Management of dental patients taking direct oral anticoagulants: Dabigatran.

Direct oral anticoagulants (DOACs) are increasingly used as alternatives to warfarin because of the superior pharmacokinetic properties. Clinical guidelines on the influences of DOACs for dental procedures have emerged, but all of necessity based on low-quality available evidence. Herein, we share our experience with a case series, and propose a protocol regarding the management of dental patients taking DOACs.

Oral Cancer Early Detection: What Do Patients Need To Know?

The purpose of the present study was to examine the educational needs of patients regarding early detection of oral cancer. A total of 790 patients without cancer were interviewed and shown a set of validated clinical images of various oral lesions including early oral cancer. Participants were asked about their perception of cancer and the action that they would take if they notice a similar lesion. Lower risk lesions (e.g., lumps) were more likely to be perceived as cancer (52.4%), while higher risk lesions (e.g., red patches) were least likely to be perceived as cancer (8.8%). The perceived appearance of the lesions was correlated with patients' perceived need for medical advice. Higher risk lesions were less likely to make patients feel the need to seek professional advice. High-risk patients were less aware about oral cancer appearance and were less likely to take action if they notice an oral lesion. Patients are not aware of the various presentations of early oral cancers, especially higher risk lesions. Patients need to know more about the clinical appearance of early oral cancer. The use of representative clinical images of early oral cancer and educational videos on self-inspection of oral mucosa is important.

Zika virus: oral healthcare implications.

Zika virus (ZIKV) infection has been recognised since 1947, but just recently it became a worldwide major public health problem. The most common features of ZIKV infection are fever, cutaneous rash, arthralgia and conjunctivitis but most affected patients with the clinical disease present with only mild symptoms. However, severe neurological complications have been described: there is an occasional association with Guillain-Barre syndrome, and emerging data indicate an association between vertical transmission of ZIKV infection and microcephaly, but no specific orofacial manifestations have yet been reported. ZIKV is present in body fluids and has also been demonstrated in the saliva, but there is as yet no reliable evidence to support ZIKV transmission via this pathway. Transmission in oral health care should be effectively prevented using standard infection control measures. There are currently no specific treatments for Zika virus disease and no vaccines available, so prevention of ZIKV is based on vector control.

An update on the implications of cyclin D1 in oral carcinogenesis.

Cyclin D1 promotes cell cycle progression during G1 phase, a key event in G1-S transition. The protein is encoded by gene CCND1, located in chromosomal band 11q13. Cyclin D1 plays key roles in cell biology, including cell proliferation and growth regulation, mitochondrial activity modulation, DNA repair, and cell migration control. CCND1 gene and its protein cyclin D1 are frequently altered by different molecular mechanisms, including amplification, chromosomal translocations, mutations, and activation of the pathways involved in cyclin D1 expression, alterations which appear to be essential in the development of human cancers, including oral carcinoma. This is the first published review of the specific features of cyclin D1 overexpression in oral oncogenesis. Starting with the physiological regulation of cyclin D1, there is an evaluation of its functions, overexpression mechanisms, and the implications of the oncogenic activation of CCND1/cyclin D1 in oral squamous cell carcinoma. The potential diagnostic and prognostic value of cyclin D1 is reviewed. The influence of CCND1/cyclin D1 on tumor size and clinical stage is reported, and an update is provided on the utilization of cyclin D1 as therapeutic target and on the combination of cyclin D1 inhibitors with cytotoxic agents. Future research lines in this field are also proposed.

Oral Cancer Knowledge and Diagnostic Ability Among Dental Students.

The purpose of this study is to examine factors that influence the diagnostic ability of dental students with regards to oral cancer and oral potentially malignant disorders. Dental students at different levels of study were directly interviewed to examine their oral cancer knowledge and diagnostic ability using a validated and pre-tested survey instrument containing validated clinical images of oral cancer and oral potentially malignant disorders. An oral cancer knowledge scale (0 to 31) was generated from correct responses on oral cancer general knowledge, and a diagnostic ability scale (0 to 100) was generated from correct selections of suspicious oral lesions. Knowledge scores ranged from 0 to 27 (mean 10.1 ± 6.0); mean knowledge scores increased with year of study; 5th year students had the highest mean knowledge score (19.1 ± 4.0), while 1st year students had the lowest (5.6 ± 3.5). Diagnostic ability scores increased with year of study and ranged from 0 to 88.5 % (mean 41.8 % ± 15.6). The ability to recognize suspicious oral lesions was significantly correlated with knowledge about oral cancer and oral potentially malignant disorders (r = 0.28; P < 0.001). There is a need to improve oral cancer education curricula; increasing students' contact with patients who have oral lesions including oral cancer will help to improve their future diagnostic ability and early detection practices.

