A long-term follow-up study on the natural course of oral leukoplakia in a Swedish population-based sample.

AIM: To assess the natural course of screening-detected oral leukoplakia (OL) among non-consulting individuals. METHODS: A cohort of 555 individuals with OL, confirmed in 1973-1974 during a population-based survey, were followed through January 2002 via record linkages with nationwide and essentially complete registers. A sample of 104 drawn from the 297 surviving cohort members who still were living in the area in 1993-1995 was invited to a re-examination. Sixty-seven of them attended. RESULTS: At the time of re-examination OL had disappeared in 29 (43%) individuals. There was a statistically significant association between cessation of/no smoking habits in 1993-1995 and the disappearance of OL. Never/previous daily smokers were thus over-represented among individuals whose OL had disappeared compared to those with persisting OL [n = 23 (82%) vs. n = 18 (47%), P < 0.01]. Eighteen (78%) of the twenty three non-smokers with disappearing OL had quit after the initial examination. One man and two women developed oral cancer during follow-up while 0.7 and 0.07, respectively, were expected. CONCLUSION: Smoking cessation was associated with an increased disappearance of OL. Hence, at least one-fourth had lesions that could be classified as tobacco-related. Small observed and expected numbers prohibited firm conclusions about a possible excess risk of developing oral cancer.

On the natural course of oral lichen lesions in a Swedish population-based sample.

OBJECTIVES: The aim was to assess the natural course of oral lichen lesions (OLL) among unselected, non-consulting individuals. SUBJECTS AND METHODS: A cohort of 327 subjects with OLL, confirmed in 1973-1974 during a population-based survey in two Swedish municipalities, was followed through January 2002 via record linkages with nationwide and essentially complete registers. A sample of 80 drawn from the 194 surviving subjects who still resided in the area in 1993-1995 was invited for interview and oral re-examination. RESULTS: At the end of follow-up, one case of oral cancer was detected, while 0.4 were expected. The overall mortality among subjects with OLL was not significantly different from that in the 15,817 OLL-free subjects who participated in the initial population based survey in 1973-1974. The lesion had disappeared in 14 (39%) of 36 re-examined subjects with white OLLs in 1973-1974, and four (11%) had transformed into red types. In the corresponding group of 19 with red forms initially, five (26%) had become lesion free and four (21%) had switched to white types. Although the cohort size does not permit firm conclusions regarding oral cancer risk, the natural course over up to 30 years appears to be benign in the great majority.

Prognostic significance of HIV-associated oral lesions and their relation to therapy.

The oral manifestations of HIV infection have been considered to be of value in assessing disease progression in the developed world. However, the potential use of oral lesions as prognostic markers in resource-poor countries has yet to be fully investigated. There is reasonably compelling evidence in the developed world for an association between oral lesions and viral load. However, the true nature of this association is less clear and there are few data available from the developing world. With the introduction of HAART, a change in prevalence of the oral manifestations of HIV infection has been observed, including regression of oral candidiasis, Kaposi's sarcoma and oral hairy leukoplakia. However, oral condylomata and herpes simplex virus infection appear to persist with HMRT therapy. Further research in partnership with resource-poor countries is required to document disease progression and the associated oral lesions in both adults and children.

Oral leukoplakia: a proposal for uniform reporting.

Leukoplakia is the most common precancerous lesion of the oral mucosa. In order to promote uniform reporting of management results, including the event of malignant transformation, recommendations have been made for the various definitions and terminologies, including the application of a certainty factor with which the diagnosis of oral leukoplakia has been established. For reporting purposes there seems to be no rationale for distinguishing "tobacco-associated" leukoplakias from non-tobaccco-associated, so-called idiopathic leukoplakias. The recommendation has been made to use a classification and staging system in which the size and the histopathologic findings are reflected. At present, there seems to be no justification to give a weighting factor to the oral subsite of leukoplakias.

Interobserver and intraobserver variability in the clinical assessment of oral lichen planus.

BACKGROUND: In 1978, a clinical definition of OLP was formulated by the WHO. To date, the validation results of this clinical definition have not been published. The aim of this study was to evaluate interobserver and intraobserver variability in the clinical assessment of oral lichen planus (OLP). METHODS: Four clinicians examined a set of 159 clinical pictures of a white lesion in a group of 60 patients. Each reviewing examiner was asked to apply the WHO definition of OLP from 1978, and to categorise each case as either: (i) diagnostic of OLP, (ii) other definable lesion, or (iii) leukoplakia. After three months, each of the four reviewing clinicians was given the clinical pictures of 45 randomly retrieved cases from the original 60. Interobserver and intraobserver variability were assessed by calculation of unweighted kappa statistics. RESULTS: Interobserver agreement varied from 0.43 (moderate) to 0.77 (substantial), while the intraobserver agreement varied from 0.62 (substantial) to 0.92 (good). CONCLUSIONS: Although the clinical WHO definition of OLP seems to be more reproducible than the histopathological one, there is still a significant amount of subjectivity in using this definition. A set of clinical and histopathological diagnostic criteria with good interobserver and intraobserver agreements (kappa values > 0.8) is very important in enabling reproducible and reliable studies on OLP to be performed.

