Prevalence and risk factors of oral potentially malignant disorders in Indonesia: a cross-sectional study undertaken in 5 provinces.

Detection of subjects with oral potentially malignant disorders in a population is key to early detection of oral cancer (OC) with consequent reduction of cancer-related morbidity and mortality. Our aim was to investigate the prevalence and associated risk factors for OPMD in representative provinces of Indonesia. This cross-sectional study was undertaken in five Indonesian provinces: West Java (WJ), Jakarta (JKT), West Papua (WP), West Kalimantan (WK) and Banda Aceh (BA). Respondents answered a previously validated questionnaire including information on ethnicity, occupation, socioeconomic status (SES), oral health practices, and behaviours associated with oral cancer. An oral examination was undertaken using WHO standardized methodology. Data were analysed using ANOVA, Chi-Square, and logistic regression to assess association between risk factors and mucosal disease. A total of 973 respondents between the ages of 17 and 82 years was enrolled (WJ 35.5%,JKT 13.3% WP 18.3%, WK 9%, BA 23.9%). Tobacco smoking (14.8%), Betel quid (BQ) chewing (12.6%) and alcohol drinking (4%) varied geographically. A well-established OPMD was detected in 137 (14.1%) respondents and 2 (0.2%) presented with chronic ulceration later diagnosed as OC. Leukoplakia was the most common OPMD found (9.7%), while the prevalence of oral submucous fibrosis (OSMF), not previously described in the nation, was 2.3%. Poor knowledge of OC risk factors, poor oral hygiene behaviours, low-income SES and ethnicity were significantly associated with the presence of an OPMD. There is a previously under-reported high prevalence of OPMD in Indonesia. Overall, we found a strong correlation between the presence of an OPMD and individual habituation to known risk factors.

An overview of the burden of oral cancer in Sri Lanka and its inequalities in the face of contemporary economic and social malaise.

OBJECTIVES: Over the past several decades, oral cancer has been the most common malignancy among Sri Lankan males and the top 10 cancer among females, disproportionately affecting low socio-economic groups. Sri Lanka is a lower-middle-income developing country (LMIC), currently striking through an economic crisis, and social and political unrest. Occurring at an accessible body site and predominantly attributed to potentially modifiable health-related behaviours, oral cancer should be preventable and controllable. Unfortunately, broader contextual factors that are socio-cultural, environmental, economic, and political and mediated through social determinants of people's lives consistently hinder progress. Many LMICs with a high burden of oral cancer are now gripped by economic crises, consequent social and political unrest, all compounded by reduced public health investments. The aim of this review is to provide a critical commentary on key aspects of oral cancer epidemiology including inequalities, using Sri Lanka as a case study. METHODS: The review synthesizes evidence from multiple data sources, such as published studies, web-based national cancer incidence data, national surveys on smokeless tobacco (ST) and areca nut use, smoking and alcohol consumption, poverty headcount ratios, economic growth, and Gross Domestic Product (GDP) health expenditure. National trends in the oral cancer, ST use, smoking and alcohol consumption in Sri Lanka are identified alongside inequalities. RESULTS: Using these evidence sources, we discuss 'where are we now?', together with the availability, accessibility and affordability of oral cancer treatment services, oral cancer prevention and control programmes, tobacco and alcohol control policies, and finally, outline macroeconomic perspectives of Sri Lanka. CONCLUSIONS: Finally, we speculate, 'where to next?' Our overarching goal of this review is to initiate a critical discourse on bridging the gaps and crossing the divides to tackle oral cancer inequalities in LMIC such as Sri Lanka.

Human papillomavirus and Epstein-Barr virus co-infection in oral and oropharyngeal squamous cell carcinomas: A systematic review and meta-analysis.

Squamous cell carcinoma of the oral cavity (OSCC) is the most common head-and-neck malignancy. Importantly, we are experiencing an alarming rise in the incidence of oropharyngeal squamous cell carcinoma (OPSCC) globally. Oncogenic viruses, human papillomavirus (HPV) and Epstein-Barr virus (EBV), are known to be co-associated with OSCC and OPSCC cases. However, the reported incidence of HPV and EBV co-infection in OSCCs and OPSCCs globally is unknown. To address this, we performed a formal meta-analysis and systematic review on published studies that report the detection of both EBV and HPV in OSCCs and OPSCCs. Our analysis revealed 18 relevant studies out of a total of 1820 cases (1181 from the oral cavity and 639 from the oropharynx). Overall, HPV and EBV co-infection was found in 11.9% of OSCC and OPSCC cases combined (95% CI: 8%-14.1%). Based on anatomical subsite, dual positivity estimates were 10.5% (95% CI: 6.7%-15.1%) for OSCC and 14.2% (95% CI: 9.1%-21.3%) for OPSCC. The highest dual positivity rates described were in European countries: for OSCC 34.7% (95% CI: 25.9%-44.6%) in Sweden and for OPSCC, 23.4% (95% CI: 16.9%-31.5%) in Poland. Given these substantive prevalence rates, the value of detecting dual infection in the diagnosis and prognosis of these cancers deserves careful longitudinal studies, as do implications for cancer prevention and therapy. We further proposed molecular mechanisms that could explain how HPV and EBV could co-contribute to the aetiology of OSCCs and OPSCCs.

