The development and implementation of a biopsy safety strategy for oral medicine.

The development and implementation of a biopsy safety strategy is described in this article. Analysis of previous adverse incidents relating to biopsies acted as a catalyst to review our biopsy pathway at Liverpool University Dental Hospital. Input from all staff involved enabled us to develop a biopsy safety strategy which was divided into five stages: preoperative assessment of patient and procedure, team briefings, biopsy surgical safety checklist, surgical removal and handling of biopsy specimens, and post-biopsy follow-up. It is hoped that other clinical teams will take the opportunity to review their own biopsy processes, in the light of our experience.

Development of ocular disease in patients with mucous membrane pemphigoid involving the oral mucosa.

AIM: To determine the rate of development of ocular disease in patients presenting with mucous membrane pemphigoid (MMP) involving their oral mucosa. METHODS: Diagnosis of oral MMP was made on the basis of clinical signs, histology, and direct and indirect immunofluorescence. Age, race, sex, age at diagnosis, progression of eye signs, duration of follow up, and time to progression of ocular disease were recorded. RESULTS: 30 patients with established oral MMP were reviewed. The mean age at diagnosis was 65.2 years (range 46-84 years) and 16/30 (53%) were male. At initial ocular review nine (30%) patients showed ocular signs of pemphigoid, of whom two had mild (IIA IIIB), four moderate (IIB IIIC), and three severe (IIC IIID) disease. The mean interval between diagnosis of oral MMP and first ophthalmic review was 19.3 months (range 0-144). Over the period of follow up two (7%) patients developed ocular disease at 19 months and 48 months, respectively, despite having had no evidence of ocular involvement at presentation. In total, 11 (37%) patients with oral disease eventually showed ocular disease with a calculated incidence rate for the development of ocular disease of 0.03 per person year over 5 years. CONCLUSIONS: MMP may affect different tissues at different stages, often separated by many years. Patients with MMP involving their oral mucosa are at significant risk of developing ocular disease and should remain under ophthalmic review.

Review article: oral ulceration--aetiopathogenesis, clinical diagnosis and management in the gastrointestinal clinic.

Oral ulceration is a common complaint of patients attending out-patient clinics. The aim of this review is to provide the gastroenterologist with a differential diagnosis of oral ulceration, and a practical guide for the management of recurrent aphthous stomatitis, including topical and systemic therapy. The association of recurrent aphthous stomatitis with Behçet's disease and other systemic disorders, including coeliac disease, is discussed. Recent evidence concerning the immunopathogenesis of Behçet's disease is reviewed, including renewed interest in the role of Streptococcus sanguis and possible infectious triggering of an inappropriate immunoinflammatory response, resulting in tissue damage. The efficacy and limitations of conventional treatment for this mutisystem disorder are outlined together with the potential role of novel biological agents, such as anti-tumour necrosis factor-alpha therapy. Oral ulceration, as a manifestation of inflammatory bowel disease and a complication of drug therapy, is described. Guidance is given concerning indications for referral of patients with oral ulceration to an oral physician/surgeon for further investigations, including biopsy if appropriate.

The effect of fluticasone propionate aqueous nasal spray on eosinophils and cytokines in nasal secretions of patients with ragweed allergic rhinitis.

Cytokines active on eosinophils are important in the pathogenesis of allergic diseases. A study was conducted to determine if nasal eosinophilia in allergic rhinitis is associated with an increase in eosinophil-active cytokines in nasal secretions and to compare the effects of fluticasone propionate aqueous nasal spray with astemizole and placebo on the levels of these cytokines. Forty-five patients with moderately severe ragweed allergic rhinitis were randomly assigned to receive 2 weeks of treatment with fluticasone propionate aqueous nasal spray 200 micrograms once daily, astemizole 10 mg once daily, or placebo. Nasal lavage was performed in July (preseason), August (peak season), September (after 2 weeks of treatment), and October (postseason). The number of eosinophils, the amount of eosinophil-derived neurotoxin (EDN), and the amount of eosinophil survival-enhancing activity were measured. Total mean nasal symptom scores, concentrations of nasal eosinophils and EDN, and eosinophil survival-enhancing cytokine activity in nasal secretions were significantly lower after 2 weeks of treatment with fluticasone propionate compared with astemizole or placebo. Survival-enhancing activity was detected in the nasal secretions of 25 patients. By blocking activity with monoclonal antibodies, specific cytokines were identified (granulocyte macrophage-colony stimulating factor, 3 samples; interleukin-3, 2 samples; interleukin-5, 5 samples). In conclusion, eosinophil-active cytokine concentrations parallel the nasal symptoms of patients with ragweed allergic rhinitis. Unlike astemizole, fluticasone propionate significantly lowers cytokine activity in nasal tissue, which may contribute to the therapeutic efficacy of the drug.

