Could Teledentistry Be a Solution in the Diagnosis of Oral Lesions?

In recent years, teledentistry has gained visibility, especially because of the COVID-19 pandemic. Concerning oral medicine, there is great expectation, particularly about its potential to promote early diagnosis of oral lesions. In southern Brazil, two initiatives have shown a positive influence on each other and have led to greater awareness of oral cancer and more access to qualified advice on diagnosing and managing oral lesions. Although the contributions of this approach are promising, there are barriers to be overcome.

Amitriptyline effectiveness in burning mouth syndrome: An in-depth case series analysis.

OBJECTIVES: To assess the effectiveness of amitriptyline (AMT), and to identify the determinants of the treatment's effectiveness in patients diagnosed with burning mouth syndrome (BMS). BACKGROUND: Treatment of BMS is challenging and no established treatment protocol is available. AMT may be an important treatment option, cout not all patients benefit from this drug. Studies assessing factors related to treatment response are valuable in improving decision-making. MATERIALS AND METHODS: This case series study examined the medical records of all patients diagnosed with BMS at an oral medicine unit in a university hospital from 2008 to 2022. The patients were divided into responders to AMT and non-responders to AMT. Data on demographic information, comorbidities, medications, types of symptoms and oral subsites affected were collected. Descriptive and bivariate analyses were conducted to assess the association between the independent variables and the outcome, using the Chi-squared test (P < .05). RESULTS: Three hundred and fourty-nine patients reported a burning mouth sensation, 50 of them (14.3%) being diagnosed with primary BMS. Of these, 35 were treated with AMT, and 26 (74.2%) responded significantly to AMT. All males responded to AMT, whereas only 67.9% of females responded. The mean dose of AMT among responders was 29.8 ± 12.3 mg, with most patients achieving a response with 25 mg (61.5% of patients), followed by 50 mg (23%). The concomitant use of an anticonvulsant resulted in non-response. CONCLUSIONS: AMT may be effective in BMS management for most patients.

Convolutional neural network misclassification analysis in oral lesions: an error evaluation criterion by image characteristics.

OBJECTIVE: This retrospective study analyzed the errors generated by a convolutional neural network (CNN) when performing automated classification of oral lesions according to their clinical characteristics, seeking to identify patterns in systemic errors in the intermediate layers of the CNN. STUDY DESIGN: A cross-sectional analysis nested in a previous trial in which automated classification by a CNN model of elementary lesions from clinical images of oral lesions was performed. The resulting CNN classification errors formed the dataset for this study. A total of 116 real outputs were identified that diverged from the estimated outputs, representing 7.6% of the total images analyzed by the CNN. RESULTS: The discrepancies between the real and estimated outputs were associated with problems relating to image sharpness, resolution, and focus; human errors; and the impact of data augmentation. CONCLUSIONS: From qualitative analysis of errors in the process of automated classification of clinical images, it was possible to confirm the impact of image quality, as well as identify the strong impact of the data augmentation process. Knowledge of the factors that models evaluate to make decisions can increase confidence in the high classification potential of CNNs.

Experiences, perceptions, and decision-making capacity towards oral biopsy among dental students and dentists.

The dentist plays a crucial role in identifying oral lesions as it is their responsibility to conduct the clinical examination for diagnosing diseases in this anatomical region. Dentists should be able to perform simple oral biopsies when this procedure is necessary. However, several studies point out that dentists lack experience and perceive themselves incapable of performing biopsies. This analytical cross-sectional study aimed to assess participants' experiences and perceptions regarding a continuing education activity focused on the biopsy procedure. The secondary aim was to evaluate their ability to determine when a biopsy is indicated. The sample consisted of 228 individuals: 143 dentists and 85 undergraduate dental students who completed questionnaires related to a lecture held in May/2021, as part of the continuing educational activities of the "Red May" Project. Participants completed two questionnaires: the first assessed their experience and self-confidence in performing oral biopsies, whereas the second evaluated their capacity to define when the biopsy is indicated by means the evaluation of 10 clinical cases. The results reveal no significant difference in the percentage of correct answers between dental students and dentists. Regarding the frequency of performing the biopsy procedure, most respondents (69.7%) reported doing so rarely or never. Furthermore, while 31.6% of the participants stated that they perform biopsies depending on the case, 68.4% prefer to refer patients to specialists, such as professionals in Stomatology/Oral Medicine. These findings highlight limitations in the educational preparation of the study population concerning biopsy procedures, oral lesions, and their management. They also indicate a concerning tendency to overestimate knowledge in this area. Thus, this study emphasizes the importance of continuing education and underscores the need to revise academic curricula and provide complementary education for all dental professionals.

