Assembling a consensus on actinic cheilitis: A Delphi study.

AIMS: To discuss the terminology to define and classify actinic cheilitis (AC) and to build a consensus on the diagnostic and therapeutic approaches to AC. METHODS: Two-round Delphi study using a questionnaire including 34 closed sentences (9 on terminology and taxonomy, 5 on potential for malignant transformation, 12 on diagnostic aspects, 8 on treatment) and 8 open questions. Experts' agreement was rated using a Likert scale (1-7). RESULTS: A consensus was reached on 24 out 34 statements (73.5%) and on 5 out of 8 (62.5%) close-ended questions. The response rate was identical in both rounds (attrition of 0%). AC is the term with the highest agreement (median of 7 (strongly agree; IQR: 6-7)) and the lowest dispersion (VC = 21.33). 'Potentially malignant disorder' was the preferred classification group for AC (median of 7) and 85.6% of participants showing some level of agreement (CV < 50). Experts (66.75%) consider AC a clinical term (median: 7; IQR: 4-7) and believe definitive diagnosis can be made clinically (median: 6; IQR: 5-7), particularly by inspection and palpation (median: 5; IQR: 4-6). Histopathological confirmation is mandatory for the management of AC (median: 5; IQR: 2.5-7), even for homogeneous lesions (median: 5; IQR: 3.5-6). Consensus was reached on all treatment statements (VC < 50). CONCLUSIONS: AC is a potentially malignant disorder with a significant lack of agreement on diagnostic criteria, procedures, biopsy indications and the importance of techniques to assist in biopsy. A consensus was reached on nomenclature and management of this disorder.

Is Periodontal Disease Associated with Alzheimer's Disease? A Systematic Review with Meta-Analysis.

BACKGROUND: In the last decade, several observational studies have suggested that there exists an association between periodontal disease (PD) and Alzheimer's disease (AD). The aim of this systematic review was to investigate whether or not this link exists. SUMMARY: The Preferred Reporting Items for Systematic Reviews and Meta-Analysis guideline for systematic review was used and registered at PROSPERO (CRD42016035377). The search strategy included using electronic databases and by hand searching articles published up to January 2016. MEDLINE via PubMed, EMBASE and Web of Science were searched by 2 independent reviewers. Observational studies including patients meeting criteria for both AD and PD were eligible to be included in the analysis. Quality assessment of selected studies was performed by the Newcastle-Ottawa Scale. From a total of 550 titles and abstracts, 5 studies were included (2 cross-sectional, 2 case-control and one cohort study) in the review. A fixed effects meta-analysis showed that the presence of PD is associated with the presence of AD (OR 1.69, 95% CI 1.21-2.35). When only severe forms of PD were evaluated, a significant association was also observed (OR 2.98, 95% CI 1.58-5.62). Key Messages: In the present review, a significant association was observed between PD and AD. Further studies should be carried out in order to investigate the direction of the association and factors that may confound it.

Association between periodontitis and ischemic stroke: a systematic review and meta-analysis.

Several observational studies have suggested an association between periodontitis and cerebral ischemia. This meta-analysis aimed to investigate whether this link exists, and if so, the degree to which it is significant. The Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) guideline for systematic review was used. The search strategy included using electronic databases and hand searching works published up to March 2015. MEDLINE via PubMed, EMBASE, Proceedings Web of Science and Current Contents Connect were searched by two independent reviewers. Case-control, cross-sectional or cohort studies including patients with measures of periodontitis and ischemic stroke were eligible to be included in the analysis. Quality assessments of selected studies were performed. From a total of 414 titles and abstracts, 57 potentially relevant full text papers were identified. After inclusion criteria were applied, 8 studies were included in the present systematic review (5 case-control and 3 cohort studies). Although it was not the intention, cross-sectional studies were excluded due to eligibility criteria were not accomplished. Therefore, meta-analyses were conducted with data retrieved from the 8 studies included. These meta-analyses showed statistically significant association between periodontitis and ischemic stroke in both cohort pooled relative risks at 2.52 (1.77-3.58), and case-control studies pooled relative risks at 3.04 (1.10-8.43). In conclusion, the present meta-analysis demonstrated an association between periodontitis and ischemic stroke. However, well-designed prospective studies should be carried out to provide robust evidence of the link between both diseases. In regards to ischemic stroke subtypes, further case-control studies should be carried out to investigate whether there is any association between the different subtypes of cerebral infarcts and periodontitis.

