Erythema multiforme: a review of epidemiology, pathogenesis, clinical features, and treatment.

Erythema multiforme (EM) is an acute, immune-mediated disorder affecting the skin and/or mucous membranes, including the oral cavity. Target or iris lesions distributed symmetrically on the extremities and trunk characterize the condition. Infections are the most common cause of EM and the most frequently implicated infectious agent causing clinical disease is the herpes simplex virus. The diagnosis of EM is typically based on the patient's history and clinical findings. Management involves controlling the underlying infection or causative agent, symptom control, and adequate hydration. The epidemiology, pathogenesis, clinical features, diagnosis, and treatment of EM are reviewed in this article.

A systematic review of dysgeusia induced by cancer therapies.

PURPOSE: The purpose was to review relevant scientific papers written since 1989 which focused on the prevalence and management of dysgeusia as an oral side effect of cancer treatment. METHODS: Our literature search was limited to English language papers published between 1990 and 2008. A total of 30 papers were reviewed; the results of 26 of these papers were included in the present systematic review. A structured assessment form was used by two reviewers for each paper. Studies were weighted as to the quality of the study design, and treatment recommendations were based on the relative strength of each paper. RESULTS: A wide range in reported prevalence of dysgeusia was identified with the weighted prevalence from 56-76%, depending on the type of cancer treatment. Attempts to prevent dysgeusia through the prophylactic use of zinc sulfate or amifostine have been of limited benefit. Nutritional counseling may be helpful to some patients in minimizing the symptoms of dysgeusia. CONCLUSIONS: Dysgeusia is a common oral side effect of cancer therapy (radiotherapy, chemotherapy, or combined modality therapy) and often impacts negatively on quality of life. From the current literature, there does not appear to be a predictable way of preventing or treating dysgeusia.

Evaluation of a suspicious oral mucosal lesion.

Dentists who encounter a change in the oral mucosa of a patient must decide whether the abnormality requires further investigation. In this paper, we describe a systematic approach to the assessment of oral mucosal conditions that are thought likely to be premalignant or an early cancer. These steps, which include a comprehensive history, step-by-step clinical examination (including use of adjunctive visual tools), diagnostic testing and formulation of diagnosis, are routinely used in clinics affiliated with the British Columbia Oral Cancer Prevention Program (BC OCPP) and are recommended for consideration by dentists for use in daily practice.

New hope for an oral cancer solution: together we can make a difference.

Oral cancer is associated with high mortality and morbidity rates, largely as a result of late diagnosis. Although dental practitioners are trained to identify premalignant and malignant lesions, an organized system is needed to offer guidance and to improve access to experts in diagnosis and management of these lesions. In this article, we describe the many ways in which the British Columbia Oral Cancer Prevention Program (BC OCPP) is addressing this challenge: by linking community dental practices and referral centres, by creating partnerships between scientists and clinicians that already have resulted in new technologies to enhance early diagnosis, by involving a broad range of stakeholders to ensure population-based screening and by engaging in provincial, national and international outreach.

Biopsy and histopathologic diagnosis of oral premalignant and malignant lesions.

Accurate diagnosis of premalignant or malignant oral lesions depends on the quality of the biopsy, adequate clinical information and correct interpretation of the biopsy results. The purpose of this paper is to review the procedures for obtaining appropriate biopsy samples, and the criteria for diagnosing and grading dysplasias. The World Health Organization's description of the architectural and cytologic epithelial changes that characterize dysplasia is detailed, and guidelines for following up patients with premalignant and malignant lesions are provided. The benefits of using the centralized services and expertise of the British Columbia Oral Biopsy Service are also reviewed.

Visualization and other emerging technologies as change makers for oral cancer prevention.

The genomic era has fueled a rapid emergence of new information at the molecular level with a great potential for developing innovative approaches to detection, risk assessment, and management of oral cancers and premalignant disease. As yet, however, little research has been done on complementary approaches that would use different technology in conjunction with molecular approaches to create a rapid and cost-effective strategy for patient assessment and management. In our ongoing 8-year longitudinal study, a set of innovative technologies is being validated alone and in combination to best correlate with patient outcome. The plan is to use these devices in a step-by-step sequence to guide key clinicopathological decisions on patient risk and treatment. The devices include a hand-held visualization device that makes use of tissue autofluorescence to detect and delineate abnormal lesions and fields requiring follow-up, to be used in conjunction with optical contrast agents such as toluidine blue. In addition, two semi-automated high-resolution computer microscopy systems will be used to quantitate the protein expression phenotype of cell nuclei in tissue sections and exfoliated cell brushings. Previously identified risk-associated molecular changes are being used to validate these systems as well as to establish their place in a population-based triage program that will filter out high-risk cases in the community and funnel them to dysplasia clinics where higher-cost molecular tools will guide intervention. A critical development for the translation of this technology into community settings is the establishment of an effective methodology for education and training of health practitioners on the front lines.

Direct fluorescence visualization of clinically occult high-risk oral premalignant disease using a simple hand-held device.

BACKGROUND: A considerable proportion of oral cancer and precancer is not clinically apparent and could contribute significantly to the late diagnosis and high mortality of oral cancer. A simple method to identify such occult change is needed. METHODS: Patients in the Oral Dysplasia Clinics at British Columbia are currently being examined with a simple hand-held device that permits the direct visualization of alterations to autofluorescence in the oral cavity. Tissue showing loss of autofluorescence is biopsied. RESULTS: We present 3 representative cases in which occult lesions were identified with fluorescence visualization during longitudinal follow-up, resulting in the diagnosis of a primary dysplasia in case 1, a second primary cancer in case 2, and cancer recurrence in case 3. CONCLUSIONS: This is the first report of the diagnosis of occult oral disease using a simple noninvasive device. These early examples indicate the potential value of this technology to guide the management of patients with oral lesions, facilitating the detection of high-risk changes not apparent with white-light visualization.

