Oral manifestations of extranodal lymphomas - a review of the literature with emphasis on clinical implications for the practicing dentist.

OBJECTIVE: Lymphoma is a heterogenous group of malignant tumours with proliferation of lymphoid cells or their precursors. Lymphomas in the head and neck region are usually found in Waldeyer's ring. Intraoral lymphomas are rare and the clinical presentation and roentgenological appearance may resemble other and benign conditions, entailing a risk for diagnostic delay. The objective of the present literature review was to identify subjective symptoms, clinical presentations and roentgenological appearances which should raise suspicion of lymphoma. MATERIALS AND METHODS: The literature review identified 41 case series with head and neck lymphomas (n = 3880) and 384 case reports (n = 567 cases) of intraoral lymphomas. Information of demographics, clinical presentation, subjective symptoms and roentgenological appearance was registered. RESULTS: The most common clinical presentation was a broad-based swelling or bulging mass with or without simultaneous ulceration, frequently with a relatively rapid growth pattern. Subjective symptoms varied considerably. Intraosseous lymphomas were frequently associated with paresthaesia or numbness. The most common roentgenological finding was a radiolucency with diffuse demarcation. CONCLUSIONS: The clinical presentation, symptomatology and roentgenological appearance of intraoral lymphomas varied. Diagnostic delay was usually associated with a lymphoma initially misdiagnosed as a lesion of dental aetiology or a reactive lesion. Inadequate healing after tooth extraction or symptoms of numbness or pain without obvious dental origin should merit further clinical and roentgenological examination. Biopsy is indicated when there is the slightest doubt of the true nature of mucosal lesion.

Pre-medical dental evaluation and treatment of oral infection - a survey study among hospital-affiliated dentists in Sweden.

OBJECTIVE: To examine how hospital-affiliated dentists assess risk and evaluate oral foci of infection in patients facing certain medical treatments, and whether the nature of upcoming medical treatment affects the choice of dental intervention. MATERIALS AND METHODS: A survey comprising six clinical cases (50 teeth) was sent to hospital-affiliated dentists in Sweden. A treatment option for the affected tooth/teeth in each case was selected whether the patient was facing heart valve surgery, chemotherapy, radiation therapy, intravenous bisphosphonate treatment, solid organ transplantation or was diagnosed with endocarditis. RESULTS: Consensus in choice of dental treatment was high in 62%, moderate in 32% and low in 6% of the assessments. High variability of choice of treatment was seen for eight teeth whereas the remaining 42 teeth often received the same therapy regardless of medical issue. Chemotherapy and radiotherapy were thought to entail the highest risk for oral infectious sequelae with a risk ranging from 1% to 100%. CONCLUSION: Pre-medical dental evaluations and recommended treatments are often uniform with the exception of the management of asymptomatic root canal treated teeth with persisting apical radiolucency and heavily decayed molars. In many instances, dental diagnosis has a greater impact on choice of treatment than the underlying medical issue and associated implications thereof.

Follow-up of need for dental treatment in 126 patients who have received radiation treatment to the head and neck region.

OBJECTIVES: The aim of this study was to evaluate the need for dental treatment, compliance with post-radiation prophylactic care and incidence of long-term complications following radiotherapy to the head and neck. METHODS: The study is a retrospective analysis of dental records of patients referred for oral examination before radiation treatment to the head and neck between 2006 and 2016. Data of dental status and need for dental treatment before radiation therapy were used as baseline information. Dental records could be obtained from 126 patients (men n = 74; women n = 52). The mean time from completed radiotherapy to follow-up was 5.8 years (SD 2.9). RESULTS: The need for dental treatment was for the majority of patients relatively modest and mainly due to caries and fractures of teeth or fillings, but extensive need for dental treatment was noted in a few patients. One hundred and twenty-five out of 126 patients had complied with individual post-radiation prophylactic care programmes provided by the regular caregiver. Ninety-two out of 126 obtained dental records (73%) described hyposalivation and/or xerostomia. Osteoradionecrosis developed in 11 patients (8.7%), frequently requiring long-term treatment. CONCLUSIONS: The results indicate that dental status may often be preserved if the patient is given regular information on oral hygiene and complies with prophylactic follow-up. Individual cases develop serious complications, and dental hygienists and dentists must be observant on early signs of rampant caries, trismus and osteoradionecrosis.

