Scandinavian Fellowship for Oral Pathology and Oral Medicine: guidelines for oral pathology and oral medicine in the dental curriculum

In Scandinavia, as in many European countries, most patients consult their general dentist once a year or more. This gives the dentist a unique opportunity and an obligation to make an early diagnosis of oral diseases, which is beneficial for both the patient and the society. Thus, the dentist must have knowledge of clinical symptoms, local and systemic signs and clinical differential diagnoses to make an accurate diagnosis. The dentist must be competent in selecting appropriate diagnostic tests, for example, tissue biopsy and microbiological samples, and conducting them correctly, as well as in interpreting test results and taking appropriate action accordingly. Furthermore, the dentist must be aware of diseases demanding multidisciplinary cooperation and be able to recognise his/her professional limitation, and to refer to other specialists when required. The dental curriculum changes over time as new approaches, treatments and diagnostic possibilities develop. Likewise, the role of the dentist in the community changes and may vary in different countries. As members of the Scandinavian Fellowship for Oral Pathology and Oral Medicine and subject representatives of oral pathology and oral medicine, we feel obliged to contribute to the discussion of how the guidelines of the dental curriculum support the highest possible standards of dental education. This article is meant to delineate a reasonable standard of oral pathology and oral medicine in the European dental curriculum and to guide subject representatives in curriculum development and planning. We have created an advisory topic list in oral pathology and oral medicine.     

舌黏膜结核性溃疡1例报告

回顾分析1例发生于左舌的结核性溃疡病例,并结合相关文献进行讨论.通过对该患者行组织活检,确诊为舌部溃疡,并给予抗结核治疗,无复发.发生于口腔内的结核性溃疡非常少见,应给予足够重视,临床应尽早行病理学检查,确诊后及时给予抗结核治疗.     

Diagnosis and management of oral soft-tissue lesions: the use of biopsy, toluidine blue staining, and brush biopsy

Upon discovery of a lesion after thorough oral soft-tissue examination, the dentist is confronted with the often-troublesome decision of how best to manage the patient. The management protocol must provide for early diagnosis in the case of oral cancer so as to reduce cancer morbidity and mortality. Options for management would include an observation period of some defined time, use of toluidine blue stain or oral brush biopsy to screen the lesion, or immediate biopsy and follow-up. This article reviews the assets and limitations of each and suggests a rational, science-based approach to diagnosis and management.     

Lingual ulcer as the only sign of recurrent mycobacterial infection in an HIV/AIDS-infected patient

The report describes an HIV/AIDS patient seen at a referral center in Mexico City, in whom a mycobacterial infection in the oral mucosa, probably tuberculosis (TB) was identified. The purpose is to describe the clinical and histological findings in an HIV-infected patient, who after being treated successfully for tuberculous lymphangitis 4 years ago, presented with a lingual ulcer as the only suggestive sign of recurrence of mycobacterial infection, probably M. tuberculosis. A 39-year-old man seen in the HIV clinic of the Instituto Nacional de Ciencias Médicas y Nutrición "Salvador Zubirán" in Mexico City since 1991 for HIV infection. In 1999 the patient developed tuberculous lymphangitis; he was managed with a 4-drug regimen for 12 months, with improvement of local and systemic symptoms. In May of 2003, the patient presented a painful superficial lingual ulcer, 0.7 cm in diameter, well circumscribed, crateriform with slightly elevated, irregular and indurated borders, of 4 months duration. The histopathological examination showed chronic granulomatous inflammation with giant multinucleated cells, suggestive of mycobacterial infection, and recurrence of TB was considered. Rifampin, isoniazide, pyrazinamide, ethambutol and streptomycin were administered. The lingual lesion improved with partial healing at the first week and total remission at 45 days after the beginning of the antituberculous treatment. In June, 2003, the patient began highly active antiretroviral therapy (HAART) that included two NRTIs and one NNRTI. At 7 months of follow-up, the patient remains free of lingual lesions. The particularity of the present case is that the lingual ulcer was the only sign of infection by mycobacteria, suggestive of TB, in an HIV/AIDS patient that probably represented a recurrence of a previous episode.     

