Martin S. Greenberg

New developments and opportunities in oral mucosal drug delivery for local and systemic disease

The oral mucosas accessibility, excellent blood supply, by-pass of hepatic first-pass metabolism, rapid repair and permeability profile make it an attractive site for local and systemic drug delivery. Technological advances in mucoadhesives, sustained drug release, permeability enhancers and drug delivery vectors are increasing the efficient delivery of drugs to treat oral and systemic diseases. When treating oral diseases, these advances result in enhanced therapeutic efficacy, reduced drug wastage and the prospect of using biological agents such as genes, peptides and antibodies. These technologies are also increasing the repertoire of drugs that can be delivered across the oral mucosa to treat systemic diseases. Trans-mucosal delivery is now a favoured route for non-parenteral administration of emergency drugs and agents where a rapid onset of action is required. Furthermore, advances in drug delivery technology are bringing forward the likelihood of transmucosal systemic delivery of biological agents.

Recurrent aphthous stomatitis

Recurrent aphthous stomatitis (RAS) is the most common ulcerative disease affecting the oral mucosa. RAS occurs mostly in healthy individuals and has an atypical clinical presentation in immunocompromised individuals. The etiology of RAS is still unknown, but several local, systemic, immunologic, genetic, allergic, nutritional, and microbial factors, as well as immunosuppressive drugs, have been proposed as causative agents. Clinical management of RAS using topical and systemic therapies is based on severity of symptoms and the frequency, size, and number of lesions. The goals of therapy are to decrease pain and ulcer size, promote healing, and decrease the frequency of recurrence.

A profile of symptomatic patients with silicone breast implants : a Sjögrens-like syndrome

Exposure of breast tissue to silicone has been associated with autoimmune diseases in the medical literature since the 1960s. Japanese women injected with raw silicone had features of a collagen vascular disease but did not meet criteria for a specific diagnosis. Subsequently, we have seen women with silicone breast implants that have similar problems. We performed a prospective noncontrolled study on women with silicone breast implants. Results from the first 50 consecutive women revealed the most prominent complaints in this group were fatigue (89%), generalized stiffness (75%), poor sleep (71%), and arthralgias (78%). Other problems included Raynauds phenomenon, alopecia, adenopathy, night sweats, and frequent sore throats. Unexpectedly, half of these women complained of dry eyes and dry mouths. Positive antinuclear antibodies and or rheumatoid factors were discovered in 38% of patients although the anti-SSA antibody was found in only one patient and anti-SSB in none. Labial salivary gland biopsies in 5 cases showed mononuclear cell infiltrates compatible with Sjögrens syndrome in 4. The infiltrating cells were predominantly CD68 positive monocyte/macrophages, which is different from what is found in Sjögrens syndrome. These findings may indicate the presence of a unique syndrome associated with silicone implants that is characterized by musculoskeletal pain and autoimmune features.

Clinical and Laboratory Differentiation of Recurrent Intraoral Herpes Simplex Virus Infections Following Fever

Recurrent herpes simplex infections occurred over three times as frequently in a group of febrile patients as in a group of nonfebrile controls. Virus was isolated from patients without lesions, patients with lip lesions only, and patients with lip and intraoral lesions. Characteristic clinical features of the intraoral lesions found in association with herpes simplex virus (HSV) were identified.

A retrospective study of the management of oral mucous membrane pemphigoid with dapsone

OBJECTIVE The purpose of this retrospective study was to investigate the efficacy of dapsone therapy in the management of mucous membrane pemphigoid. STUDY DESIGN The charts of 29 patients who had been diagnosed with mucous membrane pemphigoid by means of routine histologic analysis and direct immunofluorescence were reviewed. The oral features were graded according to severity of disease from 1 to 3. Each patient was assigned to one of 4 groups according to his or her response to therapy. RESULTS Nine patients were treated successfully with topical corticosteroids alone. Eleven patients with moderate to severe disease who were treated initially with topical steroids showed minimal improvement; after dapsone was added, 7 of the 11 had total resolution of their lesions and 4 had greater than 75% improvement. Two patients had to discontinue dapsone because of side effects. CONCLUSIONS In this group of 20 patients with moderate to severe mucous membrane pemphigoid, the use of dapsone in combination with topical corticosteroids caused greater than 75% resolution of oral lesions in all patients studied.

