Proliferative Verrucous Leukoplakia: A Diagnostic Challenge in a Clinical and Histopathological Context-With Reflections on the Health Reality in Brazil.

Proliferative verrucous leukoplakia (PVL) is an aggressive and distinct oral disorder with a high potential for malignant transformation (MT). It presents as multifocal lesions that progress over time and frequently recur, often developing carcinomas. Accurately diagnosing PVL is crucial to distinguish it from other oral mucosa lesions that have a lower risk of cancer progression. However, due to the diverse histological features observed in PVL, identifying clinical criteria and histological patterns that can be applied by unfamiliar professionals is challenging. In this study, we present a case of PVL associated with dysplasia in a 53-year-old female patient. The patient exhibited macular and leukoplakic nonscrapable lesions disseminated throughout the oral cavity, with continuous growth. The diagnosis of PVL was established during an 18-month follow-up. This case highlights the difficulties faced by both clinicians and pathologists in diagnosing PVL, emphasizing the need for careful evaluation and accurate diagnosis, particularly in patients with unusual oral lesions, and highlighting the discrepancies observed in the application of available protocols to our particular case. Distinguishing PVL from similar conditions can be challenging due to overlapping clinical signs and indistinct histopathological features.

Contribution of public oral pathology services to the diagnosis of oral and oropharyngeal cancer in Brazil.

This study aimed to evaluate the contribution of oral and maxillofacial pathology laboratories (OMPLs) in Brazilian public universities to the diagnosis of lip, oral cavity, and oropharyngeal squamous cell carcinoma (SCC). A cross-sectional study was performed using biopsy records from a consortium of sixteen public OMPLs from all regions of Brazil (North, Northeast, Central-West, Southeast, and South). Clinical and demographic data of patients diagnosed with lip, oral cavity, and oropharyngeal SCC between 2010 and 2019 were collected from the patients' histopathological records. Of the 120,010 oral and maxillofacial biopsies (2010-2019), 6.9% (8,321 cases) were diagnosed as lip (0.8%, 951 cases), oral cavity (4.9%, 5,971 cases), and oropharyngeal (1.2%, 1,399 cases) SCCs. Most cases were from Brazil's Southeast (64.5%), where six of the OMPLs analyzed are located. The predominant profile of patients with lip and oral cavity SCC was Caucasian men, with a mean age over 60 years, low schooling level, and a previous history of heavy tobacco consumption. In the oropharyngeal group, the majority were non-Caucasian men, with a mean age under 60 years, had a low education level, and were former/current tobacco and alcohol users. According to data from the Brazilian National Cancer Institute, approximately 9.9% of the total lip, oral cavity, and oropharyngeal SCCs reported over the last decade in Brazil may have been diagnosed at the OMPLs included in the current study. Therefore, this data confirms the contribution of public OMPLs with respect to the important diagnostic support they provide to the oral healthcare services extended by the Brazilian Public Health System.

Sociodemographic and clinical characterization of cases of 1,103 non-syndromic and 66 syndromic odontogenic keratocyst: a Brazilian multicenter study.

OBJECTIVES: This multicenter study aimed to evaluate cases of non-syndrome and syndromic odontogenic keratocyst, as well as cases of recurrence within these two groups. METHODS: This descriptive, analytical, retrospective cross-sectional study evaluated the sex, age and presence of multiple lesions in 1,169 individuals seen at 10 Brazilian oral and maxillofacial pathology centers. Of these, 1,341 odontogenic keratocysts were analyzed regarding clinical diagnosis, size, site, imaging appearance, signs and symptoms, type of biopsy, treatment, and recurrence. RESULTS: There was a similar distribution by sex. The median age of non-syndromic and syndromic patients was 32 and 17.5 years, respectively. The posterior mandible was the site most affected by small and large lesions in both groups and in recurrent cases. Unilocular lesions were more frequent, also in recurrent cases. Mainly small lesions showed this imaging appearance. Signs and symptoms were absent in most cases. Conservative treatment was the most frequent modality in all age groups, regardless of the patient's condition and recurrence. Recurrences were uncommon. CONCLUSION: This study showed a higher frequency of non-syndromic keratocysts in the population. Clinicopathological features related to the involvement of multiple sites, age, and recurrence may differ between syndromic and non-syndromic cases. Furthermore, we found an association between lesion size and some clinical features and between the time interval to recurrence and the syndromic spectrum. CLINICAL RELEVANCE: To contribute to a better understanding of the distribution and association between clinical, imaging, and sociodemographic characteristics in each spectrum of the lesion.

