Oral Pathology — August 24, 2018

Assessing electronic cigarette use and self-reported oral symptoms among adolescents

Use of electronic cigarettes (EC) has been increasing rapidly during the past several years, but little information is available regarding the association between EC use and oral health. Therefore, a cross-sectional study was conducted to assess the relationship between EC use and self-reported oral symptoms among adolescents in South Korea. The findings were published online July 11 in PLoS One.

What's in this issue?

Screening for oral cancer >>

Diagnostic delays among patients
with autoimmune blistering
diseases of the mouth >>

An overview of the etiology
and treatment of burning mouth syndrome >>

Product Spotlight:
2019 AAOMP Annual Meeting>>

News You Can Use:
Oral pathology courses are in high
demand at ADA 2018 >>

Data for this study were obtained from the Twelfth Korean Youth Risk Behavior Web-based Survey administered to a representative sample of middle-school– and high-school–aged students in South Korea. Of 67,983 students invited to participate, 65,528 responded; the overall response rate was 96.4% from 798 schools. The mean (standard deviation) age of respondents was 15.0 (1.7) years, and 51.6% were boys.

The survey asked participants if, during the past 12 months, they had experienced gingival pain, bleeding, or both; tongue pain, inside cheek pain, or both; or a cracked or broken tooth. In addition, students were asked if they had ever used an EC. Those who answered “yes” were then asked, “During the past 30 days, on how many days have you used ECs?” Positive responses were categorized into 2 groups: “1 to 29 days past month user” and “daily user.” Respondents also indicated whether they used nicotine-containing ECs or nicotine-free ECs.

Approximately 18.5% of the students reported that they had experienced gingival pain, bleeding, or both within the past 12 months; 11% had experienced tongue pain, inside cheek pain, or both; and 11.4% experienced a cracked or broken tooth, the authors wrote. Regarding EC use, 297 students (0.5%) reported that they used ECs on a daily basis; 1,259 (1.9%) used ECs 1 to 29 days in the past month; 3,848 (5.9%) were former EC users; and 60,124 (91.8%) were never EC users, the authors wrote.

The study findings showed statistically significantly higher odds of having experienced a cracked or broken tooth in the past 12 months among daily EC users (adjusted odds ratio [OR], 1.65; 95% confidence interval [CI], 1.19 to 2.27), 1 to 29 days past month EC users (adjusted OR, 1.26; 95% CI, 1.06 to 1.51), and former EC users (OR, 1.16; 95% CI, 1.04 to 1.30) compared with never EC users. In addition, the odds of having experienced tongue pain, inside-cheek pain, or both were significantly higher (OR, 1.54; 95% CI, 1.05 to 2.26) (P = .028) among adolescents who used ECs on a daily basis than among those who never used ECs. However, after adjusting for potential confounders, the researchers did not observe an association between EC use and gingival pain, bleeding, or both.

Owing to the cross-sectional study design, these results cannot establish a causal relationship, the authors wrote. Moreover, because oral symptoms were self-reported, recall bias is possible. The researchers recommended that future studies include oral examinations. However, they noted that this is the first large representative population study to evaluate the association between EC use and oral health.

The authors concluded that EC use among adolescents may be a risk factor for tongue pain, inside-cheek pain, or both and cracked or broken teeth.

Read the original article.

AAOMP 2019 Annual Meeting ad

graphic image of a mouth with floating cancer cells

Screening for oral cancer

Despite the rising incidence of oral cancer, no national screening programs have been implemented to date. The authors conducted a review article to examine the evidence regarding the feasibility of oral cancer screening. The results were published in the June 2017 issue of Oral Surgery Oral Medicine Oral Pathology Oral Radiology.

Screening for oral cancer involves an oral examination or a test with the objective of identifying changes that may precede or predict, with a high likelihood, the development of cancer, the authors wrote. A screening test’s validity is measured by the frequency with which the test result is confirmed by an acceptable diagnostic procedure. The sensitivity of a test refers to its ability to correctly identify people with the disease, and specificity refers to a test’s ability to correctly identify those without the disease.

Most cases of oral cancer are preceded by an oral potentially malignant disorder (OPMD), such as leukoplakia and erythroplakia, which have characteristic clinical features, the authors wrote. However, although OPMDs have a statistically increased risk of progressing to cancer, lesions may remain stable or regress. Furthermore, no histologic or molecular markers have been shown to be prognostically significant.

