Tim Hodgson

Oral lesions of HIV disease and HAART in industrialized countries.

The epidemiology of HIV-related oral disease in industrialized nations has evolved following the initial manifestations described in 1982. Studies from both the Americas and Europe report a decreased frequency of HIV-related oral manifestations of 10–50% following the introduction of HAART (highly active antiretroviral therapy). Evidence suggests that HAART plays an important role in controlling the occurrence of oral candidosis. The effect of HAART on reducing the incidence of oral lesions, other than oral candidosis, does not appear as significant, possibly as a result of low lesion prevalence in industrialized countries. In contrast to other oral manifestations of HIV, an increased prevalence of oral warts in patients on HAART has been reported from the USA and the UK. HIV-related salivary gland disease may show a trend of rising prevalence in the USA and Europe. The re-emergence of HIV-related oral disease may be indicative of failing therapy. A range of orofacial iatrogenic consequences of HAART has been reported, and it is often difficult to distinguish between true HIV-related oral disease manifestations and the adverse effects of HAART. A possible association between an increased risk of oral squamous cell carcinoma and HIV infection has been suggested by at least three epidemiological studies, with reference to the lip and tongue. These substantial and intensive research efforts directed toward enhancing knowledge regarding the orofacial consequences of HIV infection in the industrialized nations require dissemination in the wider health care environment.

Auto-inflammatory syndromes and oral health

Auto-inflammatory diseases (periodic syndromes) are rare childhood-onset disorders which are characterized by fluctuating or recurrent episodes of fever and inflammation affecting serosal surfaces, joints, eyes and/or skin without significant autoantibody production or an identifiable underlying infection. They are disorders of innate immunity and the underlying genetic defect has been identified in most of the syndromes. Diagnosis relies on clinical symptoms and evidence of an elevated acute phase response during attacks, supported by finding mutations in the relevant genes. Several syndromes can lead to systemic AA amyloidosis. Aphthous-like oral ulceration has been reported as one manifestation in several of the syndromes, including periodic fever, aphthous-stomatitis, pharyngitis, adenitis (PFAPA) familial Mediterranean fever (FMF), hyperimmunoglobulinaemia D and periodic fever syndrome, tumour necrosis factor receptor associated periodic syndrome and pyogenic sterile arthritis, pyoderma gangrenosum, acne (PAPA). Chronic jaw recurrent osteomyelitis has been recorded in chronic recurrent multifocal osteomyelitis. Advances in the molecular pathogenesis of these syndromes and the regulation of innate immunity have enhanced diagnosis, and rationalized therapies. This article reviews the periodic fever syndromes relevant to oral health and the suggested association of FMF with Behçets disease.

An international survey in postgraduate training in Oral Medicine

OBJECTIVES The aim of this preliminary study was to investigate postgraduate Oral Medicine training worldwide and to begin to identify minimum requirements and/or core content for an International Oral Medicine curriculum. MATERIALS AND METHODS Countries where there was believed to be postgraduate training in Oral Medicine were identified by the working group. Standardized emails were sent inviting participants to complete an online survey regarding the scope of postgraduate training in Oral Medicine in their respective countries. RESULTS We received 69 total responses from 37 countries. Of these, 22 countries self-identified as having postgraduate Oral Medicine as a distinct field of study, and they served as the study group. While there is currently considerable variation among Oral Medicine postgraduate training parameters, there is considerable congruency in clinical content of the Oral Medicine syllabi. For example, all of the training programs responded that they did evaluate competence in diagnosis and management of oral mucosal disease. CONCLUSIONS This preliminary study provides the first evidence regarding international Oral Medicine postgraduate training, from which recommendations for an international core curriculum could be initiated. It is through such an initiative that a universal clinical core syllabus in postgraduate Oral Medicine training may be more feasible.

(A1) Identification of Oral Health Care Needs in Children and Adults, Management of Oral Diseases:

The workshop considered five questions reviewing the identification of international oral health care needs of children and adults, and the management of oral diseases in resource-poor countries: (1) What is the role of the dental profession in the management of the HIV-infected individual? (2) Identifying health care needs-What are the epidemiology and disparities of HIV-associated oral lesions in children from different continents? (3) How effective is HIV treatment in controlling oral diseases? (4) Could we develop basic inexpensive oral and dental care protocols for economically deprived HIV-infected patients? and (5) What is the best method of arranging resources to meet the oral health care needs of people with HIV disease? The consensus of the workshop participants was that there is a need to re-target research efforts to non-established market economy countries and prioritize research in these regions to children with HIV disease. It will be important to assess commonalities and variations in oral health needs across geographical and cultural boundaries, and research efforts should be centralized in resource-poor countries to support multi-center longitudinal standardized studies. It is essential that oral health research be integrated into other health care research programs, to make these research priorities and public health initiatives feasible.

