Is there any correlation between otitis media and dental malocclusion in children? A systematic review.

PURPOSE: This study aims to evaluate whether there is a correlation between otitis and dental malocclusions. METHODS: Electronic databases were searched for observational studies published until July 2021 without language or time restrictions. PROSPERO: CRD42021270760. Observational studies on children with and without OM and/or malocclusion were included. After removing duplicates and excluding not-eligible articles, two reviewers screened relevant articles independently. Two reviewers independently extracted data and assessed data quality and validity through the Newcastle-Ottawa Scale (NOS) quality assessment tool for non-randomized studies. RESULTS: Five studies met the selection inclusion criteria and were included in the studies for a total of 499 patients. Three studies investigated the relationship between malocclusion and otitis media, while the remaining two studies analyzed the inverse relationship and one of them considered eustachian tube dysfunction as a proxy of OM. An association between malocclusion and otitis media and vice versa emerged, although with relevant limitations. CONCLUSION: There is some evidence that there is an association between otitis and malocclusion; however, it is not yet possible to establish a definitive correlation.

Taste sensitivity in healthy adults: gustatory test validation and observational study.

Gustatory sensitivity has important biological functions and taste disorders are generally difficult to diagnose and treat. The aim of this study was to investigate taste sensitivity on a sample of adult healthy patients through the validation and administration of a gustatory test, to describe a possible baseline of reference. A gustatory test was performed following a standardized protocol, using primary flavors solutions at 4 known increasing concentrations for a total of 16 sapid solutions. Taste sensitivity was investigated considering (a) the threshold of the flavor identification and (b) the intensity of stimulus perception. Seventy-one healthy patients were included in the study. Reliability measures were evaluated, supporting the validity of the test itself. Sweet, bitter, and salty flavors could be identified within the first concentration, sour flavor was detected within the second concentration in the majority of cases (p<0.05). Sour flavor showed the lowest value of perceived intensity for the less concentrated solution, sweet flavor showed the highest value. Regarding the most concentrated solution, bitter flavor showed the highest intensity value, while sour remained the lowest one. Both gender-based and age-based differences regarding threshold and intensity of perception were not statistically significant. However mean threshold averagely increased along with age. Within its limitations, this study validates a useful, easy-to-use tool for assessing taste function and it provides a possible baseline for perception of primary flavors in a healthy adult population, which can be used as a reference for future studies considering specific cohorts of patients.

Non-specific oral and cutaneous manifestations of Coronavirus Disease 2019 in children.

BACKGROUND: Coronavirus Disease 2019 (COVID-19) seems to affect children only marginally, as a result, there is less knowledge of its manifestations in childhood. The purpose of this retrospective cross-sectional study was to investigate the oral and cutaneous manifestations in children affected by COVID-19. MATERIAL AND METHODS: All the medical records of children with COVID-19 admitted to the Pediatric Clinic- ASST Spedali Civili of Brescia from March to April 2020 were reviewed. The following data were recorded: age, temperature, clinical presentation, oral mucosa lesions, taste alteration and cutaneous lesions. RESULTS: The medical records of twenty-seven pediatric patients (mean age 4,2 years + 1,7) were analyzed. The clinical presentation of the disease mainly included elevated body temperature and cough. The following oral lesions were recorded: oral pseudomembranous candidiasis (7.4 %), geographic tongue (3.7%), coated tongue (7.4 %) and hyperaemic pharynx (37 %). Taste alteration was reported by 3 patients. Six patients presented cutaneous flat papular lesions. CONCLUSIONS: As for our paediatric sample, COVID-19 resulted to be associated with non-specific oral and cutaneous manifestations.

Efficacy of ozonized water for the treatment of erosive oral lichen planus: a randomized controlled study.

