Oral Squamous Cell Carcinoma Mimicking Peri-Implantitis.

INTRODUCTION: Peri-implantitis is inflammation and alveolar bone loss around a dental implant. Published case reports have described squamous cell carcinoma (SCC) development around dental implants. CASE PRESENTATION: A 60-year-old female presented with two small fistulas on the alveolar ridge of missing tooth #18. The mucosa around the fistulas appeared normal otherwise, with no hyperplasia, erythema, or keratotic changes. The patient had a 14-year history of recurrent erythroleukoplakia (with microscopic dysplasia) on the left tongue that had been managed by surgical removal (scalpel and carbon dioxide laser), biopsies, and close follow-up. She had no other medical conditions. She reported that she had an implant placed to replace tooth #18 4 years ago that had been removed without flap reflection, curettage, or biopsy 1 year previously as a result of peri-implantitis. Periapical radiographs showed that the peri-implant radiolucency in the region of tooth #18 was unchanged in dimensions from the time of implant removal 1 year ago. Curettage and biopsy of the area were performed and showed the presence of a well-differentiated SCC. CONCLUSIONS: This is a case of peri-implant SCC development in a patient at high risk for oral SCC. The carcinoma was present within the alveolar defect in the area of a failed implant that had been removed 1 year previously. The overlying surface mucosa did not show the clinical changes typically seen in carcinoma. This case and others demonstrate the importance of periodic oral and radiographic examination after implant placement. Although rare, neoplasia must be considered in the evaluation of peri-implant pathology.

Clinical predictors of oral leukoplakia recurrence following CO2 laser vaporization.

OBJECTIVE: The objective of this study was to determine whether risk of early leukoplakia recurrence (within 3 months) following carbon dioxide (CO2) laser removal varies by clinical characteristics including lesion size, site and accessibility of margins. MATERIALS AND METHODS: A retrospective cohort study included patients with oral leukoplakia who had their first CO2 laser surgery for removal of oral leukoplakia between 2005 and 2010 at the UCSF oral medicine clinic. Twenty-six patients with 32 separate lesions met the eligibility criteria after a clinic database search was followed by review of clinical notes and biopsy reports from existing patient charts. Data analysis included computation of summary statistics, and logistic regression analyses to evaluate recurrence of leukoplakia by clinical characteristics of the lesions. RESULTS: Patient data and the characteristics of lesions were evaluated as possible predictors of early recurrence following laser removal; these included age, sex, duration, size, appearance and histopathology of the lesion. The only one that reached statistical significance was poor accessibility of the margins of the lesion (vs. good accessibility, OR = 24.57 (95% CI: 1.59-16.68), p = 0.016); the probability for trend for good, questionable, and poor accessibility was 0.0028. This finding remained significant after controlling for age, sex, duration and size of lesion. Four out of five lesions with poor accessibility showed recurrence at 3 months. Of these, three involved the gingiva and one the lateral tongue. CONCLUSIONS: This study has identified poor accessibility of the lesion margins as a predictor for early recurrence of leukoplakia following laser removal. Other variables evaluated did not reach statistical significance, possibly due to lack of power.

Oral leukoplakia development in patients with pre-existing oral lichen planus.

Oral leukoplakia and oral lichen planus are conditions that have the potential to transform into squamous cell carcinoma. This article describes a series of nine patients with an initial clinical-microscopic diagnosis of lichen planus. During close follow-up, these patients developed localized areas of leukoplakia at intervals ranging from one and a half to six and a half years. While both conditions may present with white and red oral mucosal changes, their management differs with leukoplakia requiring surgical intervention, therefore accurate diagnosis is imperative.

Oropharyngeal carcinoma arising after methotrexate and etanercept therapy for rheumatoid arthritis.

Etanercept is an anti-tumor necrosis factor α receptor agent used to treat inflammatory conditions. Previous reports described rapid development of skin squamous cell carcinoma (SCC) after etanercept use. This report describes a novel case of oropharyngeal SCC associated with the use of etanercept. A 45-year-old man with rheumatoid arthritis developed oropharyngeal pain within 2 months after the start of etanercept therapy and was diagnosed with tonsillar carcinoma. This patient had other exposures that increase the risk of oropharyngeal cancer, such as tobacco and alcohol use. However, owing to the timing of onset of his initial symptoms, etanercept should be considered as a possible factor in the etiology or progression of his tumor, especially in the context of reported skin SCC after etanercept therapy in patients at risk for SCC. Clinicians should be alert to signs of malignancy in patients on etanercept, particularly those at high risk for skin or head and neck cancers.

