Concurrent chronic hyperplastic candidosis and oral lichenoid lesion as adverse events of secukinumab therapy.

Secukinumab (Cosentyx®) is an IL-17A inhibitor which is used for the management of psoriasis, active psoriatic arthritis or ankylosing spondylitis. Oral adverse events of secukinumab therapy are not widely appreciated. This article highlights the presentation of two concurrent oral adverse events of secukinumab therapy; namely chronic hyperplastic candidosis (CHC) and oral lichenoid lesion (OLL). This is the first documented case report of CHC occurring as a consequence of secukinumab therapy, and represents a new adverse effect which general and specialist oral health practitioners should be aware of. This case highlights the importance of correlating the presence of oral lesions with the patient's medical history, keeping up to date with the development of new medications and pharmacotherapeutics, having a deep understanding of underlying biological processes related to various oral diseases, and appreciating the use of clinical adjunctive devices. Accurate diagnosis is key to formulating a correct management plan.

Steroid insensitive fixed airflow obstruction is not related to airway inflammation in older non-smokers with asthma.

There is limited evidence linking airway inflammation and lung function impairment in older non-smoking asthmatics with fixed airflow obstruction (FAO), which can develop despite treatment with inhaled corticosteroids (ICS). We assessed lung function (spirometry, forced oscillation technique (FOT)), lung elastic recoil and airway inflammation using bronchoalveolar lavage (BAL) in non-smoking adult asthmatics with FAO, following 2 months treatment with high-dose ICS/long-acting beta-agonist. Subjects demonstrated moderate FAO, abnormal FOT indices and loss of lung elastic recoil. This cross-sectional study showed a lack of a relationship between BAL neutrophils, eosinophils, inflammatory cytokines and lung function impairment. Other inflammatory pathways or the effect of inflammation on lung function over time may explain FAO development.

Narrow Band Imaging-guided resection of oral cavity cancer decreases local recurrence and increases survival.

PURPOSE: Overall local recurrence of oral squamous cell carcinoma (OSCC) is estimated at 20%. Incomplete primary tumour excision contributes to localised postsurgical recurrence of OSCC. The purpose of this study was to report on patient outcomes following resection of OSCC using Narrow Band Imaging (NBI). MATERIALS AND METHODS: Patients with OSCC requiring resection were visualised under conventional white light (WL) then NBI using an Olympus NBI ENF-VQ nasendoscope with CLV-180 light source and processor (Olympus Medical Systems, Tokyo, Japan). OSCC tissue was resected to the NBI-defined surgical margins, and patients followed for a minimum of 5 years postsurgery to assess local recurrence rate (LRR) and disease-free survival (DFS). RESULTS: Of the 20 patients recruited for this study, one patient (5%) declined follow-up. At the latest follow-up period (up to 7 years postsurgery), 14 of 19 patients (73.68%) were alive with no recurrence. Two patients (10.53%) had died from metastatic disease with no local recurrence, one patient (5.26%) had died from disease with local recurrence, and two patients (10.53%) had died disease-free from other causes. In total, 16 of 19 patients (84.21%) who were followed for a minimum of 5 years were still alive and had not developed local recurrence. Only one patient developed local recurrence. Five-year DFS was 84.21% and LRR was 5.26%. CONCLUSION: Resection to NBI-defined margins improves survival rates and decreases recurrence rates of OSCC compared to traditional methods and should be adopted as the new gold standard for determining mucosal surgical margins for treatment of oral cavity cancer. These promising results have set the scene for a multicentred randomised controlled trial comparing NBI to WL currently underway.

Molecular classification of autofluorescence excision margins in oral potentially malignant disorders.