Hypersensitivity of the oral mucosa: clinics and pathology.

Hypersensitivity reactions of the oral mucosa comprise an array of clinical manifestations. Some of the reactions are difficult to differentiate from toxic reactions. Hypersensitivity reactions of type I, type III, and type IV are well known, although, especially for types I and III, they are rarely encountered. Type-I reactions are most frequently seen related to application of polymers in the oral cavity, such as orthodontic bonding and fissure sealant materials. There may also be systemic manifestations such as urticaria. Type-IV reactions may be seen related to most dental materials used, from amalgam and gold to polymers. These reactions appear as chronic reddening and/or ulceration of the oral mucosa. Lichenoid reactions have histopathological characteristics compatible with type-IV hypersensitivity reactions and are the most prevalent material-adverse reactions seen in the oral cavity. A special variety inside the lips with multiple papules and/or diffuse redness has recently been identified. This lesion comprises a serious treatment challenge. Skin patch tests, applying a series of dental materials in non-toxic concentrations on the skin, have been used to identify sensitization. However, the value of those tests can be questioned. Exacerbation of geographic stomatitis may be another form of hypersensitivity to dental materials.

[Crohn disease of the oral cavity, illustrated by some cases]. / Crohns sykdom i munnhulen, belyst med noen kasuistikker.

BACKGROUND: We have several times experienced that Crohn's disease has not been diagnosed until several years after the start of oral symptoms. This article presents some patients with oral manifestations of Crohn's disease, as a contribution to more awareness of this possibility. MATERIAL AND METHODS: Clinical and histological data from four patients are presented. RESULTS: All patients had granulomatous inflammation of the oral mucosa. In three patients, the disease started in the mouth. The diagnosis of intestinal Crohn's disease was made from some months up to seven years later. In one patient, no granuloma was found in the intestinal tract, but the patient had intestinal symptoms. Two patients experienced disappointments in their contacts with the local health care system, with considerable delay in diagnosis. INTERPRETATION: We interpret these cases as evidence that a greater awareness of the possibility of Crohn's disease in the oral cavity may lead to a quicker diagnosis, earlier correct treatment, and less patient worry caused by uncertainty.

Oral and ocular sicca symptoms and findings are prevalent in systemic lupus erythematosus.

The aims of this study were 1) to examine the frequency of oral and ocular sicca symptoms in patients with systemic lupus erythematosus (SLE); 2) to compare saliva and tear volume, salivary proteins, and features of the oral microflora and mucosa to a matched healthy control group; and 3) to relate the findings to disease parameters. Median disease duration was 5.5 (0.5-28) years, disease activity 5 (2-20), damage score 1 (0-7), and Schirmer I test 7.5 (0-30 mm). Seventeen and twelve patients complained of oral and ocular dryness, respectively. Unstimulated whole saliva and proline-rich proteins in submandibular saliva were significantly reduced in SLE. Oral microbial counts were generally higher in the patients than controls, and the number of oral mucosal changes was increased. The results show that sicca symptoms, although frequent, were not correlated to secretory rates of saliva or tears, but to oral microbial counts. There was no obvious correlation to patient's age, disease activity or duration.

Sicca symptoms, saliva and tear production, and disease variables in 636 patients with rheumatoid arthritis.

OBJECTIVES: (1) To estimate the prevalence of ocular and oral sicca symptoms (SISY) or reduced saliva and tear production; (2) to relate SISY and sicca signs to measures of disease activity, damage, and health status; and (3) to examine the relation between symptoms and objective signs of tear and saliva production in a large sample of representative patients with rheumatoid arthritis (RA). METHODS: From an unselective county RA register 636 patients (age 20-70 years) were examined with Schirmer-I test (ST), unstimulated whole saliva (UWS), questions on SISY and measures of disease activity, damage and health status. RESULTS: Ocular sicca symptoms were reported in 38%, oral sicca symptoms in 50%, and a combination of both in 27%. Reduced tear production was present in 29%, and reduced saliva production in 17%. The minimum frequency of secondary Sjögren's syndrome was 7%. Measurements of exocrine disease manifestations were to variable extents bivariately correlated to disease activity measures, physical disability, pain, fatigue, and use of xerogenic drugs, but were not related to deformed joint count. Multivariate analyses revealed significant associations between disease activity and reduced saliva production. Only weak associations between SISY and tear or saliva production were observed. CONCLUSION: SISY, reduced tear and saliva production were frequent extra-articular manifestations in RA, but were only weakly intercorrelated. High disease activity and at least two SISY were independent predictors of reduced saliva production, but ocular and oral dryness did not seem to be closely related to disease duration, disease activity, damage or health status.

