Salivary gland and associated complications in head and neck cancer therapy.

Xerostomia and salivary gland hypofunction are two of the most common and significant complications of head and neck cancer therapy in the head and neck region. This article will provide a brief overview of salivary gland hypofunction and associated complications in head and neck cancer therapy, mainly in radiation therapy. The discussion will include quality of life issues as well as current advances in cancer therapy to reduce xerostomia and salivary gland hypofunction.

Management of xerostomia and salivary gland hypofunction.

Xerostomia and salivary gland hypofunction are conditions that have been associated with increased prevalence of caries, periodontitis, and candidiasis. Oral health care providers must be aware of the etiologies and clinical manifestations of salivary gland hypofunction in order to identify patients with this condition and to prevent its potential complications. The various modalities available to manage this condition range from frequent sips of water to the intake of systemic medications like pilocarpine or cevimeline.

Prevalence and impact of sleep disorders and sleep habits in the United States.

PURPOSE: Epidemiologic studies on sleep disorders in the USA have mostly focused on specific disorders in specific groups of individuals. Most studies on sleep habits and sleep-related difficulties have focused on children and adolescents. The authors describe the prevalence of the three common physician-diagnosed sleep disorders (insomnia, sleep apnea, and restless legs syndrome (RLS)) by age, gender, and race in the US population. In addition, the authors describe the sleep habits and sleep-related difficulties in carrying routine daily activities. The authors also investigate the impact of the sleep disorders on performing routine daily activities. METHODS: Data from the 2005-2006 National Health and Nutrition Examination Survey for 6,139 individuals over the age of 16 was analyzed for sleep-related parameters. RESULTS: The prevalence was highest for sleep apnea (4.2%), followed by insomnia (1.2%) and RLS (0.4%). Hispanics and Whites reported longer sleep duration than Blacks by 24 to 30 min. The predominant sleep habits were snoring while sleeping (48%), feeling unrested during the day (26.5%), and not getting enough sleep (26%). Difficulty concentrating (25%) or remembering (18%) were the main sleep-related difficulties in our sample. Insomnia, sleep apnea, and RLS had the highest impact on concentration and memory. CONCLUSIONS: Our findings suggest that the prevalence of sleep disorders in the USA is much lower than previously reported in the literature suggesting under diagnosis of sleep disorders by primary care physicians.

Clinical characteristics and diagnosis of atypical odontalgia: implications for dentists.

BACKGROUND: Atypical odontalgia (AO) is a poorly understood and commonly misdiagnosed condition for which patients often undergo multiple unsuccessful dental or surgical procedures. The authors conducted a study to determine the prevalence and describe the characteristics of patients with AO seen at the University of Southern California Orofacial Pain and Oral Medicine Center (USC OFP-OM Center), Los Angeles. METHODS: The authors conducted a retrospective record review from a database of more than 3,000 patient records from June 2003 to August 2007 to identify patients diagnosed with AO. RESULTS: The authors identified 64 patients (44 women and 20 men) between the ages of 26 and 93 years as having a diagnosis of AO. Of those 64 patients, 71 percent initially consulted a dentist regarding their pain, and 79 percent had undergone dental treatment that failed to resolve the pain. The pain of 64 percent of the patients had no known cause. CONCLUSIONS: Dentists, who often are the first health care providers to see patients with AO, must be aware of this condition and must follow the appropriate steps to determine its diagnosis. CLINICAL IMPLICATIONS: Dentists and physicians should understand the implications and importance of early diagnosis of patients with AO and of referral to pain specialists for treatment.

Prevalence of hypertension in patients with trigeminal neuralgia.

It is unclear whether hypertension (HTN) is a predisposing factor for the development of trigeminal neuralgia (TN). The purpose of this study was to determine the prevalence of HTN in TN patients and controls at the USC Orofacial Pain and Oral Medicine Center. A retrospective chart review was conducted from a database of over 3,000 patient records from 2003 to 2007. We identified patients diagnosed with TN with or without HTN. A total of 84 patients (54 females; 30 males) between the ages of 33 and 93 years were diagnosed with TN; 37% had TN with HTN and 32% of controls had HTN. The increased prevalence of HTN in the TN patients was not statistically significant (P = 0.50). Since, both TN and HTN are seen in the elderly, it is likely that HTN is simply a co-existing condition in patients with TN and not a risk factor for its development.

Orofacial pain and neurosensory disorders and dysfunction in cancer patients.

