An international survey of oral medicine practice: proceedings from the 5th World Workshop in Oral Medicine.

OBJECTIVES: (i) To define the current state of oral medicine clinical practice internationally, and (ii) to make recommendations for future modeling of the practice of oral medicine. MATERIALS AND METHODS: A survey was designed by an international panel of oral medicine experts to assess the current state of oral medicine practice internationally. The survey was sent to oral medicine experts across the world, and responses were electronically stored and analyzed using descriptive statistics. RESULTS: Two hundred respondents completed the survey representing 40 countries from six continents. The two most common settings for an oral medicine practice were in a hospital and a dental school. More than 88% of respondents considered management of oral mucosal disease, salivary dysfunction, oral manifestations of systemic diseases, and facial pain in the definition of oral medicine. CONCLUSIONS: (i) Oral medicine clinicians diagnose and manage a wide variety of orofacial conditions; (ii) There are significant differences in the definition of oral medicine clinical practice from country to country; (iii) India has the largest expansion of oral medicine services as defined by escalating numbers of clinicians within the specialty as compared with other countries; (iv) oral medicine practitioners have a wide range of professional responsibilities.

Kindler syndrome in two related Kurdish families.

We describe a 19-year-old girl with Kindler syndrome. She has suffered from bullae on pressure areas of the skin since birth. These healed with atrophic scars and caused marked atrophy of the skin of the palms and soles and wrinkled and parchment-like skin of the dorsum of the hands and feet. Since infancy the patient has also suffered from severe photosensitivity on exposed areas and developed poikiloderma on the skin of her face, neck, chest, and upper back. Since age 17 years the patient has been free of bullae but moderate photosensitivity exists. Oral examination showed limitation of mouth opening, ankyloglossia, overjet malocclusions, and atrophy of buccal mucosa with widespread white macules. Results of laboratory tests were within normal limits. The proposita's parents (family 1) are Jews of Kurdish origin and first cousins. She is the only one affected among five siblings. Family 1 is related to a second family (family 2) through a common great-grandfather. The parents of family 2 are first cousins and they have three affected children. An autosomal recessive mode of inheritance of Kindler syndrome is suggested in these two related families.

Salivary immunoglobulins in recipients of bone marrow grafts. I. A longitudinal follow-up.

Patients receiving bone marrow transplantation (BMT) are prone to a variety of bacterial, viral and fungal infections in their oral cavity. We have therefore followed alterations in salivary Ig levels associated with BMT. Most of the patients were transplanted with allogeneic, MHC-matched BM after T cells were depleted by ex vivo treatment with an anti-lymphocytic monoclonal antibody (Campath-1) and autologous complement. Parotid saliva was collected at various time intervals before and after BMT, and IgM, IgG and IgA concentrations were determined by an enzyme linked immunosorbent assay (ELISA). A gradual fall in Ig levels was detected following patient's conditioning with a combination of chemo- and radiation therapy beginning 10 days prior to BMT. A rise in the titer of salivary Ig could be detected as early as 4 days post-BMT, which increased continuously and reached plateau levels within 2-3 weeks. However, about 3 weeks later the Ig titers decreased again and persisted at low levels for variable periods of time. A second increase in salivary Ig was detected approximately 2 months post-BMT, which persisted for prolonged periods of time. These results suggest that Ig secreted by donor B-lymphocytes and plasma cells passively transferred with the BM can rapidly reconstitute the salivary IgM, IgG and IgA of the immunocompromised recipient. However, when these cells cease to produce Ig the patients are still immunoincompetent and therefore enter a second phase of salivary Ig deficiency which may render them highly susceptible to opportunistic oral infections.(ABSTRACT TRUNCATED AT 250 WORDS)

Salivary immunoglobulins in recipients of bone marrow grafts. III. A longitudinal follow-up of CMV specific antibodies.

Cytomegalovirus (CMV) infection is a major complication of BMT. The oral cavity is a common route for CMV infection, whose protection is provided by salivary anti-CMV antibodies. We developed an ELISA assay for the detection of CMV-specific antibodies in parotid saliva. Saliva of patients receiving BMT from CMV-positive donors was transiently reconstituted with IgG and IgA anti-CMV antibodies shortly after transplantation. The concentration of these antibodies gradually decreased during the 2 months after transplantation and increased again around day 80. A remarkable rise in the salivary concentrations of IgG and IgM anti-CMV was observed shortly after i.v. administration of Sandoglobulin. These results demonstrate, for the first time accurate monitoring of CMV-specific antibodies in saliva using a quantitative ELISA assay. The study suggests that secretion of CMV-specific antibodies in saliva of immunocompromised patients can be reconstituted by donor-derived B and plasma cells transferred with the BM or by i.v. administration of pooled Ig.

CO2 laser in oral graft-versus-host disease: a pilot study.

This paper is the first to report the benefits of CO2 laser treatment for pain control in severe oral chronic graft-versus-host disease (GVHD). A CO2 laser device was used during 17 treatment sessions in four patients. The CO2 laser was applied over the mucosal lesions using 1 W for 2-3 s/1 mm(2). This treatment resulted in a consistent and significant decrease in pain, measured using a standard visual analogue scale. These results suggest that the CO2 laser can be used for the alleviation of pain in oral chronic GVHD.

