Michaell A. Huber

A comparison of the signs of temporomandibular joint dysfunction and occlusal discrepancies in a symptom-free population of men and women☆

To date, there has been no conclusive explanation for the predominance of female patients with temporomandibular joint (TMJ) dysfunction. The purpose of this study was to survey a normal population without symptoms for the presence of certain putative signs of TMJ dysfunction in association with certain signs of occlusal discrepancy and to determine the presence of any gender variation. The subjects (217 men and 217 women) were examined for the presence of three putative signs of TMJ dysfunction: limited mandibular opening (under 37 mm), deviation on opening, and joint sounds. The subjects were also examined for the presence of four signs of occlusal discrepancy: an anterior slide from centric relation (CR) to centric occlusion (CO), lateral slide from CR to CO, nonworking occlusal contacts, and working disclusive contacts distal to the canines. CR is the mandibular position at which the condyles are in their most superior position on the posterior aspect of the articular tubercles. CO is the mandibular position at which the mandibular and maxillary teeth are in maximum intercuspation. There were no significant differences in the prevalence of the putative signs of TMJ dysfunction and occlusal discrepancy between men and women. It was concluded that factors other than the presence of these signs of TMJ dysfunction and occlusal discrepancy are responsible for the high predominance of female patients with TMJ dysfunction.

Oral and Oropharyngeal Cancer

Oral and oropharyngeal cancer (OPC) is a complex and often relentless malignancy prone to local invasion and dissemination. Despite advances in understanding of the disease and improved therapeutic interventions, it continues to be diagnosed at an advanced stage and the survival rate remains poor. The financial cost of treating OPC may be the highest of all cancers in the United States and survivors often experience major detriments to quality of life. Major risk factors for OPC are tobacco, alcohol, areca nut, and human papillomavirus infection. This article updates medical practitioners on the causes, presentation, diagnosis, and management of OPC.

White oral lesions, actinic cheilitis, and leukoplakia: confusions in terminology and definition: Facts and controversies

Many diseases affecting the cutaneous tissues may incur observable changes to the mucosal tissues of the oral cavity. As a consequence, the dermatologist should always assess the oral mucosal tissues of their patients as a matter of routine. Equivocal lesions should be referred to a dentist for further assessment. Although most encountered white oral lesions are innocuous, some potentially serious conditions may mimic an innocuous white lesion. As examples, oral lichen planus may cause significant patient discomfort and is associated with some degree of increased malignant risk, whereas actinic cheilitis and leukoplakia have a confirmed association with an increased malignant risk. This contribution reviews the characteristics and management strategies for some of the more common white oral lesions that the dermatologist may observe in clinical practice.

Diagnosis of oral hairy leukoplakia by ultrastructural examination of exfoliative cytologic specimens

Lingual exfoliative cytologic specimens (scrapings) were obtained from 18 patients positive for human immunodeficiency virus with clinical oral hairy leukoplakia. Buccal mucosal scrapings were obtained from 12 of these patients. The specimens were processed for examination by transmission electron microscopy (TEM). Sixteen (89%) of the lingual specimens revealed infection of keratinocytes by herpes-type virus. There was no evidence of virus infection in the 12 buccal mucosal scrapings. Fungal hyphae were seen by TEM in 14 (78%) of the lingual scrapings and two (17%) of the buccal scrapings. One exfoliative specimen and two biopsy specimens were stained for Epstein-Barr virus DNA with a DNA probe. The demonstration of herpes-type virions by TEM in keratinocytes from a lesion clinically suspected to be hairy leukoplakia provides direct, objective diagnosis. Furthermore, use of exfoliative cytologic specimens provides a clinically simple, noninvasive technique.

The benefit and risk of screening for oral potentially malignant epithelial lesions and squamous cell carcinoma

The perspective of an individual regarding his or her personal well-being often conflicts with that of the public health view. For the individual, a disease is either present or absent, whereas from the public health perspective, a disease is measured in terms of probability and risk. Screening for the early detection of a variety of diseases, including oral potentially malignant disorders (OPMD), oral squamous cell carcinoma (OSCC), and oropharyngeal carcinoma (OPC), has been promoted and is an expectation of the public and health care professionals. Ideal screening protocols successfully balance risk versus benefitdin the other words, to do more good than harm. This is a challenge in low-prevalence diseases, such as cancer. Recently numerous cancer screening protocols have been modified, focusing on high-risk groups and often with recommendations for less frequent screening, in an effort to improve the risk/benefit ratio. Not surprisingly, these changes have resulted in increased anxiety from the perspective of the individual. Significant changes have occurred in the etiology of OSCC and OPC, with decrease in the burden of tobaccoor alcohol-associated disease and an increase in human papilloma virus (HPV)eassociated disease burden. This shift is most apparent in OPC, where an estimated 85% of cases are attributed to HPV. Most cases of OSCC and OPC continue to be diagnosed at an advanced stage, resulting in the need for more complex and more costly therapy and ultimately compromising favorable outcomes. Premalignant, potentially detectable lesions are expected in the majority of OSCC, but it is not known if OPC arises from potentially clinically detectable precursor lesions. It is anticipated that increasing early detection and management of OPMD and early-stage SCC will lead to improved outcomes.