Deep learning applied to the histopathological diagnosis of ameloblastomas and ameloblastic carcinomas.

BACKGROUND: Odontogenic tumors (OT) are composed of heterogeneous lesions, which can be benign or malignant, with different behavior and histology. Within this classification, ameloblastoma and ameloblastic carcinoma (AC) represent a diagnostic challenge in daily histopathological practice due to their similar characteristics and the limitations that incisional biopsies represent. From these premises, we wanted to test the usefulness of models based on artificial intelligence (AI) in the field of oral and maxillofacial pathology for differential diagnosis. The main advantages of integrating Machine Learning (ML) with microscopic and radiographic imaging is the ability to significantly reduce intra-and inter observer variability and improve diagnostic objectivity and reproducibility. METHODS: Thirty Digitized slides were collected from different diagnostic centers of oral pathology in Brazil. After performing manual annotation in the region of interest, the images were segmented and fragmented into small patches. In the supervised learning methodology for image classification, three models (ResNet50, DenseNet, and VGG16) were focus of investigation to provide the probability of an image being classified as class0 (i.e., ameloblastoma) or class1 (i.e., Ameloblastic carcinoma). RESULTS: The training and validation metrics did not show convergence, characterizing overfitting. However, the test results were satisfactory, with an average for ResNet50 of 0.75, 0.71, 0.84, 0.65, and 0.77 for accuracy, precision, sensitivity, specificity, and F1-score, respectively. CONCLUSIONS: The models demonstrated a strong potential of learning, but lack of generalization ability. The models learn fast, reaching a training accuracy of 98%. The evaluation process showed instability in validation; however, acceptable performance in the testing process, which may be due to the small data set. This first investigation opens an opportunity for expanding collaboration to incorporate more complementary data; as well as, developing and evaluating new alternative models.

Can SARS-CoV-2 screening in oral biopsies aid epidemiological surveillance?

BACKGROUND: Three years after the first confirmed COVID-19 case in Brazil, the outcomes of Federal government omissions in managing the crisis and anti-science stance heading into the pandemic have become even more evident. With over 36 million confirmed cases and nearly 700 000 deaths up to January 2023, the country is one of the hardest-hit places in the world. The lack of mass-testing programs was a critical broken pillar responsible for the quick and uncontrolled SARS-CoV-2 spread throughout the Brazilian population. Faced with this situation, we aimed to perform the routine SARS-CoV-2 screening through RT-qPCR of oral biopsies samples to aid in the asymptomatic epidemiological surveillance during the principal outbreak periods. METHODS: We analyzed 649 formalin-fixed paraffin-embedded oral tissue samples from five important oral and maxillofacial pathology laboratories from the north, northeast, and southeast geographic regions of Brazil. We also sequenced the whole viral genome of positive cases to investigate SARS-CoV-2 variants. RESULTS: The virus was detected in 9/649 analyzed samples, of which three harbored the Variant of Concern Alpha (B.1.1.7). CONCLUSION: Although our approach did not value aiding asymptomatic epidemiological surveillance, we could successfully identify a using FFPE tissue samples. Therefore, we suggest using FFPE tissue samples from patients who have confirmed diagnosis of SARS-CoV-2 infection for phylogenetic reconstruction and contraindicate the routine laboratory screening of these samples as a tool for asymptomatic epidemiological surveillance.

Contribution of public oral pathology services to the diagnosis of oral and oropharyngeal cancer in Brazil

Abstract This study aimed to evaluate the contribution of oral and maxillofacial pathology laboratories (OMPLs) in Brazilian public universities to the diagnosis of lip, oral cavity, and oropharyngeal squamous cell carcinoma (SCC). A cross-sectional study was performed using biopsy records from a consortium of sixteen public OMPLs from all regions of Brazil (North, Northeast, Central-West, Southeast, and South). Clinical and demographic data of patients diagnosed with lip, oral cavity, and oropharyngeal SCC between 2010 and 2019 were collected from the patients' histopathological records. Of the 120,010 oral and maxillofacial biopsies (2010-2019), 6.9% (8,321 cases) were diagnosed as lip (0.8%, 951 cases), oral cavity (4.9%, 5,971 cases), and oropharyngeal (1.2%, 1,399 cases) SCCs. Most cases were from Brazil's Southeast (64.5%), where six of the OMPLs analyzed are located. The predominant profile of patients with lip and oral cavity SCC was Caucasian men, with a mean age over 60 years, low schooling level, and a previous history of heavy tobacco consumption. In the oropharyngeal group, the majority were non-Caucasian men, with a mean age under 60 years, had a low education level, and were former/current tobacco and alcohol users. According to data from the Brazilian National Cancer Institute, approximately 9.9% of the total lip, oral cavity, and oropharyngeal SCCs reported over the last decade in Brazil may have been diagnosed at the OMPLs included in the current study. Therefore, this data confirms the contribution of public OMPLs with respect to the important diagnostic support they provide to the oral healthcare services extended by the Brazilian Public Health System.

