Gastrointestinal stromal tumor with maxillary metastasis: a case report and literature review.

Gastrointestinal stromal tumors (GISTs) form commonly in the stomach, small intestine, colorectum, and esophagus. Metastatic GIST occurs in up to 50% of patients at presentation. The liver and peritoneal cavity are the most common (93%) metastatic sites; head and neck metastases are extremely rare. This report describes a unique case of a 77-year-old man who was diagnosed with a duodenal GIST that had been completely resected 15 years ago. Eleven years after complete resection, he presented with liver metastases and then received multiple lines of systemic therapy and ablative radiotherapy. In 2015, he presented to our oral and maxillofacial surgery department with a left exophytic maxillary mass that filled the left maxillary sinus. Incisional biopsy confirmed metastatic GIST. Further evaluation revealed extensive metastases in the patient's liver, lungs, spleen, abdominal wall, and lymph nodes. After adequate staging, the patient's condition was deemed palliative, and he was referred to the radiation oncology department for palliative treatment of the symptomatic maxillary lesion. To our knowledge, this is the first reported case of maxillary metastasis from a duodenal GIST. Inclusion of GIST in the differential diagnosis of jaw tumors in patients with nonoral malignancies is recommended. The literature on oral metastasis of GIST is reviewed and discussed in this case report.

A Comprehensive Clinical Care Pathway for Microvascular Maxillofacial Reconstructive Surgery.

PURPOSE: Clinical care pathways (CCPs) for major surgical procedures are less developed. We describe the development of a comprehensive microvascular maxillofacial reconstruction CCP and evaluate the impact. MATERIALS AND METHODS: Our team developed a comprehensive CCP for patients undergoing microvascular free flap reconstruction for benign or malignant tumors. Patient data before (n = 48) and after (n = 47) implementation of the CCP were used to evaluate the impact. Bayesian negative binomial and logistic regression analyses were used to estimate the associations between the CCP and clinical outcomes (length of stay [LOS], readmission to the operating room, and readmission within 3 months of discharge). RESULTS: The average total hospital LOS was high in the pre-CCP group (16.9 days) compared with the post-CCP group (9.8 days). Being in the post-CCP group reduced the LOS in the intensive care unit and surgical ward and reduced the risk of readmission to the operating room. CONCLUSION: Our results underscore the importance of standardized evidence-based patient care through CCPs for complex patient populations.

Cell culture of differentiated human salivary epithelial cells in a serum-free and scalable suspension system: The salivary functional units model.

Saliva aids in digestion, lubrication, and protection of the oral cavity against dental caries and oropharyngeal infections. Reduced salivary secretion, below an adequate level to sustain normal oral functions, is unfortunately experienced by head and neck cancer patients treated with radiotherapy and by patients with Sjögren's syndrome. No disease-modifying therapies exist to date to address salivary gland hypofunction (xerostomia, dry mouth) because pharmacotherapies are limited by the need for residual secretory acinar cells, which are lost at the time of diagnosis, whereas novel platforms such as cell therapies are yet immature for clinical applications. Autologous salivary gland primary cells have clinical utility as personalized cell therapies, if they could be cultured to a therapeutically useful mass while maintaining their in vivo phenotype. Here, we devised a serum-free scalable suspension culture system that grows partially digested human salivary tissue filtrates composing of acinar and ductal cells attached to their native extracellular matrix components while retaining their 3D in vivo spatial organization; we have coined these salivary spheroids as salivary functional units (SFU). The proposed SFU culture system was sub-optimal, but we have found that the cells could still survive and grow into larger salivary spheroids through cell proliferation and aggregation for 5 to 10 days within the oxygen diffusion rates in vitro. In summary, by using a less disruptive cell isolation procedure as the starting point for primary cell culture of human salivary epithelial cells, we demonstrated that aggregates of cells remained proliferative and continued to express acinar and ductal cell-specific markers.

Nasotracheal Intubation: The Preferred Airway in Oral Cavity Microvascular Reconstructive Surgery?

