Role of medical history and medication use in the aetiology of upper aerodigestive tract cancers in Europe: the ARCAGE study.

BACKGROUND: The study aimed to investigate the role of medical history (skin warts, Candida albicans, herpetic lesions, heartburn, regurgitation) and medication use (for heartburn; for regurgitation; aspirin) in the aetiology of upper aerodigestive tract (UADT) cancer. METHODS: A multicentre (10 European countries) case-control study [Alcohol-Related CAncers and GEnetic susceptibility (ARCAGE) project]. RESULTS: There were 1779 cases of UADT cancer and 1993 controls. History of warts or C. albicans infection was associated with a reduced risk [odds ratio (OR) 0.80, 95% confidence interval (CI) 0.68-0.94 and OR 0.73, 95% CI 0.60-0.89, respectively] but there was no association with herpetic lesions, heartburn, regurgitation or medication for related symptoms. Regurgitation was associated with an increased risk for cancer of the oesophagus (OR 1.47, 95% CI 0.98-2.21). Regular aspirin use was not associated with risk of UADT cancer overall but was associated with a reduced risk for cancer of oesophagus (OR 0.51, 95% CI 0.28-0.96), hypopharynx (OR 0.53, 95% CI 0.28-1.02) and larynx (OR 0.74, 95% CI 0.54-1.01). CONCLUSIONS: A history of some infections appears to be a marker for decreased risk of UADT cancer. The role of medical history and medication use varied by UADT subsites with aspirin use associated with a decreased risk of oesophageal cancer and suggestive of a decreased risk of hypopharyngeal and laryngeal cancers.

Characteristics of patients with orofacial granulomatosis.

OBJECTIVES: Orofacial granulomatosis has mostly been described in reports of very small numbers of cases. Few large case groups have been described. The aim of this study was to describe the demographics, symptoms, clinical features and laboratory findings in a large cohort of cases. SUBJECTS AND METHODS: Clinical and laboratory data for 119 cases of orofacial granulomatosis who attended oral medicine clinics in Dublin, Ireland, were examined for demographic characteristics at the time of first presentation. The male/female ratio was approximately 1:1, with a median age (and range) of 28 (5-84) years. RESULTS: Symptoms had been present for a median duration of 12 weeks. A food association was suspected by 30% of patients. The predominant complaint was lip swelling (77%) with only 15% reporting facial swelling, while 8% complained of both. Almost all patients had clinical evidence of lip or facial swelling (95%). Other common extra-oral manifestations were lip fissuring (30%), angular cheilitis (28%) and perioral erythema (28%). Common intra-oral manifestations were cobblestoning of the buccal mucosa (63%), ulcers (36%), granulomatous gingivitis (33%), mucosal tags (29%) and fissured tongue (17%). Over half of the biopsies (56%) performed were reported as typical of orofacial granulomatosis. CONCLUSION: This is one of the largest cohorts of orofacial granulomatosis patients to have been described in detail.

Socioeconomic factors associated with risk of upper aerodigestive tract cancer in Europe.

INTRODUCTION: In the European Union, there are 180,000 new cases of upper aerodigestive tract (UADT) cancer cases per year--more than half of whom will die of the disease. Socioeconomic inequalities in UADT cancer incidence are recognised across Europe. We aimed to assess the components of socioeconomic risk both independently and through their influence on the known behavioural risk factors of smoking, alcohol consumption and diet. PATIENTS AND METHODS: A multicentre case-control study with 2198 cases of UADT cancer and 2141 controls from hospital and population sources was undertaken involving 14 centres from 10 countries. Personal interviews collected information on demographics, lifetime occupation history, smoking, alcohol consumption and diet. Socioeconomic status was measured by education, occupational social class and unemployment. Odds ratios (ORs) and 95% confidence intervals (CIs) were computed using unconditional logistic regression. RESULTS: When controlling for age, sex and centre significantly increased risks for UADT cancer were observed for those with low versus high educational attainment OR=1.98 (95% CI 1.67, 2.36). Similarly, for occupational socioeconomic indicators--comparing the lowest versus highest International Socio-Economic Index (ISEI) quartile for the longest occupation gave OR=1.60 (1.28, 2.00); and for unemployment OR=1.64 (1.24, 2.17). Statistical significance remained for low education when adjusting for smoking, alcohol and diet behaviours OR=1.29 (1.06, 1.57) in the multivariate analysis. Inequalities were observed only among men but not among women and were greater among those in the British Isles and Eastern European countries than in Southern and Central/Northern European countries. Associations were broadly consistent for subsite and source of controls (hospital and community). CONCLUSION: Socioeconomic inequalities for UADT cancers are only observed among men and are not totally explained by smoking, alcohol drinking and diet.

