Impact of the Presenting Symptom on Time Intervals and Diagnostic Routes of Patients with Symptomatic Oral Cancer.

This investigation was aimed at determining the time intervals from the presenting symptoms until the beginning of oral cancer treatment and their relative contribution to the total time, and to assess the impact of the presenting symptom on diagnostic timelines and patient referral routes. A cross-sectional, ambispective study was designed to investigate symptomatic incident cases. The Aarhus statement was used as a conceptual framework. Strategies for minimizing potential recall biases were implemented. A sample of 181 patients was recruited (power: 99.5%; α = 0.05). The patient interval reached 58.2 days (95% CI, 40.3-76.2), which accounted for 74% of the whole prereferral interval and for more than one third of the total time interval. The presenting symptom (trigger for consultation) influenced both the number of primary care consultations and the length of time to diagnosis. General dental practitioners generated longer intervals to diagnosis (p < 0.005) and needed more consultations before referring a patient (RR = 0.76; 95% CI, 0.61-0.93), than general medical practitioners. The current study identifies the patient as the main target for interventions to improve awareness and reinforces the need for increased alertness amongst healthcare professionals about presenting symptoms of oral cancer and to diminish the number of prereferral consultations in order to optimize the primary care interval.

¿Cuál es su diagnóstico? / What would your diagnosis be?

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A comparative study of platelet-rich plasma, hydroxyapatite, demineralizedbone matrix and autologous bone to promote bone regeneration after mandibularimpacted third molar extraction

Objectives: 1) to compare mandibular bone regeneration by applying autologous bone, platelet-rich plasma andtwo biomaterials (synthetic calcium hydroxyapatite, and demineralized bone matrix), and thus establish the potentialbenefits of these biomaterials in the regeneration of postextraction alveolar bone, 2) to identify wich of themaccelerates more bone regeneration and 3) to determine whether there are differences in the postoperative period(pain, swelling, trismus, infection) depending on the material used.Study Design: It consists in a prospective, controlled (with a split- mouth design) and double blinded study. We useas a model an easily reproducible non-critical bone defect: the defect that remains after extraction of mandibularimpacted third molar. The study design is based on the extraction of two mandibular impacted third molars ina patient during the same surgical procedure by the same surgeon. We assessed postoperative clinical data, andshort, medium and long term neoformation of alveolar bone after extraction. We compared the two sockets (rightand left), which had been grafted in a different way with the various elements mentioned above. In addition, wecompared the postoperative inflammatory symptoms between groups.Results: The highest acceleration in bone formation was observed in groups in which we used autologous boneand demineralized bone matrix. There were no statistically significant differences between groups regarding pain,swelling, trismus and infection throughout the postoperative period.Conclusions: According to the results of our study, autologous bone persists as the gold standard material for boneregeneration. Among the assessed biomaterials, demineralized bone matrix has yielded the best results obtained.No significant differences in the postoperative (pain, swelling, trismus and infectious events) were observed, dependingon the type of material used as a graft (AU)

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Review of 793 facial fractures treated from 2001 to 2008 in a coruña university hospital: types and etiology.

The purpose of this article is to analyze the incidence, demographic distribution, type, and etiology of all facial fractures treated by the Department of Oral and Maxillofacial Surgery in A Coruña University Hospital (Spain) from 2001 to 2008. A descriptive and analytic retrospective study evaluated 643 patients treated for facial fracture (excluding nasal and dento-alveolar) by the Department of Oral and Maxillofacial Surgery in A Coruña University Hospital from January 2001 to December 2008. Five parameters were studied: year of the injury, gender, age, fracture type, and etiology. Six hundred and forty-three patients with 793 fractures were included. Of these, 83.2% were males and 16.8% were females. The patients' age ranged between 18 months and 89 years, with a mean of 37.6 and a median of 33. The major cause of injury was traffic accidents (27%), followed by assaults (20.5%), accidental traumas (20.1%), sports (11%), syncopes (7.8%), rural accidents (6.1%), industrial accidents (5.1%), and suicide attempts (0.3%). In 1.1% of the patients, it was impossible to verify the etiology. The etiology of facial fractures varies from one country to another, depending on the cultural, environmental, and socioeconomic factors. In our study, the most common cause was traffic accidents, closely followed by assaults. The number of fractures due to traffic accidents has decreased in the last 3 years. Rural accidents accounted for a significantly higher percentage of fractures than that observed in other series. The number of fractures receiving a surgical treatment from 2005 to 2008 has progressively decreased.