PURPOSE: We aimed to describe the safety and effectiveness of nasotracheal intubation (NTI) in a cohort of patients undergoing reconstruction of oral cavity defects with free tissue transfer (FTT). MATERIALS AND METHODS: We implemented a retrospective cohort study and enrolled a sample composed of consecutive patients undergoing FTT reconstruction of oral cavity, maxillary, or mandibular defects between 2013 and 2017. These patients were all subject to a newly developed enhanced recovery-after-surgery protocol. The primary outcome measurement was hospital length of stay (LOS). The secondary outcome variables were the duration of mechanical ventilation, intensive care unit (ICU) LOS, need for gastrostomy, and airway-related complications directly associated with either NTI or tracheostomy. Descriptive statistics and a multivariate logistic regression analysis were completed. RESULTS: The sample was composed of 141 patients who had undergone oral cavity FTT for both benign and malignant diseases (NTI, n = 111; tracheostomy, n = 30). Patients managed with NTI had a statistically significantly shorter hospital LOS (8 days vs 15.5 days, P < .0001) and ICU LOS (1 day vs 2 days, P = .0006), as well as a decreased requirement for gastrostomy (17.1% vs 76.7%, P < .0001). Airway-related complications were rare in both the tracheostomy (13.3%) and NTI (3.6%) groups. Multivariate analysis showed that patients undergoing tracheostomy were 3.14 (P = .004) times more likely to have a prolonged hospitalization and 10.4 (P < .0001) times more likely to require a gastrostomy. A sensitivity analysis of only patients with malignant diagnoses had similar statistically significant results. The delayed tracheostomy rate in the NTI group was 3.6%. CONCLUSIONS: To date, this is the largest study to evaluate the use of NTI in patients undergoing oral cavity reconstruction with FTT. Our results suggest that in the appropriate institutional setting, most patients can be safely managed with NTI. This approach results in a decreased hospital LOS and ICU LOS and an earlier resumption of oral intake with less need for gastrostomy.

The role of human fibronectin- or placenta basement membrane extract-based gels in favouring the formation of polarized salivary acinar-like structures.

Head and neck cancer patients treated with radiotherapy commonly experience hyposalivation and oral/tooth infections, leading to a reduced quality of life. Clinical management is currently unsatisfactory for dry mouth. Thus, there is a need for growing salivary fluid-secreting (acinar) cells for these patients. However, functionally-grown salivary acinar cells are cultured in Matrigel, a product that cannot be used clinically, owing to its source from a mouse sarcoma. Therefore, finding a gel suitable for clinical use and possessing properties similar to that of Matrigel would allow biopsied salivary cells to be expanded in vitro and transplanted into the mouths of xerostomic patients. This study tested gels made with human placenta basement membrane extract (BME) or fibronectin for the growth and differentiation of human salivary biopsies into acinar cells. We report here that, following expansion of primary human salivary gland epithelial cells (huSGs) in serum-free medium, using these gels (made from human proteins) allowed morphological and functional differentiation of salivary ductal cells into acinar-like cells. These (human) gels gave comparable results to Matrigel, such as differentiation into polarized acinar 3D units or monolayers with tight junction proteins (claudin-1, -2, -3) and exhibiting adequate transepithelial electrical resistance, acinar proteins (AQP5, α-amylase, mucin-1, NKCC1) and acinar adhesion-related cell markers (CD44, CD166). Ultrastructural, mRNA and protein analyses confirmed the formation of differentiated acinar polarized cells. The mitotic activity was highest with human placenta BME gel. This human culture model provided a reproducible approach to studying human salivary cell expansion and differentiation for tissue engineering. Copyright © 2016 John Wiley & Sons, Ltd.

Profile of bacteria colonizing the exposed bone of patients with anti-osteoclastic drug-related osteonecrosis of the jaws.