Breath biopsy, a novel technology to identify head and neck squamous cell carcinoma: A systematic review.

Head and neck cancers are a heterogeneous group of neoplasms, which together comprise the sixth most common cancer globally. Breath biopsies are a non-invasive clinical investigation that detect volatile organic compounds (VOCs) in exhaled breath. This systematic review examines current applications of breath biopsy for the diagnosis of head and neck squamous cell carcinoma (HNSCC), including data on efficacy and utility, and speculates on the future uses of this non-invasive detection method. Medline, PubMed, Web of Science, Cochrane and Scopus, as well as the grey literature were searched using a search strategy developed to identify relevant studies on the role of breath biopsy in the diagnosis of HNSCC. All included studies were subject to a thorough methodological quality assessment. The initial search generated a total of 1443 articles, 20 of which were eligible for review. A total of 660 HNSCC samples were investigated across the included studies. 3,7-dimethylundecane and benzaldehyde were among several VOCs to be significantly correlated with the presence of HNSCC compared to healthy controls. We show that current breath biopsy methods have high accuracy, specificity and sensitivity for identifying HNSCC. However, further studies are needed given the reported poor quality of the included studies.

Rates of oropharyngeal cancer continue to rise steeply amongst Australian men.

OBJECTIVE: The objective was to analyse the trends in the incidence of oropharyngeal cancers (OPC) across Australia from 1982 to 2017 with implications for prevention. METHODS: Data were obtained from the Australian Cancer Database (ACD) compiled at the Australian Institute of Health and Welfare (AIHW). Joinpoint analyses are presented. RESULTS AND DISCUSSION: There was a striking increase of age-standardised incidence rate (ASIR) of OPC by over 1.5 times; the most significant rise was between 2007 and 2017 with an annual percentage change (APC) of +5.24% (p < 0.001). Slow but gradual growth of ASIR was observed amongst women with a statistically significant APC of +1.02% (p < 0.001). Statistically significant bimodal increasing trends of APC were also observed in total ASIR of OPC. These rising trends are widely attributed to increased oral sex practices. The highest number of incident cases was found in patients aged 55-69 years attributable to continued alcohol and tobacco exposure. The most common subsites affected were base of the tongue (BOT) and 'oropharynx' from 1982 to 2017. CONCLUSION: Oropharyngeal cancer is rising rapidly across Australia, particularly in men. Whilst the national proportion of cases driven by HPV is not known, it is evident that vaccination is yet to have an impact.

Human Herpesvirus 8 in Australia: DNAemia and Cumulative Exposure in Blood Donors.

Human herpesvirus 8 (HHV-8), the causative agent of Kaposi's sarcoma, multicentric Castleman's disease and primary effusion lymphoma, predominantly manifests in immunocompromised individuals. However, infection in immunocompetent individuals does occur. The prevalence of HHV-8 exposure in blood donors from non-endemic countries ranges between 1.2% and 7.3%. Nothing was known about the prevalence in Australian blood donors. Therefore, this study investigated the active and cumulative exposure of HHV-8 in this cohort. Plasma samples (n = 480) were collected from eastern Australian blood donors and were tested for HHV-8 DNA by qPCR, and for HHV-8 antibodies by two different ELISAs. Samples initially positive on either ELISA were retested in duplicate on both, and on a mock-coated ELISA. Any samples positive two or three out of the three times tested on at least one ELISA, and repeat negative on the mock-coated ELISA, were assigned as repeat positive. None of the 480 samples tested contained HHV-8 DNA. Serological testing revealed 28 samples (5.83%; 95% CI: 3.74−7.93%) had antibodies to HHV-8. There was no difference (p > 0.05) in seropositivity between sex or with increasing age. This is the first study to show serological evidence of cumulative HHV-8 exposure and no HHV-8 DNAemia within a select blood donor population in Australia. Our molecular and serological data is consistent with published results for blood donors residing in HHV-8 non-endemic countries, which shows the prevalence to be very low.