A comparative study of platelet-rich plasma, hydroxyapatite, demineralized bone matrix and autologous bone to promote bone regeneration after mandibular impacted third molar extraction.

OBJECTIVES: 1) to compare mandibular bone regeneration by applying autologous bone, platelet-rich plasma and two biomaterials (synthetic calcium hydroxyapatite, and demineralized bone matrix), and thus establish the potential benefits of these biomaterials in the regeneration of postextraction alveolar bone, 2) to identify which of them accelerates more bone regeneration and 3) to determine whether there are differences in the postoperative period (pain, swelling, trismus, infection) depending on the material used. STUDY DESIGN: It consists in a prospective, controlled (with a split- mouth design) and double blinded study. We use as a model an easily reproducible non-critical bone defect: the defect that remains after extraction of mandibular impacted third molar. The study design is based on the extraction of two mandibular impacted third molars in a patient during the same surgical procedure by the same surgeon. We assessed postoperative clinical data, and short, medium and long term neoformation of alveolar bone after extraction. We compared the two sockets (right and left), which had been grafted in a different way with the various elements mentioned above. In addition, we compared the postoperative inflammatory symptoms between groups. RESULTS: The highest acceleration in bone formation was observed in groups in which we used autologous bone and demineralized bone matrix. There were no statistically significant differences between groups regarding pain, swelling, trismus and infection throughout the postoperative period. CONCLUSIONS: According to the results of our study, autologous bone persists as the gold standard material for bone regeneration. Among the assessed biomaterials, demineralized bone matrix has yielded the best results obtained. No significant differences in the postoperative (pain, swelling, trismus and infectious events) were observed, depending on the type of material used as a graft.

Intraosseous mandibular hemangioma. A case report and review of the literature.

Intraosseous vascular lesions are rare conditions, comprising only 0.5% to 1% of all intraosseous tumors. They mainly occur in the second decade of life especially in women. The most common locations are the vertebral column and skull; nevertheless, the mandible is a quite rare location. According to the World Health Organization, hemangiomas are benign vasoformative neoplasms of endothelial origin. However, the origin of central hemangioma is debatable. Some authors believe that it is a true neoplasm, whereas others state it is a hamartomatous lesion. Clinically, the patient may be completely symptom-free or may present discomfort, pulsatile bleeding, bluish discoloration, mobile teeth, derangement of the arch form or accelerated dental exfoliation. Most frequently radiographic finding is a multilocular radiolucent image with honeycombs or soap bubble appearance. Differential diagnosis includes neoplasms such as ameloblastoma, cystic lesions such as residual cyst, keratocyst and fibro-osseous lesions such as fibrous dysplasia. There are some therapeutic alternatives, although wide surgical excision remains as the gold standard. We now present a case report of a 51-year-old woman diagnosed in a mandibular hemangioma. Clinical, radiological and histological features of this unusual tumor are described.

Intraosseous mandibular hemangioma. A case report and review of the literature

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Intraosseous vascular lesions are rare conditions, comprising only 0.5% to 1% of all intraosseous tumors. They mainly occur in the second decade of life especially in women. The most common locations are the vertebral column and skull; nevertheless, the mandible is a quite rare location.According to the World Health Organization, hemangiomas are benign vasoformative neoplasms of endothelialorigin. However, the origin of central hemangioma is debatable. Some authors believe that it is a true neoplasm, whereas others state it is a hamartomatous lesion.Clinically, the patient may be completely symptom-free or may present discomfort, pulsatile bleeding, bluish discoloration, mobile teeth, derangement of the arch form or accelerated dental exfoliation. Most frequently radiographic finding is a multilocular radiolucent image with honeycombs or soap bubble appearance. Differential diagnosis includes neoplasms such as ameloblastoma, cystic lesions such as residual cyst, keratocyst andfibro-osseous lesions such as fibrous dysplasia.There are some therapeutic alternatives, although wide surgical excision remains as the gold standard.We now present a case report of a 51-year-old woman diagnosed in a mandibular hemangioma. Clinical, radiologicaland histological features of this unusual tumor are described

Merkel cell carcinoma of the head and neck: report of seven cases.

