HPV infection in oral cancer, our experience: prevalence, clinical implications, and current vaccination program in Spain.

Background: Oral cancer is the 11th most common type of cancer in the world, with established major risk factors as tobacco and alcohol, and recently included high-risk human papillomavirus types 16 and 18. HPV types 16 and 18 are the etiologic agents of cervical cancers and a proportion of oropharyngeal cancers. However, the picture of HPV and the clinical implications of oral cancers are not clear with most reports combining oral cancer data with head and neck cancers. It has been confirmed as a favorable prognostic factor in oropharyngeal cancer. However, the prognostic value of HPV in oral squamous cell carcinoma is still unclear. Material and Methods: The main objective of this article is to present the evidence encountered following a bibliographical review of recent publications specifically related to oral cancer and its differences from oropharyngeal cancer. The secondary goals are to present the findings of a five-year retrospective observational study of the prevalence of HPV infection in oral cancer patients treated by the Oral and Maxillofacial Surgery Department at La Paz University Hospital (Madrid, Spain), and finally, we to evaluate and compare our country's HPV prevention program in comparison to other European countries. Results: According to the review of the literature, HPV positive oral squamous cell carcinoma is associated with significantly decreased overall survival and distant control. Bibliographic review suggest HPV infection can be used as a negative prognostic factor in oral squamous cell carcinoma. Conclusions: As regards diagnostic testing for HPV, it should be extended to as many cases of oral cavity squamous cell carcinoma as possible, especially in those with risk factors. The current vaccination program in Spain does not have adequate coverage and is significantly under the level of other European Union countries; it should be expanded and catch-up strategies should be included. Key words:HPV, OSSC, Papillomavirus, oral carcinoma, prevention.

Bisphosphonate-related osteonecrosis. Application of adipose-derived stem cells in an experimental murine model

Background: Bisphosphonate-related osteonecrosis of the jaw is a pathological condition without effective established treatment and preventive strategies. The aim of this study was to analyse the effect of adipose-derived stem cells (ASC) in an experimental murine model of osteonecrosis. Material and Methods: 38 Wistar rats were injected intraperitoneally with zoledronic acid. After treatment, upper jaw molars were extracted. The animals were randomly assigned to one of two groups. In the control group, saline solution was applied over the alveolar sockets after the tooth extractions. In the treatment group, ASCs were applied instead of saline solution. The control and treatment groups were subdivided based on the time of euthanasia. A clinical and histological analysis was performed. Results: The presence of osteonecrosis in alveolar bone was observed in a similar distribution in both groups. In the ASC-treated group, new bone formation was greater than in controls. Conclusions: In this study, application of ASCs showed greater new bone formation in an osteonecrosis-like murine model. Previous inhibited post-extraction bone remodelling could be reactivated, and these findings appeared to be secondary to implantation of ASCs

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Osteochondroma of coronoid process: a rare etiology of jacob disease.

Jacob disease is a rare entity consisting of the formation of a pseudojoint between the inner surface of the zygoma and the coronoid process. This requires constant contact between the two implicated surfaces. It can be achieved by two mechanisms: one by an enlarged coronoid process and two by an anterior displacement of the coronoid process caused by a temporomandibular joint (TMJ) disorder. Although von Langenbeck described coronoid process hyperplasia in 1853, Oscar Jacob was the first author to describe the pathology in 1899. Since then, only a few cases have been published in the literature. The authors report a rare case of Jacob disease caused by an osteochondroma of the coronoid process, which is even less common, and review the literature.

Clinical, radiological and therapeutic features of keratocystic odontogenic tumours: a study over a decade.

Factors associated with the potential for recurrence of keratocystic odontogenic tumours (KCOT) still remain to be clearly determined and no consensus exists concerning the management of KCOT. The purpose of this study was to evaluate different clinical factors associated with KCOT and its treatment methods. A retrospective review was performed of 55 cases treated from 2001 to 2010. Of the 55 cases, 27% were associated with an impacted or semi-impacted tooth. The majority of the lesions (82%) were located in tooth-bearing areas, and the overall mandibular to maxilla ratio of tumour occurrence was 5:1. The treatment options included enucleation, marsupialisation, or peripheral ostectomy, with or without the use of Carnoy´s solution. Recurrence was found in 14 cases (25%). No significant association was seen between recurrence and age, symptomatic cases, location of the lesion, or unilocular or multilocular appearance. The recurrence rate was higher in the group with tooth involvement, more marked in cases with third molar involvement. Statistical analysis showed a significant relation between recurrence and the type of treatment, with higher rates in cases treated with enucleation associated with tooth extraction. In our series, those cases with a closer relation with dental tissues showed a higher risk of recurrence, suggesting the need for a distinct classification for peripheral variants of KCOT. Key words:Keratocystic odontogenic tumour, Odontogenic keratocyst, Odontogenic cysts, Keratocyst, Carnoy's solution.

