Use of Cone Beam Computed Tomography for Identification of a Distant Causative Tooth: An Unusual Case of an Apical Lesion from a Maxillary Premolar Mimicking That from Maxillary Incisors.

The article describes an unusual case of an apical lesion at the first premolar with spontaneous pain and swelling around the root and tooth mobility at the maxillary right central and lateral incisors. The patient was a 45-year-old man with a chief complaint of discomfort at the maxillary right central and lateral incisors for one year. Oral examination showed spontaneous pain, swelling, and tooth mobility of the maxillary right central and lateral incisors. Intraoral and panoramic radiographs showed clear apical radiolucency at these sites, although there were no carious incisors. Neither tooth had periodontal pockets, and there was no bleeding on probing sites. A cold thermal examination revealed normal responses of the vital dental pulp. Initial panoramic radiography showed an apical lesion of the maxillary right first premolar, which was root filled and without inflammatory symptoms. A cone beam computed tomography (CBCT) revealed that the apical lesion of the premolar had extensively spread to the anterior through the palatal side, circumventing the palatal side of the adjacent canine, and reached the apical areas of the central and lateral incisors. We treated the apical lesion of the first premolar, and the radiolucent regions had almost disappeared after three years with regard to not only the apical lesion in the first premolar and incisors but also the primary symptoms on the incisors without endodontic treatment. This case shows that CBCT is an effective alternative that allows appropriate treatment to be selected more reliably.

Melanocytic Nevus of the Colon.

Here, we report a very rare case of melanocytic nevus of the colon. A 54-year-old woman with an unremarkable medical history visited our hospital for screening colonoscopy. Colonoscopy revealed a pigmented flat lesion in the ascending colon. Histological evaluation of a biopsy specimen revealed proliferation of pigmented cells in the lamina muscularis propria. On immunohistochemical analysis, pigmented cells were positive for S-100 protein and Melan-A expression, and a diagnosis of colonic melanocytic nevus was made. Although the pathogenesis underlying colonic melanocytic nevi remains unclear, we speculate that colonic melanocytic nevi develop via abnormal migration or differentiation of neural crest cells during embryogenesis.

Human Dental Pulp Cells Express Cellular Markers for Inflammation and Hard Tissue Formation in Response to Bacterial Information.

INTRODUCTION: Lipopolysaccharide (LPS) is a major component of the outer membranes of gram-negative bacteria associated with deep dental caries and pulpitis. When bacteria invade dentinal tubes and dentin is continually destroyed, tertiary dentin is formed by preexisting odontoblasts. However, the relationship between LPS and tertiary dentin formation remains unclear. We investigated whether LPS stimulation induces the formation of hard tissue in human dental pulp cells (hDPCs). METHODS: Immortalized hDPCs were cultured, and Escherichia coli-derived LPS (1 µg/mL) was incorporated into the culture medium. Samples were obtained after 0, 1, 3, 7, 14, and 21 days, and messenger RNA expression of IL-1ß, IL-6, Wnt5a, Runx2, ALP, and alkaline phosphatase (ALP) activity was investigated. RESULTS: Quantitative real-time polymerase chain reaction revealed higher messenger RNA expression levels of IL-1ß and IL-6 in the LPS group on 1 day (P < .05). The expression levels of dentinogenesis-related markers including Wnt5a, Runx2, and ALP were higher in the LPS group (2.0-, 4.7- and 10.0-fold, respectively) than that in the control group at 14 days (P < .01). ALP activity was significantly stronger in the LPS group than in the control group at 21 days (P < .01). Treatment of Box5, an antagonist of Wnt5a, showed a decreased expression of Runx2 and ALP (P < .05). CONCLUSIONS: These results indicate that LPS stimulation induces the gene expression of inflammatory cytokines and hard tissue formation through Wnt5a signaling pathways in hDPCs.

Clinical benefit of component-resolved diagnosis in Japanese birch-allergic patients with a convincing history of apple or peach allergy.