Contribution of public oral pathology services to the diagnosis of oral and oropharyngeal cancer in Brazil.

This study aimed to evaluate the contribution of oral and maxillofacial pathology laboratories (OMPLs) in Brazilian public universities to the diagnosis of lip, oral cavity, and oropharyngeal squamous cell carcinoma (SCC). A cross-sectional study was performed using biopsy records from a consortium of sixteen public OMPLs from all regions of Brazil (North, Northeast, Central-West, Southeast, and South). Clinical and demographic data of patients diagnosed with lip, oral cavity, and oropharyngeal SCC between 2010 and 2019 were collected from the patients' histopathological records. Of the 120,010 oral and maxillofacial biopsies (2010-2019), 6.9% (8,321 cases) were diagnosed as lip (0.8%, 951 cases), oral cavity (4.9%, 5,971 cases), and oropharyngeal (1.2%, 1,399 cases) SCCs. Most cases were from Brazil's Southeast (64.5%), where six of the OMPLs analyzed are located. The predominant profile of patients with lip and oral cavity SCC was Caucasian men, with a mean age over 60 years, low schooling level, and a previous history of heavy tobacco consumption. In the oropharyngeal group, the majority were non-Caucasian men, with a mean age under 60 years, had a low education level, and were former/current tobacco and alcohol users. According to data from the Brazilian National Cancer Institute, approximately 9.9% of the total lip, oral cavity, and oropharyngeal SCCs reported over the last decade in Brazil may have been diagnosed at the OMPLs included in the current study. Therefore, this data confirms the contribution of public OMPLs with respect to the important diagnostic support they provide to the oral healthcare services extended by the Brazilian Public Health System.

Virtual learning object about oral ulcerative lesions: controlled educational intervention study.

The aim of this study was to develop a virtual learning object (VLO) to teach undergraduate dental students about the diagnostic and therapeutic approaches to oral ulcerative lesions. The VLO was developed with information on the diagnostic process, lesion classification, and clinical-surgical management of oral ulcerative lesions. The VLO content was initially validated by a group of specialists. Learning was evaluated in a sample of 58 undergraduate dental students, divided into control group (conventional theoretical class, n = 29) and intervention group (interaction with VLO, n = 29). All students answered a pre-test and post-test questionnaire. The VLO group also answered a specific questionnaire on the evaluation of the VLO. Both quantitative and qualitative descriptive analyses were performed. The validation showed that professors and students considered the VLO adequate. The use of the VLO was recommended by 100% of professors and 86.6% of students. In the intervention group, the results showed a significantly higher number of correct answers in the post-test (p < 0.01). In conclusion, the VLO proved to be a useful tool for teaching oral medicine, contributing significantly to the knowledge of ulcerated lesions in the mouth.

Use of Artificial Intelligence in the Classification of Elementary Oral Lesions from Clinical Images.

