2021年唾液腺恶性肿瘤两种国际指南的解读与比较

为给唾液腺恶性肿瘤(salivary gland malignancy,SGM)的诊疗提供循证建议,2021年美国临床肿瘤学会和美国国家综合癌症网分别制订和更新了SGM临床实践指南。本文从SGM的术前评估、手术治疗、放射治疗、系统性治疗、随访和复发转移性疾病诊疗等角度出发,对两种指南进行解读和比较分析,旨在为我国SGM的诊疗提供临床指导。     

孕期口腔诊疗临床实践指南的系统评价和总结建议

目的: 评价和总结孕期口腔疾病预防、诊断和治疗的临床实践指南,为参与孕期口腔诊疗的口腔全科医生提供总结性建议。方法: 使用“产前口腔保健”结合“指南”或“共识声明”等关键词检索在线数据库、专业机构网站和循证实践平台等网站,筛选出符合纳入标准的已发表的指南或共识声明,使用临床指南研究与评估系统II（AGREE-II）对入选指南的制定过程和报告质量进行评价,并对各临床指南间主要临床建议及其一致性进行了总结和评估。结果: 经检索共筛选出15篇孕期口腔诊疗指南或共识声明,全文评估后确定7篇符合纳入标准,随后使用AGREE-II对纳入指南进行分析。这些指南均是由专家组和共识会议在全面审查现有的最佳证据后制定的,并一致提出口腔疾病的预防、诊断、修复和牙周治疗以及拔牙在整个孕期都是安全的,并且能有效的改善和维持孕妇及其子代的口腔健康。对妊娠期口腔疾病应及时治疗,并可在怀孕的任何时期进行牙科急诊治疗。为保持孕妇口腔健康应每6个月进行一次口腔检查和牙周洁治。结论: 已发表的临床指南为口腔医生对孕妇进行及时和有效的口腔诊疗提出了清晰和一致的指导建议。口腔疾病的预防、诊断和治疗在整个妊娠周期都是安全的。     

年轻恒牙复杂冠折及冠根折的诊疗策略

年轻恒牙牙根未发育完全，复杂冠折及冠根折造成的牙体缺损、牙髓暴露可造成牙髓感染坏死甚至牙根发育停止，影响患牙保留和永久性修复。文章结合2020年国际牙外伤学会颁布的指南和牙外伤临床研究报道深入剖析年轻恒牙复杂冠折及冠根折的诊疗策略，旨在通过汇总分析当前诊疗方法，优化临床治疗规范，为年轻恒牙复杂冠折及冠根折的治疗提供最佳临床路径。     

口腔及口咽癌新版TNM分期与NCCN诊治指南部分解读

美国癌症联合委员会《AJCC肿瘤分期手册》与美国国立综合癌症网(NCCN）肿瘤学临床实践指南已广泛用于临床实践中。NCCN肿瘤诊治指南与TNM分期密切相关,指南为不同TNM分期的肿瘤制定了较为详细的诊治标准,作为依据指导临床应用。2017年第8版口腔及口咽癌TNM分期新增了较多内容,如侵袭深度（DOI）、淋巴结外扩展（ENE）、人乳头瘤病毒（HPV）等指标用于了新的分期中,并且为HPV相关的口咽癌制定了一个新的TNM分期。2018年版NCCN口腔与口咽癌指南及时反映了第8版口腔及口咽癌TNM分期中新的变化,同时亦为HPV相关的口咽癌制定了相应的诊治指南。新的TNM分期及NCCN诊治指南对口腔与口咽癌患者诊疗策略的制定及治疗方案的选择具有较大的指导意义。为了临床工作的需要,本文结合两者的变化进行了部分解读。     

ASCO指南解读：“口腔和口咽鳞状细胞癌颈部管理”

