The feasibility of academic detailing for acute oral pain management in outpatient dentistry: A pilot study.

BACKGROUND: Opioids are overprescribed in the outpatient dental setting. Therefore, opportunities exist for opioid stewardship. OBJECTIVES: The purpose of this pilot study was to test the feasibility of an academic detailing (AD) intervention to promote appropriate prescribing of opioids in outpatient dentistry. METHODS: We implemented an AD intervention targeting management of acute oral pain in a Midwestern Veterans Affairs outpatient dental facility. The intervention targeted dentists who actively prescribed opioids at the time of the study. The pilot study tested feasibility, adoption, and acceptance of the AD campaign. Visit-based prescribing rates were obtained from the Veterans Health Administration's Corporate Data Warehouse for baseline and postintervention using difference-in-differences analyses to detect potential changes in health service outcomes. RESULTS: Results indicate moderate levels of feasibility through participation rates (n = 5, 55.5%) and high levels of organizational readiness for change (average of 88.6% agree to strongly agree). Furthermore, fidelity of the AD intervention was high. Adoption measures show moderate indication of motivation to change, and trends suggest that participating dentists decreased their visit-based opioid prescribing rates (P > 0.05). CONCLUSION: The intervention demonstrated feasibility with some indications of adoption of intervention techniques and decrease in opioid prescribing. We further recommend working closely with frontline providers to gather feedback and buy-in before scaling and implementing the AD campaign.

Application Of New WHO Classification On Malignancies Of Sinonasal Tract: Correlation With Epidemiology And Survival In Pakistani Population.

Objectives: To analyse the clinicopathological characteristics of sinonasal malignancies in the light of the updates regarding head and neck tumours. METHODS: The retrospective study was conducted at the Shaukat Khanum Memorial Cancer Hospital and Research Centre, Lahore, Pakistan, and comprised data of patients diagnosed with primary malignant tumours of the sinonasal tract between 2015 and 2020. Slides related to biopsies and resection specimens were retrieved from the institutional database and reviewed by two pathologists. Follow-up data was also obtained. Data was analysed using SPSS 20. RESULTS: Of the 245 samples, 144(58.7%) were epithelial tumours, 46(18.7%) neuroectodermal tumours, 41(16.7%) haematolymphoid tumours and 14(5.7%) were malignant soft tissue tumours. A heavy reliance was placed on immunohistochemical stains to diagnose poorly-differentiated tumours. Survival was dismal, especially with early and frequent spread to the brain (33.3% in cases of Sinonasal Undifferentiated Carcinoma). CONCLUSIONS: A wide array of sinonasal malignancies was seen. Updated knowledge of the malignancies prevalent in the region is imperative for timely diagnosis and treatment.

Mammary analogue secretory carcinoma of parotid gland: Literature review and experience of a dedicated cancer institution in Pakistan.

Mammary Analogue Secretory Carcinoma (MASC) is a rare pathology of the salivary gland, most commonly involving the parotid gland. The objective of this study was to identify the characteristic features of MASC and its treatment outcomes. A retrospective review of 12 patients with histological diagnosis of MASC, who were managed between 2010 to 2019, was carried out at the Shaukat Khanum Memorial Cancer Hospital & Research Centre, Lahore. Their mean age was 34±16 years. There were 9 (75%) male and 3 (25%) female patients. Painless slow growing swelling was the most common presenting symptom. All the patients had undergone surgical excision with or without neck dissection, followed by adjuvant treatment. Of these, six patients had T2 tumours, while four had cervical lymph node metastasis. The mean follow-up period was 23±21 months. Local recurrence was seen in one patient. MASC is considered a low-grade tumour with good prognosis which can be treated with curative intent of surgery followed by radiotherapy effectively.

Prevalence of pain in oral cancer: A retrospective study.

OBJECTIVE: This study aimed to estimate the prevalence of pain among treatment-naïve patients with oral cancer and to identify the clinical and histopathological characteristics of oral cancer associated with pain occurrence. MATERIALS AND METHODS: A retrospective chart review was conducted of patients presenting with biopsy-proven oral cancer between January 2015 and December 2019. Variables, including demographic data, medical history, clinical presentation, and histopathological information, were extracted and analyzed. Appropriate descriptive and analytic statistics were computed. RESULTS: Among 1,067 participants, 682(63.9%) were males. The prevalence of pain was 67.5%. It was found to be significantly associated with the duration of symptoms, history of betel or areca nut, squamous cell carcinoma, presence of disease in tongue, palate, and lips, lesion size, clinical nodal involvement, depth of invasion, TNM classification, limited mouth opening, bleeding, and restricted tongue mobility. Logistic regression analysis suggested that pain in oral cancer was positively associated with the occurrence of disease in the tongue and negatively with TNM stage I. CONCLUSIONS: There is a high prevalence of pain among patients with oral cancer even before the initiation of any therapeutic intervention. Occurrence is significantly higher in patients with the presence of disease in the tongue and among those with TNM stage II or more.