Plasma cell gingivitis: Report of two cases

Plasma cell gingivitis is a disorder first described in the 1960s and was believed to be caused by an allergic reaction to flavored chewing gum and toothpaste. The lesion was believed to have been largely eliminated by removing the allergens from the products. We report two additional cases, not related to a known allergen. One patient was allergy tested thoroughly and given a strict elimination diet without resolution. Immunofluorescence study suggests a reactive rather than a neoplastic process.

Oral infection in immunosuppressed renal transplant patients

The most common cause of death in patients taking immunosuppressive (IS) drugs is infection. Many of the microorganisms which infect these IS patients may be found in the mouth, but the mouth has not been investigated as a potential source of lethal infection. In view of this, we studied twenty-seven IS patients taking Imuran and prednisone for 6 to 61 weeks and eighteen normal controls. The patients were followed monthly, and the incidence of oral and systemic complications was recorded. There were no deaths due to infection during the 10-month study period. Oral infection occurred as frequently as pneumonia or urinary tract infection. Systemic factors which were related to the development of dental infection were lymphocyte count and length of time on immunosuppressive drug therapy.

Temporomandibular Disorders: Evaluation and Management

Temporomandibular disorders remain a common cause of visits to primary care physicians, internists, pediatricians, and emergency departments. Advances in the clinical diagnosis, radiographic imaging, and classification of these disorders have improved long-term management. There are several types of disorders of the masticatory muscles and the temporomandibular joint as well as associated structures and each may have a complex cause, clinical course, and response to therapy. Host susceptibility plays a role at several stages of these disorders. Future research offers greater possibility in defining this heterogeneous group of disorders and providing more focused and effective treatment strategies.

Idiopathic hypoparathyroidism, chronic candidiasis, and dental hypoplasia

Abstract The case of a 16-year-old boy with a syndrome of idiopathic hypoparathyroidism, chronic mucocutaneous candidiasis, and dental hypoplasia has been presented. Enamel hypoplasia was present in teeth which formed before there was evidence of hypocalcemia, and this dental defect, in addition to the candidiasis and photophobia, helped to determine the diagnosis of idiopathic hypoparathyroidism. Because of the danger of Candida fungemia and tetany, hospitalization was required for dental extractions under general anesthesia. Elevation of the serum calcium and extraction of the teeth appeared to result in clinical improvement of the oral candidiasis, and the patient has been able to function satisfactorily with full dentures.

Burkitt lymphoma of the oral cavity: an atypical presentation

Burkitt lymphoma (BL) is an aggressive form of non-Hodgkin B-cell lymphoma with 3 variants: endemic, sporadic, and immunodeficiency-associated types. The sporadic form, most commonly involving the abdomen and ileocecal region, presents as an abdominal mass, rarely presenting in the orofacial region. A 36-year-old Indian female presented to the Hospital of the University of Pennsylvania for evaluation of a persistent intraoral swelling ulceration of the lower right mandibular alveolar ridge with minimal bony invasion. Progressive systemic symptoms of fatigue, weakness, and fever developed without resolution following treatment for a presumed odontogenic infection in the 4 weeks before presentation. An incisional biopsy revealed a diffuse proliferation of intermediate- to large-sized lymphocytes with multiple small peripheral nucleoli, scant cytoplasm, and nuclear pleomorphism. Nearly all cells displayed Ki67 expression. A final diagnosis of BL was rendered following confirmation of a cMYC translocation by fluorescence in situ hybridization. This article presents a case of the sporadic form of BL with atypical presentation clinically and morphologically, primarily involving the oral soft tissue.