Microbial etiology for anti-osteoclastic drug-related osteonecrosis of the jaw (ARONJ) was suggested. This study investigates any link between bacteria colonizing ARONJ sites and other oral cavity sites. Microbiota samples of 10 ARONJ patients were collected from the exposed bone, adjacent teeth, contralateral teeth, and tongue. DNA checkerboard hybridization was used for microbiota analysis with 43 genomic DNA probes prepared from human oral bacterial (38) and candida (5) species, using Socransky's bacterial complexes as a guide. The frequency and the mean proportion of each bacterial species were used. Eikenella corrodens, Streptococcus constellatus, and Fusobacterium nucleatum were dominant in the ARONJ sites and detected in most teeth samples. Staphylococcus aureus was also dominant in the ARONJ sites and tongue. Significant correlations were found between the mean proportions of bacterial species colonizing adjacent teeth, contralateral teeth, and tongue (p < 0.001, R(2) > 0.69). No significant correlation (p > 0.05, R(2) < 0.025) was found between bacteria colonizing ARONJ sites and other evaluated sites. Within the study limitations, it was concluded that the primary sources of microorganisms colonizing ARONJ sites could be other sites such as teeth and tongue. The microbial profile of the necrotic bone is predominantly colonized with bacteria from Socransky's green and orange complexes, as well as with species associated with bone infections.

Quality of life assessment in patients after mandibular resection and free fibula flap reconstruction.

PURPOSE: The aim of the present study was to assess patients' quality of life (QOL) after mandibular resection and reconstruction with the free fibula flap (FFF). MATERIALS AND METHODS: We performed a retrospective study of all patients who underwent segmental mandibular resection and FFF reconstruction at the Division of Oral and Maxillofacial Surgery, McGill University Health Center. The patients were contacted and asked to complete a QOL assessment at least 1 year after surgery. The patients' photographs were taken and evaluated for the esthetic outcomes after surgery by 2 dental health professionals using a visual analog scale and compared with the patients' self-evaluations. A descriptive analysis was used for data analysis. RESULTS: Seventeen patients underwent segmental mandibular resection and reconstruction with a FFF, and 11 completed the QOL questionnaire. Two patients were deceased at the start of the study, 1 refused to complete the QOL questionnaire, and 3 had developed disease recurrence and were not asked to complete the QOL questionnaire. Of the 11 patients who completed the QOL assessment, 8 rated their overall QOL as outstanding, very good, or good and 3 reported it to be fair. No significant correlation was found between the patients' self-reported esthetic evaluation and the third-party evaluations. CONCLUSIONS: Most patients who underwent mandibular resection and FFF reconstruction reported satisfaction with their overall QOL. We did not find a correlation between the patients' perceived esthetic outcome and the dental healthcare professionals' assessment.

Bisphosphonates inhibit bone remodeling in the jaw bones of rats and delay healing following tooth extractions.

OBJECTIVE: This study aimed to evaluate the impact of concurrent administration of clinically relevant doses of zoledronic acid (ZA) and dexamethasone (DX) on bone healing after tooth extraction (EXO). MATERIALS AND METHODS: Forty-four Sprague-Dawley rats (6-8 month old) were randomized into five groups: ZA + DX = weekly injection of ZA with DX for 7 weeks; WD = ZA with DX for 3 weeks then DX alone for 4 weeks; C = control saline for 7 weeks; ZA = ZA alone for 7 weeks and DX = DX alone for 7 weeks. ZA was administered at 0.13 mg/kg/week and DX at 3.8 mg/kg/week and body weights recorded at the time of injection. All rats underwent extraction (EXO) of the mandibular and maxillary first molars at 3 weeks and were euthanized at 7 weeks. The extracted and non-extracted sides of both jaws were harvested for micro-CT analyses. RESULTS: All rats, particularly those injected with ZA, exhibited weight gain till EXO followed by decline then recovery. ZA + DX group demonstrated highest fractional bone to tissue volume (BV/TV) in the non-extracted side. ZA + DX rats exhibited also highest volume and surface of sequestra. Only sequestra volume was statistically higher in the WD group compared to C group. CONCLUSION: Combined treatment with ZA and DX over a prolonged period inhibits bone remodeling and increased sequestra formation to a greater extent than either drug alone. Trauma caused by these sequestra cutting through the mucosa could play a key role in the development of BRONJ by potentially facilitating infection. ZA withdrawal may promote bone-remodeling reactivation following EXO.