Merkel cell carcinoma is a rare and aggressive primary cutaneous neoplasm. Clinically it is characterized by innocuous appearance, as a fast growing asymptomatic nodule or plaque. Head and neck are the most common sites of presentation (50%). The treatment is based on local surgery completed with cervical lymph node dissection, radiotherapy, chemotherapy and other treatments depending on the staging. Sentinel lymph biopsy seems to be useful for its treatment. Tumour staging is the only prognostic factor related to overall survival. Prognosis is very poor due to the high incidence of loco-regional recurrence and metastases. Seven cases of Merkel cell carcinoma of the head and neck are reported. These were treated in our Department over the last two and a half years. A literature review was made.

Merkel cell carcinoma of the head and neck: Report of seven cases

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Merkel cell carcinoma is a rare and aggressive primary cutaneous neoplasm. Clinically it is characterized by innocuous appearance, as a fast growing asymptomatic nodule or plaque. Head and neck are the most common sites of presentation (50%). The treatment is based on local surgery completed with cervical lymph node dissection, radiotherapy, chemotherapy and other treatments depending on the staging. Sentinel lymph biopsy seems to be useful for its treatment. Tumour staging is the only prognostic factor related to overall survival. Prognosis is very poor due to the high incidence of loco-regional recurrence and metastases. Seven cases of Merkel cell carcinoma of the headand neck are reported. These were treated in our Department over the last two and a half years. A literature review was made

[Is microvascular density an independent prognostic factor in squamous cell carcinoma of the tongue?]. / El la densidad microvascular un factor pronóstico independiente en el carcinoma epidermoide de lengua?

BACKGROUND: The relationship between tumour angiogenesis and prognosis in head and neck squamous cell carcinomas remains controversial in the literature. This study was designed to determine the role of tumour vascularization in tongue squamous cell carcinoma behaviour. MATERIAL AND METHOD: Tumour vascularization was evaluated in 43 patients with primary squamous cell carcinomas of the tongue. Anti-endothelial cell antigen (CD31) was used to stain the specimens. The correlation between tumour vascularization and both survival rate and tumour recurrence was established to determine the prognostic value of microvessel density (Cox proportional-hazards survival regression). RESULTS: Adequate staining was achieved in all specimens with anti-CD31. Mean microvessel density was 30.6 (x400 field), and the median was 27. After a 5-year follow-up, a local, regional, or distant recurrence of the tumour occurred in 29 patients (67.4 %). Twenty patients (46.5 %) were alive with or without tumour, while 23 patients (53.5 %) had died due to tumour recurrence. Statistical analysis failed to demonstrate any correlation between microvessel density and 5-year survival (P = .59) and recurrence rate (P = .31). CONCLUSIONS: Despite the controversy, these results suggest that microvascular density is not a valid independent prognostic indicator in patients with squamous cell carcinoma of the tongue.

¿El la densidad microvascular un factor pronóstico independiente en el carcinoma epidermoide de lengua? / Is microvascular density an independent prognostic factor in squamous cell carcinoma of the tongue?

Objetivos: La relación entre angiogénesis tumoral y el pronóstico en carcinomas epidermoides de cabeza y cuello continúa en controversia. Se ha diseñado este estudio para determinar el papel de la vascularización tumoral en el comportamiento de los carcinomas epidermoides de lengua. Material y método: Se ha evaluado la vascularización tumoral en 43 pacientes con carcinoma epidermoide de lengua. Se emplearon anticuerpos antiendoteliales (CD31) para teñir las muestras. Para determinar el valor pronóstico de la microvascularización tumoral, se comparó la densidad microvascular con el índice de recidiva y la supervivencia (test de regresión de Cox). Resultados: Todas las muestras se tiñeron adecuadamente mediante anti-CD31. La densidad vascular media fue 30,6 (en campos x400) y la mediana, 27. Tras un seguimiento de 5 años, en 29 (67,4 %) pacientes se iniciaron recidivas local, regional o a distancia; 20 (46,5 %) permanecían vivos con o sin tumor, mientras que 23 (53 %) habían fallecido por una recidiva tumoral. El análisis estadístico no ha demostrado ninguna relación significativa de la densidad microvascular con la supervivencia a 5 años (p = 0,59) ni con el riesgo de recidiva a los 5 años (p = 0,31). Conclusiones: Aunque hay controversias, estos resultados indican que la densidad microvascular no es un indicador pronóstico independiente y válido en pacientes con carcinoma epidermoide de lengua