BACKGROUND: Management of erosive Oral Lichen Planus (eOLP) is challenging. Currently, topical corticosteroids are widely used as first-line therapy, but they might be associated with side-effects and incomplete clinical response. Among non-pharmacological strategies, ozone at low medical concentration has proven to induce a mild activation of protective anti-oxidant pathways, thus exerting therapeutic effects in many inflammatory diseases. The aim of this randomized controlled study was to investigate the effectiveness of ozonized water in association with conventional topical corticosteroids for the treatment of eOLP. MATERIAL AND METHODS: Fifty-one patients were included in the study and randomized into 2 groups: study group (n=26) included patients receiving ozonized water treatment; control group (n=25) included patients receiving placebo treatment (i.e. double-distilled water). Treatment protocol consisted of 1-minute oral rinses, repeated for 4 times, twice a week for 4 weeks. All patients received conventional corticosteroid topical therapy (betamethasone soluble tablets, 2 rinses/day for 4 weeks). Assessment of size of lesions, sign and pain scores was performed before treatment, after 2 weeks of treatment (T1) and at the end of 4-week treatment (T2). Efficacy Index (EI) of treatment, candidiasis and relapse rates were also recorded. RESULTS: All patients experienced significant improvement of sign and pain scores with a higher rate of improvement in ozone-treated group (T1 improvement rates: Thongprasom 92.2% vs 28%; VAS pain 76.9% vs 32%; p<0.05). Pain and size reduction were significantly higher in ozone-treated group both at T1 and T2 (p<0.05). Ozone-treated group showed a higher EI at every time point (T0-T2: 72.77% vs 37.66%, p<0.01). Candidiasis (32% vs 11.5%) and relapse (40% vs 34.6%) rates were higher in control group, however the differences were not statistically significant. CONCLUSIONS: Within the limitations of this study, ozonized water seems to be effective as an adjunct therapy, in combination with topical corticosteroids, for the treatment of eOLP.

Photobiomodulation therapy for the management of recurrent aphthous stomatitis in children: clinical effectiveness and parental satisfaction.

BACKGROUND: This study aims to evaluate the effectiveness of the photobiomodulation therapy (PBMT) in the treatment of minor recurrent aphthous stomatitis (MiRAS) in children, in terms of pain relief, lesion size reduction and the parental satisfaction of the therapy. MATERIAL AND METHODS: This randomized controlled study was carried out on 60 children with clinical diagnosis of MiRAS. Patients were randomized into two groups: group A receiving laser therapy and group B receiving sham therapy (placebo). Laser therapy (diode laser, λ: 645 nm) was administered on day 1 (T0) for three consecutive days. Patients were evaluated also on day 4 (T1), on day 7 (T2) and on day 10 (T3). Oral aphthous lesions size was assessed through a periodontal probe to measure the diameter length (mm); pain was evaluated through the Visual Analogue Scale (VAS); parental satisfaction was assessed through a questionnaire. RESULTS: The difference in the reduction of ulcers diameters between the two groups resulted statistically significant at T1 and at T2 (p<0.05). A statistically significant difference in pain reduction between two groups was found at T1 (p<0.05). No statistically significant difference between the two groups of parents was found as concerns the parental acceptance of the procedure and the discomfort for the need of multiple appointments. CONCLUSIONS: PBMT is to be considered effective in the treatment of MiRAS in children and well- accepted by the parents of the children themselves.

In vitro inhibitory effect of two commercial probiotics on chromogenic actinomycetes.

PURPOSE: Black extrinsic discoloration is a common clinical and aesthetic problem. This study aims to evaluate the potential in vitro antagonistic activity of two commercial probiotics, Streptococcus salivarius M18 and Lactobacillus reuteri ProDentis, against microorganisms associated with black stains. METHODS: Streptococcus salivarius M18 and Lactobacillus reuteri were tested against Aggregatibacter actinomycetemcomitans and Actinomyces naeslundiiusing their cell-free fermentative broth in a planktonic growth inhibition test. RESULTS: Both probiotic cell-free supernatants showed the ability to reduce the pathogenic bacteria growth in a dose-dependent way. Streptococcus salivarius M18 showed a stronger antimicrobial activity than Lactobacillus reuteri ProDentis against the two indicator strains used. A. naeslundi was less susceptible to the probiotic activity of both S. salivarius and L. reuteri compared to A. actinomycetemcomitans. CONCLUSIONS: The obtained results demonstrate a potent antagonistic ability of probiotics to reduce the growth of microorganisms associated with black tooth stains. Therefore, these strains could be evaluated for a therapeutic use against dental pigmentations.

Efficacy of the photobiomodulation therapy in the treatment of the burning mouth syndrome.

