Differential Mueller matrix imaging of partially depolarizing optically anisotropic biological tissues

Since recently, a number of innovative polarization-based optical imaging modalities have been introduced and extensively used in various biomedical applications, with an ultimate aim to attain the practical tool for the optical biopsy and functional characterization of biological tissues. The techniques utilize polarization properties of light and Mueller matrix mapping of microscopic images of histological sections of biological tissues or polycrystalline films of biological fluids. The main drawback of currently developed laser polarimetry approaches and Mueller matrix mapping techniques is poor reproducibility of experimental data. This is due to azimuthal dependence of polarization and ellipticity values of most matrix elements to sample orientation in respect to incidence light polarization. Current study aims to generalize the methods of laser polarimetry for diagnosis of partially depolarizing optically anisotropic biological tissues. A method of differential Mueller matrix mapping for reconstruction of linear and circular birefringence and dichroism parameter distributions of partially depolarizing layers of biological tissues of different morphological structure is introduced and practically implemented. The coordinate distributions of the value of the first-order differential matrix elements of histological sections of brain tissue with spatially structured, optically anisotropic fibrillar network, as well as of parenchymatous tissue of the rectum wall with an “islet” polycrystalline structure are determined. Within the statistical analysis of polarization reproduced distributions of the averaged parameters of phase and amplitude anisotropy, the significant sensitivity of the statistical moments of the third and fourth orders to changes in the polycrystalline structure of partially depolarizing layers of biological tissue is observed. The differentiation of female reproductive sphere connective tissue is realized with excellent accuracy. The differential Mueller matrix mapping method for reconstruction of distributions of linear and circular birefringence and dichroism parameters of partially depolarizing layers of biological tissues of different morphological structures is proposed and substantiated. Differential diagnostics of changes in the phase (good balanced accuracy) and amplitude (excellent balanced accuracy) of the anisotropy of the partially depolarizing layers of the vagina wall tissue with prolapse of the genitals is realized. The maximum diagnostic efficiency of the first-order differential matrix method was demonstrated in comparison with the traditional methods of polarization and Mueller matrix mapping of histological sections of light-scattering biological tissues.

Oral lichen planus and thyroid gland diseases: possible associations

Background

Lichen planus (LP) is a chronic inflammatory mucocutaneous disease that commonly affects the oral cavity. Previous reports have suggested a possible association between LP and thyroid gland diseases (TGDs). The purpose of this study was to investigate possible associations between oral lichen planus (OLP) and TGDs.

Methods

Patients diagnosed with OLP, both clinically and histopathologically (N = 102), were classified according to clinical course (symptomatic/asymptomatic), type (reticular/plaque, atrophic and erosive) and location of lesions. Data on TGDs was compared to age- and gender-matched controls (N = 102) without OLP. Diagnosis of any type of TGD and related medication for study and control groups was recorded from the medical files provided by patients’ physicians. Statistical analysis used Student’s t-test and Fisher’s exact test; significance was set at p < 0.05.

Results

TGDs (all), hypothyroidism and related medications were found in 16.6, 12.7 and 12.7% of patients with OLP, respectively. These findings were similar to the control group: TGDs (all) -15.7%, hypothyroidism - 9.8% and thyroid gland disease-related medication - 9.8% (p > 0.05). No significant associations were found between different characteristics of OLP and hypothyroidism or other TGD (p > 0.05).

Conclusions

We found no significant associations between the co-existence of OLP and TGD or related-medications. Our findings are in agreement with some of the previously published similar studies but in controversy with others. Further well-designed, multicenter studies with large groups of patients and controls may help to establish the nature of the associations between OLP and TGDs.

The efficacy of minocycline mouth rinses on the symptoms associated with recurrent aphthous stomatitis: a randomized, double-blind, crossover study assessing different doses of oral rinse

OBJECTIVE

The aim of the study was to assess the efficacy of 2 different concentrations of minocycline mouthwashes on the symptoms of recurrent aphthous stomatitis (RAS).

STUDY DESIGN

The 2-year study was designed as a randomized, double-blind, crossover study. Healthy patients with frequent RAS episodes received 2 sealed and computer-randomized marked kits containing minocycline mouthwashes (0.2% and 0.5% solution). The patients were asked to use 1 of the kits on the first episode of RAS, starting with the first onset of prodromal symptoms, until the symptoms resolved or up to a maximum of 10 days (whichever came first). The patients were asked to use their second kit during a subsequent episode.

RESULTS

A total of 14 patients (8 males, 6 females) completed the 2 arms of the study. The mean intensity of pain was significantly lower when the 0.5% solution was used compared with the 0.2% solution (P = .027). The difference reached the level of statistical significance as soon as the end of the second day of use (P = .032). Only minor and temporary adverse reactions were documented.

CONCLUSIONS

We found that 0.5% minocycline mouth rinse was more effective than the 0.2% concentration, which had been suggested by our group in previous studies for the management of RAS.

Immunologic and psychologic parameters associated with geographic tongue

OBJECTIVE

Several conditions have been associated with geographic tongue (GT). However, there is no consensus on the etiology of GT. The purpose of this study was to investigate whether immunologic and psychologic parameters are associated with diagnosis of GT.

STUDY DESIGN

A case-control study was performed on 170 participants (85 with GT, 85 controls). Unstimulated whole saliva was collected, and tumor necrosis factor alpha (TNF-α) and interleukin 6 (IL-6) concentrations were measured. Anxiety level was measured using psychologic and physiologic testing instruments. An independent t test and a Pearson correlation analysis were performed with SPSS (α = .05).

RESULTS

There was a significant difference between the 2 groups regarding the salivary concentrations of TNF-α (P = .008) and IL-6 (P = .001). The concentration of salivary cortisol and state and trait anxiety levels in the GT group were significantly higher than those in the control group (P = .001).