OBJECTIVE: In northern Japan, birch pollen is the major allergen in pollinosis, while oral allergy syndrome (OAS) is caused primarily by apple and peach, and is almost exclusively related to birch pollinosis. To clarify the clinical benefit of allergen-based component-resolved diagnosis (CRD) in Japanese birch-allergic patients with OAS, we present an analysis of IgE profiles in response to crude extracts and recombinant component-resolved allergen to birch pollen and Rosaceae fruits allergens. METHODS: The sera of 30 patients with birch pollen-related OAS to apple or peach were analyzed for specific IgE reactivity to pathogenesis-related class 10 (PR-10) family (birch: rBet v 1, apple: rMal d 1, and peach: rPru p 1), profilin (birch: rBet v 2 and peach: rPru p 4), and lipid transfer protein (LTP) (apple: rMal d 3 and peach: rPru p 3) allergens, as well as to conventional crude, unfractionated extracts (birch: T3, apple: f49, and peach: f95) using the ImmunoCAP System™. Allergen-specific IgE values <0.35kUA/L were considered negative. RESULTS: Of the 30 sera CAP-positive for natural birch pollen extract, 28 (93.3%) exhibited specific IgE against Bet v1, and two (6.7%) contained specific IgE against Bet v2. Of the 26 sera of OAS to apple patients, only 17 were positive for specific IgE against f49 extract (65.4%); however, 24 were positive for specific IgE against rMal d 1 (92.3%). Similarly, only 17 of the 23 sera of OAS to peach patients contained specific IgE against the f95 extract (73.9%); however, 22 were positive for specific IgE against rPru p 1 (95.7%). CONCLUSION: Our data suggest that CRD constitutes a reliable tool for the diagnosis of birch pollen-related OAS.

[A case of undifferentiated pleomorphic sarcoma of the stomach showing rapid growth].

We report an extremely rare case of undifferentiated pleomorphic sarcoma of the stomach. A 74-year-old woman was admitted for abdominal discomfort. A 13-cm gastric submucosal tumor and multiple liver and bone metastases were detected by computed tomography. The tumor had not been detected 8 months earlier. We performed EUS-FNAB for a suspected mesenchymal tumor, but the immunohistochemical test (c-kit, CD34, desmin, SMA, S-100) findings were negative. The tumor was confirmed as wild type for c-kit and PDGFRα. It grew rapidly and the patient died 2 months after admission. Pathological analysis of the EUS-FNAB specimens and autopsy revealed an undifferentiated pleomorphic sarcoma.

Clinical significance of white gastric crypt openings observed via magnifying endoscopy.

AIM: To evaluate the relationship between Helicobacter pylori (H. pylori)-induced gastritis and white gastric mucosal crypt openings (COs) in the gastric corpus. METHODS: A total of 175 consecutive patients (including 69 patients with gastric cancer) were enrolled in this study. We used magnifying endoscopy (ME) to observe the mucosa microsurface of the lesser and greater curvature of the gastric corpus (350 areas in all). We focused on areas with a round pit microstructure (primarily observed in non-atrophied areas) and evaluated the white openings of these gastric pits. We classified the whiteness of the COs as the "white-edged dark spot" type (consisting of a dark spot bordered by white); the "white" type (pure white with no dark spot); and the "dense white pit (DWP)" type (dense white, resembling a snowball). Gastritis was also histologically evaluated according to the updated Sydney System. RESULTS: We detected round COs using ME in 246 of the 350 areas examined. The histological examination showed significantly more mononuclear cells and neutrophil infiltration in the "white" and "DWP" types than the "white-edged dark spot" type (P < 0.001). Furthermore, significantly high-grade inflammation and evidence of active H. pylori-induced gastritis was observed in the "DWP" type (P < 0.001). Significant differences were observed in the whiteness of COs between H. pylori-positive (n = 139) and negative (n = 36) patients (P < 0.001). The sensitivity and specificity of the "white" and "DWP" types for predicting H. pylori infection were 78.5% and 81.7%, respectively. Of the patients with gastric cancer, 22.5% (18/80) had "white-edged dark spots", 51.3% (41/80) had "white" COs, and 26.3% (21/80) had "DWP"-type COs. "DWPs" were frequently observed among patients with undifferentiated gastric cancer [45.7% (16/35)]. CONCLUSION: CO whiteness detected via ME was associated with histological evidence of gastritis and helps to predict the severity of inflammation and H. pylori-induced activity.

Magnifying endoscopic findings of the surface structure of non-cancerous mucosa surrounding differentiated and undifferentiated gastric carcinoma.

