E.A. Field

Oral ulceration – aetiopathogenesis, clinical diagnosis and management in the gastrointestinal clinic

Oral ulceration is a common complaint of patients attending out‐patient clinics. The aim of this review is to provide the gastroenterologist with a differential diagnosis of oral ulceration, and a practical guide for the management of recurrent aphthous stomatitis, including topical and systemic therapy. The association of recurrent aphthous stomatitis with Behçets disease and other systemic disorders, including coeliac disease, is discussed. Recent evidence concerning the immunopathogenesis of Behçets disease is reviewed, including renewed interest in the role of Streptococcus sanguis and possible infectious triggering of an inappropriate immunoinflammatory response, resulting in tissue damage. The efficacy and limitations of conventional treatment for this mutisystem disorder are outlined together with the potential role of novel biological agents, such as anti‐tumour necrosis factor‐α therapy. Oral ulceration, as a manifestation of inflammatory bowel disease and a complication of drug therapy, is described. Guidance is given concerning indications for referral of patients with oral ulceration to an oral physician/surgeon for further investigations, including biopsy if appropriate.

The establishment of a xerostomia clinic: a prospective study

The study investigated the aetiological factors and management of patients who have xerostomia. The subjects were 100 consecutive patients referred to the Oral Medicine Unit for investigation of oral dryness. A detailed case history was recorded and patients underwent a systematic examination together with sialometry, haematological, biochemical and immunological investigations. Suspected cases of Sjögrens syndrome (SS) were referred for assessment by a rheumatologist and ophthalmologist. Objective evidence of salivary gland hypofunction was found in 39 patients. A definite diagnosis of primary and secondary SS was made in 24 and 15 patients respectively, a further five cases had possible primary SS. Other causes of xerostomia were: undiagnosed diabetes (3); drug-induced (11); therapeutic radiation (3); alcohol-related (3); psychogenic (15) and idiopathic (21). Patients complaining of a dry mouth should be questioned about non-oral symptoms. In total, 40% of patients attending the dry mouth clinic had a diagnosis of SS.

Does Candida have a role in oral epithelial neoplasia

Candida species are responsible for a wide variety of superficial infections of man [59] and the pathogenic role of these yeasts in many conditions has now been defined. There is, however, a great deal of controversy concerning the role of Candida species in the development of epithelial neoplasia. Vaginal and cutaneous candidosis are relatively common but there is little firm clinical or epidemiological evidence to link them to cervical neoplasia or skin carcinoma [59]. The converse is true however for oral candidosis where chronic Candida infection and neoplasia have been strongly linked. The aim of this review is to explore and evaluate the experimental and epidemiological evidence supporting an association between Candida species and oral neoplasia.

The clinical determinants of malignant transformation in oral epithelial dysplasia

BACKGROUND While the size and clinical appearance are known risk factors for malignant transformation of potentially malignant oral the importance of site, grade of dysplasia and exposure to environmental carcinogens remains controversial. We aim to report the clinical determinants of malignant progression in a series of patients with histopathologically graded oral epithelial dysplasia (OED). METHODS We recruited patients with a histopathological diagnosis of OED to a longitudinal observational study in a tertiary oral dysplasia clinic. Clinical, histopathological and risk factor data were recorded at baseline. One of three clinical endpoints were determined: malignant transformation, progression of dysplasia grade, remission/stable dysplasia grade. RESULTS Ninety-one patients meeting the criteria gave consent for inclusion to the cohort, with outcomes reported after a median follow up of 48 months. An estimated 22% (SE 6%) of patients underwent malignant transformation within 5 years, with significant predictors being: non-smoking status (χ(2)=15.1, p=0.001), site (χ(2)=15.3, p=0.002), non-homogeneous appearance (χ(2)=8.2, p=0.004), size of lesion >200 mm(2) (χ(2)=4.7, p=0.03) and, of borderline significance, high grade (χ(2)=5.8, p=0.06). Gender, age, number of lesions and alcohol history did not predict for malignant transformation. CONCLUSIONS Although a number of these clinical determinants have previously been associated with higher malignant transformation in OED, the high-risk nature of lesions in non-smokers is of particular note and requires a greater emphasis and recognition amongst clinicians dealing with OED. It suggests that those non-smokers with OED, have an inherited or acquired predisposition and should be treated more aggressively; these should form the focus for further investigation.