Prognostic outcomes of treatment naïve oral tongue squamous cell carcinoma (OTSCC): a comprehensive analysis of 14 years.

OBJECTIVES: To analyze the factors predicting survival outcomes in treatment naïve oral tongue squamous cell carcinoma (OTSCC). MATERIALS AND METHODS: A comprehensive review of 531 oral tongue carcinoma patients treated with upfront surgery followed by adjuvant radiotherapy or chemoradiotherapy was conducted from 2004-2018. RESULTS: The mean age of presentation was 53 years (11-86) with a male to female ratio of 1.3:1. The associated risk factors were smoking (21%), betel nut (16%), naswar (9%) and alcohol (1%). Most of the cases were either well (45.1%) or moderately (46.2%) differentiated. Surgery was performed in 164 patients alone while 368 were treated with surgery in combination with adjuvant modalities. Overall (OS) and disease free survival (DFS) were 66 and 71%, respectively, with a median follow up of 2.5 years. Cox regression analysis showed nodal positivity, increased depth of invasion (DOI) and higher lymph node ratio (LNR) as significant prognosticators impacting OS and DSS. CONCLUSION: Nodal volume, DOI and LNR are the most consistent predictors of poor outcome in OTSCC. Nodal positivity, depth of invasion > 5 mm and lymph node ratio > 0.04 adversely affect OS and DSS.

Small cell neuroendocrine carcinoma of nose and paranasal sinuses: The Shaukat Khanum Memorial Cancer Hospital experience and review of literature.

Small cell neuroendocrine carcinoma (SCNEC) is a rare disease of nose and paranasal sinuses. In contrast to other regions SCNEC of this region has been reported to be recurrent and locally aggressive. No definite treatment has been established till date because of rarity of this disease. The purpose of this descriptive study is to present the series of 8 cases with SNEC of nose and paranasal sinuses. Retrospective review of 8 patients presenting with Small cell neuroendocrine carcinoma of nose and paranasal sinuses, from January, 2005 to December, 2014 treated at Shaukat Khanum Memorial Cancer Hospital & Research Centre, Lahore was performed to determine the clinical characteristics and outcome of this disease. The subjects were 7 males and 1 female with a mean age of 45±15 years (range 24 to 59 years). Tumours were present in nasal cavity (n=4), ethmoid sinus (n=3) and maxillary sinus (n=1). Almost 50% of patients presented with AJCC stage IV-A. All patients had immunohistochemistry proven diagnosis. All patients (08) received radiotherapy with mean doses 58±Gy (Range 54-66Gy). Surgery was performed in 2 while chemotherapy was administered in 4 patients. Recurrence occurred in 3 patients, one each with loco-regional, distant and both. At a median follow up of 38 months, 5 patients were alive with no evidence of disease. SCNEC is a rare but aggressive neoplasm. Current standard of care varies but multi-modality approach should be the cornerstone in management of SCNEC. Early diagnosis and intervention improve the final outcome.

Effects of locust bean gum on the structural and rheological properties of resistant corn starch.

In this study, interactions between resistant corn starch (RS) (5% w/w) and locust bean gum (LBG) (0, 0.125, 0.25, 0.50 and 1.0% w/v) on the viscoelastic, pasting and morphological characteristics of aqueous dispersions were evaluated. Results showed that the storage modulus (G'), loss modulus (G''), and apparent viscosity values of starch/gum (RS/LBG) mixtures were enhanced with the addition of LBG, and the rheograms demonstrated a biphasic behavior. RS/LBG samples were predominantly either solid like (G' > G'') or viscous (G'' > G'), depending on the added concentration level of LBG. Gum addition also caused higher peak viscosity, breakdown and total set back of RS/LBG mixtures. A strong correlation between rheological and structural properties was found. Confocal laser scanning microscopy (CLSM) images confirmed the transition of starch particles from a scattered angular shape to clustered structures cross-linked by dense aggregate junction zones justifying the observed changes in rheological properties.

Long term survival and impact of various prognostic factors in T1, T2 oral tongue cancer in Pakistan.