Oral mucosal lesions associated with betel quid, areca nut and tobacco chewing habits: consensus from a workshop held in Kuala Lumpur, Malaysia, November 25-27, 1996.

A variety of betel/areca nut/tobacco habits have been reviewed and categorized because of their possible causal association with oral cancer and various oral precancerous lesions and conditions, and on account of their widespread occurrence in different parts of the world. At a recent workshop in Kuala Lumpur it was recommended that "quid" be defined as "a substance, or mixture of substances, placed in the mouth or chewed and remaining in contact with the mucosa, usually containing one or both of the two basic ingredients, tobacco and/or areca nut, in raw or any manufactured or processed form." Clear delineations on contents of the quid (areca nut quid, tobacco quid, and tobacco and areca nut quid) are recommended as absolute criteria with finer subdivisions to be added if necessary. The betel quid refers to any quid wrapped in betel leaf and is therefore a specific variety of quid. The workshop proposed that quid-related lesions should be categorized conceptually into two categories: first, those that are diffusely outlined and second, those localized at the site where a quid is regularly placed. Additional or expanded criteria and guidelines were proposed to define, describe or identify lesions such as chewer's mucosa, areca nut chewer's lesion, oral submucous fibrosis and other quid-related lesions. A new clinical entity, betel-quid lichenoid lesion, was also proposed to describe an oral lichen planus-like lesion associated with the betel quid habit.

Evaluation of a mucosal-plaque index (MPS) designed to assess oral care in groups of elderly.

An index, called the mucosal-plaque score (MPS), was tested for intra- and inter-examiner agreement at an institution for elderly individuals with mental disabilities. This index was designed to evaluate oral health and oral hygiene in groups of individuals, particularly in hospitals or at other institutions. MPS consists of the sum of a four-point mucosal score (MS) and a four-point plaque score (PS). Intra-examiner agreement was assessed for one dentist (BMH), who examined 24 individuals twice with a one-week interval. Weighted kappa values were 0.60 for MS, 0.62 for PS, and 0.62 for MPS. Inter-examiner agreement between two dentists was conducted by duplicate examinations on 20 persons. Weighted kappa values were 0.47 for MS, 0.71 for PS, and 0.70 for MPS. In a second assessment of inter-examiner-agreement, eight individuals were each examined by a dentist, two dental hygienists, and one medical nurse. Weighted kappa values were 0.79 for MS, 0.80 for PS, and 0.77 for MPS. These results support the conclusion that the MPS can serve as a reliable measure for the assessment of oral health care in groups of older individuals.

A long-term follow-up of allergy to nickel among fixed prostheses wearers.

Skin allergic hypersensitivity to nickel is well known and well documented in the professional literature. Sixteen partially dentate patients with long-standing histories of recurrent hypersensitive skin reaction to nickel were entered into a clinical trial in 1979. All the patients received crowns or bridges made of an alloy containing 66% of nickel with porcelain fused to the metal framework. During the first three years, annual clinical dental and dermatological investigations were performed on all the subjects, including repeated patch tests. Follow-up examinations took place in 1988 and 1994. None of the subjects had any mucosal or systemic reaction following oral exposure to the nickel containing alloy, nor the exacerbations of skin lesions.

A national epidemiological survey of oral mucosal lesions in Malaysia.

The prevalence of oral mucosal lesions in Malaysia was determined by examining a representative sample of 11,707 subjects aged 25 years and above throughout the 14 states over a period of 5 months during 1993/1994. A two-stage stratified random sampling was undertaken. A predetermined number of enumeration blocks, the smallest population unit in the census publication, was selected from each state. With the selected enumeration block, a systematic sample of living quarters was chosen with a random start. The survey instrument included a questionnaire on sociodemographic characteristics and a clinical examination. The clinical examination was carried out by 16 specially trained dental public health officers and the diagnosis calibrated with a final concordance rate of 92%. The age in the sample ranged from 25 to 115 years with a mean of 44.5+/-14.0. The sample comprised 40.2% males and 59.8% females; 55.8% were Malays, 29.4% Chinese, 10.0% Indians and 1.2% other ethnic groups. Oral mucosal lesions were detected in 1131 (9.7%) subjects, 5 (0.04%) had oral cancer, 165 (1.4%) had lesions or conditions that may be precancerous (leukoplakia, erythroplakia, submucous fibrosis and lichen planus) and 187 (1.6%) had betel chewer's mucosa. The prevalence of oral precancer was highest amongst Indians (4.0%) and other Bumiputras (the indigenous people of Sabah and Sarawak) (2.5%) while the lowest prevalence was amongst the Chinese (0.5%).