Acetylcholine-evoked calcium mobilization and ion channel activation in human labial gland acinar cells from patients with primary Sjögren's syndrome

Recent evidence has indicated that the salivary gland dysfunction associated with Sjögrens syndrome (SjS) is not necessarily due to immune‐mediated destruction of acinar tissue. SjS sufferers may possess substantial reserves of acinar tissue but nevertheless be incapable of maintaining salivary flow rates in the normal range. We have investigated the ability of isolated labial gland acinar cells from SjS patients to fluid secrete by measuring agonist‐evoked changes in intracellular Ca2+ ([Ca2+]i) using fura‐2 microfluorimetry and activation of K+ and Cl− channels using the patch‐clamp whole cell technique. We can confirm that stimulation with a super‐maximal dose of acetylcholine (ACh) increased [Ca2+]i equally in both control acinar cells and those derived from SjS patients. However, at submaximal concentrations, the dose–response curve for ACh was shifted to the right by approximately one order of magnitude in acinar cells from SjS patients compared to control acinar cells. Patch‐clamp measurements consistent with the presence of Ca2+‐activated K+ and Cl− conductances were obtained from both control acinar cells and those obtained from SjS patients. Dose‐dependent activation of the ion channels by acetylcholine was also right‐shifted in acinar cells from SjS patients compared to control cells. Our data show that labial gland acinar cells from SjS patients were capable of responding to agonist stimulation by mobilizing [Ca2+]i and activating K+ and Cl− channels consistent with the requirements of fluid secretion. However, the persistent loss of sensitivity to ACh observed in from SjS patients may account for the lack of saliva production observed in these patients in vivo.

The effect of chlorhexidine irrigation on the incidence of dry socket: A pilot study

A pilot study was conducted to measure the reported incidence of dry socket following pre-operative irrigation and mouthrinsing with either 0.2% (w/v) chlorhexidine gluconate or normal saline or with no irrigation (control). Three hundred and twenty-four patients presenting for the single extraction of a lower premolar or molar under local anaesthesia were divided into three equal groups; no irrigation, irrigation with saline and irrigation with a 0.2% (w/v) chlorhexidine gluconate solution. After administration of the local anaesthetic agent, 10 ml of the test solutions were applied to the gingival crevice using a blunted needle. The solutions were retained in the patients mouth for 2 min following irrigation. Pre-operative irrigation of the gingival crevice and mouthrinsing with 0.2% (w/v) chlorhexidine gluconate significantly reduced the number of dry sockets. There was no significant reduction in the number of dry socket cases following irrigation and rinsing with normal saline. The irrigation technique, using 0.2% (w/v) chlorhexidine gluconate is safe, inexpensive, easy to apply and can be recommended for routine use in dental practice, to reduce the incidence of dry socket.

Outcomes of oral squamous cell carcinoma arising from oral epithelial dysplasia: rationale for monitoring premalignant oral lesions in a multidisciplinary clinic.

Surveillance of oral epithelial dysplasia results in a number of newly diagnosed cases of oral squamous cell carcinoma (SCC). The clinical stage of oral SCC at diagnosis influences the magnitude of treatment required and the prognosis. We aimed to document the stage, treatment, and outcome of oral SCC that arose in patients who were being monitored for oral epithelial dysplasia in a dedicated multidisciplinary clinic. Those with histologically diagnosed lesions were enrolled on an ethically approved protocol and molecular biomarker study. Details of clinical and pathological TNM, operation, radiotherapy, recurrence, second primary tumour, and prognosis, were recorded in patients whose lesions underwent malignant transformation. Of the 91 patients reviewed (median follow-up 48 months, IQR 18-96), 23 (25%) had malignant transformation. All were presented to the multidisciplinary team with stage 1 disease (cT1N0M0). Of these, 21 were initially treated by wide local excision, 2 required resection of tumour and reconstruction, and 2 required adjuvant radiotherapy. At follow-up 3 had local recurrence, one had regional recurrence, one had metachronous lung cancer, and 5 had second primary oral SCC. There were further diagnoses of oral dysplasia in 5 during follow-up, and it is estimated that 76% of patients will have one or other event in 5 years. Disease-specific survival was 100% and overall survival was 96% (22/23). Median follow-up after diagnosis of oral SCC was 24 months (IQR 11-58). Specialist monitoring of oral epithelial dysplasia by a multidisciplinary team allows oral SCC to be detected at an early stage, and enables largely curative treatment with simple and usually minor surgical intervention. The high incidence of second primary oral SCC in high-risk patients with oral epithelial dysplasia further supports intensive targeted surveillance in this group.