Many investigators have evaluated screening tests for oral cancer. A 2013 Cochrane systematic review of conventional oral examination (COE), vital rinsing, light-based detection, biomarkers, and mouth self-examination in apparently healthy adults revealed that the accuracy of COE may depend on disease prevalence.1 Study sensitivities ranged from 0.50 to 0.99, but specificity was consistently high (> 0.80). A 2015 systematic review of 16 studies of screening tests used in Europe demonstrated the feasibility of screening for OPMD and oral cancer using COE.2 The authors of this systematic review postulated that opportunistic screening in dental practices or screening of selected high-risk population groups could be considered, but further studies were needed to determine the effectiveness of interventions in these settings.

Few studies have evaluated oral cancer screening programs, the authors wrote. One randomized controlled trial that used mortality as a primary outcome was conducted in India from 1996 through 2004.3-6 Four rounds of screening by trained nonmedical university graduates were performed over a 15-year period. After 4 rounds, the researchers observed an overall significant improvement in 5- and 10-year survival rates and in early detection, but no significant improvement in mortality rates or overall mortality. However, among those who participated in all 4 rounds of screening (20% of the eligible population), there was a statistically significant overall reduction in mortality of 79% and an 81% reduction in the high-risk group (users of tobacco, alcohol, or both).

The cumulative evidence from these studies suggests the feasibility of screening for oral cancer, although some uncertainty remains, the authors wrote. OPMDs can be detected with sufficient sensitivity and specificity to justify use of COE as a screening test. However, only about 5% of lesions detected during screening are likely to progress to cancer, the authors wrote. Moreover, the rates of progression and significance of individual markers are uncertain. More accurate tests are needed, as well as further research into the natural history of oral cancer and use of adjunctive aids, the authors wrote.

On the basis of the evidence, the authors of this review article concluded that patients, particularly those in high-risk groups, should be examined for any signs of oral cancer or precancer during regular dental visits. However, high-risk people might not visit a dentist routinely; thus, further research is needed to determine how opportunistic screening can be implemented and in which health care environments.

Read the original article.

1. Walsh T, Liu JL, Brocklehurst P, et al. Clinical assessment to screen for the detection of oral cavity cancer and potentially malignant disorders in apparently healthy adults. Cochrane Database Syst Rev. 2013;11:CD010173.
2. Warnakulasuriya S, Fennell N, Diz P, Seoane J, Rapidis A; LDV Lifelong Learning Programme. An appraisal of oral cancer and pre-cancer screening programmes in Europe: a systematic review. J Oral Pathol Med. 2015;44(8):559-570.
3. Sankaranarayanan R, Mathew B, Jacob BJ, … Trivandrum Oral Cancer Screening Study Group. Early findings from a community-based, cluster-randomized, controlled oral cancer screening trial in Kerala, India. Cancer. 2000;88(3):664-673.
4. Ramadas K, Sankaranarayanan R, Jacob BJ, et al. Interim results from a cluster randomized controlled oral cancer screening trial in Kerala, India. Oral Oncol. 2003;39(6):580-588.
5. Sankaranarayanan R, Ramadas K, Thomas G, et al. Effect of screening on oral cancer mortality in Kerala, India: a cluster randomised controlled trial. Lancet. 2005;365(9475):1927-1933.
6. Sankaranarayanan R, Ramadas K, Thara S, et al. Long term effect of visual screening on oral cancer incidence and mortality in a randomized trial in Kerala, India. Oral Oncol. 2013;49(4):314-321.

AAOMP 2019 Annual Meeting ad

Photo of oral blisters

Diagnostic delays among patients with autoimmune blistering diseases of the mouth

Autoimmune blistering diseases (AIBDs) are relatively uncommon disorders that affect the skin and mucosae. The mouth is often the site of initial presentation. Owing to the uncommon nature of these diseases, nonspecific clinical presentations, and health care providers’ unfamiliarity with oral mucosal diseases, diagnosis often is delayed. In this study, published in the October 2017 issue of Oral Diseases, researchers examined the natural history of the disease and factors affecting diagnostic delays among patients with AIBDs of the mouth.

