Shared epigenetic alterations between oral cancer and periodontitis: A preliminary study.

INTRODUCTION: We recently developed a non-invasive sampling procedure for oral squamous cell carcinoma (OSCC) detection based on DNA methylation analysis of a panel of 13 genes. Oral cancer, as well as acute and chronic inflammatory diseases, may influence the methylation level of several genes in the oral cavity. In the present study, we evaluated the presence of periodontal disease (PD) and the methylation status using our 13-gene panel. METHODS: Oral brushing specimens were collected from three different patient groups: 23 gingival OSCC patients, 15 patients affected by PD, and 15 healthy volunteers lacking evidence of PD. DNA methylation analysis was performed and each sample was determined to be positive or negative based on a predefined cut-off value. RESULTS: Positive results were found for 23/23 OSCC patients, 3/15 PD patients, and 0/15 samples from healthy volunteers. The GP1BB and MIR193 genes in the PD group exhibited mean methylation levels similar to OSCC patients. ZAP70 showed different methylation levels among three groups. CONCLUSION: Preliminary data identified shared epigenetic alterations between PD and OSCC patients in two inflammatory genes (GP1BB and MIR193). This study may help to identify potential links between the two diseases and serve as a starting point for the future research focused on pathogenesis.

Prognostic role of pre-treatment magnetic resonance imaging (MRI)-based radiomic analysis in effectively cured head and neck squamous cell carcinoma (HNSCC) patients.

OBJECTIVES: To identify and validate baseline magnetic resonance imaging (b-MRI) radiomic features (RFs) as predictors of disease outcomes in effectively cured head and neck squamous cell carcinoma (HNSCC) patients. MATERIALS AND METHODS: Training set (TS) and validation set (VS) were retrieved from preexisting datasets (HETeCo and BD2Decide trials, respectively). Only patients with both pre- and post-contrast enhancement T1 and T2-weighted b-MRI and at least 2 years of follow-up (FUP) were selected. The combination of the best extracted RFs was used to classify low risk (LR) vs. high risk (HR) of disease recurrence. Sensitivity, specificity, and area under the curve (AUC) of the radiomic model were computed on both TS and VS. Overall survival (OS) and 5-year disease-free survival (DFS) Kaplan-Meier (KM) curves were compared for LR vs. HR. The radiomic-based risk class was used in a multivariate Cox model, including well-established clinical prognostic factors (TNM, sub-site, human papillomavirus [HPV]). RESULTS: In total, 57 patients of TS and 137 of VS were included. Three RFs were selected for the signature. Sensitivity of recurrence risk classifier was 0.82 and 0.77, specificity 0.78 and 0.81, AUC 0.83 and 0.78 for TS and VS, respectively. VS KM curves for LR vs. HR groups significantly differed both for 5-year DFS (p<.0001) and OS (p=.0004). A combined model of RFs plus TNM improved prognostic performance as compared to TNM alone, both for VS 5-year DFS (C-index: 0.76 vs. 0.60) and OS (C-index: 0.74 vs. 0.64). CONCLUSIONS: Radiomics of b-MRI can help to predict recurrence and survival outcomes in HNSCC.

Congenital fibrous hamartoma of the tip of the tongue: A novel peculiar entity.

Congenital fibrous hamartoma of the tip of the tongue, a peculiar and novel entity, consists of one or two asymptomatic pearly or yellowish nodules, not exceeding 0.5 cm in maximum diameter, at the tip of the tongue, ventrally or dorsally. Unlike other localizations, congenital fibrous hamartoma of the tip of the tongue is not associated with cleft lip or palate, or with feeding problems. Surgical excision should be avoided, reserved only for dubious cases, since the lesions are benign and stable over time.

Surgical Management of Primary Chronic Osteomyelitis of the Jaws: The Use of Computer-Aided-Design/Computer-Aided Manufacturing Technology for Segmental Mandibular Resection.