Orofacial pain and altered nerve sensation may be the initial sign of oropharyngeal or nasopharyngeal cancer. This article focuses on the most common orofacial pain conditions and neurosensory alterations that affect cancer patients, such as neuropathic pain, muscle spasm or contractures, mucositis, and increased or decreased sensory discrimination in the affected area. The various pharmacotherapeutic modalities for cancer pain management ranging from non steroidal anti-inflammatory drugs (NSAIDs) for mild pain to opioids for severe pain are discussed in detail.

Orofacial movement disorders.

This article reviews three poorly recognized yet relatively common presentations of hyperactive orofacial movement disorders: oromandibular dystonia, orofacial dyskinesia, and drug-induced extrapyramidal syndrome reactions. Orofacial movement disorders are often misdiagnosed as temporomandibular disorders, hence understanding these conditions is pertinent for the practitioner treating orofacial pain. Aspects of epidemiology, etiology, pathophysiology, clinical presentation, and diagnosis are discussed along with treatment considerations for these orofacial movement disorders.

Efficacy of Electrical Stimulation of the Occipital Nerve in Intractable Primary Headache Disorders: A Systematic Review with Meta-Analyses.

AIMS: To determine the efficacy of occipital nerve stimulation (ONS) in reducing the intensity, duration, and frequency of medically intractable primary headaches. METHODS: A systematic review was carried out by searching three electronic databases: the Cochrane Library, MEDLINE via PubMed, and Web of Science. Randomized controlled trials (RCTs) and case series were eligible for inclusion. RCTs were assessed for quality of evidence by using the Cochrane Risk of Bias and the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) tools. Descriptive statistics of reported outcomes in eligible studies are presented in tabular form. Meta-analyses of RCTs comparing ONS therapy to sham therapy in chronic migraine patients were conducted for the outcomes responder rate, headache frequency, and headache intensity. RESULTS: Four RCTs, 1 follow-up study, and 19 case series met the inclusion criteria. The quality of the evidence was low, with all four RCTs assessed as having a high risk of bias and small sample size. Meta-analyses of three RCTs showed patients receiving ONS therapy had a significant reduction of 3 headache days per month (difference in means = -3.061; 95% confidence interval [CI] = -5.162 to -0.961; P = .004) and a significant reduction in Migraine Disability Assessment score (standardized difference in means [SDM] = -0.634; 95% CI = -0.933 to -0.335; P < .001) compared to sham (subthreshold) therapy. There were no statistically significant differences in reduction in pain intensity (SDM = -1.220; 95% CI = -2.489 to -0.049; P = .060) or in the number of responders (risk ratio [RR] = 1.581; 95% CI = 0.749 to 3.355; P = .229). CONCLUSION: ONS may be effective when compared to sham therapy, but the small number of RCTs and the heterogeneity of outcomes suggest further research in this field is needed.

Four oral motor disorders: bruxism, dystonia, dyskinesia and drug-induced dystonic extrapyramidal reactions.

This article reviews four of the involuntary hyperkinetic motor disorders that affect the orofacial region: bruxism, orofacial dystonia, oromandibular dyskinesia, and medication-induced extrapyramidal syndrome-dystonic reactions. It discusses and contrasts the clinical features and management strategies for spontaneous, primary, and drug-induced motor disorders in the orofacial region. The article provides a list of medications that have been reported to cause drug-related extrapyramidal motor activity, and discusses briefly the genetic and traumatic events that are associated with spontaneous dystonia. Finally, it presents an approach for management of the orofacial motor disorders. The contraindications, side effects, and usual approach for medications and injections are covered. An overview of the indications, contraindications, and complications of using botulinum toxin as a therapeutic modality is discussed briefly.

Multicentric peripheral ossifying fibroma.

Peripheral ossifying fibroma (POF) is a common solitary gingival growth thought to arise from the periodontal ligament. Though the etiology of POF remains unknown, some investigators consider it an inflammatory or reactive process, while others suggest it is a neoplastic process. In this report, we present and discuss a unique case of multicentric POF, affecting the maxillary and mandibular gingiva of a 49-year-old Caucasian female with meticulous oral hygiene and routine dental care. Though biopsy samples from multiple sites revealed similar histopathologic features, consistent with POF, the fact that there was a multicentric presentation is a unique phenomenon for this lesion. Multicentric lesions presenting in the oral and maxillofacial region are not typical, but have been observed in conditions associated with known genetic mutations, such as nevoid basal cell carcinoma syndrome (multiple odontogenic keratocysts), multiple endocrine neoplasia type II (multiple neuromas), neurofibromatosis (multiple neurofibromas) and Gardner syndrome (multiple neoplasms). This case is the first one to demonstrate that there may be a multicentric variant of POF that has not been previously recognized, and given the clinical presentation and multifocal nature of disease, the lesions in this patient are likely the result of genetic mutation(s) that predisposes to gingival soft tissue overgrowths containing mineralized product.

