Pain characteristics in medication-related osteonecrosis of the jaws.

PURPOSE: To characterise pain from medication-related osteonecrosis of the jaws (MRONJ) and the effects of antimicrobial treatment on it. METHODS: Data from files of patients diagnosed with MRONJ according to the position paper of the American Association of Oral and Maxillofacial Surgeons (2014) and Multinational Association of Supportive Care in Cancer and American Society of Clinical Oncology (2019) were collected retrospectively, including gender, age, primary disease, bone-modifying agents (BMAs)/anti-angiogenics, administration route, involved jaw, location, and exposure size. The patients were treated according to the abovementioned position papers' recommendations, i.e. all patients who suffered from pain were staged as 2 or 3 and treated with systemic amoxicillin, or doxycycline or clindamycin in case of sensitivity, and local antiseptic and hygiene instructions. RESULTS: Data from 77 MRONJ patients (aged 65.09 ± 11.9 years old) were analysed. Most (90.1%) received bisphosphonates for cancer (79%) and osteoporosis (17%). A total of 67.5% experienced pain; 36.5% had moderate-to-severe pain. Female gender was significantly associated with the presence of pain (p = 0.002). Osteonecrosis lesions after dento-alveolar surgery had a higher risk of pain development than spontaneous lesions (p = 0.045). Medical and oncologic background, type of pharmacotherapy, lesion size, and location were not associated with pain levels. Worse initial pain was significantly associated with better relief following MRONJ treatment (p = 0.045). Meaningful pain reduction (≥ 50%) was significantly correlated with initial pain severity (p = 0.0128, OR = 4.75). CONCLUSIONS: Pain from infection and inflammation often accompanies MRONJ. The presence of pain is correlated with longer BMAs pre-therapy and if surgery preceded the MRONJ. Persistency of the mild pain together with a resistance to common antimicrobial treatment, although not complete, is a feature that MRONJ pain shares with neuropathic-"like" pain, and requires further study and consideration during treatment.

Novel parotid sialo-cone-beam computerized tomography features in patients with suspected Sjogren's syndrome.

OBJECTIVE: Sjogren's syndrome (SjS) causes salivary gland impairment leading to oral dryness. Parotid sialo-cone-beam computerized tomography (sialo-CBCT) demonstrates ductal architecture and to a lesser extent gland activity. This study characterizes radiographic features of patients suspected for SjS and looks for a possible correlation with the diagnosis of SjS. METHODS: The clinical and radiographic data of suspected SjS/dry mouth patients referred for sialo-CBCT in 2011-2014 were reviewed retrospectively. Two observers studied the scans for various radiographic features including duct morphology, level of branching, ductopenia and sialectasia. These features were analysed taking the specific clinical data and two sets of SjS criteria: The 2002 American-European Consensus Group (AECG) and the 2012 American College of Rheumatology (ACR) Group. RESULTS: Sialo-CBCT scans of 67-referred patients suffering from dry mouth (115 parotid glands) were included. Intraradiographic association was found between ductopenia and all other radiographic parameters. Minimal, yet important, radiographic differences were found between left and right parotid glands. AECG-confirmed-SjS patients showed strong correlation with radiographic features, whereas ACR 2012-confirmed-SjS patients did not. CONCLUSION: Sialo-CBCT demonstrates novel radiographic features which may clarify the diagnosis of SjS. Further studies are needed to determine the role of sialo-CBCT in diagnosis of SjS.

Improvement of dry mouth following intraductal irrigation of salivary glands.

OBJECTIVES: To assess the effect of major salivary gland intraductal irrigations (IGs) to relieve mouth dryness. METHODS: We retrospectively analyzed the records of patients with mouth dryness who underwent major salivary gland IG during 2013-2015. Records included demographics, medical background, dry mouth etiologies and symptomatology, and results of sialometry and sialo-cone-beam computerized tomography. Subjective improvement following the IG procedure (yes/no) and sustained subjective improvement (mouth dryness relief for ≥1 month) were recorded. Objective improvement was assessed by comparing the mean unstimulated (USF) and stimulated (SSF) whole salivary flow (WSF) rate before and after the IG. RESULTS: Seventy-four patients were included [mean age: 59.08 ± 12.46 years]. Improvement was detected in the USF (p = .027), but not in the SSF (p = .878). Fifty-five (84.6%) noted subjective improvement, while 10 (15.4%) did not. Subjective improvement was positively associated with the USF following IG (p = .037), with salivary gland swelling episodes (p = .033), and with difficulties in swallowing dry foods (p = .014). Of those with subjective improvement, 45 (81.8%) reported sustained improvement, which was positively associated with lack of a gritty eye sensation (p = .042) and abnormal sialo-CBCT findings (p = .001). CONCLUSIONS: Major salivary gland IG is a simple and safe procedure that may relieve dry mouth for a relatively extended duration. Further studies are needed to confirm these preliminary findings and assess their underlying mechanisms.