The term osteomyelitis of the jaws identifies different pathological patterns characterized by the involvement of the cortical bone and bone marrow in osteoarticular infections.At the head and neck level, the segment most affected by osteomyelitis is the mandible and in most of the cases the cause of the infection is bacterial, as a result of pulp or periodontal infections, post-extraction alveolitis, foreign bodies and fractures. The mandibular PCO often presents with an insidious onset, without a striking acute phase, and it is characterized by recurrent episodes of pain, swelling, lockjaw, latero-cervical lymphadenopathy, without signs of suppuration.Three patients have been collected and recorded for the study.The authors believe that in the more advanced cases of PCO in adult patients, in which the mandibular bone appears almost entirely sclerotic and deformed, and that are not responsive to pharmacological therapy or to conservative surgical therapies such as decortication, it is necessary to perform a complete removal of the portion affected by osteomyelitis, with lower alveolar nerve preservation and contextual reconstruction with free microvascular bone flap.Our review aims to describe the clinico-pathological features of a rare pathological entity, propose a surgical treatment algorithm using computer-aided-design/computer-aided manufacturing technology and review the existing literature.

Use of Kinesiography to Assess Mandibular Function Following Segmental Resection and Microvascular Reconstruction.

Mandibular reconstruction has attained adequate morphological outcomes. However, some patients encounter difficulties in oral function and limited mandibular movements. An objective: evaluation has seldom featured actual kinetic measurements after mandibular reconstruction.Thirty patients who underwent mandibular reconstruction using bony free flap were enrolled in the study. Twenty-two patients were recruited after surgery and compared to a control group of 8 healthy subjects; 8 patients underwent both pre and postoperative evaluations. For each patient, a kinesiographic scan was obtained, recording maximum mouth opening, maximal laterality, and maximal protrusion.All postoperative kinesiographic evaluations were performed at least 6 months after surgery to ensure complete healing. In the first group of 22 patients, all measured movements were less than those of healthy controls, in particular maximum mouth opening. In the second study group (pre and postoperative evaluation), the postsurgical values did not achieve the control ones, but were no less than the preoperative values, granting adequate functional outcomes.The kinesiograph appears useful for objectively recording the functional outcomes in patients who have undergone mandibular reconstruction. The postoperative jaw movements were acceptable, ensuring a sufficient functional recovery.

Pre-Operative Evaluation of DNA Methylation Profile in Oral Squamous Cell Carcinoma Can Predict Tumor Aggressive Potential.

BACKGROUND: Prognosis of oral squamous cell carcinoma (OSCC) is difficult to exactly assess on pre-operative biopsies. Since OSCC DNA methylation profile has proved to be a useful pre-operative diagnostic tool, the aim of the present study was to evaluate the prognostic impact of DNA methylation profile to discriminate OSCC with high and low aggressive potential. METHODS: 36 OSCC cases underwent neoplastic cells collection by gentle brushing of the lesion, before performing a pre-operative biopsy. The CpG islands methylation status of 13 gene (ZAP70, ITGA4, KIF1A, PARP15, EPHX3, NTM, LRRTM1, FLI1, MiR193, LINC00599, MiR296, TERT, GP1BB) was studied by bisulfite Next Generation Sequencing (NGS). A Cox proportional hazards model via likelihood-based component-wise boosting was used to evaluate the prognostic power of the CpG sites. RESULTS: The boosting estimation identified five CpGs with prognostic significance: EPHX3-24, EPHX3-26, ITGA4-3, ITGA4-4, and MiR193-3. The combination of significant CpGs provided promising results for adverse events prediction (Brier score = 0.080, C-index = 0.802 and AUC = 0.850). ITGA4 had a strong prognostic power in patients with early OSCC. CONCLUSIONS: These data confirm that the study of methylation profile provides new insights into the molecular mechanisms of OSCC and can allow a better OSCC prognostic stratification even before surgery.

Intratumoral Heterogeneity in Recurrent Metastatic Squamous Cell Carcinoma of the Oral Cavity: New Perspectives Afforded by Multiregion DNA Sequencing and mtDNA Analysis.

