Lichenoid morphology could be an early feature of oral proliferative verrucous leukoplakia.

BACKGROUND: Recognition and differentiation of early forms of proliferative verrucous leukoplakia (PVL) could be a challenge to both clinicians and pathologists. OBJECTIVE: To report on a retrospective study that was carried out on 51 cases of PVL that were initially diagnosed as frictional keratosis, oral leukoplakia or oral lichen planus. A secondary objective is to report on the outcome of malignant transformation during follow-up. METHODS: Records of patients seen at an oral medicine clinic with the final clinical diagnosis of PVL were audited for early clinical and histopathologic features in their biopsy at first presentation, and for subsequent malignant transformation. RESULTS: Fifty-one patients (25 men and 26 women) with a mean age 51 years (men) and 53 years (women) at initial presentation were studied. 28% men and 11.5% women were current smokers. Initial clinical diagnoses were frictional keratoses (n = 4), Leukoplakia (n = 17) and lichen planus (n = 30). Epithelial dysplasia was reported in the initial biopsy in 12 cases and lichen planus/lichenoid features in 22 cases (22/51; 43%). Malignant transformation occurred in 11/51 patients (21.5%). CONCLUSION: Lichen planus or lichenoid lesions could be the initial presentation of many PVL cases that later develop multiple leukoplakic lesions with a final diagnosis of PVL.

Predicting malignant progression in clinically high-risk lesions by DNA ploidy analysis and dysplasia grading.

The value of image cytometry DNA ploidy analysis and dysplasia grading to predict malignant transformation has been determined in oral lesions considered to be at 'high' risk on the basis of clinical information and biopsy result. 10-year follow up data for 259 sequential patients with oral lesions clinically at 'high' risk of malignant transformation were matched to cancer registry and local pathology database records of malignant outcomes, ploidy result and histological dysplasia grade. In multivariate analysis (n = 228 patients), 24 developed carcinoma and of these, 14 prior biopsy samples were aneuploid. Aneuploidy was a significant predictor (hazard ratio 7.92; 95% CI 3.45, 18.17) compared with diploidy (p < 0.001). The positive predictive value (PPV) for severe dysplasia was 50% (95% CI 31.5, 68.5) and for aneuploid lesions, 33.3% (95% CI 19.0, 47.6). Combined DNA aneuploidy and severe dysplasia increased PPV to 56.3% (95% CI 31.9, 80.6). Diploid-tetraploid and non-dysplastic status had high negative predictive values (NPV) of 94.6% (95% CI 91.4, 97.8) and 99.17% (95% CI 97.4, 100.8) respectively. DNA ploidy predicts malignant transformation well and combining it with dysplasia grading gave the highest predictive value. The predictive values reported here exceed those from other investigations to date.

Oral Lichenoid and Lichen Planus-like Lesions.

Many red and white lesions of the mouth are clinically indistinguishable from those of oral lichen planus (OLP). These lesions, often referred to as oral lichenoid lesions (OLL), can occur as a result of contact sensitivity (lichenoid contact reactions), drug reactions or as part of chronic graft versus host disease (GVHD). Oral lesions in discoid lupus erythematosus (DLE) and systemic lupus erythematosus (SLE) can also have a similar clinical appearance to OLP. Distinguishing oral lichen planus from oral lichenoid lesions, lupus lesions, or other red and white lesions of the mouth can be difficult (even impossible) but it is important, for optimal management of each condition. All patients with red and white pathological lesions should be referred to an oral medicine or a local oral or maxillofacial surgery department, where a biopsy and other investigations can help to establish a diagnosis, and appropriate treatment and monitoring can be commenced. Dentists and other members of the dental team, such as hygienists and dental therapists, should also equip themselves with the knowledge to be able to explain different pathologies of the mouth to their patients and discuss risk factors.

Spontaneous Oral Mucosal Bleeding Unmasking Undiagnosed Sarcoidosis: A Case Report.

Sarcoidosis is a multisystem, non-caseating, chronic, granulomatous disease affecting any organ. In the head and neck region, salivary glands and lymph nodes are most commonly involved. Oral manifestations are rare but these lesions, occasionally haemorrhagic, may be the first sign of systemic disease. It is important to recognize the oral manifestations of sarcoidosis and to be aware of potential secondary disease-driven processes, such as thrombocytopenia. The purpose of this paper is to present a previously undiagnosed case of sarcoidosis, initially presenting with oral manifestations, including mucosal bleeding, and to review the current literature on oral sarcoidosis. Clinical relevance: Oral lesions can be the first sign of undiagnosed systemic sarcoidosis.

Oral lichenoid contact lesions to mercury and dental amalgam--a review.

Human oral mucosa is subjected to many noxious stimuli. One of these substances, in those who have restorations, is dental amalgam which contains mercury. This paper focuses on the local toxic effects of amalgam and mercury from dental restorations. Components of amalgam may, in rare instances, cause local side effects or allergic reactions referred to as oral lichenoid lesions (OLLs). OLLs to amalgams are recognised as hypersensitivity reactions to low-level mercury exposure. The use of patch testing to identify those susceptible from OLL is explored, and recommendations for removing amalgam fillings, when indicated are outlined. We conclude that evidence does not show that exposure to mercury from amalgam restorations poses a serious health risk in humans, except for an exceedingly small number of hypersensitivity reactions that are discussed.

Sensory purinergic receptor P2X3 is elevated in burning mouth syndrome.

Recent studies show that P2X(3) may play a role in neuropathic pain, including orofacial pain. Burning mouth syndrome (BMS) is a chronic neuropathic pain condition affecting 0.6-12% of post-menopausal women in the Western world. This study evaluates, for the first time, P2X(3) immunoreactivity levels in lingual mucosa in BMS patients. Patients diagnosed with BMS (n=9) in accordance with International Association for the Study of Pain criteria and patients attending for wisdom tooth removal (n=10, controls), were involved in this study. A pain history and score was recorded on a visual analogue scale (VAS) prior to obtaining a lingual biopsy. Immunohistochemistry and image analysis were used to quantify submucosal nerve fibres expressing P2X(3) and the structural marker neurofilaments. P2X(3) positive fibres were significantly increased in BMS compared with controls (p=0.024). In contrast, neurofilament-staining fibres were reduced in BMS, and when expressed as a ratio of the neurofilament percentage area, there was a trend for an increase of P2X(3) positive fibres in the BMS group. Increased P2X(3) immunoreactivity in the trigeminal sensory system may play a role in the symptoms observed in BMS. P2X(3) may therefore be a therapeutic target for treating BMS and trigeminal neuropathic pain.

Angioleiomyoma: an unusual diagnosis for a lump in the cheek.

Buccal swellings such as fibroepithelial polyps and granulomas are commonly seen in any oral diagnostic clinic, but occasionally an unusual mass presents. We describe a rare case of a man with a four-year history of a slowly enlarging, painless buccal mass that was confirmed histologically as an angioleiomyoma. Deep dissection to excise the mass completely caused no damage to nerves and there has been no recurrence.

An unusual primary presentation of myasthenia gravis.

This patient presented with progressive eating difficulties, having been originally investigated for mechanical gastroenterological problems. Fruitless examinations led to referral to a tertiary oral medicine unit and a detailed review of his history, where the significance of progressive fatiguability during and after mastication became apparent in his dysphagia. The insidious onset contrasted with his more rapid decline in function between the initial examination and specialist electromyographic investigations, neurological admission and management. The dangers of fatigue and pharyngeal incompetence are of particular relevance to oral and maxillofacial clinicians.