Nuclear F-actin Cytology in Oral Epithelial Dysplasia and Oral Squamous Cell Carcinoma.

Oral cavity cancer has a low 5-y survival rate, but outcomes improve when the disease is detected early. Cytology is a less invasive method to assess oral potentially malignant disorders relative to the gold-standard scalpel biopsy and histopathology. In this report, we aimed to determine the utility of cytological signatures, including nuclear F-actin cell phenotypes, for classifying the entire spectrum of oral epithelial dysplasia and oral squamous cell carcinoma. We enrolled subjects with oral potentially malignant disorders, subjects with previously diagnosed malignant lesions, and healthy volunteers without lesions and obtained brush cytology specimens and matched scalpel biopsies from 486 subjects. Histopathological assessment of the scalpel biopsy specimens classified lesions into 6 categories. Brush cytology specimens were analyzed by machine learning classifiers trained to identify relevant cytological features. Multimodal diagnostic models were developed using cytology results, lesion characteristics, and risk factors. Squamous cells with nuclear F-actin staining were associated with early disease (i.e., lower proportions in benign lesions than in more severe lesions), whereas small round parabasal-like cells and leukocytes were associated with late disease (i.e., higher proportions in severe dysplasia and carcinoma than in less severe lesions). Lesions with the impression of oral lichen planus were unlikely to be either dysplastic or malignant. Cytological features substantially improved upon lesion appearance and risk factors in predicting squamous cell carcinoma. Diagnostic models accurately discriminated early and late disease with AUCs (95% CI) of 0.82 (0.77 to 0.87) and 0.93 (0.88 to 0.97), respectively. The cytological features identified here have the potential to improve screening and surveillance of the entire spectrum of oral potentially malignant disorders in multiple care settings.

Clinical evaluation of MGI 209, an anesthetic, film-forming agent for relief from painful oral ulcers associated with chemotherapy.

PURPOSE: This open-label, multicenter trial evaluated the efficacy of a mucoadherent, anesthetic medication (MGI 209) for relief from painful oral ulcers associated with cytotoxic chemotherapy. PATIENTS AND METHODS: Twenty-eight eligible cancer patients who had up to five discrete oral ulcers (total area < or = 5 cm2) completed this study. Mean age was 53.5 years (range, 21 to 81). Subjective assessments of oral discomfort before and after an orange juice pain challenge (OJPC), which was measured using a visual analog scale (VAS), and visual estimates of the amount of MGI 209 that remained on treated ulcers were collected at (1) baseline (before MGI 209 treatment); and (2) 30, 60, 120, and 180 minutes posttreatment. RESULTS: Most subjects had low VAS scores (4 or less), which was indicative of oral discomfort, at baseline before and after the OJPC. At 30, 60, 120, and 180 minutes after MGI 209 treatment, most subjects had high VAS scores before and after an OJPC compared with baseline scores, which was indicative of a substantial increase in oral comfort; these differences were statistically significant (P < .0001). Mean percent of MGI 209 estimated to remain on ulcers at the previously mentioned times was 93.7%, 90.3%, 79.6%, and 71.3% of the total amount applied, respectively. CONCLUSION: Benzocaine hydrochloride in combination with the protective, mucoadherent film-coating relieved discomfort for at least 3 hours even with exposure to an irritating beverage. MGI 209 treatment should allow patients with chemotherapy-induced oral ulcers to drink and eat with significantly diminished pain or no pain.

A randomized trial of continuous or intermittent therapy with fluconazole for oropharyngeal candidiasis in HIV-infected patients: clinical outcomes and development of fluconazole resistance.

PURPOSE: The effects of continuous or intermittent therapy with fluconazole on the recurrence of and the development of fluconazole resistance are not known. PATIENTS AND METHODS: We studied human immunodeficiency virus (HIV)-positive patients with CD4 cell count <350 x 10(6)/L and oropharyngeal candidiasis in a prospective, randomized study. After initial treatment, 20 patients (16 of whom completed 3 months of follow-up) received continuous fluconazole at 200 mg/day, and 48 patients (28 of whom completed follow-up) received intermittent therapy at the time of symptomatic relapses. Oral samples were obtained weekly during episodes of infection and quarterly as surveillance cultures. Development of resistance was defined as a fourfold rise in minimum inhibitory concentration (MIC) to at least 16 microg/mL from the initial culture in the same species, the emergence of new, resistant (MIC > or =16 microg/mL) species, or a significant increase in the proportion of resistant isolates. RESULTS: During a mean follow-up of 11 months, median annual relapse rates were lower in patients on continuous therapy (0 episodes/year) than in patients on intermittent therapy (4.1 episodes/year; P <0.001). Sterile cultures were seen in 6 of 16 (38%) patients on continuous therapy compared with 3 of 28 (11%) on intermittent therapy (P = 0.04). Microbiological resistance developed in 9 of 16 (56%) patients on continuous treatment, compared with 13 of 28 (46%) on intermittent treatment (P = 0.75). However, despite isolates with increased MICs, 42 of 44 patients responded to fluconazole in doses up to 800 mg/day. CONCLUSIONS: In patients with frequent recurrences, continuous suppressive therapy significantly reduced relapses and colonization. Resistance occurred with both continuous and intermittent therapy; however, therapeutic responses were excellent.

