Eosinophilic sialodochitis: An emerging atopic condition.

OBJECTIVE: To report the clinical characteristics of the largest single centre cohort of patients with eosinophilic sialodochitis. METHODS: Analysis of data relating to 37 patients seen in a dedicated multidisciplinary clinic was performed. Demographic, clinical, haematological, cytological, histological and radiological features were collated. Response to trials of allergy treatment was assessed. RESULTS: Thirty-seven patients (30 female, seven male) were identified, 42% of whom were of Afro-Caribbean origin, with a mean age of 50.4 years (range 28-80 years). Mean symptom duration at presentation was 10 years (range 2-33 years). Parotid and submandibular gland involvement was equally reported. The most commonly reported symptoms were swelling (97%), itching of the overlying skin (92%), salivary gland discomfort (84%) and "string-like" mucus discharge from salivary duct orifices (76%). Twenty-three patients (62%) demonstrated atopic disease and serum IgE level elevated in 57%. All 37 patients had eosinophils present in aspirated duct contents samples while raised peripheral eosinophil count was seen in 41%. Anecdotal symptom improvement was reported with antihistamine, antileukotriene or steroid treatment. CONCLUSION: Eosinophilic sialodochitis should be considered in any patient presenting with recurrent salivary gland swelling. Further studies are needed to evaluate treatments directed at a likely allergic pathogenesis.

Pain Part 8: Burning Mouth Syndrome.

Burning mouth syndrome (BMS) is a rare but impactful condition affecting mainly post-menopausal women resulting in constant pain and significant difficulty with eating, drinking and daily function. The aetiology of BMS remains an enigma. Recent evidence suggests it likely to be neuropathic in origin, the cause of which remains unknown. There is no cure for this condition and the unfortunate patients remain managed on a variety of neuropathic pain medication, salivary substitutes and other non-medical interventions that help the patient 'get through the day'. Some simple strategies can assist both clinician and patient to manage this debilitating condition. CPD/Clinical Relevance: The dental team will recognize patients presenting with burning mouth syndrome. They are difficult patients to manage and are often referred to secondary care and, ultimately, depend on their general medical practitioners for pain management.

The continuation of oral anticoagulation and antiplatelet therapy for dento-alveolar surgery: a service evaluation.

Background Patients taking oral anticoagulants (OACs) and oral antiplatelets (OAPs) have a risk of post-operative bleeding when dental extractions are required. Guidance exists to assist dental practitioners on how best to clinically manage these patients, but this is based upon low-quality evidence. The current service evaluation provides real world clinical data when these drugs are not discontinued for oral surgery procedures.Materials and methods All OACs and OAPs were continued and patients requiring dental extractions had local haemostatic measures (local anaesthesia with adrenaline, socket packing with haemostat and resorbable sutures). All patients were offered a follow-up via a telephone clinic service after surgery to assess any post-operative bleeding.Results A total of 439 patients underwent 513 surgical episodes, equating to 1,001 dental extractions. Overall, 412 (95.9%) patients reported no post-operative bleeding complications. A total of 18 (4.1%) patients reported post-operative bleeding requiring further intervention. All but two patients were managed with local haemostatic measures, and no patient required hospital admission. For the single novel OAC cohort of patients, 8/185 (4.3%) procedures had post-operative bleeding.Conclusion This current service evaluation highlights that the risk of significant or life-threatening bleeding following dental extraction when OACs or OAPs are continued remains rare.

Obstructive salivary gland disease.

This paper provides an overview of the most common cause of salivary gland complaints presenting to the general dental practitioner, obstructive salivary gland disease (OSGD). It is important to be aware of the characteristic signs and symptoms to allow for appropriate management and onward referral.

The impact of the cessation of primary dental care services on oral cancer diagnosis at a single institution in the UK's epicentre during the COVID-19 pandemic.

Aims: COVID-19 put an unprecedented strain on healthcare services that was complicated by the widespread cessation of all face-to-face primary care dental activity from 23 March 2020 for 7 weeks. This led to a focus on telephone triage and remote prescribing that potentially impeded urgent referrals for suspected oral cancer. Guy's and St Thomas' NHS Foundation Trust (GSTFT) screens and diagnoses potential head and neck cancer patients via a 2-week wait (2 WW) clinic and provides access to patients with urgent oral health needs through an Acute Dental Care (ADC) service. The current service evaluation aims to assess and report on the impact of COVID-19 and the cessation of primary care dentistry on oral cancer diagnosis at GSTFT during a period of time where patients had extremely limited access to healthcare. Materials and Methods: Data regarding oral cancer diagnoses were collected retrospectively from secure logbooks and clinical records from the point at which routine dental practice was nationally halted (23 March 2020) to the date at which services were permitted to resume (08 June 2020). Individual patient pathways prior to diagnosis and through to treatment were recorded. Results: Sixteen new diagnoses of oral cancer were made during the described timeframe. Findings suggest that the paralysis of routine dental services resulted in delayed referral of suspicious lesions and highlights the limitations of a predominately telephone-based assessment service in primary care. Conclusion: The importance of the role of the primary care practitioner in the early identification of oral cancer has been emphasised.

Sodium channel Na v 1.7 immunoreactivity in painful human dental pulp and burning mouth syndrome.

