Clinical medical sciences for undergraduate dental students in the United Kingdom and Ireland - a curriculum.

The technical aspects of dentistry need to be practised with insight into the spectrum of human diseases and illnesses and how these impact upon individuals and society. Application of this insight is critical to decision-making related to the planning and delivery of safe and appropriate patient-centred healthcare tailored to the needs of the individual. Provision for the necessary training is included in undergraduate programmes, but in the United Kingdom and Ireland there is considerable variation between centres without common outcomes. In 2009 representatives from 17 undergraduate dental schools in the United Kingdom and Ireland agreed to move towards a common, shared approach to meet their own immediate needs and that might also be of value to others in keeping with the Bologna Process. To provide a clear identity the term 'Clinical Medical Sciences in Dentistry' was agreed in preference to other names such as 'Human Disease' or 'Medicine and Surgery'. The group was challenged to define consensus outcomes. Contemporary dental education documents informed, but did not drive the process. The consensus curriculum for undergraduate Clinical Medical Sciences in Dentistry teaching agreed by the participating centres is reported. Many of the issues are generic and it includes elements that are likely to be applicable to others. This document will act as a focus for a more unified approach to the outcomes required by graduates of the participating centres and act as a catalyst for future developments that ultimately aim to enhance the quality of patient care.

Potentially malignant oral lesions in Northern Ireland: size (extent) matters.

OBJECTIVES: We examined clinical parameters of patients from Northern Ireland with potentially malignant lesions (PML) to determine association with development of intraoral squamous cell carcinoma (SCC). DESIGN: retrospective, cross-sectional, population-based, clinically validated, laboratory-verified. SUBJECTS AND METHODS: All patients who had more than one incisional oral mucosal biopsy diagnosed from 1975-1991 were abstracted from a database of all PML and SCC and their clinical records and biopsies reviewed. Patients were excluded if there was priorlsynchronous SCC or radiotherapy, frictional keratosis or lichen planus, missing clinical records/biopsy material or follow-up of <24 months. From the 50 suitable patients, gender, age, smoking status, site, clinical appearance and extent of lesion(s), treatment and year of diagnosis were recorded. Patients who developed SCC from PML were compared with those who did not. RESULTS: Squamous cell carcinoma occurred significantly more often in patients with single rather than multiple PML, those with 'non-homogenous' PML and in patients diagnosed prior to 1980. In Cox's survival analysis, only the clinical extent was predictive of SCC. CONCLUSIONS: Of all the features considered in our series, size (extent) was the most important clinical factor in determining the risk of future SCC in PML, particularly when several adjacent anatomical sites were affected.

Paradental cysts: a role for food impaction in the pathogenesis? A review of cases from Northern Ireland.

We present the clinical, radiographic and histological findings of 15 paradental cysts. These were the second most common type of cyst associated with mandibular third molars, comprising 25% of all lesions at this site. Ten patients were aged 30 years or younger and 13 gave a history of pericoronitis. There was a close relationship between the site of the cyst and the angle of the impacted tooth; the cyst lay mesially to two mesioangularly impacted teeth, buccal to two vertically impacted teeth and distal/distobuccal to the remainder, all but one of which were distoangular in impaction. The pericoronal follicular space was preserved in nine cases, a useful diagnostic sign. Most cysts were lined with epithelium that resembled that seen in radicular cysts, although the lining of three cysts resembled that of unicystic ameloblastoma, a potential diagnostic pitfall. We propose that the relation between location of cyst and angle of impaction points to a role for food impaction in the pathogenesis of paradental cysts.

Suprabasal p53 immunoexpression is strongly associated with high grade dysplasia and risk for malignant transformation in potentially malignant oral lesions from Northern Ireland.