An appraisal of oral cancer and pre-cancer screening programmes in Europe: a systematic review.

BACKGROUND: Close to 50% of oral cancer (OC) patients still present in advanced stages of disease. Screening, in medicine and dentistry, is a strategy to identify an unrecognised disorder in individuals without signs and symptoms. There are several cancers that fit valid criteria for screening, but whether or not to screen a population for OC remains a dilemma. However, many screening programmes for OC and detection of potentially malignant disorders are described. Many of these have been conducted in Europe, but the feasibility of screening for OC has not been systematically addressed. METHODS: A systematic review was conducted using the key words of interest. Based on our inclusion criteria, 16 European studies spanning three decades were selected from the published English literature. These studies were systematically analysed. The results were discussed with an expert EU consortium built with the task to promote the early detection of OC. RESULTS: There were no consistent results or conclusions across the studies reviewed, largely as a result of there being a wide variety in the screening models and methods of data analysis adopted by each group. In nine of the studies reviewed, whilst descriptive findings from screening were presented, the authors had not attempted to analyse the outcomes. Additionally, only one study reported follow-up data of the screened population. CONCLUSIONS: In order to uphold the benefits of screening, it is necessary to demonstrate an improvement in survival rates following early detection. No such randomised control trials (RCT) on OC have been undertaken in Europe. Undertaking such a RCT may be difficult in the European setting. However, the feasibility of screening for OPMDs by conventional oral examination has been demonstrated, supporting a strategy to adopt appropriate screening models, and further action from the European countries should be to demonstrate methods of halting their progression by tested interventions. We provide a brief guideline for future screening studies.

Available web-based dental implants information for patients. How good is it?

BACKGROUND: Massive use of the Internet for health issues has raised concerns about the quality of the information available and about consumers' ability to tell "good" from "bad" information. PURPOSE: To assess the quality of patient-addressed, dental implants-related websites in terms of reliability, accessibility, usability and readability. MATERIALS AND METHODS: Two search engines (Google and Yahoo) were used in this study. The first 100 sites, as listed by each engine, were considered for the study. Each site was categorised and analysed for quality using the DISCERN and the LIDA instruments. The Flesch-Kinkaid Reading Grade Level (FKRGL) and the Flesh Reading Ease Score (FRES) were used to assess legibility. RESULTS: After applying the inclusion and exclusion criteria, 32 single websites entered the study. The median score for the DISCERN instrument (3 [2-3]) indicated serious or potentially important shortcoming in the quality of the information obtained. LIDA scores showed modest percentages for accessibility (79.36 [74.60-85.31]) and intermediate for usability (59.20 (50.46-68.51)) and reliability (55.55 [45.37-66.66]). Legibility indices reached scores within the range of difficult to read (FRES = 51.72 [38.70-55.27]); FKRGL = 12.76 [10.07-14.87]). CONCLUSIONS: Available e-health information on dental implants in English language is difficult to read for the average patient and poor in terms of quality.

Available web-based teaching resources for health care professionals on screening for oral cancer.

OBJECTIVES: To identify websites with adequate information on oral cancer screening for healthcare professionals (HCPs) and to assess both their quality and contents. STUDY DESIGN: Websites were identified using Google and HON medical professional search engines using the terms "screening for oral cancer". The first 100 sites retrieved by each engine were analysed using the DISCERN questionnaire (reliability), the V instrument (contents on oral cancer) and further by the Flesch-Kinkaid Reading Grade Level and the Flesch Reading Ease (readability). RESULTS: The overall rating showed minimal shortcomings in the quality of the information in the websites. The coverage and correctness of information on "visual examination" was rated as fair/good, whereas updating of contents resulted very variable (eg: 81% for visual examination and 18.2% for molecular biomarkers). These results permitted to rank the websites housing relevant information for oral cancer. Top ranking websites were affiliated to the Oral Cancer Foundation (USA), WHO Collaborating Centre for oral cancer (UK) whose webpage is entitled "Oral Cancer Education and Research", and the Clinical Guidelines maintained by the British Columbia Cancer Agency (Canada) and the British Dental Association (UK) respectively. CONCLUSIONS: There are web-based, HCP-addressed, resources on screening for oral cancer housing heterogeneous information both in quality and contents. The use of specific evaluation tools permits the selection of reliable websites on this topic with a potential to improve the existing educational gaps among HCPs.

