Oral premalignant lesions: is a biopsy reliable?

PURPOSE: The purpose of the present retrospective study was to learn whether a biopsy of oral premalignant lesions, leukoplakia and erythroplakia, shows histopathological findings representative of the whole surgically removed lesion. Moreover, to see whether histopathological characteristics of the whole lesion are significant for future malignant development after surgery. MATERIALS AND METHODS: A total of 101 lesions in 96 patients were included, 42 lesions (41%) being homogenous and 50 (50%) non-homogenous leukoplakias, whereas nine (9%) were erythroplakias. The lesions were biopsied and subsequently surgically removed on the average of 10.4 months after biopsy. Surgical specimens were examined in two or more step sections distributed throughout the specimen. The histological findings of the biopsies were compared with those of the whole lesions. After surgical intervention the patients were followed (mean 6.8 years, range: 1.5-18.6), and new biopsies taken in case of recurrences. Smokers (73%) were encouraged to quit smoking and candidal infections were treated. The possible influence of different variables on the risk of malignant development was estimated by means of logistic regression analysis. RESULTS: Histological examination of the whole lesions showed that seven lesions (7%) harboured a carcinoma and 70 lesions (69%) showed a degree of epithelial dysplasia or carcinoma in situ. Eleven lesions (12%) developed carcinoma after a mean follow-up period of 7.5 years. A comparison of the degree of dysplasia in the biopsies with that of the whole lesion demonstrated variation with concurrent diagnosis in 49% of the lesions and in 79% after inclusion of lesions with one degree up or down the scale of epithelial dysplasia. CONCLUSION: The estimated odds ratio showed that none of the associated variables including presence of any degree of epithelial dysplasia in the whole lesion, site, demarcation and smoking had influence on the risk of malignant development.

Long-term treatment outcome of oral premalignant lesions.

The purpose of the present retrospective study was to learn the long-term outcome of oral premalignant lesions, leukoplakia and erythroplakia, with or without surgical intervention and to relate the outcome to factors supposed to be significant for malignant development including clinical type, demarcation, size, site, presence of epithelial dysplasia, smoking and surgery. A total of 269 lesions in 236 patients were included. Ninety-four lesions were surgically removed, 39 lesions (41%) being homogenous and 46 (49%) non-homogenous leukoplakias whereas nine (5%) were erythroplakias. Seventy-three percent of the lesions were associated with tobacco habits. The mean size of the lesions was 486 mm(2), and 71% of the lesions showed a degree of epithelial dysplasia. After excision the defects were closed primarily by transposition of mucosal flaps or they were covered by free mucosal or skin grafts. A few defects were left for secondary healing. After surgical treatment the patients were followed (mean 6.8 yrs, range 1.5-18.6 yrs), and new biopsies taken in case of recurrences. One hundred and seventy five lesions had no surgical intervention, 149 lesions (85%) being homogenous and 20 (11%) non-homogenous leukoplakias, and 6 (3%) erythroplakias. Eighty-one percent of the lesions were associated with smoking. The mean size of the lesions was 503 mm(2) and 21 of the lesions (12%) exhibited epithelial dysplasia. Sixty-five lesions were not biopsied. These patients were also followed (mean 5.5 yrs, range 1.1-20.2 yrs), and biopsies taken in case of changes indicative of malignant development. All patients were encouraged to quit smoking and candidal infections were treated. The possible role of different variables for malignant development was estimated by means of logistic regression analysis. Following surgical treatment 11 lesions (12%) developed carcinoma after a mean follow-up period of 7.5 yrs. Non-homogenous leukoplakia accounted for the highest frequency of malignant development, i.e. 20%, whereas 3% of the homogenous leukoplakias developed carcinomas. Surgically treated lesions with slight, moderate, severe and no epithelial dysplasia developed carcinoma with similar frequencies, i.e. 9-11%. Without surgical intervention 16% of the 175 lesions disappeared whereas seven lesions (4%) developed carcinoma after a mean observation period of 6.6 yrs. The highest frequency of malignant development (15%) was seen for non-homogenous leukoplakias, this figure being 3% for homogenous leukoplakias. Fourteen percent of lesions with slight epithelial dysplasia developed malignancy and 2% of lesions with no dysplasia showed malignant transformation. Logistic regression analysis showed a seven times increased risk (OR = 7.0) of non-homogenous leukoplakia for malignant development as compared with homogenous leukoplakia and a 5.4 times increased risk for malignant development for lesions with a size exceeding 200 mm(2). No other examined variables including presence of any degree of epithelial dysplasia, site, demarcation, smoking and surgical intervention were statistically significant factors for malignant development.

