Nilce Santos de Melo

Abordagem do câncer da boca : uma estratégia para os níveis primário e secundário de atenção em saúde

Progress in cancer management by health systems involves improvements in surveillance, organization of healthcare services, specific programs focused on primary and secondary prevention, and scientific and technical advances in diagnosis and treatment. Despite well-known progress in the management of malignant neoplasms in all the above areas, oral cancer displays persistently high morbidity and mortality rates, apparently failing to reflect the accumulated scientific knowledge on the disease. The current article discusses the reasons for this mismatch, the need for redefining priorities in oral cancer management, and the implementation of such priorities as a public health policy.

Imaging Findings of Bisphosphonate-Related Osteonecrosis of the Jaws: A Critical Review of the Quantitative Studies

Objectives. This paper offers a critical review of published information on the imaging strategies used for diagnosing bisphosphonate-associated osteonecrosis of the jaw (BRONJ) in patients taking intravenous bisphosphonates, pointing at the different methodologies and results of existing literature. Methods. Electronic literature search was performed in order to identify as many quantitative studies that discussed the imaging findings of BRONJ up to February 2014. Initially, the search for articles was based on the following four types of imaging modalities for evaluating BRONJ: computed tomography, plain film radiographs, magnetic resonance imaging, and nuclear bone scanning. Results. Eleven out of the 79 initially selected articles met the inclusion criteria. Most of the selected articles were cross-sectional studies. Regarding the selected studies, 54.5% have used plain films radiographs and 54.5% were based on computed tomography findings. All of the selected studies showed a small number of patients and none of the selected studies have tested the accuracy of the imaging examination for evaluating BRONJ. Conclusions. This critical review showed a scarcity of quantitative studies that analyzed the typical imaging findings related to BRONJ. Further studies are necessary in order to analyze the role of different imaging techniques in the assessment of BRONJ.

Dental panoramic indices and fractal dimension measurements in osteogenesis imperfecta children under pamidronate treatment.

OBJECTIVES To verify radiomorphometric indices and fractal dimension (FD) in dental panoramic radiographs (DPRs) of children with different types of osteogenesis imperfecta (OI) and also to verify the effect of pamidronate (PAM) treatment in such panoramic analyses. METHODS In this retrospective study, 197 DPRs of 62 children with OI Types I, III and IV who were in treatment with a comparable dosage of intravenous PAM were selected. The mandibular cortical width (MCW), mandibular cortical index, visual estimation of the cortical width and FD of three standardized trabecular and cortical mandibular regions of interest were obtained from the radiographs. Factorial analysis of variance and Fisher test were used to compare FD and MCW measurements in children with different types of OI for different PAM cycles. RESULTS Children with all types of OI have thinner and more porous mandibular cortices at the beginning of treatment. There were significant differences between MCW and FD of the cortical bone, regarding different types of OI and number of PAM cycles (p = 0.037 and p = 0.044, respectively). FD measurements of the trabecular bone were not statistically different among OI types nor were PAM cycles (p > 0.05). CONCLUSIONS Children with OI presented cortical bone alterations after PAM treatment. Both MCW and the FD of the cortical bone were higher in children with OI after PAM treatment. It is argued that cortical bone should be considered for analyzing patients with OI, as well as to monitor the progress of PAM treatment.

Comparison between computed tomography and clinical evaluation in tumour/node stage and follow-up of oral cavity and oropharyngeal cancer

OBJECTIVES The aim was to verify the concordance of CT evaluation among four radiologists (two oral and maxillofacial and two medical radiologists) at the TN (tumour/node) stage and in the follow-up of oral cavity and oropharyngeal cancer patients. The study also compared differences between clinical and CT examinations in determining the TN stage. METHODS The following clinical and tomographic findings of 15 non-treated oral cavity and oropharyngeal cancer patients were compared: tumour size, bone invasion and lymph node metastases. In another 15 patients, who had previously been treated, a clinical and tomographic analysis comparison for the presence of tumoural recurrence, post-therapeutic changes in muscles and lymph node metastases was performed. The concordances of tomographic evaluation between the radiologists were analysed using the kappa index. RESULTS Significant agreement was verified between all radiologists for the T stage, but not for the N stage. In the group of treated patients, CT disclosed post-therapeutic changes in muscles, tumour recurrence and lymph node metastases, but no concordance for the detection of lymph node metastases was found between radiologists. In the first group, for all radiologists, no concordance was demonstrated between clinical and tomographic staging. CT was effective for delimitating advanced lesions and for detecting lymph node involvement in N0 stage patients. CT revealed two cases of bone invasion not clinically detected. CONCLUSIONS Interprofessional relationships must be stimulated to improve diagnoses, and to promote a multidisciplinary approach to oral cavity and oropharyngeal cancer. Although CT was important in the diagnosis and follow-up of cancer patients, differences between medical and dental analyses should be acknowledged.

