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JADA Specialty Scan - O & M Pathology
JADA Specialty Scan

Oral hygiene and head and neck cancers

A multinational team of scientists examined the potential relationship between oral hygiene and head and neck cancer (HNC) in patients from 5 continents. Their findings were published in the May issue of Annals of Oncology. 

The authors noted that identification of any causal and independent role of oral hygiene in HNC development has been inconclusive owing to limited numbers of cases and inclusion of a limited number of oral hygiene indicators in most studies. This analysis is the largest and most comprehensive assessment of a potential relationship between oral hygiene indicators and HNCs, including oral cavity, laryngeal, hypopharyngeal, and oropharyngeal cancers, the authors said.

In this case-control study, investigators included 12 studies from the United States, Central Europe, Latin America, and Japan, as well as 1 international multicenter study. Investigators from all 13 studies participated in the International Head and Neck Cancer Epidemiology Consortium. Dentists administered questionnaires to patients about their oral hygiene in the Central Europe study, and patients in the other studies reported about their oral hygiene practices in face-to-face interviews. The pooled analysis included 8,925 cases of HNC and 12,527 control participants and compared data regarding 5 potential indicators of oral hygiene: no denture wear, no gum disease (or bleeding), fewer than 5 missing teeth, toothbrushing at least daily, and visiting a dentist once per year or more. Investigators used multivariable logistic regression analysis to estimate the effects of each oral hygiene indicator on cumulative HNC risk, adjusting for tobacco smoking and alcohol consumption.

They found inverse relationships between all indicators studied and HNCs except for wearing dentures, although the extent of risk reduction was modest. Among the specific HNCs, the inverse association of HNC with oral hygiene was greatest for oral cavity cancers, a finding that the authors claimed strengthened the possibility of a causal role. Having fewer than 5 missing teeth demonstrated the greatest inverse association with HNC.

Authors proposed possible mechanisms by which poor oral hygiene may be associated with HNCs, focusing primarily on trauma and inflammation. “Causes of trauma and inflammation are due to coexisting disease and/or negligence of oral hygiene,” they said. “Thus, these indicators may be indicative of dysbiotic shifts in the commensal oral microbiome … and general health maintenance,” both of which may be linked to cancer. The authors, however, acknowledged that their analysis is potentially limited by confounding factors such as systemic inflammatory conditions, socioeconomic status, educational attainment, and recall bias.

Read the original article.


Consulting Editor: Paul C. Edwards, MSc, DDS, FRCD(C)
Editor, American Academy of Oral and Maxillofacial Pathology
Professor, Department of Oral Pathology, Medicine and Radiology
School of Dentistry, Indiana University

Associate Consulting Editor: Kelly R. Magliocca, DDS, MPH
Assistant Professor of Oral and Maxillofacial Pathology
Department of Pathology and Laboratory Medicine
School of Medicine, Emory University

AAOMP position on oral lichen planus

The authors of an American Academy of Oral and Maxillofacial Pathology position paper focused on the challenges of establishing a diagnosis of oral lichen planus (OLP), identify key clinical and histopathologic criteria, and propose a checklist to assist in clinicopathologic correlation, a critical component in the diagnosis of OLP. The article, published online July 9 in Oral Surgery, Oral Medicine, Oral Pathology and Oral Radiology, also includes an overview of OLP, summarizing its historical background, epidemiologic and clinical features, etiology, and pathogenesis.

Highlighting recently published comprehensive reviews, the authors call out the importance of patient education before treatment in appropriate management. “The patient should be advised that therapy is not curative but is directed at controlling inflammation and reducing the associated symptoms,” the authors said. “As response to therapy is often delayed and continuous maintenance is necessary, it is best that patients are prepared for prolonged periods of treatment.”

In addition, the authors recommended that patients should be advised about possible linkages between OLP and the development of oral cancer, although acknowledging that this remains controversial. The paper includes a discussion of the reasons for the controversy regarding malignant transformation. The authors asserted that the premalignant nature of OLP remains unresolved, calling for more research to address the complex issues concerning potential or actual transformation of OLP to oral cancer.

The authors discussed the potential for clinicopathologic mimicry of OLP, advising that before initiation of therapy, patients should be made aware of this and the need for continued clinical follow-up. “Confidence in diagnostic validity is most often achieved through clinical observation over time, noting responses to therapies and sequential evaluation of oral mucosal status,” they advised.

The authors reviewed a selection of therapies; however, they said that the validity of treatment options was hampered by a paucity of relevant published placebo-controlled double-masked studies and the absence of consensus-based objective measures of disease activity.

Challenges in diagnosis of OLP are discussed in detail and include the observation that several other disorders can resemble OLP clinically, histopathologically, or both. Differentiating OLP from lichenoid lesions is the focus of a large section of the position paper.

A set of diagnostic criteria that include both clinical and histopathologic criteria is presented. The authors proposed that a diagnosis of OLP requires fulfillment of all the criteria.