Marginal bone level after Le Fort I osteotomy.

The object of the study was to assess the effect of Le Fort I osteotomy and maxillary interdental osteotomy on the marginal bone level. Forty patients (25 female, 15 male, mean age 24 years, range 15-46) treated for dentofacial deformities comprised the subjects of the study and underwent Le Fort I osteotomy with or without simultaneous interdental osteotomy. Outcome was measured by marginal bone level measured in radiographs before and 1 year after operation. All patients had good oral hygiene. There was an overall significant mean marginal bone loss of 0.2 mm at surfaces without interdental osteotomy (P = 0.001). When the bone loss of the different types of teeth was considered separately, only those of central incisors (0.5 mm, P = 0.0001) and canines (0.4 mm, P = 0.004) were significant. Interdental osteotomy caused an overall mean marginal bone loss of 0.4 mm, but this was not significantly different from that of teeth without interdental osteotomy (P = 0.07). When the bone loss of different types of teeth after interdental osteotomy was considered separately, the only difference that achieved significance was that of premolars (0.3 mm, P = 0.04). Though there were significant differences, none of them was large enough to have any clinical relevance. Le Fort I osteotomy and interdental osteotomy may only in a few instances cause marginal bone loss of clinical relevance. However, the present study was performed on patients with good oral hygiene. The above conclusions may therefore not be valid for patients who, prior to surgery, already have a compromised marginal bone level.

[Penicillin treatment of non-nosocomial pneumonia in Danish medical departments. A questionnaire]. / Penicillinbehandling af ekstranosokomielt erhvervet pneumoni på medicinske afdelinger i Danmark. En spørgeskemaundersøgelse.

This study describes the most common penicillin-regime for hospitalized patients with community-acquired pneumonia in Denmark. One hundred and seventy-one consultant physicians received an anonymous questionnaire, 85% were returned and 75% were evaluated. The most common regime is a treatment duration of six to ten days with 3-6 million IU of penicillin daily given in three doses. The most common route of administration is intravenously until the patient's body temperature drops. Then the same dose is given orally. Variations in strategy were revealed and call for further investigations to establish and maintain restrictive antibiotic regimes.

Human papillomavirus in oral premalignant lesions.

The aetiology of oral premalignant lesions is generally accepted to be multifactorial. Tobacco and alcohol are established as important cofactors in malignant development in the oral cavity, but in addition microorganisms, such as human papillomavirus (HPV), have gained much interest over the past decade. For many years, HPV has been accepted as an important cofactor in the development of cervical cancer, originating from a mucous membrane with similarities to the oral mucosa. 49 patients with oral premalignant lesions and 20 control patients with normal oral mucosa and no history of HPV infection were examined for the presence of HPV by immune histochemical staining using the peroxidase anti-peroxidase technique (PAP), DNA-DNA in situ hybridisation (ISH), and polymerase chain reaction (PCR) analysed by Southern blot hybridisation with an HPV 16 specific probe. The investigations revealed that HPV was found in 62.5% of the verrucous leucoplakias, 50.0% of the erythroplakias, 45.5% of the homogeneous leucoplakias, 33.3% of erythroleucoplakias and in 12.5% of the nodular leucoplakias. An overall HPV detection rate in the examined premalignant lesions was 40.8% and no patients in the control sample were positive. Concerning oral cancer development, it seems likely that HPV may be a cofactor, as 100% of patients who developed oral cancers within 4-12 years were all positive for HPV, one being positive for HPV 16.

[Laser therapy of Achilles tendinitis]. / Laserbehandling af akillessenetendinit.