Pseudoepitheliomatous hyperplasia after diode laser oral surgery. An experimental study.

BACKGROUND: to examine the process of epithelial reparation in a surgical wound caused by diode laser. MATERIAL AND METHODS: An experimental study with 27 Sprage-Dawley rats was undertaken. The animals were randomly allocated to two experimental groups, whose individuals underwent glossectomy by means of a diode laser at different wattages, and a control group treated using a number 15 scalpel blade. The animals were slaughtered at the 2nd, 7th, and 14th day after glossectomy. The specimens were independently studied by two pathologists (blinded for the specimens' group). RESULTS: at the 7th day, re-epithelisation was slightly faster for the control group (conventional scalpel) (p=0.011). At the 14th day, complete re-epithelization was observed for all groups. The experimental groups displayed a pseudoepitheliomatous hyperplasia. CONCLUSIONS: it is concluded that, considering the limitations of this kind of experimental studies, early re-epithelisation occurs slightly faster when a conventional scalpel is used for incision, although re-epithelisation is completed in two weeks no matter the instrument used. In addition, pseudoepitheliomatous hyperplasia is a potential event after oral mucosa surgery with diode laser. Knowledge about this phenomenon (not previously described) may prevent diagnostic mistakes and inadequate treatment approaches, particularly when dealing with potentially malignant oral lesions.

Neurological adverse events related to lip biopsy in patients suspicious for Sjögren's syndrome: a systematic review and prevalence meta-analysis.

OBJECTIVE: The aim of this study was to compare the prevalence of neurological complications related to lip biopsy for SS diagnosis using conventional vs minimally invasive techniques. METHODS: We performed a systematic review and prevalence meta-analysis using the search strategy [(salivary gland biopsy OR labial biopsy OR lip biopsy) AND (Sjögren)] in the MEDLINE, EMBASE and Web of Science Conference Proceedings Citation Index databases. Studies were selected if they included original data for minor salivary gland biopsy, sample size, exposure of interest (technique description), number of complications and number of affected patients. The prevalence of total and permanent neurological adverse effects was calculated. Both fixed-effects and random-effects pooled estimates were assessed. Heterogeneity was calculated using an adaptation of the DerSimonian and Laird Q test. RESULTS: Sixteen articles were selected for the study. In the minimally invasive group (n = 3), the pooled prevalence of total adverse events is almost four times higher than that in the linear incision group (n = 12) (4.73% vs. 1.20%). In contrast, the pooled prevalence of the permanent or potentially permanent neurological adverse events is 8.5 times lower in the minimally invasive technique group than in the studies using linear incisions (0.17% vs. 1.45%). CONCLUSION: With the limitations intrinsic to the potential biases in the studies included in this meta-analysis, we conclude that the minimally invasive lip biopsy technique for SS diagnosis induces fewer permanent neurological complications than conventional approaches with large linear incisions in the lower lip.

Minor salivary gland biopsy in Sjögren's syndrome: a review and introduction of a new tool to ease the procedure.