The efficacy of fluticasone propionate aqueous nasal spray for allergic rhinitis and its relationship to topical effects.

Fluticasone propionate aqueous nasal spray is an intranasal corticosteroid for the treatment of patients with allergic rhinitis. This double-masked, double-dummy, parallel-group study was conducted to confirm that the efficacy of fluticasone propionate nasal spray is attributable to topical rather than systemic effects. A total of 304 patients with documented seasonal allergic rhinitis were randomly assigned to receive fluticasone propionate nasal spray 200 micrograms once daily (n = 77), oral fluticasone propionate 5 mg once daily (n = 73), oral fluticasone propionate 10 mg once daily (n = 77), or placebo (n = 77) for 14 days. Plasma fluticasone propionate concentrations were determined at baseline and after 14 days of treatment (day 15). Nasal symptoms were recorded daily by patients and assessed weekly by clinicians. On day 15, more patients in the oral fluticasone propionate 5-mg or 10-mg groups, compared with patients in the fluticasone propionate nasal spray group or the placebo group, had detectable plasma fluticasone propionate concentrations, and mean concentrations were higher in the oral fluticasone propionate groups. Both clinician- and patient-rated total and individual nasal symptom scores for obstruction, rhinorrhea, sneezing, and itching were significantly lower in the fluticasone propionate nasal spray group compared with either of the oral fluticasone propionate groups or the placebo group. With few exceptions, oral fluticasone propionate (5 mg or 10 mg) was not significantly different from placebo on any measures of efficacy. These findings indicate that the efficacy of fluticasone propionate nasal spray (200 micrograms once daily) in the treatment of allergic rhinitis results from direct topical effects rather than from indirect effects after systemic absorption.

The sensitivity to chlorhexidine and cetyl pyridinium chloride of staphylococci on the hands of dental students and theatre staff exposed to these disinfectants.

The aim of this investigation was to study the possible emergence of resistant isolates of the genus Staphylococcus on the hands of dental personnel who use 'Hibiscrub' (chlorhexidine-detergent preparation) and cetyl pyridinium-coated gloves. Resistance was determined by a rate-of-kill technique. In four dental student groups (first, second, third and fourth years) no microorganisms survived 30 min exposure to cetyl pyridinium chloride (CPC) or to chlorhexidine diacetate (CDA). In a theatre staff group, no microorganisms survived 30 s exposure to CPC; and only one of 23 isolates survived 30 min exposure to CDA, but was killed after 60 min exposure. It is concluded that staphylococci resistant to either of these disinfectants do not present a problem in dental students or theatre staff.

Delayed suppression of serum luteinizing hormone after naloxone treatment in neonatal female rats.

In female neonatal rats, opiate receptor blockade markedly raises serum luteinizing hormone (LH) levels. The LH effect of acute treatment with opiate antagonists is apparently brief in older rats; however, age-related differences in antagonist pharmacokinetics may result in different LH response patterns. The duration of LH response to naloxone (NAL) and naltrexone (NTX) was examined in 5 day-old (d.o.) female rats and compared to the duration of analgesia blockade. The rise in serum LH following opiate receptor blockade in 5 d.o. rats was of similar duration to that previously observed in older animals and much briefer than blockade of analgesia. Furthermore, neonatal rats exhibited a delayed suppression of LH 6 hr following NAL, but not NTX, treatment. Stimulation and later suppression of LH were still observed after five repetitive NAL treatments at 6 hr intervals.

Immediate knowledge increase from an oral cancer information leaflet in patients attending a primary health care facility: a randomised controlled trial.

