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)

Biochemical evidence of cannibalism at a prehistoric Puebloan site in southwestern Colorado.

The existence of cannibalism is one of the most controversial issues in the archaeology of the American Southwest. Disarticulated, cut-marked and heat-altered human remains from non-burial contexts at prehistoric Puebloan (Anasazi) archaeological sites in the Four Corners region of the American Southwest have been interpreted by some scholars as evidence of cannibalism. Osteological studies indicate that many of the disarticulated bodies found at these sites were processed in a manner consistent with food preparation. Opponents of this interpretation point out that non-cannibalistic practices such as secondary interment, corpse mutilation and ritualized witch executions might account for the assemblages. Osteological evidence alone does not document the actual ingestion of human flesh. Here we show consumption of human flesh did occur as demonstrated in preserved human waste containing identifiable human tissue remains from a site with osteological evidence of cannibalism.

The influence of smoking on 3-year clinical success of osseointegrated dental implants.

BACKGROUND: Health risks associated with smoking have been exhaustively documented and include increased incidence of periodontal disease, greater risk of osteitis following oral surgery, and compromised wound healing due to hypoxia. Information related directly to dental implants, although limited, points to higher rates of implant failures among smokers than non-smokers. This paper reports on long-term clinical outcomes of osseointegrated dental implants placed in smokers and non-smokers in a longitudinal clinical study of endosseous dental implants. METHODS: In 1990, the Dental Implant Clinical Research Group (DICRG) of the Department of Veterans Affairs (DVA) launched an 8-year, randomized, prospective clinical study of more than 2,900 endosseous dental implants in more than 800 patients at 32 study centers. Confounding variables, including smoking patterns, were recorded. For this report, new follow-up data were analyzed for two groups: 1) current smokers and 2) those who never smoked combined with those who quit. Most of the variables recorded for each implant were screened on a univariate basis as possible predictors associated with implant survival/failure. Those with P values less than 0.15 and those likely to be a factor of clinical importance were placed in a logistic regression equation and analyzed for a simultaneous effect on survival. A step-wise procedure was used to eliminate those variables that showed the least significance, until only those variables with a Wald chi-square of significance in the presence of others remained. The effects of clustering within patients and of unbalanced distribution within hospitals were standardized to facilitate analysis of influence of demographic variables. The GEE analysis was performed with the patient as the primary cluster. RESULTS: Current data do not support earlier findings that smoking contributes to early implant failure (placement to uncovering). A trend of greater failures in smokers appeared between the time after uncovering and before insertion of the prosthesis. Hydroxyapatite (HA)-coated implants had significantly lower failure rates. For the entire 3-year period, overall failures were significantly higher for smokers than non-smokers. CONCLUSIONS: Results suggest that increased implant failures in smokers are not the result of poor healing or osseointegration, but of exposure of peri-implant tissues to tobacco smoke. Data also suggest that detrimental effects may be reduced by: 1) cessation of smoking; 2) the use of preoperative antibiotics; and 3) the use of HA-coated implants.

Detection of radiation-induced, accelerated atherosclerosis in patients with osteoradionecrosis by panoramic radiography.

PURPOSE: Osteoradionecrosis (ORN) of the mandible has long been considered the most destructive complication of head and neck irradiation. Recently, therapeutic irradiation has been implicated as the cause of induced/accelerated atherosclerosis of the cervical carotid artery and subsequent stroke. Panoramic radiography, previously shown to be capable of identifying carotid artery atherosclerosis in nonirradiated individuals, was used to assess the carotid vasculature of patients being treated for ORN. PATIENTS AND METHODS: The panoramic radiographs of 61 men (mean age, 60.5 years; range, 41 to 77 years) who received therapeutic irradiation to the neck 36 months or more previously were assessed for the presence of carotid artery atherosclerotic lesions. Sixty-one control subjects who never received therapeutic irradiation, but who were similarly susceptible to atherosclerosis by virtue of age, were assessed in a like manner. RESULTS: The irradiated individuals sustained a dose of 40 to 72 Gy to the area of the carotid bifurcation. Seventeen individuals (27.9%) with an irradiation dosage to the carotid bifurcation that averaged 59.2 Gy had a panoramic radiograph with a carotid atheroma (11 with unilateral lesions and six with bilateral lesions). The radiographs of the control subjects showed that three individuals (4.9%) had calcified carotid lesions. The mean age of these subjects was 66.1 years; two had unilateral lesions, and one had bilateral lesions. The difference in the proportion of individuals with ORN who manifested carotid artery atherosclerosis on their panoramic radiographs was statistically significant (P = .001) when compared with the nonirradiated control subjects. The lesions seen in both populations had a similar morphologic appearance and were radiographically located within the soft tissues of the neck 1.5 to 4.0 cm inferior-posterior to the angle of the mandible. CONCLUSIONS: Individuals with radiation doses sufficient to cause osteoradionecrosis of the mandible are at significantly higher risk of developing carotid artery atherosclerotic lesions than age-matched, nonirradiated controls.