Fluorescence visualization detection of field alterations in tumor margins of oral cancer patients.

PURPOSE: Genetically altered cells could become widespread across the epithelium of patients with oral cancer, often in clinically and histologically normal tissue, and contribute to recurrent disease. Molecular approaches have begun to yield information on cancer/risk fields; tissue optics could further extend our understanding of alteration to phenotype as a result of molecular change. EXPERIMENTAL DESIGN: We used a simple hand-held device in the operating room to directly visualize subclinical field changes around oral cancers, documenting alteration to fluorescence. A total of 122 oral mucosa biopsies were obtained from 20 surgical specimens with each biopsy being assessed for location, fluorescence visualization (FV) status, histology, and loss of heterozygosity (LOH; 10 markers on three regions: 3p14, 9p21, and 17p13). RESULTS: All tumors showed FV loss (FVL). For 19 of the 20 tumors, the loss extended in at least one direction beyond the clinically visible tumor, with the extension varying from 4 to 25 mm. Thirty-two of 36 FVL biopsies showed histologic change (including 7 squamous cell carcinoma/carcinomas in situ, 10 severe dysplasias, and 15 mild/moderate dysplasias) compared with 1 of the 66 FV retained (FVR) biopsies. Molecular analysis on margins with low-grade or no dysplasia showed a significant association of LOH in FVL biopsies, with LOH at 3p and/or 9p (previously associated with local tumor recurrence) present in 12 of 19 FVL biopsies compared with 3 of 13 FVR biopsies (P=0.04). CONCLUSIONS: These data have, for the first time, shown that direct FV can identify subclinical high-risk fields with cancerous and precancerous changes in the operating room setting.

The development, implementation, utilization and outcomes of a comprehensive dental program for older adults residing in long-term care facilities.

This paper documents the experience of the University of British Columbia's Geriatric Dentistry Program (GDP) with emphasis on the dental treatment needs of patients during its first year of operation. The GDP provided access to dental care for residents of longterm care facilities, education for hospital staff concerning daily mouth care, education of dental students and an opportunity for research. The first year of clinical activity saw a small, yet significant, improvement in oral health for residents using the dental services. We hope that the outcomes of this new dental program for long-term care facilities will encourage dentists to provide care for this vulnerable population.

Simple device for the direct visualization of oral-cavity tissue fluorescence.

Early identification of high-risk disease could greatly reduce both mortality and morbidity due to oral cancer. We describe a simple handheld device that facilitates the direct visualization of oral-cavity fluorescence for the detection of high-risk precancerous and early cancerous lesions. Blue excitation light (400 to 460 nm) is employed to excite green-red fluorescence from fluorophores in the oral tissues. Tissue fluorescence is viewed directly along an optical axis collinear with the axis of excitation to reduce inter- and intraoperator variability. This robust, field-of-view device enables the direct visualization of fluorescence in the context of surrounding normal tissue. Results from a pilot study of 44 patients are presented. Using histology as the gold standard, the device achieves a sensitivity of 98% and specificity of 100% when discriminating normal mucosa from severe dysplasia/carcinoma in situ (CIS) or invasive carcinoma. We envisage this device as a suitable adjunct for oral cancer screening, biopsy guidance, and margin delineation.

Erythema multiforme: a review and contrast from Stevens-Johnson syndrome/toxic epidermal necrolysis.

Erythema multiforme and Stevens-Johnson syndrome/toxic epidermal necrolysis are separate diseases. Recent evidence suggests that they have different etiologies and require different treatments. This article provides an overview of the two conditions with emphasis on the differences between them. An outline of the diagnosis and management of the diseases is included.

Oral disorders and chronic systemic diseases in very old adults living in institutions.

This study evaluated whether oral disorders were associated with chronic systemic diseases in 532 Canadian adults who are old and very old and living in institutions. A brief oral examination documented tooth retention, caries, and periodontal and gingival health. Medical records provided information about chronic systemic conditions. A history of stroke was associated with a higher experience of caries, a higher ratio of decayed-to-present teeth, and more gingival and periodontal problems. Participants with high blood pressure, osteoporosis, or diabetes were more likely to be edentulous or to have fewer teeth than participants who did not have these conditions. Participants who had arthritis retained more teeth with age. Participants who had more diseases also tended to have poorer gingival or periodontal conditions, fewer teeth, and higher risk of edentulousness. The associations between systemic diseases and more severe oral disorders may be direct or may be mediated by underlying factors such as health behaviors.

Oral disorders in institution-dwelling elderly adults: a graphic representation.

This study was conducted to assess the oral health status and dental care needs of elderly adults living in long-term care facilities. Dentists examined 601 elderly adults, living in one of six extended-or intermediate-care facilities, between September 1999 and May 2000. Data from 532 of the subjects were analyzed with descriptive statistics and zero-order inverse polynomials. Using a computer program, the authors compiled summaries of oral health data on individuals and institutional levels. This study suggests that there are numerous unmet dental needs among elderly adults who live in institutions. The CODE index used to assess the oral health of these residents offers a systematic portrayal of oral disorders in terms of severity. As the authors demonstrated, this index can be readily analyzed using zero-order inverse polynomials to summarize collected data into a graphic description, which can be helpful in managing and administrating oral health care interventions in long-term care facilities.