Emerging and changing viral diseases in the new millennium.

Most viral infections encountered in resource-rich countries are relatively trivial and transient with perhaps fever, malaise, myalgia, rash (exanthema) and sometimes mucosal manifestations (enanthema), including oral in some. However, the apparent benignity may be illusory as some viral infections have unexpected consequences - such as the oncogenicity of some herpesviruses and human papillomaviruses. Infections are transmitted from various human or animal vectors, especially by close proximity, and the increasing movements of peoples across the globe, mean that infections hitherto confined largely to the tropics now appear worldwide. Global warming also increases the range of movement of vectors such as mosquitoes. Thus recent decades have seen a most dramatic change with the emergence globally also of new viral infections - notably human immunodeficiency viruses (HIV) - and the appearance of some other dangerous and sometimes lethal infections formerly seen mainly in, and reported from, resource-poor areas especially in parts of Asia, Latin America and Africa. This study offers a brief update of the most salient new aspects of the important viral infections, especially those with known orofacial manifestations or other implications for oral health care.

YouTube as a source of information on mouth (oral) cancer.

OBJECTIVES: We examined the content of YouTube(™) videos on mouth (oral) cancer and evaluated their usefulness in promoting early detection of oral cancer. MATERIALS AND METHODS: A systematic search of YouTube(™) for videos containing information on mouth cancer was conducted using the keywords 'mouth cancer' and 'oral cancer'. Demographics of videos, including type, source, length, and viewers' interaction, were evaluated, and three researchers independently assessed the videos for usefulness in promoting early detection of oral cancer. RESULTS: A total of 188 YouTube(™) videos (152 patient-oriented educational videos and 36 testimonial videos) were analyzed. The overall usefulness score ranged from 0 to 10 (mean = 3.56 ± 2.44). The most useful videos ranked late on the viewing list, and there was no significant correlation between video usefulness and viewing rate, viewers' interaction, and video length. Videos uploaded by individual users were less useful compared with videos uploaded by professional organizations or by healthcare professionals. CONCLUSION: Healthcare professionals, academic institutions, and professional organizations have a responsibility for improving the content of YouTube(™) about mouth cancer by uploading useful videos, and directing patients to reliable information sources.

Psychological disorders and oral lichen planus: matched case-control study and literature review.

OBJECTIVE: Oral lichen planus (OLP) may be linked to psychological disorders. This study investigated psychological factors associated with OLP. METHODS: A case-control study with incident OLP case patients and age-gender-socio-economic status-matched controls, recruited from among relatives, accompanying persons, and departmental staff, investigated psychological traits using the Psychological General Well-Being Index-Short form. Common factor analysis was used to generate a set of psychological dimensions. The association between these dimensions and OLP adjusted for confounders (education, number of lifetime sexual partners, drinking-smoking) and interactions was assessed through conditional logistic regression and odds ratios (OR) were estimated. RESULTS: A total of 67 case-control pairs were recruited. Psychological dimensions generated were: dimension-1 (anxiety, low vitality), dimension-2 (negative well-being, low vitality), dimension-3 (depressed mood, low self-control). The ORs for OLP were, dimension-1, 1.0 (95% confidence interval -95CI, 0.3-2.6); dimension-2, 0.5 (95CI, 0.2-1.2); dimension-3, 4.8 (95CI, 1.8-12.9). Dimension-3 was highly associated with mild, but not associated with severe, OLP. Literature searching provided 21 studies, with anxiety and depression principally associated with OLP. CONCLUSIONS: Depressed mood and low self-control were highly associated with OLP, particularly the reticular-papular forms. These traits could have a causative role in OLP development-progression, but further investigations are necessary.

Global burden of oral diseases: emerging concepts, management and interplay with systemic health.