AIMS: No good predictive marker for the malignant transformation of potentially malignant oral lesions (PMOLs) is currently available. This study re-evaluated the value of p53 immunoexpression to predict malignant transformation of PMOLs after discounting possible confounding factors. METHODS: PMOLs from 18 patients who showed progression to carcinoma, 16 of the respective carcinomas, and PMOLs from 18 matched controls were evaluated by immunohistochemistry (IHC) for p53 expression. A mouse monoclonal antibody that detects wild-type and mutant forms of human p53 was used. The p53 immunostaining pattern was also correlated with the degree of dysplasia. RESULTS: Suprabasal p53 staining was significantly associated with high grades of dysplasia (p < 0.01). The specificity and positive predictive value (PPV) for malignant transformation of suprabasal p53 staining were superior to the assessment of dysplasia, but sensitivity was inferior. All carcinomas derived from PMOLs with suprabasal p53 showed strong p53 immunostaining. However, the absence of suprabasal p53 staining and/or dysplastic changes did not preclude malignant transformation in a considerable proportion of PMOLs. CONCLUSIONS: This study confirms and extends previous findings that suprabasal p53 immunoexpression has a high PPV for malignant transformation of PMOLs and can be used as a specific marker for lesions that are at high risk for malignant transformation. The absence of suprabasal p53 staining (that is, absence of, or basal, p53 staining) is non-informative for prognostic purposes. Because of its limited sensitivity, p53 IHC is not a substitute for the assessment of dysplasia in the evaluation of PMOLs. Instead, p53 IHC emerges as a clinically useful supplement of histopathological assessment in the prognosis of PMOLs.

Potentially malignant oral lesions in northern Ireland: a 20-year population-based perspective of malignant transformation.

This retrospective laboratory-based study investigates the potential for malignant transformation of oral mucosal lesions in a population of 1.6 million. Over the 20-year period there were 745 patients diagnosed with primary intra-oral squamous cell carcinoma (OSCC), 165 patients with dysplasia and 1182 patients with 'non-dysplastic' lesions (epithelial hyperplasia, hyperkeratosis epithelial atrophy, lichen planus and lupus erythematosus). Malignant transformation occurred in 15% of dysplasias and in 1% of 'non-dysplastic' lesions at average intervals after diagnosis of 48 and 65 months respectively. Only 6% of patients with OSCC had a pre-invasive lesion biopsied. These data suggest that white lesions are only rarely the pre-invasive phase of OSCC. It is possible therefore that early changes are red, small or even microscopic with carcinoma developing without a clinically observable phase. More effective management strategies will require the development of tissue markers to enhance early detection.

Odontogenic keratocysts in a 5-year-old: initial manifestations of nevoid basal cell carcinoma syndrome.

The purpose of this paper is to report the occurrence of odontogenic keratocysts in a young child. Odontogenic keratocysts are one of the principal features of nevoid basal cell carcinoma syndrome. Their occurrence in this syndrome is usually during the second or third decades of life. This report describes the occurrence of odontogenic keratocysts in a 5-year-old, which proved to be the initial presentation of nevoid basal cell carcinoma syndrome and highlights the need to consider this syndrome as a possible diagnosis in all cases of odontogenic keratocysts.

Oral white sponge naevus: response to antibiotic therapy.

White sponge naevus is a rare benign inherited disorder of the mucous membranes, principally the oral mucosa. Although the condition is painless, patients are often symptomatic, complaining of an altered texture of the mucosa or that the lesions are unaesthetic. No standard treatment for the condition exists although numerous treatments have been tried. We now report on six patients who were prescribed systemic antibiotic therapy; three were adult men aged 24 years, 32 years, and 52 years, one an 11-year-old woman, one a 6-year-old woman (daughter of the 32-year-old man) and an 18-month-old boy (son of the 24-year-old man). Four responded as judged by clinical examination, although not the 6-year-old female or the 18-month-old male; the discontinuation of therapy then resulted in clinical recurrence in those who had responded, but long-term low dose treatment maintained the remission.

Cheilo-candidosis in an adult.

A rare case of candidal infection of the lips is presented. Predisposing factors appeared to be intra-oral candidal carriage, actinic lip damage and Sjögren's syndrome. Systemic antifungal therapy with fluconazole resolved the initial infection and a subsequent recurrence.