为提供口腔和口咽鳞状细胞癌颈部管理的循证建议,美国临床肿瘤协会（ASCO）成立了专家组,对1990—2018年相关文献进行了分析,包括系统评价、荟萃分析、随机对照试验、前瞻性和回顾性观察对照试验。共纳入124篇,形成2019版指南。该指南设定了6种常见临床情形,其中口腔和口咽鳞状细胞癌各3种。从生存率、疾病控制情况、复发率及生存质量等角度,讨论了高质量颈淋巴清扫术、术后辅助放疗或放化疗、手术或非手术治疗的适应证,以及单独放化疗是否充足等问题,分条依次提出临床治疗建议。对多种慢性病患者、指南的局限性和适用范围也进行了阐述。本文就2019版ASCO指南进行解读,为诊治口腔颌面部肿瘤提供临床指导。     

2019年NCCN口腔口咽癌诊疗指南更新解读

美国癌症联合委员会2017年第8版《AJCC肿瘤分期手册》出版,口腔及口咽癌TNM分期标准中新增侵袭深度（DOI）、淋巴结外扩展（ENE）、人乳头瘤病毒（HPV）等指标,并将口咽癌分为HPV阳性（p16+）与HPV阴性（p16-）,分别制定了不同的TNM分期标准。2018年,美国国立综合癌症网（NCCN）首次为HPV阳性（p16+）口咽癌制定了诊疗指南。2019年第1版NCCN头颈癌诊疗指南已经发布,其中对口腔口咽癌指南做了部分修订。为临床工作需要,本文结合2版变化进行部分解读。     

年轻恒牙脱位性损伤的诊疗原则

年轻恒牙外伤是影响儿童及青少年牙颌发育与健康的重要疾病，其中脱位性牙外伤常同时累及多颗牙齿和口腔颌面部其他软硬组织，病情复杂，治疗相对困难，远期并发症较多。文章结合2020年国际牙外伤学会颁布的指南，对年轻恒牙脱位性损伤的检查诊断要点、治疗原则和预后进行介绍，为临床儿童牙外伤的诊疗提供参考。     

完全脱位牙再植的牙髓、牙周膜愈合:从生物学基础到牙外伤指南

牙完全脱位又称牙撕脱伤,是一种严重的牙外伤,指在外力作用下,牙齿从牙槽窝中脱出,导致牙髓血运中断,牙周膜细胞暴露于体外。首选治疗方法是根据国际牙外伤协会(IADT,2012年)和美国牙髓病协会(AAE,2013年)修订的完全脱位牙再植治疗指南对患牙进行再植,以增大牙周膜愈合及牙髓血运重建的可能。但是完全脱位牙的预后受到多种临床因素影响。在某些情况下,即使按照指南进行规范治疗,完全脱位牙的术后并发症仍无法完全避免。因此,本文详细介绍牙外伤指南制定的相关生物学基础,结合临床病例,帮助临床医生理解和应用上述指南来治疗完全脱位牙及评估患牙的预后,以期为临床提供参考。     

乳牙外伤处理策略

乳牙外伤是儿童口腔急诊的常见病,与恒牙外伤相比,其处理存在特殊性,且国内在其诊疗方面存在不规范等问题。文章参考2012年国际牙外伤协会指南,全面系统地阐述乳牙外伤的概念、分类、临床特征以及各类型乳牙外伤的应急处理原则,为乳牙外伤的诊疗提供参考 。     

口腔扁平苔藓诊疗指南(修订版)

口腔扁平苔藓是一种临床常见的口腔黏膜慢性炎性疾病,以中年女性多见,大多数患者有疼痛、粗糙不适等症状,部分病例还有癌变风险,对患者身心造成较大危害。积极预防、准确诊断和规范治疗对有效防治口腔扁平苔藓具有重要意义。本指南是在2012年试行版基础上进行修订,主要涵盖口腔扁平苔藓的病因及病史采集、临床表现、病理表现、诊断、鉴别诊断、治疗前检查、疾病治疗及预防等8个方面,为该病的临床诊疗提供科学依据和指导。     

Efficacy of sodium hypochlorite and coconut soap used as disinfecting agents in the reduction of denture stomatitis, Streptococcus mutans and Candida albicans