Iatrogenic diplopia [corrected].

Diplopia is a very disturbing condition that has been reported as a complication of several surgical procedures. The following review aims to identify the ocular and nonocular surgical techniques more often associated with this undesirable result. Diplopia is reported as an adverse outcome of some neurosurgical procedures, dental procedures, endoscopic paranasal sinus surgery, and several ophthalmic procedures. The most common patterns and some recommendations in order to prevent and treat this frustrating outcome are also given.

Melanoma de mucosa intraoral: ¿enfermedad local o sistémica? / Oral mucosal melanoma: a local or systemic disease?

Objetivo: Realizar una revisión de la situación actual en el tratamiento del melanoma de mucosa oral (MMO).Describir el protocolo de tratamiento que haya demostrado mejores resultados dada la experiencia y los estudios realizados por la institución de referencia. Material y métodos: Los autores realizan una amplia revisión de la literatura abordando las nuevas líneas terapéuticas de investigación. Resultados: Descripción del protocolo de tratamiento que siguen en uno de los centros con mayor cáustica en la literatura internacional. Conclusiones: El MMO es una neoplasia maligna poco frecuente, con etiología y patogenia desconocida y un pronóstico infausto. El tratamiento debe basarse en un diagnóstico temprano y un abordaje multidisciplinar (AU)

Objective: To review the current situation in the treatment of oral mucosal melanoma. To describe the treatment protocol that has shown better results, given the experience and studies by the reference institution. Methods: The authors conducted an extensive review of the literature addressing the newlines of therapeutic research. Results: Description of the treatment regimen followed at one of the most experienced centers in the international literature. Conclusions: Oral mucosal melanoma is a rare malignancy with an unknown etiology and pathogenesis and poor prognosis. Treatment should be centered on early diagnosis and a multidisciplinary approach (AU)

Rehabilitación mandibular implanto-soportada sobreinjerto microvascularizado de peroné. Empleo de la cirugía guiada por ordenador / Implant-supported mandible rehabilitation over microvascularised fibula graft. Use of computer-guided surgery

INTRODUCCIÓN: En el tratamiento de los pacientes afectos de tumores malignos de la cavidad oral, la cirugía combina la resección y la reconstrucción inmediata con el fin de preservar las funciones que concentra la cavidad oral (fonación, deglución, masticación, estética). El empleo de colgajos microvascularizados constituye una práctica habitual en estos pacientes para reponer los tejidos resecados. La rehabilitación dental de estos pacientes suele ser muy compleja, y el empleo de sistemas de cirugía implantológica guiada evita muchos de los problemas que se presentan en estos pacientes. CASO CLÍNICO: Paciente sometido a a hemimandibulectomía sin reconstrucción y tratamiento adyudante con radioterapia que es remitido para reconstrucción. Inicialmente se practica un colgajo microvascularizado de peroné que aporta hueso y partes blandas. Posteriormente se rehabilita con una prótesis híbrida sobre implantes, que se colocan mediante una férula quirúrgica mucosoportada tras planificación con la herramienta FacilitateTM. DISCUSIÓN: el colgajo microvascularizado de peroné es el caballo de batalla en la reconstrucción mandibular del paciente oncológico. Su principal desventaja es la dificultad para la colocación de implantes dentales y su posterior rehabilitación. El empleo de cirugía implantológica guida permite obviar muchos de estos problemas. CONCLUSIONES: La reconstrucción del paciente oncológico de cavidad oral mediante injertos microvascularizados, y su posterior rehabilitación dental con implantes osteointegrados permite ofrecer al paciente una calidad de vida aceptable