Clinical photography: Attitudes among dental students in two dental institutions.

INTRODUCTION: Clinical photography is an important tool in teaching, clinical practice and academia especially for mucosal pathologies. Our aim was to examine differences in attitude towards clinical photography for mucosal pathologies among students. METHODS: Questionnaires about clinical photography were completed by students in dental teaching hospitals in Birmingham (UK) and in Israel (ISR). The questionnaires focussed on the perceived value of clinical photography for a number of purposes and also explored perceived barriers to clinical photography and technology in general. The two departments have different access to clinical photography; in the United Kingdom a separate dedicated photography unit takes all the photographs, whereas in ISR the clinicians take their own photographs. Pearson Chi-squared tests determined statistical significance between categorical variables (P < 0.05). RESULTS: Among the 163 respondents, there were no significant differences in the value of photography between countries or genders. The participants felt that the aims of photography included: teaching (99.4%), monitoring premalignancy (97.6%) and clinician communication (95.8%). More than 90% thought photography should be used for dysplasia and erosive lichen planus cases. Respondents from ISR were more in favour of photographing pathologies including simple leukoplakia, reticular lichen planus, vesiculobullous or pigmented lesions (P < 0.001 compared to the UK). Overall, the main reasons for not using photography were time constraints (25.5%) and access (21.8%). CONCLUSIONS: This study highlights a favourable attitude towards clinical photography for various teaching and clinical indications thereby demonstrating its importance. In order to maximise the benefits of clinical photography, access should be simplified.

Radiographic findings of space-occupying lesions in sialo-CBCT of the major salivary glands.

OBJECTIVES: When performing CBCT sialography (sialo-CBCT), space-occupying lesions may be identified incidentally. The objective was to describe their radiologic-clinical-histopathologic correlations. METHOD AND MATERIALS: The archive of sialo-CBCT scans was retrospectively searched for suspected space-occupying lesions. Based on the scan and clinical-histopathologic data, the cases were divided into "pathologic" vs "normal," "intra-parenchymal" vs "extra-parenchymal," and "benign" vs "malignant." Two precalibrated, blinded radiologists performed a survey of the radiographic features of each scan. Cohen kappa, chi-square, Kruskal-Wallis, and Mann-Whitney tests assessed inter-observer agreement and radiologic-clinical-histopathologic correlations. RESULTS: In total, 27 (1.5%) suspected space-occupying lesions were found in 1,758 reports. Full follow-up data were available for 15 cases: four were "malignant," six were "benign," and the remaining five were "normal." Kappa showed substantial inter-observer agreement (0.8 to 1.0). Constant swelling correlated with "pathologic" cases (P = .003). Lesion diameter was greater in "pathologic" than "normal" (P < .001) cases, with a cut-off of 12.6 mm. Clinical and radiographic features were similar in "benign" and "malignant" lesions. "Intra-parenchymal" and "extra-parenchymal" space-occupying lesions correlated with "no-fill-region" (P = .01) and "main-duct-displacement" (P = .002), respectively. CONCLUSIONS: Suspected space-occupying lesions in sialo-CBCT with a diameter greater than 12.6 mm are likely to be "pathologic." No radiographic features were able to differentiate between "malignant" and "benign" space-occupying lesions.

Exploring the Effect of Ethnicity on Chronic Orofacial Pain: A Comparative Study of Jewish and Arab Israeli Patients.

The relationship between ethnicity and chronic pain has been studied worldwide. The population of Israel includes two main ethnic groups, 75% Jews and 21% Arabs. The purpose of this study was to compare orofacial chronic pain characteristics and treatment outcomes between Jewish and Arab Israeli citizens. Two hundred patients admitted to the Orofacial Pain Clinic at Hebrew University-Hadassah School of Dental Medicine between 2017 and 2022 were selected randomly for this historical cohort study. Our cohort included 159 (79.5%) Jews and 41 (20.5%) Arabs. Twenty-six pain-related variables were compared of which only two differed significantly between the two groups, awakening due to pain and mean muscle sensitivity; both indicators were higher in the Arab group (p < 0.05). No differences were found in any of the other variables such as diagnosis, pain severity, onset, and treatment outcome. This minimal difference may be explained by the equal accessibility to medical services for all citizens, and the diversity of our staff that includes Jew as well as Arab service providers. These factors minimize or even eliminate racial bias, language, and cultural barriers, and is reflected in the minor differences in orofacial pain characteristics found between the two main ethnic groups in Israel.

Standardization of terminology, imaging features, and interpretation of CBCT sialography of major salivary glands: a clinical review.