Lesion characteristics and responses after CO2 laser vaporization in five patients With gingival leukoplakia.

Gingival leukoplakia, a premalignant condition, can pose difficulties to surgical access because of the presence of teeth and potential extensions into the periodontal ligament. We present a series of five patients with gingival leukoplakia who were treated with carbon dioxide laser vaporization. We describe lesion characteristics and recurrence patterns suggesting that presence of gingival leukoplakia on facial and palatal/lingual aspect through the interproximal areas may increase the risk of recurrence after conservative surgical removal.

Influence of continuing education on dental hygienists' knowledge and behavior related to oral cancer screening and tobacco cessation.

PURPOSE: There are more than 35,000 new cases of oral and pharyngeal cancers (OPC) diagnosed each year. Most OPCs are diagnosed in advanced stages, requiring aggressive treatment and resulting in higher morbidity and mortality than when diagnosed early. The overall 5 year survival rate of OPC is about 60%. Early detection of OPC lesions are the key to survival. A major risk factor for OPC is chronic tobacco use. The purpose of this paper is to report changes in dental hygienists' knowledge, attitudes and behaviors 6 months after attending a standardized lecture format continuing education (CE) course on early OPC detection and tobacco cessation counseling compared to baseline values. METHODS: A total of 64 CE courses were given for dental professionals throughout the 10 U.S. public health districts to determine if OPC screenings and tobacco cessation counseling behaviors could be modified at 6 months post-training. Questionnaires were obtained at baseline and 6 months later using a pre-/post-test design. RESULTS: A total of 1,463 dental hygienists participated at baseline and 543 at a 6 month follow-up. Data showed a significant difference in knowledge and behavior compared to baseline values. CONCLUSION: CE appeared to have a significant influence on participants' OPC and tobacco cessation knowledge and behavior, and could potentially make a difference on prevention, early detection and ultimately on OPC control.

A case report of conservative management of extensive proliferative verrucous leukoplakia using a carbon dioxide laser.

OBJECTIVE: The purpose of this report was to describe a clinical case of conservative management of extensive proliferative verrucous leukoplakia (PVL) using a carbon dioxide laser, as an alternative to complete glossectomy, which led to a sustained successful outcome over a 12-year follow-up period. BACKGROUND DATA: Patients with oral PVL, a high risk premalignant condition, are often treated by wide surgical excision. This approach can lead to significant morbidity and compromised quality of life. CASE DESCRIPTION: A 50-year-old male with PVL and superficially invasive carcinoma, who had previously refused a complete glossectomy, presented for treatment. A baseline MRI and careful clinical evaluation by symptom review, inspection, palpation, toluidine blue staining, and biopsy were performed at baseline and at each follow-up to rule out invasive carcinoma. The PVL was treated on an outpatient basis by serial carbon dioxide laser excisions and/or vaporizations. This approach resulted in good clinical response and decreased morbidity over a 12-year follow-up period, as compared with the option of wide surgical excision. CONCLUSIONS: This case illustrates the benefit of a more conservative treatment approach than wide surgical excision for PVL with superficially invasive carcinoma. This approach requires greater skills, training, and experience in the evaluation of oral premalignant or malignant changes. However, decreased long-term morbidity and improved quality of life make it a valuable treatment option for PVL.

Implementing cancer prevention into clinical practice.

