Immunoprofile of the adenomatoid odontogenic tumor.

This study was focused on the immunohistochemical profile of the adenomatoid odontogenic tumor. A Pub/Medline search revealed a number of immunohistochemical studies including cytokeratin profiles, extracellular matrix proteins, Integrins, ameloblast-associated proteins resorption regulators (RANK, RANKL), p53, PCNA, MDM2 protein, cyclin D1, Ki-67, Bcl-2 metallothionein, metalloproteinases, D56 hepatocyte growth factor, c-met, DNA methyltransferase, podoplanin, TGF-ßI, Smad-2/3, Smad-I-5/-8, Smad 4, beta- catenin, calretinin, and clonality. Careful interpretation of the findings indicates that the adenomatoid odontogenic tumor may be more of a hamartomatous than neoplastic nature.

End-of-life care in the head and neck cancer patient.

Past the point of no longer being able to control malignancies of the oral cavity and head and neck, the decision-making process must shift to one that essentially concerns itself with creating comfort for the patient. The role of family, physicians, and other caregivers becomes, in many ways, more directed as active neoplasia-related concerns become less relevant. Challenges remain significant in terms of continuing management of prior treatment-related side effects and functional impairments to providers concerning themselves with maintenance of dignity, honoring the wishes of the family, and creating full understanding of on the part of all parties concerned what the goals of treatment cessation and palliation are key as death approaches.

Clinical practice guidelines for oral management of Sjögren disease: Dental caries prevention

"BACKGROUND: Salivary dysfunction in Sjögren disease can lead to serious and costly oral health complications. Clinical practice guidelines for caries prevention in Sjögren disease were developed to improve quality and consistency of care. METHODS: A national panel of experts devised clinical questions in a Population, Intervention, Comparison, Outcomes format and included use of fluoride, salivary stimulants, antimicrobial agents, and nonfluoride remineralizing agents. The panel conducted a systematic search of the literature according to pre-established parameters. At least 2 members extracted the data, and the panel rated the strength of the recommendations by using a variation of grading of recommendations, assessment, development, and evaluation. After a Delphi consensus panel was conducted, the experts finalized the recommendations, with a minimum of 75% agreement required. RESULTS: Final recommendations for patients with Sjögren disease with dry mouth were as follows: topical fluoride should be used in all patients (strong); although no study results link improved salivary flow to caries prevention, the oral health community generally accepts that increasing saliva may contribute to decreased caries incidence, so increasing saliva through gustatory, masticatory, or pharmaceutical stimulation may be considered (weak); chlorhexidine administered as varnish, gel, or rinse may be considered (weak); and nonfluoride remineralizing agents may be considered as an adjunct therapy (moderate). CONCLUSIONS AND PRACTICAL IMPLICATIONS: The incidence of caries in patients with Sjögren disease can be reduced with the use of topical fluoride and other preventive strategies."

Neuralgia-inducing cavitational osteonecrosis: a status report.

Neuralgia-inducing cavitational osteonecrosis remains controversial several years following the initial description. Changing etiologic concepts have led to confusion as well as the significant departures from the concept first defined by Ratner which served as the basis for the explaining the pain syndrome with features of trigeminal neuralgia. Since the earliest publications on the subject by Bouquot and colleagues there have been many challenges and counterclaims to the concept introduced, with a discussion of these included. Finally, absence of any form of research design and approval by institutional review panels remains a weakness in terms of acceptance of the information provided in the literature said to support the stated etiology of this entity.

Chondrosarcomas of the skull base and temporal bone.

OBJECTIVE: To evaluate the clinical presentation and outcomes of treatment for patients with chondrosarcomas involving the skull base and temporal bone. STUDY DESIGN: Retrospective review. SETTING: Tertiary medical centre. PATIENTS: Cases of histologically confirmed chondrosarcoma involving the skull base and temporal bones. INTERVENTION: Surgery. MAIN OUTCOME MEASURES: Demographic features of presenting patients; presenting symptoms and signs; surgical approach employed; use of post-operative radiation therapy; histological grade of tumour; and interval of post-operative follow up. RESULTS: Twelve patients were identified with chondrosarcomas involving the skull base, with post-operative follow up ranging from three to 33 years. The average age at presentation was 42 years. The most common presenting symptoms were diplopia, decreased visual acuity and headaches. Five of the 12 patients required multiple surgical procedures. CONCLUSIONS: Patients with chondrosarcoma involving the skull base and temporal bone may present in a variety of ways. Surgical resection, even subtotal, in combination with radiation therapy, can often provide good tumour control over many years for these rare tumours.

Oral cancer. The importance of early diagnosis and treatment.