CONCLUSIONS

Immunologic and psychologic parameters appear associated with GT and may constitute risk factors of this condition.

Oral manifestations of habitual khat chewing: a case-control study

BACKGROUND AND OBJECTIVES

Khat, or qat (Catha edulis), is a shrub indigenous to Yemen and certain parts of eastern Africa. Chewing the leaves, which have sympathomimetic and euphoric effects, is a popular habit in numerous countries including the Yemenite population in Israel. Khat has potentially significant toxic effects; however, its oral effects have been only sporadically examined and some changes suggested. The aim of this study was to assess the association between habitual Khat use and oral/dental pigmentation, gingival health, and reports of oral dryness.

STUDY DESIGN

Forty-seven Yemenite Israeli individuals >30 years old, who chewed Khat at least twice a week for over 3 years, and 55 control subjects were studied. All individuals underwent standard clinical oral examinations for color changes and gingival health.

RESULTS

White changes were significantly more prevalent in the khat chewers, identified primarily at the chewing site (83% vs. 16%). The difference in the prevalence of oral mucosal pigmentation between nonchewing nonsmoking (66.7%) and the khat-chewing (100%) groups was highly significant. The mean gingival index and the depth of periodontal pockets of the khat-chewing subjects were significantly reduced at the chewing side compared with the nonchewing side. Increased gingival recession was recorded on the khat-chewing side. Discoloration of the teeth adjacent to the site of chewing was recorded. Oral dryness occurring 30 minutes after initiating the khat-chewing session was reported by khat users.

CONCLUSION

Khat chewing may result in a number of changes in the oral mucosa and the dentition. The mechanical and chemical irritation may result in the development of mucosal white lesions and dark pigmentation. Khat chewing may reduce aspects related to risk of gingival and periodontal inflammation, but it appears to be associated with attachment loss at the site of chewing.

Dose-dense (DD) doxorubicin and cyclophosphamide (AC) followed by weekly paclitaxel (P) with trastuzumab (T) and lapatinib (L) in HER2/neu-positive breast cancer is not feasible due to excessive diarrhea: updated results

Abstract #2108

Background: DD q 2 weekly (w) AC → P + T x 1 year (y) has an acceptable safely profile w/ congestive heart failure (CHF) rate of 1/70 pts (Dang, JCO 2008). Lapatinib (L) is effective in HER2 (+) BC. We conducted a pilot study of dd AC → w P + T + L to determine its feasibility and cardiac safety.&#x2028; Methods: Enrolled pts had HER2 (+) BC; LVEF &gt; 50%. Rx consisted of AC at 60/600 mg/m2 x 4 q 2 w (w/ pegfilgrastim 6 mg day 2) → P at 80 mg/m2 x 12 q w + T x 1 y; L (1000 mg daily beginning w/ P + T and continued x 1 y). MUGA is obtained at baseline and at months (mo) 2, 6, 9, and 18. Rx is considered feasible if 1) &gt; 80% pts can complete the PTL phase without a dose delay or reduction and 2) the cardiac event rate (CHF or cardiac death) is &lt; 4%. Pts can remain on-Rx w/ one dose reduction of L (1000 mg → 750 mg) for a G 3 event or &lt; G 3 toxicity (unacceptable).&#x2028; Results: From March 2007 to April 2008, we enrolled 95 pts. Median (med) age was 45 years (range, 28-73). At a med follow-up of 7 months, 90 are evaluable. Of the 90 pts, 34 (37%) withdrew from study during the PTL phase; 29 for a 2nd event of G 3 or unacceptable &lt; G 3 toxicities (15 G 3 diarrhea, 4 G 1/2 diarrhea, 1 G 3 rash, 2 G 2 rash, 1 G 3 dyspnea and also had G 3 diarrhea, 1 G 3 ↑QTc also had G 3 diarrhea, 1 G 3 ↑ALT also had G 3 diarrhea, 1 G 3 paronychia, 1 G 3 pneumonitis, 1 asymptomatic LVEF ↓, 1 myocarditis) and 5 for other reasons (2 personal reason, 1 PCP pneumonia, 1 progression, 1 P hypersensitivity). Overall, 25/90 (27%) pts had G 3 diarrhea and 31/90 (34%) pts required a dose reduction of lapatinib. Med LVEF at baseline is 67% (N=95), at mo 2 is 68% (N=90), at mo 6 is 65% (N=53), and mo 9 is 65% (N=28). To date there are no patient drop-outs due to significant LVEF declines after dd AC; one patient dropped during PTL out due to an asymptomatic LVEF decline.&#x2028; Discussion: L at 1000 mg/day is not feasible combined w/ weekly P and T by protocol stipulation (&gt; 20% pts required L dose reduction) primarily due to excessive G 3 diarrhea. These results have led to the modification of Design 2 (Arm D) of ALTTO. We will report updated results.

Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 2108.

Giant cell arteritis misdiagnosed as temporomandibular disorder: a case report and review of the literature

Giant Cell Arteritis Misdiagnosed as Temporomandibular Disorder: A Case Report and Review of the Literature Shoshana Reiter Ephraim Winocur Carole Goldsmith Alona Emodi-Perlman Meir Gorsky Giant cell arteritis (GCA) is a systemic vasculitis involving medium and large-sized arteries, most commonly the extracranial branches of the carotid artery. Early diagnosis and treatment are essential to avoid severe complications. This article reports on a GCA case and discusses how the orofacial manifestations of GCA can lead to misdiagnosis of GCA as temporomandibular disorder. GCA should be included in the differential diagnosis of orofacial pain in the elderly based on the knowledge of related signs and symptoms, mainly jaw claudication, hard end-feel limitation of range of motion, and temporal headache.