Unusual leiomyomatous hamartoma of the hard palate: a case report.

Harmartomas of the head and neck are common lesions, often taking the form of melanocytic nevi or vascular malformations such as hemangiomas and lymphangiomas. Hamartomas composed of other tissue types are much rarer and within the oral cavity are usually located on the tongue near the foramen cecum or on the anterior hard palate near the incisive papilla. Although most occur as isolated phenomena, a small number may be associated with other local developmental defects or with a syndrome complex. A normal 5-year-old girl had a 1 cm soft sessile swelling in the vault of the hard palate on the left side. Histopathologic examination showed bundles of smooth muscle embedded in fibrovascular stroma and accompanied by abundant mature fat and a small amount of salivary tissue. The features were regarded as those of a leiomyomatous hamartoma and could be distinguished from a smooth-muscle tumor, teratoma, and benign mesenchymoma by virtue of the clinical and histopathologic features. No recurrence has been seen after excision.

Detection of human papilloma virus DNA sequences in oral squamous cell papillomas by the polymerase chain reaction.

Nineteen clinically diagnosed, and histologically confirmed oral squamous cell papillomas were analyzed for the presence of human papilloma virus DNA sequence by the highly sensitive polymerase chain reaction technique, followed by dot blot hybridization of the polymerase chain reaction product with digoxigenin-labeled, type-specific oligonucleotide probes for human papilloma virus DNA types 6, 11, 16, and 18. Human papilloma virus DNA types 6 and 11 were identified in 68% of these oral lesions, which raises the possibility of an etiologic role for human papilloma virus in the pathogenesis of oral squamous cell papillomas.

Acinic cell carcinoma in Northern Ireland: a 10-year review.

12 cases of acinic cell carcinoma diagnosed in Northern Ireland from 1942 to 1982 on which there was at least 10 years' follow-up were reviewed, by pooling cases from all regional pathology laboratories. Clinical findings at presentation were established from case notes, together with details of eventual clinical outcome. Sections were examined to determine tumour size, morphological pattern and cytological constitution, the presence or absence of cytological atypia, mitotic activity, lymphocytic and desmoplastic responses, and to assess for infiltrative margins and adequacy of excision. The tumours arose in 8 females and 4 males, aged 22 to 86 years at presentation. Eleven tumours were in the parotid, one in the soft palate. Two patients suffered local recurrence, both more than 7 years after diagnosis. Five patients had regional lymph node metastasis, four at presentation. No patient suffered haematogenous metastasis or died of tumour. Of the features examined, incomplete excision increased the risk of local recurrence. While numbers are small, the acinic cell carcinoma in Northern Ireland is an unpredictable low-grade malignant tumour which is capable of recurrence and metastasis. Adequate excision at presentation appears to be the most appropriate therapy.

Adenosquamous carcinoma. A rare neoplasm with an aggressive course.

We report a case of adenosquamous carcinoma that arose in the maxillary alveolus of a 61-year-old woman, metastasized rapidly to submandibular and deep cervical lymph nodes, and caused death in spite of surgery and radiotherapy. Our case highlights the aggressive behavior associated with this tumor when it occurs in the oral cavity and at most other body sites. In addition, the oral adenosquamous carcinoma may not be as rare as the small number of reported cases might suggest because the adenocarcinoma component may form a very small proportion of the tumor as in our case, and the histopathologic criteria for diagnosis are not clearly established. Thus some cases of adenosquamous carcinoma may not be recognized as such. This underlines the important role of the histopathologist in the diagnosis of oral cancer by the recognition of specific subtypes of cancer and their associated prognostic significance.

Secretor status and oral cancer.

