Francisco Samuel Rodrigues Carvalho

Oxygen metabolism in oral cancer: HIF and GLUTs (Review)

Oral cancer is a significant cause of morbidity and mortality, and has a poor prognosis. This has encouraged additional studies into factors that may affect the development of this disease. The biological behavior of malignant neoplasms is complex. Studies have investigated the energy metabolism of tumor cells, in an endeavor to elucidate the tumor biology. The identification of molecular signatures and mechanisms, in order to understand tumor progression, may facilitate the identification of novel predictive and prognostic markers. Pathways that influence tumor progression, such as those involving hypoxia-inducible factor (HIF) and glucose transporter (GLUT) proteins, have been the targets of recent studies.

Local hemostatic measures in anticoagulated patients undergoing oral surgery: a systematized literature review

PURPOSE To conduct a systematized review of the literature about the main local hemostatic measures to control postoperative bleeding in anticoagulated patients. METHODS A systematized review of literature was performed in the electronic database Medline (PubMed) without restriction of the publication date. The eligibility criteria were studies involving maintenance of the anticoagulant therapy, prospective studies, retrospective studies, randomized clinical trials, controlled clinical studies, comparative studies, multicentric studies or case-control studies. Studies discontinuing anticoagulant therapy, case reports, literature reviews, in vitro studies, animal experiments and articles written in language not compatible with the search strategy adopted in this work were excluded. RESULTS Twenty-four articles that met the adopted eligibility criteria were selected, enrolling 3891 subjects under anticoagulant therapy. A total of 171 cases of hemorrhage was observed. Tranexamic acid was the main local hemostatic measure used to controlling of postoperative bleeding. CONCLUSION The local hemostatic measures proved to be effective according to previously published studies. Nevertheless, further clinical studies should be conducted to confirm this effectiveness.

Solitary neurofibroma of the palate.

A 54-year-old female patient with melanoderma without systemic involvement, was referred for evaluation of an asymptomatic intraoral pedunculated nodular lesion lo-cated on the palate, similar in color to the adjacent mucosa, that measured approximately 8 mm (Fig. 1A), exhibited an uneven surface, had a fibrous consistency, and had been present for three months. Extraoral physi-cal examination revealed characteristic stigmata of neu-rofibromatosis, involving the chest. An excisional biop-sy and histopathological examination were performed, and revealed mucosal fragments covered with stratified squamous epithelium (ortho or parakeratinized), with acanthosis. The lamina propria showed spindle cell proliferation, so-metimes with undulated nuclei amid marked collagen fiber deposition, arranged in variable-sized bundles in addition to mast cells (Fig. 1B-C). The report suggested a diagnosis of neurofibroma, with the analysis revealing strong immu-nohistochemical staining for S-100 protein (Fig. 1D). The patient is undergoing clinical follow-up and has shown no signs of recurrence (Fig. 1E).

An adult blind man presenting severe impairment of the right finger, ecchymosis in the thorax region, and haemorrhagic blisters on the oral mucosa.

Editor Thrombocytopenia is defined as a reduced platelet count within blood (<100 9 10 units/L), generating a primary haemostatic defect. This condition may be observed in diseases associated with (i) impaired platelet production (e.g. aplastic anaemia, myelodysplastic syndrome, chemotherapy), and (ii) increased splenic sequestration (e.g. splenomegaly, disseminated intravascular coagulation, thrombotic microangiopathy). Immune thrombocytopenic purpura (ITP) consists of an acquired immune-mediated disorder with severe dermatological manifestations in which auto-antibodies establish a direct link with specific glycoproteins expressed on platelet surfaces, such as IIbIIIa and Ib-IX, promoting platelet destruction by macrophages from the reticuloendothelial system. A 56-year-old blind man residing in a low-income rural district in the city of Sobral (Brazil), presented to the Stomatology Service of the Federal University of Cear a (Sobral Campus, Brazil) for a dental appointment complaining of oral discomfort. Patient reported a last dental visit 5 years before the present consultation, at the same time in which complete blindness had been diagnosed as a result of uncontrolled systemic hypertension, and untreated glaucoma. The primary care physician had previously screened patient for dietary restrictions, alcohol consumption, drug abuse, hepatitis B/C, HIV infection and diabetes (plasma glucose, 86.9 mg/dL; laboratory reference value, 66– 99 mg/dL), and patient’s medical chart/labs did not confirm the presence of these conditions. Physical examination showed reddened stains and ecchymosis in the thorax region, haemorrhagic petechiae on the fingers, and severe impairment of the right finger (Fig. 1). On intraoral exam, haemorrhagic blisters were observed on the lower lip and left buccal mucosa (Fig. 1), in addition to palatal petechiae and spontaneous gingival bleeding. To investigate any pre-existing blood dyscrasias, a complete haemogram was requested. The haemogram showed a low platelet count of 14 000 units/mm3 (laboratory reference value of 150 000–450 000 units/mm3) and a normal total white blood cell count of 6.1 9 10/mm (laboratory reference value of 4–10 9 10/mm). All other laboratory values were within normal limits: red blood cell count (RBC) of 4.32 9 10/mm; haemoglobin (Hgb) of 13.4 g/dL; and a haematocrit (Hct) of 40.3%. In view of these clinical findings, presence of severe thrombocytopenia, and need for dental extractions, the patient was referred to the Regional Center of Hematology and Hemotherapy of Sobral (Brazil) for medical evaluation and appropriate diagnosis. New laboratory exams confirmed the existence of persistent thrombocytopenia (35 000 units/mm), with normal values for RBC (4.47 9 10/mm), Hgb (14.6 g/dL), Hct (42.6%), mean corpuscular volume (95 fL) and total leucocyte count (6200 cells/mm). Thus, the final diagnosis was ITP. Presently, corticosteroid therapy was the elected treatment alternative (prednisone: 80 mg/day), which leads the patient to a gradual regression of oral lesions, re-establishing platelet counts to acceptable levels after a 24-month follow-up period (initial: 14,000 units/mm3; final: 118,000 units/mm3). In this case, the patient reported interruption and irregular use of the prescribed medication, increasing the severity of thrombocytopenia