BACKGROUND: Several reports have described the usefulness of magnifying endoscopy in observing the surface structure in gastric neoplasia. The aim of the present study was to evaluate the characteristics of the surface structure of non-cancerous mucosa surrounding gastric cancer. METHODS: Sixty Japanese patients with early gastric cancer were enrolled in this study. We observed the non-cancerous gastric mucosa surrounding gastric carcinoma by magnifying endoscopy and classified the magnified view into four patterns: (A) dotted; (B) short-linear; (C) striped; and (D) granular, according to Sakaki's classification. RESULTS: All patients were diagnosed as having Helicobacter pylori infection, and histological evaluation revealed 46 types of differentiated and 14 types of undifferentiated-type gastric carcinomas. There were significant differences in the gender, age and endoscopic-atrophic-border scale between patients with these two types. In all, the surface structure at 240 points (4 points each in 60 patients) of non-cancerous mucosa was observed by magnifying endoscopy. The prevalences of the surface patterns of the mucosa surrounding differentiated carcinoma were: A, 1.1%; B, 8.1%; C, 28.3%; D, 62.5%, and those of the mucosa surrounding undifferentiated carcinoma were: A, 8.9%; B, 73.2%; C, 14.3%; D, 3.6%. There were significant differences in the surface structure of the non-cancerous mucosa surrounding differentiated and undifferentiated gastric carcinoma. CONCLUSION: The microsurface structure of the gastric mucosa surrounding gastric cancer lesions differed between patients with differentiated and undifferentiated gastric cancer. These findings are expected to be useful for the early detection of gastric carcinoma lesions or for the determination of extensions of carcinoma lesions.

Topographic differences in gastric micromucosal patterns observed by magnifying endoscopy with narrow band imaging.

BACKGROUND AND AIM: The distributions and grades of Helicobacter pylori induced gastritis are known to vary among H. pylori-associated diseases. The aim of this study was to investigate the differences in distributions of gastric micromucosal structures observed by magnifying narrow band imaging (NBI) endoscopy among patients with different H. pylori-associated diseases. METHODS: Ninety-five patients with active duodenal ulcers (n = 24) and diffuse-type (n = 24) and intestinal-type (n = 47) early gastric cancers were enrolled. The magnified NBI findings were evaluated at the lesser and greater curvatures in the upper gastric corpus and were classified according to the modified A-B classification system. Biopsy specimens were also evaluated. RESULTS: In a total of 190 areas observed with magnifying NBI, histological grading (inflammation, activity, atrophy and intestinal metaplasia) showed significant differences among the classified micromucosal patterns (P < 0.001). Types B-1 and B-2, with mild atrophic changes and few areas of intestinal metaplasia, were seen mostly in the duodenal ulcers group. Types B-3 and A-1, with moderate atrophic changes, were seen in the diffuse-type early gastric cancers at the lesser curvature. Types A-1 and A-2, with severe atrophic change and a high frequency of intestinal metaplasia, were seen in the intestinal-type early gastric cancers at the lesser curvature. The prevalence of micromucosal structures differed significantly among the three groups both at the lesser and greater curvatures (P < 0.001). CONCLUSIONS: Magnifying NBI endoscopy clearly revealed detailed micromorphological differences corresponding to the histology and endoscopic findings among patients with different H. pylori-associated diseases.

Oral bacterial extracts facilitate early osteogenic/dentinogenic differentiation in human dental pulp-derived cells.

OBJECTIVES: Bacterial metabolites demineralize dental hard tissues, and soluble factors lead to tertiary dentinogenesis in the area of the dentin-pulp complex. However, it is unclear whether the oral bacteria are directly involved in the differentiation of dental pulp cells. In this study, we evaluated the effect of oral bacterial extracts on cellular differentiation in human dental pulp-derived cells (hDPC). STUDY DESIGN: The hDPC were obtained from third molar teeth, and the cells were subcultured. The sonicated extracts were obtained from Porphyromonas gingivalis (gram-negative) and Streptococcus mutans (gram-positive). The effect of bacterial extracts on cellular growth and differentiation in hDPC were tested. RESULTS: Alkaline phosphatase activity and bone sialoprotein (BSP) gene expression were increased in hDPC exposed to low concentrations of both sonicated extracts, whereas the activity was decreased upon exposure to high concentrations of sonicated extracts from P. gingivalis. CONCLUSION: This is the first evidence that oral bacteria have a positive effect on cellular differentiation in hPDC.