OBJECTIVES: To review the existing techniques for minor salivary gland biopsy (MSGB) in the lip and to suggest a new approach to ease the procedure and reduce post-operative complications. STUDY DESIGN: A comprehensive literature review and a descriptive study of a new surgical technique. RESULTS: Diverse incisions have been suggested for MSGB with different designs (ellipse, circular, linear), different directions (parallel, oblique, vertical) and a wide range of lengths (from 1 mm up to 3 cm), but no comparative studies supporting the advantages of a particular type of incision over the others could be retrieved. A variety of features of the existing techniques for MSGB are linked to undesired events and surgical complications which could be minimized by modifying certain aspects of these procedures. The technique described, together with the use of the S forceps, represents a significant improvement over the already described chalazion forceps because it allows for a better access and positioning of the lower lip, improves the ergonomic conditions of the assistant, and facilitates the identification of lip areas with more superficial gland lobules. CONCLUSION: The suggested approach for lip MSGB includes a specifically designed instrument whose performance during lip biopsy may contribute to minimize post-operative complications.

Oral self-injury: an update.

BACKGROUND: Self-inflicted oral injuries of organic origin are particularly common in certain diseases, syndromes, and systemic disorders. In this article, we discuss the characteristics of these oral lesions and their treatment. LITERATURE SEARCH: The authors have reviewed the most relevant literature relating to oral self-injury through a search in textbooks and published articles included in the Medline database for the years 1970-2010, and selected published cases from the last two decades. RESULTS: The majority of the literature on oral self-injury is in the form of case reports. Self-injury is particularly prevalent in patients with Lesch-Nyhan syndrome, a heterogeneous group of neurological disorders, congenital insensitivity to pain with anhidrosis, and mental retardation. It is most common in males in the early years of life, and the sites most frequently involved are the lower lip and the tongue. Therapeutic approaches in these patients have included psychological and pharmacological treatment, intraoral devices, and surgical procedures. CLINICAL IMPLICATIONS: Intraoral devices are the best therapeutic option for self-injury of organic origin, although this approach is not free of complications. The current lack of standardized treatment protocols for oral self-injury means that therapy must be individualized.

Oral Health Scales: design of an oral health scale of infectious potential.

OBJECTIVES: In this paper we propose a new Global Oral Health Scale that will allow the infectious potential of the oral cavity, clinically manifest as local and focal infections, to be condensed into a single parameter. STUDY DESIGN: Based on a number of oral health scales previously designed by our group, we designed a final version that incorporates dental and periodontal variables (some of them evaluated using corroborated objective indices) that reflect the presence of caries and periodontal disease. RESULTS: The application of the proposed oral health scale requires the examination of 6 sites per tooth (mesio-buccal, medio-buccal, disto-buccal, disto-lingual, medio-lingual and mesio-lingual). The following variables are analysed: number of tooth surfaces with supragingival plaque, determined using the O'Leary index; number of teeth with caries and the severity of the caries; number of tooth surfaces with gingival inflammation, determined using the Ainamo and Bay index; and number of tooth surfaces with pockets ≥ 4 mm and severity of the pockets. These variables are then grouped into 2 categories, dental and periodontal. The final grades of dental and periodontal health correspond to the grades assigned to a least 2 of the 3 variables analysed in each of these categories. The category (dental or periodontal) with the highest grade is the one that determines the grade of the Global Oral Health Scale. CONCLUSION: This scale could be particularly useful for the epidemiological studies comparing different populations and for analysis of the influence of distinct degrees of oral health on the development of certain systemic diseases.

Lateral transport osteogenesis in maxillofacial oncology patients for rehabilitation with dental implants: a retrospective case series.

OBJECTIVES: To report on the use of lateral transport osteogenesis in cancer patients after maxillo/mandibular resections and on the implant survival rate in the generated bone MATERIAL AND METHODS: Four patients treated using lateral transport osteogenesis entered this descriptive study and were retrospectively studied (mean age 55; range 41-62). RESULTS: Reconstruction of segmentary defects after surgical and radiological cancer treatment on maxilla and mandible was achieved. No relevant intra- or post-operative complications occurred. No differences on implant survival were observed between patients who had received radiotherapy and those who had not. CONCLUSIONS: This approach can be considered a recommendable reconstructive option after oral cancer treatment - including radiotherapy- particularly for high-surgical-risk, collaborative patients.

Simulation for training in oral cancer biopsy: a surgical model and feedback from GDPs.