Cosmetic oral and maxillofacial surgery options

BACKGROUND: Dentistry and its related specialties have made exponential increases in the functional and cosmetic treatment of the maxillofacial region. Oral and maxillofacial surgeons historically have been involved in functional and cosmetic rejuvenation of the face, and newer technologies have enhanced the ability to make patients look and feel better. METHODS: Cosmetic oral and maxillofacial surgery is being taught in residency programs, is included in the oral and maxillofacial surgery board examinations and represents a part of contemporary oral and maxillofacial surgery. The author discusses common facial rejuvenation procedures with an emphasis on newer treatment technologies. RESULTS: Many oral and maxillofacial surgeons have the ability to improve the esthetics of the maxillofacial area and related structures. The large number of aging baby boomers and technological advances in cosmetic facial surgery have made these procedures easier to perform and more popular than ever. CONCLUSION: A global diagnosis and treatment plan to include facial esthetics can enhance cosmetic dentistry and serve to frame the work of the restorative dentist. The oral and maxillofacial surgeon can help the dentist and patient pursue both functional and cosmetic improvement with safe and effective procedures. CLINICAL IMPORTANCE: All dentists should be aware and abreast of advances in all areas of dentistry and have a basic understanding of available procedures that can benefit their patients. Cosmetic oral and maxillofacial surgery can enhance the work of the restorative dentist and improve facial esthetics, as well as enhance the well-being of the patient.     

Treatment and prognosis of oral cancer

Squamous cell carcinoma is the most common variety of malignant oral tumour. Most commonly oral carcinomas occur at the lateral tongue surfaces and at the anterior part of the floor of the mouth. If oral cancer is suspected, a dentist will refer the patient to an oral and maxillofacial surgeon who will perform a biopsy. When the diagnosis squamous cell carcinoma is established, the patient will be referred to a multidisciplinary head and neck oncological centre for additional diagnostics and treatment. Depending upon size, location and extent of the tumour and the presence or absence of regional metastases, the management may include surgical excision, radiotherapy or a combination of surgery and radiotherapy. The prognosis is mainly determined by the size of the tumour and regional lymph node involvement. Therefore, early detection is of utmost importance.     

Tuberculous ulcer of the tongue as presenting feature of pulmonary tuberculosis and HIV infection

Tuberculosis (TB), once a lethal disease, has shown a decrease in incidence with improved public health measures and availability of antituberculous drugs. But with the advent of human immunodeficiency virus (HIV) infection and acquired immunodeficiency syndrome (AIDS), it has re-emerged alarmingly as an opportunistic infection in immunocompromised patients. Lungs are the most commonly affected organs and involvement of the oropharyngeal region in TB is very rare. Two cases of TB manifesting as ulcer of the tongue are reported here. Interestingly, both of these cases were reported within a span of six months and both of the patients were in their early thirties. A primary diagnosis of both pulmonary TB and HIV sero-positivity was made after the diagnosis of the oral TB ulcer.     

Oral tuberculosis mimicking a traumatic denture ulcer

Tuberculosis (TB) of the oral cavity may be overlooked in the differential diagnosis of oral lesions and can be misdiagnosed and managed incorrectly. A 66-year-old man with complete dentures presented with a nonhealing mucosal ulcer in the upper lip. Despite the treatments performed by a local medical clinic, the ulcerative lesion on the denture-bearing area had not improved over 5 months. A partial excisional biopsy was performed to investigate further. Histopathologic examination revealed granulomatous inflammation caused by TB, and a chest radiograph showed consolidation and cavitation of the upper lobes. The patient was diagnosed with pulmonary TB. This clinical report describes the management of oral TB mimicking a traumatic denture ulcer in a patient with long-term complete denture use.     