Cancer prevention has been associated with decreased rates of cancer incidence and increased survival. Cancer prevention, however, can have a greater impact if barriers to implementing cancer prevention into practice are removed and opportunities are both fostered and seized. The purpose of this article is to identify barriers and opportunities to cancer prevention in clinical practice and provide recommendations for the future. A multidisciplinary team participated in "The Future Directions Cancer Prevention and Control: Workforce Implications for Training, Practice and Policy" workshop on October 17-18, 2009 at The University of Texas MD Anderson Cancer Center in Houston, TX. During the meeting, the team discussed barriers and opportunities for the implementation of cancer prevention into clinical practice. Further data were collected from peer-reviewed journals and published government and cancer agencies reports. Several issues were identified: (1) The funding allocated to basic cancer prevention research and application is not optimal and less than that for cancer treatment; (2) participation in cancer prevention behaviors and screening practices are lower than desired, especially among the uninsured; (3) a shortage in healthcare professionals is a major challenge in meeting the future needs of cancer prevention; (4) demands on medical schools to balance increased enrollment, incorporate cancer prevention in an already crowded curriculum, and develop faculty are daunting; and (5) healthcare reforms in 2010 provide both opportunities and additional challenges for cancer prevention. Based on the current state of cancer prevention, we formed six recommendations: (1) additional funding for cancer prevention research with a focus on implementation into practice, (2) improved tracking of cancer prevention research funding and the outcomes associated with it, (3) continued monitoring of cancer prevention services participation with emphasis on closing the gap in health disparities, (4) financial and technical assistance to healthcare professional schools for incorporating cancer prevention into curricula, (5) assessment of the current state of technology in cancer prevention care, and (6) the use of effective multidisciplinary teams in cancer prevention care. Improved delivery of cancer prevention services can have a tremendous impact on cancer incidence and survival rates.

High-dose curcuminoids are efficacious in the reduction in symptoms and signs of oral lichen planus.

BACKGROUND: Curcuminoids are components of turmeric (Curcuma longa) that possess anti-inflammatory properties. OBJECTIVE: We sought to study the efficacy of curcuminoids in controlling the signs and symptoms of oral lichen planus, at doses of 6000 mg/d (3 divided doses), and their safety at this dose. METHODS: Twenty consecutive, eligible patients who consented were enrolled into this randomized, double-blind, placebo-controlled clinical trial in 2007 through 2008. Measurement of symptoms and signs of oral lichen planus using the Numerical Rating Scale (NRS) and the Modified Oral Mucositis Index (MOMI), respectively; complete blood counts; liver enzymes; C-reactive protein; and interleukin-6 levels was done at baseline and day 14. Two-sided P values are reported. RESULTS: In the placebo group, the percentage changes from baseline in NRS (median [interquartile range] = 0.00 [-29 to 16.7], P > .99), erythema (0.00 [-10 to 16.7], P = .98), ulceration (0.00 [0.00 to 26.7], P = .63), and total MOMI scores (-3.2 [-13 to 9.09], P = .95) were not statistically significant, whereas they were statistically significant in the curcuminoids group: NRS (-22 [-33 to -14], P = .0078); erythema (-17 [-29 to -8.3], P = .0078), ulceration (-14 [-60 to 0.00], P = .063), MOMI (-24 [-38 to -11], P = .0039). The curcuminoids group showed a greater reduction in clinical signs and symptoms as compared with the placebo group, measured by percentage change in erythema (P = .05) and total MOMI score (P = .03), and proportion showing improvement in NRS (0.8 vs 0.3, P = .02) and total MOMI score (0.9 vs 0.5, P = .05). Adverse effects were uncommon in both groups. LIMITATIONS: The small sample size resulted in limited power, particularly for multivariate analyses. CONCLUSIONS: Curcuminoids at doses of 6000 mg/d in 3 divided doses are well tolerated and may prove efficacious in controlling signs and symptoms of oral lichen planus.

A randomized, double-blind, placebo-controlled trial of misoprostol for oral mucositis secondary to high-dose chemotherapy.

PURPOSE: Misoprostol, a synthetic analog of prostaglandin E1, has anti-inflammatory and mucosa-protecting properties. The objective of this study was to evaluate the efficacy of misoprostol oral rinse in reducing the severity of oral mucosal injury caused by high-dose chemotherapy. METHODS: The study used a randomized, double-blind, placebo-controlled, parallel-group design. Oncology patients receiving myeloablative high-dose chemotherapy, in preparation for a hematopoietic stem cell transplant, were randomized to misoprostol or placebo rinse. The primary outcome measure was the severity of oral mucositis, measured using the modified Oral Mucositis Index. Additional outcome measures included the severity of mouth pain (measured using a Visual Analog Scale and the Pain Affect Faces Scale), duration of hospital stay, and days on total parenteral nutrition. RESULTS: This study was originally planned to accrue 160 subjects but was terminated early due to revised sponsor research priorities. The intent-to-treat population consisted of 22 subjects randomized to misoprostol rinse and 26 subjects randomized to placebo rinse. There was no significant difference between the two groups in mucositis or pain severity. In both groups, duration of hospital stay was approximately 19 days, and number of days on total parenteral nutrition was 17-18 days. There were no serious adverse events attributable to misoprostol rinse. CONCLUSIONS: Although this study did not find a beneficial effect of a misoprostol rinse in mucositis secondary to high-dose chemotherapy, the small sample size limits the strength of this conclusion. Given the proposed importance of the prostaglandin pathway in the pathogenesis of oral mucositis, additional studies are warranted.