OBJECTIVES: This study presents the global burden of major oral diseases with an exegetical commentary on their current profiles, the critical issues in oral healthcare and future perspectives. METHODS: A narrative overview of current literature was undertaken to synthesise the contexts with critical elaboration and commentary. RESULTS: Oral disease is one of the most common public health issues worldwide with significant socio-economic impacts, and yet it is frequently neglected in public health policy. The oral data extracted from the Global Burden of Disease Study in 2010 (Murray et al, 2012) show that caries, periodontal disease, edentulism, oral cancer and cleft lip/palate collectively accounted for 18 814 000 disability-adjusted life-years; and the global burden of periodontal disease, oral cancer and caries increased markedly by an average of 45.6% from 1990 to 2010 in parallel with the major non-communicable diseases like diabetes by 69.0%. Oral diseases and non-communicable diseases are closely interlinked through sharing common risk factors (e.g. excess sugar consumption and tobacco use) and underlying infection/inflammatory pathways. CONCLUSIONS: Oral disease remains a major public health burden worldwide. It is of great importance to integrate oral health into global health agenda via the common risk factor approach. The long-term sustainable strategy for global oral health should focus on health promotion and disease prevention through effective multidisciplinary teamwork.

Factors Influencing Early Detection of Oral Cancer by Primary Health-Care Professionals.

The purposes of this study are to determine early detection practices performed by primary healthcare professionals, to compare medical and dental sub-groups, and to identify factors that influence the ability of medical and dental practitioners to recognize precancerous changes and clinical signs of oral cancer. A 28-item survey instrument was used to interview a total of 330 Jordanian primary health-care professionals (165 dental and 165 medical). An oral cancer knowledge scale (0 to 31) was generated from correct responses on oral cancer general knowledge. An early detection practice scale (0 to 24) was generated from the reported usage and frequency of procedures in oral cancer examination. Also, a diagnostic ability scale (0 to 100) was generated from correct selections of suspicious oral lesions. Only 17.8 % of the participants reported that they routinely performed oral cancer screening in practices. Their oral cancer knowledge scores ranged from 3 to 31 with a mean of 15.6. The early detection practice scores ranged from 2 to 21 with a mean of 11.6. A significant positive correlation was found between knowledge scores and early detection practice scores (r = 0.22; p < 0.001). The diagnostic ability scores ranged from 11.5 to 96 with a mean of 43.6. The diagnostic ability score was significantly correlated with knowledge scores (r = 0.39; p < 0.001), but not with early detection practice scores (r = 0.01; p = 0.92). Few significant differences were found between medical and dental primary care professionals. Continuous education courses on early diagnosis of oral cancer and oral mucosal lesions are needed for primary health-care professionals.

How many individuals must be screened to reduce oral cancer mortality rate in the Western context? A challenge.

OBJECTIVE: Controlling oral cancer (OC) through screening is appealing. Advantages of this are as follows: OC is often preceded by visible premalignant lesions, early-stage survival is threefold greater than late-stage survival, and visual screening is inexpensive. Disadvantages of this are as follows: high frequency of false positives, undemonstrated cost-effectiveness, and irregular screening attendance by high-risk individuals. Screening effectiveness in Western countries has not been proven, because of low OC prevalence, which disproportionally increases the number of individuals needed to screen (NNS) to decrease mortality. This study estimated the NNS to obtain an evident decrease in OC mortality rate in the UK. METHODS: Data gathered from reliable databanks were used. NNS to detect one case (NNScase ) was estimated using a Bayesian approach. NNS to prevent one death (NNSdeath ) was assessed multiplying NNScase by the number of cases that must be screen-detected to prevent one death. NNS to decrease mortality rate by 1% (NNSmortality ) was assessed multiplying NNSdeath by 1% of annual OC deaths. RESULTS: NNSmortality was overall 1 125 000 (95% confidence interval - 95CI, 690 000-1 870 000), males 551 000 (95CI, 337 000-916 000), and females 571 000 (95CI, 347 000-942 000). CONCLUSIONS: An OC visual screening campaign capable of producing an evident decrease in mortality rate in the UK requires a large number of adults to be annually and regularly screened.

Systemic use of non-biologic agents in orofacial diseases: other immunomodulatory agents.

Systemic non-biologic agents have long been in clinical use in medicine--often with considerable efficacy, albeit with some adverse effects--as with all medications. With the advent of biologic agents, all of which currently are restricted to systemic use, there is a growing need to ensure which agents have the better therapeutic ratio. The non-biologic agents (NBAs) include a range of agents, most importantly the corticosteroids (steroids). Previous articles by us in this series have discussed systemic use of corticosteroids and purine synthesis inhibitors; the other immunomodulating agents (calcineurin inhibitors, thalidomide, dapsone, colchicine and cyclophosphamide) are reviewed in this final article.