Marketing versus science: a call for evidence-based advertising in dentistry

The health care industry is experiencing an explosion of research, which promises to shift the paradigm in the detection, diagnosis, and management of oral diseases. Some new diagnostic methods, such as individual molecular and genomic testing, adjunctive visual aids, cytology, and salivary diagnostics, are being, or will be, actively marketed. These products are often promoted as advanced “must have” products for the contemporary dental practice. Although we firmly believe in the future of technologic advances, we must objectively scrutinize their putative benefits and assess the potential risks in their use before incorporating them into clinical practice. We can recall the proclamation made in 1969 during the so-called golden age of antibiotics and vaccination: “It is time to close the book on infectious diseases, and declare the war against pestilence won.” Fast forward 46 years, and we now know that not only was that proclamation grossly overoptimistic, buts its attribution to the then United States Surgeon General, Dr. William H. Stewart, has never been confirmed. Whoever the true originator was, this proclamation serves as a classic cautionary reminder to the health care community to avoid hubris. One of the primary methods employed by the dental profession to avoid making unsubstantiated proclamations is to thoroughly and objectively vet the available science before issuing clinical guidelines or recommendations. The American Dental Association Clinical Practice Guidelines are developed by a panel of experts, who critically appraise, summarize, and interpret the clinical relevance of the total body of evidence of a given topic to develop practical recommendations. In the hierarchy of evidence levels, systematic reviews are the highest-level evidence, preferable to narrative reviews, for answering focused clinical questions. Evidence-based guidelines and recommendations addressing dental products or procedures are typically published in peer-reviewed professional journals. Although evidence-based guidelines or recommendations can be developed to address dental products or procedures based on a disciplined consideration of the totality of the best evidence available, there are no such constraints to the actual marketing of dental devices or products. By its very nature, the marketing of dental products may embellish their positive attributes, but this must be balanced by knowledge of the level and veracity of the evidence, the potential for conflicting evidence, and the nature of the data on which marketing is based. As a consequence, the marketing claims for a given product may conflict with some or even the majority of the accumulated available evidence, or the evidence may be insufficient to support the marketing claim. As an example, let us consider the recently marketed light-based adjunctive devices (e.g., chemiluminescence, fluorescence, ultraviolet detector), which claim to markedly improve the practitioner’s ability to discover mucosal abnormalities that might be missed while performing a routine oral examination, especially oral premalignant or malignant lesions. In reality, such claims are essentially based on “proof of concept” case assessment type studies or case series, which cannot be arbitrarily translated to real-world clinical practice. To address this apparent contradiction, a brief explanation of the U.S. Food and Drug Administration (FDA) regulatory device clearance process is necessary. With the signing into law of the Medical Device Amendments of 1976, the FDA was assigned, on May 28, 1976, the authority to regulate medical devices. Today, the FDA’s Center for Devices and Radiological Health regulates medical devices sold in the United States, and any therapeutic device that enters the oral cavity is regulated by the FDA. Examples include powered toothbrushes, caries detection devices, cements, mercury, implants, and saliva substitutes. Devices are classified into one of three regulatory classes (I, II, III), based on the level of control necessary to ensure the safety and effectiveness of the device. The FDA neither develops nor tests new devices but gives advice and evaluates the data submitted by manufacturers. There are basically two options for the manufacturer of a medical device when applying for clearance by the FDA. The Premarket Approval application option requires a manufacturer to submit valid clinical data to support the claims made for the submitted device. In contrast, the Premarket Notification 510(k) process (also known as 510(k)) establishes a much less stringent path to obtain marketing approval. In submitting a 510(k), the manufacturer of the device in question need only show that the submitted device is at least as safe and effective asdthat is, substantially equivalent toda device that was legally marketed

Gastrointestinal Illnesses and Their Effects on the Oral Cavity

Many disease processes affecting the gastrointestinal (GI) tract may cause observable changes to the oral cavity. In fact, oral cavity changes may represent the first clinical manifestation of an underlying GI condition. Recognition and appropriate referral of a possible GI condition contribute to overall health and wellness in patients. Some of the more important GI conditions that may manifest oral cavity involvement include: reflux disorders, inherited GI polyposis syndromes, and inflammatory bowel disease. This article briefly reviews the aforementioned topics.