Oral lesions in children/teenagers: a cross-sectional study of 225 reports in a pathology service in Amazon.

BACKGROUND: Epidemiologic studies of oral lesions in pediatric patients are scarce in Brazil, and especially in the northern region of the country. We aim to describe the distributions of oral lesions in children and teenagers diagnosed in a Pathology service of Amazon for over 15 years. METHODS: The oral pathology files were retrospectively retrieved from January 2002 to December 2016 of patients younger than 18 years old at the Pathology Service of the Federal University of Amazonas. Patient information such as gender, age, race, aspect of the lesion, anatomical site, and histological type was compiled from the file of requisitions and histopathologic reports. Oral lesions were subdivided into 11 categories. RESULTS: From a total of 2437 histopathological oral reports, 225 of them were from children. Of these, 125 (55.6%) were from male patients and 100 (44.4%) from female patients with a median age of 13 years. Of the 11 categories of oral pathologies, the one of the highest numbers was salivary gland disease (N.=50, 22.2%) with the subtype mucocele (N.=41, 18.22%) as the most prevalent followed by Miscellaneous pathology (N.=27, 12%) with the predominance of the subtype granulation tissue (N.=11, 4.89%) and finally Odontogenic tumors (N.=26, 11.6%) in third place, with odontoma (N.=16, 7.11%) as the most prevalent subtype. CONCLUSIONS: Mucocele was the most prevalent lesion found, showing that a traumatic etiology is likely to be the most common situation in children and teenagers, while neoplastic lesions are generally rare.

A multicenter study of oral sarcomas in Brazil.

OBJECTIVES: The aim of this study was to investigate the prevalence of oral sarcomas from geographic regions of Brazil. MATERIALS AND METHODS: A cross-sectional study was conducted on biopsies obtained from January 2007 to December 2016 at twelve Brazilian oral and maxillofacial pathology centres. Gender, age, evolution time, clinical aspects, tumour location, tumour size at diagnosis, radiographic aspects and histopathological diagnosis were evaluated. Data were analysed using descriptive statistical methods. RESULTS: From 176,537, a total of 200 (0.11%) oral sarcomas were reported, and the most prevalent were osteosarcomas (74 cases; 37%) and Kaposi's sarcomas (52 cases; 26%). Males were more affected than females at a mean age of 32.2 years old (range of 3-87 years). The most common symptoms were swelling¸ localised pain and bleeding at a mean evolution time of 5.14 months (range <1-156 months). The lesions were mostly observed in the mandible (90 cases; 45%), with a mean tumour size of 3.4 cm (range of 0.3-15 cm). Radiographically, the lesions presented a radiolucent aspect showing cortical bone destruction and ill-defined limits. CONCLUSIONS: Oral sarcomas are rare lesions with more than 50 described subtypes. Osteosarcomas and Kaposi's sarcomas were the main sarcomas of the oral cavity in Brazil.

Clinicopathological and immunohistochemical features of the oral lymphoepithelial cyst: A multicenter study.