PURPOSE: Improvements in sequencing technologies have shown that genetic differences among neoplastic cells can reflect clonal expansion. Intratumor heterogeneity (ITH) has been suggested to explain differences in prognosis and treatment response, indicating that personalized medicine is the goal of the future. This study evaluated ITH in 5 patients with recurrent metastatic oral squamous cell carcinoma (OSCC) and tracked the evolution from non-neoplastic tissue to neoplastic events developing after primary tumor formation. PATIENTS AND METHODS: Representative regions were macrodissected from specimens obtained from patients with OSCC of the tongue (n = 4) and floor of the mouth (n = 1). ITH and tumor evolution were explored by analyzing DNA mutations disclosed by next-generation sequencing of specific driver genes combined with changes in the mtDNA D-loop hypervariable region. Phylogenetic trees were generated employing MAFFT tool with UPGMA/Jukes-Cantor serving as the substitute model. RESULTS: High levels of heterogeneity were observed within and among tumors. ITH emerged as metastatic and recurrent events progressed, but the evolutionary patterns differed. In some patients, specific subclones persisted during tumor relapse. Neighboring tissue also was heterogeneous at the premalignant level. CONCLUSIONS: A multiregion approach yielded more representative data than did single samples when tumors were subjected to molecular investigation. Persistent mutations that might be targeted by individualized medicine were thus exposed. Mitochondrial DNA is a useful adjunct tool when studying the phylogenetic evolution of subclones. The clinical implications of "field" heterogeneity should be studied in depth.

A Noninvasive Test for MicroRNA Expression in Oral Squamous Cell Carcinoma.

MicroRNAs have recently been proposed as non-invasive biomarkers in Oral Squamous Cell Carcinoma (OSCC). The aim of this study was to analyze the expression of a panel of miRNAs in epithelial cells collected by oral brushing from OSCCs from regenerative areas after OSCC surgical resection and from their respective normal distant mucosa. Oral brushing specimens were collected from 24 healthy donors, 14 OSCC patients with specimens from tumour and normal distant mucosa, and from 13 patients who had OSCC resection, with samples from regenerative areas after OSCC resection and normal distant mucosa. Expression levels of eight targets (miR-21, miR-375, miR-345, miR-181b, miR-146a, miR-649, miR-518b, and miR-191) were evaluated by real-time Polymerase Chain Reaction (PCR). A highly significant between-group difference was found for miR-21 (F = 6.58, p < 0.001), miR-146a (F = 6.974, p < 0.001), and miR-191 (F = 17.07, p < 0.001). The major difference was observed between samples from healthy donors and from OSCC brushing, whereas no significant differences were observed between areas infiltrated by OSCC and their respective normal distant mucosa. Furthermore, altered expression of miR-146a and miR-191 was also observed in regenerative areas after OSCC resection. CONCLUSIONS: Oral brushing could be proposed as a noninvasive method to study microRNA expression in oral mucosa in OSCC patients.

Tumor Infiltration Depth as Predictor of Nodal Metastasis in Early Tongue Squamous Cell Carcinoma.

PURPOSE: A retrospective longitudinal study was conducted to identify the cutoff value of infiltration depth for predicting the risk of lymph node metastasis of the neck in a well-defined population of surgically treated patients affected by stage T1 to T2 oral squamous cell carcinoma of the tongue. PATIENTS AND METHODS: Sixty-seven patients were enrolled in this study. Forty-four patients (65.5%) had pN0 status and 23 (34.5%) had pN(+) status. Thirty-five positive lymph nodes were analyzed. The median follow-up for these patients was 51.4 months. RESULTS: The mean infiltration depth of the N-negative group was 2.4 mm; this was substantially different from the mean value observed in the N-positive group at 5.5 mm. A meaningful cutoff was identified at an infiltration depth value of 4 mm. CONCLUSION: Infiltration depth was identified as an important predictor for neck nodal status. In this specific population, mortality was associated with increasing tumor infiltration depth.

Orbital Reconstruction: Patient-Specific Orbital Floor Reconstruction Using a Mirroring Technique and a Customized Titanium Mesh.

