The status of jaw lesions and medication-related osteonecrosis of jaw in patients with multiple myeloma.

BACKGROUND/PURPOSE: Myeloma jaw lesions are not uncommon. The study aimed to investigate the status of jaw lesions and medication-related osteonecrosis of jaw (MRONJ) in multiple myeloma (MM) patients. METHODS: One hundred and twenty-two consecutive newly-diagnosed MM patients seeking dental care at a hospital of southern Taiwan was examined according to jaw lesions with complete follow-up data. RESULTS: Median age of the patients was 67.8 years, and 88.5% of patients were of DS stage III and 41.0% were of ISS stage III at diagnosis. Median survival was 37.9 months for 43 (35.2%) patients with jaw lesions and 57.4 months for 79 patients without jaw lesions. 1-year, 5-year and >7-year overall survival rates for patients with jaw lesions versus patients without jaw lesions were 94.9%, 67.2%, 56.7% vs 83.7%, 51.8%, 26.8% respectively. Patients with jaw lesions had the worse survival (P = 0.03). Neither age nor stage affected survival. Jaw lesions involved the mandible more often than the maxilla and stopped progressing during remission, but did not repair. Jaw lesions were the first evidence or recurrent sign of MM in six (4.9%) patients. Long-term monthly antiresorptive therapy changed the radiographic patterns of jawbones and induced MRONJ developing in 16.7% (8/48) of patients. Five (62.5%) MRONJ sites spontaneously occurred without local risk factors. CONCLUSION: Nearly one-third of MM patients develop osteolytic jaw lesions that seem to be associated with poorer survival. Jaw lesion is an independent prognostic predictor of survival in myeloma. Antiresorptive drugs at less frequent dosing regimen are crucial to minimize spontaneous MRONJ.

Treatment effectiveness of levamisole plus prednisolone on oral lichen planus patients with emphasis on levamisole-induced agranulocytosis or pancytopenia.

BACKGROUND/PURPOSE: Physicians' and dentists' knowledge of levamisole-induced agranulocytosis or pancytopenia remains incomplete. This study aimed to evaluate the treatment effectiveness of levamisole plus prednisolone on oral lichen planus (OLP) patients with emphasis on levamisole-induced hematological changes. METHODS: Ninety patients with erosive OLP were given 120 mg/day new levamisole (Levazol) and 15 mg/day prednisolone for three consecutive days each week. Three cases with levamisole-induced blood-cytopenias were assessed and treated within one year. RESULTS: Most patients reported significant pain relief and showed no evidence of erosive OLP after 4-8 weeks of treatment with few side effects; nevertheless, three female patients developed agranulocytosis or granulocytopenia with concomitant thrombocytopenia or pancytopenia within 2-6 weeks after levamisole (Levazol) treatment. One case with previously unknown double episodes of agranulocytosis revealed her first episode following interruption of levamisole (Decaris) treatment for 4 months. High fever and sore throat were the most common symptoms, but two agranulocytosis cases remained asymptomatic one week before diagnosis, and were treated with levamisole withdrawal and empiric antimicrobial initiation as well as utilization of granulocyte colony-stimulating factors. Neutrophil recovery took about 1 week, but over 4 weeks in one of the cases (an elderly patient) with septic shock. CONCLUSION: Agranulocytosis or pancytopenia usually developed within 2 months after levamisole treatment, but it might be delayed. Agranulocytosis was more likely to occur in females and onset was acute. Levamisole is an effective immunomodulator for OLP patients; however, it should be used with caution and administered with regular blood monitoring.

Management of dental extractions in patients on warfarin and antiplatelet therapy.

BACKGROUND/PURPOSE: Planning dental extractions for Taiwanese patients on antithrombotic therapy remains controversial. This study aimed to examine management of dental extraction in patients on warfarin and antiplatelet therapy. METHODS: Subjects comprised 1331 patients, with (1) 60 on warfarin with intentional normalized ratio (INR) below 4.0 (warfarin continued: 28 patients/33 occasions; warfarin stopped and switched to heparin under hospitalization: 32 patients/37 occasions); (2) 183 on antiplatelet therapy (aspirin: 125 patients/185 occasions; clopidogrel: 42 patients/65 occasions; dual therapy: 16 patients/24 occasions); and (3) a control group of 1088 patients/1472 occasions without any antithrombotic therapy. The patient's clinico-demographic parameters, warfarin effectiveness (dose and INR levels) and antiplatelet therapy, number and type of dental extraction and incidence of postoperative bleeding were investigated. RESULTS: Incidence of postoperative bleeding in the warfarinized group (warfarin continued: 9.1%; warfarin stopped: 8.1%) was higher than in the antiplatelet group (aspirin: 1.1%; clopidogrel: 3.1%; dual antiplatelet: 4.2%), and the control group (0.7%), but these differences were not significant and unrelated to INR or number and type of dental extraction. Postoperative hemorrhage was managed successfully by repacking with Gelfoam impregnated with tranexamic acid powder in most patients. CONCLUSION: The study indicated that there is no need to interrupt warfarin (INR<4.0) and antiplatelet therapy before dental extractions in Taiwanese patients. A sufficient hemostasis could be obtained using local measures. This approach can save these individuals from becoming exposed to the risk of thromboembolism and the inconvenience of bridging anticoagulation with heparin.