Effectiveness of FDG-PET/CT for evaluating early response to induction chemotherapy in head and neck squamous cell carcinoma: A systematic review.

Background:18F-Fluoro-Deoxy-Glucose Positron Emission Tomography with Computed Tomography (18F-FDG PET/CT) may be a powerful tool to predict treatment outcome. We aimed to review the effectiveness of 18F-FDG PET/CT in the assessment of early response to induction chemotherapy (IC) in patients with advanced Head and Neck Squamous Cell Cancer (HNSCC) without previous treatment. Methods:PubMed, Cochrane Library, Science Direct and Web of Science were searched to May 2016. Reference lists of the included articles and additional studies identified by one nuclear medicine expert were screened for potential relevant studies that investigated the effectiveness of 18F-FDG PET/CT performed before and after IC. Three authors independently screened all retrieved articles, selected studies that met inclusion criteria and extracted data. The methodology of the selected studies was evaluated by using the risk of bias checklist of the Agency for Healthcare Research and Quality (AHRQ). Results:Seven out of 170 eligible studies met our inclusion criteria. A total of 207 advanced HNSCC patients were evaluated with 18F-FDG PET/CT at baseline and after IC in the selected articles. Six from seven studies concluded that 18F-FDG PET/CT allowed early evaluation response to IC and predicted survival outcomes. Conclusion:The present systematic review confirms the potential value of 18F-FDG PET/CT as a diagnostic tool for early IV response assessment in HNSCC patients. However, the lack of standard definitions for response criteria and heterogeneous IC protocols indicate the need to further studies in order to better define the role of 18F-FDG PET/CT in these patients.

Dento-osseous anomalies associated to familial adenomatous polyposis mimicking florid cemento-osseous dysplasia

Familial adenomatous polyposis (FAP) is a colorectal cancer syndrome characterized by the development of multiple polyps of the colon and rectum with high risk of malignant transformation. The extraintestinal manifestations such as dento-osseous changes are associated with FAP. This is a case report of a 36-year-old female patient who was referred for dental treatment with the initial diagnosis of florid cemento-osseous dysplasia (FCOD). However, the association of the imaging dento-osseous findings with the medical history confirmed the diagnosis of FAP. The paper illustrates the clinical characteristics and imaging findings associated with FAP, and also discusses misdiagnosis based exclusively on imaging features.

Systematic review with hierarchical clustering analysis for the fractal dimension in assessment of skeletal bone mineral density using dental radiographs

ObjectivesTo systematically review the relationship between the fractal dimension (FD) on jaw bones and skeletal bone mineral density (BMD), focusing on the different methodologies and results in the existing literature.MethodsAn electronic literature search was performed to identify articles that evaluated the relationship between the mandibular and maxillary FD and BMD up to February 2014. After selecting the articles, a hierarchical clustering analysis was performed to verify the dissimilarity of the studies. The following variables were grouped into clusters, and assessed for reliability of the cluster distribution: kind of study, method for calculating FD, relationship between FD and low BMD, digital imaging, and kind of dental radiography. The relative frequencies of the categories of variables were calculated and compared.ResultsOnly 15 studies were selected and three clusters were obtained. Most articles were in the third cluster, and primarily consisted of clinical studies that used the box-counting method to calculate FD on panoramic radiographs. A significant association was found for the variable relationship between FD and low BMD and the clusters. Most of the clinical studies were performed on trabecular bone, but three studies found differences in FD between individuals with normal mandibular cortex and individuals with cortical porosity.ConclusionsThe kind of study, method for calculating FD, relationship between FD and low BMD, and imaging modality should be better standardized to minimize the controversies found in published studies. The performance of FD on the cortical and trabecular bone for osteoporosis screening deserves further investigation.

Pamidronate Affects the Mandibular Cortex of Children with Osteogenesis Imperfecta

We hypothesized that mandibular cortical width (MCW) is smaller in children with osteogenesis imperfecta (OI) than in healthy children and that pamidronate can improve the cortical mandibular thickness. The aim of this study was to assess changes in the MCW on dental panoramic radiographs (DPRs) of children with normal bone mineral density (BMD) and with OI. We also compared the MCW of children with different types of OI regarding the number of pamidronate cycles and age at the beginning of treatment. MCW measurements were retrospectively obtained from 197 DPRs of 66 children with OI types I, III, and IV who were in treatment with a comparable dosage of cyclical intravenous pamidronate between 2007 and 2013. The control group had 92 DPRs from normal BMD children. Factorial analysis of variance was used to compare MCW measurements among different age groups and between sexes and also to compare MCW measurements of children with different types of OI among different pamidronate cycles and age at the beginning of treatment. No significant differences in results were found between male and female subjects in both OI and healthy children, so they were evaluated altogether (P > 0.05). There was an increase of MCW values related to aging in all normal BMD and OI children but on a smaller scale in children with OI types I and III. Children with OI presented lower mean MCW values than did children with normal BMD at the beginning of treatment (P < 0.05). A linear model estimated the number of pamidronate cycles necessary to achieve mean MCW values equivalent to those of healthy children. The thinning of the mandibular cortex depended on the number of pamidronate cycles, the type of OI, and the age at the beginning of treatment. DPRs could thus provide a way to identify cyclic pamidronate treatment outcomes in patients with OI.

