Evidence-based clinical practice guideline for the evaluation of potentially malignant disorders in the oral cavity: a report of the American Dental Association

BACKGROUND: An expert panel convened by the American Dental Association (ADA) Council on Scientific Affairs and the Center for Evidence-Based Dentistry conducted a systematic review and formulated clinical recommendations to inform primary care clinicians about the potential use of adjuncts as triage tools for the evaluation of lesions, including potentially malignant disorders (PMDs), in the oral cavity. TYPES OF STUDIES REVIEWED: This is an update of the ADA's 2010 recommendations on the early diagnosis of PMDs and oral squamous cell carcinoma. The authors conducted a systematic search of the literature in MEDLINE and Embase via Ovid and the Cochrane Central Register of Controlled Trials to identify randomized controlled trials and diagnostic test accuracy studies. The authors used the Grading of Recommendations Assessment, Development and Evaluation approach to assess the certainty in the evidence and to move from the evidence to the decisions. RESULTS: The panel formulated 1 good practice statement and 6 clinical recommendations that concluded that no available adjuncts demonstrated sufficient diagnostic test accuracy to support their routine use as triage tools during the evaluation of lesions in the oral cavity. For patients seeking care for suspicious lesions, immediate performance of a biopsy or referral to a specialist remains the single most important recommendation for clinical practice. In exceptional cases, when patients decline a biopsy or live in rural areas with limited access to care, the panel suggested that cytologic testing may be used to initiate the diagnostic process until a biopsy can be performed (conditional recommendation, low-quality evidence). CONCLUSIONS AND PRACTICAL IMPLICATIONS: The authors urge clinicians to remain alert and take diligent action when they identify a PMD. The authors emphasize the need for counseling because patients may delay diagnosis because of anxiety and denial.(AU)

Characterization of indoor particle sources: A study conducted in the metropolitan Boston area.

An intensive particle monitoring study was conducted in homes in the Boston, Massachusetts, area during the winter and summer of 1996 in an effort to characterize sources of indoor particles. As part of this study, continuous particle size and mass concentration data were collected in four single-family homes, with each home monitored for one or two 6-day periods. Additionally, housing activity and air exchange rate data were collected. Cooking, cleaning, and the movement of people were identified as the most important indoor particle sources in these homes. These sources contributed significantly both to indoor concentrations (indoor-outdoor ratios varied between 2 and 33) and to altered indoor particle size distributions. Cooking, including broiling/baking, toasting, and barbecuing contributed primarily to particulate matter with physical diameters between 0.02 and 0.5 microm [PM((0.02-0.5))], with volume median diameters of between 0.13 and 0.25 microm. Sources of particulate matter with aerodynamic diameters between 0.7 and 10 microm [PM((0.7-10))] included sautéing, cleaning (vacuuming, dusting, and sweeping), and movement of people, with volume median diameters of between 3 and 4.3 microm. Frying was associated with particles from both PM((0.02-0.5)) and PM((0.7-10)). Air exchange rates ranged between 0.12 and 24.3 exchanges/hr and had significant impact on indoor particle levels and size distributions. Low air exchange rates (< 1 exchange/hr) resulted in longer air residence times and more time for particle concentrations from indoor sources to increase. When air exchange rates were higher (> 1 exchange/hr), the impact of indoor sources was less pronounced, as indoor particle concentrations tracked outdoor levels more closely.

Evidence-based dentistry: an overview of a new approach to dental practice.

Dental students' clinical questions and problems are solved by a combination of instructors' intuition, training, and clinical experience, which may or may not be based on scientific evidence. This type of training, which relies heavily on clinical experience and information learned in dental school, seminars, or from colleagues, can lead to inappropriate treatment outcomes. Evidence-based dentistry attempts to answer clinical questions based on a critical review of the best available scientific evidence together with one's clinical experience and scientific knowledge.

Histologic effects of a thermally cooled Nd: YAG laser on the dental pulp and supporting structures of rabbit teeth.

The histologic response of the pulp, periapical tissues, supporting periodontal ligament, and alveolar bone adjacent to the incisor teeth of adult rabbits was compared after laser treatment (etching) or drilling with a high-speed dental rotary handpiece (enamelplasty) on the buccal enamel surface. Observations were made at four time periods, 2 days, 14 days, 60 days, and 180 days after treatment. Block sections were removed, and serial sections were prepared and examined by an independent veterinary pathologist for occurrences of histopathologic changes with untreated control teeth used for comparison. Under the conditions of this study, there were no differences between either the laser-treated or the drilled specimens compared with the untreated control teeth on the basis of the histologic appearance.

The effect of lasers on dental hard tissues.

There is a quest to find a method to remove diseased and healthy dental hard tissues without the negative stimuli associated with dental handpieces. Today, lasers are being considered as a potential replacement. This report evaluates effects of three lasers on dentin and pulpal tissues. The Er:YAG laser appears to have a lesser thermal effect.

Evaluation of thermal cooling mechanisms for laser application to teeth.

Experimental cooling methods for the prevention of thermal damage to dental pulp during laser application to teeth were compared to conventional treatment in vitro. Pulp temperature measurements were made via electrical thermistors implanted within the pulp chambers of extracted human third molar teeth. Experimental treatments consisted of lasing without cooling, lasing with cooling, laser pulsing, and high-speed dental rotary drilling. Comparisons of pulp temperature elevation measurements for each group demonstrated that cooling by an air and water spray during lasing significantly reduced heat transfer to dental pulp. Laser exposures followed by an air and water spray resulted in pulp temperature changes comparable to conventional treatment by drilling. Cooling by an air water spray with evacuation appears to be an effective method for the prevention of thermal damage to vital teeth following laser exposure.

Removal of benign intraoral masses using the CO2 laser.

Benign soft tissue lesions of the mouth can be removed using the CO2 laser. This type of laser surgery is faster and offers less postoperative complication as compared with conventional surgery and electrosurgery. Presently, the CO2 laser can be used for intraoral biopsy of benign masses, gingivectomies, and frenectomies.

Reduced mitotic activity and atrophy in oral epithelium of the rat following elimination of masticatory movements.

Rats 16 weeks old were fed a liquified diet consisting of a suspension of finely ground commercial rat pellets for a period of 35 days. Weight-matched controls were fed isocaloric amounts of the dry pellets. Numbers of dividing epithelial cells and dimensions of the cellular and keratin layers were determined using precisely matched homologous areas in histologic sections from experimental animals and controls. Three mucosal regions which during the masticatory movements in controls are subjected to friction, compression and deformation ("masticatory mucosa") and one region subjected to distension and friction ("lining mucosa") showed experimental mitotic rates ranging from one-fourth to less than half the rates in controls. The epithelium of experimental masticatory mucosa showed consistent, statistically significant atrophic changes in both cellular and keratin layers, while that of lining mucosa showed atrophic changes in the cellular layer only. It is concluded that the concept of disuse atrophy should be extended to include oral surface epithelia.