Characteristics of rheumatoid arthritis patients with self-reported sicca symptoms: evaluation of medical, salivary and oral parameters.

OBJECTIVES: To examine the prevalence of sicca symptoms in rheumatoid arthritis (RA)-patients, and to evaluate medical, salivary, and oral parameters in matched subgroups of patients with and without sicca symptoms as well as in healthy controls. PATIENTS AND METHODS: The prevalence of self-reported sicca symptoms was examined by a postal questionnaire in a representative cohort of RA-patients (n = 105, aged 52-74 years, disease duration 10-20 years, 77% females, 56% RF-positive). Patient subgroups and controls (9-10 in each group) underwent examinations of disease activity, blood analyses, tests of tear and salivary secretion, and examination of oral mucosa and microflora. Analyses of salivary acidic proline-rich proteins (PRPs), statherin and histatins were performed. RESULTS: One or more sicca symptoms were reported by 65% of RA-patients. Sicca patients (having > or = 4 sicca symptoms) had a more active and severe disease with higher scores for disability, fatigue and tender joints than patients without such symptoms. Other significant findings in the sicca group were lower values of unstimulated whole saliva, output of PRPs, statherin and histatins in submandibular saliva, and higher counts of oral Candida species. CONCLUSIONS: Sicca symptoms were prevalent in RA. Qualitative and quantitative salivary tests distinguished between sicca and non-sicca RA-patients, though overlap was considerable for some parameters.

Training examiners for a national epidemiological survey of oral mucosal lesions.

Ensuring the validity and reliability of data collected in epidemiological surveys is an important consideration. The purpose of the present report is to describe a training and calibration programme for 16 examiners taking part in a national survey of oral mucosal lesions and to present an evaluation of the results. The programme included the distribution of a pictorial manual to participants and a series of lectures followed by three diagnostic sessions, two using slides and the last involving patients. At the final session, the trainees classified 88 per cent of 16 patients correctly in comparison with the definitive diagnoses of the trainer, and their sensitivity on recording oral carcinoma, leukoplakia and lichen planus was at least 0.88. However, correctly classifying submucous fibrosis on the basis of slides alone proved problematic. At the conclusion, the diagnostic accuracy of two examiners for all types of lesion remained appreciably lower than the majority. Training strategies for various types of study are discussed. The method reported is considered to represent a model approach to training and calibrating examiners for this type of survey work.

Adverse reactions in the oral mucosa associated with anterior composite restorations.

This is a descriptive study of patients with symptomatic lichenoid-like reactions of the lips in contact with composite restorations (n = 12). Clinically, the lesions appeared as symptomatic single or multiple erythematous areas that included white papules. Candida was found by cultivation or histopathological examination in 7 of the lesions. Patch testing (n = 7) did not reveal any reactions to composite components, except for one patient who showed a delayed hypersensitivity reaction to formaldehyde. Replacement of existing dental materials parallel to antifungal treatment resulted in healing or significant improvement in 7 of 9 patients. This study shows that resin components can be associated with adverse reactions in the oral mucosa of the lips and that these reactions may be accompanied by an infection with Candida.

Oral white lesions with special reference to precancerous and tobacco- related lesions: conclusions of an international symposium held in Uppsala, Sweden, May 18-21 1994. International Collaborative Group on Oral White Lesions.

An international group of epidemiologists, clinicians and pathologists with a special interest in oral white lesions and their precancerous significance has reviewed earlier work on this topic and identified some of the problems associated with previous definitions, descriptions and classifications. Modifications to these definitions, descriptions and classifications have been proposed, accompanied by explanations of the reasons for identifying the need for changes to be made. Leukoplakia may be a provisional or definitive diagnosis dependent upon the circumstances of oral examination and the availability of other information. Guidelines are provided to assist in the application of the definitions of oral leukoplakia and illustrations depict the homogeneous and non-homogeneous clinical variants. Consideration is also given to the importance of a red component in a white lesion, or a lesion that is entirely red (erythroplakia). A new clinical staging procedure for oral leukoplakia is also proposed.