Screening for and diagnosis of oral premalignant lesions and oropharyngeal squamous cell carcinoma: role of primary care physicians

OBJECTIVE; To describe the role that primary care physicians can play in early recognition of oral and oropharyngeal squamous cell carcinomas (OOSCCs) and to review the risk factors for OOSCCs, the nature of oral premalignant lesions, and the technique and aids for clinical examination.

QUALITY OF EVIDENCE

MEDLINE and CANCERLIT literature searches were conducted using the following terms: oral cancer and risk factors, pre-malignant oral lesions, clinical evaluation of abnormal oral lesions, and cancer screening. Additional articles were identified from key references within articles. The articles contained level I, II, and III evidence and included controlled trials and systematic reviews.

MAIN MESSAGE

Most OOSCCs are in advanced stages at diagnosis, and treatment does not improve survival rates. Early recognition and diagnosis of OOSCCs might improve patient survival and reduce treatment-related morbidity. Comprehensive head and neck examinations should be part of all medical and dental examinations. The head and neck should be inspected and palpated to evaluate for OOSCCs, particularly in high-risk patients and when symptoms are identified. A neck mass or mouth lesion combined with regional pain might suggest a malignant or premalignant process.

CONCLUSION

Primary care physicians are well suited to providing head and neck examinations, and to screening for the presence of suspicious oral lesions. Referral for biopsy might be indicated, depending on the experience of examining physicians.

Association between season and temperature and unstimulated parotid and submandibular/sublingual secretion rates

OBJECTIVE

The purpose of the present study was to evaluate parotid and submandibular/sublingual (SM/SL) unstimulated salivary secretion rate in a group of healthy individuals in winter and summer, and to observe the effect of room-adjusted temperature (air-conditioning) on salivary flow-rate in those seasons.

DESIGN

Unstimulated salivary secretion rates of the right parotid and the SM/SL glands were measured in 50 healthy Israeli volunteers. Each volunteer was evaluated four times during the study: twice in winter (February-March) and twice in summer (July-August).

RESULTS

Parotid and SM/SL salivary mean secretion rate in winter was significantly higher than in summer (p<0.02 and p<0.05, respectively). Room heating in winter lowered significantly the mean parotid flow. Air-conditioning cancelled almost completely the seasonal effects on parotid and SM/SL secretions.

CONCLUSIONS

The results of this study suggest that room temperature is an important factor in measurement of salivary secretion rate. Hence, temperature should ideally be recorded and reported when assessing salivary flow-rates.

Radiographic and clinical features of temporomandibular dysfunction in patients following indirect trauma: A retrospective study

OBJECTIVES

Patients developing temporomandibular dysfunction (TMD) following a motor vehicle accident (MVA) have been reported to respond poorly to standard TMD treatment compared with TMD patients who have not sustained an MVA. The purpose of this study was to determine clinical and radiographic differences between post-MVA and nontrauma TMD patients and to determine whether radiographic findings in post-MVA patients undergoing litigation show more severe anatomical changes than post-MVA patients not undergoing litigation.

STUDY DESIGN

One hundred thirty-six files with magnetic resonance imaging (MRI) and/or bone scan studies of TMD patients were randomly drawn (54 post-MVA and 82 nontrauma TMD).

RESULTS

Patients with post-MVA TMD demonstrated significantly more orofacial pain complaints but significantly less disk displacements on MRI (47.5% post-MVA vs. 69.2% control; P = .03). Litigating post-MVA patients had significantly more nonreducing disks than the nonlitigating group (37.7% litigating vs. 7.7% nonlitigating; P = .05).

CONCLUSION

Based on these findings, it is suggested that treatment limited to the temporomandibular joints (TMJs) in post-traumatic TMD patients may fail without consideration that pain may originate in structures other than the TMJs. Within the post-MVA group, the more severe anatomical changes were found in the litigating patients, suggesting that some of their symptoms are associated with anatomical changes.

Topical minocycline and tetracycline rinses in treatment of recurrent aphthous stomatitis: a randomized cross-over study

Recurrent aphthous stomatitis (RAS) is a common ulcerative condition of the oral mucosa. We assessed minocycline and tetracycline oral rinses in patients with frequent episodes of RAS in a clinical randomized crossover trial. Seventeen patients with high frequency recurrent minor RAS were randomly allocated to a cross-over topical therapy with 0.2 percent minocycline or 0.25 percent tetracycline aqueous solution mouthwash. The minimum interval between the cross-over was 30 days. The intensity of pain was recorded daily using a visual analogue scale. Minocycline mouthwashes as compared to topical tetracycline rinses resulted in significantly improved pain control, by reducing the severity and duration of pain. Topical minocycline rinse may be a potential treatment for other mucosal diseases that result in mucosal ulceration and pain.

Association between hepatitis C virus infection and oral lichen planus in Israeli patients

BACKGROUND

Oral lichen planus is a cell-mediated immune condition of unknown etiology. A possible association of OLP with hepatitis C virus infection has been documented in specific populations. However, no such possible association has been studied in Israel.

OBJECTIVES

To assess the prevalence of HCV antibodies among patients with OLP in Israel.

METHODS

The prevalence of HCV seropositivity was studied in OLP patients (n=62) and compared with that of a control group (n=65) and with the prevalence among healthy volunteer blood donors (n=225,452) as representatives of the general population.

RESULTS

The prevalence of HCV, as detected by the presence of anti-HCV antibodies screened by enzyme-linked immunosorbent assay, and confirmed by recombinant immunoblot assay, was 4.8%, 1.5% and 0.1%, respectively. HCV seropositivity in the OLP patients was significantly higher than in the healthy blood donors (P< 0.001).

CONCLUSIONS

A possible association between OLP and HCV is suggested. Therefore, screening OLP patients for antibodies to HCV is recommended.