INTRODUCTION: In the treatment of the patients with malignant tumours of the oral cavity, the surgery combines the resection and immediate reconstruction with the aim of preserving the functions concentrated in the oral cavity (phonation, deglutition, mastication, aesthetics). The use of microvascularised flaps is a common practice in these patients in order to replace the resected tissues. Dental rehabilitation of these patients is usually very complex, and the use of guided implant surgical systems avoids many of the problems that occur in these patients. Clinical case: A patient who underwent hemimandibulectomy without reconstruction and adjuvant treatment with radiotherapy, who is sent for reconstruction. Initially, a microvascularised fibula flap is performed that provides bone and soft tissues. Subsequently, he is rehabilitated with a hybrid prosthesis over implants, which is placed by means of a mucosa-supported surgical ferrule after planning with the FacilitateTM tool.. DISCUSSION: The microvascularised fibula flap is the key process in mandibular reconstruction of cancer patients. Its principal disadvantage is the difficulty in the placement of the dental implants and subsequent rehabilitation. The use of guided implant surgery prevents many of these problems

Transfusion Requirements in Microsurgical Reconstruction in Maxillofacial Surgery: Ethical and Legal Problems of Patients Who Are Jehovah's Witnesses.

Objective To study transfusion requirements in patients with cancer undergoing head and neck reconstructive surgery and to discuss surgical and anesthetic strategies to reduce blood loss when the patient is a Jehovah's Witness. Material and Methods A descriptive study to expose the percentage of blood transfusions performed in patients with cancer undergoing microsurgical reconstructions in the department of oral and maxillofacial surgery of the referred hospital in the past 9 years. Results Two hundred thirty-seven microsurgical reconstructions were performed in head and neck tumors between January 2001 and December 2009. Statistical analysis shows a significant decrease (p = 0.035) in the number of patients needing transfusions patients in recent years. Conclusions The treatment of patients who are Jehovah's Witnesses is an ethical and moral dilemma for the clinician and in particular for surgeons.

Anticoagulación en microcirugía reconstructiva en los servicios de Cirugía Maxilofacial en España / Anticoagulation in reconstructive microsurgery in maxillofacial surgery departments in Spain

Objetivo. Conocer el protocolo de terapia anticoagulante que siguen en el perioperatorio de este tipo de intervención los principales servicios de Cirugía Oral y Maxilofacial de España que realizan microcirugía reconstructiva de cabeza y cuello. A partir de aquí, resumir la terapia anticoagulante mayoritaria e intentar unificar criterios. Material y métodos. Los autores realizan un estudio descriptivo tras contactar a través de encuesta telefónica y/o por correo electrónico con los principales servicios de Cirugía Oral y Maxilofacial de los hospitales en España en los que se realiza cirugía reconstructiva con injertos libres microvascularizados. Resultados. De los 65 servicios de Cirugía Oral y Maxilofacial de España, 29 (44%) son los integrantes del estudio. El resto de servicios se excluyen por no realizar regularmente reconstrucción microquirúrgica o no notificar los resultados de la encuesta. De estos 29 servicios participantes, 22 (73%) siguen un protocolo de antitrombosis en los procedimientos microquirúrgicos. Conclusión. Pese a no existir una pauta estandarizada de antitrombosis, hay datos concluyentes de que el dextrano no debe utilizarse por el alto riesgo de complicaciones sistémicas, así como de que los únicos fármacos que han conseguido una reducción de la trombosis microvascular son la heparina y el AAS con respecto a la ausencia de terapia antitrombótica(AU)

Objective. To find out the protocol for anticoagulation therapy in the perioperative period following microvascular reconstruction in major Oral and Maxillofacial Surgery Departments in Spain. From this, to summarise the majority anticoagulant therapy and attempt to unify criteria. Material and Methods. The authors conducted a descriptive study. A survey was performed contacting by telephone and/or email with the major Oral and Maxillofacial Surgery departments in Spain who perform reconstructive surgery with microvascular free flaps. Results. Of the 65 services of Oral and Maxillofacial Surgery Departments in Spain, 29 (44%) participated in the study. The other services were excluded owing to not practicing microsurgical reconstruction or not providing the results of the questionnaire. Of these 29 participating departments, 22 (73%) followed an antithrombotic protocol in microsurgical procedures. Conclusion. Despite the lack of a standardised antithrombotic pattern there is evidence that dextran should not be used due to the high risk of systemic complications, and heparin and aspirin are the only drugs that have achieved a reduction in microvascular thrombosis compared to the absence of antithrombotic therapy(AU)

Evaluating phantom image quality parameters to optimise patient radiation dose in dental digital radiology.

