinoma patients. A high proportion of LK patients are tobacco smokers (84%) and alcohol abusers (at least 35%). LK is almost always found on the true vocal cords and is usually bilateral (67%). Clinical signs of high risk include, in decreasing order of importance: erythroplakia, surface granularity, increased keratin thickness, increased size, recurrence after conservative removal, and long duration. The annual incidence of LK in the United States is 10.2 and 2.1 lesions per 100,000 males and females, respectively.

Reviewing oral leukoplakia: clinical concepts for the 1990s

Microscopic evidence of dysplasia is not necessary to diagnose leukoplakia. Rather leukoplakia is clinically diagnosed not so much by defining appearances as by excluding other lesions also appearing as oral white plaques.

Metastases to and from the upper aerodigestive tract in the population of Rochester, Minnesota, 1935-1984

The present investigation is the first population-based study to provide incidence and clinicopathologic data for metastases to and from the upper aerodigestive tract (UAT). In a patient cohort with relatively minimal referral bias it was determined that cervical and distant metastases occurred in 21% and 2%, respectively, of UAT carcinomas by the time of diagnosis; incidence rates per 100,000 person-years for cervical and distant metastases from UAT carcinomas were 2.8 and 0.3, respectively; occult primary lesions represented 3.8% of all UAT carcinomas; 3.6% of all invasive UAT carcinomas were actually metastatic from another body site; and the clinicopathologic literature has overestimated the prevalence of metastases at diagnosis relative to UAT carcinomas.

Carcinoma in situ of the upper aerodigestive tract. Incidence, time trends, and follow-up in Rochester, Minnesota, 1935-1984

Epidemiologic analyses of carcinoma in situ (CIS) of the upper aerodigestive tract (UAT) are virtually nonexistent. The current investigation summarizes the total UAT CIS experience of a white, middle class community from 1935 through 1984. Average annual incidence rates varied between genders (3.1 per 100,000 person-years for males versus 0.6 per 100,000 person-years for females), and increased from 1.5 to 3.1 lesions per 100,000 person-years between 1935 and 1964, and 1965 and 1984. Virgin CIS lesions represented 13% of all UAT carcinomas and the vermilion borders of the lips accounted for 42% of all UAT CIS cases. Age-specific incidence rates for males demonstrated a continuous increase with increasing age to 40.5 per 100,000 for males older than 75 years. A clinicopathologic analysis of these lesions is provided.

Epidemiology of carcinoma in situ of the upper aerodigestive tract

Epidemiologic analyses of upper aerodigestive tract (UAT) carcinoma in situ (CIS) are nonexistent, hence only hospital records and surgical pathology resources are available for its descriptive characterization. The National Cancer Institute's Surveillance, Epidemiology and End Results investigation has, however, published valuable raw data pertaining to CIS of the UAT. This information is analyzed here and summarized for the first time, demonstrating the following: a male incidence rate which is four times greater than the female rate (0.8/100,000 males versus 0.2/100,000 females); similar ages at diagnosis for both sexes (62.7 and 60.0 years of age for males and females, respectively); no significant urban/rural incidence differences; that CIS represents 2.8% of all UAT malignancies; that 2.0% of all CIS lesions in humans are found at UAT sites; and that CIS of the uterine cervix is not a good model for CIS of the UAT.

Juvenile juxtavermilion candidiasis: yet another form of an old disease?

Five cases of a chronic, self-limiting Candida albicans infection of the lip vermilion and juxtavermilion skin in young persons are presented. These infections typically appeared as erythematous, pruritic, yellow crusting plaques of the juxtavermilion skin, with or without desquamation of vermilion surfaces. Evidence of intraoral candidiasis, especially loss of filiform lingual papillae, was present in several cases. The disorder mimics the early stage of chronic mucocutaneous candidiasis but remains within a few millimeters of the mucocutaneous junction and affected individuals appear (with a possible exception) to be immune competent. Mild trauma apparently triggers the infection. The authors emphasize that a scientifically sound cause-and-effect relationship between this new disease and Candida albicans is not herein established and present these cases in the hope that others will thereby be identified and a firmer causal relationship be established.