Isolation of non-tuberculosis mycobacteria in treated dental unit waterlines.

OBJECTIVE: The purpose of the study was to investigate the presence of non-tuberculosis mycobacteria (NTM) in dental unit waterlines that were being routinely treated with an intermittent use waterline cleaner. STUDY DESIGN: The study was conducted at a hospital dentistry clinic where immunocompromised patients are seen. Water samples from two lines on one of two dental units were taken before and after routine weekend chemical treatment. Sampling was repeated on two subsequent occasions, on the same unit, at three monthly intervals. Laboratory techniques included centrifugation and membrane filtration to detect small numbers of organisms. RESULTS: Mycobacterium simiae was isolated from one of the four pre-treatment samples and from two of the four post-treatment samples. Mycobacterium mucogenicum was isolated from one of the four post-treatment samples. CONCLUSIONS: This pilot study found that NTM were present in DUWLs that were being routinely treated with an intermittent use chemical cleaner. Practitioners are urged to understand the limitations of available DUWL treatments, and to consider the use of sterile water for non-surgical, as well as surgical, treatment of immunocompromised patients.

Treatment of oral chronic graft-versus-host disease with PUVA therapy: case report and literature review.

Chronic graft-versus-host disease commonly appears with oral manifestations subsequent to allogeneic bone marrow transplantation. These manifestations include leukoplakia, mucosal atrophy, erythema, ulcers, and xerostomia. Some lesions are resistant to treatment with immunosuppressive medications. Ultraviolet A irradiation therapy with oral psoralen has been shown to be effective in treating these resistant lesions. This article presents a review of the literature and a case report.

Candida dubliniensis in radiation-induced oropharyngeal candidiasis.

Candida dubliniensis is a recently described species that has been shown to cause oropharyngeal candidiasis in patients with HIV. We present a detailed evaluation of a patient undergoing head and neck radiation for oral cancer who developed oropharyngeal candidiasis from a mixed infection of C dubliniensis and Candida albicans. To our knowledge, this is the first described case of C dubliniensis contributing to oropharyngeal candidiasis in this patient population.

Coronary artery stents: review and patient-management recommendations.

BACKGROUND: Coronary artery stents are metallic scaffold devices that physically support narrowed coronary arteries to alleviate symptoms of ischemic coronary artery disease. They are placed during invasive procedures similar to that of percutaneous transluminal coronary angioplasty, and patients are maintained with antiplatelet medications to lessen the chances of stent stenosis. METHODS: The authors provide a brief overview of coronary artery stents and discuss the dental management of patients who have received stents. CONCLUSIONS: After stent placement, patients usually are maintained with antiplatelet regimens, which may necessitate choosing medications that do not potentiate their effects. Any discussion as to the possible need for antibiotic prophylaxis of patients with stents largely is missing from the literature. Recent literature, however, indicates that antibiotic prophylaxis, if required, may only be needed during the first few weeks after stent placement. CLINICAL IMPLICATIONS: Dental professionals should become knowledgeable about coronary artery stents. Although these devices have a higher success rate than other procedures in alleviating symptoms of ischemic coronary artery disease, some patients are still at risk of experiencing significant cardiac events.

Diagnosis and management of orofacial herpes simplex virus infections.

HSV disease remains a significant problem for the dental profession because of its widespread occurrence and ready transmission. Fortunately, available diagnostic techniques are highly sensitive and specific, antiviral therapy is effective in limiting the course of infection, and contemporary infection control procedures adequately safeguard dental personnel and the patient. Unfortunately, there is still a large segment of the population already infected with HSV-1 and the number of immunosuppressed latently infected patients continues to increase. Thus, patients will continue to need the help of the knowledgeable and willing dentist who can diagnose HSV-1 infection, provide effective treatment, and prevent transmission.