OBJECTIVE: To determine the outcome in patients with early squamous cell carcinoma of oral tongue, and the impact of various prognostic factors on survival. METHODS: The retrospective study was conducted at Shaukat Khanum Memorial Cancer Hospital and Research Centre, Lahore, Pakistan, and comprised records of patients treated for squamous cell carcinoma of early stage tongue between March 2003 and October 2009. Various factors, including demographics, risk factors, stage, and grade of the tumour were determined. Kaplan Meier curves were plotted to determine the 5-year overall survival, relapse-free survival, local control, regional control, and loco-regional control. RESULTS: A total of 137 patients with early oral tongue tumours were treated. With a median follow-up of 46 months, the overall survival of T1, T2 early tongue tumour was 73% and 64%. The incidence of occult metastasis was 30%. The overall survival for Stage I/II and III/IV was 78% and 50% (p=0.002). Patterns of failures included; local 19 (13%), regional 22 (16%), loco-regional 4 (3%) and distant 5 (4%) respectively. The 5-year local control, regional control, loco-regional control was 86%, 82% and 72%. The only significant predictor of overall survival was clinical and pathological N stage in T1 patients, and surgical procedure, grade, pathological N stage in T2 cases. CONCLUSIONS: Treatment of early squamous cell carcinoma of oral tongue effectively achieved local control and disease-free survival. Nodal stage was the most important prognostic factor in terms of survival and recurrence.

Patterns of cancer cell sphere formation in primary cultures of human oral tongue squamous cell carcinoma and neck nodes.

Recently a sub-population of cells with stem cell characteristics, reported to be associated with initiation, growth, spread and recurrence, has been identified in several solid tumors including oral tongue squamous cell carcinoma (OTSCC). The aim of our pilot study was to isolate CD44+ cancer stem cells from primary cultures of OTSCC and neck node Level I (node-I) biopsies, grow cell spheres and observe their characteristics in primary cultures. Parallel cultures of hyperplastic lesions of tongue (non-cancer) were set up as a control. Immunohistochemistry was used to detect CD44/CD24 expression and magnetic activated cell sorting to isolate CD44+ cell populations followed by primary cell culturing. Both OTSCC and node-I biopsies produced floating spheres in suspension, however those grown in hyperplastic and node-I primary cultures did not exhibit self-renewal properties. Lymph node metastatic OTSCC, express higher CD44/CD24 levels, produce cancer cell spheres in larger number and rapidly (24 hours) compared to node negative OTSCC (1 week) and non-cancer specimens (3 weeks). In addition, metastatic OTSCC have the capacity for proliferation for up to three generations in primary culture. This in vitro system will be used to study cancer stem cell behavior, therapeutic drug screening and optimization of radiation dose for elimination of resistant cancer cells.

Secretory carcinoma of minor salivary glands of buccal mucosa: A case report and review of the literature.

INTRODUCTION AND IMPORTANCE: Secretory carcinoma (SC) is an uncommon salivary gland neoplasm of the oral cavity that microscopically may mimic acinic cell carcinoma (ACC) and mucoepidermoid carcinoma (MEC). Secretory carcinoma (SC) of the salivary gland has been recently added in fourth edition of the head and neck world health organization. Most of these tumors are located on the parotid gland with very few cases reported in the minor salivary glands of the buccal mucosa. This work has been reported in line with the SCARE criteria. PRESENTATION OF CASE: A 42 years old hypertensive male, shop keeper by occupation, with no prior addiction history, no dental extraction or trauma, presented with complaint of nodular lesion on left buccal mucosa for five years. On Clinical examination, adequate mouth opening, dentulous patient with 2.4 × 2 cm well circumscribed, nodular, non-tender, benign looking lesion was observed on left buccal mucosa near upper alveolus. Overlying mucosa appeared normal with no clinically palpable cervical lymphadenopathy. Histopathology revealed salivary gland neoplasm favoring secretory carcinoma. MRI scan showed lobulated enhancing nodular lesion arising from left buccal mucosa of size 2.3 ∗ 1.3 ∗ 1.7 cm, close to left superior alveolus without involving any cortical areas of marrow infiltration, with bilateral symmetrical level IIa reactive cervical nodes. Wide local excision and ipsilateral selective neck dissection [level 1, 2, 3] was done. Post-operative period was smooth with no complain of paresthesia observed. The final histopathology report showed secretory carcinoma. Two out of six lymph nodes from level I were positive for metastatic carcinoma with no extra nodal extension. Final stage of the tumor was pT1N2bMx. Patient underwent post-operative adjuvant radiotherapy for period of 6 weeks, received total 30 fractions and total dose of 6000 centigray. CLINICAL DISCUSSION: SC behaved clinically an indolent being painless and having long duration of symptoms with normal overlying mucosa. But histopathologically there was cervical node metastasis. That changed final staging and added adjuvant treatment for this patient. The discrepancy in clinical and pathological diagnosis might be due to the indolent clinical behavior of SC arising in the minor salivary gland of buccal mucosa. In the present case, the absence of zymogen granules and presence of microcytic pattern with eosinophilic cytoplasm and eosinophilic secretory material were suggestive of SC. CONCLUSION: This case report represents a rare case of SC of minor salivary glands of buccal mucosa, which was indolent as per clinical presentation but on final histopathological report it had cervical nodal metastasis that changed the final stage of the disease, for which adjuvant radiotherapy was needed. Although Secretory carcinomas are generally considered having a favorable prognosis and are regarded as low- grade carcinomas with limited number of recurrence and cervical nodal metastasis, but sometimes they do metastasize to cervical nodes for which accurate and timely intervention in the form of neck dissection may be performed to establish final staging and start additional treatment modality if required for better outcome of the disease.