OBJECTIVE: Enophthalmos is a severe complication of primary reconstruction of orbital floor fractures. The goal of secondary reconstruction procedures is to restore symmetrical globe positions to recover function and aesthetics. The authors propose a new method of orbital floor reconstruction using a mirroring technique and a customized titanium mesh, printed using a direct metal laser-sintering method. METHODS: This reconstructive protocol involves 4 steps: mirroring of the healthy orbit at the affected site, virtual design of a patient-specific orbital floor mesh, CAM procedures for direct laser-sintering of the customized titanium mesh, and surgical insertion of the device. Using a computed tomography data set, the normal, uninjured side of the craniofacial skeleton was reflected onto the contralateral injured side, and a reconstructive orbital floor mesh was designed virtually on the mirrored orbital bone surface. The solid-to-layer files of the mesh were then manufactured using direct metal laser sintering, which resolves the shaping and bending biases inherent in the indirect method. An intraoperative navigation system ensured accuracy of the entire procedure. RESULTS: Clinical outcomes were assessed using 3dMD photogrammetry and computed tomography data in 7 treated patients. CONCLUSION: The technique described here appears to be a viable method to correct complex orbital floor defects needing delayed reconstruction. This study represents the first step in the development of a wider experimental protocol for orbital floor reconstruction using computer-assisted design-computer-assisted manufacturing technology.

Updates on the Construction of an Eyeglass-Supported Nasal Prosthesis Using Computer-Aided Design and Rapid Prototyping Technology.

This study was undertaken to design an updated connection system for an eyeglass-supported nasal prosthesis using rapid prototyping techniques. The substructure was developed with two main endpoints in mind: the connection to the silicone and the connection to the eyeglasses. The mold design was also updated; the mold was composed of various parts, each carefully designed to allow for easy release after silicone processing and to facilitate extraction of the prosthesis without any strain. The approach used in this study enabled perfect transfer of the reciprocal position of the prosthesis with respect to the eyeglasses, from the virtual to the clinical environment. Moreover, the reduction in thickness improved the flexibility of the prosthesis and promoted adaptation to the contours of the skin, even during functional movements. The method described here is a simplified and viable alternative to standard construction techniques for nasal prostheses and offers improved esthetic and functional results when no bone is available for implant-supported prostheses.

Computer-Aided Rehabilitation of Maxillary Oncological Defects Using Zygomatic Implants: A Defect-Based Classification.

PURPOSE: A complete maxillectomy for neoplastic lesions leads to serious oral dysfunction. Zygomatic implants for fixed bridge support are considered beneficial for maxillary defects after tumor resection. MATERIALS AND METHODS: This clinical study examined the management of patients with different maxillary defect types who underwent delayed rehabilitation using zygomatic implants and immediate prosthetic loading. Virtual preoperative planning and intraoperative navigation were performed in all cases. RESULTS: Five patients were treated with this new method. The total number of zygomatic implants positioned was 17. Four patients had immediate loading of a fixed prosthesis and 1 had delayed loading. One patient had 1 failed implant. CONCLUSION: The use of preoperative virtual surgical planning and an intraoperative navigation system allows the surgeon to achieve safer implant positioning in a complex anatomic site. A systematic bone defect classification was created and a specific treatment protocol is proposed for each type of defect.

Aggressive Central Giant Cell Granuloma of the Mandible Treated With Conservative Surgical Enucleation and Interferon-α-2a: Complete Remission With Long-Term Follow-Up.

Central giant cell granuloma (CGCG) is a benign tumor of the jaws. Aggressive lesions present a strong tendency toward recurrence after surgical enucleation; thus, en bloc resection and microvascular bone free flap transfer are usually performed. However, in young patients, aggressive surgical treatment is a not always suitable solution. This report describes the case of a young female patient who developed an aggressive recurrence of CGCG after its diagnosis and enucleation from the mandible. Surgical enucleation with subcutaneous injection of interferon-α-2a was performed. The patient was evaluated every 6 weeks, and after 6 months radiographic evidence of complete bone regeneration was obtained. No sign of recurrence was seen after 8 years of follow-up. A review of the literature proved that interferon treatment is an effective strategy to avoid extensive surgery in patients with aggressive CGCG.