Head and neck cancer N-glycome traits are cell line and HPV status-dependent.

Glycosylation is the most common post-translational modification of proteins, and glycosylation changes at cell surfaces are frequently associated with malignant epithelia including head and neck squamous cell carcinoma (HNSCC). In HNSCC, 5-year survival remains poor, averaging around 50% globally: this is partly related to late diagnosis. Specific protein glycosylation signatures on malignant keratinocytes have promise as diagnostic and prognostic biomarkers and as therapeutic targets. Nevertheless, HNSCC-specific glycome is to date largely unknown. Herein, we tested six established HNSCC cell lines to capture the qualitative and semi-quantitative N-glycome using porous graphitized carbon liquid chromatography coupled to electrospray ionisation tandem mass spectrometry. Oligomannose-type N-glycans were the predominant features in all HNSCC cell lines analysed (57.5-70%). The levels of sialylated N-glycans showed considerable cell line-dependent differences ranging from 24 to 35%. Importantly, α2-6 linked sialylated N-glycans were dominant across most HNSCC cell lines except in SCC-9 cells where similar levels of α2-6 and α2-3 sialylated N-glycans were observed. Furthermore, we found that HPV-positive cell lines contained higher levels of phosphorylated oligomannose N-glycans, which hint towards an upregulation of lysosomal pathways. Almost all fucose-type N-glycans carried core-fucose residues with just minor levels (< 4%) of Lewis-type fucosylation identified. We also observed paucimannose-type N-glycans (2-5.5%), though in low levels. Finally, we identified oligomannose N-glycans carrying core-fucose residues and confirmed their structure by tandem mass spectrometry. This first systematic mapping of the N-glycome revealed diverse and specific glycosylation features in HNSCC, paving the way for further studies aimed at assessing their possible diagnostic relevance.

Potential Role of Epstein-Barr Virus in Oral Potentially Malignant Disorders and Oral Squamous Cell Carcinoma: A Scoping Review.

Though the oral cavity is anatomically proximate to the nasal cavity and acts as a key reservoir of EBV habitation and transmission, it is still unclear whether EBV plays a significant role in oral carcinogenesis. Many studies have detected EBV DNA in tissues and exfoliated cells from OSCC patients. However, very few studies have investigated the expression of functional EBV proteins implicated in its oncogenicity. The most studied are latent membrane protein 1 (LMP-1), a protein associated with the activation of signalling pathways; EBV determined nuclear antigen (EBNA)-1, a protein involved in the regulation of gene expression; and EBV-encoded small non-polyadenylated RNA (EBER)-2. LMP-1 is considered the major oncoprotein, and overexpression of LMP-1 observed in OSCC indicates that this molecule might play a significant role in oral carcinogenesis. Although numerous studies have detected EBV DNA and proteins from OSCC and oral potentially malignant disorders, heterogeneity in methodologies has led to discrepant results, hindering interpretation. Elucidating the exact functions of EBV and its proteins when expressed is vital in establishing the role of viruses in oral oncogenesis. This review summarises the current evidence on the potential role of EBV in oral oncogenesis and discusses the implications as well as recommendations for future research.

Economic cost of managing patients with oral potentially malignant disorders in Sri Lanka.

OBJECTIVES: Cancer of the oral cavity is the leading malignancy amongst males in Sri Lanka, and eighth amongst women. Almost all malignancies are developed from a clinically visible precursor stage called an oral potentially malignant disorder (OPMD). The objective of this study was to estimate costs of managing patients with OPMD in Sri Lanka for a 12-month period from diagnosis. METHODS: A hospital-based costing study was conducted in Sri Lanka in the years 2016-2017. Three selected treatment centres participated. For societal perspectives, healthcare, household and indirect costs were used. Costs to the healthcare system included clinic visits, diagnostic biopsy, consumables and drug costs. Capital costs included apportioned value of land, buildings, equipment and furniture. Household costs consisted of out-of-pocket expenditure and indirect costs of lost income. RESULTS: Sixty-two patients were recruited (39 male and 23 female). The majority had awareness of oral potentially malignant disorders (OPMDs). Total average cost of managing a single patient with an OPMD for 1 year was SLR 19 547 (US$ 140) which includes a health system cost of SLR 7320 (US$ 52) and household cost of SLR 12 227 (US$ 87). Travel loss and income loss were a substantial burden to patients and their families. CONCLUSIONS: Managing patients with an OPMD, even with annual monitoring, is less costly than managing patients with oral cancer. Out-of-pocket costs are very high, and these could be reduced by revising the National Management Guidelines to allow care closer to home.

Compositional profile of mucosal bacteriome of smokers and smokeless tobacco users.