Oral lichen planus - Differential diagnoses, serum autoantibodies, hematinic deficiencies, and management.

Oral lichen planus (OLP) is a chronic inflammatory oral mucosal disease that occurs more frequently in middle-aged and elderly female patients. Previous studies indicate that OLP is a T-cell dysfunction-induced localized autoimmune disease. Clinically, six types of OLP, namely reticular, papular, plaque-like, atrophic/erosive, ulcerative, and bullous types, can be identified. OLP more commonly affects buccal mucosa, tongue, and gingiva. It always has a bilateral and symmetric distribution of the oral lesions. Plaque-like and atrophic/erosive OLP may be misdiagnosed as oral leukoplakia and oral erythroleukoplakia, respectively. Our previous study found serum autoantibodies in 195 (60.9%) of the 320 OLP patients. Specific serum anti-nuclear, anti-smooth muscle, anti-mitochondrial, gastric parietal cell, thyroglobulin, and thyroid microsomal autoantibodies are present in 28.1%, 8.4%, 1.6%, 26.3%, 21.3%, and 24.4% of 320 OLP patients, respectively. Furthermore, we also discovered that 21.9%, 13.6%, 7.1%, 0.3%, and 14.8% of 352 OLP patients have hemoglobin, iron, vitamin B12, and folic acid deficiencies, and abnormally high serum homocysteine level, respectively. Therefore, it is very important to examine the serum autoantibody, hematinic and homocysteine levels in OLP patients before starting the treatments for OLP patients. Because OLP is an immunologically-mediated disease, corticosteroids are the drugs of choice for treatment of OLP.

Numb chin with mandibular pain or masticatory weakness as indicator for systemic malignancy - A case series study.

BACKGROUND/PURPOSE: Numb chin syndrome (NCS) is a critical sign of systemic malignancy; however it remains largely unknown by clinicians and dentists. The aim of this study was to investigate NCS that is more often associated with metastatic cancers than with benign diseases. METHODS: Sixteen patients with NCS were diagnosed and treated. The oral and radiographic manifestations were assessed. RESULTS: Four (25%) of 16 patients with NCS were affected by nonmalignant diseases (19% by medication-related osteonecrosis of the jaw and 6% by osteopetrosis); yet 12 (75%) patient conditions were caused by malignant metastasis, either in the mandible (62%) or intracranial invasion (13%). NCS was unilateral in 13 cases and bilateral in three cases. Mandibular pain and masticatory weakness often dominate the clinical features in NCS associated with cancer metastasis. In two patients, NCS preceded the discovery of unknown malignancy (breast cancer and leukemia). In nine others, NCS heralded malignancy relapse and progression. Metastatic breast cancer in four (36%) cases accounted for the most common malignancy. Other metastatic diseases included two multiple myelomas, and one each of leukemia, prostate cancer, colon cancer, lung cancer, maxillary sinus adenoid cystic carcinoma and adrenal gland neuroblastoma. Radiographic examinations showed obvious mandibular metastasis with compression of the inferior alveolar nerve or mental nerve in nine patients, and leptomeningeal seeding or intracranial metastasis to the trigeminal nerve root at the skull base in two patients. CONCLUSION: NCS without obvious odontogenic causes or trauma often signals systemic malignancy. It may be the first clue of occult malignancy.

Environment-noise-free optical heterodyne retardation measurement using a double-pass acousto-optic frequency shifter.

We demonstrate an environment-noise-free optical heterodyne interferometer (OHI) based on a double-pass acousto-optic frequency shifter (AOFS) for phase retardation measurements. The OHI generates intermediate-frequency (IF) heterodyne beat signals for each orthogonal linear polarization mode of a birefringence sample. The phase differences of the IF signals are compared by using a wide-bandwidth lock-in amplifier. This scheme provides 20 dB rejection of common-mode environmental disturbances. Measurements of the half-wave voltage of an electro-optics modulator and the electro-optic coefficient of an LiNbO3 plate are demonstrated as application examples.