Factors associated with geographic tongue and fissured tongue.

OBJECTIVES: The primary objective of this study was to investigate the association of systemic diseases, use of medications, allergies and tobacco habits with geographic tongue (GT) and fissured tongue (FT) lesions. The secondary objectives were to evaluate the clinical characteristics of tongue lesions and to compare the overall results for referred and non-referred patients. METHODOLOGY: Non-referred patients with GT (GTgp; n = 130) and FT (FTgp; n = 62) were examined by general practitioners (gp) and compared to a control group without oral mucosal lesions (C; n = 1029). Referred patients with GT (GTs; n = 166) and FT (FTs; n = 15) were examined by oral medicine specialists (s) and compared to GTgp and FTgp. Statistical analyses were performed using unpaired t-test or Fisher's exact test. A multiple logistic regression model was developed to control for age and gender as confounders. RESULTS: Compared to the C group, GTgp patients used more anti-hypertensive medications and Swedish snus (p < 0.01). The GTgp group consisted of older males (p < 0.001) compared to C. Compared to the GTgp group, the GTs group was younger, more likely to have symptomatic lesions (p < 0.0001) and comprised of more females. Among the groups examined, FT patients had the highest mean age. CONCLUSION: This study identified an association between GT and anti-hypertensive medications, as well as the use of Swedish snus. It also found differences in the activities and symptoms of the lesions between referred patients and their counterparts who were seen in general dental practice; these parameters influenced the results when these conditions were taken into account.

Clinical characteristics of patients with concomitant oral lichen planus and thyroid disease.

OBJECTIVE: To study the prevalence and profile of thyroid disease in a cohort of referred patients with oral lichen planus (OLP) in comparison with a random population sample and to examine the clinical characteristics of OLP patients with and without thyroid disease. STUDY DESIGN: Data from 1611 patients with OLP and 1615 patients from the general population were collected by using a standardized registration method. Patients with OLP using levothyroxine (OLP/levothyroxine+) were re-examined to collect information about existing OLP lesions and to confirm the thyroid disease diagnosis. The clinical characteristics of OLP lesions in this group were compared with those in an age- and gender-matched population of patients with OLP without a history of thyroid disease or levothyroxine medication (OLP/levothyroxine-). RESULTS: Nearly 11% (n=170) of the patients with OLP were taking levothyroxine compared with 2.5% (n=40) of the controls (multivariate odds ratio 2.99, 95% confidence interval 2.03-4.44; P<.0001). No difference was found in the thyroid disease profile between the groups. At the time of re-examination, patients with OLP/levothyroxine- displayed more erythematous OLP lesions and complained of more severe symptoms compared with the OLP/levothyroxine+ group (P<.001). CONCLUSIONS: The prevalence of thyroid disease in patients with OLP was significantly higher than in the general population. The OLP lesions of patients with concomitant thyroid disease have a different presentation over time, which indicates a specific subgroup of OLP.

World Workshop on Oral Medicine VI: Utilization of Oral Medicine-specific software for support of clinical care, research, and education: current status and strategy for broader implementation.

