Concept, diagnosis and classification of bisphosphonate-associated osteonecrosis of the jaws. A review of the literature.

BACKGROUND: Bisphosphonates (BPs) and other antiresorptive agents such as denosumab are widely prescribed for the treatment of osteoporosis and are also used in patients with multiple myeloma and metastatic breast or prostate cancer for avoiding bone reabsorption and fractures that result in increased morbidity-mortality among such individuals. MATERIAL AND METHODS: We made a bibliographic search to analyze the concept, diagnosis and the different classifications for bisphosphonate-associated osteonecrosis of the jaws. RESULTS: Osteonecrosis of the jaws (ONJ) is an important complication of exposure to BPs or other antiresorptive agents, and although its prevalence is low, it can pose management problems. The definition, diagnosis and classification of osteonecrosis have evolved since Marx reported the first cases in 2003. CONCLUSIONS: The present study offers a literature review and update on the existing diagnostic methods and classification of the disorder, with a view to facilitating earlier and more effective treatment.

Erythema multiforme: diagnosis, clinical manifestations and treatment in a retrospective study of 22 patients.

BACKGROUND: Erythema multiforme (EM) is an acute disorder of the skin and mucosal membranes manifesting in the oral cavity (60-70% of all patients) as polymorphic erosive, ampullar, and bloodstained crusts. The etiology is unclear, although an autoimmune mechanism is involved. Infections and drugs have been implicated in the etiopathogenesis. With the exception of corticosteroids, no specific treatment for EM is available. METHODS: Data were collected on the clinical manifestations, antecedents of viral infection, and the use of drugs substances as possible etiological factors, treatment, and response to topical and systemic corticotherapy. RESULTS: A total of 22 patients were studied (14 males and 8 females), with a mean age of 47±20.4 years. A relationship was clearly suspected between drug use and lesion outbreak in 6 patients (27.2%). On the contrary, in 7 patients (31.8%) the triggering factor could have been herpes virus infection (herpes labialis). One half of the patients (11 cases) were classified as presenting minor EM, 36.4% (8 cases) presented major forms of the disease, and 13.6% (3 cases) were classified as corresponding to Stevens-Johnson syndrome. Systemic and/or topical corticosteroids proved effective in controlling the outbreaks in all of our patients. CONCLUSION: The oral mucosa is the most affected mucosal region in EM, with a predilection for the lip mucosa, erosive forms and bloodstained crusts. Systemic corticosteroids are effective in controlling the outbreaks, although their use as maintenance therapy is not clearly indicated.

Peripheral ameloblastoma.

A 73-year-old male ex-smoker of 10 cigarettes/day (up until 10 years ago) with a history of hypertension treated with Diovan 80 (Valsartan) was referred by his dentist. For the past 6 months the patient has presented an ulcer located in the right retromolar trigone region. In the last 2 months the patient has used chlorhexidine rinses, and is not wearing his dentures; the lesions fail to heal, however. Intraoral examination showed an ulcer in the right retromolar trigone area (Fig. 1-2), with a fibroelastic consistency. No regional lymph nodes were palpable. A panoramic X-ray study (Fig. 3), biopsy (Fig. 4-6) and CT exploration were requested.

Lichen sclerosus et atrophicus manifesting with localized loss of periodontal attachment.

Lichen sclerosus et atrophicus (LSA) is a chronic mucocutaneous inflammatory disorder of uncertain aetiology that is clinically characterized by the appearance of well delimited white plaques or papules, preferentially affecting the skin and genitals, and more rarely the oral cavity. We present the case of a woman with LSA limited to the oral cavity in the form of a well delimited, flat whitish lesion affecting the vestibular gingiva of the right upper incisors and left central incisor, and extending towards the vestibular fundus and frenulum of the upper lip. Widening of the periodontal space was observed, with gingival recession and attachment loss limited to these teeth. Local corticosteroid injections caused the mucosal lesion but not the periodontal alterations to resolve. Emphasis is placed on the importance of knowledge of this condition in relation to establishing a diagnosis, and on its periodontal repercussions.

Retinoids: application in premalignant lesions and oral cancer.

Squamous cell carcinoma (SCC) of the oral cavity is a multistep process, progressing through a series of discrete, irreversible and complementary alterations in genes that control cell growth, death, and differentiation. In the premalignant state, the oral mucosa progresses through various grades of epithelial dysplasia, with the potential to convert to SCC. Natural and synthetic vitamin A metabolites and analogs (retinoids) were found to suppress head and neck and lung carcinogenesis in animal models, and inhibit carcinogenesis in individuals with premalignant lesions and a high risk to develop cancer of the aerodigestive tract. Likewise, retinoids prevent the development of second primary cancers in head and neck and lung cancer patients who had been treated for the first primary. These effects are thought to result from changes in the expression of genes that regulate cell growth and differentiation. Chemopreventive strategies are designed to suppress, reverse, or prevent the formation of premalignant lesions and their subsequent progression to SCC. This is a review of the application of retinoids in the chemoprevention of head and neck cancer.

Renal hemodialysis patients: oral, salivary, dental and periodontal findings in 105 adult cases.

OBJECTIVES: A study of the dental, periodontal, oral mucosal and salivary condition of adult patients with chronic renal failure (CRF) receiving hemodialysis (HD). MATERIAL AND METHODS: A total of 105 patients on HD were studied, together with 53 healthy age and sex-matched controls. Indices employed included carious, absent and obturated teeth index (CAO index), plaque index, calculus index and loss of periodontal attachment. Whole and parotid salivary secretions were also measured. RESULTS: The CAO index was not significantly higher among HD patients than controls (14.9 +/- 8.7 vs 13.3 +/- 7.9, respectively; t = 1.1; P = 0.3). However, plaque and calculus indices were significantly higher in HD patients (2.1 +/- 0.8 and 2.3 +/- 0.6, respectively) than controls (1.3 +/- 0.8 and 1.6 +/- 0.9) (P < 0.001). Loss of periodontal attachment was similar in both groups (4.9 +/- 2.5 vs 4.2 +/- 2.5 in the HD patients and controls, respectively) (t = 1.8; P = 0.07). There was no more oral mucosal pathology in HD patients than in controls (chi-square = 5.8; P = 0.3). Stimulated salivary secretion was significantly higher in controls than HD patients for both whole (t = -5.2; P < 0.001) and parotid (t = -2.6; P = 0.01) salivas. CONCLUSIONS: The results show significantly higher plaque and calculus indices and lower salivary secretion among the HD patients than in healthy controls.