“We recognize that adherence to this proposed guideline may exclude some OLP cases,” the authors said. “However, we believe that implementation of the proposed diagnostic system will yield a patient population with enhanced disease homogeneity—composed of individuals more likely to have OLP than one of the several lichenoid mimics.” They also advised that further “investigations are urgently needed to elucidate disease pathogenesis and malignant transformation potential, and to develop possible ancillary diagnostic protocols that could guide future efforts to enhance the diagnostic process.”

Read the original article.

Editor’s note: Drs. Edwards and Magliocca are members of the American Academy of Oral and Maxillofacial Pathology (AAOMP) Research and Scientific Affairs Committee that recommended approval of this article as an official AAOMP position paper.


Free oral pathology course in Denver
Dr. Susan Muller, president of the American Academy of Oral and Maxillofacial Pathology, will present “Distinguishing the Benign from the Deadly: Oral Pathology Update,” Oct. 22, noon-2 p.m. at ADA 2016 at the Colorado Convention Center in Denver, CO, (course 7332). Earn 2.0 continuing education credits for the course and an additional 1.0 CE credits for an extended conversation after the lecture. Register online.


Periodic fever, aphthous stomatitis, pharyngitis, and adenitis syndrome

Periodic fever, aphthous stomatitis, pharyngitis, and adenopathy (PFAPA) syndrome is an autoinflammatory disease typically affecting young children, usually between 2 to 5 years of age. The presence of aphthous stomatitis, one of the features of this disease, may lead the patient and family to seek the opinion of the dental practitioner as the first clinical contact, although a child with a recurrent fever may instead present to their pediatrician. Authors note that that despite the presence of recurrent fever and pharyngitis, PFAPA is not contagious, although disease flares can resemble an infectious illness.

The findings, published in the July/August 2016 issue of Clinics in Dermatology, examined possible causes and recommended treatments for patients with PFAPA.

The study’s authors outlined 5 criteria for PFAPA diagnosis:

  • Periodic fevers before age 5
  • Presence of aphthous stomatitis, adenitis, or pharyngitis in the absence of an upper respiratory infection
  • Exclusion of other period fever symptoms, such as cyclic neutropenia
  • Normal health between fever episodes
  • Normal growth and development

The study’s authors also note that biomarkers such as elevated C-reactive protein in the absence of elevated procalcitonin, CD64, CXCL10, mean corpuscle volume, and other inflammatory markers may help in the diagnosis of PFAPA in the absence of an infectious explanation for fever.

The authors noted that current research continues to point to a dysregulated innate immune response and inappropriate T-cell activation as two key factors. Studies showing abnormal T-cell activation found levels of cytokines consistent with a T helper 1 inflammatory response in blood samples of PFAPA patients. The authors cited another study that found increased levels of monocytes and neutrophils, along with elevated IL-1b production, in PFAPA patients.

Possible genetic markers for PFAPA include the Mediterranean fever (MEFV) gene. In their review of research, the authors noted that in some studies MEFV gene variants were implicated as possibly modifying disease severity. PFAPA episodes were milder and shorter in people with the heterozygous variant.

Recommended pharmacological treatment for PFAPA includes systemic corticosteroids and IL-1 blockers such as anakinra, rilonacept and canakinumab. The authors note that surgical adenotonsillectomy or tonsillectomy alone remain the only definitive treatments.

Although considered an exclusively pediatric disease, case reports of adult-onset PFAPA have been reported. The authors concluded that “Research into adult-onset PFAPA, the pathogenesis and genetic nature of PFAPA, and the use of IL-1 blockade in PFAPA syndrome remain to be explored.”

Read the original article.


Obsolete tobacco control themes can be hazardous

Tobacco control efforts should emphasize differences in the degree of risk between different classes of tobacco/nicotine products in an effort to focus on eliminating combustible tobacco products, the deadliest of the tobacco/nicotine products, projected to cause 1 billion premature deaths by 2100.

That’s the key suggestion of the authors of an article published online May 24 in BMC Public Health.

The authors reviewed the shifting approach to tobacco control efforts since 1964. They noted that before the 1980s, public health efforts aimed at reducing the adverse health effects from tobacco recognized 2 key themes: the absolute risk of the product and the availability of different methods to reduce that risk (that is, harm reduction). The authors noted, however, that as a result of the debacle resulting from the widespread acceptance of fraudulent claims of harm reduction from so-called low-tar cigarettes and filtered cigarettes in the 1960s, the focus shifted toward the view that all tobacco products were equally harmful.

The authors pointed out that “the data that not all tobacco products were equally harmful (i.e., smoked versus smokeless) was overshadowed by the truism that there was some harm caused by all tobacco use. Thus the harm reduction baby was thrown out with the bathwater and a major swing to an all or nothing stance was adopted.”

Instead, the authors recommended not treating all forms of tobacco and nicotine use equally, but to focus on a product’s absolute risk. “It is now crystal clear,” the authors noted, “that it is the inhaled deadly smoke from cigarettes/combustibles that stands alone by orders of magnitude as a pinnacle of deadliness that greatly exceeds the disease and disability costs of a large number of consumer products added together … .”