The efficacy of oral lumenoscopy (ViziLite) in visualizing oral mucosal lesions

Early diagnosis of oral mucosal lesions has been advocated as a means of improving outcomes of cancer therapy. Improved visualization of mucosal lesions may aid in diagnosis by guiding tissue sampling or referral. This multicenter study reports the effect of chemiluminescent light (ViziLite) upon visualization of mucosal lesions. The chemiluminescent light did not appear to improve visualization of red lesions, but white lesions and lesions that were both red and white showed enhanced brightness and sharpness.

Assessment of the use of sialogogues in the clinical management of patients with xerostomia

This study was conducted to assess the clinical efficacy and adverse effects of pilocarpine, bethanechol and cevimeline in patients with xerostomia. In this open-label crossover assessment in 20 patients with xerostomia, a one- to two-week course of each medication with a one-week washout period was prescribed. Side effects, symptoms, whole stimulated and unstimulated saliva were measured. Each sialogogue was found to increase saliva and decrease symptoms. A mixed-effects analysis showed a greater increase in stimulated saliva on bethanechol compared to pilocarpine (0.106, p = 0.0272). Increased sweating was the most common side effect, experienced more frequently with pilocarpine as compared to bethanechol (p = 0.0588) or cevimeline (p = 0.0143). A carryover effect beyond the washout period was seen. Effects on saliva and side effects vary between sialogogues, suggesting a benefit of trials with different sialogogues to determine individual patient preference. The observed carryover effect suggests that intermittent treatment may be an alternative to continuous treatment with sialogogues.

A Survey of Pain, Pressure, and Discomfort Induced by Commonly Used Oral Local Anesthesia Injections

Intraoral local anesthesia is essential for delivering dental care. However, it is often perceived by some patients as the most painful and in some instances as the only painful part of the treatment, leading in extreme cases to avoidance of dental care. The present study measured the variables of pain, pressure, and discomfort caused by 4 commonly used local anesthesia injections: local infiltration, mental nerve block, inferior alveolar nerve block, and periodontal ligament injections. Patients were asked to grade pain, discomfort, and pressure on a visual analog scale as associated with needle insertion, operator finger position in the mouth, and pressure at injection. The inferior alveolar injection was graded to be the most painful followed by periodontal ligament and then mental nerve block injections. The periodontal ligament injections yielded the highest pressure scores. The inferior alveolar block injection yielded significantly more discomfort than local infiltration and mental nerve block injections when comparing finger and needle position. Local infiltration in the anterior maxillary region yielded the highest needle insertion and finger position discomfort scores. The present study suggests that the dental operator should be aware of local anesthesia injection pain, pressure, and discomfort together with efficacy of technique.

Dental management of patients with myasthenia gravis: A literature review

Myasthenia gravis is a chronic neuromuscular disease characterized by muscular weakness and fatigability. Dental management of patients diagnosed with myasthenia gravis presents a challenge to the dental profession. A MEDLINE search of the English medical (limited to provision in dental care) and dental literature on myasthenia gravis and dental management published between 1975 and 2004 was conducted. In the dental literature, 12 articles were found, and only a few focused on myasthenia gravis and dental care. The purpose of this article was to review and summarize the clinical signs and symptoms associated with myasthenia gravis, highlighting the role of the dental profession in the process of the diagnosis and management of the oral and dental complications that might be associated with the disease, while avoiding myasthenic crisis.

Preemptive analgesia and local anesthesia as a supplement to general anesthesia: a review

General anesthesia (GA) and local anesthesia (LA) evolved on separate tracks. Procedures that could not be performed under LA were typically conducted under GA. Decoding of afferent linkage of peripheral noxious stimuli has provided important understanding that may change the way we traditionally treat surgical pain. In the 1980s, animal studies suggested that preemptive peripheral blocking of painful (nociceptive) stimuli to the central nervous system with regional anesthesia or LA and nonsteroidal analgesics could be beneficial in attenuating postoperative pain. Clinical studies based on this knowledge suggest combining LA with GA, and perhaps non-steroidal analgesics with or without narcotics, to reduce the severity of postoperative pain. General anesthetics can be given in lower minimal alveolar concentration when combined with LA, and recovery characteristics are superior. Increasing evidence suggests that the combined use of GA and LA may reduce the afferent barrage of surgery, and that preemptive analgesia may reduce postoperative pain and should be used in patient care. This article reviews the evidence supporting the combined use of LA or analgesics with GA or sedation to provide improved pain management after surgery.

[Evaluation of unstimulated and stimulated parotid salivary flow rate in Israeli healthy subjects aged 60 years and older]

Saliva plays a critical role in the maintenance oral health. Clinical studies showed that 25% of the elderly population suffers from oral dryness and its related complaints. Studies that measured parotid gland salivary flow rate, both unstimulated and stimulated, in healthy older individuals did not find age-related functional changes. However, histological studies have revealed an age-dependent reduction in the parotid acinar tissue component. To our knowledge there are still no reports of the parotid salivary flow rate in the elderly population in Israel. The goal of this study was to evaluate the rate of the parotid unstimulated and stimulated salivary flow rate among healthy Israeli people aged over 60 years old--the findings may serve as basic standard values to be compared to data collected from patients with complaints of xerostomia and to data reported in other studies. Thirty healthy volunteers aged 60 to 77 years (average 64.7), 23 females and 7 males, were evaluated. Twenty five of the subjects used to live in kibbutzim and 5 lived in a city. The mean unstimulated parotid salivary secretion rate was 0.044+/-0.063 ml/min and the mean stimulated secretion was 0.163+/-0.291 ml/min. Those rates were found to be lower than the unstimulated and stimulated parotid salivary flow rates reported in most other studies. Fourteen (43.3) of the subjects had zero flow rate at rest. This figure was higher then the 20% zero flow at rest that was reported by others among persons with a broader age range. No significant differences were recorded in the parotid salivary flow, both unstimulated and stimulated, between subjects living in the kibbutzim compared to those living in the city. Similar to other studies the differences in the secretion rates between men and women were non significant. The low mean unstimulated and stimulated salivary flow rates, and the high prevalence of no flow at rest can be explained by the fact that saliva collections were done during the very warm Israeli summer and it is speculated that the subjects might be dehydrated. General dehydration can be observed in warm climate areas. No significant differences were found in the parotid salivary flow rates, (unstimulated and stimulated), between the city subjects compared to those from the kibbutzim. Further similar studies in different weather conditions (winter-summer) are needed to establish data of the normal parotid salivary secretion in the over 60 years old Israeli population.