A prospective study was undertaken of 100 Sri Lankan patients with oral cancer and an equal number of age and sex matched control individuals. Each subject's secretor status was established from samples of appropriately prepared whole saliva using a haemagglutination technique. No significant differences were recorded in the distribution of secretors or non-secretors between the patient and control groups. In contrast to studies of Caucasians with potentially malignant oral lesions such as candidal leukoplakia in which non-secretor status predominates, secretor status does not appear to be an associated risk marker for the development for oral cancer in a selected Sri Lankan population.

'Strawberry gums'--a case of Wegener's granulomatosis.

We report a case of Wegener's granulomatosis (WG), localised to the upper aerodigestive tract, which presented as an unusual form of hyperplastic gingivitis in a 36-year-old female. The clinical, serological and histopathological findings are described. The resemblance of the affected gums to over-ripe strawberries is emphasised, in order to draw attention to this characteristic oral manifestation of a rare and potentially life-threatening condition. The response to co-trimoxazole as sole therapy is noted.

Strawberry gums: a clinicopathological manifestation diagnostic of Wegener's granulomatosis?

AIMS: To highlight an uncommon but characteristic gingival lesion associated with Wegener's granulomatosis, emphasising the presence of pseudoepitheliomatous hyperplasia, microabscesses, and multinucleate giant cells; and the paucity of the currently accepted histopathological criteria of Wegener's granulomatosis--namely necrosis, vasculitis, and granulomata. METHODS: The histopathological features of a gingival biopsy specimen from a case of Wegener's granulomatosis limited to the upper aerodigestive tract in a 36 year old woman were compared with those of 14 similar reported cases. RESULTS: Pseudoepitheliomatous hyperplasia, microabscesses, and multinucleate giant cells were recorded as present in almost all cases of gingival Wegener's granulomatosis. Necrosis, vasculitis, and granuloma formation were present in only a few cases. CONCLUSIONS: The combination of pseudoepitheliomatous hyperplasia, microabscesses, and multinucleate giant cells in a gingival biopsy specimen from erythematous, swollen gums, clinically resembling over-ripe strawberries, in a patient with a severe systemic upset, is so typical of Wegener's granulomatosis as to be virtually diagnostic. Recognition of this characteristic lesion may aid early diagnosis and treatment in cases where other diagnostic variables are absent.

Candidal infection as a complication of barrier membrane placement in a diabetic patient.

This report describes candidal infection as a complication of barrier membrane placement in a diabetic patient. This resulted in failure of the regenerative procedure and necessitated extraction of the tooth involved. Candidal hyphae were demonstrated within the dentinal tubules of the tooth. Subsequent to appropriate medical treatment to regain control of the diabetes there was an improvement in oral health.

Retro-pharyngeal liposarcoma.

We present a case of extensive recurrence of a retro-pharyngeal liposarcoma following surgical removal 18 years previously. The surgery and pathology are discussed, and management strategies of head and neck liposarcomas are reviewed.

Sublingual adult rhabdomyoma. Report of a case.

A case of intraoral adult extracardiac rhabdomyoma is reported. There has been no recurrence in 4 years follow-up. We estimate this to be the 111th reported case of extracardiac rhabdomyoma, the 29th to present in the tongue and sublingual regions.

Benign lymphoid hyperplasia of the palate: report of two cases and immunohistochemical profile.

Two cases of benign lymphoid hyperplasia (BLH) of the palate are reported. The histologic appearances are those of a benign or reactive lymphoid aggregate and correlate well with other published accounts of this lesion. Using a battery of antileukocyte antibodies suitable for formalin-fixed tissue, analysis of the antigenic profile of oral BLH has been performed. The results indicate its benign nature: the germinal centres show tingible-body macrophages and polyclonal light chain restriction, the mantle zones are composed of both mature and immature B-cells, and the extramantle zones contain both B- and T-lymphocytes, plasma cells, macrophages, polymorphonuclear leukocytes and eosinophils. The histologic and immunohistochemical features are those of benign rather than malignant proliferation of lymphocytes. This is in agreement with published accounts of long-term follow-up, which have found no correlation between BLH in the mouth with either malignant association or malignant transformation.