The authors noted 3 significant developments in the tobacco and nicotine delivery marketplace: nicotine replacement therapies; alternative nicotine delivery systems, which include electronic-cigarettes; and new data from Sweden/Scandinavia regarding the successful use of low-nitrosamine snus for harm reduction. Although the authors noted that alternative nicotine delivery systems and snus are “not harmless,” they suggested that “it seems like hyperbole to argue” that these products approach the lethality of cigarettes. They likewise acknowledged disagreement among tobacco control advocates as to whether smokeless tobacco should be marketed as a less-harmful alternative to smoking. However, they cautioned that “It is a very limited contribution to health communication to say a product is ‘not safe’ with no indication of the level of absolute or relative risk of harm."

The authors also briefly reviewed the evidence—including the data from Sweden—as to whether low–nitrosamine smokeless tobacco products could serve as gateways to conventional combusted cigarette use.
The authors concluded by stating that “tobacco control arguments should be proportionate to the absolute and relative harms of each class of products, … and we should work hardest to reduce demand for and the appeal of cigarettes/combustibles which remain highly lethal when used as intended and deadly to more individuals each year than heroin, cocaine, alcohol, AIDS, fires, homicide, suicide and automobile crashes COMBINED.”

Read the original article.

Join the conversation with AAOMP at ADA 2016

Join the American Academy of Oral and Maxillofacial Pathology at ADA 2016 — America’s Dental Meeting, Oct. 22, noon-2 p.m., at the Colorado Convention Center in Denver, CO, for a chance to earn continuing education credit and network with specialists at a free course in the exhibit hall.

Dr. Susan Muller, a private practice dentist at Atlanta Oral Pathology and president of the AAOMP, will present “Distinguishing the Benign from the Deadly: Oral Pathology Update” (course 7332).

This lecture will be heavy on clinical pictures with the goal of illustrating a variety of conditions that can be encountered frequently in the dental office. Growths that can be seen in a wide spectrum of ages from children to the elderly will be reviewed. Dr. Muller will focus on developing a differential diagnosis for various growths in the oral cavity, both benign and malignant. Examples of both precancerous and early cancer will be highlighted along with how to examine high-risk sites for oral cancer plus the signs and symptoms of oropharyngeal carcinoma and the role of HPV.
After this course, you will be able to describe the list of differential diagnoses for common oral growths, identify normal variations and when to refer for biopsy, and recognize the most common areas for oral cancer. This presentation will be followed by an extended conversation hour where attendees can ask questions, engage in peer-to-peer discussion, and network.

Participants who register for this free course will earn 2.0 continuing education credits for the course and 1.0 additional CE credit for the extended conversation.

Register here.

Resources on enrolling in, opting out of Medicare available

If you send biopsies to an oral pathology laboratory for a Medicare-eligible patient, you must register with the Centers for Medicare & Medicaid Services (CMS) using Form 855I or Form 855O or formally opt out of Medicare for the oral pathologist to get paid for his or her services.

The easiest of these options is to register with CMS as an ordering and referring provider using Form 855O, which is a much shorter and easier form to complete. By doing so your patients enrolled in Medicare will be allowed to get any drugs you have prescribed that are covered under Medicare Part D paid for by Medicare. Medicare will not pay for these drugs if you fail to register by February 1, 2017. Completing Form 855O will also allow you to submit claims to Medicare Advantage plans, some of which do cover dental services. If you formally opt out of Medicare, Medicare will not cover oral pathology services; however, there are still forms that will need to be filled out, and you will not be able to submit claims to Medicare Advantage plans.

Please remember, opting out of Medicare is not the same as doing nothing. A decision tree, frequently asked questions, and a tutorial video can be found at


Learn and network with oral pathology experts Oct. 22
Join the American Academy of Oral and Maxillofacial Pathology at ADA 2016 — America’s Dental Meeting, Oct. 22, in Denver, CO, for a chance to earn continuing education credit and network with specialists. The free course in the exhibit hall, “Distinguishing the Benign from the Deadly: Oral Pathology Update” (course 7332) offers 2.0 CE credits and 1.0 additional CE credit for attending an extended conversation following the lecture. Register today.


What is Specialty Scan?

This is one in a series of quarterly newsletters updating dentists on selected specialties in dentistry. Information presented is aggregated and summarized from previously published materials, each item attributed to its publication of origin. This issue of JADA Specialty Scan focuses on oral pathology, the third in the series on this topic for 2016. Other Specialty Scan issues are devoted to endodontics, oral and maxillofacial radiology, orthodontics, periodontics and prosthodontics. The ADA has engaged the specialty organizations in these areas as well as its own Science Institute and Division of Legal Affairs to assist with these newsletters. We welcome feedback on this and all Specialty Scan issues.

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Any statements of opinion or fact are those of the authors and do not necessarily reflect the views of the American Dental Association. Neither the ADA nor any of its subsidiaries have any financial interest in any products mentioned in this publication. Any reference to a product or service, whether in advertisements or otherwise, is not intended as an endorsement or as approval by the ADA or any of its affiliated organizations unless accompanied by an authorized statement that such approval or endorsement has been granted.

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