What is the optimal site and biopsy technique for the diagnosis of oral mucosal autoimmune blistering disease?

BACKGROUND: The aim of this study was to determine which biopsy method produces the best diagnostic yield in patients presenting with autoimmune blistering diseases (AIBDs) of the oral mucosa. METHODS: This was a retrospective audit of patients who were biopsied at least once for a suspected AIBD of the oral mucosa. The type (incisional or punch) and site of biopsies were recorded in conjunction with case notes, electronic records and histopathological reports in order to calculate sensitivity, specificity and the method of biopsy which produced the superior diagnostic yield. RESULTS: A total of 125 biopsy samples from 66 patients were identified and reviewed. A diagnosis of AIBD was established in 49 (74%) patients. The chi-square test showed there was a statistically significantly higher (P = 0.0016) diagnostic yield using the punch biopsy technique compared to the scalpel method. The gingiva was the best biopsy site in terms of achieving a definitive diagnosis (P = 0.0001) regardless of the biopsy method used. CONCLUSIONS: A punch biopsy is more likely than scalpel biopsy to obtain a definitive diagnosis in patients presenting with a suspected oral AIBD. The gingiva is the optimal site to sample.

Quality of life and communication in orthognathic treatment.

OBJECTIVE: The primary aim was to determine what, if any, relationships exist between communication and quality of life in patients receiving orthognathic treatment since this has not been explored. A secondary aim was to compare the Quality of Life (QoL) of a pre-treatment sample with those at 2 years post-surgery. DESIGN: A cross-sectional questionnaire method was used. SETTING: Outpatient clinics providing orthognathic treatment at four UK hospital sites. PARTICIPANTS: Two separate samples of pre-treatment (n = 73) and 2-year post-surgery (n = 78) patients participated in the study. METHODS: At clinic appointments, all eligible patients were invited to complete the Orthognathic Quality of Life Questionnaire (OQLQ), a previously validated condition-specific quality of life measure. At the same time, participants at the 2-year post-surgery stage also completed a second short questionnaire, the Communication Assessment Tool-Team (CAT-T), where they rated the quality of communication they had received during treatment. RESULTS: One hundred and fifty-one complete responses were received. The average age was 24.5 years (S.D. 9.77) and the majority (67%) were female in both groups. Statistically significant associations were found between QoL and quality of communication in the treated sample. Findings also showed a comparatively poorer QoL for the pre-treatment participants. This reduced QoL was more pronounced in females than males for all aspects except dentofacial appearance. CONCLUSIONS: There was an improvement in QoL for patients at 2 years post-surgery compared to pre-treatment. There is an association between QoL and quality of communication as reported by participants at 2 years post-surgery. These novel findings are similar to outcomes in other patient settings such as oncology, but further investigation is required to establish the direction of cause and effect.

Dentigerous Cyst and Ameloblastoma of the Jaws.

AIM: To determine how many ameloblastomas were misdiagnosed as dentigerous cysts (DCs) by correlating the radiological and histopathological features of a series of both entities. METHODS AND RESULTS: Histopathology reports and radiological imaging of 135 DCs and 43 ameloblastomas were reviewed. Any clinical or radiological feature that suggested that the diagnosis of DC was wrong-for example, absence of an unerupted tooth-prompted review of the original histology. A total of 34 cases coded as DC at diagnosis were excluded; in the remaining 101 patients, the clinicoradiological and histopathological features were consistent with DC in 96 (95.0%). Review of the histology revealed that 4 patients had actually had odontogenic keratocysts (OKCs) and one a luminal/simple unicystic ameloblastoma (UA). One other OKC and 3 other ameloblastomas (1 luminal UA, 2 solid/multicystic) had originally been diagnosed as DC; these had been identified prior to the study. Of the 9 misdiagnosed patients, 6 were ≤20 years old. Clinically, DC had been the only, or one of the differential, diagnoses in 7 patients; in the other 2, the clinical diagnosis was radicular cyst. In none of the 4 misdiagnosed ameloblastomas was the radiology compatible with a diagnosis of DC. Incorrect terminology had been used on the histopathology request form in 5 of the 34 excluded cases where the clinical diagnosis was DC, despite the cyst being periapical to an erupted carious or root-filled tooth. CONCLUSIONS: The entire clinical team must ensure that a histopathological diagnosis of DC is consistent with the clinicoradiological scenario, particularly in younger patients.

Use of dental loupes among dental trainers and trainees in the UK.