OBJECTIVE: To define molecular differences between autofluorescence and white light defined excision margins in oral potentially malignant disorders (OPMD) using transcriptome expression profiles. MATERIALS AND METHODS: Excisional biopsy specimens were taken from 11 patients at three different sites for each lesion: centre, white light margin and autofluorescence margin. The lesions were diagnosed histopathologically as oral epithelial dysplasia, oral lichenoid dysplasia, oral lichen planus or other. Transcriptome analysis was performed by RNA sequencing, hierarchical clustering, differential expression and biological pathway analysis. RESULTS: For hierarchical clustering, the samples broadly clustered according to histology rather than the margins with lichenoid samples clustering together. Differential expression analysis showed that independent of histology, there was greater molecular dysregulation between the lesion centre and autofluorescence margin compared to the lesion centre and white light margin. Furthermore, the autofluorescence and white light margins were molecularly distinct, indicating the white light margins harboured abnormality. CONCLUSION: Our results indicate that the molecular profile of OPMD changes with divergence away from the centre of the lesion, and that autofluorescence determined margins are superior to the white light margin in achieving a clear molecular margin when excising an OPMD.

Knowledge of oral cancer risk factors amongst high-risk Australians: findings from the LESIONS programme.

BACKGROUND: Patient awareness of risk factors associated with cancer has been shown to increase patient presentation for screening and early detection. This study aimed to identify the level of awareness of oral cancer risk factors in a high risk Australian population. METHODS: Participants were recruited from the LESIONS programme between April 2012 and April 2014. Demographics were collected via semi-structured interview. A self-administered questionnaire was provided, listing a number of possible oral cancer risk factors. Participants were requested to indicate their level of agreement on a three-point scale. Bivariate and multivariable analysis was performed. RESULTS: A total of 1498 participants took part in the LESIONS programme and were invited to complete the questionnaire. The most common risk factors thought to be associated with oral cancer were smoking (87.5%), poor oral hygiene (67.9%) and family history (61.1%). Only 50.2% of respondents were aware of alcohol consumption as a risk factor. CONCLUSIONS: While most participants were aware of the association between smoking and oral cancer, only half were aware of the significant risk alcohol consumption poses. A significant portion of participants also held a number of inaccurate beliefs in relation to oral cancer risk. These findings can benefit both clinicians and public health policy makers in targeting oral cancer education.

Patterns of differentially expressed genes in oral mucosal lesions visualised under autofluorescence (VELscope(™) ).

OBJECTIVES: We aimed to elucidate the molecular pathways associated with fluorescence properties of oral potentially malignant disorders (OPMD) visualised under direct tissue autofluorescence (VELscope(™)). MATERIALS AND METHODS: Forty-two oral mucosal biopsies correlated with clinical fluorescence characteristics were categorised based on histopathological diagnosis. Four oral squamous cell carcinoma (OSCC), 15 oral epithelial dysplasia (OED), nine oral lichen planus (OLP) and 14 oral epithelial hyperplasia (OEH) presenting with three fluorescence patterns including retained fluorescence (RF), loss of fluorescence (LAF) with blanching (LB) and LAF with no blanching (LNB) were assessed. Relative gene expression was measured through RNA sequencing. RESULTS: Although each lesion type had a specific set of histology-related differentially expressed genes (DEGs), all tested samples shared a number of DEGs, and we could not identify a discriminatory component between histological groups. Gene ontology enrichment revealed LAF in OEH was mostly due to changes in inflammation, cell cycle regulation and apoptosis, while in OED was due to inflammation, angiogenesis and extracellular matrix remodelling. Inflammatory reactions were associated with diascopic fluorescence (DF) for both OEH and OED. CONCLUSION: Uncovering the molecular mechanisms underlying LAF and DF may lead to reduction in the number of false-positive and false-negative findings and improve the efficacy and utility of VELscope(™).

Narrow band imaging: clinical applications in oral and oropharyngeal cancer.

