Yolanda Jiménez

Oral cancer: Clinical features

Oral squamous cell carcinoma (OSCC) is a well-known malignancy that accounts for more than 90% of all oral cancers. In this article we will perform a brief review of its clinical characteristics and the differential diagnosis. Regarding symptoms, pain is the most frequent presentation and the tongue and the floor of the mouth have the highest occurrence. OSCC in its initial stages shows an erytholeukoplastic area without symptoms but in advanced stages there are ulcers and lumps with irregular margins which are rigid to touch. The different diagnosis should be established with other oral malignant diseases such as lymphomas, sarcomas and metastasis, which have rapid growth rates as opposed to the typical OSCC.

Preliminary investigation of the association of oral lichen planus and hepatitis C

OBJECTIVE The aim of this investigation was to determine if an association exists between hepatitis C virus and oral lichen planus. STUDY DESIGN Three groups of subjects were selected: 505 patients with hepatitis C virus infection (group 1), 100 patients with oral lichen planus (group 2), and a randomly selected control group (age- and gender-matched) of 100 healthy subjects (group 3). The prevalence of oral lichen planus was determined in groups 1 and 3, and the prevalence of hepatitis C virus infection was established in groups 2 and 3. RESULTS The prevalence of oral lichen planus was 3.36% (n = 17) in group 1 and 1% (n = 1) in the control group; the prevalence of hepatitis C virus infection was 23% (n = 23) in group 2, and 5% (n = 5) in the control group. No significant differences were observed in the incidence of oral lichen planus in group 1 between those patients who received interferon and those who did not. The 17 patients in group 1 who manifested oral lichen planus and hepatitis C virus infection simultaneously exhibited a marked tendency to have only reticular lesions (70.6%), with involvement of the buccal mucosa in 88.2% of these patients, the tongue in 29.4%, and the gingiva in 11.8%. Analyzing a randomized subgroup of 143 patients from group 1 (subgroup 1) that was matched by age and gender with groups 2 and 3, we found that the incidence of oral lichen planus in patients with hepatitis C virus infection (subgroup 1) was greater than in the control group (5.59% vs 1%), though this was not statistically significant (chi2 = 0.119; p = 0.06). In contrast, group 2 exhibited a statistically significant higher incidence of hepatitis C virus infection (23%) than the controls (5%; chi2 = 0.259, p = 0.0002). CONCLUSIONS The prevalence of hepatitis C virus infection in patients with oral lichen planus was greater than in the control series. In our opinion this observation warrants the investigation of potential concomitant hepatitis C virus infection in patients with oral lichen planus.

Collagen telopeptide (serum CTX) and its relationship with the size and number of lesions in osteonecrosis of the jaws in cancer patients on intravenous bisphosphonates

Osteonecrosis of the jaws (ONJ) is an important possible late adverse effect of bisphosphonates. Serum C-terminal cross-linking telopeptide of type I collagen (CTX) can determine bone turnover and can act as a biological marker of bone resorption. We studied this biological marker in 15 patients (Group 1) with bisphosphonate-induced ONJ comparing with a control group of 10 healthy people matched by age and gender. We found no statistically significant relationships in Group 1 either between the serum CTX and the number of areas of exposed bone nor with the size of the osteonecrotic area.

Psychologic factors and oral lichen planus: A psychometric evaluation of 100 cases

