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)

Longitudinal Stability of Common TMJ Structural Disorders.

The longitudinal course of temporomandibular joint (TMJ) disc displacement (DD) and degenerative joint disease (DJD) has never been conclusively described with magnetic resonance imaging and computed tomography, respectively. This 8-y observational study's objective was to assess the longitudinal stability of DD and DJD among 401 subjects. The Validation Project provided baseline measures; follow-up was performed in the TMJ Impact Project. With magnetic resonance imaging, 2 radiologists rendered a consensus diagnosis of normal/indeterminate, DD with reduction, or DD without reduction. Computed tomography consensus diagnoses included normal/indeterminate, grade 1 DJD, or grade 2 DJD. Radiologist reliability was assessed by kappa; a Hui-Walter model was used to estimate, after accounting for diagnostic disagreement, the frequency of diagnostic progression and reversal. Permutation tests were used to test the statistical influence of concurrent baseline diagnoses on diagnostic changes at follow-up. Of 789 baseline joint-specific soft tissue diagnoses of DD, 598 (76%) joints showed no change; 109 (14%) demonstrated progression; and 82 (10%) had reversal. Of 794 joints with baseline joint-specific hard tissue diagnoses of DJD, progression was observed in 122 (15%) joints, no change in 564 (71%), and reversal in 108 (14%). Radiologist reliability (kappa) was 0.73 (95% CI, 0.64 to 0.83) for DD and 0.76 (95% CI, 0.68 to 0.83) for DJD. After accounting for the influence of diagnostic disagreement, progression of hard tissue diagnoses in the right TMJ occurred in 15.2% of subjects (95% CI, 10.5% to 20.8%) and reversal in 8.3% (95% CI, 4.9% to 12.3%); results were similar for soft tissue diagnoses and the left TMJ. Concurrent baseline soft tissue diagnoses were associated with hard tissue diagnostic changes at follow-up ( P < 0.0001). Baseline hard tissue diagnoses showed no statistical association with soft tissue changes at follow-up ( P = 0.11). Longitudinally, 76% of baseline TMJ soft tissue diagnoses and 71% of the baseline hard tissue diagnoses remained stable. Diagnostic reversal and progression were confirmed for both soft and hard tissues.

The coagulopathy and thrombotic risk associated with L-asparaginase treatment in adults with acute lymphoblastic leukaemia.

The dramatic improvements seen in the outcome of paediatric patients with acute lymphoblastic leukaemia (ALL) have led to increasing incorporation of L-asparaginase (L-Asp) in adult treatment protocols. However, its use is associated with a disruption in the physiological balance between haemostatic and anticoagulant pathways, with the predominant clinical manifestation being thrombosis. Although L-Asp therapy is known to be associated with an acquired deficiency of antithrombin (AT), the concurrent depletion of fibrinogen and other haemostatic proteins means that the precise mechanism of thrombosis remains to be defined. In vitro coagulation assays are often prolonged but thrombosis rather than haemorrhage is the primary concern. Management of thrombotic events in these patients is based around agents that rely on AT for their anticoagulant effect, even though it is usually depleted. There is currently only limited evidence supporting the use of AT concentrates in either primary prevention or management following an established event. Evidence-based guidelines for prevention and management strategies are lacking.

Reliability and validity of Axis I of the Research Diagnostic Criteria for Temporomandibular Disorders (RDC/TMD) with proposed revisions.

The research diagnostic criteria for temporomandibular disorders (RDC/TMD) have been employed internationally since 1992 for the study of temporomandibular muscle and joint disorders (TMD). This diagnostic protocol incorporates a dual system for assessment of TMD for Axis I physical diagnoses as well as Axis II psychological status and pain-related disability. Because the reliability and criterion validity of RDC/TMD had not yet been comprehensively characterised, the National Institute of Dental and Craniofacial Research funded in 2001 the most definitive research to date on the RDC/TMD as a U01 project entitled, 'Research Diagnostic Criteria: Reliability and Validity'. The results of this multi-site collaboration involving the University of Minnesota, the University of Washington, and the University at Buffalo were first reported at a pre-session workshop of the Toronto general session of the International Association of Dental Research on 2 July 2008. Summaries of five reports from this meeting are presented in this paper including: (i) reliability of RDC/TMD Axis I diagnoses based on clinical signs and symptoms; (ii) reliability of radiographic interpretations used for RDC/TMD Axis I diagnoses; (iii) reliability of self-report data used for RDC/TMD Axis I diagnoses; (iv) validity of RDC/TMD Axis I diagnoses based on clinical signs and symptoms; and (v) proposed revisions of the RDC/TMD Axis I diagnostic algorithms.