The aim was to determine the immediate influence of a validated patient information leaflet (PIL) on oral cancer and knowledge in primary care attenders. Participants were patients (n=800) attending their primary health care provider from 14 general practices (eight dental and six medical) in the north west of England. Measures were a previously validated knowledge questionnaire (36 dichotomous items), self-reported dental service attendance history and demographic variables. The results showed that patients who had read the oral cancer PIL demonstrated a significant increase in knowledge regardless of clinical setting (F[1,739]=246.24, P<0.0001). Patients showed improvements in selecting the correct signs and risk factors associated with disease. Immediate knowledge gain from a simple PIL about oral cancer was found and independent of the primary care facility, where the PIL was distributed.

The experimental evaluation of an oral cancer information leaflet.

The aims of our series of studies were: (1) to prepare an information leaflet about oral cancer for the general public; (2) to design a questionnaire to assess the level of knowledge about oral cancer; and (3) to evaluate the newly prepared leaflet. A study was conducted for each aim. For study 1, multiple drafts of oral cancer leaflets were distributed for comment and editing. For study 2, a large number of statements (100) about oral cancer were compiled and judged. Redundant items were withdrawn. The final version was administered to criterion groups (students, dentists and the public) to assess reliability and validity. For study 3, a multigroup pre- and post-test randomised design (comprising an experimental and two control groups) was adopted to evaluate knowledge improvement from exposure to the oral cancer leaflet. The participants in each study were as follows: in study 1, questions were judged by the authors, colleagues (n=2) and a non-patient group (n=10); in study 2, undergraduate psychology students (n=41), medical students (n=60), dental students (n=82), members of the public (n=54) and general dental practitioners (n=22) were respondents for the reliability/validity assessment; and in study 3, the dental students and members of the public from the previous study participated. The measure was a true/false 36-item questionnaire with additional demographic questions. In study 1 the Flesch readability index for the leaflet equalled approximately 80, i.e. 'fairly easy'. In study 2 the Kuder-Richardson 20 reliability coefficient of the questionnaire equalled 0.76. Criterion validity was confirmed with general dental practitioners scoring greater knowledge than members of the public (p<0.05). In study 3 participants who had access to the leaflet showed a significant increase in knowledge at post-test in comparison to pre-test. Control group results were supportive of a positive effect from leaflet exposure. In conclusion, the design of a health information leaflet, the assessment of reliability and validity of an associated knowledge questionnaire and evaluation of the influence of such a leaflet should be conducted in a series of planned steps. This approach can be used for other health-related issues which require dissemination of information. Three studies have demonstrated the successful application of this design and evaluation model to the area of oral cancer education.

Randomised trial of the psychological effect of information about oral cancer in primary care settings.

AIM: To determine the immediate influence of a validated patient information leaflet (PIL) on patient anxiety and intention to have a screen for oral cancer in primary care attenders. PARTICIPANTS: Patients (n=800) attending their primary health care provider. SETTING: Fourteen general practices (eight dental and six medical) in the northwest of England. DESIGN: Randomised controlled trial with two arms: leaflets provided in information group, leaflet was absent in control group. MEASURES: Single item ratings of (1) intention to have an oral cancer screen, and (2) anxiety towards a screen, (3) perceived risk of oral cancer. Knowledge of oral cancer, self-reported dental service attendance history and demographic variables were also collected. RESULTS: Patients who had read the oral cancer PIL demonstrated an increase in their intention to have a screen (Mann Whitney U test: z=-3.67, P<0.001) and reduced anxiety (Mann Whitney U test: z=-2.07, P<0.05). Subjective risk was not elevated by the extra information. Intention to have a screen was predicted by knowledge level and anxiety (odds ratios: 1.10 and 0.70 respectively, both P's<0.001). CONCLUSION: The influence of an information leaflet appeared to have a positive effect on anxiety level and intentions to agree to receive an oral cancer screen.

Oral tylosis: a re-appraisal.

The oral lesions in patients with tylosis (palmoplantar keratoderma) associated with oesophageal cancer, are evaluated, based on their clinical presentation, histological features and long term follow-up. The terminology of these lesions is discussed, together with a proposed reclassification of some forms of palmoplantar keratoderma.

An oral cancer information leaflet for smokers in primary care: results from two randomised controlled trials.