INTRODUCTION: Smoked, and especially smokeless, tobacco are major causes of oral cancer globally. Here, we examine the oral bacteriome of smokers and of smokeless tobacco users, in comparison to healthy controls, using 16S rRNA gene sequencing. METHODS: Oral swab samples were collected from smokers, smokeless tobacco users, and healthy controls (n = 44). Microbial DNA was extracted and the 16S rRNA gene profiled using the Illumina MiSeq platform. Sequencing reads were processed using DADA2, and taxonomical classification was performed using the phylogenetic placement method. Differentially abundant taxa were identified using DESeq2, while functional metagenomes based on KEGG orthology abundance were inferred using LIMMA. RESULTS: A significantly higher microbial diversity was observed in smokeless tobacco users and smokers relative to controls (P < 0.05). Compositional differences in microbial communities were observed in all comparisons with healthy controls (PERMANOVA P < 0.05) but not between smokers and smokeless tobacco users. Levels of Fusobacterium spp., Saccharibacterium spp., and members of Shuttleworthia were elevated in smokers when compared to controls (BH adj P < 0.01). In addition, the relative abundance of three bacterial taxa belonging to genera Fusobacterium spp., Catonella, and Fretibacterium spp. was significantly increased in smokeless tobacco users relative to controls (BH adj P < 0.01). Major functional pathways significantly increased in smokeless tobacco users relative to both controls, and smokers were similar and involved amino acid metabolism including glutamate and aspartate biosynthesis and degradation (log FC > 1.5; BH adj P < 0.01). CONCLUSIONS: A distinct taxonomic and functional profile of oral microbiome in smokers and smokeless tobacco users as compared to healthy controls implicates a significant role of microbes and their metabolites in diseases associated with tobacco use including oral cancer. CLINICAL RELEVANCE: Future efforts in preventive, diagnostic, curative, and prognostic strategies for diseases associated with tobacco use in smokers and smokeless tobacco users could incorporate the oral microbiome.

Development and validation of the parenting and child tooth brushing assessment questionnaire.

OBJECTIVE: We report the development and validation of a comprehensive Parenting and Child Tooth brushing Assessment (PACTA) questionnaire. METHODS: This cross-sectional study was conducted with community-recruited Australian parents (N = 450) of children aged 2-8 years. Parents completed an online survey including the newly developed PACTA (comprising four scales assessing children's tooth brushing behaviours, parenting strategies, attitudes and knowledge) and established scales assessing parenting behaviours, attitudes and self-efficacy. RESULTS: Exploratory factor analyses revealed two-factor structures for scales assessing child behaviour ('noncompliance' and 'avoidance behaviour'), parenting strategies ('effective strategies' and 'ineffective strategies') and attitudes ('emotional reactions' and 'lack of concern'), whereas the knowledge scale was unidimensional. Internal consistencies were satisfactory (>0.7) for all except the knowledge scale. There was good evidence of convergent and predictive validity. All subscales predicted children's parent-reported tooth brushing frequency; children were more likely to brush at least twice per day when parents reported fewer tooth brushing behavioural problems, using effective parenting strategies, and having better attitudes and knowledge. Poorer scores on the 'lack of concern' subscale of the attitudes scale were the strongest unique predictor of twice-daily brushing (OR, 95% CI: 1.51, 1.36-1.67). CONCLUSIONS: PACTA demonstrates satisfactory validity and reliability. Further research assessing sensitivity to change following intervention is warranted.

Development and validation of a parent-proxy health-related quality of life survey for Australian First Nations children.

OBJECTIVE: Within Australia, Aboriginal and Torres Strait Islander (First Nations) populations perceive health and well-being differently to non-Indigenous Australians. Existing health-related quality of life (HR-QoL) measurement tools do not account for these differences. The objective of this study was to develop and validate a culturally specific parent-proxy HR-QoL measurement tool for First Nations children. DESIGN: Scale development was informed by parents/carers of children with a chronic illness and an expert panel. The preliminary 39-item survey was reviewed (n=12) and tested (n=163) with parents/carers of First Nations children aged 0-12 years at baseline with comparative scales: the Kessler Psychological Distress Scale, generic HR-QoL (Paediatric QoL Inventory 4.0, PedsQL4.0) and Spence Children's Anxiety Scale, and repeated (n=46) 4 weeks later. Exploratory Factor Analysis was used for scale reduction. Reliability and validity were assessed by internal consistency, test-retest, and correlations with comparison scales. RESULTS: Items within our First Nations-Child Quality of Life (FirstNations-CQoL) were internally consistent with Cronbach's alpha coefficients of ≥0.7 (quality of life, 0.808; patient experience, 0.880; patient support, 0.768) and overall test-retest reliability was good (r=0.75; 95% CI 0.593 to 0.856). Convergent validity was observed with the PedsQL4.0 with Pearson's coefficients of r=0.681 (ages 2-4 years); r=0.651 (ages 5-12 years) and with the Kessler Psychological Distress scale (r=-0.513). Divergent validity against the Spence Anxiety Scale was not demonstrated. CONCLUSIONS: The FirstNations-CQoL scale was accepted by the participants, reliable and demonstrated convergent validity with comparison measures. This tool requires further evaluation to determine responsiveness, its minimal important difference and clinical utility.