Narrow Band Imaging (NBI) is an endoscopic optical imaging enhancement technology that improves the contrast of mucosal surface texture, and enhances visualisation of mucosal and submucosal vasculature. White light is filtered to emit two 30-nm narrow bands of blue (415 nm) and green light (540 nm) light simultaneously, the former corresponding to the main peak absorption spectrum of haemoglobin, and the latter allowing visualisation of blood vessels in the deeper mucosal and submucosal layers. NBI has been used to better assess oral potentially malignant disorders (OPMD), identify oral and oropharyngeal squamous cell carcinoma (SCC), and to define surgical margins of head and neck malignancies. NBI shows great potential in improving detection rates of OPMD, facilitating better assessment of oral and oropharyngeal SCC, and reducing the risk of recurrence for oral SCC. Although further research is required to better understand and define intrapapillary capillary loop (IPCL) patterns and to relate these with clinical, histopathological and molecular parameters especially for early mucosal changes, there is building evidence to recommend its use as the new gold standard for endoscopic assessment in head and neck oncology.

Oral mucosal disease in an Australian urban Indigenous community using autofluorescence imaging and reflectance spectroscopy.

BACKGROUND: The aim of this study was to document the oral mucosal burden in an urban Indigenous community and to evaluate the efficacy of an adjunctive optical device (Identafi(™) ) in a general dental practice. METHODS: Three hundred and forty-two patients who presented to an urban Aboriginal and Torres Strait Islander Community Health Service (ATSICHS) were examined using conventional oral examination (COE) and with a multispectral device (Identafi(™) ). Loss of autofluorescence (LAF) and the visibility of diffuse vasculature were noted. RESULTS: The urban Indigenous community assessed did not display significantly higher rates of smoking, alcohol consumption or lesion prevalence compared to non-Indigenous counterparts. The white and violet light functions of Identafi(™) provided excellent lesion visibility in 84.5% and 77.9% of cases respectively compared to 75% with COE, and were capable of highlighting new lesions not seen during COE. CONCLUSIONS: The urban Indigenous community does not appear to display a significantly higher prevalence of risk factors such as smoking and alcohol consumption compared to their non-Indigenous counterparts living in the same region, nor are they more likely to have oral mucosal lesions. The incidence of intraoral pigmentation has the potential to complicate use of autofluorescence screening devices, emphasizing the importance of skill and training when using this technology.

Screening and referral of oral mucosal pathology: a check-up of Australian dentists.

BACKGROUND: Oral squamous cell carcinomas and potentially malignant oral disorders can be detected early by visually inspecting the oral soft tissues. This study aimed to determine Australian dentists' opinions and practices regarding oral mucosal screening, referral and oral cancer prevention. METHODS: Nine hundred and ninety-nine randomly selected general dentists were mailed a questionnaire. The questionnaire queried practitioners' opinions and perceptions of oral mucosal screening, their referral practices and their beliefs regarding detection and prevention of oral cancer. RESULTS: A total of n=640 individuals responded, yielding a response rate of 70.2%. Most Australian dentists reported to routinely perform oral mucosal screening. Lack of training, confidence, time and financial incentives were seen as barriers to performing mucosal screening to at least some degree by participants in this study. Most dentists manage referrals for oral mucosal pathology appropriately; however, only about half believe in following up with referred patients. Only half of dentists surveyed believed that they could influence a patient to quit smoking. CONCLUSIONS: Australian dentists place importance on oral mucosal screening. Some changes to dental education and training could be made to further improve confidence and ability of dentists in detecting and referring oral mucosal pathology.

Coping with an altered mouth and perceived supportive care needs following head and neck cancer treatment.

PURPOSE: Oral health is essential to general health and well-being and is severely impacted by head and neck cancer (HNC) and its treatment. This study aimed to describe how people who have been treated for HNC cope with altered oral health and function and to identify their supportive care needs. METHODS: A qualitative, descriptive approach was used. Data was collected from individual interviews with six participants 6 months after treatment. Data analysis was performed by qualitative content analysis involving inductive and directed approaches. Directed content analysis was guided by the Stress, Appraisal and Coping Model. RESULTS: Three themes describing changed oral health were identified from the data: dimensions of eating, maintaining oral health after treatment and adapting to the chronic side effects of treatment. A strong use of problem-focussed coping was described, in addition to the importance of peer support in adapting to the psychosocial outcomes of treatment. Support needs identified related to increased access to specialist dental oncology services post treatment, information needs and a need for more psychological support. CONCLUSION: The study findings describe the experience of a sample of people who have received treatment for HNC. Due to a demographically homogenous sample and the strong use of positive coping strategies, the results presented may not describe the experience of the wider HNC population; however, these results provide insight into factors that may influence positive coping.