Awareness of oral cancer in the Mersey region

The purpose of this study was to assess the levels of awareness and knowledge about oral cancer in the Liverpool area. This included the awareness of oral cancer compared to other cancers, risk factors, symptoms and where people would go to seek advice in the event of experiencing oral cancer symptoms. Five hundred and thirty-five people agreed to take part in a street survey that was done in four locations (Liverpool city centre, Bootle, Crosby, and Southport). A quota sampling approach was used to achieve a reasonable balance by sex, age, and locality. When asked without prompting to name all the cancers they had heard of, oral cancer was stated first by only 1%; it was given within the first three responses by 4%, and by 11% overall. Cervical cancer was mentioned without prompting by 22%, and two-thirds thought that it was more common than oral cancer. When asked without prompting 74% were aware that smoking could be a likely cause, but only 21% mentioned alcohol. Without prompting, 35% said that a non-healing mouth ulcer was a symptom of oral cancer. When asked without prompting what they would do if a painful mouth ulcer had lasted for more than three weeks, 61% said they would see their doctor and 27% their dentist, which is encouraging.     

Antineoplastic agents and their oral manifestations.

The use of antineoplastic agents is rapidly increasing. A general classification of these drugs and their mechanisms of action is presented. Many of the drugs have an adverse effect on oral tissue, and the practicing dentist today must be well acquainted with these effects. A discussion of the features of these reactions and their management is presented.     

A review of premalignant oral conditions

The value of mass oral cancer screenings has come under scrutiny, as a consequence of a lack of improvement in the long-term outcomes associated with oral carcinoma over the past several decades. However, it is generally accepted that most oral carcinomas are preceded by visible changes to the mucosa and certain high risk lesions have been identified. The responsibility to evaluate the mucosal tissues of the oral cavity clearly falls under the purview of the dentist. The dentist must clearly grasp the distinction between reactive lesions which usually change in 7 to 14 days and malignant and premalignant lesions which do not. Therefore, appropriate diagnostic procedures (i.e., biopsy of the lesion) must be implemented as a matter of course in the evaluation of any lesion that does not respond to usual therapy in 7 to 14 days.     

Eosinophilic ulcer of oral mucosa: a case report

Eosinophilic Ulcer (EU) is a rare self-limiting chronic benign lesion of the oral mucosa with pathogenesis still unclear, however it may resemble malignancies, traumatic ulcerations and some infections such as deep fungal infections, tuberculosis and primary syphilis. This is a case report of a patient with EU in the lateral border of the tongue with no history of associated trauma and refractory to treatment with drugs. The ulcer rapidly healed after an incisional biopsy and the definite diagnosis was achieved only combining histologic findings and the clinical follow-up.     

Contemplations on responsibility for oral healthcare

The academic dental education in The Netherlands has been extended to 6 years, among other reasons in order to make it possible for responsibility for oral healthcare to be borne in a wide medical context. It is the job of the 3 national dental schools to make this happen. The new dentist should know and recognize all (peri-)oral disorders and oral symptoms of systemic diseases, and he should be able to deliver oral healthcare to medically compromised patients. Accepting this responsibility is required for dentistry to be transformed into medical oral healthcare and for dentists to be upgraded to oral physicians.     

Knowledge, attitudes, behaviour and prevalence of TB infection among dentists in the western Cape.