Parotid gland secretion of the aging rat

Saliva secretion stimulated by alpha adrenergic beta adrenergic and muscarinic cholinergic neurotransmitters was evaluated in young adult and old rats. Parotid saliva was collected following methoxamin (METH) (6 mg/kg), isoproterenal (ISO) (30 mg/kg), or pilocarpin (PILO) (7.5 mg/kg) as secretory stimuli. The flow rate and the concentrations of protein, Na+ and K+ were measured. Saliva flow rate was 40%-50% lower (P < 0.01) in old rats following METH and PILO, but there was no difference following ISO stimulation. Saliva of old rats stimulated by METH or PILO contained about 30%-40% more (P < 0.01) protein. Comparable protein levels were in saliva stimulated by ISO. No changes were found in Na+ and K+ concentrations in all saliva samples. These results suggest that the age-related alteration in flow rate is not a general phenomenon, but rather specific and limited to the high flow rate stimulants (alpha-adrenergic and muscarinic-cholinergic). Transport alteration from the circulatory system into the parotid gland may be the underlying mechanism.

Patients with oropharyngeal cancer: A comparison of adults living independently and patients living in long-term care facilities

The low survival rate of persons with oropharyngeal cancer (OPC) is directly related to the size of the primary tumor, lymph node involvement and to the smoking history. The association between medical independence and the survival rate of oral cancer is unclear. The purpose of this study was to assess the survival rate of institutionalized patients with oral cancer compared to those living independently. Information regarding gender, age, tobacco habits, disease characteristics, and survival status were recorded and statistically analyzed from 30 patients with oral cancer who were institutionalized compared to 543 patients with oral cancer who were non-institutionalized. Patients living in long-term care facilities (LTC) were significantly older than the independent patients (67% were 70 years or older versus 28% of independent patients) (p = 0.0001). No differences in smoking habits were noted between the two groups but more patients who were institutionalized stopped smoking at the time of diagnosis (p = 0.47). More patients who were institutionalized were diagnosed with positive lymph node involvement (p = 0.09). Significantly higher all-cause and disease-free 5-year survival rates were noted in the patients living independently, compared to the adults who were institutionalized (32% and 60% compared to 7% and 26% respectively; p < 0.05). The disease-specific 5-year survival was directly related to age (p = 0.001), size of the tumor (p = 0.001), and lymph node involvement (p < 0.001). Significant longer survival rates were observed for patients living independently. The more advanced disease seen in the patients who were institutionalized may be due to a delay in diagnosis, which may be associated with fewer symptoms, limited report of symptoms, a lack of attention or a misdiagnosis of the oral lesion.

Current practice and knowledge of oral care for cancer patients: a survey of supportive health care providers

BACKGROUND

The Oral Care Study Section of the Multinational Association of Supportive Care in Cancer (MASCC) and the International Society for Oral Oncology (ISOO) conducted a survey on clinical practices of oral/dental management of cancer patients among supportive health care providers. The main purpose was to evaluate the knowledge and current practice for preventing and managing oral side effects associated with intensive chemotherapy (ICT), hematopoietic cell transplant (HCT), and radiation therapy to the head and neck (H&N RT).

MATERIALS AND METHODS

A questionnaire designed and pretested was sent to 212 MASCC/ISOO members around the world with different dental and medical backgrounds.

MAIN RESULTS

Seventy-four individuals (35%) responded. The majority of respondents were aware of possible oral complications and provided patients with clinical strategies and recommendations although there was considerable variability among the respondents. Approximately 75% stated that patients were referred for oral/dental care prior to H&N RT and ICT including HCT. However, integrated dental and medical services were reported available in only about 25% of the institutions, and most patients were referred to community-based dental professionals.

MAIN CONCLUSIONS

The survey represents a first review of current, international oral care practices. It suggests a need to develop evidence-based clinical guidelines to support effective oral/dental interventions and management strategies for this population. Furthermore, strategies for implementation of oral care protocols and better integration of dental and medical services should be developed. Caution in interpreting these findings is urged due to the limited response rate.

Carcinoma of the tongue: A case series analysis of clinical presentation, risk factors, staging, and outcome

OBJECTIVE

Oral cancer is primarily a disease of epithelial origin. The tongue is the most common site of oral cancer. Oropharyngeal cancer accounts for approximately 2% of all cancer deaths. The purpose of this study was to analyze a case series of patients with tongue cancer.

STUDY DESIGN

The medical records of 322 consecutive patients diagnosed with squamous cell carcinoma (SCC) of the tongue treated from 1979-1994 were reviewed.