INTRODUCTION: Magnification loupes are used in dentistry where increased visual performance is needed. The interest and use of loupes among dental practitioners and students appears to be growing. Despite this little quantitative data regarding the use of loupes in clinical practice and factors governing their purchase among dental trainers and trainees is available. OBJECTIVE: To determine the extent of use of loupes among dental trainers and trainees in the UK and identify what factors influence their choice of selection. METHOD: A proforma questionnaire was designed to collect the information required and was handed out dental trainers and trainees. RESULTS: Use of loupes is more common among the dental trainers (44%) than trainees (28%). Of the nonusers, increased interest among the trainees (83.6%) and trainers (50%) in purchasing loupes was noted. Price was found to be the most important factor during purchase. The majority of users opted for 2.5×; and a light source was a popular choice. Both users and nonusers in the study group had an affinity towards "through-the-lens" type. No significant variation in back/neck discomfort between the users and nonusers was found. CONCLUSION: Use of loupes among dental trainers and trainees remains low. Reduction in price and provision of information could increase the number of loupe users.

Orthognathic treatment of asymmetry: two cases of "waferless" stereotactic maxillary positioning.

We present 2 cases in which navigation-guided surgery was used to correct complex facial asymmetry. The merits and challenges of using stereotactic technology to allow "waferless" positioning of the maxilla in orthognathic surgery are illustrated by patients who were operated on without the use of acrylic wafers to achieve three-dimensional correction of the maxillary deformity. Biometric assessment was made clinically and recorded with computed tomographic (CT) scanning. The operation was planned using Voxim(®) software and the operation done with the aid of the Voxim(®) navigation system.

Osteomyelitis of the mandible secondary to pericoronitis of an impacted third molar.

UNLABELLED: Impacted third molars are a common reason for referral to the hospital dental service. Third molar impaction can be complicated by infection. We present two cases of osteomyelitis of the mandible developing secondary to pericoronitis of partially erupted lower third molars. One of the cases reported was recently diagnosed and treated while the other was diagnosed and treated 20 years ago. The most commonly reported pathology associated with impacted lower third molars is pericoronitis. Osteomyelitis of the mandible secondary to pericoronitis is rare. CLINICAL RELEVANCE: It is helpful if dental practitioners are able to distinguish between the cases of pericoronitis that need emergency referral to hospital and the cases that can be managed in practice and referred to an outpatient clinic.

Use of an image-guided navigation system for insertion of a Lester-Jones tube in a patient with disturbed orbito-nasal anatomy.

Image-guided navigation systems are increasingly used in orbito-facial surgery where advanced pre-operative image manipulation and intra-operative localisation have proved invaluable. We describe the novel use of one such system for Lester-Jones tube placement to the contralateral nasal space in a 54-year-old man with left nasolacrimal duct obstruction following left rhinectomy, hemi-maxillextomy, radiotherapy and reconstruction for a left sinonasal squamous cell carcinoma. Reconstruction included a vascularised iliac crest graft, titanium mesh implant and polyaryletheretherketone (PEEK) maxillo-orbital implant. Pre-operative image analysis was used to determine the required tube length to extend to the right nasal space. Passive optical tracking facilitated intra-operative localisation of suitable entry and exit sites for the tube to avoid the orbital implants and achieve drainage into the contralateral nasal cavity. Free drainage and good positioning of the tube was confirmed by nasal endoscopy. This case supports a role for image-guided navigation in complex lacrimal surgery, particularly in cases with distorted anatomy.

An atypical presentation of breast cancer metastasis.

A 78-year-old woman heard a crack in her left mandible while eating a biscuit and reported to her dentist, who urgently referred her to the oral and maxillofacial surgery department. On examination she had a lesion in the body of her left mandible, which had eroded through the lower border and caused a pathological fracture. Her past medical history included a left mastectomy and level II axillary lymph node dissection for a 27 mm grade III invasive ductal carcinoma of the left breast 9 months prior to her mandibular fracture. A transoral incisional biopsy was performed which confirmed the mandibular lesion to be an osteolytic metastasis from the breast. The metastasis was subsequently surgically removed and the remaining mandible repaired with a reconstruction plate followed by postoperative radiotherapy. The patient regained full function of her mandible and is now eating normally. She is being closely followed-up in the oncology outpatient department.

Free vascularised iliac crest graft: an audit of 26 consecutive cases.

Over an 18 month period 26 vascularised myo-osseus, and one myo-osseus-cutaneous iliac crest flaps were used to reconstruct 18 mandibular and eight maxillary defects. During the operation one flap failed to reperfuse and was removed. Postoperatively three patients were returned to theatre for appraisal and reanastomoses, which in two cases involved thrombolysis. In all three salvage was deemed successful but in all there was partial muscle necrosis. There were 10 cases of anaesthesia of the skin supplied by the lateral cutaneous nerve of the thigh, three incisional hernias, one wound dehiscence in the thigh, two oronasal fistulas, one wound dehiscence in the neck, one infection by methicillin resistant Staphylococcus aureus in the thigh, and two long-term and one medium-term disturbances of gait. Complications were graded as severe (4%), intermediate (27%), and minor (46%).