Delayed Orbital Floor Reconstruction Using Mirroring Technique and Patient-Specific Implants: Proof of Concept.

Enophthalmos is a severe complication of primary reconstruction following orbital floor fractures, oncological resections, or maxillo-facial syndromes. The goal of secondary orbital reconstruction is to regain a symmetrical globe position to restore function and aesthetics. In this article, we present a method of computer-assisted orbital floor reconstruction using a mirroring technique and a custom-made titanium or high-density polyethylene mesh printed using computer-aided manufacturing techniques. This reconstructive protocol involves four steps: mirroring of the healthy orbit computer tomography files at the contralateral affected site, virtual design of a customized implant, computer-assisted manufacturing (CAM) of the implant using Direct Metal Laser Sintering (DMLS) or Computer Numerical Control (CNC) methods, and surgical insertion of the device. Clinical outcomes were assessed using 3dMD photogrammetry and computed tomography measures in 13 treated patients and compared to a control group treated with stock implants. An improvement of 3.04 mm (range 0.3-6 mm) in globe protrusion was obtained for the patients treated with patient-specific implants (PSI), and no major complications have been registered. The technique described here appears to be a viable method for correcting complex orbital floor defects needing delayed reconstruction.

Morpho-functional analysis of the temporomandibular joint following mandible-first bimaxillary surgery with mandible-only patient-specific implants.

The aim of this study was to evaluate condylar and glenoid fossa remodeling after bimaxillary orthognathic surgery guided by patient-specific mandibular implants. In total, 18 patients suffering from dentofacial dysmorphism underwent a virtually planned bimaxillary mandibular PSI-guided orthognathic procedure. One month prior to surgery, patients underwent a CBCT scan and optical scans of the dental arches; these datasets were re-acquired 1 month and at least 9 months postsurgery. Three-dimensional models of the condyles, glenoid fossae, and interarticular surface space (IASS) were obtained and compared to evaluate the roto-translational positional discrepancy and surface variation of each condyle and glenoid fossa, and the IASS variation. The condylar position varied by an average of 4.31° and 2.18 mm, mainly due to surgically unavoidable ramus position correction. Condylar resorption remodeling was minimal (average ≤ 0.1 mm), and affected skeletal class III patients the most. Later condylar remodeling was positively correlated with patient age. No significant glenoid fossa remodeling was observed. No postoperative orofacial pain was recorded at clinical follow-up. The procedure was accurate in minimizing the shift in relationship between the bony components of the TMJ and their remodeling, and was effective in avoiding postoperative onset of orofacial pain. An increase in sample size, however, would be useful to confirm our findings.

Thirteen-gene DNA methylation analysis of oral brushing samples: A potential surveillance tool for periodic monitoring of treated patients with oral cancer.

BACKGROUND: We evaluated the prognostic role of 13-gene DNA methylation analysis by oral brushing repeatedly performed during the follow-up of patients surgically treated for oral cancer. METHODS: This is a nested case-control study including 61 patients for a total of 64 outcomes (2/61 patients experienced multiple relapses). Samples were collected at baseline (4-10 months after OSCC resection) and repeatedly every 4-10 months until relapse or death. DNA methylation scores were classified as persistently positive, persistently negative, or mixed. RESULTS: Twenty cases who had persistently positive scores and 30 cases with mixed scores had, respectively, an almost 42-fold (p < 0.001) and 32-fold (p = 0.006) higher likelihood of relapse, compared to 14 patients with persistently negative scores. The last score before reoccurrence was positive in 18/19 secondary events. CONCLUSIONS: The 13-gene DNA methylation analysis may be considered for the surveillance of patients treated for oral carcinoma.

Pre-operative incisional biopsy of oral squamous cell carcinoma: high podoplanin expression is related to perineural invasion and may be a useful predictor of disease progression.