The reported prevalence of oral lichen planus: a review and critique.

OBJECTIVE: To examine all studies reporting prevalences of oral lichen planus (OLP) for epidemiological validity and to extract prevalence data from the valid papers. DESIGN: Computer based literature searches were carried out using the MeSH headings 'lichen planus, oral and (prevalence or incidence)' and were supplemented by manual searching. MAIN OUTCOME MEASURES: Each paper was examined for five criteria: clinic-based or population study, adequate demographic description (by sex and age group) of the population, adequate demographic description of the sample (if the population was sampled), adequate demographic description of the OLP cases identified, and histological confirmation of the clinical diagnosis. RESULTS: Forty-five relevant papers were identified, 21 clinic-based and 24 population studies. All but one of the population studies was deficient. One study, while having some defects, was probably sufficiently valid to permit the findings to be regarded as useful. An overall age-standardized prevalence of 1.27% (0.96% in men and 1.57% in women) can be calculated from this study. CONCLUSIONS: There appears to be only one usable prevalence study of OLP. Other large-scale studies are required in other populations. Such studies need to distinguish between OLP and lichenoid reactions.

Regional variations in oral cancer incidence in Ireland.

Oral cancer has anecdotally been held to have a regional distribution in Ireland, with higher incidence rates in western areas. The first all-Ireland data sets on oral cancer incidence rates were recently published by cancer registries in Northern Ireland and the Republic of Ireland, for the years 1994-1998 and 1994-1997 respectively. The objective of this study was to analyse these rates according to the 12 health administrative regions on the island of Ireland. All rates were standardised to the world population using standard methodology, and were examined separately for lip, intra-oral, salivary and pharyngeal cancers for men and for women. Rates were mapped to highlight any regional variations. In general, the anecdotal evidence for higher incidences in the west of Ireland has not been borne out, except for lip cancers in men, which in turn is reflected in the slight western preponderance in the distribution of all oral cancers. The incidences of intra-oral cancers in both men and women were highest in the regions that include the two large conurbations (Belfast and Dublin). We conclude that the anecdotal evidence for a higher incidence of oral cancer in the west of Ireland was probably based on the distorting effect of the high incidences of lip cancer in men in these regions.

Policies and practices of European dental schools in relation to smoking; a ten-year follow-up.

OBJECTIVE: To investigate the policies and practices of European dental schools in relation to smoking as a ten-year follow-up. DESIGN: A postal survey questionnaire. SETTING: European dental schools in 2003. MATERIALS AND METHODS: Two hundred and one European dental schools were identified from the DentEd database. A postal questionnaire was sent to each with up to three follow-up letters to non-responders. MAIN OUTCOME MEASURES: Results were tabulated and compared with the previous study (1993). RESULTS: The effective response rate (allowing for errors in the database) was 149 of 199 schools (72%). Eighty schools (59%) had written tobacco policies, 132 (92%) banned smoking in clinical areas, 127 (89%) in non-clinical areas and 122 (85%) in public access areas. One hundred and seven (76%) expected students to take tobacco histories from all patients, while 79 (69%) and 100 (70%) respectively taught students anti-smoking advice and expected them to give such advice. The number of schools teaching the role of tobacco in oral cancer aetiology was 133 (93%), in periodontal disease was 135 (94%) and in osseointegrated implant failure was 127 (91%). There was considerable regional variation between northern, southern and eastern Europe. Direct comparison of the responses of the 78 schools that replied in both 1993 and 2003 showed some improvements in most of their policies and practices. However, there was some deterioration in the practices of southern European schools. CONCLUSIONS: While improvements were seen in the practices of most schools, comparison with recent US data suggests that European schools lag behind. However, self-selection of respondents may have introduced bias into the results.

Periapical status and quality of endodontic treatment in an adult Irish population.

AIM: To determine the prevalence of apical periodontitis and the quality of root fillings in an adult Irish population using a retrospective analysis of orthopantomograms (OPGs). METHODOLOGY: A systematic sample of clinical records and OPGs of 302 adult patients attending the Dublin Dental Hospital, Ireland, were screened by two examiners to determine the quality of root canal treatment and the prevalence of apical periodontitis. The operators who carried out the treatment were unknown. Two examiners inspected OPGs after inter-examiner correlation. European Society of Endodontology (ESE) guidelines were used to determine adequacy of root treatment. RESULTS: Of the 7427 teeth examined 2% had root fillings. Apical periodontitis was evident in 1.6% of all nonroot filled teeth whilst 33.1% of the subjects had at least one tooth with apical periodontitis. Of the root filled teeth, 25% had apical periodontitis and 52.6% were considered technically inadequate by ESE guidelines. There was a statistically significant (P < 0.05) negative correlation between the quality of the root fillings and the prevalence of apical periodontitis. Posterior root filled teeth (premolars and molars) had a greater prevalence of apical periodontitis than anterior root filled teeth. CONCLUSIONS: The technical quality of root fillings in an adult Irish population was poor and was consistent with a high prevalence of apical periodontitis.