BACKGROUND: This study aims to evaluate the efficacy of the photobiomodulation therapy (PBMT) - in terms of pain and of quality of life- in patients affected by burning mouth syndrome (BMS). MATERIAL AND METHODS: This study was designed as a randomised double-blinded prospective study. Patients diagnosed with BMS in the period from June 2015 to June 2018 were recruited. The patients were randomised into two groups and each received treatment once a week for ten weeks: group A received laser therapy (K Laser Cube 3) while group B was given sham therapy (placebo). Pain was evaluated through the Visual Analogue Scale (VAS) and quality of life was assessed with the short form of the Oral Health Impact Profile (OHIP-14). Assessment was done at baseline and after every therapy session. The researchers were blind to the randomised allocations. RESULTS: A total of 85 patients were analysed. Group A (laser treatment) was composed of 43 patients while group B (sham therapy) of 42 patients. Patients treated with PBMT showed a significant decrease in symptoms ( p=0.0008) and improved quality of life related to oral health ( p=0.0002). CONCLUSIONS: PBMT has demonstrated to have a positive effect in relieving BMS symptoms and in improving a patient's overall quality of life.

Long-term evaluation of the efficacy on the podalic support and postural control of a new elastic functional orthopaedic device for the correction of Class III malocclusion.

AIM: Correlations between occlusion and posture are open to new perspectives, which include treatment of functional alterations traditionally approached separately. The aim of this study is to evaluate whether the treatment of Class III malocclusion, through an innovative elastic functional orthopaedic device, allows an overall improvement of the podalic support. MATERIALS AND METHODS: A 5½-year-old patient with Angle Class III malocclusion and c anterior ross bite in deciduous dentition has been treated for 7 years with a functional orthopaedic device (MSB Class III). Assessment of frontal and lateral postural plumb line was performed with stabilo-baro-podometric platform analysis, in order to record the podalic support discrepancy between feet, both in static phase and in dynamic phase. The patient has been posturally re-evaluated at nine and twelve years old. RESULTS: The functional device allowed the restoration of the correct intermaxillary relationship, favourably conditioning also the posture. In particular, the correction of the valgus flat foot and a significative reduction of the podalic support discrepancy between feet has been obtained. CONCLUSIONS: A global approach to the patient can successfully address both malocclusion and postural alterations.

Effectiveness of a spray containing 1% malic acid in patients with xerostomia induced by graft-versus-host disease.

BACKGROUND: To evaluate the clinical effectiveness of a topical sialogogue spray (malic acid, 1%) in the treatment of xerostomia in patients with chronic Graft versus Host Disease (cGVHD). MATERIAL AND METHODS: This study was designed as a randomized double-blind clinical study. Twenty-eight patients with cGVHD suffering from xerostomia were divided into 2 groups: the first group (14 patients) received a topical sialagogue spray containing malic acid 1% (SalivAktive®) whereas the second group (14 patients) received a placebo. Both groups received treatment for 2 weeks. Dry Mouth Questionnaire (DMQ) scores and unstimulated salivary flows rate were collected before and after treatment. RESULTS: DMQ scores increased significantly from 1.3 ± 0.4 to 3.5 ± 0.4 points (p<0.05) after two weeks of treatment with malic acid, whereas in the control group DMQ scores increased from 1.2 ± 0.7 points to 1.4 ± 0.6 (p>0.05). The unstimulated salivary flow rate in patients treated with malic acid increased significantly from 0.15 ± 0.06 mL/min to 0.24± 0.08 mL/min, while that of the patients treated with placebo went from 0.16 ± 0.07 mL/min to 0.17 ± 0.09 mL/min (p>0.05). CONCLUSIONS: Malic acid 1% spray can be considered effective in the treatment of GVHD induced xerostomia.

Influence of occlusal characteristics, food intake and oral hygiene habits on dental caries in adolescents: a cross-sectional study.