OBJECTIVE: Immunohistochemical analysis of podoplanin expression as a pre-operative molecular marker for perineural invasion (PNI) may represent an attractive strategy for surgical management of oral squamous cell cancer (OSCC). We evaluated the relationship between podoplanin expression and PNI in pre-operative incisional biopsies of OSCC. STUDY DESIGN: After performing pathological staging and histologic and immunohistochemical evaluation of 83 surgical specimens, we performed multivariable logistic regression analysis to examine the relationship between PNI and independent variables. To evaluate the utility of podoplanin immunopositivity for discrimination of PNI status pre-operatively, we calculated the sensitivity, specificity, positive predictive value, and negative predictive value. We performed receiver operating characteristic curve analysis to evaluate the diagnostic accuracy of podoplanin immunopositivity for predicting PNI alone and in combination with age, T stage, N stage, and index site. RESULTS: We observed podoplanin expression in 42 (50.6%) of all the 83 pre-operative incisional biopsies and 29 of the pre-operative biopsies of the 31 (93.5%) postoperative specimens with PNI. The rate of podoplanin expression was significantly higher in patients with pT3 to pT4 stage and pN+ stage disease. Podoplanin positivity in the pre-operative biopsy showed high sensitivity in predicting PNI in the surgical specimen. CONCLUSION: Podoplanin expression appears to be an independent pre-operative variable significantly related to PNI and a possibly valuable prognostic marker for therapeutical planning and surgical treatment of OSCC.

Direct healthcare costs of oral cancer: A retrospective study from a tertiary care center.

The aim of this study was to retrospectively evaluate the direct costs of OSCC treatment and postsurgical surveillance in a tertiary hospital in northeast Italy. Sixty-three consecutive patients surgically treated for primitive OSCC at S. Orsola Hospital in Bologna (Italy) between January 2018 and January 2020 were analyzed. Billing records of the Emilia Romagna healthcare system and institutional costs were used to derive specific costs for the following clinical categories: operating theatre costs, intensive and ordinary hospitalization, radiotherapy, chemotherapy, postsurgical complications, visits, and examinations during the follow-up period. The study population comprised 17 OSCC patients classified at stage I, 14 at stage II, eight at stage III, and 24 at stage IV. The estimated mean total direct cost for OSCC treatment and postsurgical surveillance was €26 338.48 per patient (stage I: €10 733, stage II: €19 642.9, stage III: €30 361.4, stage IV: €39 957.2). An advanced diagnosis (stages III and IV), complex surgical procedure, and loco-regional recurrences resulted in variables that were significantly associated with a higher cost of OSCC treatment and postsurgical surveillance. Redirection of funds used for OSCC treatment to screening measures may be an effective strategy to improve overall health outcomes and optimize national health resources.

Dissecting human anatomy learning process through anatomical education with augmented reality: AEducAR 2.0, an updated interdisciplinary study.

Anatomical education is pivotal for medical students, and innovative technologies like augmented reality (AR) are transforming the field. This study aimed to enhance the interactive features of the AEducAR prototype, an AR tool developed by the University of Bologna, and explore its impact on human anatomy learning process in 130 second-year medical students at the International School of Medicine and Surgery of the University of Bologna. An interdisciplinary team of anatomists, maxillofacial surgeons, biomedical engineers, and educational scientists collaborated to ensure a comprehensive understanding of the study's objectives. Students used the updated version of AEducAR, named AEducAR 2.0, to study three anatomical topics, specifically the orbit zone, facial bones, and mimic muscles. AEducAR 2.0 offered two learning activities: one explorative and one interactive. Following each activity, students took a test to assess learning outcomes. Students also completed an anonymous questionnaire to provide background information and offer their perceptions of the activity. Additionally, 10 students participated in interviews for further insights. The results demonstrated that AEducAR 2.0 effectively facilitated learning and students' engagement. Students totalized high scores in both quizzes and declared to have appreciated the interactive features that were implemented. Moreover, interviews shed light on the interesting topic of blended learning. In particular, the present study suggests that incorporating AR into medical education alongside traditional methods might prove advantageous for students' academic and future professional endeavors. In this light, this study contributes to the growing research emphasizing the potential role of AR in shaping the future of medical education.