Our objective was to obtain images of a predictable level of quality using an intraoral X-ray system with digital imaging, avoiding patient overexposure. A polymethylmethacrylate (PMMA) physical test phantom was imaged at different exposure times and at various PMMA thicknesses using a dental imaging coupled charge device. Two identical regions of interest (ROIs) were chosen in every image file, and quality was numerically evaluated by measuring high-contrast spatial resolutions, low-contrast thresholds and signal-to-noise ratios. In addition, three practitioners proposed personal quality scores by image inspection. Numerical contents in the ROIs, related to the image quality, were plotted against exposure time. From here, a simple expression linking the exposure time with the thickness to obtain images of comparable quality was deduced. As a result, the optimum exposure time for imaging with a predictable level of quality can be inferred. The potential effect could imply savings above 1000 man Sv, roughly 20 % of the collective dose due to dental imaging, over a population of 1540 millions.

Mandibular osteomyelitis in red deer (Cervus elaphus hispanicus) and fallow deer (Dama dama): occurrence and associated factors in free-living populations in southern Spain.

The prevalence of mandibular osteomyelitis, which results in a condition called lumpy jaw, and factors associated with its occurrence were investigated in syntopic free-living populations of red deer (Cervus elaphus hispanicus) and fallow deer (Dama dama) in Spain. The study material consisted of 3,586 mandibles from 2,548 red deer and 1,038 fallow deer shot during sport hunting, herd management culls, and programs for population control between 1988 and 1997 (period 1) and 2002 and 2009 (period 2) in eastern Sierra Morena, southern Spain. Disease prevalence ranged from 0.36% to 10.91% among age groups. Older animals were significantly more likely to be affected than younger ones. Red deer stags had higher prevalence than other groups. There was a significantly higher prevalence in period 1, probably associated with differences in climatic and population conditions. High population densities of female red deer contributed significantly to occurrence of disease. Intensive herd management and poor environmental conditions were considered risk factors that increased susceptibility to disease. The study of this affliction could be useful for monitoring general herd welfare and ecologic changes in Mediterranean ecosystems.

Atypical case of congenital maxillomandibular fusion with duplication of the craniofacial midline.

We report the first case of syngnathia with hypophyseal duplication and describe the central nervous system (CNS) and craniofacial anomalies associated with hypophyseal duplication in the reported autopsy case. We studied clinical reports, scanner images, and autopsy results of a 2-months-old female baby. The propositus had frontonasal dysmorphism, retrognathia, and bifid tongue. She also presented maxillomandibular bony fusion (syngnathia) and an intraoral hairy polyp. In the cranium, the sella turcica was broadened, with two complete hypophyses and two infundibulums. The CNS had both olfactory bulbs and corpus callosum agenesis. There are 27 previous cases of maxillomandibular fusion and seven previous autopsy cases of hypophyseal duplication associated with other frontonasal malformations. As far as the authors know, this is the first case reported in the literature that associates syngnathia with duplication of the craniofacial midline including hypophyseal duplication.

Salud en las metrópolis: desafíos en el conurbano bonaerense / Metropolitan health: metropolitan area challenges

Contenido: Gestión territorial en salud. Lo local y lo regional: tensiones y desafíos para pensar la agenda de la política sanitaria en el conurbano bonaerense. El sistema de salud argentino y metropolitano: desafíos y agenda futura. El uso de los hospitales públicos de la Ciudad Autónoma de Buenos Aires: un análisis desde la perspectiva metropolitana. La perspectiva de los determinantes ambientales en el proceso salud-enfermedad. Un análisis de la problemática en la Cuenca Matanza-Riachuelo.

Rhytidectomy approach for surgical treatment of branchial cyst.

Surgical treatment of benign diseases of the neck produces a cervicotomy scar. A modified rhytidectomy incision has been used since 2003 in our department in selected cases of parotid gland tumours. However, there is no mention in bibliography about using facelift approach for treatment of cervical diseases. We have operated on three patients with brachial cysts using this technique. We introduce a clinical case of a 28-year-old woman with a right cervical swelling at the level of the anterior side of the sternocleidomastoid muscle. This technique allows a wide surgical approach. There is no donor-site morbidity, minimum additional operating time, hidden scar and no extra cost, and patients are very satisfied with the results.

Rhinoorbitocerebral mucormycosis: a case report and literature review.