OBJECTIVES: To describe a new bench model for oral precancer/cancer biopsy training and to assess its effectiveness in terms of trainees' perception. STUDY DESIGN: Cross-sectional, descriptive, performed on 424 general dental practitioners (GDP) who undertook biopsies on a pig tongue. The participants were assessed by direct observation for 2.5 hours using specific check-lists and by means of a self-applied questionnaire. RESULTS: The workshop was perceived as "very interesting" even by those with previous surgical experience (Xi - Xj = 0.07; 95%CI= -0.20-0.09). Most GDPs considered themselves able to undertake oral biopsies on real patients after the workshop. Those who had previously received theoretical continuous education courses on oral biopsy scored higher values within the group (Xi - Xj = 0.20; 95%CI= 0.04-0.37). CONCLUSIONS: There is a need for including clinical abilities workshops when instructing on oral biopsy techniques. More studies are needed to validate the procedure and to address cognitive and communication skills.

Tongue necrosis secondary to giant cell arteritis.

Tongue necrosis is a rare clinical finding because of its rich vascularisation. Giant cell arteritis (GCA) is the most frequent cause of it, and when present, it is usually one side affected. We describe a patient with several months of constitutional syndrome; during that period, she develops headache followed by tongue necrosis, which lead to clinical suspicion of GCA, later confirmed by a temporal artery biopsy. Before the biopsy, she was treated with corticosteroids. We discuss this illness and tongue necrosis as a rare manifestation to consider.

Predictors for tumor recurrence after primary definitive surgery for oral cancer.

PURPOSE: The purpose of this study was to identify significant predictors for oral squamous cell carcinoma recurrence. PATIENTS AND METHODS: This Ambispective cohort study was performed in consecutive metastasis-free patients treated for oral squamous cell carcinoma with curative intent from 1998 through 2003. Variables included gender, age, tumor site, macroscopic pattern of the lesion, coexisting disorders (diabetes, hepatic and heart disorders, other tumors/diseases), degree of differentiation, and pathologic TNM stage. Tumor recurrence was considered the dependent variable (outcome). The distribution of recurrences was assessed with χ(2) test. Survival times were estimated by Kaplan-Meier curves and differences were examined with log-rank test. Multiple Cox regression study was also performed. The significance level chosen for all tests was P < .05. RESULTS: One hundred eighteen patients entered the study. Tumor recurrence was 44.9% during the follow-up period (10% local, 29.7% regional, and 5% distant). The mean period that had elapsed before recurrence was 15 months (1.5 to 81.8), with most recurrences (66%) during the first year after treatment (84.9% before 2 years). Multivariate Cox regression analysis indicated the presence of a coexisting disorder (P = .022) as the most relevant prognostic factor for relapse, because patients with associated diseases had a 2.43-fold risk of recurrence. Tumor stage (P = .037), degree of differentiation (P = .042), and macroscopic pattern of the lesion (P = .022) were also identified as prognostic factors for relapse. CONCLUSIONS: The risk profile for oral cancer recurrence includes patients younger than 60 years with coexisting diseases whose primary tumor occurred as an ulcerated lesion, and diagnosed at an advanced stage with a poorly differentiated tumor.

Simulation for training in sinus floor elevation: new surgical bench model.

OBJECTIVES: to describe a bench model (workshop of abilities) for sinus floor elevation (SFE) training that simulates the surgical environment and to assess its effectiveness in terms of trainees' perception. STUDY DESIGN: thirty-six randomly selected postgraduate students entered this cross-sectional pilot study and asked to fill in an anonymous, self-applied, 12-item questionnaire about a SFE workshop that included a study guide containing the workshop' s details, supervised practice on a simulated surgical environment, and assessment by means of specific check-lists. RESULTS: Thirtiy-six fresh sheep heads were prepared to allow access to the buccal vestible. Using the facial tuber, third premolar and a 3D-CT study as landmarks for trepanation, the sinus membrane was lifted, the space filled with ceramic material and closed with a resorbable membrane. The participants agreed on their ability to perform SFE in a simulated situation (median score= 4.5; range 2-5) and felt capable to teach the technique to other clinicians or to undertake the procedure for a patient under supervision of an expert surgeon (median= 4; range 1-5 ). There were no differences on their perceived ability to undertake the technique on a model or on a real patient under supervision of an expert surgeon (p=0.36). CONCLUSIONS: Clinical abilities workshops for SFE teaching are an essential educational tool but supervised clinical practice should always precede autonomous SFE on real patients. Simulation procedures (workshop of abilities) are perceived by the partakers as useful for the surgical practice. However, more studies are needed to validate the procedure and to address cognitive and communication skills, that are clearly integral parts of surgical performance.