Perception of iron deficiency from oral mucosa alterations that show a high prevalence of Candida infection.

BACKGROUND/PURPOSE: Iron deficiency (ID) is the most common cause of anemia. The aim of this study was to investigate patients with oral mucosa alterations as the initial manifestation of ID or ID anemia (IDA). METHODS: Sixty-four patients (50 IDA and 14 ID) with a wide range of sore mouth were diagnosed and treated. The oral and physical manifestations as well as iron studies and anemia classification based on the mean and heterogeneity of red cell size were assessed. RESULTS: ID predisposed 64 patients to a high incidence of Candida infection (85%) and showed a variety of oral manifestations including angular cheilitis (63%), atrophic glossitis (AG; 59%), pseudomembranous candidosis (44%), erythematous candidosis (41%), median rhomboid glossitis (5%), chronic mucocutaneous candidosis (5%), papillary hyperplastic candidosis (3%), and cheilocandidosis (3%). Others included pale oral mucosa (31%), burning mouth (28%), and recurrent oral ulcers (6%). Colorectal cancers in two patients were diagnosed. The values of hemoglobin (Hb) in 64 ID patients varied from normal to life-threatening levels, but none had developed advanced systemic symptoms except fatigue. All had low serum iron and ferritin. Sixty (94%) patients had transferrin saturation < 16%; however, 19 (30%) patients remained normocytic and 14 (22%) patients were nonanemic. CONCLUSION: The study demonstrates that oral mucosa alterations accompanying oral candidosis are a sensitive indicator of ID. All oral changes can be successfully ameliorated by iron therapy plus antifungals when candidosis exists. Investigating the origin of IDA is necessary, because it may be the first sign of a more serious disease, particularly malignancy.

Oral Candidosis: Pathophysiology and Best Practice for Diagnosis, Classification, and Successful Management.

Oral candidosis is the most common fungal infection that frequently occurs in patients debilitated by other diseases or conditions. No candidosis happens without a cause; hence oral candidosis has been branded as a disease of the diseased. Prior research has identified oral candidosis as a mark of systemic diseases, such as hematinic deficiency, diabetes mellitus, leukopenia, HIV/AIDS, malignancies, and carbohydrate-rich diet, drugs, or immunosuppressive conditions. An array of interaction between Candida and the host is dynamic and complex. Candida exhibits multifaceted strategies for growth, proliferation, evasion of host defenses, and survival within the host to induce fungal infection. Oral candidosis presents a variety of clinical forms, including pseudomembranous candidosis, erythematous candidosis, angular cheilitis, median rhomboid glossitis, cheilocandidosis, juxtavermillion candidosis, mucocutaneous candidosis, hyperplastic candidosis, oropharyngeal candidosis, and rare suppurative candidosis. The prognosis is usually favorable, but treatment failure or recurrence is common due to either incorrect diagnosis, missing other pathology, inability to address underlying risk factors, or inaccurate prescription of antifungal agents. In immunocompromised patients, oropharyngeal candidosis can spread to the bloodstream or upper gastrointestinal tract, leading to potentially lethal systemic candidosis. This review therefore describes oral candidosis with regard to its pathophysiology and best practice for diagnosis, practical classification, and successful management.

Resolution of an active peri-implantitis in a chronic steroid user by bone augmentation with PepGen P-15 and a barrier membrane.

Dental implant treatment can be complicated with infection. A list of possible causes includes overheating during the osteotomy, bacterial contamination from an adjacent tooth, residual bacteria from the infected tooth that previously occupied the site, bone microfractures from overloading or loading too soon, and residual space left around the implant after it is seated. Most treatments entail surgical debridement of the lesion and chemical detoxification of the apical or exposed portion of the implant surface with citric acid, tetracycline, or chlorhexidine gluconate as well as guided tissue regenerative or guided bone regenerative procedures. This article describes the case of an active labiolateral peri-implantitis from a previous infectious site at tooth 12 in a patient who was a chronic steroid user. The patient was treated with surgical debridement and no implant surface detoxification and regenerative procedures with xenograft of PepGen P-15 and an absorbable collagen membrane. The patient was advised to discontinue steroid therapy. This resulted in resolution of the associated signs and symptoms of infection and new bone formation in the radiograph. The negative effect of corticosteroids on calcium metabolism and bone regeneration is discussed. The potential implications of steroid use for implant dentistry are critically appraised, and guidelines are proposed for pre- and postoperative management that may assist in the successful implant-supported rehabilitation of this patient category.