Diagnostic accuracy of Narrow Band Imaging for the detection of oral potentially malignant disorders.

OBJECTIVE: To determine the clinical diagnostic accuracy of Narrow Band Imaging(™) for the detection of oral potentially malignant disorders in a prospective series of patients. MATERIALS AND METHODS: New and existing patients referred to an oral medicine and pathology specialist clinic for assessment of at least one white, red or red-white oral mucosal lesion underwent conventional oral examination, followed by examination with the white light mode and then narrow band imaging mode of a Narrow Band Imaging(™) system. The clinical presentation, microvascular architecture and relevant histopathology of all lesions were recorded. RESULTS: A total of 272 lesions from 95 patients were observed. The sensitivity, specificity, positive predictive value, negative predictive value and accuracy for the detection of oral potentially malignant disorders or worse by Narrow Band Imaging(™) were 100%, 74.63%, 92.38%, 100% and 93.77%, respectively, when compared with conventional oral examination. Narrow Band Imaging(™) aided the detection of 24 lesions undetected by conventional oral examination and 13 lesions undetected by white light endoscopy. CONCLUSION: Narrow Band Imaging(™) demonstrates great utility as a visualisation adjunct for detecting and monitoring oral potentially malignant diseases, particularly lesions not identified by conventional oral examination or white light examination alone.

Oral mucosal screening and referral attitudes of Australian oral health therapists and dental hygienists in Queensland.

OBJECTIVES: The aim of this study was to describe oral mucosal screening and referral attitudes of Australian oral health therapists (OHTs) and dental hygienists (DHs). METHODS: Questionnaires were distributed to participants who attended dental hygiene courses run in both regional and metropolitan Queensland. RESULTS: One hundred and two participants comprised 58 OHTs and 44 DHs, with a mean of 8.9 years since graduation. Thirty-four participants worked in regional locations, while 68 were from metropolitan areas. 97% of participants agreed that mucosal screening should be performed for all new and recall patients, while a minority (5%) agreed that patients will detect an oral mucosal change themselves. The majority (77%) agreed that oral cancer would be encountered in their practising career. Most participants (81%) felt comfortable discussing the presence of a suspicious lesion with patients and 88% agreed that it was their role to screen. In terms of barriers to oral cancer screening, lack of training was seen as the most prevalent barrier (56%) followed by lack of confidence (51%). Lack of time was seen as the third most prevalent barrier (40%), and lack of financial incentives was the least prevalent barrier (16%). CONCLUSIONS: Oral health therapists and DHs understand the importance of oral mucosal screening and are likely to be alert to oral mucosal changes. While lack of time and financial incentives was perceived to be impediments to mucosal screening, lack of confidence and training was the most prevalent barriers. This issue should be addressed through implementation of effective continuing education courses targeting oral cancer screening and referral practices.

Patient perspectives of diagnostic delay for suspicious oral mucosal lesions.

BACKGROUND: This study aimed to investigate patient experiences regarding the discovery of and subsequent referral for suspicious oral mucosal pathology. The population under investigation were patients of an oral medicine clinic in Australia who had been referred for oral lesions suspected for malignancy. METHODS: A self-completed questionnaire gathered information regarding patient experiences and beliefs leading up to diagnosis at their review appointments. RESULTS: Fifty-four per cent of participants knew about their mucosal pathology before referral. The highest proportion of delay occurred between self-discovery of a lesion and seeking help. Ninety-one per cent of self-aware participants had reason for seeking help in relation to their mucosal pathology. The three most common reasons for this was the desire for an explanation, being advised by a health care provider or presence of pain. CONCLUSIONS: Some patients were unaware of their own oral mucosal pathology and some seek help only when worried, in pain or following advice. Practitioners should examine the oral mucosa to detect suspicious oral mucosal pathology since patients may not be aware of its existence.