OBJECTIVES: Artificial intelligence has generated a significant impact in the health field. The aim of this study was to perform the training and validation of a convolutional neural network (CNN)-based model to automatically classify six clinical representation categories of oral lesion images. METHOD: The CNN model was developed with the objective of automatically classifying the images into six categories of elementary lesions: (1) papule/nodule; (2) macule/spot; (3) vesicle/bullous; (4) erosion; (5) ulcer and (6) plaque. We selected four architectures and using our dataset we decided to test the following architectures: ResNet-50, VGG16, InceptionV3 and Xception. We used the confusion matrix as the main metric for the CNN evaluation and discussion. RESULTS: A total of 5069 images of oral mucosa lesions were used. The oral elementary lesions classification reached the best result using an architecture based on InceptionV3. After hyperparameter optimization, we reached more than 71% correct predictions in all six lesion classes. The classification achieved an average accuracy of 95.09% in our dataset. CONCLUSIONS: We reported the development of an artificial intelligence model for the automated classification of elementary lesions from oral clinical images, achieving satisfactory performance. Future directions include the study of including trained layers to establish patterns of characteristics that determine benign, potentially malignant and malignant lesions.

Use of Deep Neural Networks in the Detection and Automated Classification of Lesions Using Clinical Images in Ophthalmology, Dermatology, and Oral Medicine-A Systematic Review.

Artificial neural networks (ANN) are artificial intelligence (AI) techniques used in the automated recognition and classification of pathological changes from clinical images in areas such as ophthalmology, dermatology, and oral medicine. The combination of enterprise imaging and AI is gaining notoriety for its potential benefits in healthcare areas such as cardiology, dermatology, ophthalmology, pathology, physiatry, radiation oncology, radiology, and endoscopic. The present study aimed to analyze, through a systematic literature review, the application of performance of ANN and deep learning in the recognition and automated classification of lesions from clinical images, when comparing to the human performance. The PRISMA 2020 approach (Preferred Reporting Items for Systematic Reviews and Meta-analyses) was used by searching four databases of studies that reference the use of IA to define the diagnosis of lesions in ophthalmology, dermatology, and oral medicine areas. A quantitative and qualitative analyses of the articles that met the inclusion criteria were performed. The search yielded the inclusion of 60 studies. It was found that the interest in the topic has increased, especially in the last 3 years. We observed that the performance of IA models is promising, with high accuracy, sensitivity, and specificity, most of them had outcomes equivalent to human comparators. The reproducibility of the performance of models in real-life practice has been reported as a critical point. Study designs and results have been progressively improved. IA resources have the potential to contribute to several areas of health. In the coming years, it is likely to be incorporated into everyday life, contributing to the precision and reducing the time required by the diagnostic process.

Diagnosis, Treatment, and Total Rehabilitation of a Secondary Type Ameloblastic Carcinoma.

Ameloblastic carcinoma (AC) is an uncommon malignant odontogenic tumor, with about 200 cases published in the literature. Here, we report a case of AC occurring in the maxilla - at the same anatomical location of an ameloblastoma 8 years earlier. A 23-year-old woman with maxillary swelling of 6-month duration was referred to our service. Extraoral examination revealed a swelling over the right side of the face, lifting her lip and nose. Intraorally, a firm, reddish, nodular swelling involving the right maxilla was observed. Computed tomography showed a hypodense image invading the right maxilla, maxillary sinus, and nasal fossa. An incisional biopsy was performed, followed by histopathologic examination and an immunohistochemical panel, which led to the diagnosis of AC. The lesion was treated with partial maxillectomy followed by immediate rehabilitation. Neither local recurrence of the tumor nor distant metastasis was observed during a 4-year follow-up. AC is a highly malignant lesion which requires aggressive therapy. Its diagnosis should be based on combined clinical, imaging, and pathological manifestations in order to improve diagnostic accuracy.

Association between perceived self-confidence and abilities to distinguish oral mucosal lesions amongst dental students.