Tongue-coating as risk indicator for aspiration pneumonia in edentate elderly.

Silent aspiration of oral microorganisms is a major cause of aspiration pneumonia. To establish oral hygiene criteria for the prevention of aspiration pneumonia in edentulous elderly persons, we investigated the relationship between presence of tongue-coating and number of oral bacteria in saliva and episodes of pneumonia. A total of 71 edentulous Japanese people aged 65 years or older living in nursing homes were enrolled in the study. A tongue plaque index (TPI) was used to evaluate quantity of tongue-coating, with TPI0 signifying no tongue-coating and TPI1 signifying presence of tongue-coating. Edentate elderly with TPI1 demonstrated significantly higher salivary bacterial counts than those with TPI0 (p<0.05). The number of elderly patients developing aspiration pneumonia was larger (p<0.005) in patients with TPI-based poor scores (average TPI>0.5) than in those with TPI-based good scores. The relative risk of developing pneumonia in the good tongue hygiene group compared with in the poor tongue hygiene group was 0.12, 95% confidence interval (CI): 0.02-0.9. The results demonstrate that tongue-coating is associated with number of viable salivary bacterial cells and development of aspiration pneumonia, suggesting that tongue-coating is a risk indicator of aspiration pneumonia in edentate subjects.

[A case of gastrointestinal stromal tumor of the stomach arising from the muscularis mucosae].

A 75-year-old man, in whom upper gastrointestinal endoscopy revealed a submucosal tumor in the greater curvature of the gastric angle, was hospitalized for further investigations. Since the tumor was shown to be located in the submucosal layer by endoscopic ultrasonography, we performed endoscopic mucosal resection. Pathological studies of the resected specimen revealed a gastrointestinal stromal tumor of the stomach. It was also formed that the tumor was connected not to muscularis propria, but to the muscularis mucosae. There has been no previous report about a case of gastrointestinal stromal tumor of the stomach arising from the muscularis mucosae in Japan.

Oral hygiene evaluation for effective oral care in preventing pneumonia in dentate elderly.

The purpose of this study was to establish criteria for the visual evaluation of oral hygiene by analyzing the relationship between status of oral hygiene and number of oral bacteria in saliva for use in predicting the development of pneumonia. A total of 145 Japanese people of advanced age living in nursing homes were enrolled in the study. We evaluated the Dental Plaque Index (DPI) and Tongue Plaque Index (TPI) as simple measures of status of oral hygiene. We also determined the number of viable microorganisms in the saliva of each subject. The relationship between the status of oral hygiene and episodes of pneumonia was investigated over a period of one year. Dentate patients with poor oral hygiene as indicated by their DPI and TPI scores demonstrated significantly higher salivary bacterial counts than those with a good score for oral hygiene (p<0.01 and p<0.05, respectively). Both the number of febrile days was significantly higher (p=0.0012), and number of patients developing pneumonia larger (p<0.01) in dentate patients with DPI-based poor scores than those with DPI-based good scores. These results demonstrate a significant positive correlation between salivary bacteria and visual evaluation of oral hygiene in dentate patients according to number of febrile days and development of pneumonia.

Professional oral care reduces influenza infection in elderly.

Influenza is a major cause of respiratory infection and has a high mortality rate in the elderly. Neuraminidase (NA) on the surface of the influenza virus and bacterial trypsin-like proteases (TLP) play key roles in influenza virus infections. We investigated the effects of oral care on influenza, evaluating in particular the activities of NA and TLP in saliva, as they may contribute to an increased risk of infection with influenza. One hundred ninety elderly patients who visited day care service facilities once a week were randomly assigned to either a professional oral care group or to an own oral care group as the control group. Nine individuals in the control group and one person in the professional oral care group were diagnosed with influenza during the follow-up period. The relative risk of developing influenza while under professional oral care compared to that in the control group was 0.1 (95% CI 0.01-0.81, p=0.008). Significant decreases in numbers of salivary anaerobic bacterial CFUs, and NA and TLP levels were observed in the professional oral care group compared to that in the control group (p<0.01). This study suggests that maintenance of oral hygiene is effective in the prevention of influenza in the elderly.

Involvement of periodontopathic anaerobes in aspiration pneumonia.