OBJECTIVE The purpose of this study was to analyze the importance of psychologic factors in patients with oral lichen planus, and attempts were made to identify possible personality features characteristic of patients with oral lichen planus. STUDY DESIGN The study involved 100 patients with oral lichen planus (group 1) and 50 control subjects (group 2). We applied the following psychometric tests to both groups: Spielberger State-Trait Anxiety Inventory, Cattell Personality Questionnaire 16PF, Hassanyeh Rating of Anxiety-Depression-Vulnerability, Beck Depression Inventory, Raskin Depression Screen, and Covi Anxiety Screen. RESULTS The patients with oral lichen planus were found to exhibit greater anxiety, as reflected by statistically significant scores with the anxiety tests that were used (Spielberger State-Trait Anxiety Inventory, Cattell Personality Questionnaire 16PF, Hassanyeh Rating of Anxiety-Depression-Vulnerability, and Covi Anxiety Screen). The patients with oral lichen planus likewise exhibited greater depression than the controls in all 3 depression tests applied (Beck Depression Inventory, Hassanyeh Rating of Anxiety-Depression-Vulnerability, and Raskin Depression Screen) and were more vulnerable to psychic disorders on the basis of the PD subscales (vulnerability) of the Hassanyeh questionnaire. Three features (conformity to the group, astuteness, and rebelliousness) defined the personalities of our patients with oral lichen planus, according to the Cattell 16PF questionnaire. Finally, those patients with erosive lichen planus exhibited higher depression scores than patients with nonerosive lichen planus. CONCLUSIONS Despite the higher anxiety scores observed in patients with oral lichen planus, it was not established that the observed psychologic alterations constitute a direct etiologic factor of oral lichen planus; nor was it established that such alterations are a consequence of oral lichen planus and its lesions.

Osteonecrosis of the jaws in patients treated with intravenous bisphosphonates (BRONJ): A concise update

Bisphosphonate-related osteonecrosis of the jaws (BRONJ) is a severe complication seen most frequently in patients on intravenous bisphosphonates treatment for malignant diseases. High potency bisphosphonates are generally implicated and risk factors also include dental extractions. Prevention is of paramount importance. Management is controversial but there is little evidence basis and the consensus is to be conservative. Recent advances in this area are summarised in this concise review.

Osteonecrosis of the jaws in intravenous bisphosphonate use: Proposal for a modification of the clinical classification

Osteonecrosis of the jaws induced by bisphosphonates, first reported by Marx is now widely recognised: more than 260 reports appear in Medline-PubMed. There are many series of cases presented in the last years. A clinical stage classification has been proposed, based on clinical symptoms (mainly pain) and the presence of lesions and complications such as jaw fractures and skin fistulas by Ruggiero et al. There are three stages in this Ruggiero classification: Stage 1 is exposed bone necrosis without symptoms; Stage 2 is exposed bone necrosis with symptoms; and Stage 3 is where there are jaw fractures, skin fistulas or osteolysis extending to the inferior border. This classification is used to guide treatment and may also be useful to establish international criteria. However, based on observations made since the original paper, we now propose the following two modifications of Stages 1 and 2; Stage 1. That the inclusion criteria include patients with an oral fistula without obvious bone exposure, since these patients cannot be classified in the original Ruggiero’s classification and yet must have a small intraoral fistula (Table 1). Stage 2. That the Ruggiero classification, which consists of a patient who has an exposed necrotic jaw bone with symptoms, should be divided.

Candida biotypes in patients with oral leukoplakia and lichen planus

Prevalence of yeasts in 35 leukoplakia and 34 oral lichen planus patients was compared with that observed in persons without oral diseases. Serotype and morphotype were determined on Candida albicans isolates. Yeasts were isolated from the oral cavity specimens of 43.7% of the patients. C. albicans (serotype A) was the predominant species (76% in leukoplakia, 88.2% in lichen planus and 60.8% in healthy persons). Sixteen morphotypes were encountered on malt extract agar, being 732, 733, 734, 753 and 754 the most frequently found. Morphotypes SP1N and SP1Y were the most common on Sabouraud-trypheniltetrazolium agar (68.4% of the isolates from leukoplakia and 73.3% from lichen planus, but only 46.6% of the isolates from healthy oral mucosa showed SP1N morphotype). Presence of oral lesions was associated with a marked reduction in the yeast species and C. albicans biotypes, suggesting that C. albicans and particularly some of its biotypes, show a high potential of adaptation to the changes associated with the development of oral leukoplakia and lichen planus.