RESULTS

Patients had a mean age of 61.1 years and a 1.5:1 male to female ratio. Approximately, half of the cancers were diagnosed at an advanced stage and most involved the base of the tongue. The majority of oral tongue tumors were diagnosed at an early stage and had more well-differentiated cell types than those of the base of the tongue. Localized discomfort was the most common complaint (66.5%), present for up to 6 months in patients prior to diagnosis and were related to the oral tongue in 90% of cases. Symptoms associated with base of tongue lesions included neck masses, dysphagia, ear pain, and weight loss. Seventy-nine percent of the patients smoked, 58% consumed alcohol on a daily basis, and 43% consumed more than 4 alcoholic drinks daily. Primary radiotherapy was the treatment of 49.6% lesions, of which 57% were at an early stage at diagnosis. The mean overall survival was 3 years and 5 months, with a 5-year overall survival of 40%. Patients with stage 1 tumors had a disease-specific survival of over 80%. The 5-year survival of patients with cancer of the oral tongue was 43% and cancer of the base of the tongue was 27%.

CONCLUSION

The prognosis is poorer for patients presenting with advanced stage and with tumors involving the base of the tongue. Symptoms were more common in tumors of the oral tongue, which likely results in earlier diagnosis. Patients with SCC of the base of the tongue presented with advanced stage of disease and were typically poorly differentiated lesions.

Oral white lesions associated with chewing khat

Introduction

Khat is a cultivated plant whose leaves when chewed elevate mood. Unlike the chewing of betel nut, no association between the white oral mucosal lesions in khat users and oral malignancies has been reported. Chewing of khat has been documented in many countries and has increased with worldwide migration. The impact of chewing khat upon the oral mucosa is essentially unknown.

Purpose

The purpose of this study was to assess the occurrence of oral white changes in chronic khat chewers. Oral mucosal changes in a group of 47 Yemenite Israeli men over 30 years of age, who had chewed khat more than 3 years, were compared to those of 55 Yemenite men who did not chew.

Results

White lesions were significantly more prevalent in the khat chewers (83%) compared to the non chewing individuals (16%) (P < 0.001). White oral lesions were identified primarily on the lower buccal attached gingival mucosa, the alveolar mucosa and the lower mucobuccal fold on the chewing side (p < 0.001). There was no significant association between the occurrence of the white lesions and smoking. Even though the majority of the white lesions (85.4%) were homogenous, 71.4% of the non homogenous lesions were identified in khat chewers. Vital staining with toluidine blue and exfoliative cytology was conducted on a subset of patients with homogenous and non-homogenous oral lesions, and there were no findings suspicious for pre-malignant or malignant changes.

Discussion

This study demonstrated a relationship between khat chewing and oral white lesions, which we attribute to chronic local mechanical and chemical irritation of the mucosa. Our findings also suggest that mucosal changes associated with khat are benign, however, this initial study requires further studies including follow-up of khat users to confirm the current findings, including the likely benign changes associated with chronic use and histologic findings of clinical lesions.

Prevalence of Fissured Tongue, Geographic Tongue and Median Rhomboid Glossitis among Israeli Adults of Different Ethnic Origins

BACKGROUND

Fissured tongue (FT), geographic tongue (GT) and median rhomboid glossitis (MRG) are frequently misdiagnosed and overtreated. FT is a relatively common variant of the tongue that includes numerous grooves or fissures on the dorsum of the tongue, while GT usually appears as areas of atrophy and raised white borders. MRG is an erythematous patch of atrophic papillae located in the central area of the dorsum of the tongue. The prevalence of these lesions varies among different ethnic groups. However, their occurrence among the adult Israeli Jewish population of different ethnic origins is unknown.

OBJECTIVE

To examine the prevalence of benign tongue lesions among adult Israeli Jewish urban, rural and industrial populations of different ethnic origins.

METHODS

A total of 2,464 healthy Israeli adults were clinically examined and divided into three ethnic groups, Ashkenazi, Sephardic or Eastern, based on place of birth of both parents. The prevalences of FT, GT and MRG were evaluated. FT was subdivided according to four subtypes: mild, moderate, typical and central.

RESULTS

The prevalence of FT was 30.5%. The most prevalent, typical FT, grooves over one third of the dorsal tongue, was noted in 11.5% of the study group. GT and MRG were found in 12.7 and 2.4% of the study population, respectively. A strong correlation was found between the occurrence of FT and GT, and a gradual increase in prevalence of FT and GT was noted with age. MRG decreased with age.

CONCLUSIONS

Although no statistically significant differences were found in the prevalence of FT, GT and MRG among the different ethnic groups, ethnic background probably plays some role in its occurrence.

Smoking habits among patients diagnosed with oral lichen planus

INTRODUCTION

Oral lichen planus (OLP) is one of the most common dermatologic diseases that manifests in the oral cavity. The purpose of this study was to evaluate the association between smoking habits and the clinical subtypes of OLP.

METHODS

Oral findings and smoking data from 187 charts of OLP patients from an oral medicine clinic was reviewed and compared to data from 76 matched control patients.

RESULTS AND DISCUSSION

Ninety-three patients were diagnosed with reticular OLP, 55 with atrophic and 39 with erosive forms of the disease. Symptomatic OLP occurred in 63.6% of patients. Fewer cases of reticular OLP were symptomatic than erosive OLP (p < 0.001). Significantly fewer OLP patients smoked than the control group (16% versus 25%) (p = 0.04). More patients with reticular OLP smoked than those with atrophic and erosive OLP (p = 0.002). It is hypothesized that the heat and irritation of smoking may aggravate symptomatic OLP lesions, and the risk of malignant transformation associated with tobacco use may play a role in patients stopping tobacco use. Because there were fewer smokers in patients with OLP, and because OLP carries an increased malignant risk, transformation of OLP may be due to a different etiology and of a different pathogenesis than squamous cell carcinoma not arising from lichen planus. Close follow-up of patients with OLP is indicated.