The effects of low level laser treatment in soldiers with achilles tendinitis were studied in a prospective, randomized and double blind trial. Eighty-nine soldiers were enrolled in the study. Forty-six were randomized to treatment with active laser and 43 to treatment with placebo laser. No statistically significant differences in the number of consultations, morning stiffness, tenderness, crepitation, swelling, redness, VAS-score of pain and degree of unfitness for duty were found between the two treatment groups.

Pitfalls in orthognathic model surgery. The significance of using different reference lines and points during model surgery and operation.

The planning of orthognathic surgery usually involves a simulation of jaw movements in a semi-adjustable articulator. The use of vertical and horizontal references during model surgery and operation have previously been described in great detail. The purpose of the present study was to quantify the errors resulting from using different reference lines and points in model surgery and operation. The results indicate that clinically significant differences between the planned and surgical jaw movement can result from the erroneous transfer of reference lines and points between model surgery and operation. Solutions to some of the problems discussed are suggested.

Identification of capillaries in sections from skeletal muscle by use of lectins and monoclonal antibodies reacting with histo-blood group ABH antigens.

This study was performed to evaluate the application of different lectins and monoclonal antibodies against ABH antigens to detect and characterize carbohydrate structures in capillaries of skeletal muscle from humans and laboratory animals. Blood group specific lectins (Griffonia simplicifolia, Griffonia simplicifolia isolectin B4, Lotus tetragonolobus, Ulex europaeus, and Dolichos biflorus) and monoclonal antibodies reacting with histo-blood group carbohydrate antigens belonging to type 1 (Le(a)) and type 2 (H, A and Le(y)) chains were used as histological markers for capillaries in sections from skeletal muscle. The material consisted of 20 human masseter muscle biopsies from individuals with known blood types: (eight blood group O, nine blood group A, two blood group B, and one blood group AB) and masseter muscles specimens from different laboratory animals (mouse, rat, rabbit, cat, dog, pig, cow, and macaca monkey). Unfixed sections and an avidin alkaline phosphatase method were used to visualize the specific reaction. Ulex lectin stained capillaries in all human biopsies either strongly or moderately. Strong muscle capillary reaction was observed in biopsies from O, B and AB individuals while capillaries from A individuals were only moderately stained. Griffonia simplicifolia marked capillaries in A, B, and AB individuals and Griffonia simplicifolia isolectin B4 stained capillaries in muscle biopsies from B and AB donors. Dolichos biflorus was a weak marker of muscle capillaries from A individuals. Only capillaries from O individuals were stained with the antibody against H type 2. Capillary reaction was not observed with the other antibodies used. Girffonia simplicifolia was an excellent marker for capillaries in mouse muscle while Griffonia simplicifolia isolectin B4 is recommended for rat muscles.(ABSTRACT TRUNCATED AT 250 WORDS)

Mandibular autorotation in orthognathic surgery: a new method of locating the centre of mandibular rotation and determining its consequence in orthognathic surgery.

Rotation of the mandible is simulated through the centre of the condyle in planning orthognathic surgery. Previous studies have suggested that the initial mandibular movement is better characterized as multiple parts of the segments of a circle with the average centre located below and behind the centre of the condyle. This paper describes a method of locating the centre of mandibular rotation by computer-analysis of two lateral cephalograms with different degrees of opening. The method was used on 10 normal individuals showing an average centre of mandibular rotation 14.9 mm below and 5.0 mm behind the superior midsurface of the condyle for movements from occlusion to an opening of 10 mm. The implications of the located centre of rotation on orthognathic surgery was determined by simulating a closure of a 9.5 mm open bite. An error of up to 9.3 mm in the horizontal position of the maxilla would occur if the centre of the condyle was used. A retrospective study on 10 patients with increased anterior facial height was undertaken and a mean centre of rotation 8.4 mm behind and 25.1 mm below the centre of the condyle was found. Simulating the rotation of the mandible through the centre of the condyle would have resulted in a difference between the predicted and actual horizontal position of the maxilla ranging from 0.4-10.4 mm. It was concluded that using the centre of the condyle as the centre of mandibular rotation in the planning of superior maxillary movement with a Le Fort I osteotomy may cause considerable error in the horizontal position of the maxilla in most cases.

