The role of the dentist in the diagnosis and management of patients with oral mucosal diseases.

Based on a few case reports of oral mucosal diseases a number of questions is raised about the role of dentists-general practitioners in the diagnostic procedure and management of patients with such diseases. For instance, are dentists prepared to prescribe topical corticosteroids and should dentists be taught how and when to take a biopsy? And how about palpation of the neck? A strong recommendation is made to take clinical pictures for proper documentation and, if needed, for telediagnostic procedures. Another issue relates to the communication between dentists and dental specialists when dealing with patients with oral diseases. In case of a patient suffering from burning mouth syndrome or any other type of chronic orofacial pain, the question is raised whether dentists-general practitioners are prepared to manage such patients. Furthermore, there is a call for structuring the collaboration between dentists-general practitioners and dental specialists, including oral and maxillofacial surgeons.

Professional diagnostic delay in osteosarcomas of the jaws

A series of 20 consecutive patients with an osteosarcoma of the jaws has been evaluated with regard to possible professional diagnostic delay. When set at an arbitrarily chosen period beyond three months, professional delay occurred in 15 patients, the mean being 21 months and the median 11 months. In five of the 15 patients a wrong diagnosis has been rendered on the biopsy specimen, being fibrous dysplasia (2x), osteoma (2x) and, in case of palatomaxillary swelling, pleomorphic adenoma (1x). In the other ten patients the initial clinicoradiographic features were misleading and apparently not indicative of a malignancy, except for one patient in whom a distinct widening of the periodontal ligament, as expressed on a periapical film, has been overlooked or not properly interpreted. It has not been possible to assess the possible influence of the delayed diagnosis on the prognosis

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Professional diagnostic delay in osteosarcomas of the jaws.

A series of 20 consecutive patients with an osteosarcoma of the jaws has been evaluated with regard to possible professional diagnostic delay. When set at an arbitrarily chosen period beyond three months, professional delay occurred in 15 patients, the mean being 21 months and the median 11 months. In five of the 15 patients a wrong diagnosis has been rendered on the biopsy specimen, being fibrous dysplasia (2x), osteoma (2x) and, in case of palatomaxillary swelling, pleomorphic adenoma (1x). In the other ten patients the initial clinicoradiographic features were misleading and apparently not indicative of a malignancy, except for one patient in whom a distinct widening of the periodontal ligament, as expressed on a periapical film, has been overlooked or not properly interpreted. It has not been possible to assess the possible influence of the delayed diagnosis on the prognosis.

Oral leukoplakia; a proposal for simplification and consistency of the clinical classification and terminology.

There is a distinct lack of uniformity in the definitions and clinical terminologies related to oral leukoplakia and leukoplakialike lesions and disorders. Proposals have been put forward to subclassify leukoplakia into a homogeneous and a non-homogeneous type based on color only, being either predominantly white or mixed whiteand-red, respectively, irrespective of the texture of the lesion. In this proposal there is no need anymore to regard the poorly defined proliferative verrucous leukoplakia as a separate entity. Since keratosis is primarily a histopathological term, its clinical use is discouraged. Alternative terminology for these so-called keratotic lesions and disorders has been put forward. Finally, a suggestion has been made to rename the term hairy leukoplakia, being a well defined, not potentially malignant disorder particularly related to HIV-infection, into 'EBV-positive white lesion of the tongue (EBVposWLT).

How general dentists could manage a patient with oral lichen planus.

BACKGROUND: The literature hardly contains information on how patients suffering from oral lichen planus could be managed by dentists. MATERIAL AND METHODS: Based on the limited available literature and particularly on the long-term clinical and histopathological experience of one of the authors, suggestions on how dentists could manage patients with oral lichen planus have been put forward. RESULTS: In most cases, the dentist should be able to establish a correct diagnosis. Occasionally, the dentist may call upon a specialist, usually an oral medicine specialist or an oral and maxillofacial surgeon for confirmation of the diagnosis, possibly a biopsy procedure, and management of the patient in case of severe symptoms. Proper patient information is of utmost importance in the management. CONCLUSIONS: General dentists can be expected to manage the majority of patients with oral lichen planus. Some patients may need to be referred for diagnostic purposes to a specialist; this is also the case for the rare patient with severe symptoms, possibly requiring systemic treatment.