Using oral medications, infusions and injections for differential diagnosis of orofacial pain.

Chronic orofacial pain is a rapidly evolving and challenging field that deals with the management of pain originating from neurogenic, osseous, muscular, or vascular structures of the head and neck. The challenge lies in the accurate diagnosis of orofacial pain conditions, which may be difficult to differentiate in many clinical situations. As pain cannot be "seen" or precisely located or its intensity measured with any device, clinicians must rely heavily on the patient's own description of type, duration and location of pain, and thus, history plays a crucial role in diagnosis. Advances in neuroscience, pharmacology, and pain management have made medications one of the primary therapeutic modalities in the management of pain including orofacial pain conditions. Despite this, these medications will not help patients if the origin and nature of pain is not accurately diagnosed. Hence, diagnosis is critical for successful management of orofacial pain conditions. Experience and knowledge of practice in pain management have led clinicians to devise several clinical diagnostic tests using medications in various forms (topical, oral, injections, intravenous infusions) to differentiate certain orofacial pain disorders where the nature of pain is unclear and the presentation of pain is at multiple sites. Although the diagnostic tests are not 100 percent accurate, they are very effective in many clinical scenarios, especially in orofacial pain conditions. Topical medications such as anesthetics and anti-inflammatories, oral medications such as anti-inflammatory drugs and skeletal muscle relaxants, injections such as local anesthetics and corticosteroids, and vapocoolant sprays are some examples of the modalities used by clinicians to manage orofacial pain conditions. These medications may also be used for diagnostic tests to aid in accurate diagnosis of some orofacial pain conditions. In addition, there are special cases where medications such as triptans, carbamazepine and indomethacin may be used as diagnostic tests to confirm diagnosis of migraines, neuralgias, or stabbing headaches, respectively. Based on the concept of using medications to predict which treatment would be best for certain pain conditions or to aid in better diagnosis, diagnostic intravenous infusions of lidocaine, morphine, and ketamine have been studied to test the response to adjuvant analgesics and oral dextromethorphan. Paradoxically, taking the patients off their current medications can be of diagnostic significance in conditions like medication overuse headache and serotonin selective reuptake inhibitor-induced clenching. In summary, this paper focuses on the use of medications in different forms as useful diagnostic tests for differential diagnosis of orofacial pain conditions that are difficult to diagnose or are refractory to past or current treatment.

Orofacial Movement Disorders.

Orofacial movement disorders (OMDs) include dystonia, dyskinesia, drug-induced extrapyramidal reactions, and bruxism. The definition, epidemiology, pathophysiology, clinical features, and management are detailed. OMDs are often disabling and affect patients' overall quality of life with pain, difficulty chewing food, speech difficulty, drooling, and social embarrassment. Management involves medications, botulinum toxin injections, and peripheral or central surgery. Botulinum toxin injections are the most effective management, often used in conjunction with medications. Surgery is the last resort for patients who fail to respond to medications or develop resistance to botulinum toxin type A.

Lack of Utility of Cytokeratins in Differentiating Pseudocarcinomatous Hyperplasia of Granular Cell Tumors from Oral Squamous Cell Carcinoma.

Granular cell tumor (GCT) of the oral cavity is a benign lesion. Half of oral GCTs demonstrate pseudocarcinomatous hyperplasia (PCH) of the mucosa which can mimic invasive islands of oral squamous cell carcinoma (SCC). Such similarity can be confusing when diagnosing or evaluating the two conditions, potentially leading to misdiagnosis or misclassification. Indeed, several misdiagnosed cases of oral GCT have been reported in the literature as OSCC or malignant oral GCT that resulted in unnecessary aggressive treatment for the affected patients. The aim of this study was to investigate if the cytokeratin pattern of the PCH can help in differentiating GCT from oral SCC. To distinguish between these two entities, we examined 12 patient specimens of oral GCT-PCH and oral SCC histologically and via immunohistochemistry (IHC) for CK13, CK17 and P75. The results suggest that the cytokeratin profile of PCH is similar to that of oral SCC. Therefore, consideration of IHC findings for epithelial markers alone may lead to erroneous diagnosis; thus, the presence of the granular tumor underneath the PCH and its immunopositivity for P75 or other neural definition markers can be essential to identify the underlying tumor and exclude oral SCC. Finally we recommend more studies on the molecular biology of PCH to understand how it can mimic oral SCC histologically without harboring its malignant phenotype clinically, which could have significant translational potential for understanding invasive oral SCC.