Predicting dental caries increment using salivary biomarkers in a remote Indigenous Australian child population.

BACKGROUND: The burden of childhood dental caries amongst Indigenous Australians is higher than in other Australians. Because of differences in lifestyle and the evolutionary history of the oral microbiota, associated risk indicators may differ. Here, we evaluate associations between caries increment, salivary biomarkers and baseline caries among children aged 5-17 years residing in a remote rural Indigenous community. METHODS: This study was part of a trial assessing cost-effectiveness of an intervention to prevent dental caries among children. Baseline epidemiology and application of topical caries-preventive measures was conducted in 2015, followed-up in 2016 and 2017. Children who did not consent or failed to attend the prevention visits but did attend for follow-up epidemiology constituted a natural comparison group for evaluating the intervention. Saliva flow, pH, buffering and bacterial loads were measured at all visits. Caries was scored by the International Caries Detection and Assessment system. Outcome was caries increment. Explanatory variables were sex, being in experimental or comparison group, baseline caries, saliva flowrate and buffering, pH, and salivary loads of mutans streptococci (MS), Lactobacilli (LB), and yeast. Chi Square tests compared caries incidence in relation to explanatory variables and Generalised Linear Models explored associations between explanatory and outcome variables. RESULTS: Of 408 participants at baseline, only 208 presented at 2-year follow-up. Of caries-free children at baseline, significantly fewer had incipient (p = 0.01) and advanced (p = 0.04) caries after two years. Children in the experimental group experienced fewer tooth surfaces with advanced caries (p = 0.02) than comparison children. Having caries at baseline (p = 0.02) and low salivary flow-rates (p < 0.001) saw a significant increase in advanced caries after two years. Children with high salivary loads of MS (p = 0.03) and LB (p = 0.004) experienced more advanced carious surfaces. Multivariable analysis revealed 58% reduction (p = 0.001) in advanced caries among children with high salivary flow rates. Caries increment was 61% (p = 0.03) more for incipient and 121% (p = 0.007) more for advanced caries among children who harboured higher loads of MS. CONCLUSION: As with other ethnicities, children with low salivary flow and those with high MS had higher incipient and advanced caries increments after two years. Such risk assessments facilitate targeted preventive interventions for such communities. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry (ANZCTR), No: ACTRN12615000693527: 3 July 2015.

Implications in the quantification of SARS-CoV2 copies in concurrent nasopharyngeal swabs, whole mouth fluid and respiratory droplets.

OBJECTIVE: Association of SARS-CoV2 burden in the aerodigestive tract with the disease is sparsely understood. We propose to elucidate the implications of SARS-CoV2 copies in concurrent nasopharyngeal swab (NPS), whole mouth fluid (WMF) and respiratory droplet (RD) samples on disease pathogenesis/transmission. METHODS: SARS-CoV2 copies quantified by RT-PCR in concurrent NPS, WMF and RD samples from 80 suspected COVID-19 patients were analysed with demographics, immune response and disease severity. RESULTS: Among the 55/80 (69 %) NPS-positive patients, SARS-CoV2 was detected in 44/55 (80 %) WMF (concordance with NPS-84 %; p = 0.02) and 17/55 (31 %) RD samples. SARS-CoV2 copies were similar in NPS (median:8.74 × 10^5) and WMF (median:3.07 × 10^4), but lower in RD (median:3.60 × 10^2). The 25-75 % interquartile range of SARS-CoV2 copies in the NPS was significantly higher in patients who shed the virus in WMF (p = 0.0001) and RD (p = 0.01). Multivariate analyses showed that hospitalized patients shed significantly higher virus copies in the WMF (p = 0.01). Hospitalized patients with more severe disease (p = 0.03) and higher IL-6 values (p = 0.001) shed more SARS-CoV2 virus in the RD. CONCLUSIONS: WMF may be used reliably as a surrogate for diagnosis. High copy numbers in the NPS probably imply early disease onset, while in the WMF and RD may imply more severe disease and increased inflammation.