Knowledge about oral leukoplakia for use at different levels of expertise, including patients.

OBJECTIVE: The purpose of this contribution is to discuss how the subject of oral leukoplakia might be communicated among the various healthcare workers and also among patients. MATERIAL AND METHODS: The discussion is based on the available literature and on many decades of clinical and histopathological experience of the author. RESULTS: The literature does not contain guidelines on what level of expertise can be expected from the various dental and medical healthcare workers in the field of oral leukoplakia, nor on how to communicate this disorder with patients. Based on personal experience, a number of suggestions have been proposed to overcome this shortcoming. CONCLUSION: Knowledge about oral leukoplakia varies among the various healthcare workers, depending on their level of expertise. Communication on this subject with patients should be in easy to understand wording, avoiding professional terminology as much as possible.

A clinical diagnosis of oral leukoplakia; A guide for dentists.

BACKGROUND: In view of the many white or predominantly white lesions of the oral mucosa it is a challenge for dentists to clinically identify a leukoplakia, being a potentially (pre)malignant lesion. MATERIAL AND METHODS: Based on the available literature and experience of the authors the parameters of a clinical diagnosis of oral leukoplakia have been studied. RESULTS: A guide has been presented that should help dentists to establish a clinical diagnosis of leukoplakia as accurate as possible. CONCLUSIONS: Probably in most parts of the world dentists will need the help of a specialist for confirmation or exclusion of the clinical diagnosis of oral leukoplakia and for further management of the patient, including patient information.

Malignant transformation of oral leukoplakia in a well-defined cohort of 144 patients.

OBJECTIVES: Oral leukoplakia is a potentially malignant disorder of the oral mucosa. The aim of this retrospective study was to identify the factors that possibly predict malignant transformation in a well-defined cohort of patients with a long-term follow-up. All leukoplakias were staged according to a clinicopathological classification and staging system. Furthermore, a certainty factor has been used with which the diagnosis has been established. MATERIAL AND METHODS: The group consisted of 144 patients. The size, presence and degree of epithelial dysplasia were incorporated into a clinicopathological classification and staging system. Initial management consisted of surgical excision, CO2 laser vaporisation or observation only. The mean follow-up period was 51.2 months (s.d. = 39.33, range 12-179 months). RESULTS: In 16 of 144 patients (11%), malignant transformation occurred between 20 and 94 months (mean 57.0 months) after the first visit, the annual malignant transformation rate being approximately 2.6%. A large size of the lesion (≥ 4 cm) showed to be the only statistically significant predictor of malignant transformation (P = 0.034). CONCLUSION: A size of ≥ 4 cm showed to be the only significant predicting factor of malignant transformation in oral leukoplakia. No other epidemiological, aetiological, clinical or histopathological parameters were of statistical significance.

[Dental focus examination: a proposal for a more nuanced approach]. / Odontogeen focusonderzoek: een voorstel voor een meer genuanceerde benadering.

Oral and maxillofacial surgeons and hospital dentists are often requested to perform a dental focus examination in patients (to be) admitted in a hospital and for whom the state of their teeth is of importance for a medical treatment or situation. The main reasons for a dental focus examination include unexplained fever, heart surgery, chemotherapy, organ or artificial joint transplants, use of oral or intravenous bisphosphonates and radiotherapy of the head and neck. In daily practice, there is a need for a clear algorithm which is easy to apply for the diagnosis and treatment of dentalfoci for the various medical indications. The medical conditions described above have in common that subclinical infections can lead to complications under exceptional conditions. The influence and the nature of the development ofa dental infection varies in each of the situations mentioned. This has consequences for the need to eliminate dentalfoci. The diagnosis and treatment of dental foci in relation to various medical situations therefore requires a nuanced approach.