Swallowing dysfunction in cancer patients.

PURPOSE: Dysphagia (swallowing dysfunction) is a debilitating, depressing, and potentially life-threatening complication in cancer patients that is likely underreported. The present paper is aimed to review relevant dysphagia literature between 1990 and 2010 with a focus on assessment tools, prevalence, complications, and impact on quality of life in patients with a variety of different cancers, particularly in those treated with curative chemoradiation for head and neck cancer. METHODS: The literature search was limited to the English language and included both MEDLINE/PubMed and EMBASE. The search focused on papers reporting dysphagia as a side effect of cancer and cancer therapy. We identified relevant literature through the primary literature search and by articles identified in references. RESULTS: A wide range of assessment tools for dysphagia was identified. Dysphagia is related to a number of factors such as direct impact of the tumor, cancer resection, chemotherapy, and radiotherapy and to newer therapies such as epidermal growth factor receptor inhibitors. Concomitant oral complications such as xerostomia may exacerbate subjective dysphagia. Most literature focuses on head and neck cancer, but dysphagia is also common in other types of cancer. CONCLUSIONS: Swallowing impairment is a clinically relevant acute and long-term complication in patients with a wide variety of cancers. More prospective studies on the course of dysphagia and impact on quality of life from baseline to long-term follow-up after various treatment modalities, including targeted therapies, are needed.

A case-control study of burning mouth syndrome and sleep dysfunction.

OBJECTIVE: The objective of this study was to evaluate whether sleep dysfunction is a risk factor for burning mouth syndrome (BMS). STUDY DESIGN: An age- and sex-matched case-control study of patients with BMS and controls with various oral conditions was conducted. A numerical rating scale for oral discomfort and the sleep scale from the medical outcomes study were used for measurements, and statistical analyses included use of logistic regression models. RESULTS: The odds ratios for lowest versus highest quartiles were sleep disturbance (OR = 9.7, P = .0095), sleep problems index (SLP)6 (OR = 7.5, P = .032), and SLP9 (OR = 27, P = .0058), which remained significant after controlling for age and number of sedating medications. CONCLUSIONS: Findings from this cross-sectional study, although unable to establish a causal relationship, demonstrate that patients with BMS report a greater degree of sleep problems as compared with controls, and suggest that sleep dysfunction may be a risk factor for BMS and a possible target for treatment.

Oral and pharyngeal cancer control and early detection.

Sixty-four standardized continuing education courses were given for dentists throughout the ten public health districts of the USA to determine if certain behaviors regarding oral and pharyngeal cancer (OPC) control could be modified. Questionnaires were obtained at baseline and at 6 months along with matched control groups. One thousand eight hundred two general dentists participated at baseline and 988 at a 6-month questionnaire follow-up. Analysis of the data indicated that continuing education courses had a positive influence on participants' oral cancer attitudes, knowledge, and behavior that potentially could make a difference on prevention, early detection, and ultimately OPC control.

Oral and pharyngeal cancer control through continuing education.

A standardized continuing education course was developed to determine if behavior in dental practices could be modified to improve office participation in oral and pharyngeal cancer control through early detection and tobacco-use cessation.

Validation of instruments to measure the symptoms and signs of oral lichen planus.

OBJECTIVE: The aim of this study was to validate the visual analog scale (VAS), numeric rating scale (NRS), and change in symptoms scale (CSS) in measuring symptoms of oral lichen planus, and the modified oral mucositis index (MOMI) in measuring the signs of oral lichen planus. STUDY DESIGN: Criterion validity, construct validity, and internal consistency reliability were evaluated using data from a randomized, double blind, placebo-controlled clinical trial of curcuminoids in oral lichen planus. RESULTS: Moderate to high correlations were found between VAS, NRS, and CSS. Correlations of symptom scores with clinical signs ranged from minimal to high. Correlation of NRS with clinical signs was stronger than that of VAS with clinical signs. Significant changes from baseline at each follow-up in NRS, VAS, and MOMI scores were seen. The Cronbach alpha for erythema and ulceration scores from the MOMI were 0.66. CONCLUSIONS: This study gives some evidence of the validity of NRS, VAS, CSS, and MOMI for use in oral lichen planus. The NRS has better construct validity than VAS, based on higher correlations with clinical signs. Erythema plus ulceration is a better measure than ulceration alone.