Oral cancer is an important health issue. The WHO predicts a continuing worldwide increase in the number of patients with oral cancer, extending this trend well into the next several decades. In the US the projected number of new cases of oral and oropharyngeal cancer will exceed 31,000 per year. Mortality due to cancers in this region exceeds the annual death rate is the US caused by either cutaneous melanoma or cervical cancer. Significant agents involved in the etiology of oral cancer in Western countries include sunlight exposure, smoking and alcohol consumption. Use of the areca or betel nut in many cultures is a major etiological factor outside of the USA. Other etiologic factors associated with oral squamous cell carcinoma, but far less significant statistically, include syphilis and sideropenic dysphagia. Recently, strong evidence for an etiological relationship between human papilloma virus and a subset of head and neck cancers has been noted. It is generally accepted that most sporadic tumors are the result of a multi-step process of accumulated genetic alterations. These alterations affect epithelial cell behavior by way of loss of chromosomal heterozygosity which in turn leads to a series of events progressing to the ultimate stage of invasive squamous cell carcinoma. The corresponding genetic alterations are reflected in clinical and microscopic pathology from hyperplasia through invasiveness. A wide range of mucosal alternations fall within the rubric of leukoplakia. Proliferative verrucous leukoplakia represents a relatively new type of leukoplakia that is separate from the more common or less innocuous form of this condition. Erythroplakia is particularly relevant considering its almost certain relationship with dysplasia or invasive carcinoma. Squamous cell carcinoma will develop from antecedent dysplastic oral mucosal lesions if an early diagnosis has not been made and treatment given. Early diagnosis within stages I and II correspond to a vastly improved 5-year survival rate when compared with more advanced stage III and IV lesions. Surgical management of this disease remains the mainstay of treatment. Other therapies include radiation and chemotherapy options that may be used adjunctively and palliatively. Following treatment, it is important to understand the significant risks of second primary cancers developing within the upper aerodigestive tract as a result of field cancerization. The most important message is that early detection of the asymptomatic early stage oral cancer translates in general terms to satisfactory clinical outcome and cure in most patients.

The treatment of oral aphthous ulceration or erosive lichen planus with topical clobetasol propionate in three preparations: a clinical and pilot study on 54 patients.

BACKGROUND: This study evaluated the clinical use of a corticosteroid in three preparations (topical clobetasol propionate ointment, clobetasol propionate in an oral analgesic base, and clobetasol propionate in an adhesive denture paste). METHODS: Fifty-four patients (34 males and 20 females) with a history of vesiculo-ulcero-erosive oral lesions were selected: 24 with oral erosive lichen planus and 30 with aphthae. The subjects enrolled were randomly divided into three groups, each of 18 patients (10 with aphthae and 8 with lichen planus): the first was treated with topical clobetasol propionate ointment (0.05%) directly on the lesion(s) three times a day; the second with clobetasol propionate in an adhesive denture paste in equal amounts (1:1) two times a day; the third with clobetasol propionate in an oral analgesic base (Orabase-B) in equal amounts (1:1) two times a day. Each subject scored his or her symptoms daily from most severe (7) to none (0) by verbal assessments using a categorical scale. RESULTS: In all cases, the administration of the corticosteroid was effective in producing remission of symptoms in each group of patients. Significant differences (P<0.05) between groups were determined by the Kruskal-Wallis test. The Dunn test was used in order to detect which group differs from the others; clobetasol and adhesive denture paste correlated with an early remission of pain in lichen and apthous lesions. CONCLUSION: The results suggest that topical application of clobetasol in an adhesive denture paste is an effective drug for symptomatic oral vesiculo-erosive and/or ulcerative lesions.

A possible role of catenin dyslocalization in pemphigus vulgaris pathogenesis.

BACKGROUND: Pemphigus vulgaris (PV) is an autoimmune blistering disease of the skin and mucosa due to the presence of autoantibodies against the components of desmosomes. To date, less is known about the expression levels of beta- and gamma-catenins in blistering diseases. The objective of this study was to evaluate the role of beta- and gamma-catenins in the pathogenesis of acantholysis in pemphigus vulgaris. METHODS: beta- and gamma-catenin expression was evaluated by immunohistochemistry in 30 cases of PV at various stages of the disease and, as controls, in 18 specimens of the skin/oral mucosa of healthy patients. RESULTS: Healthy skin and normal oral mucosa showed a strong beta- and gamma-catenin expression in basal and spinous layers with a prevalent cellular membrane distribution; the intensity of staining progressively decreased toward the superficial layers of epithelium. In PV patients, cytoplasmic expression of gamma-catenin was detected in 28/30 cases, and in 19/30 cases of PV for beta-catenin. Moreover, a progressive displacement of the signal toward the nucleus was found in 14/30 cases for beta-catenin, with dyslocalization toward the nucleus, particularly in areas with intense acantholysis, and in 22/30 cases of PV for gamma-catenin. CONCLUSIONS: Abnormal distribution of gamma-catenin, consequent to PV IgG, may be considered a direct consequence of Dg3 dissociation from catenin. gamma-catenin likely plays a direct role in PV pathogenesis through its dyslocalization toward the nucleus or indirectly through the beta-catenin dyslocalization toward the nucleus, which is thought to induce transcription of selected target genes, such as uPAR.