Survival Outcomes and Patterns of Failure in Maxillary Alveolus Squamous Cell Carcinoma.

Introduction Squamous cell carcinoma (SCC) of the maxillary alveolus is a relatively rare disease. There is lack of data on this subsite as compared with other sites. The factors that affect survival in cases of maxillary alveolar SCC are tumor stage, local and cervical metastases, histological grading, and the margin status. Objectives To evaluate the overall survival (OS), the disease free survival (DFS), and the complex interaction and effects of margin status, histological differentiation, habits (such as smoking and the use of smokeless tobacco products), and cervical and distant metastases based on clinicopathological data. Methods We examined the electronic database at our hospital from 2003 to 2017. We included all cases with a histopathological diagnosis of SCC of the maxillary alveolus. Tumors originating primarily from the maxillary alveolus were included, while those originating from adjacent subsites, like the hard palate, the buccal mucosa or the maxillary sinus were excluded. We also excluded all the patients who were not operated on with a curative intent. Results More than half of the patients had stage-IV tumors at the time of presentation, while only one fourth of them had nodal metastasis. The rate of recurrence increased in cases of primary tumors in advanced stages and the degree of histological differentiation. The 2-year and 5-year OS rates were of 54.5% (18 patients) and 30.3% (10 patients) respectively. Conclusion Primary tumors in advanced stages, histological grade, and presence of nodal metastasis are poor prognostic markers in terms of long-term survival.

Post-Pancreatectomy Acute Pancreatitis-The New Criteria Fail to Recognize Significant Presentations.

BACKGROUND: Post-pancreatectomy acute pancreatitis (PPAP) is a newly described clinical entity defined as elevated serum amylase sustained ≥ 48 h postoperatively, radiological findings consistent with acute pancreatitis, and associated clinically relevant features. This study aimed to investigate the incidence of PPAP and the rate of major complications after pancreatoduodenectomy (PD) in patients with only transiently elevated serum amylase. METHODS: A retrospective single-center observational study was conducted including consecutive patients ≥ 18 years of age undergoing PD at Karolinska University Hospital, between 2008 and 2020. Serum amylase on postoperative day (POD) 1 and 2 and records from computer tomography were analyzed and correlated with postoperative major complications by logistic regressions. RESULTS: Of some 1078 patients that underwent PD, 284 exhibited sustained elevated serum amylase (according to PPAP criteria) and 183 transiently elevated serum amylase on either POD1 or POD2. Of the patients with sustained elevated levels, 43% (n = 123) developed major complications, but only 6.3% (n = 18) showed findings consistent with acute pancreatitis on imaging. Of the 183 cases that exhibited only transiently elevated serum amylase on either POD1 or POD2, 32% (n = 58) developed major complications. CONCLUSION: Sustained hyperamylasemia was observed in 26% of patients after PD, and an additional 17% of patients had a transient elevation of serum amylase postoperatively. Acute pancreatitis after PD may be underdiagnosed, partly by overlooking transiently elevated serum amylase and partly by requiring imaging that potentially fails to recognize mild but complication-prone acute pancreatitis.

Treatment Outcomes of Maxillary Sinus Squamous Cell Carcinoma at a Dedicated Cancer Institute: A Retrospective Study.