Utility of toluidine blue in oral premalignant lesions and squamous cell carcinoma: continuing research and implications for clinical practice.

Toluidine blue (TB) has been shown to aid in the detection and diagnosis of oropharyngeal squamous cell carcinoma (OSCC) and oral premalignant lesions (OPLs). TB has been shown to enhance visualization of oral lesions and assist in identifying sites of increased risk of dysplastic/malignant change and promote biopsy. TB has been shown to identify lesions with molecular changes associated with risk of progression of OPLs to OSCC. A recent prospective longitudinal study showed TB retention in histologic benign lesions and lesions with mild dysplasia that are at increased risk of progression to cancer. Clinical trials show that TB is useful in identifying asymptomatic OSCC and premalignant lesions at risk of progressing to SCC, which might otherwise be undetected until lesions become more advanced. The data supports TB use in oral examination of patients at risk of OSCC.

Diagnosis and management of oral mucositis.

Oral mucositis is a common complication in cancer patients receiving chemotherapy and/or radiation therapy. Nearly all patients undergoing myeloablative therapy for stem-cell or bone marrow transplantation experience oral mucositis. Those receiving radiation therapy for head and neck cancer are at especially high risk. However,this toxicity also occurs with standard-dose chemotherapy and can be seen in association with treatment of many other tumor types. Oral mucositis significantly complicates cancer treatment by contributing to pain, dysphagia, weight loss, depression, higher risk of infection, decreased quality of life, and increased healthcare costs. This review summarizes the impact of oral mucositis in patients with cancer, including its pathogenesis, diagnosis, financial implications, and management. Current treatment guidelines are presented, and novel targeted therapies are discussed. Newer agents, such as palifermin (recombinant human keratinocyte growth factor-1), have been shown in clinical trials to reduce the incidence and severity of oral mucositis,and Saforis (an oral glutamine suspension) may also promote recovery from mucosal damage following chemotherapy or radiation therapy. Continued advances in understanding the pathobiology of oral mucositis should lead to the development of additional agents for its effective prevention and treatment in patients undergoing cancer therapy.

Mucosal lesions in older adults.

BACKGROUND AND OVERVIEW: Many oral diseases/conditions associated with aging are complex and can have a significant effect on the quality of life for ambulatory older adults. Among these are oral cancers and premalignant lesions, vesiculoerosive diseases, candidiasis, aphthous ulcers and herpes virus reactivation. The practitioner should establish the diagnosis so that appropriate management can be instituted. CONCLUSIONS: The challenge to the practitioner is to formulate a differential diagnosis from oral mucosal signs and symptoms, arrange tests and referrals as needed, and establish a definitive diagnosis so that appropriate management can be instituted. CLINICAL IMPLICATIONS: Recognition of benign and malignant mucosal lesions will accelerate proper treatment that will help control a variety of oral diseases and conditions. It also will improve the quality of life for many elderly patients who experience associated pain and altered oral functions.

Antimicrobial mouthrinse as part of a comprehensive oral care regimen. Safety and compliance factors.

BACKGROUND: Antimicrobial mouthrinses often are used as part of daily oral care to reduce plaque and gingivitis. Although several safety factors have been associated with long-term use of alcohol-containing mouthrinses, numerous studies support the safety of these products in daily care. Patient compliance with daily rinsing is important for successful outcomes. TYPES OF STUDIES REVIEWED: The authors reviewed studies relating to the safety and efficacy of alcohol-containing mouthrinses, as well as studies indicating that most patients fail to comply with oral health care recommendations. The authors also reviewed a behavioral change theory and applied it to oral health care. CONCLUSIONS: Alcohol-containing antimicrobial mouthrinses are safe and effective as part of a daily oral care regimen to prevent or minimize periodontal disease. However, many patients do not comply with instructions on how to use them. CLINICAL IMPLICATIONS: Antimicrobial mouthrinses are safe and effective, and when used in conjunction with brushing and flossing, they are an important method of reducing plaque and gingivitis. To improve compliance, dental health care professionals should adapt oral health care recommendations to fit patients' specific needs.