AIM: Dental caries is one of the most common oral diseases affecting children. The complex multifactorial aetiology of caries involves host (saliva composition and tooth enamel characteristics), oral microflora and substrate (oral hygiene quality and dietary habits composition). Occlusal characteristics may be also a factor in dental caries development. The aim of this aepidemiologic study was to verify the association between DMFT (Decayed, Missed, Filled Teeth) index and occlusal characteristics, dietary habits, oral hygiene habits and parents' education level in a sample of 12-year-old schoolchildren from Southern Italy. MATERIALS AND METHODS: A sample of 536 children was examined to detect dental caries status and several occlusal variables (i.e. molar relationship, overjet and overbite, presence of crossbite, scissor bite, crowding, diastemas and/or midline deviation). A questionnaire to retrieve parents' educational level, patient's dietary and oral hygiene habits was administered. The associations among these variables were assessed statistically through the ?2 test. RESULTS: A positive association was found between caries, parents' social status and some occlusal disorders. va specificato, l'abstract non può essere una caccia al tesoro. In relation to occlusal variables, crossbite (?2=3.96, P=0.04) was significantly associated to caries. A significant association was also found between the education level of mothers (?2=7.74, P<0.01) and fathers (?2=6.35, P=0.01) and the presence of caries. Dietary habits, oral hygiene and remaining occlusal characteristics were not associated with caries presence (all P>0.05). CONCLUSIONS: Of the evaluated occlusal characteristics only posterior crossbite was associated with caries prevalence. Education level of the parents was the other factor significantly associated with caries. Dietary habits, oral hygiene frequency and the remaining occlusal characteristics were not associated with dental caries.

A new emerging oral infection: Raoultella planticola in a boy with haematological malignancy.

BACKGROUND: Oral mucositis is a common complication in pediatric cancer patients, affecting up to 80% of children. Due to neutropenia and disruption of the mucosal barrier, chemotherapy-induced oral mucositis is often complicated by super-infections. CASE REPORT: A 16-years old male with stage 3 Burkitt's lymphoma developed chemotherapy induced oral mucositis grade 3 (according to WHO scale). Ulcers were quickly growing (reaching a maximum diameter of 3 cm) and became greyish in colour, resulting in dysphagia and pain. A swab of the lesions was taken and microbiological tests were performed. The sample grew for Raoultella planticola, an encapsulated Gram-negative bacterium whose full pathogenic potential still needs to be defined. TREATMENT: The patient received antibiotic combination therapy with Amikacin and Ceftazidime for 8 days. Complete healing of the lesions and resolution of the symptoms were reached and he completed his antineoplastic therapy without further complications. FOLLOW-UP: Twelve months after the infection, he is alive and well, with no oral complaints. CONCLUSION: This is the first report of a Raoultella planticola infection in a patient with chemotherapy induced oral mucositis. This type of infection must be added to the list of organisms to be considered when caring for these patients.

Oral hygiene grade and quality of life in children with chemotherapy-related oral mucositis: a randomized study on the impact of a fluoride toothpaste with salivary enzymes, essential oils, proteins and colostrum extract versus a fluoride toothpaste without menthol.

AIM: The aim of this study was to assess the impact of the use of a fluoride toothpaste (Bioxtra® , Biopharm, Milan, Italy) with salivary enzymes, essential oils, proteins and colostrum extract versus a fluoride toothpaste without menthol on the oral hygiene grade and on the quality of life (QoL) of children with oral mucositis (OM) grade 1 or 2 receiving chemotherapy for Acute Lymphoblastic Leukaemia (ALL). METHODS: Patients between 6 and 14 years with OM were randomly assigned to two groups, group A (Bioxtra® toothpaste) and group B (fluoride toothpaste without menthol). The patients were instructed to brush their teeth at least twice a day using a soft toothbrush with a small head. Oral hygiene grade was assessed using the simplified oral hygiene index (OHI-s); quality of life was assessed using the short form of the Oral Health Impact Profile (OHIP-14) questionnaires. The patients were evaluated on day 1(diagnosis of OM-T0) and on day 8 (T1). Statistical analysis was performed. RESULTS: A total of 64 patients were enrolled. A significant difference (P < 0.001) between the mean of the OHI-s in group A (0.9 ± 1.2) and in group B (1.5 ± 1.3) was found; the overall OHIP-14 scores were not associated with the use of one or the other toothpaste (P = 0.33). CONCLUSIONS: Although the use of Bioxtra® toothpaste does not affect the QoL of children undergoing chemotherapy, it may be recommended as clinically effective in improving the oral hygiene grade.

Occlusal traits in children with neurofibromatosis type 1.