OBJECTIVES: To assess the current scope and status of Oral Medicine-specific software (OMSS) utilized to support clinical care, research, and education in Oral Medicine and to propose a strategy for broader implementation of OMSS within the global Oral Medicine community. STUDY DESIGN: An invitation letter explaining the objectives was sent to the global Oral Medicine community. Respondents were interviewed to obtain information about different aspects of OMSS functionality. RESULTS: Ten OMSS tools were identified. Four were being used for clinical care, one was being used for research, two were being used for education, and three were multipurpose. Clinical software was being utilized as databases developed to integrate of different type of clinical information. Research software was designed to facilitate multicenter research. Educational software represented interactive, case-orientated technology designed for clinical training in Oral Medicine. Easy access to patient data was the most commonly reported advantage. Difficulty of use and poor integration with other software was the most commonly reported disadvantage. CONCLUSIONS: The OMSS presented in this paper demonstrate how information technology (IT) can have an impact on the quality of patient care, research, and education in the field of Oral Medicine. A strategy for broader implementation of OMSS is proposed.

The morbidity of oral mucosal lesions in an adult Swedish population

OBJECTIVE: To study the severity of symptoms and estimate the prevalence of oral mucosal lesions in a non-referral adult Swedish population, as registered by general dental practitioners. This study also aims to evaluate the possibility of dental practitioners collecting large quantities of reliable and accurate clinical data on oral mucosal lesions. STUDY DESIGN: Data from 6,448 adult Swedish patients were collected by general dental practitioners using a standardized registration method. A correlation analysis between a group with oral mucosal lesions and a control group, with no oral mucosal lesions, was performed for various parameters such as symptoms from the oral mucosa, systemic diseases, medication, allergy history, tobacco habits and the patient's own assessment of their general health. In addition, clinical photos were taken of all (..)(AU)

The morbidity of oral mucosal lesions in an adult Swedish population.

OBJECTIVE: To study the severity of symptoms and estimate the prevalence of oral mucosal lesions in a non-referral adult Swedish population, as registered by general dental practitioners. This study also aims to evaluate the possibility of dental practitioners collecting large quantities of reliable and accurate clinical data on oral mucosal lesions. STUDY DESIGN: Data from 6,448 adult Swedish patients were collected by general dental practitioners using a standardized registration method. A correlation analysis between a group with oral mucosal lesions and a control group, with no oral mucosal lesions, was performed for various parameters such as symptoms from the oral mucosa, systemic diseases, medication, allergy history, tobacco habits and the patient's own assessment of their general health. In addition, clinical photos were taken of all oral mucosal lesions in order to determine the degree of agreement between the diagnoses made by general dental practitioners and those made by oral medicine specialists. RESULTS: A total of 950 patients (14.7%) presented with some type of oral mucosal lesion and of these, 141 patients (14.8%) reported subjective symptoms. On a visual analogue scale, 43 patients (4.5%) scored their symptoms <30, 65 patients (6.8%) scored their symptoms ≥30, and 28 patients (2.6%) scored their symptoms ≥60. The most debilitating condition was aphthous stomatitis and the most common oral mucosal lesion was snuff dipper's lesion (4.8%), followed by lichenoid lesions (2.4%) and geographic tongue (2.2%). There was agreement between the oral medicine specialists and the general practitioners over the diagnosis of oral mucosal lesions on the basis of a clinical photograph in 85% of the cases (n=803). CONCLUSIONS: Nearly 15% of the patients with oral mucosal lesions reported symptoms. General practitioners could contribute significantly to the collection of large quantities of reliable and accurate clinical data, although there is a risk that the prevalence of oral mucosal lesions may be underestimated.

Squamous cell carcinoma in a patient with oral lichen planus treated with topical application of tacrolimus.

Oral lichen planus (OLP) is a chronic mucosal disorder of unclear etiology. The mainstay of therapy is topical use of steroids but other immuno-modulating therapies have also been tried. One such example is topical application of tacrolimus. Tacrolimus was in 2000 approved for treatment of atopic dermatitis, but in 2005 a boxed warning was included because of a potential risk of cancer development and for lack of long-term studies of the safety of the drug. The present study describes a patient who in 2003 was diagnosed with OLP and where treatment has included an intermittent use of tacrolimus. Five years after diagnosis, the patient developed a squamous cell carcinoma in the region where tacrolimus had been applied. The possible relationship between the use of tacrolimus and cancer development and rationale to include tacrolimus in OLP treatment is discussed.