Enhancing the efficacy of treatment for temporomandibular patients with muscular diagnosis through cognitive-behavioral intervention, including hypnosis: a randomized study

OBJECTIVE This study evaluated the efficacy of a cognitive-behavioral therapy (CBT), including hypnosis, in patients with temporomandibular disorders (TMDs) with muscular diagnosis. STUDY DESIGN Seventy-two patients (65 women and 7 men with an average age of 39 years) were selected according to the Research Diagnostic Criteria for TMD, and assigned to the experimental group (n = 41), receiving the 6-session CBT program, and the control group (n = 31). All patients received conservative standard treatment for TMD. The assessment included pain variables and psychologic distress. RESULTS There were significant differences between the groups, the experimental group showing a higher improvement in the variables evaluated. Specifically, 90% of the patients under CBT reported a significant reduction in frequency of pain and 70% in emotional distress. The improvement was stable over time, with no significant differences between posttreatment and 9-month follow-up. CONCLUSIONS CBT, including hypnosis, significantly improved conservative standard treatment outcome in TMD patients.

Mental Neuropathy as a Manifestation Associated With Malignant Processes : Its Significance in Relation to Patient Survival

PURPOSE Mental neuropathy (MN) is characterized by the presence of a sensory defect in the form of paresthesias or dysesthesias in the territory innervated by the mental nerve. MN may be the first manifestation of systemic cancer, a symptom of spread of an established tumor, or a sign of infiltration in an intraoral lesion. In any of these cases, the symptom is indicative of a very poor patient prognosis. MATERIALS AND METHODS A total of 22 cancer patients with chin paresthesia were studied. Group 1 comprised patients with chin paresthesia who had a primary tumor in some other region at a distance from the oral cavity or maxillofacial zone. Group 2 in turn comprised patients with primary malignancies of the oral and/or maxillofacial territory and who likewise presented with chin paresthesia. Data were collected relating to patient age, gender, primary intraoral lesion (location, size, histologic diagnosis), primary systemic tumor, and mean patient survival. RESULTS Group 1 consisted of 11 patients (8 men and 3 women), aged between 36 and 81 years (mean, 58.09 +/- 14.99 years), with different systemic cancers. The mean survival after the diagnosis of chin paresthesia was 14.8 +/- 16.5 months, and only 1 patient was still alive after 9 months. Group 2 consisted of 11 patients (8 men and 3 women), aged between 33 and 72 years (mean, 56.18 +/- 15.69 years). All presented with oral squamous cell carcinoma, with the single exception of 1 case of fibrosarcoma. In this group the mean survival of the 8 patients who died was 28.2 +/- 29.6 months. Three patients survived for a mean of 17 months. CONCLUSIONS Chin paresthesia is a very important prognostic symptom determining the degree of infiltration of intraoral lesions, and in some cases it may be indicative of the existence of a primary tumor (identified or otherwise), with poor short-term survival--given that 81.9% of the patients studied (18 cases) had died before a mean of 20 months. Although mean survival was shorter (14.8 months) among the patients in group 1 than in group 2 (28.2 months), the difference was not statistically significant.

Utility of imaging techniques in the diagnosis of oral cancer

PURPOSE Imaging techniques such as magnetic resonance imaging (MRI), computed tomography (CT), and positron emission tomography (PET) are often used to complement the clinical exploration and staging of oral squamous cell carcinoma (OSCC). Which of these techniques is best in establishing correct staging and treatment planning is not clear, however. This study aims to determine which technique is most appropriate for diagnosing the primary tumor and for detecting bone invasion and neck metastases. MATERIAL AND METHODS A Medline literature search was made over the last 10 years. In each selected study, we recorded the sample size and sensitivity, specificity and precision. Strengths and limitations of each study were assessed also. RESULTS Eight articles relating to detection of the primary tumor, 19 to bone invasion, and 28 to neck metastases were selected and compared. CONCLUSION Despite the high precision of positron emission tomography (PET) or hybrid techniques in detecting the primary tumor, they have not replaced magnetic resonance imaging (MRI) or computed tomography (CT), particularly in the case of small lesions. MRI and CT are adequate techniques in the assessment of bone invasion.Recent studies have shown good results with PET-CT and cone-beam CT, but future studies are needed to demonstrate their benefits. Despite the high precision of PET and PET-CT, their use in assessing neck metastases remains subject to controversy, and their use in all patients with OSCC is not justified. CT and MRI are useful in determining the N category.