OBJECTIVES: Literature is poor of data about the occlusion in children affected by neurofibromatosis type 1 (NF1). This case-control study investigated the occlusal traits in a group of children with NF1. SETTING AND SAMPLE POPULATION: A hundred and fifteen children with NF1 were enrolled; non-NF1 controls were sequentially selected among subjects referred to the Pediatric Dentistry Department. MATERIAL AND METHODS: All patients underwent a clinical dental examination and a panoramic radiography. The following orthodontic variables were considered: molar relationship, overjet, overbite, cross-bite, scissor bite, and crowding/spacing. RESULTS: Class III molar relationship resulted significantly (p = 0.01) more common in children with NF1 than in the control group as well as the unilateral posterior cross-bite (p = 0.0017). Forty-three children with NF1 (37.3%) showed radiographic abnormalities; in one case, a plexiform neurofibroma was detected. CONCLUSIONS: An early orthodontic evaluation might be planned in the management of children with NF1 to prevent or decrease the need for extensive orthodontic interventions.

The Turin Shroud face: the evidence of maxillo-facial trauma.

The Turin Shroud (TS) is a linen cloth commonly associated with Jesus Christ, his crucifixion and burial. Several medical specialists have debated the injuries of the TS Man, nevertheless there are no detailed and quantitative data about the anatomy of the TS face. The purpose of this study was to analyse the cephalometric measurements of the face image of the TS. The TS face image was acquired by a picture and processed using a cephalometric software, Oris Ceph® (Up to date 2012). The image of the soft tissues was processed in order to obtain skeletal points and a cephalometric analysis of the soft and skeletal tissues was performed. Image processing of the TS face shows that the Man represented in it has undergone a maxillo-facial trauma, especially a left displacement of the mandible, probably due to temporo-mandibular joint lesions. This condition has not been described before, despite several studies on the subject.

Immunocytochemical detection of dentin matrix proteins in primary teeth from patients with dentinogenesis imperfecta associated with osteogenesis imperfecta.

Dentinogenesis imperfecta determines structural alterations of the collagen structure still not completely elucidated. Immunohistochemical analysis was used to assay Type I and VI collagen, various non-collagenous proteins distribution in human primary teeth from healthy patients or from patients affected by type I dentinogenesis imperfecta (DGI-I) associated with osteogenesis imperfecta (OI). In sound primary teeth, an organized well-known ordered pattern of the type I collagen fibrils was found, whereas atypical and disorganized fibrillar structures were observed in dentin of DGI-I affected patients. Expression of type I collagen was observed in both normal and affected primary teeth, although normal dentin stained more uniformly than DGI-I affected dentin. Reactivity of type VI collagen was significantly lower in normal teeth than in dentin from DGI-I affected patients (P<0.05). Expressions of dentin matrix protein (DMP)-1 and osteopontin (OPN) were observed in both normal dentin and dentin from DGI-I affected patients, without significant differences, being DMP1 generally more abundantly expressed. Immunolabeling for chondroitin sulfate (CS) and biglycan (BGN) was weaker in dentin from DGI-I-affected patients compared to normal dentin, this decrease being significant only for CS. This study shows ultrastructural alterations in dentin obtained from patients affected by DGI-I, supported by immunocytochemical assays of different collagenous and non-collagenous proteins.

Risk factors for oral mucositis in children receiving hematopoietic cell transplantation for primary immunodeficiencies: a retrospective study.

OM is a frequent complication for patients undergoing HSCT. The aim of this study was to evaluate the possible risk factors for OM in children undergoing HSCT for PI. A retrospective study was carried out on 55 consecutive medical records of patients with PI (including osteopetrosis) who underwent HSCT. Age at the time of HSCT, gender, diagnosis, type of donor, conditioning regimen, engraftment, graft-versus-host disease, and severity and duration of OM were collected at the beginning of the conditioning until day 100 post-HSCT or death. OM was measured using the WHO scale. Patients' age range at the time of HSCT was quite wide; 59.2% of the patients who were under nine months (n = 13) developed OM vs. 87.8% of the patients older than nine months (n = 29) (p = 0.01). T-cell positive patients had a statistically significant higher risk of developing OM (p = 0.04), as did those receiving a more intensive conditioning regimen (p < 0.01). PI patients undergoing HSCT are at higher risk of developing OM if the PI is a T-lymphocyte-positive disease and/or if the HSCT recipient is over nine months of age.

Development and validation of a taste sensitivity test in a group of healthy children.