Systematic Review and Meta-analysis of the Efficacy of Oral Medications Compared with Placebo Treatment in the Management of Postherpetic Neuralgia.

AIMS: To conduct a systematic review to determine the efficacy of oral medications for the management of postherpetic neuralgia (PHN). METHODS: Three electronic databases were searched: Cochrane Library (up to 7 July 2015), MEDLINE via PubMed (from 1950 to 7 July 2015), and Web of Science (1864 to 7 July 2015). Studies were limited to double-blind, placebo controlled, randomized controlled trials on oral medications used to treat PHN. Risk of bias was independently assessed in duplicate. RESULTS: A total of 256 abstracts were screened by two independent reviewers and 26 full-text articles were assessed for eligibility. A total of 11 relevant articles were selected for inclusion. These 11 articles were included in a qualitative synthesis and 8 were included in a meta-analysis; however, all the included studies had a high or unclear risk of bias and the interventions were heterogenous. In a subgroup analysis of five studies, anticonvulsants (gabapentin, pregabalin, and divalproex sodium) were found to improve short-term pain intensity (standardized mean difference [SMD] = -0.484, 95% confidence interval [CI] = -0.622 to -0.346, P < .001). In a second subgroup analysis of five studies, it was found that patients taking anticonvulsants were 2.5 times as likely to have a 50% or more reduction in pain after treatment than patients taking placebo. CONCLUSION: This review has provided favorable but low-quality evidence to support the use of anticonvulsants for PHN. Although statistically significant effects were observed for posttreatment pain and the percent of responders, the number of studies in each subgroup analysis for anticonvulsants was small and the included studies had high or unclear risk of bias. Further high-quality methodologic studies are needed to explore the effects of orally administered anticonvulsants for PHN.

Effect of premedication to provide analgesia as a supplement to inferior alveolar nerve block in patients with irreversible pulpitis.

BACKGROUND: The authors' objective was to determine whether scientific evidence supports the use of oral premedication to increase the efficacy of inferior alveolar nerve block (IANB) and to decrease endodontic treatment pain in patients with diagnosed irreversible pulpitis. TYPES OF STUDIES REVIEWED: The authors included randomized controlled trials that involved enteral premedication and 2% lidocaine IANB for adults with irreversible pulpitis compared with placebo. In particular, the authors reviewed studies comparing nonsteroidal anti-inflammatory drugs (NSAIDs), benzodiazepines, acetaminophen, and corticosteroids with placebo. The authors searched the following electronic databases: the Cochrane Library, MEDLINE, and Web of Science. RESULTS: The authors analyzed 9 randomized controlled clinical trials. Patients who took the NSAIDs under study, including ibuprofen, ketorolac, diclofenac, indomethacin, and lornoxicam, 1 hour before endodontic treatment showed statistically significant improvement in the outcome of having "little or no pain" during endodontic treatment compared with patients who took a placebo 1 hour before endodontic treatment (risk ratio [RR], 1.989; 95% confidence interval [CI], 1.495-2.646; P < .001). Benzodiazepines were not as well represented in the literature, but the 2 included studies did not show a significant improvement in patients' having "little or no pain" during endodontic treatment over placebo (RR, 0.989; 95% CI, 0.677-1.444; P = .954). CONCLUSIONS AND PRACTICAL IMPLICATIONS: There is moderate evidence to support the use of oral NSAIDs-in particular, ibuprofen (600 milligrams)-1 hour before the administration of IANB local anesthetic (1.8-3.6 milliliters of 2% lidocaine) to provide additional analgesia to the patient.

The efficacy of botulinum toxin for the treatment of trigeminal and postherpetic neuralgia: a systematic review with meta-analyses.

OBJECTIVE: To evaluate the efficacy of a botulinum toxin type A (BoTN-A) in treating trigeminal neuralgia (TN) and postherpetic neuralgia (PHN). STUDY DESIGN: Three databases were searched: Medline, Web of Science, and Cochrane Library. The search was restricted to English-language randomized, placebo-controlled trials. Three review authors evaluated the cases for risk of bias. RESULTS: Six studies were eligible for inclusion. Pooled results showed a difference in post-treatment pain intensity of -3.009 (95% confidence interval -4.566 to -1.453; P < .001) in favor of BoTN-A compared with placebo in managing TN or PHN. Of the six studies, five had unclear risk of bias, and one showed high risk. CONCLUSIONS: Although the studies had unclear or high risk of bias, moderate evidence regarding the efficacy of BoTN-A in treating TN and PHN was found. BoTN-A might be an alternative treatment to those patients who are either unable to manage their pain medically or would like adjunct therapy.