BACKGROUND: Analyze the clinical, demographic, histopathological, and immunohistochemical features of oral lymphoepithelial cyst (OLEC). METHODS: Samples were retrospectively retrieved from five oral pathology services. Clinical and demographic data were collected from patient charts. Histopathological and immunohistochemical (CD3 and CD20) features were evaluated. Data analysis involved descriptive statistics and bivariate analyses (P ≤ .05). RESULTS: Seventy-seven cases were found among a total of 146 150 specimens (0.05%). OLEC was predominantly diagnosed in females (70.1%). Mean patient age was 46.51 years. The lesions arose mainly on the lateral border of the tongue (40.3%), measured up to 1 cm (61.0%), and were asymptomatic (64.9%). Twenty-four lesions (31.2%) were white. Forty-one cases (53.2%) presented lymphocytic inflammatory infiltrate with no specific arrangement. The cystic lining was composed of a non-keratinized stratified epithelium (59.7%) presenting hyperplasia (39.0%). Connection with the surface, epithelium was found in 23 cases (29.9%) and 31 (40.3%) cases had two or more cystic cavities. The lumen content was predominantly desquamated cells (48.1%). Subgemmal neurogenous plaque was found in 11/42 (26.2%) cases involving the tongue. CD20+ cells predominated in 36/63 cases (57.2%), and lymphocytic inflammatory infiltrate was not always continuous around the cystic cavity (52.4%). CONCLUSION: Lymphoepithelial cyst is an uncommon lesion of the oral cavity. The present study offers the largest sample of OLEC for which clinical, demographic, histopathological, and immunohistochemical features were evaluated. The clinical and demographic findings were similar to those described in previous reports, but the microscopic analyses revealed interesting aspects of the cystic epithelium and the lymphocytic inflammatory infiltrate in OLEC.

Revisão dos aspectos morfológicos e imunoistoquímicos do linfoma difuso de grandes células B (LDGCB) com ênfase em boca / Review of the morphological and immunohistochemical aspects of diffuse large B cell lymphoma (DLBCL) with emphasis on the mouth

Os linfomas compreendem um grupo diverso de neoplasias malignas, provenientes de células do sistema imunológico em diferentes estágios de diferenciação. Objetivo: o propósito deste artigo é facilitar o diagnóstico do linfoma difuso de grandes células B (LDGCB) por meio de seus aspectos clínicos, morfológicos e imunoistoquímicos, além de suas peculiaridades como manifestação primária em boca. Revisão de literatura: foi realizada uma revisão narrativa da literatura por intermédio de artigos selecionados nas bases de dados PubMed, Medline, SciELO e Lilacs, pela busca por palavras-chave. Aspectos relacionados a classificação e manifestações clínicas também foram considerados, a fim de facilitar o entendimento da lesão e de suas particularidades em boca. Verificou-se que o LDGCB representa a variante mais comum em boca. Os sinais e sintomas clínicos relacionados a essa condição podem ser: aumento de volume, dor, ulceração, alteração de cor da mucosa ou até mesmo parestesia. Morfologicamente, os LDGCBs apresentam células grandes, com padrão de crescimento difuso, citoplasma escasso, nucléolos evidentes e mitoses. Na imunoistoquímica, os LDGCBs são geralmente positivos para CD20 e outros marcadores da linhagem B (CD19, CD79a, PAX5 e CD138), dependendo do estágio de maturação em que se encontram as células B. Considerações finais: o diagnóstico do LDGCB em boca representa um desafio contínuo para os patologistas, em função da heterogeneidade de suas características morfológicas e imunofenotípicas.(AU)

Lymphomas comprise a diverse group of malignant neoplasias from cells of the immune system at different stages of differentiation. Objective: this article aimed to facilitate the diagnosis of diffuse large B-cell lymphoma (DLBCL) through its clinical, morphological, and immunohistochemical aspects, as well as its particularities as a primary manifestation in the mouth. Literature Review: hence, a narrative review of the literature was performed using articles selected in the PubMed, Medline, SciELO, and Lilacs databases through keyword search. Aspects related to classification and clinical manifestations were also considered to facilitate the understanding of the lesion and its particularities in the mouth. It was verified that the diffuse large B-cell lymphoma (DLBCL) represents the most common variant in the mouth. The clinical signs and symptoms related to this condition may be increased volume, pain, ulceration, changed mucosal color, or even paresthesia. Morphologically, DLBCL presents large cells with diffuse growth pattern, scarce cytoplasm, evident nucleoli, and mitoses. In immunohistochemistry, DLBCL is usually positive for CD20 and other markers of lineage B (CD19, CD79a, PAX5, and CD138) depending on the maturation stage in which B cells are found. Final considerations: the diagnosis of oral DLBCL represents a continuous challenge for pathologists due to the heterogeneity of its morphological and immunophenotypic characteristics.(AU)

Oral manifestations and histopathology of minor salivary gland from patients with Sjögren's Syndrome and its diagnosis in a public health system