Early bony changes associated with bisphosphonate-related osteonecrosis of the jaws in rats: A longitudinal in vivo study

OBJECTIVE To evaluate early bony changes in an animal model of Medication-Related Osteonecrosis of the Jaw (MRONJ) at the side of the local trauma and at the contralateral side, comparing with a control group. Bony changes were evaluated by Microcomputed Tomography (MicroCT) at three times points: at baseline (T0), after drug administration (T1) and after dental extraction (T2). DESIGN Two groups were compared: the experimental group in which zoledronic acid (ZA) was administered (17 rats) and the control group (13 rats). Dental extractions of the lower left first molars were performed in all animals. The left side was considered as the supposed affected area in the ZA group, and the right side was considered as the unaffected area. In these areas, the following structural microtomographic bone parameters were calculated: Bone Mineral Density (BMD), Trabecular Thickness (Tb.Th), and Bone Volume Proportion (BV/TV). The comparison of quantitative bone parameters among the different sides and experimental phases of both studied groups were performed by ANOVA-factorial. RESULTS None of the animals of the control group developed MRONJ. In the ZA group, 76% presented bone exposure. From T0 to T1, Tb.Th and BV/TV increased, and in T2, the mean values were higher in ZA group than in the control group. BMD increased throughout the different phases of both groups. CONCLUSIONS Structural bony changes occurred in the ZA group at both mandibular sides before the dental extraction (T1). Tb.Th and BV/TV should be further investigated as potential early bone markers of MRONJ.

Oral health promotion: expanding the boundaries of knowledge

The following professors participated in the symposium discussions as panelists: Maria Fidela de Lima Navarro (Univ de São Paulo, Bauru, SP, Brazil); Joana Carvalho (Univ de Louvain, Louvain, Belgium); Alexandre Rezende Vieira (Univ of Pittsburgh, Pittsburgh, PA, USA); Mário Taba Júnior (Univ de São Paulo, Ribeirão Preto, SP, Brazil); Tiago Sousa Coelho (Univ de Brasília, Brasília, DF, Brazil); and the following professors participated as moderators: Jaime Aparecido Cury (Univ de Campinas, Piracicaba, SP, Brazil); Nilce Tomita (Univ de São Paulo, Bauru, SP, Brazil); Lilian Marly de Paula (Univ de Brasília, Brasília, DF, Brazil). Jaime Cury: The analysis of the “SB Brazil 2010” National Oral Health Survey shows a steady reduction in the number of caries in our country. Nevertheless, there are still regional disparities, especially when we consider the Northern and Northeastern regions of the country, where the indicators are worse. What solutions, whether genetic, behavioral or political in nature, do the panelists propose to reduce this imbalance? Alexandre Vieira: The disparity problem is mainly related to the unequal allocation of resources and access to services, among other things. Unfortunately, the underlying genetic component does not provide immediate answers to this issue. My studies analyzing individual susceptibility as a risk factor for dental caries are still at an early stage and cannot yet be translated into clinical practice. Joana Carvalho: In my opinion, we have to work together with other health areas, as well as with the families, in order to reduce dental caries and to promote better healthcare in these regions. I think this is the simplest way of working with primary care, i.e., through education and basic oral healthcare measures. These simple actions have proven very effective in promoting long-term qualitative and quantitative improvements in this area. I believe the best thing we can do, practically speaking, is to educate people about the importance of tooth brushing and the use of toothpaste. This would be my recommendation. Maria Fidela: Social determinants are complex. There is no single factor that can determine how people will react. If the population lacks basic understanding about this matter, even the simplest educational actions may be hard to assimilate. It’s a known fact that the low-income populations are more vulnerable to a larger number of diseases, including oral diseases. Oral health cannot be analyzed as an isolated element. It is a part of a person’s overall health condition. In order to change this complex situation, we need sound public policies. In that sense, our country has created the Prouni (University for All Program) and the Bolsa Familia cash transfer program. These initiatives are enabling changes to be Lilian Marly de Paula Nilce Santos de Melo Heliana Dantas Mestrinho (organizers)