Oral spindle cell lipoma.

Lipoma is an uncommon benign, oral, soft-tissue neoplasm commonly found on the buccal mucosa. It is predominantly composed of mature fat with or without other mesenchymal tissue elements, showing a variety of histologic subtypes, one of which is the rare "spindle cell variant" with only nine previously reported cases in the English literature. In this report, we review clinical and histomorphologic data of 164 cases of oral lipomas retrieved from the files of Long Island Jewish Medical Center, Department of Dental Medicine (New Hyde Park, NY). Of these, only two cases were diagnosed as the spindle cell variant, further confirming the rarity of this histologic subtype. A review of oral lipoma with particular reference to the spindle cell variant is also presented.

Ductal papillomas of salivary gland origin: A report of 19 cases and a review of the literature.

The term ductal papilloma is used to identify a group of 3 rare benign papillary salivary gland tumors known as inverted ductal papilloma, sialadenoma papilliferum, and intraductal papilloma. They represent adenomas with unique papillary features and arise from the salivary gland duct system. We describe the clinical and microscopic features of 19 new cases of ductal papillomas and combine them with 116 cases previously published in the English-language medical literature. These 19 cases were composed of 13 inverted ductal papillomas, 3 sialadenoma papilliferums, and 3 intraductal papillomas. Collectively, these 19 ductal papillomas occurred most commonly in the sixth to eighth decade of life, with an average patient age of 54 years. Men predominated 1.37:1. The sialadenoma papilliferums presented as papillary lesions clinically with all 3 misinterpreted as squamous papillomas by the surgeons. The inverted ductal papillomas and intraductal papillomas appeared as submucosal nodules. The lip and the palate were the most common locations for inverted ductal papilloma and sialadenoma papilliferum, respectively. The sites for the 3 intraductal papillomas were the parotid papilla of the Stensen's duct, the upper lip, and the buccal mucosa. With light microscopy, inverted ductal papillomas appeared to arise from the excretory ducts near the mucosal surface, whereas intraductal papillomas appeared to arise from the excretory ducts at a deeper level. Sialadenoma papilliferum had a more complex histology, with a biphasic growth pattern of exophytic papillary and endophytic components. All 19 cases were treated by surgical excision. Follow-up information was available in only 2 cases, both inverted ductal papillomas. Neither case recurred during a 20-year period. Sialadenoma papilliferum, with a literature-derived recurrence rate of 10% to 15%, seems to assert a more significant biological behavior than inverted ductal papilloma and intraductal papilloma. Our findings justify the separation of these 3 entities based on clinical and histologic parameters. They are tumors of adulthood and, in addition, have in common their relationship to the excretory duct system, their anatomical distribution, and their general behavior.

Oral cancer and its detection. History-taking and the diagnostic phase of management.

BACKGROUND: Comprehensive patient evaluation begins with an accurate analysis of all factors of the patient's history before the physical examination is performed. Risk factor identification is particularly important in most cases of oral mucosal dysplasia and carcinoma, as it alerts the clinician to an increased susceptibility for such alterations. The armamentarium of the dentist, which ranges from noninvasive indicators to a scalpel biopsy, permits a thorough evaluation of any observed mucosal changes. Newer additions to this armamentarium have been developed and are emerging that aid in the process of characterizing lesions, thereby facilitating appropriate management. METHODS: The author presents methods of assessing and analyzing a patient's oral health status. He discusses carcinogens and cofactors, as well as dietary considerations, in the development of oral mucosal precancer and cancer. He also presents details of the clinical evaluation, which can lead the clinician to possible further evaluation and analysis by an expanding array of diagnostic tools. RESULTS: The article identifies the factors a clinician should consider when evaluating the dental patient, from initial presentation and risk factor identification to the use of traditional assessment parameters. New and evolving diagnostic tools, coupled with cell and tissue characterization by an oral and maxillofacial pathologist, remain critical in terms of patient management and in maintaining optimum standards of care. CONCLUSIONS AND CLINICAL IMPLICATIONS: A comprehensive oral examination must include integration of each patient's in-depth health history and the physical findings. Appreciation of subtle surface changes as a possible harbinger of pathology and the traditional process of observation combined with new and emerging tools now allow for earlier diagnosis that will translate into improved outcomes.