INTRODUCTION: Dentists usually refer to difficulties in performing the diagnosis of oral mucosal lesions. This may be attributed to limited access to theoretical lectures and practical training on this subject along the graduation course. The primary aim of this cross-sectional study was to verify if there is an association between the perception of time dedicated to lectures/training and oral diagnosis abilities in oral medicine. The secondary aim was to evaluate the association between self--confidence to perform oral mucosal lesions diagnosis and performance in a diagnostic abilities test. MATERIALS AND METHODS: The sample comprised 36 final-year dental students of a South-Brazilian dental school. The participants answered a questionnaire on their perception of time dedicated to lectures on oral medicine along the course (sufficient or insufficient) and their self-confidence to diagnose oral mucosal lesions or oral cancer (yes or not). The students were also submitted to a diagnostic abilities test based on 30 clinical photos of oral lesions, which should be classified as benign, potentially malignant or malignant. Moreover, the participants had to inform their clinical impression for each case. Finally, the participants informed their decision making for the case (refer the patient to a specialist or not). RESULTS: Students with higher self-confidence showed a higher percentage of correct answers on classification of the nature of lesions (81.1% vs. 68.5%, p = .03, teste t de Student) and on their clinical impression (66.3% vs. 41.7%, p < .01, Student's t-test). The perception of time dedicated to theoretical lectures on oral medicine as sufficient did not influence the students' diagnostic abilities (p > .05, Student's t-test) CONCLUSION: It may be concluded that self-confidence to diagnose oral lesions is associated with dental students' diagnostic abilities.

Generalized gingival necrosis in a patient under methimazole use.

Hyperthyroidism is a common disease, with a prevalence between 0.2% and 0.5%, characterized by an increase in the synthesis and release of thyroid hormones. Management of this condition requires medical intervention to correct the hormonal imbalance and control its clinical manifestations. Methimazole is a thionamide derivative considered among the first-choice treatment options for hyperthyroidism. However, it may cause serious side effects such as neutropenia or agranulocytosis, which, although rare, can lead to death. The clinical manifestations of this complication range from fever, ulcerations in the oral and pharyngeal mucosa, tonsillitis, and lymphadenopathy to hemorrhagic necrosis and septicemia. This report describes the case of a patient with generalized gingival necrosis that was related to the use of methimazole for the treatment of hyperthyroidism.

Virtual learning object about oral ulcerative lesions: controlled educational intervention study

Abstract The aim of this study was to develop a virtual learning object (VLO) to teach undergraduate dental students about the diagnostic and therapeutic approaches to oral ulcerative lesions. The VLO was developed with information on the diagnostic process, lesion classification, and clinical-surgical management of oral ulcerative lesions. The VLO content was initially validated by a group of specialists. Learning was evaluated in a sample of 58 undergraduate dental students, divided into control group (conventional theoretical class, n = 29) and intervention group (interaction with VLO, n = 29). All students answered a pre-test and post-test questionnaire. The VLO group also answered a specific questionnaire on the evaluation of the VLO. Both quantitative and qualitative descriptive analyses were performed. The validation showed that professors and students considered the VLO adequate. The use of the VLO was recommended by 100% of professors and 86.6% of students. In the intervention group, the results showed a significantly higher number of correct answers in the post-test (p < 0.01). In conclusion, the VLO proved to be a useful tool for teaching oral medicine, contributing significantly to the knowledge of ulcerated lesions in the mouth.

Contribution of public oral pathology services to the diagnosis of oral and oropharyngeal cancer in Brazil

Abstract This study aimed to evaluate the contribution of oral and maxillofacial pathology laboratories (OMPLs) in Brazilian public universities to the diagnosis of lip, oral cavity, and oropharyngeal squamous cell carcinoma (SCC). A cross-sectional study was performed using biopsy records from a consortium of sixteen public OMPLs from all regions of Brazil (North, Northeast, Central-West, Southeast, and South). Clinical and demographic data of patients diagnosed with lip, oral cavity, and oropharyngeal SCC between 2010 and 2019 were collected from the patients' histopathological records. Of the 120,010 oral and maxillofacial biopsies (2010-2019), 6.9% (8,321 cases) were diagnosed as lip (0.8%, 951 cases), oral cavity (4.9%, 5,971 cases), and oropharyngeal (1.2%, 1,399 cases) SCCs. Most cases were from Brazil's Southeast (64.5%), where six of the OMPLs analyzed are located. The predominant profile of patients with lip and oral cavity SCC was Caucasian men, with a mean age over 60 years, low schooling level, and a previous history of heavy tobacco consumption. In the oropharyngeal group, the majority were non-Caucasian men, with a mean age under 60 years, had a low education level, and were former/current tobacco and alcohol users. According to data from the Brazilian National Cancer Institute, approximately 9.9% of the total lip, oral cavity, and oropharyngeal SCCs reported over the last decade in Brazil may have been diagnosed at the OMPLs included in the current study. Therefore, this data confirms the contribution of public OMPLs with respect to the important diagnostic support they provide to the oral healthcare services extended by the Brazilian Public Health System.