Orofacial granulomatosis in childhood-a clinical entity that may indicate Crohn's disease as well as food allergy.

AIM: Orofacial granulomatosis (OFG) is a rare clinical entity with orofacial swelling in association with oral lesions such as mucosal oedema, ulcerations and mucosal tags. The aim of this prospective study was to evaluate the connection between OFG in childhood and systemic disease. METHODS: During a 3-year period, eight children (9-16 years old) who had been referred to the clinic of oral medicine were diagnosed solely with OFG. Thus, none of them had any known systemic disease or gastrointestinal symptoms at the time of referral. The children were then medically examined and followed up for 6-8 years at the department of paediatrics for systemic disease with specific emphasis on inflammatory disorders elsewhere in the gastrointestinal tract. RESULTS: During follow-up, four patients were diagnosed with Crohn's disease (CD). Further, one girl was found to have a food allergy-induced OFG, with delayed-type hypersensitivity to oats. One boy developed both diabetes and celiac disease during the follow-up. Only two patients had no diagnosis of systemic disease at the end of the observation period. CONCLUSION: OFG in childhood seems to be frequently related to systemic disease, and children with OFG should be referred to a paediatrician for examination and follow-up.

MedView: an instrument for clinical research and education in oral medicine.

The etiology for many of the mucosal lesions we encounter in clinical practice is frequently uncertain or unknown and there is reason to believe that multicausality plays an important role. To detect multicausal relationships, the analysis must include multiple variables and large amounts of data. A traditional retrospective analysis is often based on a limited number of variables and frequently entails methodological errors where vital information may be missing. Prospective studies may be hampered by the fact that the prevalences of many conditions are relatively low. The search for new knowledge in oral medicine should therefore be facilitated by prospective use of formalized information gathered in multicenter studies. MedView is a computer program that is based on formalized input and registration of all clinical information. The output applications are focused on visualization and statistical analysis. MedView is aimed at clinical research and is well suited for multicenter studies. It also contains applications for education and distant consultations.

Cancer and oral lichen planus in a Swedish population.

Oral lichen planus (OLP) is generally regarded as a premalignant condition. The objective of the present study was to assess the number of oral malignant tumours in a retrospective analysis of 1028 patients (mean age=55 years; range=18-86; female, n=667; men, n=351) who between 1978 to end of 1993 were diagnosed with OLP at the Faculty of Odontology, Göteborg University, Sweden. Patients with malignant tumours were identified through the Swedish Cancer Registry at the National Board of Health and Welfare, which annually reports the incidence of malignant neoplasms in the Swedish population. The incidence of oral squamous cancer (OSCC), other malignant tumours and survival in the study group was compared to the Swedish population. The total time with OLP in the study group amounted to 7009 person years, with a mean follow up of 6.8 years (SD=4.9). The observed incidence of OSCC was higher than the expected incidence in the study group. The difference was statistically significant (P<0.001). No statistically significant difference was found for any other malignant tumours than OSCC. Also, no statistically significant difference could be identified in survival between study group and the population. The results from the present study gives further support to the concept of a small but increased risk for development of squamous cell carcinoma in patients with OLP.

Oral lichen planus and malignant transformation: is a recall of patients justified?

There has been a continuous debate regarding the possible malignant potential of oral lichen planus (OLP). Based on the results from follow-up studies, OLP is regarded by several authors as a pre-malignant condition, and patients with OLP have been recommended to have their lesions monitored two to four times annually. This recommendation needs reconsideration, because a recall system of all patients with OLP requires substantial economic resources. In a reality where such resources are limited, a recall system must be weighed against other benefits and the fact that the malignant potential of OLP is most likely very low. The present review focuses on the diagnostic criteria for OLP, the pre-malignant potential of OLP, and the extent to which the available information can be used to reduce morbidity and mortality of oral cancer related to OLP.