Simple mucin-type carbohydrates in oral stratified squamous and salivary gland epithelia.

Simple mucin-type carbohydrate antigens, T, Tn, and sialosyl-Tn, have been found to be good markers of malignant transformation in several epithelial tissues as a result of incomplete synthesis with precursor accumulation. The T, Tn, and sialosyl-Tn antigens represent the initial, most immature glycosylation of serine and threonine amino acids of proteins. In normal adult cells these structures are generally masked by addition of further saccharides to form more complex structures. We analyzed simple mucin-type carbohydrates in human labial stratified squamous and minor salivary gland epithelia in order to define the glycosylation pattern in normal cells in relation to epithelial differentiation and maturation. A panel of monoclonal antibodies with well-characterized specificity for T, Tn, sialosyl-Tn and the histo-blood group H and A variants hereof were used in immunohistology of sections from 30 individuals with known ABO, Lewis, and secretor status. In stratified epithelium the sialylated T structure was confined to cell membranes of immature basal cells, whereas the H and A variants were observed on cell membranes of more mature parabasal and spinous cell layers. Furthermore, superficial spinous cells produced a fine granular cytoplasmic staining for Tn and sialosyl-Tn antigens. In minor salivary glands mucous cells expressed Tn and sialosyl-Tn as well as the H and A variants in the area of the nucleus, whereas T and the H variant were found in duct cells and unsubstituted T antigen in myoepithelial cells. These results indicate that incomplete synthesis, i.e., deletion of sialyltransferases and/or histo-blood group ABH transferases, may result in accumulation of T, Tn, and sialosyl-Tn antigens in oral epithelia, thus offering a baseline for further studies of changes in premalignant and malignant oral epithelia.

Soft tissue changes after advancement genioplasty performed as pedicled or free transplants.

The influence of soft tissue attachment in augmentation genioplasty on postoperative soft tissue changes was studied in 25 patients. The soft tissue was completely detached from the advanced genial segment in 14 patients and lingual soft tissue was maintained in 11 patients. The patients were followed for a minimum of 1 year after operation and the soft tissue and bone changes were analysed by measuring linear distances and areas on lateral cephalograms. The result indicated that the soft tissue changes after surgery were significantly different between the two types of graft. In the free grafts there was found to be an increased risk of creating a larger interlabial gap and exposure of the labial surface of mandibular incisors. The higher correlations between hard and soft tissue changes in the pedicled grafts indicated that the predictability is better with this operative technique.

The significance of an erroneous recording of the centre of mandibular rotation in orthognathic surgery.

The effect of post-operative jaw position of an error in locating the true centre of mandibular rotation was evaluated using a computer-simulation model and a mock surgery model. The centre of the condyle serves as a reference point in surgical procedures involving the maxilla. The purpose of this study was to describe the amount of malpositioning of the jaws at surgery due to a discrepancy between a simulated true centre of rotation and the centre of the condyle. The results showed, that a 20 mm error in location of the true centre of rotation could result in a 3 mm horizontal malpositioning of the maxilla.

Bone resorption after advancement genioplasty. Pedicled and non-pedicled grafts.

The influence of soft tissue attachment in augmentation genioplasty on the amount of postoperative bone remodelling was studied in 29 patients. The soft tissue was completely detached from the advanced genial segment in 15 patients and the lingual soft tissue was maintained in 14 patients. The advancement of the chin and postoperative bone remodelling was analysed by measuring linear distances and areas on lateral cephalograms. The genial segments with a soft tissue pedicle underwent significantly less resorption than the free grafts (p less than 0.01). The difference in postoperative infection between the two groups (p less than 0.05) indicates that the likelihood of postoperative infection is significantly reduced by maintaining the soft tissue pedicle. Considerably less variation in amount of bone resorption was also observed in the patients with a pedicled graft.

The calcifying epithelial odontogenic tumor. A review of recent literature and report of a case.