Personality of dental students in two dental schools in the United Kingdom and in Ireland.

The personality characteristics of students from two dental schools, one in the United Kingdom which admitted students using interviews, and one in Ireland which accepted students solely on examination results, were assessed using the short form of the Eysenck Personality Questionnaire. Results were compared with norms for age and sex. Personality scores of students from the Irish dental school were not significantly different from normal scores. Female and male students from the United Kingdom school scored higher than would be expected on extraversion, and male students from the same school scored lower than would be expected on neuroticism. The differences in personality between the two schools may be explained by the different methods of admission.

Patients' pain experience following oral mucosal biopsy under local anaesthesia.

OBJECTIVE: To examine the incidence and severity of post-operative pain and use of analgesics following biopsy of oral mucosal lesions. DESIGN: A patient survey using a self-completed pain diary. SUBJECTS AND METHODS: Seventy-six patients attending an oral medicine clinic for investigation of oral mucosal disease recorded overall and worst pain experiences and analgesic usage over 7 post-operative days following biopsy using visual analogue scales in patient completed diaries. RESULTS: One third of patients reported no post-operative pain on any day. Most patients recorded no pain or mild pain. The percentage experiencing pain dropped from the first day (61%) to the seventh day (21%). Most patients did not use any analgesics. Analgesic use was not related to the presence of pain. Only a small minority of patients recorded severe pain. CONCLUSION: Biopsy of oral mucosal lesions does not cause undue pain in most patients.

Lichen planus--specific antigen in oral lichen planus and oral lichenoid drug eruptions.

OBJECTIVE: To investigate the usefulness of lichen planus-specific antigen as a marker to distinguish idiopathic oral lichen planus from oral lichenoid drug eruptions. STUDY DESIGN: Biopsy samples were taken from 6 patients with oral lichenoid drug eruptions and 6 patients with idiopathic oral lichen planus. Each biopsy sample was examined for the presence of lichen planus-specific antigen by using a modification of a previously described immunofluorescence method that uses autologous serum and also allogenic sera from the remaining 11 cases. RESULTS: All autologous and allogenic immunofluorescence tests showed negative findings for lichen planus-specific antigen. CONCLUSIONS: Lichen planus-specific antigen is not a useful marker to distinguish oral lichenoid drug eruptions from idiopathic lichen planus. This finding is in contrast with our findings in an earlier study of basal cell cytoplasmic autoantibodies.

Patient satisfaction in an emergency dental clinic.

OBJECTIVES: Attendance at emergency clinics may be accompanied by extensive waiting times and frustration and may not result in patients obtaining the treatment which they expected. The objective of the study was to ascertain patient satisfaction with the overall provision of day time emergency services in a university dental teaching hospital, for quality assurance purposes. METHODS: Patients (or persons accompanying child patients) attending the clinic, selected according to a sampling frame designed to identify approximately 10 per cent of attendees, completed a questionnaire. RESULTS: High levels of patient satisfaction were found; 17 of 24 questions scoring satisfaction on a scale 1-5 had median scores of 5, six had median scores of 4 and one had a median score of 3. The lower scores related mostly to patient facilities rather than treatment. CONCLUSIONS: Overall patient satisfaction with their dental A & E experience has been extremely positive, probably attributable to a well motivated staff using a team approach.

Clinical management of oral lichen planus.

Oral lichen planus is a relatively common chronic disease of the mucous membranes which may have more transient cutaneous manifestations. It has a number of well-recognized clinical signs and a wide range of symptoms from none through mild discomfort to severe debilitating intra-oral erosions and ulceration. It often does not respond to treatment and, in a small proportion of cases, undergoes malignant transformation to squamous cell carcinoma. Although there is an array of treatments, they are palliative rather than curative. Corticosteroids in various forms remain the mainstay of treatment but newer immunomodulatory agents have an increasing role. In this paper, we review current thinking about the management of oral lichen planus and summarize a recent European consensus protocol.

Patient attitudes to glove use by dentists.