AIM: This was to validate a taste test on healthy school children. A cross-sectional study was designed to perform a standardised clinical evaluation of the gustatory sensitivity. MATERIALS AND METHODS: Forty (18 males and 22 females) children were selected. Inclusion criteria were age between 5 and 12 years, absence of systemic disease and no antibiotic treatment in the last six months. The taste assessment tests were performed following a standardised protocol, repeated at two different intervals: a) tested at time 0; b) tested after 20-30 days. Tests were performed using a pipette with the sample solution: sucrose, sodium chloride, citric acid and quinine hydrochloride at different concentrations. The examiner reported in a grid the flavour perceived by the subject. A placebo (tap water) was administered in between the flavours RESULTS: The majority of the subjects detected the bitter taste at the lowest concentration (mean=1.83). The sour taste was detected with the second concentration (mean=2.56). The sweet solution was detected with the most diluted concentration (mean=1.56). The salty taste has a threshold of 2 (mean=2.04), which means that the majority of subjects detected the salty solution with the second concentration. Regarding the perceived intensity, it increases with the increasing concentrations and it reaches maximum values that are inversely proportional to the threshold, corresponding to the second concentration. Moreover, no statistically significant gender differences were detected regarding the threshold values or the perceived intensity. CONCLUSION: The proposed test allows for a controlled, reliable and standardised evaluation of the gustatory modality.

Oral findings in 50 children with neurofibromatosis type 1. A case control study.

AIM: The scientific literature is poor of data concerning NF1-related oral manifestations in children. The purpose of this study was to investigate the oral findings in a group of children with NF1. MATERIALS AND METHODS: This study was designed as a clinical research. A total of 50 children affected by NF1 were enrolled. Non-NF1 controls were selected among subjects referred to the Paediatric Dentistry Department of the Dental Clinic at the University of Brescia, Italy. The craniofacial and all the dental examinations were carried out. The following parameters were investigated: dental caries, dental abnormalities, periodontal status, oral and perioral neurofibromas, orthodontic features, mandible and temporomandibular joint abnormalities. Statistics Unpaired Student's t test was calculated for Gaussian distributed variables; Fisher's test for non-Gaussian distributed binomial variables was used. The values inferior to p <0.05 (threshold) were considered significant for the study. RESULTS: Children with NF1 showed poorer oral hygiene conditions, more frequent Class III dental malocclusions and severe alterations of the mandible and the temporal mandibular joint, if compared with the control group. CONCLUSION: NF1 related-oral manifestations are evidenced also during childhood, even if some of the best known, like the neurofibromas, are not yet developed. It is important to keep a long-term follow-up to monitor the possible development of other oral lesions.

Narrow band imaging and high definition television in evaluation of oral and oropharyngeal squamous cell cancer: a prospective study.

Narrow band imaging (NBI) is an optical technique in which filtered light enhances superficial neoplasms based on their neoangiogenic pattern. The accuracy of NBI can be augmented by combining it with high definition television (HDTV). The aim of this study was to prospectively assess the diagnostic value of NBI in combination with HDTV in evaluation of oral (O) and oropharyngeal (OP) squamous cell carcinoma (SCC). Between April 2007 and December 2009, we analyzed 96 patients who were divided into 2 groups: Group A included 35 patients previously biopsied and diagnosed with OSCC or OPSCC and subjected to pre- and intraoperative HDTV white light (WL) and HDTV NBI endoscopy; Group B included 61 subjects already treated for OSCC or OPSCC and followed-up with HDTV WL and HDTV NBI. Fourteen of 35 (40%) patients in Group A showed adjunctive findings with NBI compared to standard WL. All of these findings were histologically confirmed. Twelve of 61 (20%) patients in Group B showed positive NBI findings, which were all confirmed by histology. The sensitivity, specificity, positive, negative predictive values, and accuracy for HDTV WL were 51%, 100%, 100%, 87%, and 68%, respectively, whilst for HDTV NBI were 96%, 100%, 100%, 93%, and 97%, respectively. Overall, 26 of 96 (27%) patients had a diagnostic advantage in applying NBI and HDTV: 6 patients received a diagnosis of recurrence and 1 of persistence after previous treatments; 5 showed a metachronous tumour; in 4 a synchronous tumour was diagnosed; 9 lesions were upstaged; in 1 patient previously diagnosed with an unknown primary by fine needle aspiration cytology on the neck, an anterior tonsillar pillar cancer was identified.