Unilateral ear fullness and temporary hearing loss diagnosed and successfully managed as a temporomandibular disorder: a case report.

BACKGROUND AND OVERVIEW: A 73-year-old woman had a 4-month history of debilitating left-sided otic fullness, hearing loss, and a watery sensation in her ear without obvious cause. She had consulted with an otolaryngologist who cleared the ear of all middle ear pathology and then placed ventilation tubes in the tympanic membrane to relieve her symptoms of ear fullness. The ventilation tubes did not produce long-lasting relief so she was referred to the dental clinic. CASE DESCRIPTION: The patient did not have substantial symptoms of jaw dysfunction or jaw pain and was clearly bothered more by her ear symptoms; she exhibited the following signs and symptoms: limited mandibular range of motion (37 millimeters), crepitation in the left temporomandibular joint (TMJ), active trigger points in the left superficial masseter, and severe pain on palpation in the left TMJ (lateral and dorsal). A panoramic radiograph and maxillary computed tomography scan revealed moderate degenerative changes observed bilaterally in the TMJs. A diagnosis of localized osteoarthritis (OA) of the TMJ (TMJ-OA) and masticatory myofascial pain was given. The authors provided 3 months of treatment that included self-applied physical therapy (stretch and thermal packs), full-arch stabilization splint, trigger point injection, and a TMJ injection using triamcinolone acetonide (20 milligrams). RESULTS: The patient reported a 90% improvement in her TMJ and ear-related symptoms as a result of the treatments. The authors speculated that TMJ-OA and myofascial muscle disorders are potentially contributory to a tensor tympani muscle dysfunction, which could explain her ear fullness and hypoacusis. CONCLUSIONS AND PRACTICAL IMPLICATIONS: Diagnosis and management of TMJ dysfunction (pain on palpation, OA, and limitation of motion) should be considered when patients have symptoms of unexplained ear fullness and have been cleared for ear infection or other ear-related pathology.

Pseudo bilateral tonsilloliths: a case report and review of the literature.

Tonsilloliths are very rare concretions found in the tonsillar crypt. They are usually single and unilateral, but occasionally may be multiple or bilateral. Small concretions in the tonsils are common, but well formed giant unilateral or bilateral tonsilloliths are extremely uncommon. Only two cases of bilateral tonsilloliths have so far been reported in the literature. A case of unilateral tonsillolith, mimicking bilateral tonsilloliths taken with the orthopantogram (OPT) in a 57-year-old Malaysian Indian female with squamous cell carcinoma of the oral cavity is described. Although the OPT is a reliable and standard panoramic X-ray unit used in dentistry, superimposition of a lesion involving one side of the jaw creates a pseudo or ghost image on the contralateral side leading to a misdiagnosis of bilateral lesions. This report highlights that tonsilloliths, though rare, should be considered in the differential diagnosis of radiopaque masses involving the mandibular ramus, and that investigations such as CT scan or MRI may be required to differentiate pseudo or ghost images from true bilateral pathologies.

Osteoma of the condyle as the cause of limited-mouth opening: a case report.

Osteoma is a benign tumour consisting of mature bone tissue. It is an uncommon lesion that occurs mainly in the bones of the craniofacial complex. Only a few cases involving the condylar process have been reported. An osteoma of the left condyle causing limited mouth-opening in a 32-year-old Malaysian Chinese female is reported here to alert the practitioner to consider this lesion as a diagnostic possibility in instances of trismus or limited-mouth opening.

Oral candidosis in non-Hodgkin's lymphoma: a case report.

Though oral candidosis is an opportunistic fungal infection that commonly affects immunocompromised patients, little is known of its occurrence as a complication of Non-Hodgkin's lymphoma. This paper reports a case of oral candidosis in a 20-year-old Indonesian woman with this lymphoproliferative disease. She presented with acute pseudomembranous candidosis on the dorsum and lateral borders of the tongue, bilateral angular cheilitis and cheilocandidosis. The latter is a rare clinical variant of oral candidosis, and the lesions affecting the vermilion borders presented as an admixture of superficial erosions, ulcers and white plaques. Clinical findings were confirmed with oral smears and swabs that demonstrated the presence of hyphae, pseudohyphae and blastospores, and colonies identified as Candida albicans. A culture from a saline rinse was also positive for multiple candidal colonies. Lip and oral lesions were managed with Nystatin. The lesions regressed with subsequent crusting on the lips, and overall reduction in oral thrush. As Non-Hodgkin's lymphoma is a neoplastic disease that produces a chronic immunosuppressive state, management of its oral complications, including those due to oral candidosis, is considered a long-term indication.