Tuberculosis (TB) remains the most important communicable disease in the world and in South Africa it accounts for 80% of all notifiable diseases. The impact of HIV on the TB epidemic is potentially catastrophic. HIV increases the susceptibility of the HIV-positive person to TB. The resurgence of TB as a public health problem has rekindled interest in this disease among oral health workers. The major concern is the risk of transmission in the dental setting. The aim of this study was to determine the prevalence of TB among dental practitioners and to assess their knowledge, attitudes and practices pertaining to TB. A cross-sectional survey was carried out. A structured questionnaire was used to obtain information on demography, infection control, TB status, behaviour, knowledge and perceived risk. In addition, Mantoux and multipuncture tests were performed to assess prevalence. The response rate was 78%. The sample consisted of 78 dentists, 80% male, with a mean age of 40 years. Ninety-two per cent reported always using gloves, 78% masks (68% surgical masks and 18% paper masks) and 50% glasses when treating patients. Two-thirds reported that they sterilise suction and three-in-one tips. Only 11% reported use of a rubber dam. No practitioner reported the use of high-volume externally vented aspirators or ultraviolet germicidal irradiation. Five per cent reported ever being diagnosed with TB, all after having qualified as a dentist. Half of the sample reported having being vaccinated against TB. The prevalence of those who developed a positive reaction was 33%. Thirty-one per cent reported having referred a patient suspected of having TB for further diagnosis and management. Dentists have a duty to take appropriate precautions to protect themselves, their staff and their patients from the risk of cross-infection. The implementation of infection control policies is critical to the provision of such protection. In addition, a dental health facility provides the opportunity for TB screening which has not as yet been tapped into to its fullest extent in a developing country setting where TB is endemic. Referral and integration of TB screening in high HIV and TB prevalence areas will provide early diagnosis, treatment of TB and possibly prevention and reduced risk of nosocomial infection.     

An oral disease prevention program for patients receiving radiation and chemotherapy

Thirteen years of treating more than 2,950 patients at the National Institute of Dental Research clinic have shown that a variety of potential oral sequelae associated with cancer therapy can be prevented, reduced in severity, or palliatively alleviated when the dental team has an opportunity to participate in the patient's care. The keystone of this success is based on early referral of the patient for dental consultation, treatment before the initiation of cancer therapy, and a well-defined orientation program to inform patients and their families about the difficulties they may experience. Meticulous attention to oral microbial control, prophylactic use of fluoride gels, and palliative treatment of soft tissue lesions may significantly reduce the oral morbidity associated with radiation and cytotoxic chemotherapy. Diligent personal oral health care and frequent dental recall appointments are recommended for the remainder of the patient's life. It has been our experience that patients who are not followed closely after irradiation therapy have an increased incidence of caries as a result of noncompliance with preventive regimens. The ethical and medicolegal responsibility to fully inform the patient of these recommendations lies with both the medical and dental personnel at the facility providing the radiation-chemotherapy service. The general dentist shares the responsibility for continuity of long-term oral health care.     

General dentistry and oral medicine in the hospital.

General dentistry in a hospital should not be confined to restorative dentistry happens to be performed in a hospital dental clinic. In addition to expertise in restorative dentistry and other dental specialties, general practitioners participating in hospital programs must also be students of two major areas-- diagnosis of diseases involving the head and neck as well as dental management of patients with severe medical disease. In the preceding short review a few examples of disorders about which the hospital dentist may be consulted were reviewed along with the proper protocol for requesting and answering consultations. This list is necessarily short and incomplete. A different group of disorders could have been discussed in this article. The competent hospital dentist must be a continual student of disease and its possible effect upon dental treatment and oral diagnosis. The task is formidable but rewarding and interesting.     

The role of the dentist in the diagnosis, screening and followup of lesions of the oral mucosa

The early detection and follow up of oral mucosa lesions are a must for every dentist. The importance of these activities is tremendous for oral cancerous and precancerous lesions, so every dentist is officially responsible for this important role in the public health. The modalities of such early detection and follow up are described.     

Referral of patients with non-odontogenic oral diseases to an oral and maxillofacial surgeon

Patients with non-odontogenic oral diseases may be referred to an oral and maxillofacial surgeon by a dentist, a general medical practitioner or a medical specialist. At the department of Oral and Maxillofacial Surgery of a medical centre, a survey involving 96 referred patients with a non-odontogenic oral disease addressed the clinician who was responsible for the referral, the patient characteristics, and the nature and location of the oral disease. From the patients who regularly visited a dentist, 53% were referred by a dentist. From the patients who visited a dentist irregularly, 73% were referred by a general medical practitioner. No significant correlation was found between the nature and location of the non-odontogenic oral disease and the profession of the clinician who was responsible for the referral, with an exception for the tongue, for which a medical specialist was more often responsible for the referral.