Salivary microRNAs in oral cancer.

OBJECTIVE: This study investigated the use of three salivary microRNAs (miRNA-21, miRNA-184, and miRNA-145) as possible markers for malignant transformation in oral mucosal lesions. MATERIALS AND METHODS: Salivary whole unstimulated samples were collected from a study group of 100 subjects, consisting of 20 clinically healthy controls, 40 patients with oral potentially malignant disorders (PMDs) [20 with dysplastic lesions and 20 without dysplasia], 20 with biopsy-confirmed oral squamous cell carcinoma (OSCC), and 20 with recurrent aphthous stomatitis (RAS) as disease controls. Total RNA was isolated and purified from saliva samples using the microRNA Isolation Kit (Qiagen, UL). miRNA expression analysis was performed using qRT-PCR (Applied Biosystems). RESULTS: There was a highly significant increase in salivary miRNA-21 and miRNA-184 in OSCC and PMD (with and without dysplasia) when compared to healthy and disease controls (P < 0.001). Conversely, miRNA-145 levels showed a highly significant decrease in OSCC and PMD overall (P < 0.001). RAS cases showed no significant difference from normal controls in any measured miRNA (P > 0.05). The only microRNA to discriminate between OSCC and PMD with dysplasia was miRNA-184. When receiver operating characteristic curves were designed for the three miRNAs, cutoff points delineating the occurrence of malignant change were a fourfold increase in miRNA-21 with specificity 65% and sensitivity 65%, a 0.6 decrease in miRNA-145, with specificity 70% and sensitivity 60%, and a threefold increase of miRNA-184, with specificity 75% and sensitivity 80%. Calculating the area under the curve revealed that miRNA-184 was the only one among the studied miRNAs that provided good diagnostic value. CONCLUSION: Salivary determination of the miRNAs tested might furnish a noninvasive, rapid adjunctive aid for revealing malignant transformation in oral mucosal lesions, particularly miRNA-184.

The contribution of histopathological examination to the diagnosis of cervico-facial actinomycosis: a retrospective analysis of 68 cases.

Cervico-facial actinomycosis is an infectious, suppurative, and granulomatous disease due to Actinomyces species. Usually, the diagnosis is confirmed by microbiological cultures; however, the need for careful anaerobic handling of specimens often makes it difficult to obtain an effective microbial growth. Therefore, we conducted a retrospective study on biopsy samples from patients with a clinical suspicion of cervico-facial actinomycosis, in order to determine whether accurate histopathological examination could reliably confirm the diagnosis. A retrospective revision of formalin-fixed, paraffin-embedded archival material from 68 cases of cervico-facial lesions, with negative culture for anaerobic/microaerophilic microorganisms, was performed. Twelve serial sections for each case were cut from the paraffin blocks, individually collected on positively charged slides to obtain good section-to-slide adhesion, and stained with hematoxylin and eosin (H&E) and periodic acid-Schiff (PAS). Histopathological examination of the serial sections allowed the identification of bacterial colonies consistent with actinomycetes in 22 cases (32 %). The proposed histopathological examination allowed the retrospective diagnosis of cervical actinomycosis in one-third of clinical specimens that remained misdiagnosed following traditional H&E examination.

Challenges in predicting which oral mucosal potentially malignant disease will progress to neoplasia.

Probably the greatest challenge to those managing patients with oral diseases is the dilemma of attempting to predict which oral erythroplakias, leukoplakias, lichenoid and other potentially malignant mucosal disease (PMD) such as oral submucous fibrosis will progress to neoplasia--notably oral squamous cell carcinoma (OSCC). The paper reviews progress over the past decade and the application to the clinical situation.

Antiretroviral therapy: effects on orofacial health and health care.