Increasing evidence has linked the anaerobic bacteria forming periodontopathic biofilms with aspiration pneumonia in elderly persons. In experiments designed to eliminate the potent respiratory pathogens forming biofilms in the oral cavity, we have shown that the mechanical and chemical oral cleansing using povidone-iodine effectively reduced the detection rates and numbers of methicillin-sensitive Staphylococcus species, Streptococcus pneumoniae, and Haemophilus influenzae in patients scheduled to undergo oral surgery requiring endotracheal intubation. We confirmed the pathogenicity of periodontopathic anaerobic bacteria for aspiration pneumonia in an experimental mouse model. Based upon the finding of the coexistence of Porphyromonas gingivalis with Treponema denticola in chronic periodontitis lesions, we innoculated a mixed culture of P. gingivalis and T. denticola into the mouse trachea; the resulting infection induced inflammatory cytokine production and caused pneumonia. In another series of investigations, professional oral health care (POHC), mainly cleansing administered by dental hygienists once a week for 24 months to elderly persons requiring daily care, resulted in the reduction of the number of total anaerobes, Candida albicans, and Staphylococcus species and in the number of cases of fatal aspiration pneumonia. We also found that the POHC treatment of elderly persons for 6 months in the winter season reduced the salivary levels of protease, trypsin-like activity, and neuraminidase and also decreased the frequency of influenza cases.

Involvement of Periodontopathic Anaerobes in Aspiration Pneumonia.

Increasing evidence has linked the anaerobic bacteria forming periodontopathic biofilms with aspiration pneumonia in elderly persons. In experiments designed to eliminate the potent respiratory pathogens forming biofilms in the oral cavity, we have shown that the mechanical and chemical oral cleansing using povidone-iodine effectively reduced the detection rates and numbers of methicillin-sensitive Staphylococcus species, Streptococcus pneumoniae, and Haemophilus influenzae in patients scheduled to undergo oral surgery requiring endotracheal intubation. We confirmed the pathogenicity of periodontopathic anaerobic bacteria for aspiration pneumonia in an experimental mouse model. Based upon the finding of the coexistence of Porphyromonas gingivalis with Treponema denticola in chronic periodontitis lesions, we innoculated a mixed culture of P. gingivalis and T. denticola into the mouse trachea; the resulting infection induced inflammatory cytokine production and caused pneumonia. In another series of investigations, professional oral health care (POHC), mainly cleansing administered by dental hygienists once a week for 24 months to elderly persons requiring daily care, resulted in the reduction of the number of total anaerobes, Candida albicans, and Staphylococcus species and in the number of cases of fatal aspiration pneumonia. We also found that the POHC treatment of elderly persons for 6 months in the winter season reduced the salivary levels of protease, trypsin-like activity, and neuraminidase and also decreased the frequency of influenza cases.

Effect of professional oral health care on the elderly living in nursing homes.

OBJECTIVE: We evaluated the effectiveness of professional oral health care (POHC) given by dental hygienists once a week for 24 months to 141 elderly persons needing daily care and living in 2 nursing homes. STUDY DESIGN: Elderly subjects with POHC and without POHC living in 2 nursing homes were examined for 24 months to detect any fevers of 37.8 degrees C or more and the prevalence of fatal aspiration pneumonia. The numbers of Staphylococcus species and Candida albicans in swab samples from oral cavities were compared between the POHC group and the non-POHC group. The amounts of methylmercaptan exhaled in the POHC group were determined and compared with those in the non-POHC group. RESULTS: The prevalence of fevers of 37.8 degrees C or more in the subjects receiving POHC was significantly lower than in the non-POHC group (P < .05). We found that the ratio of fatal aspiration pneumonia in the POHC group during the 24 months was significantly lower than in the non-POHC group (P < .05). Numbers of C albicans species in samples obtained from the oral cavity after 6 months of POHC were significantly lower than those in the non-POHC group (P < .01). POHC resulted in the reduction of the presence of Staphylococcus but not to a statistically significant extent. The amounts of methylmercaptan exhaled by the POHC group were significantly less than those of the non-POHC group (P <.05). CONCLUSION: This study showed that POHC administered by dental hygienists to a group of elderly patients needing daily nursing care was associated with a reduction in prevalence of fever and fatal pneumonia.