Objective: to analyze the oral manifestations, sialometry and the histopathology of the minor salivary glands of patients with Sjögren Syndrome (SS) treated in a public health system and diagnosed according to European American Consensus Group (EACG) criteria. Material and Methods: the 32 patients were submitted to Shirmer test, oral cavity exam, unstimulated and stimulated salivary flow measurement and, in some cases, to the serological testing. For certain patients a minor salivary gland biopsy was carried out. Results: 10 patients were diagnosed with Sjögren Syndrome (SS), among whom: 40% were diagnosed with primary (pSS) and 60% with secondary Sjögren Syndrome (sSS). All patients diagnosed with this condition complained of xerostomia and xeropthalmia. Besides xerostomia, the most frequent oral manifestations were difficulty in swallowing, dry lips, hyperemic gums and atrophic change in tongue papillae. The average scores of the Schirmer and salivary flow tests were lower in patients with sSS. Conclusion: the oral signs and symptoms are extremely important in the multisystem involvement of the SS, which emphasizes the dental surgeon responsibility in managing these patients. The establishment of multidisciplinary diagnostic centers is of utmost importance, as well as the ability to offer more objective exams in the public health system aiming at increasing the accuracy of Sjögren Syndrome diagnosis.

Manifestações bucais em pacientes portadores de doenças sexualmente transmissíveis / Oral manifestations in subjects with sexually transmitted diseases

Introdução: a despeito dos avanços tecnológicos ocorridos na área médica nas últimas décadas, as DST persistem em nosso meio como importanteagravo de Saúde Pública, ancorado, quiçá, na falta de conhecimento dos seus mecanismos de transmissão. Particularmente a cavidade oral não tem sido objeto de muitos estudos aprofundados sobre o seu papel na transmissão e no desenvolvimento das DST. O presente estudo visa diminuir tal vácuo de informações em nosso município, assim como contribuir para o conhecimento da epidemiologia das DST em nosso meio. Objetivo: averiguar a prevalência de manifestações intraorais em pacientes portadores de doenças sexualmente transmissíveis (DST) na cidade de Manaus, Amazonas, no ano de 2008. Métodos: foram avaliados 157 portadores de doenças sexualmente transmissíveis em atendimento na Fundação Alfredo da Matta. As lesões orais foram detectadas por exame clínico oral, exames citopatológicos (raspados das lesões) e histopatológicos (biópsias). Resultados: em 24,2% dos participantesforam encontradas 46 (29,1%) lesões orais possivelmente relacionadas com as DST. Observou-se associação signifi cativa entre o nível educacional e o conhecimento acerca da relação entre lesões orais e DST, porém não se obteve associação entre a presença de lesões orais e práticas do sexo oral, nível de escolaridade ou grau de higienização bucal. As análises estatísticas foram feitas no SPSS (nível de confi ança 95%) e foram aplicados testes de qui-quadrado. Conclusão: este estudo evidenciou a existência de demanda reprimida de portadores de DST com relação ao diagnóstico de lesões em mucosa oral, assim como de tratamento e/ou encaminhamento para outros serviços especializados. A necessidade de implantação e oferta de atenção à saúde na área de estomatologia no Amazonas deve ser considerada

Introduction: despite the technological progresses that have taken place in the medical fi eld in the last decades, STD persist to be an aggravating factor in public health. This is perhaps due to the lack of knowledge of our transmission mechanisms. Particularly, the role of the oral cavity in the transmission and development of STD has not been the subject of many detailed studies. This study aims to reduce the information vacuum in our municipality, as well as contribute to the knowledge of epidemiology in STD in our . Objective: investigating the prevalence of oral manifestations of sexually transmitted diseases (STD) in infected individuals in Manaus, Amazon, in the year 2008. Methods: 157 people with confi rmed clinical and laboratorial STD diagnosis undergoing treatment at the Alfredo da Matta Foundation. The oral lesions were detected by oral clinical examination and microscopic techniques for cells and tissue studies. Results: in 24,2% participants 46 (29,1%) oral lesions were observed, which could possibly linked to STDs. Direct correlation was observed between educational level and knowledge of oral lesions and STD, but no correlation was found between oral lesions and oral sexual practice,educational level or oral hygiene. The statistical analysis was done on SPSS (95% confi dence level) and chi-square tests were applied. Conclusion: this study showed the existence of a hidden population of individuals with needs on precocious oral lesions diagnosis, treatment and referring for other specialized services, for example, the Oncology, considering the risk of malignancy of some lesions. The necessity to establish a stomatology service in the Amazon must be considered.