OBJECTIVE: To evaluate the attitudes of patients on the importance of glove wearing by dentists. DESIGN: A patient survey using a self-completed patient questionnaire. SETTING: Ireland. SUBJECTS AND METHODS: 164 consecutive patients attending a dental accident and emergency department were asked to participate. All the patients were aged 16 years or over. Of the surveyed patients, 157 completed a questionnaire designed to elucidate the patients' attitudes to the wearing of gloves by dentists. RESULTS: Most patients (93.6%; n = 147) considered that dentists should routinely wear gloves, while 1.9% (n = 3) thought the wearing of gloves was unnecessary. 94.9% (n = 149) considered that gloves were worn to protect both the dentist and the patient, with 1.9% (n = 3) feeling that only the dentist was protected. 72% of patients (n = 113) would not attend a dentist who did not wear gloves. 87.2% (n = 138) of patients thought that the dentist should change gloves between patients, while 1.3% (n = 2) considered glove washing to be sufficient. The remaining 11.4% (n = 17) felt that this decision should be left to the dentist. CONCLUSION: The majority of surveyed individuals indicated that dentists should wear gloves while treating patients. The results suggest that many patients refuse to have dental treatment carried out by a dentist who does not wear gloves.

Levels of dangerousness: an analysis of Irish dentists' clinical responses to HIV-seropositive patients.

Work conducted in the mid-1980s suggested that dentists in the Republic of Ireland felt uncomfortable about treating patients who were HIV-seropositive. It seemed that with greater understanding of the behaviour of the virus, dentists' attitudes would be modified accordingly. The aim of this study was to assess the reactions of Irish dentists to the treatment of HIV-positive patients. All dentists currently on the register were sent a questionnaire to assess their knowledge, attitudes and clinical behaviours. Over 60% of dentists responded. The study highlights dentists' responses to HIV infection suggesting that they are fearful of the virus. They perceive HIV as dangerous to themselves, their other patients and their practice. The findings indicate that attitudes relating to dangerousness remain a significant obstacle in the treatment of this patient group.

Oral lichenoid drug eruptions.

OBJECTIVES: To identify, from amongst drugs reported as causing lichenoid drug eruptions, those affecting the oral mucous membranes and to review the clinical, histological and immunological features of such oral lichenoid drug eruptions in comparison to oral lichen planus, amalgam contact lesions and lichen planus-like eruption in graft-versus-host disease (GVHD). DATA SOURCES: Ovid Medline data searches on CD-Rom were carried out for the years 1966-1996 to identify reports of oral lichenoid drug eruptions and their clinical, histological and immunological features. Articles retrieved were examined for further appropriate references in the period 1940-1996. DATA EXTRACTION AND SYNTHESIS: Each paper was critically examined for evidence of a clinically verifiable lichenoid drug-eruption affecting the oral mucous membranes and the effects of subsequent drug withdrawal. Available clinical, histological and immunological features were recorded. The papers examined were too diverse in nature to permit a structured criticism. The extracted data have been tabulated where appropriate. CONCLUSIONS: The reports of oral lichenoid drug eruptions are considerably fewer than those of cutaneous eruptions and fewer drugs have been reported as causing oral rather than cutaneous lichenoid eruptions. Histology and immunology cannot be used reliably to differentiate lichenoid drug eruptions from idiopathic lichen planus, amalgam contact lesions and lichen planus-like eruption in GVHD. Lichenoid drug eruptions may also show some histological characteristics of oral discoid lupus erythematosus. An accepted protocol agreed by a number of international centres would permit the gathering of substantial information on LDE and could lead to a greater understanding of the mechanisms involved.

Expression of CD1 and HLA-DR by Langerhans cells (LC) in oral lichenoid drug eruptions (LDE) and idiopathic oral lichen planus (LP).

Numbers of Langerhans cells (LC) expressing the common thymocyte antigen (T6/CD1) are similar in oral lichen planus (LP) and in normal oral epithelium; however, expression of class II major histocompatibility antigens (HLA-DR/Ia) by Langerhans cells is greater in lichen planus than in normal epithelium, a phenomenon believed to be associated with activation and antigen presentation. This study quantified the numbers of T6+ve and HLA-DR + ve Langerhans cells in oral lichen planus and lichenoid drug eruptions (LDE) to investigate whether differences may reflect differing routes of antigen presentation. Six patients with oral lichenoid drug eruptions and six control idiopathic oral lichen planus patients had lesional biopsies. An immunoperoxidase technique was used to demonstrate binding of T6 and HLA-DR antibodies to identify dendritic intraepithelial cells as Langerhans cells and activated Langerhans cells, respectively. In lichenoid drug eruptions, the number of HLA-DR + ve LC was significantly lower than the number of T6 + ve LC (P < 0.05), whereas in idiopathic lichen planus the numbers of T6 + ve and HLA-DR + ve LC did not differ significantly (P = 0.20). The results provide evidence for differences in the routes of antigen presentation in lichenoid drug eruptions and idiopathic lichen planus.

Uremic stomatitis mimicking oral hairy leukoplakia: report of a case.

Report on an unusual case of uremic stomatitis mimicking oral hairy leukoplakia. The similarities of the two lesions are discussed, and the differential diagnosis reviewed.