OBJECTIVES: To investigate whether primary care patients who claim to smoke tobacco gain greater benefit of a patient information leaflet (PIL) on oral cancer than nonsmokers. METHODS: Two studies were conducted. Study 1 examined the research question initially, and Study 2 acted as a replication and inclusion of additional secondary outcome measures. The leaflet was designed and tested in an earlier study. Knowledge of oral cancer was assessed by a previously validated 36-dichotomous-item scale. A single-item question ascertained self-reported smoking status (kappa = 0.94). Study 1 participants were drawn from 14 practices (6 medical, 8 dental). A randomised control group design was adopted. The experimental group received the leaflet on attendance to the practice and then completed the questionnaire. The control group received the questionnaire only. Complete data were collected from 739 respondents. The design of Study 2 was identical; 786 new respondents from 16 practices (7 medical, 9 dental) were collected. RESULTS: Both studies confirmed that smokers knew less about oral cancer than nonsmokers (P < 0.05) when access to the leaflet had been denied. On receipt of the leaflet, there was no distinction in oral cancer knowledge between the smoking status categories of respondents. Evidence of reassurance about screening from leaflet exposure was supported by the second study. CONCLUSION: This programmed research has demonstrated an effect of a brief PIL to offset the decrement in oral cancer knowledge observed in primary care patients who use tobacco in comparison to their nonsmoking counterparts. The leaflet reduced anxiety about oral health screening in smokers.

The use of powdered gloves in dental practice: a cause for concern?

OBJECTIVES: To critically review the potential hazards associated with the use of powdered, natural rubber latex (NRL) gloves in dental practice and to report some practical difficulties which may be encountered when handling dental materials with powdered NRL gloves. DATA SOURCES: Articles published in the international literature over the last 10 years. STUDY SELECTION: A number of recent studies in the medical and surgical literature have confirmed that NRL proteins leach out of latex gloves and bind to surgical glove powders. The most serious, potential hazard associated with the continued use of powdered NRL gloves in dental practice is that of latex sensitization by exposure to aerosolized NRL proteins. Hand dermatitis is now recognized as an occupational hazard in dentistry and has been associated with the continuous wearing of protective gloves. Studies, in the dermatological literature, have suggested that glove powders may exacerbate an irritant dermatitis and enhance the potential for adverse reactions to other components of NRL gloves. The surgical literature has already highlighted the risks of post-operative granuloma formation, due to glove powder contamination of the surgical wound. The possible effects of powder contamination of dental implant sites, on the outcome and success of implants has yet to be established. Recent in vitro studies have investigated the effect of latex glove contamination on the shear-bond strength of porcelain laminate veneers: one study demonstrated that starch powder significantly affected the bond strength, whereas the other showed that latex glove contamination of the porcelain surface did not have any significant effect. Long-term, in vivo studies are now required. CONCLUSIONS: Dental practitioners should consider the potential health risks which are associated with the use of powdered NRL in dental practice. Powder contamination may affect the long-term results and success of clinical procedures in dentistry.

Rings and watches: should they be removed prior to operative dental procedures?

OBJECTIVES: There is no clear evidence to support the recommendation that rings and watches should be removed prior to operative dental procedures. The aim of this study was to measure and identify the bacteria isolated from the skin under rings and watches worn by a group of dental surgeons and to compare the results with a group of non-clinical staff. METHODS: Forty volunteers participated in the study; of these 20 were dental surgeons and 20 were non-clinical staff. Four skin sites were sampled for each volunteer; the skin directly under the ring and on the same finger of the other hand and the skin under the watch face and wrist of the control hand. Bacteria on the swabs were dispersed and inoculated onto plates, which were incubated aerobically for 24 h at 37 degrees C. RESULTS: In both groups of volunteers there was a significantly greater number of bacteria isolated from under rings and watches compared with control sites. Few qualitative differences were found between the microflora found on the skin under rings and watches in the two volunteer groups. CONCLUSIONS: The bacterial flora isolated from volunteers do not commonly cause oral infections but could pose a threat to the immunocompromised patient, particularly in the event of gloves becoming torn or perforated. Effective hand disinfection is difficult to achieve if ring and watches are not removed; they should therefore be removed prior to hand disinfection and donning of gloves.