Initial diagnosis of anemia from sore mouth and improved classification of anemias by MCV and RDW in 30 patients.

Thirty patients with a wide range of sore mouth that led to the diagnosis of iron deficiency in 12 patients, pernicious anemia in 8 patients, combined deficiency of iron and vitamin B12 in 2 patients, and anemia of chronic disease in 8 patients were investigated. The oral signs and symptoms included glossitis, glossodynia, angular cheilitis, recurrent oral ulcer, oral candidosis, diffuse erythematous mucositis, and pale oral mucosa. The values of hemoglobin in 30 patients varied from normal to severe life-threatening levels, but none had developed generalized symptoms sufficiently advanced to arouse suspicions of anemia before they visited the Oral Medicine Clinic. The aim of this paper is to describe a retrospective study of 30 patients with oral changes as the initial manifestation of nutritional deficiency or anemia of chronic diseases. Improved diagnosis and classification of anemia based on the mean and heterogeneity of red cell size will be discussed.

Seroprevalence of anti-HCV among patients with oral lichen planus in Southern Taiwan.

A possible association between oral lichen planus (OLP) and hepatitis C virus (HCV) infection has been documented in certain populations such as Japan and Southern Europe; however, the issue remains controversial. The aim of this study was to investigate the prevalence of HCV antibodies among patients with OLP in Southern Taiwan, and to assess the possible association between OLP and HCV infection. All patients enrolled in the study sought care at a hospital dental clinic. Serum samples of 104 patients with OLP and 100 controls with healthy oral mucosa, whose age and gender were matched, were respectively screened for anti-HCV antibodies by the microparticle enzyme immunoassay (AxSYM HCV version 3.0). The prevalence of HCV infection was 22.1% in the study group (23 of 104 OLP patients) and 2% in the control group (2 of 100 control subjects) respectively (P < .001). Eleven of 23 HCV-infected OLP patients (47.8%) were unaware of their HCV infection status in the study. A positive association between OLP and HCV in Southern Taiwan exists, suggesting that routine HCV infection testing of patients with OLP in Southern Taiwan should be considered.

Secondary syphilis-related oral ulcers: report of four cases.

Establishing a diagnosis of syphilis, whatever the stage of the disease, can be difficult because syphilis is a great mimic in clinical morphology and histology. Many patients infected with venereal diseases have oral manifestations, but very few dentists and physicians have the proper experience to diagnose syphilis or other STDs from oral lesions. Oral secondary syphilis appears to be very uncommon, and few cases have been reported over the recent past. We present 4 patients who developed secondary syphilis-related oral lesions of moist ulcers, irregular linear erosions termed 'snail-track' ulcers, or erythematous mucous patches on the labial mucosa, buccal mucosa, palate, or tongue. Concurrent human immunodeficiency virus (HIV) infection was diagnosed in 1 patient. The histological examination in 2 patients showed dense subepithelial inflammatory cell infiltration comprised predominantly of plasma cells, and it was of practical help in the diagnosis of syphilis. The diagnostic value of a histological examination, serologic tests, and treatment of syphilis are discussed. Obviously, coinfection with HIV will complicate the clinical presentation, diagnosis, and management of syphilis. Concurrent HIV infection should be considered in any patient with a sexually transmitted disease including syphilis.

Levamisole aids in treatment of refractory oral candidiasis in two patients with thymoma associated with myasthenia gravis: report of two cases.

Oral candidiasis is associated with defects in cell-mediated immunity and is common among patients undergoing cytotoxic chemotherapy, or corticosteroid or antibiotic therapy, and those patients seropositive for AIDS and HIV (human immunodeficiency virus). This paper demonstrates the important role of cell-mediated immunity in oral candidiasis in 2 cases of thymoma associated with myasthenia gravis. Both suffered from recurrent oral candidiasis after a thymectomy, radiotherapy, and chemotherapy. There was an initial good response to conventional antifungal therapy, which later became refractory. Lymphocyte subset quantitation showed a T cell deficiency and a decreased CD4/CD8 ratio. Levamisole, an immunomodulator, or an immunopotentiating drug was added as adjunctive therapy in combination with oral nystatin treatment. Oral candidiasis responded favorably, and substantial relief was obtained with a concurrent increase in T cells and the CD4/CD8 ratio. These findings clearly demonstrate a significant role of cell-mediated immunity in oral candidiasis, and that eradication of infection is dependent on the host defense mechanism.