Oral topical doxepin rinse: analgesic effect in patients with oral mucosal pain due to cancer or cancer therapy.

Oral mucositis is a treatment limiting toxicity of cancer therapy. The purpose of this study was to assess the impact of doxepin oral rinse in the management of oral mucosal pain in cancer patients. Forty-one cancer patients with oral mucosal pain were provided a solution of doxepin (0.5%) for oral rinsing. Oral pain was assessed prior to rinsing, and following rinsing for 4 h using a visual analogue scale (VAS). Adverse effects were recorded. Doxepin rinse resulted in a reduction of pain intensity of more than 50%, with pain relief extending for more than 3 h with pain not returning to baseline 4 h after rinsing. The rinse was tolerated by patients with mucosal damage, and had acceptable taste, and infrequent mucosal stinging with use. Some patients reported sedation after use, likely due to systemic absorption. The results of this single dose trial suggest that topical doxepin rinse has significant ability to provide clinically significant pain relief in patients with mucosal damage with an extended duration of effect.

The roles of beliefs, catastrophizing, and coping in the functioning of patients with temporomandibular disorders.

Pain-related beliefs, catastrophizing, and coping have been shown to be associated with measures of physical and psychosocial functioning among patients with chronic musculoskeletal and rheumatologic pain. However, little is known about the relative importance of these process variables in the functioning of patients with temporomandibular disorders (TMD). To address this gap in the literature, self-report measures of pain, beliefs, catastrophizing, coping, pain-related activity interference, jaw activity limitations, and depression, as well as an objective measure of jaw opening impairment, were obtained from 118 patients at a TMD specialty clinic. Controlling for age, gender, and pain intensity, significant associations were found between (1) pain beliefs and activity interference, depression, and non-masticatory jaw activity limitations, (2) catastrophizing and activity interference, depression, and non-masticatory jaw activity limitations, and (3) coping and activity interference and depression. Controlling for age, gender, pain intensity, and the other process variables, significant associations were found between (1) beliefs and activity interference and depression, and (2) catastrophizing and depression. No process variable was associated significantly with the objective measure of jaw impairment. The results suggest that for patients with moderate or high levels of TMD pain and dysfunction, beliefs about pain play an important role in physical and psychosocial functioning.

Characteristics of dental emergency clinic patients with and without disabilities.

This study compared oral health and demographic characteristics of patients with and without disabilities at a dental school emergency clinic. Of 407 consecutive patients surveyed, 20.4% reported disabilities. Two groups matched by age and gender, those with disabilities (DIS, n = 79) and those without disabilities (ND, n = 177), were compared on questionnaire responses; two subgroups, DIS (n = 38) and ND (n = 44), were assessed clinically. The mean ages of the DIS and ND groups were 44.0 years (SD +/- 11.6) and 43.0 years (SD +/- 12.3), respectively. By chi-squared analysis, DIS vs. ND subjects had significantly lower levels of education, employment, income, and dental insurance, and greater dependence on Government funding. In the DIS group, 79.5% were not working, while 6.4% did work regularly. In the ND group, the corresponding values were 30.9% and 46.9%, respectively. In the DIS group, 51.9% identified Medicaid acceptance as the reason they sought care at the clinic, while 62.7% of the subjects in the ND group identified the lower fee structure as the reason for clinic selection. More DIS than ND subjects reported dentists' unavailability and inability to manage the disability, lack of transportation, effect of dental problems on health, and referral by a health professional. DIS vs. ND subjects had significantly fewer sound teeth and more missing teeth. The results suggest that one in five dental school emergency clinic patients has disabilities.

Temporomandibular disorders and science: a response to the critics.

This article was prepared by the above authors and submitted to members of the TMD academic community for their endorsement. A total of 120 people signed an endorsement; their names are available on request.

Comparison of clinical and magnetic resonance imaging diagnosis in patients with disk displacement in the temporomandibular joint.