Asymptomatic bilateral palatal swelling as a rare initial presentation of a rapidly progressive and fatal disease in an elderly man.

An elderly man was referred to the Clinic of Stomatology, Federal University of Ceará (Sobral, Brazil) complaining of an asymptomatic intraoral swelling. Previously, he was diagnosed with a palatal nodule during a dental consultation for oral prosthetic rehabilitation. His past medical history showed a controlled systemic hypertension not associated with other underlying diseases. The patient denied any functional impairment, respiratory distress, fever or weight loss. Intraorally, a firm diffused bilateral swelling on the hard palate covered by a non-ulcerated red-purple tissue was observed (Fig. 1a). Radiographically, imaging signs were unremarkable. Laboratory parameters showed thrombocytopenia, leukocytosis, lymphocytosis, neutrophilia and anemia. An incisional biopsy was carried out. Microscopically (Fig. 1b), a proliferation of diffused lymphocytic infiltrate constituted by numerous lymphocytes of small size was observed. The immunohistochemical panel showed a diffuse positivity pattern to cyclin D1, CD5, Bcl-2, CD20 and CD45. The neoplastic lymphocytes showed negative immunohistochemical staining to AE1/AE3, CD3, CD10 and Bcl-6. Ki-67 immunoreaction was evident in more than 80% of the malignant cells. The

Unusual Occurrence of Tongue Sensorial Disorder after Conservative Surgical Treatment of Lymphoepithelial Cyst

Lymphoepithelial cyst is a rare lesion of the oral cavity, with the mouth floor being the most common site of occurrence. The therapeutic approach of choice is the surgical treatment, which has rare cases of postoperative complications. The aim of this study is to report the case of a 53-year-old patient who came to Dental Service in the Federal University of Ceará complaining of a small nodular lesion (0.5 cm) located in the ventral tongue. Excisional biopsy was performed and the surgical specimen was submitted for anatomopathological analysis, which found that there was an oral lymphoepithelial cyst. The patient returned after seven days for suture removal and reported loss of sensitivity around the ventral tongue. We prescribed Citoneurin for ten days; however, there was not any significant improvement of the sensitivity. Low frequency laser therapy sessions were applied. The only postoperative symptom was dysesthesia, where there is only a sensitivity decrease. Currently, the patient has a postoperative period of 1 year without recurrence of the lesion. Although previous reports have no described tongue sensorineural disorders associated with this lesion, the occurrence of this event may be related to an unexpected anatomical variation of the lingual nerve.

A suitable device for cystic lesions close to the tooth-bearing areas of the jaws.

Different devices for decompression of cystic lesions of the jaw have been described in the literature. Although there are no rigorous rules for choosing a particular design or method, the choice depends on situational needs. Although minor, most techniques are associated with certain difficulties and complications, such as the need for long-term monitoring, inappropriate decompression tube size, soft tissue trauma, suture dehiscence, soft tissue invagination, dislodgement, and malpositioning of the tube into the lesion. These complications may have a negative impact on the level of treatment acceptance, especially when devices are used over long periods. The aim of this study was to present a new suitable device for cystic lesions close to tooth-bearing areas of the jaws.