Hafnium Germanate from a Hydrous Hafnium Germanium Oxide Gel.

The gel chemistry of germanium is explored through the formation and composition of a hydrous metal oxide precursor gel used in the preparation of the HfGeO(4) and HfGeO(4):Ti X-ray phosphors. The enhanced solubility of hexagonal GeO(2) in dilute ammoniacal solutions is exploited to give a convenient and high-yield precipitation. The precursor gel is shown by FT-IR to be a diphasic mixture of hydrous hafnia and an ammonium germanate gel. Thermal treatment drives the crystallization of a hafnium-rich, simple tetragonal Hf(1)(-)(x)()Ge(x)()O(2) structure at 893 degrees C, that upon further heating to 1200 degrees C yields scheelite HfGeO(4).

Positive effect of surgical experience with implants on second-stage implant survival.

This Dental Implant Clinical Research Group study defined a learning curve for dental implant placement. Implants placed by inexperienced surgeons (< 50 implants) failed twice as often as those placed by experienced surgeons (> or = 50 implants). Implants placed during the first 6, 8, 10, 12, and 16 cases were compared with all others. The greatest difference was seen between the first nine cases and all others (P = .001), with later cases failing significantly less often. Inexperienced surgeons had more failures in the first nine cases (5.9%) than more experienced surgeons (2.4%). Surgeons with little or no previous experience must expect a definite learning curve. Previous experience may transfer and result in a shallower learning curve for subsequent systems.

The influence of 0.12% chlorhexidine digluconate rinses on the incidence of infectious complications and implant success.

The effect of perioperative chlorhexidine on the frequency of infectious complications through stage II was examined. Chlorhexidine was used perioperatively in 54.6% of patients (52.5% of implants) in a Dental Implant Clinical Research Group study with a database of 2,641 implants (595 patients). With chlorhexidine, there was a significant reduction in the number of infectious complications (4.1% vs 8.7%). Two percent of implants failed in the absence of an infectious complication, whereas 12% with infectious complications failed. This sixfold difference is highly significant. Chlorhexidine may reduce microbial complications when used in the immediate perioperative period.

Skeletal evidence for child abuse: a physical anthropological perspective.

Analysis of the skeletal remains of abused children can prove challenging for forensic pathologists and radiographers who are inexperienced in the direct examination of bones. In such cases, radiographically invisible skeletal lesions that document a history of trauma can often be identified by a physical anthropologist with appropriate osteological experience. This is illustrated by cases in which skeletal remains of four murdered children and a mentally handicapped adult produced evidence of antemortem trauma and perimortem injuries that was critical in developing murder cases against the assailants. In these cases, well-healed areas of subperiosteal new bone formation were identified that were below the threshold of radiographic detection. Such injuries provide strong evidence for a history of physical abuse.

The influence of maxillary sinus augmentation on the success of dental implants through second-stage surgery.

An interim evaluation of the status of 102 implants placed in 42 augmented sinuses in 27 patients involved in an alternate category of the Dental Implant Clinical Research Group's long-term, randomized, prospective clinical investigation is presented. Autogeneic, allogeneic, and alloplastic sinus grafts were used, individually or mixed. Through second-stage surgery, 101 implants were found to be integrated. The mean Periotest value at uncovering was -3.36, with a standard deviation of 4.19. The results suggest that root form implants placed in augmented sinuses are successful through second-stage surgery, regardless of the augmentation material or implant design used.

The effect of smoking on implant survival at second-stage surgery: DICRG Interim Report No. 5. Dental Implant CLinical Research Group.

Smoking has been reported to have a deleterious effect on the oral cavity. Research has associated smoking with oral cancer, periodontal disease, leukoplakia, stomatitis nicotina, and impaired gingival bleeding. In 1991 the Dental Implant Clinical Research Group initiated a prospective, randomized clinical study in cooperation with the Department of Veterans Affairs to investigate the influence of implant design, application, and site of placement on long-term clinical performance and crestal bone height. Over 70 dental and medical history variables and exclusion factors were analyzed to determine relationships, if any, with implant failure at the time of second-stage surgery. The variables were analyzed separately for individual implants, cases (prostheses), and patients. The cases ranged from one to five implants each, and more than one case from a single patient could be included in the investigation. At this interim analysis, 2,066 implants have been placed representing 433 cases in 310 patients. With regard to implant failure rates, possible exclusion variable (9) and medical history variables (39) were not found to be statistically significant. For the dental history variables (23), only the question related to smoking was statistically significant on an implant, case, and patient basis (P < 0.007). Results of this interim analysis suggest that smoking is detrimental to implant success.