Factors related to late stage diagnosis of oral squamous cell carcinoma.

AIMS: To identify factors related to advanced-stage diagnosis of oral cancer to disclose high-risk groups and facilitate early detection strategies. STUDY DESIGN: An ambispective cohort study on 88 consecutive patients treated from January 1998 to December 2003. INCLUSION CRITERIA: pathological diagnosis of OSCC (primary tumour) at any oral site and suffering from a tumour at any TNM stage. Variables considered: age, gender, smoking history, alcohol usage, tumour site, macroscopic pattern of the lesion, co-existing precancerous lesion, degree of differentiation, diagnostic delay and TNM stage. RESULTS: A total of 88 patients (mean age 60±11.3; 65.9% males) entered the study. Most patients (54.5%) suffered no delayed diagnosis and 45.5% of the carcinomas were diagnosed at early stages (I-II). The most frequent clinical lesions were ulcers (70.5%). Most cases were well- and moderately-differentiated (91%). Univariate analyses revealed strong associations between advanced stages and moderate-poor differentiation (OR=4.2; 95%CI=1.6-10.9) or tumour site (floor of the mouth (OR=3.6; 95%CI=1.2-11.1); gingivae (OR=8.8; 95%CI=2.0-38.2); and retromolar trigone (OR=8.8; 95%CI=1.5-49.1)). Regression analysis recognised the site of the tumour and the degree of differentiation as significantly associated to high risk of late-stage diagnosis. CONCLUSIONS: Screening programmes designed to detect asymptomatic oral cancers should be prioritized. Educational interventions on the population and on the professionals should include a sound knowledge of the disease presentation, specifically on sites like floor of the mouth, gingivae and retromolar trigone. More studies are needed in order to analyse the part of tumour biology on the extension of the disease at the time of diagnosis.

Nodular lymphangitis due to nocardiosis.

Nodular lymphangitis is an infectious disease characterised by the development of inflammatory skin nodules that follow the direction of lymphatic drainage. We present a woman in her 70s with nodular lymphangitis that developed after mild trauma with a cactus. Surgical intervention was performed on a finger abscess with isolation of Nocardia brasiliensis in the microbiological samples. Initial antibiotherapy was modified, treating with cotrimoxazole, firstly intravenous and finally oral, therapy during 3 months with a complete resolution of the infection.

Diagnostic Interval in Extranodal Non-Hodgkin Head and Neck Lymphomas.

The aim of this study is to measure the diagnostic interval (DI) of primary extranodal non-Hodgkin lymphomas (PE-NHL) affecting the head and neck and to discover any associated factors. With this aim, we performed a retrospective observational study in northwestern Spain on patients diagnosed between 1 January 2005 and 1 January 2016. A search was made across the electronic health records of the public health system of this region (SERGAS). DI was used as the dependent variable, and different clinicopathological data of the corresponding patients and tumors were analyzed as exposure variables. PE-NHLs were mostly located in Waldeyer's ring, and they presented a B phenotype and had a median DI of 65 days. Shorter diagnostic intervals were observed in (1) PE-NHL patients who had comorbidities (p = 0.02), (2) PE-NHL that caused symptoms of dysphagia (p = 0.04), (3) tumors with the highest proliferative activity (Ki67 > 80%) (p = 0.04), and (4) tumors diagnosed in the advanced stages of the disease (p = 0.004). Univariate analysis revealed a significant association between dysphagia and a shorter DI. We conclude that raising awareness about these neoplasms and warning about the presenting symptoms can contribute to earlier diagnoses of these tumors and to better outcomes.