OBJECTIVE: The purpose of this study was to validate the Research Diagnostic Criteria for Temporomandibular Disorders (RDC/TMD) for the diagnostic subgroup of disk displacement with reduction, with magnetic resonance imaging used as a gold standard. STUDY DESIGN: The diagnoses from the clinical examination of 78 joints in 39 patients, each with disk displacement with reduction in at least one TMJ, were compared with magnetic resonance imaging diagnoses. The readers of the magnetic resonance images were blinded to the clinical diagnoses. The data analysis included kappa statistics and calculation of predictive values. RESULTS: The predictive value of the RDC/TMD for disk displacement with reduction was 0.65. For disk displacement alone-the movement of the disk on opening not being considered-the predictive value was 0.92. The diagnostic agreement between RDC/TMD and magnetic resonance imaging diagnoses for all joints examined was 53.8%. Most of the disagreement was due to false negative clinical diagnoses for asymptomatic joints. CONCLUSIONS: A positive RDC/TMD examination is predictive for internal derangement but not reliable with regard to the type of disk displacement; such examination is therefore of limited value in determining the true disk position and its functional movements.

Diagnosis and management of dental erosion.

Early recognition of dental erosion is important to prevent serious irreversible damage to the dentition. This requires awareness of the clinical appearance of erosion compared to other forms of tooth wear. An understanding of the etiologies and risk factors for erosion is also important. These form the basis of a diagnostic protocol and management strategy that addresses the multifactorial nature of tooth wear. The primary dental care team has the expertise and the responsibility to provide this care for their patients with erosion.

Temporomandibular disorders and science: a response to the critics.

This article was prepared and submitted to members of the TMD academic community for their endorsement. A total of 120 people signed an endorsement; their names are available on request.

Comparison of incoming dental school patients with and without disabilities.

A survey of incoming dental school patients compared 64 adult patients (DECOD) and 73 patients without disability (ND), regarding past dental experience, current needs, and basis for selecting the school's clinics. The responses indicated that, for DECOD patients, clinic selection was based largely on Medicaid acceptance, staff experience, and inability of other dentists to manage their disability; for ND patients, selection was based on lower fee structure. Both groups expressed high treatment need, but the rate was lower for DECOD than for ND patients. More DECOD patients reported severe dental anxiety and adverse effects of dental problems on general health. Chart records revealed that clinical findings exceeded perceived need for both DECOD and ND patients. While both groups had high periodontal disease rates (91%), DECOD patients had significantly poorer oral hygiene and less restorative need than ND patients. The findings suggest differences between persons with disabilities and other patient groups in difficulty of access to dental services in the community, reasons for entering the dental school system, and in presenting treatment need and/or treatment planning.

Topical cyclosporine in a bioadhesive for treatment of oral lichenoid mucosal reactions: an open label clinical trial.

Oral lichenoid reactions may present as chronic symptomatic mucosal reactions. Lichen planus-like reactions include those associated with drug reactions, graft-versus-host disease after bone marrow transplantation, and idiopathic lichen planus. The mainstay of management is topical steroids; in resistant cases, topical and systemic corticosteroids may be used. We evaluated the use of cyclosporine administered in an adhesive hydroxypropyl cellulose base in patients with oral lichenoid reactions that remained active despite the prior use of high-potency topical steroids and in some cases despite the combined use of topical and systemic immunosuppression. Signs and symptoms of ulcerative oral graft-versus-host-disease improved more than 50% in three of four patients with oral graft-versus-host disease treated with the addition of topical cyclosporine. However, in patients with persistent oral lichen planus less effect was seen with 7 of 14 patients demonstrating a partial reduction in signs and symptoms. The topical use of cyclosporine in a bioadhesive base may represent a useful adjunctive approach in management of oral lichenoid reactions, although dose escalation and placebo-controlled studies are needed.

Identifying and treating HIV-related oral conditions: a clinical grand rounds approach.

The authors describe an innovative method for teaching dental professionals to differentially diagnose and treat HIV-related oral lesions. The method included a half day of didactic presentations and a half day of clinical grand rounds. The clinical grand rounds featured clinical stations where small groups of practitioners observed HIV oral manifestations and interacted with patients. Their observations were discussed with two dentists expert in diagnosing and managing oral complications of HIV. Videotapes of the patients' oral lesions augmented the discussions.

Chlorhexidine swabbing applications under various conditions of use in preventive oral care for persons with disabilities.

A sample of 44 adults with severe disabilities completed a randomized single-blind cross-over study testing chlorhexidine swabbing under various conditions: with/without prior dental prophylaxis, reduced frequency of application (2 vs. 5 times per week), and prolonged use (42 weeks). All subjects received therapeutic doses of 10 mL 0.12% chlorhexidine gluconate (Peridex, Procter & Gamble) and 10 mL 0.05% NaF applied with a Toothette (Sage Products). Clinical effectiveness of chlorhexidine swabbing compared with placebo was previously reported. In the present study, while initial benefits were observed to be independent of dental prophylaxis, significant reductions in periodontal scores were sustained by a combination of dental prophylaxis and swabbing protocol, at reduced frequency of application and over prolonged time. High levels of acceptance and compliance by subjects/caregivers were maintained. Subjects/caregivers reported improvements in dental health as well as in attitude, quality of life, and smile. Chlorhexidine swabbing at maintenance frequency, combined with periodic dental prophylaxis, may offer an effective and pragmatic long-term preventive regimen for persons with disabilities.