Modulation of human lymphocyte transformation by bacterial products and leukocyte lysates.

Blast transformation of human peripheral blood lymphocytes by PHA is shown to be modulated by lipoteichoic acid (LTA) of Streptococcus mutans, by a cell-sensitizing factor of Actinomyces viscosus, as well as by a frozen and thawed extract of human leukocytes (LE). While small amounts of LE (5-50 micrograms/10(6) cells) significantly enhanced PHA-induced transformation, higher amounts showed a lesser effect on the blastogenic response. Both LTA and the A. viscosus extract did not cause any lymphocyte blastogenic effect when used alone. On the other hand LTA had an inhibitory effect and the A. viscosus extract had an enhancing effect when lymphocytes were pretreated by these agents and then exposed to PHA.

Thalidomide-induced perioral neuropathy.

Thalidomide was administered as a therapeutic agent for chronic graft-versus-host disease after allogeneic peripheral blood stem cell transplantation in a patient with breast cancer. Although side effects of thalidomide have been described earlier, this is the first instance of perioral neuropathy associated with thalidomide treatment. Awareness of this specific side effect may contribute to early diagnosis and appropriate treatment.

A longitudinal follow-up of salivary secretion in bone marrow transplant patients.

Salivary gland dysfunction is a common sequela of the bone marrow transplantation procedure. We determined the effect of different bone marrow transplantation protocols on parotid salivary flow rate. Salivary secretion was substantially reduced during conditioning of all the recipients. A gradual flow rate reconstitution could be detected as soon as a few days after the bone marrow transplantation. Eight patients conditioned with total lymph node irradiation and chemotherapy or chemotherapy alone displayed earlier and complete recovery of saliva secretions 2 to 5 months after the grafting. Recovery was delayed and incomplete when total body irradiation was added to the conditioning regimen (seven patients). Six of these patients also developed graft-versus-host disease. The results suggest that total body irradiation induces irreversible damage to the parotid glands resulting in profound xerostomia followed by opportunistic infections. Chemotherapy with or without total lymph node irradiation does not induce such damage.

Ultraviolet B irradiation: a new therapeutic concept for the management of oral manifestations of graft-versus-host disease.

Ultraviolet irradiation inhibits the proliferative responses of lymphoid cells to mitogens and alloantigens by inactivation of T lymphocytes and antigen-presenting cells. Its immunosuppressive capacity led to the introduction of UV irradiation into clinical practice for the treatment of dermatologic manifestations of chronic graft-versus-host disease. The cumulative experience with psoralen-UV-A rays in the treatment of cutaneous and oral graft-versus-host disease was the incentive for the application of oral UV-B rays in 2 patients with oral graft-versus-host disease signs and symptoms after allogeneic marrow transplantation. Intraoral UV-B irradiation (0.02 mJ/cm(2)) was administered 2 or 3 times per week on an ambulatory basis; the dose was increased by 0. 02 mJ/cm(2) every fourth session. Both patients responded early and satisfactorily, displaying only minimal side effects at a relatively low cumulative dose. Intraoral UV-B proved a valuable modality in the treatment of resistant chronic oral graft-versus-host disease.

Dental health care workers at risk.

Healthy DHCWs do not seem to be at significantly higher risk for occupationally acquired diseases when compared with other HCWs. Special attention should be paid to DHCWs who are more susceptible to diseases potentially transmitted in a dental setting. These DHCWs include pregnant women, due to their immunologic changes, and the developing fetus; DHCWs; those with habits such as excessive intake of alcohol; DHCWs following splenectomy, radiotherapy, and long-term corticosteroid therapy; and DHCWs suffering from diseases that have an impact on the first and secondary defense against infections, such as diabetes mellitus, chronic renal failure, sickle cell anemia, leukemia, lymphoma, or HIV.

Pulmonary edema: a complication following dental treatment under general anesthesia.

This article describes pulmonary edema in two young, physically healthy individuals following routine intensive dental treatment under general anesthesia. The etiology, diagnosis, prognosis, and treatment are discussed. This paper demonstrates that young, healthy patients may develop pulmonary edema in the perianesthesia period or even during anesthesia itself. Obstructive events, which occur especially in the post extubation period, may trigger this condition, as may other well-known phenomena. Early diagnosis and intensive treatment are mandatory in order to effectively resolve the situation.

Bleeding tendency: a practical approach in dentistry.

The dental profession faces the problems of exaggerated bleeding on a daily basis. The hemostatic, as well as the fibrinolytic processes are better understood today, and the dentist should be familiar with them. The activation of coagulation factors and their clinical expression in the circulation are both described. The most frequently used blood coagulation tests are explained. Antithrombotic medications are frequently used and their implications in dentistry are accentuated. Protocols of prevention and treatment of exaggerated bleeding following dental procedures are included. Among them, the transfusion of clotting factors and the administration of antifibrinolytic medications (tranexamic acid) are recommended for both congenital or acquired bleeding tendencies.