Development of ocular disease in patients with mucous membrane pemphigoid involving the oral mucosa

Aim: To determine the rate of development of ocular disease in patients presenting with mucous membrane pemphigoid (MMP) involving their oral mucosa. Methods: Diagnosis of oral MMP was made on the basis of clinical signs, histology, and direct and indirect immunofluorescence. Age, race, sex, age at diagnosis, progression of eye signs, duration of follow up, and time to progression of ocular disease were recorded. Results: 30 patients with established oral MMP were reviewed. The mean age at diagnosis was 65.2 years (range 46–84 years) and 16/30 (53%) were male. At initial ocular review nine (30%) patients showed ocular signs of pemphigoid, of whom two had mild (IIA IIIB), four moderate (IIB IIIC), and three severe (IIC IIID) disease. The mean interval between diagnosis of oral MMP and first ophthalmic review was 19.3 months (range 0–144). Over the period of follow up two (7%) patients developed ocular disease at 19 months and 48 months, respectively, despite having had no evidence of ocular involvement at presentation. In total, 11 (37%) patients with oral disease eventually showed ocular disease with a calculated incidence rate for the development of ocular disease of 0.03 per person year over 5 years. Conclusions: MMP may affect different tissues at different stages, often separated by many years. Patients with MMP involving their oral mucosa are at significant risk of developing ocular disease and should remain under ophthalmic review.

Immediate knowledge increase from an oral cancer information leaflet in patients attending a primary health care facility: a randomised controlled trial

The aim was to determine the immediate influence of a validated patient information leaflet (PIL) on oral cancer and knowledge in primary care attenders. Participants were patients (n=800) attending their primary health care provider from 14 general practices (eight dental and six medical) in the north west of England. Measures were a previously validated knowledge questionnaire (36 dichotomous items), self-reported dental service attendance history and demographic variables. The results showed that patients who had read the oral cancer PIL demonstrated a significant increase in knowledge regardless of clinical setting (F[1,739]=246.24, P<0.0001). Patients showed improvements in selecting the correct signs and risk factors associated with disease. Immediate knowledge gain from a simple PIL about oral cancer was found and independent of the primary care facility, where the PIL was distributed.

The use of an information leaflet for patients undergoing wisdom tooth removal

Attempts to inform the patient about surgical procedures have increased for the purposes of ensuring informed consent and improving satisfaction with the service provided. Leaflets are being used as an additional aid in general practice and in hospital units. However, such written information is seldom evaluated. This study was conducted to assess the influence of using an information leaflet for patients attending oral surgery clinics at a local dental hospital. Sixty-six patients were included in the study and invited to complete a questionnaire to assess knowledge of wisdom tooth removal at the time of examination and just prior to surgery. The validity of the knowledge measure had been previously tested. At 1 month follow-up a patient satisfaction questionnaire was completed by the sample. Patients were randomised at the examination appointment into four groups. The first group was provided with the leaflet and prompted to read it by the dentist (WTL + Prompt). The second group was given the leaflet but not prompted (WTL only). The two other groups acted as controls. The third group was provided with a dental health education leaflet with no prompting (Control 1). The fourth and final group was given no additional written material (Control 2) but provided with verbal information and routine warnings in a similar way to all other groups participating in the study. The WTL + Prompt Group showed increased knowledge on retest (P < 0.001). The WTL Group showed a trend to greater knowledge (P < 0.06) however the control groups showed no improvement (P > 0.5). Patient satisfaction, although greatest in the group given a leaflet without prompting, was not simply related to leaflet provision.