MutSα and MutLα immunoexpression analysis in diagnostic grading of oral epithelial dysplasia and squamous cell carcinoma.

OBJECTIVES: This study explored the expression of DNA mismatch repair (MMR) proteins in a range of oral biopsies. We further evaluated the significance of MMR protein expression combined with basic demographic data in differentiating grades of oral epithelial dysplasia (OED) and oral squamous cell carcinoma (OSCC). STUDY DESIGN: Immunohistochemical expression of MutSα (hMLH1 and hPMS2) and MutLα (hMSH2 and hMSH6) were compared in 98 formalin-fixed paraffin embedded oral biopsies: 21 normal, 24 mild-dysplasia (MD), 8 moderate-to-severe-dysplasia (SD), and 45 OSCC. RESULTS: Expression of hMLH1, hPMS2, and hMSH2 was reduced in MD, SD, and OSCC compared with the normal. Reduced hMSH2 immunoreactivity discriminated poorly differentiated OSCC from well-differentiated OSCC. The diagnostic model correctly classified 71.4% of cases and revealed that hPMS2-negative biopsies were more likely to be cancerous (odds ratio [OR], 0.11; 95% confidence interval [CI], 0.000-0.813; P = .040). CONCLUSION: The results suggested a diagnostic role for MMR proteins in OED and OSCC.

Oral cancer in Australia 1982-2008: a growing need for opportunistic screening and prevention.

BACKGROUND: Globally, a decline in the incidence of oral cancer has been noted, while the mortality rates have remained relatively stable. The aim of this study was to provide an update on the incidence and mortality of oral cancer in Australia on a national and state level. METHODS: Data regarding new cases and deaths associated with cancer of the lip, oral cavity and oropharynx were obtained from the Australian Institute of Health and Welfare for the period 1982-2008. Crude- and age-standardized incidence and mortality rates were calculated for all of Australia and for each state and territory. RESULTS: A total of 60 826 cases of lip, oral cavity and oropharyngeal cancer were diagnosed in Australia. Between 1992 and 2008, a decline in the annual percentage change of age-standardized incidence was noted. The lip, followed by the tongue, continue to represent the most common sites of new oral cancer cases. There was no significant change in the rates of mortality for oral cancer over the time period. CONCLUSIONS: These findings show that the oral cancer mortality rate remains high despite a decline in incidence over the past three decades, highlighting a greater need for dental practitioners to undertake preventive strategies and opportunistic screening for patients.

A retrospective analysis of oral and maxillofacial pathology in an Australian adult population.

BACKGROUND: The prevalence of oral and maxillofacial pathology has not previously been reported in the Australian adult population. This study aimed to audit a large pathology service to provide insight into the prevalence of head and neck pathologies. METHODS: Written records of a major Australian oral pathology service were imported into an electronic database. Age, gender and histological diagnosis were assessed. Prevalence of histological diagnoses as a percentage of the major diagnostic categories and of the whole sample were calculated, as well as gender predilections and mean age of presentation of disease. RESULTS: A total of 6344 oral pathology specimens, collected from adults aged 17 years and over were included in the analysis. Mucosal pathology was the most common pathology (37.2%), followed by odontogenic cysts (16.3%) and dental pathology (14.5%). The three most common histological diagnoses were fibrous hyperplasia (15.2%), chronic periapical granuloma (9.6%) and radicular cyst (9.5%). The male:female ratio of the entire sample was 0.74. CONCLUSIONS: This is the first study to describe the prevalence of oral and maxillofacial pathology among adult patients in an Australian population. The trends seen in this study are repeated in studies from other parts of the world, and are of diagnostic importance.

A retrospective analysis of oral and maxillofacial pathology in an Australian paediatric population.