Clinical Aspects, Imaging Features, and Considerations on Bisphosphonate-Related Osteonecrosis Risk in a Pediatric Patient with Osteogenesis Imperfecta

Osteogenesis imperfecta (OI) is a rare hereditary condition caused by changes in collagen metabolism. It is classified into four types according to clinical, genetic, and radiological criteria. Clinically, bone fragility, short stature, blue sclerae, and locomotion difficulties may be observed in this disease. OI is often associated to severe dental problems, such as dentinogenesis imperfecta (DI) and malocclusions. Radiographically, affected teeth may have crowns with bulbous appearance, accentuated constriction in the cementoenamel junction, narrowed roots, large root canals due to defective dentin formation, and taurodontism (enlarged pulp chambers). There is no definitive cure, but bisphosphonate therapy is reported to improve bone quality; however, there is a potential risk of bisphosphonate-related osteonecrosis of the jaw. In this study we report a case of OI in a male pediatric patient with no family history of OI who was receiving ongoing treatment with intravenous perfusion of bisphosphonate and who required dental surgery. In addition, we discussed the clinical and imaging findings and briefly reviewed the literature.

Salivary duct cyst in the upper lip: Case report and review of the literature

Salivary duct cyst (SDC) in an uncommon lesion of the minor salivary glands, with etiology related to obstruction of the salivary duct. It presents with a color similar to that of the mucosa, is mobile, measures between 3 and 10 mm and affects preferentially the bottom lip, floor of the mouth and the jugal mucosa. SDC have a predilection for the male and individual in elderly groups. The pathogenesis of SDC is associated with the formation of a mucous plug that causes partial or total obstruction of the salivary gland system duct, resulting in the dilation of the duct and increase in intraluminal pressure. They present clinical-pathological characteristics similar to those of salivary gland tumors, making diagnosis difficult and subject to errors in treatment. It is important for the dentist to include SDC in the differential diagnosis of lesions that affect the upper lip, although it is relatively rarely found in this anatomic site.

Development of Educational Material for Oral and Maxillofacial Training

The performance of a procedure in oral and maxillofacial surgery requires the acquisition of surgical skills, as well as technical knowledge, repetitive training, and professional ability to adapt when submitted to different clinical situations [1]. The preclinical incision and suture training have usually been performed through sponge and molding material-related simulators [2], gypsum, molding material and orange peel [3], and animal tissue-based models. Although these methods have provided mucosa-like texture and skin, they do not simulate clinical conditions such as oval palate and alveolar ridge. These facts may limit the simulation process and teaching-related feedback. Thus, this technical note aimed to present an alternative, simple, and low-cost educational method of training mucoperiosteal flaps and sutures in oral and maxillofacial surgery. Firstly, a cast was made using type 4 gypsum. It was duplicated, covered with a 2.0-mm wax #7 layer, and then, a single acrylic resin custom tray was obtained. This procedure allowed to create a custom tray simulating an alveolar mucosa with 2.0 mm of thickness to be further fulfilled by the modeling material. The custom tray is used for modeling the aforementioned stone cast with condensation-cured silicone (Fig. 1). The obtained model presents a suitable silicone thickness for surgical training since it simulates the alveolar ridge gingiva (Fig. 2). This model allows to perform incisions with a similar consistency of mucoperiosteal tissues, and it produces a sensation of ‘‘scratching the bone’’ after using the scalpel. Also, it allows the detachment of the material in a similar way to the soft mucosal tissue, as well as the suture procedures (Figs. 2, 3). The repetition of surgical procedures favors the reduction in technical errors and related variables for the time required to perform the surgical activity. However, it does not guarantee adequate levels of concentration and physiological stress attributed to the task [4]. The repetitive training of surgical procedures associated with feedback performed by experts in the field of oral and maxillofacial surgery has benefits that favor the acquisition of suitable skills. The present designed teaching-related model potentially enhances the simulation of mucoperiosteal flaps in maxillary and mandibular casts, which may be helpful for reproducing common surgical conditions by graduate students and professionals in continuing education programs. Regarding the previous published dental models [2, 3], it was commonly observed a limitation of simulating different types of incisions on bone tissue to design mucoperiosteal flaps. Interestingly, the present model shows versatility for using by different academic levels of training (graduate and postgraduate), as well as for different specialties (surgery and periodontics). In summary, the present method has a simple methodology, low-cost, fast to run, easy reproducibility, and reusable, since it is possible to reuse the stone cast by & Francisco Samuel Rodrigues Carvalho samuelcarvalho@unifor.br