Critical review of lymphomatoid papulosis of the oral cavity with case report.

A 60-year-old woman was referred to the Department of Dental Medicine at Long Island Jewish Medical Center for evaluation of multiple lesions of the tongue. She reported a long history of recurrent papular cutaneous eruptions that waxed and waned. A biopsy specimen of one of the cutaneous lesions was diagnosed as lymphomatoid papulosis. Sporadic, recurrent oral ulcers that resolved spontaneously were noted 10 to 14 days before the initial visit. These ulcers had recurred for the past 17 years. The most recent oral lesion was an erythematous, irregular, solitary ulcerated area on the middle third dorsum of tongue. The area quickly enlarged, ultimately developing extensive surface necrosis. Shortly after, a similar lesion on the posterior dorsum of the tongue developed. Biopsy specimens of the former lesion showed numerous, large, atypical, pleomorphic, and hyperchromatic cells with abundant mitoses. The large, atypical cells were immunohistochemically proven to be T lymphocytes. A diagnosis of lymphomatoid papulosis was made. Two weeks later, the tongue lesions had spontaneously and totally resolved. The clinical, histomorphologic, and immunohistochemical features, as well as gene rearrangement studies of this rare entity, are presented.

Oral precancer and cancer: etiology, clinical presentation, diagnosis, and management.

Oral and oropharyngeal cancers represent 3% of all cancers in the United States annually, with nearly 50% of people diagnosed with oral and oropharyngeal cancers dying as a result of the disease. Because the dental practitioner is in an ideal position for recognizing any abnormality of the oral mucosa, he or she is involved in the battle against oral cancer by helping establish the diagnosis at an early stage. This article presents the clinical appearance, explains the origins, and describes steps for the management of oral precancer and cancer.

Improving detection of precancerous and cancerous oral lesions. Computer-assisted analysis of the oral brush biopsy. U.S. Collaborative OralCDx Study Group.

BACKGROUND: A study group composed of researchers from across the United States undertook a study to evaluate the sensitivity and specificity of OralCDx (OralScan Laboratories Inc.), a computer-assisted method of analysis of the oral brush biopsy, in the detection of precancerous and cancerous lesions of the oral mucosa. METHODS: The study group conducted a multicenter double-blind study comparing results of OralCDx analysis with those of scalpel biopsy of suspicious oral lesions, as well as using OralCDx on oral lesions that appeared benign clinically. RESULTS: In 945 patients, OralCDx independently detected every case of histologically confirmed oral dysplasia and carcinoma (sensitivity = 100 percent, false-negative rate = 0 percent). Every OralCDx "positive" result was subsequently confirmed by histology as dysplasia or carcinoma. The specificity for the OralCDx "positive" result was 100 percent, while the specificity for the OralCDx "atypical" results was 92.9 percent. In 4.5 percent of clinically benign-appearing lesions that would not have received additional testing or attention other than clinical follow-up, OralCDx uncovered dysplasia or carcinoma (statistical sensitivity > 96 percent, P < .05, n = 131; statistical specificity for the OralCDx "positive" result > 97 percent and for the "atypical" result > 90 percent, P < .05, n = 196). CONCLUSIONS: The authors propose that this multicenter trial demonstrates that OralCDx is a highly accurate method of detecting oral precancerous and cancerous lesions. OralCDx can aid in confirming the nature of apparently benign oral lesions and, more significantly, revealing those that are precancerous and cancerous when they are not clinically suspected of being so. All OralCDx "atypical" and "positive" results should be referred for scalpel biopsy and histology to completely characterize the lesion. CLINICAL IMPLICATIONS: Given the difficulty in clinically differentiating premalignant and malignant lesions from benign lesions with a similar appearance, OralCDx appears to determine the significance of an oral lesion definitively and detect innocuous-appearing oral cancers at early, curable stages.

Heterotopic oral gastrointestinal cyst: report of 2 cases and review of the literature.

Oral heterotopic gastrointestinal cyst is a rare entity occurring in infants and children and showing a predilection for males. The cyst usually appears as an asymptomatic swelling in the floor of the mouth. Difficulty in feeding, swallowing, respiration, and speech have been reported in approximately 30% of those affected. The tongue-in particular, its anterior aspectis involved in up to 60% of reported cases. The clinical, radiographic, and histopathologic features of cases of heterotopic gastrointestinal cyst involving the anterior tongue in a 2-year-old girl and the anterior floor of the mouth in a 2-month-old boy are presented, and theories of pathogenesis are discussed.