BACKGROUND: Voltage gated sodium channels Na v 1.7 are involved in nociceptor nerve action potentials and are known to affect pain sensitivity in clinical genetic disorders. AIMS AND OBJECTIVES: To study Na v 1.7 levels in dental pulpitis pain, an inflammatory condition, and burning mouth syndrome (BMS), considered a neuropathic orofacial pain disorder. METHODS: Two groups of patients were recruited for this study. One group consisted of patients with dental pulpitis pain (n = 5) and controls (n = 12), and the other patients with BMS (n = 7) and controls (n = 10). BMS patients were diagnosed according to the International Association for the Study of Pain criteria; a pain history was collected, including the visual analogue scale (VAS). Immunohistochemistry with visual intensity and computer image analysis were used to evaluate levels of Na v 1.7 in dental pulp tissue samples from the dental pulpitis group, and tongue biopsies from the BMS group. RESULTS: There was a significantly increased visual intensity score for Na v 1.7 in nerve fibres in the painful dental pulp specimens, compared to controls. Image analysis showed a trend for an increase of the Na v 1.7 immunoreactive % area in the painful pulp group, but this was not statistically significant. When expressed as a ratio of the neurofilament % area, there was a strong trend for an increase of Na v 1.7 in the painful pulp group. Na v 1.7 immunoreactive fibres were seen in abundance in the sub-mucosal layer of tongue biopsies, with no significant difference between BMS and controls. CONCLUSION: Na v 1.7 sodium channel may play a significant role in inflammatory dental pain. Clinical trials with selective Na v 1.7 channel blockers should prioritize dental pulp pain rather than BMS.

Coronectomy root retrievals: a review of 92 cases.

BACKGROUND: Coronectomy has become an increasingly prescribed surgical treatment for mandibular third molars that are deemed to pose a risk to the inferior dental nerve. Retention of the roots poses a risk of need for root retrieval in the future if symptoms are present. Long-term outcomes and the symptoms that lead to root retrieval via coronectomy have not been well documented or studied, and this has understandably led to hesitation in some clinicians in offering the procedure. The current series assesses patients who have undergone root retrieval, their reported indications for removal, and the histopathologic status of the removed roots. STUDY DESIGN: A total of 92 cases of root retrievals via coronectomy carried out at Guy's Dental Hospital are included in this analysis. Data were collected retrospectively from patient records regarding patient symptoms, clinical and radiographic findings, function of the inferior dental nerve, and histologic results. RESULTS: The mean age of patients in the study group was 31.6 years (range 19-70 years), with a female-to-male ratio of 62:18 (77.5% female). Mean time to the second surgery for root retrieval was 17 months. In "successfully" performed coronectomies, 75.3% (61 of 81) of root pulps appeared vital histopathologically. Mucosal tenderness (39 of 81 [48.1%]) was the most common symptom leading to root retrieval. CONCLUSIONS: Root retrieval after coronectomy should be based on findings from sound clinical and radiographic examinations. In the presence of obvious indications, such as an unhealed socket resulting from retained enamel or soft tissue infection after eruption of roots, then retrieval should be performed with confidence that resolution would occur. However, if the coronectomy root appears an unlikely culprit, then the clinician should consider and investigate alternative diagnoses, such as overerupted upper third molars causing trauma, temporomandibular dysfunction, and the dental status of the adjacent tooth as potential causes of symptoms.

Coronectomy and dentigerous cysts: a review of 68 patients.

OBJECTIVE: This large case series retrospectively reviewed the outcomes of coronectomy in conjunction with dentigerous cyst removal in 68 patients at the oral surgery department of Guy's Hospital. STUDY DESIGN: A retrospective review of 68 patients was undertaken in a single department where 73 teeth with associated dentigerous cysts were treated by coronectomy to reduce the risk of inferior alveolar nerve injury or mandibular fracture. RESULTS: One patient experienced permanent injury of the inferior alveolar nerve. There were no intraoperative mandibular fractures in this series. Four coronectomy roots required retrieval at 2, 4, and 20 months and 10 years after the initial surgery due to persistent surgical site infection and incomplete coronectomy with retained enamel and associated cystic tissue leading to symptoms. The longest follow-up in this series was 10 years for 2 patients, and 30 of 68 patients were reviewed between 1 and 3 years postoperatively. CONCLUSION: Coronectomy in conjunction with dentigerous cysts is an effective treatment, with minimal morbidity seen in both short- and long-term periods.

Histological evaluation of mandibular third molar roots retrieved after coronectomy.

There is a resurgence of interest in coronectomy for the management of mandibular third molars because it has a low risk of injury to the inferior dental nerve. However, there is concern that the root that is left in place will eventually become a source of infection. We describe the histological evaluation of 26 consecutive symptomatic coronectomy roots in 21 patients. All roots had vital tissue in the pulp chamber and there was no evidence of periradicular inflammation. Persistent postoperative symptoms related predominantly to inflammation of the soft tissue, which was caused by partially erupted roots or failure of the socket to heal.

Sensory purinergic receptor P2X3 is elevated in burning mouth syndrome.

Recent studies show that P2X(3) may play a role in neuropathic pain, including orofacial pain. Burning mouth syndrome (BMS) is a chronic neuropathic pain condition affecting 0.6-12% of post-menopausal women in the Western world. This study evaluates, for the first time, P2X(3) immunoreactivity levels in lingual mucosa in BMS patients. Patients diagnosed with BMS (n=9) in accordance with International Association for the Study of Pain criteria and patients attending for wisdom tooth removal (n=10, controls), were involved in this study. A pain history and score was recorded on a visual analogue scale (VAS) prior to obtaining a lingual biopsy. Immunohistochemistry and image analysis were used to quantify submucosal nerve fibres expressing P2X(3) and the structural marker neurofilaments. P2X(3) positive fibres were significantly increased in BMS compared with controls (p=0.024). In contrast, neurofilament-staining fibres were reduced in BMS, and when expressed as a ratio of the neurofilament percentage area, there was a trend for an increase of P2X(3) positive fibres in the BMS group. Increased P2X(3) immunoreactivity in the trigeminal sensory system may play a role in the symptoms observed in BMS. P2X(3) may therefore be a therapeutic target for treating BMS and trigeminal neuropathic pain.