[Oral medicine 6. Ulcerations of the oral mucosa]. / Oral medicine 6. Ulceraties van de oral mucosa.

An ulcer can be defined as a superficial defect of the skin or the mucosa, caused by tissue degeneration, and having little tendency to heal. With a careful review of the medical history and the findings of inspection of the oral cavity, including palpation of the ulcer, the dentist will in many cases be able to determine the diagnosis and also the treatment. There are, however, also ulcerations which require referral to a specialist, most often the oral and maxillofacial surgeon.

Treatment results of CO2 laser vaporisation in a cohort of 35 patients with oral leukoplakia.

OBJECTIVES: The aim of the present study was to evaluate the treatment results of CO2 laser vaporisation in a well-defined cohort of patients with oral leukoplakia (OL). MATERIAL AND METHODS: The group consisted of 35 patients. Before treatment, a clinical photograph and an incisional biopsy were performed in all cases. Also posttreatment results were documented with clinical photographs. The assessment of the treatment results was performed by an independent clinician who had not performed the treatment. The mean follow-up period was 61.9 months (range 12-179 months). RESULTS: In 14/35 patients, there was a recurrence between 1 and 43 months (mean 18.7 months), the annual recurrence rate being approximately 8%. In three of these patients, malignant transformation occurred at a later stage. In two other patients, a malignancy occurred without a prior recurrence. In altogether 5 of 35 patients, malignant transformation occurred in a mean period of 54 months, the annual malignant transformation rate being approximately 3%. CONCLUSIONS: The results in the present study are worse than those reported in the literature, perhaps owing to the use of different diagnostic criteria for OL, differences in the employed laser technique and assessment of possible recurrences by an independent clinician.

Survey response of oral and maxillofacial surgeons on invasive procedures in patients using antithrombotic medication.

The aim was to evaluate the management strategies of Dutch oral and maxillofacial surgeons when performing invasive dental or oral surgery in patients using oral antithrombotic medication (OAM). In November 2009 a survey was mailed to all 213 members of the Dutch Society for Oral and Maxillofacial Surgery. A response rate of 57% was achieved with 79 surveys returned through mail and 38 surveys answered through the Internet. The results show that many different treatment strategies are advocated by Dutch oral and maxillofacial surgeons, regarding preferred international normalised ratio (INR) value and continuation or discontinuation of OAM prior to invasive dental or oral surgery. The risk of bleeding during or after an invasive dental procedure was overestimated. A need for a practice guideline on this topic was expressed by 73% of respondents.

[An adolescent boy with fibrous dysplasia of the maxillary bone]. / Een adolescente jongen met fibreuze dysplasie van het kaakbot.

After a diagnostic study involving computer tomography and bone scintigraphy, a 16-year-old boy appeared to be suffering from the monostotic type of fibrous dysplasia of the maxilla. The diagnosis was confirmed by histopathological examination ofa biopsy. During a follow-up period of 8 years, no signs of progression were evident. Fibrous dysplasia is a rather poorly understood benign bone disease which may occur anywhere in the skeleton. In general, histopathological confirmation using a bone biopsy is recommended. Fibrous dysplasia can be divided into 3 types: 1. monostotic, 2. polyostotic, and 3. polyostotic with endocrine problems. In the majority of cases, a wait-and-watch strategy is sufficient. Malignant transformation is extremely rare and appears almost exclusively in polyostotic cases.

[Osteoradionecrosis of the jaw, presumably caused by a removable partial denture]. / Osteoradionecrose van de mandibula, vermoedelijk veroorzaakt door een frameprothese.