This study summarizes the adverse effects of antiretroviral therapy (ART) agents against HIV on orofacial health and health care. Current antiretroviral agents fall mainly into three major classes: nucleoside reverse-transcriptase inhibitors (NRTIs), non-nucleoside reverse-transcriptase inhibitors (NNRTIs) and protease inhibitors (PIs) - now with the new classes of fusion inhibitors, entry inhibitors--CCR5 co-receptor antagonists and HIV integrase strand transfer inhibitors. Many of the ART agents can have adverse orofacial effects, or can give rise to allergies or drug interactions--the optimum anti-HIV drug has yet to be found. There are few orofacial adverse effects that characterize a particular ART class, but erythema multiforme (EM), ulcers and xerostomia may be associated with reverse-transcriptase inhibitors (RTI); parotid lipomatosis, taste disturbance, xerostomia and perioral paraesthesia mainly related to PIs. Facial lipoatrophy is a common adverse effect of NRTIs; EM is more frequently associated with NNRTIs. Thus, although most of the more recent ART drugs and combinations of them show improved safety profiles, some may give rise to orofacial adverse effects, and may affect oral health care.

Systemic use of non-biologics in orofacial diseases: 2. Purine synthesis inhibitors.

Systemic non-biological agents (NBAs) have been extensively used for immunosuppression in clinical medicine, often with considerable efficacy, although sometimes accompanied with adverse effects as with all medicines. With the advent of biological agents, all of which currently are restricted to systemic use, there is a rising need to identify which agents have the better therapeutic ratio. The NBAs include a range of agents, most especially the corticosteroids (corticosteroids). This article reviews the purine synthesis inhibitors (azathioprine and mycophenolate), which are currently the most commonly used systemically immunosuppressive agents in the management of orofacial mucocutaneous diseases. Subsequent articles discuss other corticosteroid-sparing agents used in the management of orofacial disease, such as calcineurin inhibitors, and the cytotoxic and other immunomodulatory agents.

Systemic use of non-biologic corticosteroids in orofacial diseases.

Systemic non-biologic agents have long been in clinical use in medicine - often with considerable efficacy, albeit with some adverse effects--as with all medications. With the advent of biologic agents, all of which currently are restricted to systemic use, there is a growing need to ensure which agents have the better therapeutic ratio. The non-biologic agents (NBAs) include a range of agents, most especially the corticosteroids (corticosteroids). This study reviews the corticosteroids in systemic use in management of orofacial mucocutaneous diseases; subsequent studies discuss corticosteroid-sparing agents used in the management of orofacial diseases, such as calcineurin inhibitors used to produce immunosuppression; purine synthetase inhibitors; and cytotoxic and other immunomodulatory agents.

Biologics in oral medicine: ulcerative disorders.

Inflammatory ulcerative diseases of the oral mucosa are wide ranging but include especially aphthous and aphthous-like ulceration, vesiculobullous disorders and erosive lichen planus (LP). While most patients with these conditions respond to conventional topical and/or systemic immunosuppressive agents, treatment-resistant cases remain challenging. In these, the use of biologics such as tumour necrosis factor alpha (TNF-α) inhibitors or rituximab may be of benefit. This article reviews the use of biologics in ulcerative oral conditions, highlighting potential benefits, adverse effects and principles of use and future developments. TNF-α inhibitors such as infliximab can be effective in inducing resolution in oral aphthous and aphthous-like ulcers and may be an appropriate therapy in those patients in which disease is severe and refractory to, or patients are intolerant of, traditional immunomodulatory regimens. There would also seem support and rationale for use of biologics (mainly rituximab) in pemphigus but not in oral LP or other oral ulcerative conditions.

Biologics in oral medicine: Sjogren syndrome.

Oral Diseases (2012) doi:10.1111/j.1601-0825.2012.01932.x Biologic therapy has a potential to benefit patients with orofacial manifestations of Sjogren syndrome (SS). The most appropriate use of biologics would appear to be in patients with severe or multisystem features of SS, but their use early in the pathogenesis has the potential to prevent disease progression. Tumour necrosis factor-alpha blockade has not proven effective in SS. B-cell depletion using rituximab has been of benefit, mainly in relation to extraglandular features, and to some extent in relation to hyposalivation where there is still residual salivary function. Rituximab is also effective in the treatment of SS-associated (extrasalivary) lymphomas, although the therapeutic response in salivary lymphoma is poorer. Rituximab is given as a single or periodic intravenous infusion. Potential adverse effects exist, notably infusion reactions and infection, and so a full risk/benefit analysis is indicated for prospective patients. This and clinical use is best performed and monitored in conjunction with rheumatologists with appropriate training and experience in biologic therapies. Further studies of rituximab in SS are ongoing, and newer agents under trial include belimumab.