Technique for standardization of panoramic radiographs using helium-neon laser guided positioning.

A limitation of the use of panoramic radiography in implant dentistry has been variations in patient positioning, which can produce dissimilar radiographs and is a serious problem in longitudinal investigations. Previous techniques to standardize panoramic radiographs have been cumbersome and technique sensitive. Bilateral helium-neon lasers were mounted on two-axis micrometer translation stages and projected as cross-hairs on a phantom skull. The cross-point of each pattern was superimposed on a facial soft tissue landmark on either side of the skull. Laser coordinates were recorded and an initial radiograph was produced for each of three experimental groups. Two investigators repeated radiographs for each group six times using the original settings. The radiographs were digitized and the variance calculated and compared using a video digital analysis program. Repeat radiographs were compared to the originals by superimposing each pair and measuring the variance in radiographic markers. The variance ranged from 0.1 to 2.2 mm with the experimental groups and from 2.5 to 38.7 mm with the control group. Repeated measures analysis of variance showed no statistical significance (P > 0.125) among each of the experimental groups using the laser system and a significant difference (P < 0.001) when the control group is included in the analysis. Variance for experimental groups was not significant between the examiners (P > 0.45). A laser repositioning system may have application in implant dentistry by standardizing panoramic radiographs for comparisons in long-term investigations.

Three-dimensional computed tomography and anatomic replicas in surgical treatment planning. Report of a case.

A case that demonstrates the use of three-dimensional computed tomography and anatomic replication in the management of a severe anterolateral open bite deformity is presented. Preoperative surgical treatment planning was facilitated by rehearsal model surgery. Construction of an accurate surgical splint enabled precise positioning of osteotomized segments at surgery.

Age and sex biases in the preservation of human skeletal remains.

Inaccuracies introduced through biases in preservation are a major source of error in paleodemographic reconstructions. Although it is generally assumed that such biases exist, little is known about their magnitude. To investigate this problem, we studied age and sex differences in the preservation of skeletal remains from Mission La Purisima and a prehistoric cemetery (Ca-Ven-110). Comparison of mortality profiles obtained through analysis of skeletal remains and burial records from the mission indicates that biases in preservation can be very significant in poorly preserved skeletal collections. The Purisima burial records show that most of the people interred in the cemetery were either infants or elderly adults. The skeletal remains, in contrast, are predominantly those of young adults. The burial records and skeletal collection produced comparable sex ratios. These results show that age biases in preservation are much more important than sex biases. This conclusion is supported by data on the completeness of the skeletons from La Purisima and Ca-Ven-110. At both sites, the remains of young adults were better preserved than those of children or elderly adults, and the completeness of male and female skeletons was comparable.

Hemimandibulectomy without bone grafting: report of a case.

Some patients require hemimandibulectomy who are poor candidates for reconstructive surgery or who do not want to subject themselves to multiple surgical episodes. With the use of an articulated external skeletal fixation appliance, near-normal esthetics and function can be achieved in these patients without bone grafting. A report of one such case is presented.

A two-piece surgical splint to facilitate hydroxylapatite augmentation of the mandibular alveolar ridge.

Details of the design and fabrication of a two-piece splint that facilitates the HA augmentation of the mandibular alveolar ridge are presented. The use of the splint has eliminated migration of HA particles, reduced elevation of the vestibule, and increased the predictability of the outcome of the procedure.

The British-Norwegian migrant study: 5-year mortality differentials due to cigarette smoking.

Cigarette smoking and 5-year survivorship of 20,017 British and 10,016 Norwegian migrants to the United States were compared with 17,696 British and 26,155 Norwegian nonmigrants. The highest mortality ratios for 5-year age-adjusted death rates observed were of cigarette smokers to nonsmokers, ranging from 1.40 to 1.60 for men and from 1.18 to 1.36 for women. Mortality ratios of nonmigrants to migrants ranged from 1.07 to 1.19 for men and from 1.22 to 1.36 for women. Mortality ratios for British to Norwegian groups ranged from 1.13 to 1.27. Some differences in mortality ratios for cardiovascular diseases contrasted with mortality ratios for noncardiovascular diseases were noted. The most important of these differences was the apparent lack of any consistent difference between nonmigrants and migrants in their 5-year cardiovascular mortality rates, although there were consistent differences for noncardiovascular diseases.