Dental management of children with asthma.

Asthma affects about 1 in 10 children. The condition is characterized by acute respiratory distress brought on by environmental factors. The condition is treated with medications aimed to reduce reaction to stimulants by the airway. Dental management involves attention to the status of the patient and awareness of stimulants of the reactive airway. Clinical recommendations are provided.

Oral herpes simplex virus infection with cardiac transplantation.

Oral herpes simplex virus infection is a common complication of cardiac transplantation. Lesions are secondary to reactivation of the virus, are atypical in appearance, and can involve any oral and perioral surface. Diagnosis on clinical grounds is difficult and should be confirmed with laboratory testing. A case report and review of the literature are presented to support the features of this infection.

A comparison between fluconazole tablets and clotrimazole troches for the treatment of thrush in HIV infection.

Fluconazole, a newly available triazole, has been evaluated extensively as a treatment for thrush. It has been effective in the treatment of this condition in patients with HIV infection. Clotrimazole troches have been a common treatment for thrush in patients with HIV infection for several years. This study compared the efficacy and safety of fluconazole 100 mg tablets once per day versus clotrimazole 10 mg troches five times per day in the treatment of thrush in patients with HIV infection. Patients were evaluated at baseline, day 7, 14, 28, and 42. The following parameters were evaluated: clinical cure, colonization at the end of treatment, relapse at day 28, and relapse at day 42. Side effects including liver enzyme values were also monitored. Clinical cure was superior with fluconazole tablets than with clotrimazole troches. Also, rates of colonization at the end of therapy and relapse at days 28 and 42 were less with fluconazole tablets than with clotrimazole troches. However, these differences were not statistically significant. Patient compliance with fluconazole was superior to that of clotrimazole. This difference was statistically significant. Both fluconazole tablets and clotrimazole troches are effective in treating thrush in patients with HIV infection. The avoidance of multiple-per-day dosing would appear to favor fluconazole.

The epidemiology of non-albicans Candida in oropharyngeal candidiasis in HIV patients.

Oropharyngeal candidiasis (OPC) is the most common fungal infection in patients with HIV infection. Fluconazole has been proven to be very effective in treating this infection, but decreased susceptibility of Candida to this drug has emerged. Certain non-albicans species such as C. glabrata and C. krusei are commonly less susceptible to fluconazole than C. albicans and are being isolated with increased frequency in HIV patients. The purpose of this study was to determine if the presence of non-albicans Candida with OPC in HIV patients had an impact on clinical presentation. This study shows that late-stage HIV patients have a high prevalence of Candida with decreased susceptibility to fluconazole, especially non-albicans species. OPC episodes with non-albicans isolates were more likely to require higher doses of fluconazole to achieve clinical cure. Also, the presence of non-albicans Candida was more frequently associated with severe symptoms.

Treating the discomfort of oral ulceration resulting from cancer chemotherapy.

Chemotherapy-induced oral mucositis can result in inadequate oral intake, local and systemic infection, a prolonged hospital stay, and increased cost of treatment. Treatment of the pain resulting from this condition can greatly lessen these problems. Hydroxypropyl cellulose gel with benzocaine (Zilactin B) has been shown to effectively reduce the pain of mucositis for up to 3 hours.

Dental management and treatment of xerostomic patients.

Saliva is extremely important for the health and comfort of the oral cavity. Diminution in salivary flow is accompanied by a plethora of problems. A salivary flow inadequate to protect the oral cavity may be an occult condition. Dentists should evaluate those patients presenting with a high incidence or increased incidence of dental caries for a decreased salivary flow. We have presented diagnostic aids, management techniques and treatment modalities for these patients.

PGY1: what is it and why is it important?

The interest in a year of additional training for the practice of dentistry has grown over the past fifteen years. Debates at national conferences and careful study by committees of professional organizations led to the recommendation that over the next five to ten year period the profession should move toward creating a postgraduate experience for each graduate prior to independent practice. While study of this issue will undoubtedly continue, it behooves us to proceed with the process of expanding the number of postgraduate positions, first, to meet the demand by graduating students who are voluntarily selecting a year of additional training, and later, so we are at a position to fully consider such a year as mandatory for independent practice. If we use the next five to ten years productively, we can create an environment where the public and the graduates will benefit from this additional year of training.