Background: The relationship between tumour angiogenesis and prognosis in head and neck squamous cell carcinomas remains controversial in the literature. This study was designed to determine the role of tumour vascularization in tongue squamous cell carcinoma behaviour. Material and method: Tumour vascularization was evaluated in 43 patients with primary squamous cell carcinomas of the tongue. Anti-endothelial cell antigen (CD31) was used to stain the specimens. The correlation between tumour vascularization and both survival rate and tumour recurrence was established to determine the prognostic value of microvessel density (Cox proportional-hazards survival regression). Results: Adequate staining was achieved in all specimens with anti-CD31. Mean microvessel density was 30.6 (x400 field), and the median was 27. After a 5-year follow-up, a local, regional, or distant recurrence of the tumour occurred in 29 patients (67.4 %). Twenty patients (46.5 %) were alive with or without tumour, while 23 patients (53.5 %) had died due to tumour recurrence. Statistical analysis failed to demonstrate any correlation between microvessel density and 5-year survival (P = .59) and recurrence rate (P = .31). Conclusions: Despite the controversy, these results suggest that microvascular density is not a valid independent prognostic indicator in patients with squamous cell carcinoma of the tongue

Carcinoma de células de Merkel / Merkel cell carcinoma

Introducción: El carcinoma de células de Merkel es un tumor primario de la piel con diferenciación neuroendocrina poco frecuente y agresivo, que aparece en áreas fotoexpuestas en pacientes de raza blanca y edad avanzada. Pacientes y métodos: Se realiza un análisis retrospectivo de 5 pacientes diagnosticados de carcinoma de células de Merkel en el Servicio de Dermatología del Complejo Hospitalario Universitario Juan Canalejo (A Coruña) en el periodo 1998-2003. Resultados: Se trataba de 4 mujeres y un varón, de edades comprendidas entre 55 y 83 años. En el momento del diagnóstico, dos de ellos se encontraban en estadio Ia, dos en estadio II y otro en estadio III. En tres de ellos se detectaron ganglios regionales afectados y en un caso existía también diseminación linfática a distancia. A todos se les realizó exéresis amplia del tumor. A tres se les extirpó una adenopatía local y a dos se les practicó una linfadenectomía regional. En uno de los 2 casos sin adenopatías palpables se realizó una biopsia del ganglio centinela. Cuatro pacientes recibieron radioterapia postoperatoria local. Dos pacientes desarrollaron metástasis a distancia y fallecieron; el resto no han presentado recidivas en un periodo de seguimiento que varía de 3 a 70 meses. Conclusiones: El carcinoma de Merkel es un tumor de gran malignidad, que requiere un diagnóstico precoz, puesto que el factor pronóstico más importante en el estadio de la enfermedad en el momento de su diagnóstico. No existe un protocolo de tratamiento, y actualmente se recomienda un tratamiento multidisciplinar, basado en el tratamiento quirúrgico y radioterapia adyuvante (AU)

Complex oncologic reconstruction of a mandibular and floor of mouth defect with a fibula free flap in an achondroplastic patient.

The fibular free flap is seen as one of the foremost technical options in mandibular reconstruction, especially in those defects where long bone is required. Cases with squamous-cell carcinoma of the floor of the mouth with mandibular spread and subsequent segmentary mandibular removal are the cornerstone examples. A case of squamous-cell carcinoma of the whole floor of the mouth with mandibular invasion is reported. Radical resection of the floor of the mouth and bilateral mandibular horizontal ramus was performed, with a bony defect extending from angle to angle. The patient revealed an achondroplastic condition, with remarkable dwarfism and long-bone morphological alterations, that minimized the potential fibular length to transfer. A microsurgical reconstruction with an osteocutaneous fibular free flap was undertaken. The flap design was technically compromised by the forward bowing of the fibula and the ossification of the interosseous membrane. Specific intraoperative strategies for dealing with anatomic variations are discussed. The fibular free flap is an excellent technique for mandibular reconstruction. Morphological deviations can modify the design of the flap. Achondroplasia is not a deterrent in successful use of the free fibula flap for reconstruction of the head and neck in adequately selected cases.