Histopathologic evaluation of proliferating cell nuclear antigen (PC10) in oral epithelial hyperplasias and premalignant lesions.

As the therapeutic options for malignant lesions expand, early accurate diagnosis of premalignancy is becoming increasingly important in the concept of cancer prevention. Because it has been hypothesized that abnormal cell proliferation is related to subsequent malignant transformation, many proliferation markers such as proliferating cell nuclear antigen have been studied in a variety of malignant tumors. In oral surface epithelium, proliferating cell nuclear antigen activity is restricted to basal layers of normal squamous mucosa. In this preliminary study, 169 formalin-fixed, paraffin-embedded oral epithelial lesions, including 28 carcinomas in situ, 82 epithelial dysplasias, 21 epithelial atypia, and 38 typical epithelial hyperplasias, were studied with a monoclonal antibody, PC10, to determine whether proliferating cell nuclear antigen suprabasal expression correlated with premalignancy. The findings revealed that with progression of lesions toward malignancy, there was a significant predilection for basal/suprabasal staining pattern for proliferating cell nuclear antigen as compared with the strictly basal staining pattern seen in normal and benign epithelial conditions. One unexpected staining pattern, suprabasal positive stain only, was also noted mostly in reactive hyperplasia and dysplasia. The data suggested that a positive basal/suprabasal staining pattern for proliferating cell nuclear antigen is indicative of premalignancy in oral epithelial lesions.

The chemotherapeutic management of chronic and persistent orofacial pain.

The use of medication in chronic orofacial pain is not without risk. It is important to be vigilant regarding side effects, including abuse. The treatment of chronic pain can be frustrating and confusing because most patients with pain experience remissions and relapses. The initial report of reduced pain by the patient to any of the treatments that have been attempted may lead to false optimism about the nature of the condition or the potential long-term response to medication. With time the patient may report a reduced response to the medication and suggest either a higher dose or a different medication. In such patients it is important to reexamine the original differential diagnosis. When in doubt, additional consultation with pain centers, other clinicians with experience in managing patients with chronic pain, and consultation with the patient's physician may be needed. If the patient develops an abnormal personality or behavioral profile, referral to a specialist in behavioral medicine may also be needed. The treatment of chronic benign pain should proceed as planned, being careful not to place the patient in an "at-risk position" regarding medications and their effects or side effects.

A comparison of oral health in spinal cord injury and other disability groups.

A controlled pilot study determined oral health in persons with quadriplegia due to spinal cord injury, and compared dental disease rates in spinal cord injury and other disability groups. Seventeen adults with spinal cord injury and 17 controls were assessed for dental/medical/social history; manual function; head, neck, and oral lesions; salivary flow; DMFS; and gingivitis, periodontal pockets, plaque, and calculus. Findings were compared with those from prior studies according to the same protocol, for groups of similar age with mental retardation, cerebral palsy, traumatic brain injury, and chronic mental illness. No significant differences between spinal cord injury and control subjects were noted, except that fewer spinal cord injury subjects brushed daily or flossed (p < 0.05); dependent subjects tended to have more plaque and gingivitis than those brushing independently. Subjects with spinal cord injury and mental illness had less gingivitis than those with mental retardation and cerebral palsy (p < 0.001); on calculus, subjects with spinal cord injury ranked lower than subjects with mental illness (p < 0.05). On DFS, mentally ill subjects and those with traumatic brain injury ranked higher than mentally retarded and cerebral palsy groups, with spinal cord injury subjects intermediate. Mentally retarded and traumatic-brain-injured subjects had fewer teeth than other groups (p < 0.05). The findings suggest differences in oral health status and oral care for various disabled populations.

Temporomandibular disorders: a survey of dentists' knowledge and beliefs.

General dentists and specialists likely to treat TMD were surveyed to gain information on their understanding of TMD causes, diagnosis and treatment. While the role of psychophysiologic factors in the etiology of TMD has been widely acknowledged in the practicing community, there is still a high level of controversy about the pathophysiologic aspects of TMD and appropriate diagnoses and treatment.