This study evaluated the reduction of denture stomatitis and the antimicrobial activity of 0.05% sodium hypochlorite opposed to Candida albicans and Streptococcus mutans (SGM) when associated with brushing complete dentures with coconut soap. The mucosal characteristics were evaluated according to Newton's classification at baseline, after cleansing the dentures with coconut soap for 15 days in group 1 (nine patients). In the other group (19 patients) the analysis were made before and after cleansing the dentures with coconut soap and with disinfection in a soak solution of 0.05% sodium hypochlorite for 10 min during 15 days. Microbiological tests were used to isolate C. albicans and SGM. Mann-Whitney and Wilcoxon tests were used to compare the mucosal characteristics and Fisher test and McNemar test to compare C. albicans and SGM levels. Statistical analysis at the 95% confidence level (P < 0.05) showed that: (i) the association of coconut soap and 0.05% sodium hypochlorite significantly reduced clinical signs of denture stomatitis, (ii) C. albicans did not reduce in counts, (iii) SGM were reduced but not significantly and (iv) the association of coconut soap and 0.5% sodium hypochlorite was effective in controlling denture biofilm.     

The craniomandibular index: validity

The CMI appears to be valid for use in clinical studies, but users must be aware of its numerous potential errors and its associated strict methodologic guidelines to ensure accuracy and reproducibility of results. The subjective nature of some items demands that the same rater who is unaware of the management status of the patient perform both evaluations. If multiple raters are used, it is recommended that the raters discuss all items, and compare scoring of demonstration subjects before the study and use a pressure algometer for muscle palpation.     

Emergency route diagnosis of mucoepidermoid carcinoma initially diagnosed as a temporomandibular disorder

Salivary gland malignancy (SGM) can affect both major and minor glands and manifests clinically with various presentations. The most common type of SGM is mucoepidermoid carcinoma (MEC), which has been previously reported to be associated with symptomatology associated with temporomandibular disorders (TMD). This case report describes a patient with an aggressive form of MEC of the parotid gland that was initially diagnosed as TMD. In addition, the patient's MEC was diagnosed emergently based on development of acute clinical symptomatology. To the best of our knowledge, emergency route diagnosis of MEC affecting the parotid gland has not been previously reported in the literature.     

Evaluating dietary intake in dental practices: doing it right

BackgroundIn three separate scenarios, the authors illustrate dietary assessment evaluations completed in dental settings by oral health care professionals (OHCPs) using time-efficient guidelines and targeted realistic patient education messages.ConclusionsPatients' responses to key questions can provide OHCPs with a road map for conducting dietary assessments and evaluations, selecting specific assessment approaches, and developing targeted patient nutrition and oral health education messages.Clinical ImplicationsTo individualize and enhance comprehensive patient care, OHCPs can conduct dietary assessments, evaluate results, refer patients when indicated, and provide patient nutrition and oral health education.     

What is new in the 2020 International Association of Dental Traumatology emergency treatment guidelines?

Over the past eight years, there have been marked changes in the recommendations for the management of traumatic dental injuries (TDIs). The recently published International Association of Dental Traumatology (IADT) guidelines for the emergency management of TDIs provide a comprehensive manual for clinicians to refer when assessing and managing patients presenting with these types of injuries. Clinicians should be prepared to utilize these new guidelines which were released in 2020. The aim of this short communication is to support those with previous knowledge regarding the IADT guidelines, to identify the changes in treatment modality, and to provide backing for those exposed to trauma guidelines for the first time. In the present communication, the areas of TDIs have been separated into primary and permanent teeth plus avulsions, with a tabular format highlighting the main changes in the emergency management from the previous version in 2012. This format has been devised to aid the clinicians' understanding of the variations over time and facilitate recall of the new guidelines. For the first time, the 2020 IADT Guidelines present a Core Outcomes Set (COS) that includes outcomes that were relevant to all TDIs and outcomes related to only one or several TDIs. However, the COS is not the object of the present publication.     