Prognostic factors from squamous cell carcinoma of the hard palate, gingiva and upper alveolar ridge.

The purpose of this study was to evaluate the clinicodemographic characteristics and treatment protocol as prognostic factors in patients with oral squamous cell carcinoma (OSCC) of the hard palate, upper gingiva, and alveolar ridge (HPUGAR). This retrospective cohort study collected data of patients treated in two head and neck surgery departments in southern Brazil between 1999 and 2021. Information on clinicodemographic data, habits, site, size, clinical aspect, clinical staging, cervical metastasis, treatment, and survival was collected. Associations between independent variables and outcomes were assessed using Pearson's chi-square test and binary regression. Kaplan-Meier test was employed to compare the survival between the neck approaches. Forty-one patients were included; most were male (61%), with a mean age of 68.8 (± 13.9) years. The consumption of tobacco (p = 0.003) and alcohol (p = 0.02) was significantly higher in male than in female patients. The main clinical features observed in the study sample were lesions larger than 2 cm (48.7%), no cervical (90.2%), or distant metastasis (90.2%). Surgery alone was the main treatment approach (48.8%). The watch-and-wait strategy was adopted in 34 cases (83.0%), while elective neck dissection was applied in five (12.2%). Only two patients with cN0 disease (4.9%) presented with cervical metastasis at follow-up. Eight patients (12.2%) died of the disease. Clinicodemographic variables, habits, surgical margins, and histological subtype were not significantly associated with cervical metastasis or survival. Cervical metastasis (p = 0.004) was associated with poor survival. No difference was detected in survival between different neck approaches (p = 0.28). Cervical metastasis and local recurrence are negative prognostic factors for HPUGAR OSCC.

Use of an audience response system during a continuing education action about oral lesion diagnosis.

OBJECTIVES: The present cross-sectional study aimed to evaluate the perceptions of continuing education action (CEA) participants on the use of an audience response system (ARS). Secondarily, the study assessed the association between the diagnostic abilities of participants and their self-confidence in managing oral lesions METHODS: Oral medicine specialists, dentists, hygienists, and students (n = 193) who attended the 'Maio Vermelho Project', a CEA held in a Southern Brazilian State, answered a diagnostic ability test using the ARS Socrative software during a case discussion section. The test comprised 16 simulated clinical cases based on photos of oral lesions. The questions required classification of the lesion's nature, diagnostic hypothesis, and decision making (manage the case or refer it to a specialist) for each case. A second questionnaire composed of 12 questions was also applied to evaluate satisfaction and perception of the use of ARS Socrative RESULTS: Hygienists displayed lower scores in the diagnostic abilities test, whereas the other groups' performances were quite similar. Dentists and dental students who scored higher on the diagnostic abilities test showed higher self-confidence in the management of benign lesions. All participants stated that the use of technology can improve their learning experience and should be incorporated into the classroom. Moreover, the participants' perception was highly favorable to the use of Socrative in educational activities CONCLUSION: Our findings showed good acceptance of the ARS tool in a CEA environment and suggest an association between performance on the questionnaire and self-confidence in oral lesion management.

Distance learning course improves primary care dentists' diagnosis and self-efficacy in the management of oral lesions.