Leukoplakia and carcinoma in situ synchronously associated with invasive oral/oropharyngeal carcinoma in Rochester, Minn., 1935-1984

Previous investigations into the association between oral/oropharyngeal carcinoma and clinical white patches (leukoplakia) have noted that the latter lesion is found adjacent to malignancies in 10% to 100% of all carcinomas of this site. This is an unacceptable variation in results and probably relates more to the referral biases inherent in hospital-based studies than to any other factor. The present population-based study, which is relatively free of selection bias, demonstrates that 62%, 36%, and 18% of invasive carcinomas of the labial vermilion, oral cavity proper, and oropharynx, respectively, have leukoplakia lesions of immediately adjacent mucosal surfaces. Only 7% of invasive carcinomas have juxtaposed carcinoma in situ, whereas another 2% have severe epithelial dysplasia. Mucosal carcinomas associated with leukoplakias appear to be smaller, more mature histologically, and more likely to be only superficially invasive; such carcinomas present with fewer metastases at diagnosis and provide a better prognosis than similar carcinomas not associated with leukoplakia.

Esophageal carcinoma metastatic to the oral cavity

A rare case of esophageal carcinoma metastatic to the oral cavity is described. The clinical and light microscopic findings supporting the diagnosis are presented.

Oral exophytic lesions in 23,616 white Americans over 35 years of age

This study provides the first detailed epidemiologic analysis of benign oral soft tissue masses and bony prominences. Of 1,453 such lesions found in 23,616 white persons over 35 years of age, the most common were palatal and mandibular tori, with a combined prevalence rate of 27.1 lesions/1,000 persons. Other lesions commonly found were irritation fibromas (12.0 lesions/1,000 population); hemangiomas (5.5/1,000); papillomas (4.6/1,000); epulides fissurata (4.1/1,000); mucoceles (2.5/1,000); and others. The prevalence of all oral masses was 61.4/1,000 (33.5 if bony lesions are excluded). Sex-specific and site-specific clinical information is offered and is contrasted with the literature.

Leukoplakia, lichen planus, and other oral keratoses in 23,616 white Americans over the age of 35 years

This investigation provides the first detailed population-based reporting of white keratotic lesions of the oral mucosa in a United States population. More than 21% of 3,783 oral mucosal and connective tissue lesions reported from 23,616 white Americans, usually over 35 years of age, were keratotic lesions, representing 3.4% of the entire group of examinees. Leukoplakia was the most common of all lesions diagnosed and was the most common of the keratotic lesions (85.5% of the latter). The prevalence rate for leukoplakia was 28.9/1,000 white Americans over 35 years of age and was twice as high for males as for females (43.2/1,000 males versus 20.9/1,000 females). Age-specific leukoplakia prevalence rates demonstrated a tenfold increase for males from the third to the eighth decade of life, and twofold increase for females from the fourth to the seventh decade. Sites of leukoplakia involvement, in decreasing order of frequency, were lip vermillion, buccal mucosa, mandibular gingiva, tongue, oral floor, hard palate, maxillary gingiva, lip mucosa, and soft palate. Almost 7% of leukoplakias demonstrated carcinoma or severe dysplasia microscopically. Prevalence rates for other white oral mucosal lesions were tobacco/snuff pouch keratosis, 1.6/1,000; chronic cheek bite, 1.2/1,000; lichen planus, 1.1/1,000; palatitis nicotina, 0.7/1,000; and leukoedema, 0.3/1,000.

Common oral lesions found during a mass screening examination

The first detailed study of common oral connective tissue and mucosal lesions in US adults is reported. More than 10% of the 23,616 white Americans who participated in a mass screening examination had at least one oral lesion. The 30 most common lesions, which represented more than 93% of all reported lesions, are ranked according to gender-specific prevalence rates. Leukoplakia was the most common mucosal lesion. Oral carcinoma ranked 24th overall. Data from this study are compared with data from other studies dealing with the prevalence of oral lesions.

Nonendemic American Burkitt's lymphoma

A case of nonendemic American Burkitt's lymphoma with jaw involvement is presented. The oral findings are described and the distinctions of American form of the disease from the African form are discussed.