The calcifying epithelial odontogenic tumor (CEOT) was described as an entity by Pindborg in 1955. In 1976 a review of the world literature comprising 113 cases was published. Since then, several studies concerned with pathological aspects of this tumor have appeared. Many of these studies have focused on the nature of the amyloid-like material present in CEOT. In this paper a new case is presented and the literature after 1976 is reviewed with respect to histopathological aspects of CEOT.

Facial growth and oral function in a case of juvenile rheumatoid arthritis during an 8-year period.

The present report is a detailed analysis of facial growth and oral function in a girl with juvenile rheumatoid arthritis of the temporomandibular joints. She was followed from 9 to 17 years of age prior to and after orthognathic surgery. Facial growth was assessed by facial photographs, dental casts, and roentgencephalometry, and oral function was assessed clinically by electromyography, kinesiography, and bite force. In addition, histological and histochemical analysis was performed on biopsy material from her masseter muscle obtained at the time of surgery. The study showed a clear relationship between facial growth and oral function. Dysplastic growth of the mandible led to an increasingly unstable occlusion with poor working conditions for the masticatory muscles. The muscles became weak, and even revealed marked structural histological and histochemical changes. Based on these observations it is suggested that the conventional treatment strategy with postponement of orthodontic or orthognathic surgical treatment until cessation of growth is abandoned and that early treatment should be undertaken to maintain occlusal stability throughout the growth period.

Pulp canal obliteration after Le Fort I osteotomy.

A longitudinal study of 51 patients was carried out to determine the frequency of pulp canal obliteration (PCO) after Le Fort I osteotomy for the correction of dentofacial anomalies and to analyse pre- and peroperative factors influencing the development of PCO. PCO developed in 14 (2.3%) of 617 maxillary teeth followed for an average period of 28 months (range 11-59). The highest frequency of PCO was demonstrated in canines (6.0%) and premolars (4.4%). Total PCO was present in 9 teeth and partial PCO in 5 teeth. PCO was more frequent among teeth adjacent to a vertical interdental osteotomy than in teeth with no relation to a vertical osteotomy (p less than 0.0001). Change in blood supply after the operation was suggested to be responsible for PCO, although it might have been effected by the combined surgical and orthodontic treatment. Long-term follow-up, including periapical radiographs, of teeth with PCO is suggested, as pulp necrosis may develop many years after surgery.

The inflammatory paradental cyst.

The inflammatory paradental cyst has previously been described as the collateral inflammatory cyst, the inflammatory lateral periodontal cyst, the paradental cyst, or the mandibular infected buccal cyst. Clinical, radiographic, and histologic features of 29 inflammatory paradental cysts diagnosed over a 5-year period were studied. The cysts occurred in relation to a partly or fully erupted tooth with a vital pulp. Twenty-seven of the cysts were located in the mandible and the remaining two in the maxilla. The mandibular cysts were in all cases associated with a molar. The observation that the cysts are diagnosed within a few years after tooth eruption and the demonstration of a statistically significant difference (p = 0.001) in age distribution and in the type of tooth involved suggest that eruption is important for the development of the cysts. The consistent finding of a hyperplastic, nonkeratinized stratified squamous epithelium with an intense inflammation in the connective tissue is in accordance with the hypothesis that inflammation is important for the development of these cysts.

Pulp sensibility and pulp necrosis after Le Fort I osteotomy.

A longitudinal study comprising 617 teeth in 51 patients was carried out to determine the frequency of pulp necrosis and loss of pulpal sensibility after Le Fort I osteotomy. A negative pulpal sensibility was found in 39 (6%) teeth after an average follow-up period of 28 months, range 11-59 months. Development of pulp necrosis, determined by pulp testing and periapical radiolucency, was only demonstrated in 3 (0.5%) teeth. The extent of horizontal or vertical displacement of the maxilla had no influence on pulpal sensibility. Teeth adjacent to a vertical interdental osteotomy showed a significantly higher frequency of negative reactions compared to the group without an interdental osteotomy (p = 0.002). The canines demonstrated a significantly greater number of teeth with a negative sensibility reaction compared to the other tooth types. A close relationship between the apex of the canines and a wire osteosynthesis was demonstrated to have significant importance for pulpal sensibility.