Oral cancer represents a public health issue because of its high mortality rate, resulting mainly from diagnostic delays. Insufficient training in oral diagnosis is usually perceived by dentists. Distance learning could be used as an auxiliary tool to bridge that gap. This study evaluated the impact of a distance learning course on oral mucosal lesion diagnosis offered to public healthcare dentists. Participants of an online course answered a pretest/posttest comprising clinical images of 30 clinical cases. Participants were questioned about the diagnosis and informed their decision on the cases (referring the cases to a specialist or managing them themselves), as a parameter of perceived self-efficacy. A total of 442 dentists enrolled in the course. Their pass rate was 97%. Classification of the nature of the lesions, diagnostic hypotheses, sensitivity, and specificity improved by 13.4%, 10.0%, 13.4%, and 6.6%, respectively (p<0.01, Wilcoxon test). Regarding management, there was a 16.6% reduction in the intention to refer cases, while confidence in the diagnosis of benign lesions increased by 40%. A distance learning course may be useful in continuing education actions for primary care dentists, improving their diagnostic abilities and encouraging them in the management of oral lesions. Moreover, this strategy could contribute to disseminating knowledge to remote regions, particularly among primary health care professionals.

4-nitroquinoline-1-oxide (4NQO) induced oral carcinogenesis: A systematic literature review.

OBJECTIVE: Based on a critical review of published studies, we aimed to develop a good practice guide for using 4-nitroquinoline-1-oxide (4NQO) as an inducer of oral carcinogenesis in Wistar rats. DESIGN: A systematic search was performed on Medline Ovid, PubMed, Embase, Web of Science, and Scopus databases. The SYRCLE's risk of bias tool was used to assess the quality of the studies. RESULTS: Thirty-five articles met the selection criteria; 22 (62.9%) of them administered 4NQO systemically in drinking water, with a mean concentration of 30.2 ppm (SD±15.9) and during a mean period of 20.8 (SD±7.8) weeks. The other 13 (37.1%) studies performed topical applications of 4NQO painting the oral mucosa of the animals three times a week (100%) with a mean period of administration of 16.8 (SD±7.0) weeks. Different 4NQO concentrations used for other periods achieved significant tumor development. Most studies didn't perform quantitative clinical analysis, and the histopathological diagnosis/grading criteria varied considerably. CONCLUSIONS: A poor description of solution care, adverse effects, and the number of losses were observed, and the reporting of these features needs to be improved. Suggestions to guide the development of future research are provided.

Diagnostic accuracy of a telediagnosis service of oral mucosal diseases: A multicentric survey.

OBJECTIVE: The aim of this multicentric study was to assess the diagnostic accuracy of a telediagnosis service for oral mucosal disorders. STUDY DESIGN: This study included 100 patients seen at the oral medicine outpatient clinic of 3 Brazilian Dental Schools (University of Campinas, Federal University of Pernambuco, and Federal University of Santa Catrina) from March 2019 to October 2019. In addition to the face-to-face assistance provided by graduate students and the final diagnosis validated by the professors of these institutions, a remote evaluation was requested for these patients through the EstomatoNet/TelessaúdeRS platform. RESULTS: The sensitivity and specificity of telediagnosis were compared with those of the face-to-face approach and found to be 100% and 97.4%, respectively. The concordance between the examiners was 95%, and case management was relatively simple in approximately 60% of cases. CONCLUSIONS: Based on the results, telediagnosis for oral diseases can be considered a reliable method, representing a promising alternative for the clinical support of health professionals, particularly in remote locations.

Oral medicine (stomatology) in Brazil: the first 50 years and counting.

This review outlines the historical perspective, status, and future challenges of oral medicine (stomatology) in Brazil based on the records of the Brazilian Society of Stomatology and Oral Pathology (SOBEP) and the Brazilian Federal Dental Council as well as expert evidence input from academic leaders from 3 different generations of Brazilian oral medicine specialists. The beginning of oral medicine in Brazil dates to 1969, followed by the organization of SOBEP in 1974; however, official recognition as an independent specialty was achieved more recently within the Brazilian Federal Dental Council in 1992. After a 50-year maturation period of oral medicine in Brazil in terms of specialty crystallization across dentistry, medicine, and research, it is now time to follow the historical trends of the specialty internationally and establish a standard curriculum at a post-graduate level that will lead to uniformity of training for oral medicine in Brazil.