Introduction Squamous cell carcinoma arising at the maxillary sinus is a rare neoplasm, characterized by an aggressive growth pattern and glooming prognosis. The proximity of the maxillary sinus with complex anatomical structures such as the eye, skull base, infratemporal fossa, pterygomaxillary fossa, nasal cavities, and ethmoid sinuses makes the surgical treatment of tumors infiltrating into these structures very challenging. The study's objective was to investigate the prognostic factors of survival and maxillary sinus SCC treatment outcomes. Methods We did a retrospective analysis of patients treated for maxillary sinus SCC at our institution between 2004 -2018. The study included all the patients with histologically proven maxillary sinus SCC treated with curative intent. The medical record of 43 patients was reviewed and utilized for the analysis. The Kaplan-Meier curve calculated five-year overall survival. Results A total of 43 patients were analyzed. At the presentation time, the mean age was 54.56 years (SD ± 11.65). Smoking (n=13, 30.2%) was the common risk factor. 36 (83.7%) patients presented with stage IV disease. Surgery was performed in 16 (37.2%) patients, whereas 27 (62.8%) patients received radiation and chemotherapy. Treatment failure was seen in 35 (81.4%) patients with locoregional recurrence in 30 (85.7%) patients and distant metastases in 5 (14.3%) patients. The five years overall survival in our study was 22%. Loco-regional recurrence and distant metastasis were the significant factors impacting survival (p=0.01). Conclusion Maxillary sinus SCC is rare cancer that is more common in males and usually presents at an advanced stage with a poor outcome. These tumors have a higher rate of treatment failure with a poor prognosis. Locoregional recurrence and distant metastasis adversely impact the overall survival.

Carcinoma ex-pleomorphic adenoma of mandible: A case report and review of literature.

INTRODUCTION AND IMPORTANCE: The most common benign neoplasm of major and minor salivary glands is pleomorphic adenoma (PA). Around 80 % of all parotid neoplasms are pleomorphic adenomas, while 44-68 % and 38-43 % tumors were pleomorphic adenomas of submandibular and minor salivary gland tumors. PA has been reported in a variety of anatomic locations including true intraosseous mandibular tumor, external ear canal, TMJ region, lacrimal gland, epiglottis, larynx and nasopharynx, breast, lung, esophagus, sinonasal and skull base and trachea. Pleomorphic adenoma has a tendency to transform into a number of malignancies; carcinoma ex-pleomorphic adenoma, carcinosarcoma or metastasizing pleomorphic adenoma. Pleomorphic adenomas most commonly transform into carcinoma ex-pleomorphic adenoma (CEPA). CASE PRESENTATION: A 30-year-old male presented with the primary complaint of a long-standing swelling at his right mandibular region for past 18 months. On intra oral examination, there was a non-healing alveolar socket of right lower 3rd molar tooth while rest of the dentition and mucosal surfaces were normal. On extra oral examination, mouth opening was adequate with intact lower border of the mandible and no palpable lymph nodes in the neck. Initial biopsy of lesion showed pleomorphic adenoma, but later the lesion came out to be carcinoma ex-pleomorphic adenoma, for which he underwent segmental mandibulectomy and free fibular flap. CLINICAL DISCUSSION: The prevalence of CEPA transformation from pleomorphic adenoma is 1.5 % within the first 5 years of diagnosis, going up to 10 % after 15 years. The true rate of malignant transformation in recurrent pleomorphic adenoma is reported to be 3.3 %. We report a case of an intra-osseous carcinoma ex pleomorphic adenoma (CEPA) of the mandible. It is thought that ectopic entrapment of salivary tissue or developmentally included embryonic remnants of submandibular glands within recesses or lacunae of the mandibular bone could explain the intraosseous origin of a salivary gland tumor in the mandible. Since carcinoma ex pleomorphic adenoma (CEPA) arises from primary or recurrent pleomorphic adenoma, therefore it poses a diagnostic challenge for histopathologists. The radiographic picture of primary tumor/recurrence can mimic odontogenic cyst/tumor; therefore, a sinister disease process should always be kept in mind. In the post operative period, regular follow up is required to treat any recurrence. The recurrence rate for such disease has not been documented. CONCLUSION: Intra osseous CEPA is a very rare tumor. Intra bony tumors which rapidly increase in size have signs and symptoms of nerve involvement and cause bony destruction should have a high suspicion of index of malignancy. Therefore, biopsy must be correlated with clinical and radiological features. Regular follow up is necessary to detect any recurrence promptly.

An Update on the Treatment of Periimplantitis.

As implant placement increases within all dental specialties, it is expected that the number of suboptimal results will increase, as well. The goal of this article is to provide clinicians with an outline of the management of periimplantitis cases, ranging from simple to complex. It will review signs and symptoms, diagnosis, case selection, and armamentarium. In addition, this chapter will discuss basic techniques which can be utilized at various stages to salvage the compromised implant.