National and international guidelines on the replacement of missing teeth with dentures for head and neck cancer patients post-radiotherapy: A rapid review

BackgroundReplacement of missing teeth is not a straightforward task in head and neck cancer (HNC) patients post-radiotherapy. There is debate regarding the best way to care for these patients as it has been reported that using dentures by HNC patients after receiving treatment with radiotherapy might initiate the development of osteoradionecrosis.AimThis rapid review aimed to collate and compare the national and international guidelines for the use of dentures following radiotherapy for HNC patients.Materials and methodsThree steps were included in data collection of this rapid review (first step; identification of dental and relevant non-dental associations/societies, second step, identification of national and international guidelines regarding the dental management of HNC patients, and third step; identification of recommendations about the replacement of missing teeth in HNC patients).ResultsIn the 193 countries recognized by the United Nations, there were 238 relevant societies found, from those 175 confirmed that they do not have clear guidelines. Only 32 associations/societies (all in either Europe and North America) recommend guidelines for their dentists (N = 12 guidelines) about the dental management of HNC patients and show their position regarding the use of dentures for HNC patients after receiving treatment with radiotherapy.ConclusionsThere are very few guidelines and those that do exist differ, lack detail, and rarely go beyond routine advice. Accordingly, clear, detailed, and evidence-based guidelines are required to inform the management of patients with missing teeth following radiotherapy for HNC patients.     

Management of temporomandibular disorders: a rapid review of systematic reviews and guidelines

Temporomandibular disorders (TMD) impact a significant proportion of the population. Given the range of management strategies, contemporary care should be evidence-informed for different TMD types. A knowledge-to-action rapid review of systematic reviews published in the past 5 years and guidelines published in the past 10 years concerning the management of TMD was conducted. The Cochrane, Embase, MEDLINE, PEDro, and PubMed databases were searched. A qualitative data analysis was undertaken, with quality assessment completed using the AMSTAR 2 checklist. In total, 62 systematic reviews and nine guidelines considering a range of treatment modalities were included. In concordance with current guidelines, moderate evidence supports a multi-modal conservative approach towards initial management. Contrary to existing guidelines, occlusal splint therapy is not recommended due to a lack of supporting evidence. The evidence surrounding oral and topical pharmacotherapeutics for chronic TMD is low, whilst the evidence supporting injected pharmacotherapeutics is low to moderate. In concordance with current guidelines, moderate quality evidence supports the use of arthrocentesis or arthroscopy for arthrogenous TMD insufficiently managed by conservative measures, and open joint surgery for severe arthrogenous disease. Based on this, a management pathway showing escalation of treatment from conservative to invasive is proposed.     

The hypertensive patient in dental practice: updated recommendations for classification, prevention, monitoring, and dental management

The Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure recently published new guidelines for the management of adult patients at risk for developing hypertension, cardiovascular disease, and associated conditions. These new guidelines include a new risk category (designated as prehypertension) and indicate a lower range for classifying normal blood pressure. This article provides a brief review of recent literature and highlights the pertinent changes from previous guidelines. In consideration of the new hypertension categories, the implications of monitoring blood pressure in the dental office are discussed and the classifications are correlated with specific recommendations for dental management.     

Diffusion-weighted imaging with histogram analysis of the apparent diffusion coefficient maps in the diagnosis of parotid tumours

The aim of this study was to investigate the role of diffusion-weighted imaging (DWI) with histogram analysis of apparent diffusion coefficient (ADC) maps in the characterization of parotid tumours. This prospective study included 39 patients with parotid tumours. All patients underwent magnetic resonance imaging with DWI, and ADC maps were generated. The whole lesion was selected to obtain histogram-related parameters, including the mean (ADC_mean), minimum (ADC_min), maximum (ADC_max), skewness, and kurtosis of the ADC. The final diagnosis included pleomorphic adenoma (PA; n = 18), Warthin tumour (WT; n = 12), and salivary gland malignancy (SGM; n = 9). ADC_mean (×10^?3 mm²/s) was 1.93 ± 0.34 for PA, 1.01 ± 0.11 for WT, and 1.26 ± 0.54 for SGM. There was a significant difference in whole lesion ADC_mean among the three study groups. Skewness had the best diagnostic performance in differentiating PA from WT (P = 0.001; best detected cut-off 0.41, area under the curve (AUC) 0.990) and in discriminating WT from SGM (P = 0.03; best detected cut-off 0.74, AUC 0.806). The whole lesion ADC_mean value had best diagnostic performance in differentiating PA from SGM (P = 0.007; best detected cut-off 1.16 × 10^?3 mm²/s, AUC 0.948). In conclusion, histogram analysis of ADC maps may offer added value in the differentiation of parotid tumours.