Sialography combined with cone beam computerized tomography (sialo-CBCT) is an imaging technique that demonstrates the ductal system of the major salivary glands and allows evaluation of gland function. This review describes the sialo-CBCT technique, terminology, common pitfalls and limitations, as well as radiographic features and suggested pathogenicity of various salivary gland disorders, based on 1,758 sialo-CBCT examinations conducted over the last decade in one institution, and the current literature. The adoption of standardized terminology is proposed to prevent miscommunication, facilitate formulation of differential diagnoses, and thereby promote patient management: (1) Sialo-CBCT requires specific training, and operator experience is required for adequate glandular filling with minimal extravasation; (2) Limit injection-to-scan time to avoid pre-mature emptying; (3) The sialo-CBCT report should include a description of the morphology of the primary duct as well as the secondary, tertiary, and descending branches, the maximal branching level, the presence of sialectasis, overall glandular size, and parenchymal findings; (4) Functional evaluation is based on assessment of iodine clearance in the post evacuation image; (5) Sialectasis and ductopenia are the main findings in Sjogren syndrome and recurrent juvenile parotitis; (6) Sialodochitis with or without fillings defects or hyperdense calcifications characterize obstructive sialadenitis and sialolithiasis; (7) The findings following radioactive-iodine-induced damage are similar to obstructive sialadenitis, with atrophy in late stages; (8) In chronic graft-versus-host disease (cGVHD), variable presentations of ductopenia, sialectasis, and sialodochitis may be evident; (9) The red flags indicating a space-occupying lesion include areas of no filling, splaying of ducts, and primary duct deviation.

Proteomic profiling of whole-saliva reveals correlation between Burning Mouth Syndrome and the neurotrophin signaling pathway.

Burning mouth syndrome (BMS) is characterized by a spontaneous and chronic sensation of burning in the oral mucosa, with no apparent signs. The underlying pathophysiological and neuropathic mechanisms remain unclear. Here, we attempt to elucidate some of these mechanisms using proteomic profiling and bioinformatic analyses of whole-saliva (WS) from BMS patients compared to WS from healthy individuals. Qualitative and quantitative proteomic profiling was performed using two dimensional gel electrophoresis (2-DE) and quantitative mass spectrometry (q-MS). In order to improve protein visibility, 21 high abundance proteins were depleted before proteomic profiling. Quantitative proteomic analysis revealed 100 BMS specific proteins and an additional 158 proteins up-regulated by more than threefold in those with BMS. Bioinformatic analyses of the altered protein expression profile of BMS group indicated high correlations to three cellular mechanisms including the neurotrophin signaling pathway. Based on this finding, we suggest that neurotrophin signaling pathway is involved in the pathophysiology of BMS by amplifying P75NTR activity, which in turn increases neural apoptosis thereby reducing sub-papillary nerve fiber density in the oral mucosa.

Anterior mandibular rehabilitation causing chronic obstructive sialadenitis: ?A series of sialo-CBCT cases and literature review.

OBJECTIVE: The aim of this study was to assess and present, using sialo-cone beam computed tomography (sialo-CBCT) examination, cases of submandibular gland (SM) chronic obstructive sialadenitis (COS) caused by dental rehabilitation. DATA SOURCES: Clinical and radiographic data of all patients referred for SM sialo-CBCT imaging in the Oral and Maxillofacial Imaging Unit with recurrent SM swelling between January 2012 and July 2015 were reviewed. Cases with suggested iatrogenic cause were selected and described. A literature review of similar cases was also performed. RESULTS: Seventy-one patients with salivary gland (SG) swelling were referred for SM sialo-CBCT. Of these, 16 had implant-supported fixed partial prostheses and seven had full mandibular overdentures. In five patients, COS was diagnosed and a causal relationship between their dental rehabilitation and symptoms was suggested. A literature search revealed 11 cases of SM COS secondary to anterior mandibular rehabilitation. CONCLUSION: Clinicians rehabilitating the anterior edentulous mandibular region should be aware that both fixed and removable devices may block the orifices of the SM, causing COS.

Levels of Sirolimus in saliva vs. blood--the rationale of topical oral use for oral malignancy.

BACKGROUND: Sirolimus is a potent blocker of mammalian target of Rapamycin (MTOR), with anti proliferative activity. Its potential for the management of oral cancer has been suggested. Our aim was to establish an analytical method for determining sirolimus levels in human saliva and to calculate the blood vs. saliva ratio in individuals using sirolimus chronically in order to evaluate the total oral tissue exposure. PATIENTS AND METHODS: Chemiluminescent microparticle immunoassay technology (CMIA) was used to determine the blood and saliva levels of sirolimus in four transplant patients chronically-treated with sirolimus. RESULTS: An analytical method for determining sirolimus levels in human saliva was established. We demonstrated that saliva levels were on average six times lower than blood levels. CONCLUSION: The specific sensitive analytical method showed that the saliva levels of sirolimus are significantly lower than blood levels, thus reinforcing the rationale for the use of topical oral sirolimus to enhance availability, efficacy and safety for treating oral malignancies.