An 81-years-old man developed a severe osteoradionecrosis of the mandible following surgery and radiotherapy in the head and neck area as a result of a carcinoma at the front ofthe floor of the mouth. Presumably, the osteoradionecrosis had been developed by an injury of the oral mucosa due to a removable partial denture. There are no uniform guidelines for the treatment of osteoradionecrosis of the jaw bones. Treatment modalities vary from removal of sequesters, sometimes long-term use of antibiotics, treatment with hyperbaric oxygen and wide surgical resection with or without reconstruction of the jaw.

Scandinavian Fellowship for Oral Pathology and Oral Medicine: guidelines for oral pathology and oral medicine in the dental curriculum.

In Scandinavia, as in many European countries, most patients consult their general dentist once a year or more. This gives the dentist a unique opportunity and an obligation to make an early diagnosis of oral diseases, which is beneficial for both the patient and the society. Thus, the dentist must have knowledge of clinical symptoms, local and systemic signs and clinical differential diagnoses to make an accurate diagnosis. The dentist must be competent in selecting appropriate diagnostic tests, for example, tissue biopsy and microbiological samples, and conducting them correctly, as well as in interpreting test results and taking appropriate action accordingly. Furthermore, the dentist must be aware of diseases demanding multidisciplinary cooperation and be able to recognise his/her professional limitation, and to refer to other specialists when required. The dental curriculum changes over time as new approaches, treatments and diagnostic possibilities develop. Likewise, the role of the dentist in the community changes and may vary in different countries. As members of the Scandinavian Fellowship for Oral Pathology and Oral Medicine and subject representatives of oral pathology and oral medicine, we feel obliged to contribute to the discussion of how the guidelines of the dental curriculum support the highest possible standards of dental education. This article is meant to delineate a reasonable standard of oral pathology and oral medicine in the European dental curriculum and to guide subject representatives in curriculum development and planning. We have created an advisory topic list in oral pathology and oral medicine.

[A non-pigmented naevus as an uncommon gingival swelling]. / Een niet-gepigmenteerde naevus als ongewone gingivazwelling.

A 67-year-old woman had an epulis-like swelling of the gingiva in the region of teeth 32 and 33. On histopathologic examination, it became clear that it was a non-pigmented intramucosal naevus which rarely occurs in the oral cavity.

[A gingival hyperplasia in a patient suffering from neurofibromatosis]. / Een gingivahyperplasie op basis van neurofibromatose.

A 30-year-old woman suffering from neurofibromatosis type 1 was referred by her dentist to the department of oral and maxillofacial surgery of a university medical centre for excision of a gingival hyperplasia in the mandibular frontal region. The hyperplasia was a neurofibroma, which was surgically removed, as were 2 neurofibromas of the tongue, a postauricular neurofibroma and 2 neurofibromas of the feet.

[Diseases of the maxillary sinus: an overview]. / Afwijkingen van de sinus maxillaris: een overzicht.

Because of the intimate relationship between the maxillary teeth and the maxillary sinus, it is no surprise that odontogenic infections, odontogenic cysts and tumours which have their origin in the mucosa and the bone of the maxilla may extend into the maxillary sinus and, occasionally, into the nasal cavity. Diseases of the maxillary sinus can also extend into the oral cavity and can cause symptoms that mimic those of odontogenic diseases. Important diseases of the maxillary sinus are maxillary sinusitis, oroantral communications, antroliths, cysts and neoplasms.

[Bisphosphonate-related osteonecrosis of the jaws]. / Bisfosfonaatgerelateerde osteonecrose van de kaak.

Bisphosphonate-related osteonecrosis of the jaws is a complication which can occur in patients treated with bisphosphonates. The pathogenesis is still poorly understood. Risk factors are invasive oral treatments with tooth extraction as a leading cause. Because of the complexity of the treatment of osteonecrosis of the jaws, prevention is of the utmost importance. Invasive oral treatments needed, should be performed before starting the treatment with bisphosphonates. Since osteonecrosis of the jaws is presenting relatively rare, it is understandable that guidelines with respect to prevention and treatment are not evidence-based.