Burning mouth syndrome and other oral sensory disorders: a unifying hypothesis

Burning Mouth Syndrome (BMS) is a sensory disorder which results in constant, bilateral burning pain of the tongue, lips, and other oral mucous membranes. Atypical odontalgia (AO) is another sensory disorder, usually defined as a toothache-like pain for which no dental cause can be identified. Previous literature has suggested that AO is often associated with a concomitant temporomandibular disorder (TMD). This hypothesis paper explores the possibility that BMS, AO and TMD can be related through hyperactivity of both the sensory and motor components of the trigeminal nerve following loss of central inhibition as a result of taste damage in the chorda tympani and/or the glossopharyngeal nerves.

The efficacy of pilocarpine and bethanechol upon saliva production in cancer patients with hyposalivation following radiation therapy

PURPOSE

Pilocarpine and bethanechol have been reported as potentially effective sialogogues for xerostomic patients. The purpose of the present study was to compare the efficacy of bethanechol to that of pilocarpine in patients with dry mouth following cancer therapy.

STUDY DESIGN

Patients with documented hyposalivation were provided pilocarpine or bethanechol for 2-3 weeks in an open-label randomized crossover study. Baseline and weekly whole resting saliva (WRS) and whole stimulated saliva (WSS) were obtained for 5 minutes. Subjective response and side effects were recorded.

RESULTS

Forty-two xerostomic patients who had received radiation therapy to the head and neck participated. The increase in the WRS and WSS with each medication independently was limited. Statistically significant increase in WRS was seen for both medications when all patients using either agent were analyzed, but no statistically significant increase in WSS was found.Twenty-seven patients completed the crossover protocol. No significant difference in the effect was noted between each of the 2 drugs whether they were prescribed as the first or second drug in the crossover. Statistically significant improvement in subjective report of saliva production/mouth wetness was seen for patients on either medication. This study suggests that subjective improvement in symptoms of dry mouth may be related to resting saliva production, and not to stimulated saliva production. No statistically significant differences in adverse side effects were reported between the medications prescribed. The most common side effects were minor and included frequent urination, dizziness, and increased sweating.

CONCLUSIONS

The findings indicate that head and neck radiation-treated patients with established hyposalivation will respond minimally to systemic sialagogues and while they may experience an increase in resting saliva little change in stimulated saliva may occur. It is not known whether relatively small increases in saliva are beneficial in maintaining oral health; however, subjective improvement suggests improved quality of life. While it is not known if prolonged use of a sialagogue will have increased effects, the limited increase in saliva seen following the second drug of the crossover suggests that prolonged use of a sialagogue may further increase saliva production.

Smoking Habits Among Patients Diagnosed with Oral Lichen Planus

Introduction

Oral lichen planus (OLP) is one of the most common dermatologic diseases that manifests in the oral cavity. The purpose of this study was to evaluate the association between smoking habits and the clinical subtypes of OLP.

Methods

Oral findings and smoking data from 187 charts of OLP patients from an oral medicine clinic was reviewed and compared to data from 76 matched control patients.

Results and Discussion

Ninety-three patients were diagnosed with reticular OLP, 55 with atrophic and 39 with erosive forms of the disease. Symptomatic OLP occurred in 63.6% of patients. Fewer cases of reticular OLP were symptomatic than erosive OLP (p < 0.001). Significantly fewer OLP patients smoked than the control group (16% versus 25%) (p = 0.04). More patients with reticular OLP smoked than those with atrophic and erosive OLP (p = 0.002). It is hypothesized that the heat and irritation of smoking may aggravate symptomatic OLP lesions, and the risk of malignant transformation associated with tobacco use may play a role in patients stopping tobacco use. Because there were fewer smokers in patients with OLP, and because OLP carries an increased malignant risk, transformation of OLP may be due to a different etiology and of a different pathogenesis than squamous cell carcinoma not arising from lichen planus. Close follow-up of patients with OLP is indicated.

Oral White Lesions Associated with Chewing Khat

Introduction

Khat is a cultivated plant whose leaves when chewed elevate mood. Unlike the chewing of betel nut, no association between the white oral mucosal lesions in khat users and oral malignancies has been reported. Chewing of khat has been documented in many countries and has increased with worldwide migration. The impact of chewing khat upon the oral mucosa is essentially unknown.

Purpose

The purpose of this study was to assess the occurrence of oral white changes in chronic khat chewers. Oral mucosal changes in a group of 47 Yemenite Israeli men over 30 years of age, who had chewed khat more than 3 years, were compared to those of 55 Yemenite men who did not chew.

Results

White lesions were significantly more prevalent in the khat chewers (83%) compared to the non chewing individuals (16%) (P < 0.001). White oral lesions were identified primarily on the lower buccal attached gingival mucosa, the alveolar mucosa and the lower mucobuccal fold on the chewing side (p < 0.001). There was no significant association between the occurrence of the white lesions and smoking. Even though the majority of the white lesions (85.4%) were homogenous, 71.4% of the non homogenous lesions were identified in khat chewers. Vital staining with toluidine blue and exfoliative cytology was conducted on a subset of patients with homogenous and non-homogenous oral lesions, and there were no findings suspicious for pre-malignant or malignant changes.

Discussion

This study demonstrated a relationship between khat chewing and oral white lesions, which we attribute to chronic local mechanical and chemical irritation of the mucosa. Our findings also suggest that mucosal changes associated with khat are benign, however, this initial study requires further studies including follow-up of khat users to confirm the current findings, including the likely benign changes associated with chronic use and histologic findings of clinical lesions.

Collection of autologous PBSC in patients with polycythemia vera

BACKGROUND

Allogeneic stem-cell transplantation (SCT) can eradicate myelofibrosis (MF), but is limited by donor availability and toxicity. We previously reported normalization of counts and resolution of MF after ablative, syngeneic SCT in spent phase polycythemia vera (PV). Hence, GvL is not required to eradicate MF. Autologous SCT may advance treatment for spent phase PV by restoring effective hematopoiesis. The influence of organomegaly, myelosuppression and MF on PBSC collection has not been studied in the setting of PV.