BACKGROUND: The prevalence of oral and maxillofacial pathology has not previously been reported in the Australian paediatric population. This study aimed to audit a large pathology service to provide insight into the prevalence of oral and maxillofacial pathology. METHODS: Written records of a major Australian oral pathology service were imported into an electronic database. Age, gender and histological diagnosis were assessed. Prevalence of histological diagnoses as a percentage of the major diagnostic categories and of the whole sample were calculated, as well as gender predilections and mean age of presentation of disease. RESULTS: A total of 1305 oral pathology specimens, collected from paediatric patients aged 16 and under were included in the analysis. The most common pathology was dental pathology (24.4%), followed by odontogenic cysts (18.5%) and mucosal pathology (17.0%). The most frequently encountered lesion was the dentigerous cyst (9.4%), followed by fibrous hyperplasia (8.3%), radicular cyst (5.2%) and chronic periapical granuloma (5.2%). CONCLUSIONS: In the paediatric population, dental pathology and specifically, the dentigerous cyst is the most common pathology type sent for histopathology, suggesting a high prevalence of pathology of dental origin occurring in Australian children.

Oral health impacts and quality of life in an urban homeless population.

BACKGROUND: Homeless people experience a much higher burden of general health conditions and have much poorer oral health than the rest of the population. The aim of this study was to determine the oral health impacts and general quality of life of an urban homeless population. METHODS: A convenience sample of 58 adults (dentate n = 56) experiencing homelessness were assessed using a survey which included the 14-item Oral Health Impact Profile and the 26-item World Health Organization's Quality of Life - short version. A subset (n = 34) also underwent a dental examination. RESULTS: The study participants were younger, more likely to be Indigenous, smoked daily and avoided dental care because of cost than the rest of the population. Dentate homeless adults reported significantly greater oral health impacts when compared with the Australian dentate population. General quality of life was significantly poorer than for the rest of the population. Treatment need was associated with greater oral health impacts. CONCLUSIONS: Poor oral health is prevalent and adversely impacts quality of life for homeless people, but it is only one of a range of complex social and health challenges being faced by these individuals. Dental care should be better integrated within homeless support services.

Harnessing massively parallel sequencing in personalized head and neck oncology.

Advances in the management of patients with head and neck squamous cell carcinoma (HNSCC) have not significantly changed the prognosis of this tumor over the past five decades. Molecular heterogeneity of HNSCC and its association with HPV, in addition to the increase in the number of cancers arising in traditionally low-risk patients, are among some of the obstacles to the successful management of this group of tumors. Massively parallel sequencing, otherwise known as next-generation sequencing (NGS), is rapidly changing conventional patient management by providing detailed information about each patient's genome and transcriptome. Despite major advances in technology and a significant reduction in the cost of sequencing, NGS remains mainly limited to research facilities. In addition, there are only a few published studies that have utilized this technology in HNSCC. This paper aims to report briefly on current commercially available NGS platforms and discuss their clinical applications, ethical considerations, and utilization in personalized patient care, particularly as this relates to head and neck cancer.

Oral mucosal lesions: findings from the Australian National Survey of Adult Oral Health.

BACKGROUND: The prevalence of oral mucosal lesions (OMLs) and factors associated with these has not previously been reported in the Australian population. This study aimed to report on the prevalence of OMLs in Australian adults and to evaluate their association with socio-demographic factors. METHODS: This study utilized data from the Australian National Survey of Adult Oral Health 2004-06, which employs a multi-stage, stratified random sample selection procedure. Information on socio-demographics, smoking and presence of OMLs were collected using telephone interview, self-reported questionnaires and comprehensive oral examination. A multivariate regression model was generated to estimate effect of factors on the prevalence of non-ulcerated OMLs. RESULTS: A total of 3551 dentate adult Australians had complete data for this analysis. Over 20% of study participants presented with an OML on the day of examination. The prevalence of suspected malignancy was less than 1% and over 17% for non-ulcerated OMLs. Prevalence of non-ulcerated OMLs was associated with age, gender, residential location, household income and smoking. CONCLUSIONS: The study reported that epidemiological survey can provide useful information on OMLs. Certain population groups had a higher risk of having the condition. Preventing smoking uptake and smoking cessation can reduce the prevalence of OMLs in the population.