Mucormycosis is a rare oportunistic infection typically described in diabetic patients with a ketoacidotic status, as well as neutropenic patients. The infection is caused by a group of saprophytic fungi of the class Phycomicetes, being the most frequent ones the Rhizomucor, Rhizopus and Mucor. Its hystological findings include vascular trombosis and tissue necrosis, predominantly in the rino-orbito-cerebral area. Even though the frequency of presentation is very low, given its rapid evolution and severe consequences which include a high mortality rate, it is very important to be aware of the main features of the disease and treat it promptly. Although the diagnosis is based on the high clinical suspect, the computed tomography (CT) and the magnetic resonance image (MRI) plays an important role in determining the extension. The patients should receive treatment in a reference hospital so that a multidisciplinary approach is ensured. In this sense, we present a case of rhino-orbito-cerebralmucormycosis in a diabetic patient, recently treated in our Department. A comprehensive review of the literature has been performed to update the physiopathology and diagnosis. Finally, we describe the different treatment options focusing in the surgical approach, as well as the medical treatment with amphotericine and posaconzole.

Rhinoorbitocerebral mucormycosis: A case report and literature review

Mucormycosis is a rare oportunistic infection typically described in diabetic patients with a ketoacidotic status, aswell as neutropenic patients. The infection is caused by a group of saprophytic fungi of the class Phycomicetes, beingthe most frequent ones the Rhizomucor, Rhizopus and Mucor. Its hystological findings include vascular trombosisand tissue necrosis, predominantly in the rino-orbito-cerebral area.Even though the frequency of presentation is very low, given its rapid evolution and severe consequences which includea high mortality rate, it is very important to be aware of the main features of the disease and treat it promptly.Although the diagnosis is based on the high clinical suspect, the computed tomography (CT) and the magnetic resonanceimage (MRI) plays an important role in determining the extension. The patients should receive treatment ina reference hospital so that a multidisciplinary approach is ensured.In this sense, we present a case of rhino-orbito-cerebralmucormycosis in a diabetic patient, recently treated in ourDepartment. A comprehensive review of the literature has been performed to update the physiopathology and diagnosis.Finally, we describe the different treatment options focusing in the surgical approach, as well as the medicaltreatment with amphotericine and posaconzole (AU)

Masa intraoral de rápido crecimiento. A propósito de un caso / Intraoral tumor with rapid growing. Report of a case

La aparición de una masa intraoral supone un motivo de consultafrecuente en nuestra especialidad. La mayoría de los casoscorresponden a lesiones benignas y, dentro de las malignas, atumores primarios intraorales. Las metástasis suponen menosdel 1 % de las lesiones malignas.Presentamos el caso de una mujer de 86 años de edad, sin antecedentesoncológicos, que acudió a nuestro servicio presentandouna masa intraoral asintomática, de crecimiento rápido y volumenconsiderable, sin otros hallazgos de interés a la exploración.La lesión se acompañaba de erosión ósea subyacente. Elresultado de la biopsia fue de adenocarcinoma metastático deprobable origen abdominal, si bien el tumor primario no pudoser identificado con las técnicas diagnósticas no invasivas quese llevaron a cabo.Valorando el estado deteriorado de la paciente, así como el malpronóstico de dichas lesiones, se optó por un tratamiento únicamentesintomático, consiguiendo una adecuada calidad de viday sin aparición de recidivas locales en el momento actual

The appearance of an intraoral mass is common in our speciality. Most are benign lesions, but some are primary malignancies.Metastases account for less than 1% of all oral malignances.An 86 year old woman was referred to our department witha large, asymptomatic, intraoral, fast-growing mass. She hadno previous cancer history or other relevant physical findings.The radiology studies showed underlying bone erosion. Thehistological study showed a metastatic adenocarcinoma with asuspected origin in the abdomen. We were unable to identify itby non invasive diagnostic procedures.Given the patient’s general status and despite the ominous prognosisof such lesions, we decided not to perform any aggressivetherapy beyond removing the oral mass, in order to maintainher quality of life. There have been no local recurrences untilthis time

Intraoral tumor with rapid growing. Report of a case.

The appearance of an intraoral mass is common in our specialty. Most are benign lesions, but some are primary malignancies. Metastases account for less than 1% of all oral malignancies. An 86 year old woman was referred to our department with a large, asymptomatic, intraoral, fast-growing mass. She had no previous cancer history or other relevant physical findings. The radiology studies showed underlying bone erosion. The histological study showed a metastatic adenocarcinoma with a suspected origin in the abdomen. We were unable to identify it by non invasive diagnostic procedures. Given the patient's general status and despite the ominous prognosis of such lesions, we decided not to perform any aggressive therapy beyond removing the oral mass, in order to maintain her quality of life. There have been no local recurrences until this time.