METHODS

Sixteen patients with PV underwent PBSC collection. Mobilization was with filgrastim alone, with a target cell content of 2.5 x 10(6) CD34(+)/kg. All myelosuppression was discontinued 2 weeks prior to collection.

RESULTS

Median ages at diagnosis and collection were 47 and 57 years, respectively. Organomegaly, MF and use of myelosuppressive therapies were present in 10 (63%), 4 (25%) and 7 (44%) patients. Median total nucleated cells (TNC) and CD34(+) counts were 8.3 x 10(8)/kg and 4.98 x 10(8)/kg. MF had an adverse effect on TNC (p=0.05) but not on the CD34(+) content. Time from diagnosis and the use of myelosuppresion had no influence on TNC and CD34(+) contents. Four patients had CD34(+) contents <2.5 x 10(6)/kg. Complete blood count (CBC) parameters were not predictive of CD34(+) content.

DISCUSSION

Autologous PBSC collection is feasible in PV several years after diagnosis. Organomegaly and MF are not absolute contraindications for collection. Discontinuing myelosuppresion for 2 weeks before mobilization appears sufficient to collect adequate numbers of CD34(+) progenitors.

Oral lichen planus: progress in understanding its malignant potential and the implications for clinical management

Oral lichen planus (OLP) is an inflammatory lesion that has malignant potential, but few cases of OLP progress to malignancy. A diagnosis of OLP should be confirmed on the basis of historical, clinical, and histologic data. The presence of dysplasia in an OLP-like lesion increases the risk of malignant transformation, mandating management and close follow-up. A molecular assessment of OLP may provide the best evidence of malignant risk and will likely become available for clinical use. In addition, exfoliated cells may be examined for loss of heterozygosity and may become a valuable clinical tool for patient follow-up. The treatment of OLP should include elimination of tissue irritants and recurring exposure to oral carcinogens. If OLP is symptomatic, appropriate treatment with immunosuppressive medications, particularly corticosteroids, should be undertaken. For lesions with dysplastic changes, management may include attention directed to the inflammatory change and follow-up biopsies to assess residual histologic changes that may represent dysplasia. Dysplastic OLP may be best treated as other oral dysplastic conditions; thus, regular, more frequent follow-up is required.

The diagnosis and management of recurrent aphthous stomatitis: a consensus approach

BACKGROUND

Recurrent aphthous stomatitis, or RAS, is a common oral disorder of uncertain etiopathogenesis for which symptomatic therapy only is available. This article reviews the current data on the etiopathogenesis, diagnosis and management of RAS in a primary care setting.

METHODS

The authors reviewed publications on Medline from 1995 through 2000, the period since the last major reviews were published.

RESULTS

RAS may have an immunogenetic background owing to cross-reactivity with Streptococcus sanguis or heat shock protein. Predisposing factors seen in a minority include haematinic (iron, folate or vitamin B12) deficiency, stress, food allergies and HIV infection. While topical corticosteroids remain the mainstay for therapy, a number of other immunomodulatory modalities now are available.

CONCLUSIONS

There is still no conclusive evidence relevant to the etiopathogenesis of RAS, and therefore therapy can attempt only to suppress symptoms rather than to address the basic issues of susceptibility and prevention.

CLINICAL IMPLICATIONS

In the majority of patients, symptomatic relief of RAS can be achieved with topical corticosteroids alone, with other immunomodulatory topical agents or by combination therapy.

The prevalence of herpes simplex virus shedding and infection in the oral cavity of seropositive patients undergoing head and neck radiation therapy

OBJECTIVE

Herpes viruses are characterized by their ability to establish and maintain a latent infection that can reactivate. Only 2 preliminary studies have examined herpes simplex virus (HSV) reactivation in patients receiving head and neck radiotherapy. The role of radiation therapy in the reactivation of a latent virus has not been established. The purpose of the present study was to evaluate the incidence of HSV reactivation in patients receiving radiation treatment for head and neck malignancies.

METHODS

Twenty patients, 19 of whom were HSV seropositive, undergoing head and neck radiation therapy were assessed weekly before and during radiation therapy, and HSV cultures were completed during cancer treatment.

RESULTS

Only 3.6% of the cultures were positive for HSV during radiation therapy. HSV was cultured in 4 men receiving a mean of 6,000 cGy to the head and neck area. Recovery from HSV was seen in patients nearing completion of radiation therapy.

CONCLUSIONS

The results of this study suggest that HSV reactivation is not common during radiation therapy. Therefore, this study does not support prophylaxis of HSV in patients undergoing head and neck irradiation.

The effect of retinoids on premalignant oral lesions: focus on topical therapy

BACKGROUND

Retinoids have been studied as chemopreventive treatment for patients with oropharyngeal carcinoma. Vitamin A modulates growth and differentiation of cells, and its deficiency enhances susceptibility to carcinogenesis. The chemopreventive mechanism of action of vitamin A is discussed, and a review of clinical results and side effects of the systemic use of vitamin A is included. The objective of the current report was to review the possible role of topical vitamin A and vitamin A derivatives in the management of patients with oral lesions with a risk of transformation to carcinoma.

METHODS

A Medline search was conducted and references identified within the identified papers were also reviewed.

RESULTS

Only four studies using topical vitamin A for patients with oral leukoplakia have been reported. A complete response was achieved in 10-27% of patients, and a partial response was achieved in 54-90% of patients; however, recurrence of leukoplakia was reported after withdrawing the medication in approximately 50% of patients. The side effects of the topical use were minimal.

CONCLUSIONS

Although the direct application of higher concentrations of retinoic acid results in suppression of oral leukoplakias only, its use in the treatment of patients with recurrent and persistent lesions may be justified for controlling lesions that otherwise may progress. Further controlled clinical studies are needed.