Gingival carcinoma: retrospective analysis of 72 patients and indications for elective neck dissection.

Gingival squamous cell carcinoma (SCC) is relatively uncommon, and little is known about its metastatic pattern. We retrospectively reviewed 864 consecutive patients with oral SCC who were seen at the University of Maryland Department of Oral and Maxillofacial Surgery (1991-2005), and identified 111 cases of gingival SCC. Inclusion criteria were fulfilled in 72 patients (mean duration of follow up 49 (1-153) months). Mean (range) age was 72 (45-93) years; 41 patients were women and 31 men. Distribution was almost equal: mandible 35 and maxilla 37. Forty (56%) were in the early stages (pI/II) and 32 (44%) in the later stages (pIII/IV). Twenty-nine patients had primary neck dissections, of whom 7/21 had clear, and 6/8 invaded, cervical nodes. The total number of occult nodal metastases was 9/29 (31%) in the mandible and 14/35 in the maxilla (one patient with initially clear nodes had both invaded nodes at neck dissection and a recurrence in the neck). The number of early compared with late stage occult metastases was 4 of 20 patients (20% T1/T2) and 5 of 9 patients (55% T3/T4) in the mandible and 2 of 22 patients (9% T1/T2) and 2 of 13 patients (15% T3/T4) in the maxilla. Two of 9 patients developed occult nodes within T2 maxillary gingival SCC. Bony invasion was identified in 17 patients (24%) occurring in 8 of 19 patients (42%) with invaded nodes compared with 9 of 53 patients (17%) with clear nodes. Overall survival at 2 and 5 years was 53 of 72 patients (74%) and 27 of 72 patients (38%) respectively. Elective neck dissection is indicated for all stages of mandibular gingival tumours and T3/T4 carcinomas of the maxillary gingiva. T2 maxillary SCC should be considered for elective neck dissection. Overall disease-free survival was worse among those with cervical metastases (p=0.004) and those who had had marginal resections (p=0.04).

Orofacial granulomatosis presenting as persistent lip swelling: review of 6 new cases.

PURPOSE: Orofacial granulomatosis (OFG) is an uncommon disease, which presents usually as a persistent swelling of the soft tissues in the orofacial region and is characterized histologically by a granulomatous inflammation. The term orofacial granulomatosis is used in the literature to describe a nonspecific granulomatous inflammation. A subset, cheilitis granulomatosa (CG), which presents clinically as persistent lip swelling, is a granulomatous inflammation of unknown origin of the lips. CG may also be part of the triad of the Melkersson-Rosenthal syndrome (MRS) and some consider it as an oligosymptomatic form of MRS. PATIENTS AND METHODS: In a retrospective study, we reviewed the clinical records of all patients between the years 1990 and 2002 with the histologic diagnosis of granulomatous inflammation of the lip from the Department of Pathology at the Montreal General Hospital. The age at biopsy, sex, site of lesion, other signs of MRS, signs and symptoms of systemic granulomatous disease, and the treatment were compiled. RESULTS: Six subjects were included in the study, 5 females and 1 male. Four had swelling of the lower lip and 2 of the upper lip. In one patient a history of facial nerve palsy was reported and in another one a mild fissured tongue was present. No signs or symptoms of systemic granulomatous disease were noted. The treatment consisted of intralesional steroids with good results in 5 out of 6 patients. CONCLUSION: A thorough work-up to eliminate other etiologies of granulomatous disease is essential when a patient presents with granulomatous inflammation of the lip. CG seems to respond well to steroid treatment and the need for surgery is minimal and should be reserved for recalcitrant cases.