Onset and progression of clinical manifestations of orofacial granulomatosis

BACKGROUND There remain few studies describing in detail the early occurrence and long-term progression of clinical manifestations of orofacial granulomatosis (OFG) in a substantial number of patients. OBJECTIVES The aim of this study was to determine the early and late clinical manifestations of a large case series of patients with OFG. PATIENTS/METHODS Clinically relevant data of 49 patients with OFG who attended an Oral Medicine unit in the UK were examined retrospectively. The analyzed parameters included occurrence and typology of initial manifestations at onset and with respect to long-term follow-up. RESULTS Five major patterns of disease onset were observed. Recurrent facial swelling with/without intra-oral manifestations was the single most common presentation at onset followed by intra-oral ulcers, and other intra-oral and neurological manifestations. The majority of patients later developed a spectrum of additional features. CONCLUSIONS OFG results in multiple manifestations at different time points. The disease onset is characterized by manifestations other than facial swelling in about half of affected individuals. However, patients can develop cosmetically unacceptable lip/facial swelling at a later stage. Nearly all affected individuals ultimately develop lip/facial swelling while about half of all patients develop oral ulceration.

Global Oral Health Inequalities Oral Infections–Challenges and Approaches

Four oral mucosal infections were identified as Global Oral Health Priorities: (a) HIV and associated viral, bacterial, and fungal infections; (b) tuberculosis; (c) NOMA; and (d) sexually transmitted diseases. Huge global inequalities exist in all four. HIV-associated infections constitute the major challenge. Oral manifestations of AIDS can be specifically diagnostic, indicating a significant role for dentists within health teams. The World Workshops in Oral Health & Disease in AIDS have identified a research program, elements of which are being implemented. Data on oral mucosal involvement in tuberculosis, syphilis, and gonorrhea are incomplete in developed countries and virtually non-existent in low- and middle-income countries, indicating the need for further epidemiological studies. Oral manifestations of tuberculosis and sexually transmitted diseases are largely associated with general health, so action programs should be integrated with agencies treating the systemic diseases. NOMA is very much in the oral health domain. It is a preventable disease associated with malnutrition and unidentified bacterial factors. Prevalence is probably grossly overestimated at present; but nevertheless it constitutes a challenge to the profession, especially in the NOMA belt. Current treatment is surgical, but plans for its eradication should be achievable. The global oral health community, especially the IADR, has a major role to play.

World Workshop on Oral Medicine VI: a systematic review of the treatment of mucocutaneous pemphigus vulgaris

OBJECTIVE To determine the efficacy and safety of interventions for pemphigus vulgaris (PV). STUDY DESIGN We conducted a systematic review from 2003 to 2013 according to the Cochrane Collaboration methodology. Randomized controlled trials (RCTs) or controlled clinical trials (CCTs) and observational studies were conducted along with diagnosis confirmed by clinical, histopathologic, and immunofluorescence criteria. Primary outcomes were disease remission and mortality; several relevant secondary outcomes were also included. RESULTS Fourteen RCTs or CCTs and 110 observational studies were included in the final analyses. RCTs or CCTs demonstrated considerable heterogeneity in outcome measures, and all had a high risk of bias for at least 1 of 8 domains. Of the studies, 96.8% (120) described the use of oral corticosteroids. Azathioprine and mycophenolate-mofetil were the most commonly cited treatments. An increasing number of studies described biologic therapies (rituximab, intravenous immunoglobulin [IVIg]). Evidence supporting recent comprehensive treatment guidelines was reviewed. CONCLUSIONS We found persisting wide variations in treatment practice and inadequate quality of research supporting optimal PV treatment.

Bisphosphonate-related osteonecrosis of the jaws and its relevance to children--a review.

Bisphosphonate-related osteonecrosis of the jaws (BRONJ) has been detailed extensively in adults, but to date, there have been no similar cases in children. Members of the dental team may treat children prescribed bisphosphonate therapy often for management of osteogenesis imperfecta (OI). There is uncertainty as to how best treat this patient group. This review explores the background of bisphosphonates, indications for their prescription in children, adverse effects with special emphasis on BRONJ, and protocols available to guide dental management.

Validity and reliability of the Chronic Oral Mucosal Diseases Questionnaire in a UK population.

OBJECTIVE The objective of this study was to investigate the validity and reliability of a the Chronic Oral Mucosal Diseases Questionnaire in a UK population METHODS Two hundred patients with chronic oral mucosal disease (oral lichen planus, recurrent aphthous stomatitis, mucous membrane pemphigoid, pemphigus vulgaris) were enrolled in this study from the Oral Medicine Department of University College London Hospitals Trust (UCLHT) Eastman Dental Hospital. Individuals were interviewed using Oral Health Impact Profile (OHIP-14), Visual Analogue Scale (VAS) and Chronic Oral Mucosal Diseases Questionnaire (COMDQ), and the construct validity and internal reliability were examined. RESULTS Of the 200 study participants, 100 respondents had oral lichen planus, 42 had recurrent aphthous stomatitis and 58 had vesiculobullous conditions (mucous membrane pemphigoid or pemphigus vulgaris). With regard to construct validity, a moderate to good degree of convergent validity was found between OHIP-14 and VAS and most subscales and the total COMDQ score except the patient support subscale of COMDQ (0.21-0.37). CONCLUSION COMDQ is a valid and reliable patient-reported outcome measure for patients with chronic oral mucosal diseases in a UK population. It can be considered a valuable instrument in both clinical practice and in oral medicine research.

Aetiology, diagnosis and treatment of oral lichen planus

Oral lichen planus is a common condition which can have negative effects on a patients quality of life. This article reviews the aetiopathogenesis, management and malignant potential of oral lichen planus.