The study sample comprised 27 patients (4 males, 23 females) (mean age, 52.6 years) who were diagnosed with an immune-mediated oral blistering disease in the oral medicine unit of the University of Jordan in Amman, Jordan. Clinical diagnosis and subtype were confirmed by means of histopathologic and immunologic findings.

The same author interviewed all of the participants at their first appointment. They were asked about the onset of symptoms; presence and onset of cutaneous, genital, or ocular symptoms; date of first medical consultation; number of previous medical consultations; types of specialists consulted; and previous treatments (including prescription drugs, over-the-counter medications, and home remedies). The researchers defined patient delay as the time from symptom onset to the first medical consultation, and professional delay as the time from the first medical consultation to the definitive diagnosis.

One oral medicine specialist examined all patients. The Saraswat scoring system—which incorporates both objective and subjective parameters—was used to determine the severity of presentation. The disease extent score was determined objectively by evaluating 11 anatomic sites in the oral cavity and oropharynx (total possible score, 0-11). Symptom severity was scored on the basis of the patient’s reports of pain, bleeding, or both during eating or drinking of 9 types of foods (total possible score, 0-45).

Of the 27 patients, 10 (37%) exhibited desquamative gingivitis at the initial visit (gingival erythema, erosion, desquamation, or ulceration), and 17 (63%) exhibited oral mucosal erosions and ulcers, the authors wrote. All participants complained of oral pain, and 14 (52%) complained of difficulty in eating.

The mean (standard deviation [SD]) disease extent score was 5.8 (3.6), and the mean (SD) symptoms severity score was 21.3 (13.7), the authors wrote. In patients who exhibited desquamative gingivitis at the initial visit, the mean (SD) symptoms severity score was significantly lower (8.3 [5.7]) than that in patients who exhibited mucosal ulcers and erosions (31.7 [7.8]) (P < .05).

The mean (SD) time from symptom onset to the first medical consultation was 92.6 (22.7) days. Delays were not associated with participant age, sex, presence of extraoral involvement, or disease subtype, but were significantly longer in patients with desquamative gingivitis (mean [SD], 105.4 [14.2] days) than in those with ulcers and erosions (mean [SD], 79.8 [19.3] days) (P < .01). Moreover, patients who used over-the-counter medications and home remedies (n = 18) experienced significantly longer delays than those who did not (P < .01). The authors also observed a statistically significant negative correlation between patient delays in seeking medical consultation and symptoms severity scores.

Of the 27 patients, 21 had more than 1 medical or dental consultation (mean, 3.1). The mean (SD) time needed to reach a definitive diagnosis and start treatment was 83.2 (21.4) days (range, 21-130 days). The researchers observed a significant correlation between professional delays and the number of consultations (r = .78); professional delay also was significantly longer among patients who exhibited desquamative gingivitis compared with those who exhibited ulcers and erosions (P < .05).

In this cross-sectional study, diagnostic delays were more common in patients with desquamative gingivitis and less severe disease. The authors concluded that such delays might be reduced by improving patients’ and clinicians’ awareness of and knowledge about AIBDs.

Read the original article.


Woman spitting fire

An overview of the etiology and treatment of burning mouth syndrome

Burning mouth syndrome (BMS) is a debilitating chronic condition with a poorly understood etiopathogenesis. In this review article, published online June 18 in Journal of Dental Research, researchers provide an overview of the literature pertaining to the etiology and treatment of this condition.

BMS generally is characterized by oral pain and discomfort and a normal-appearing mucosa, the authors wrote. Before making a diagnosis of BMS, clinicians must rule out all systemic and local conditions typically associated with oral pain (Candida infection, diabetes mellitus, thyroid disease, nutritional deficiencies).

Study findings suggest that 30% to 60% of patients with BMS experience neuropathic pain (that is, pain thought to be generated and maintained by the nervous system), and these people can be grouped into 3 subsets: those with peripheral small fiber neuropathy, those with major subclinical central trigeminal neuropathy, and those who exhibit inhibitory dopaminergic deficiency.1

Researchers also have reported an association between BMS and dysgeusia. A 2017 case-control study of patients with BMS and age- and sex-matched controls used electrogustometry to evaluate taste detection thresholds.2 The study findings revealed that patients with BMS had diminished taste sensitivity in fungiform and foliate taste buds. More studies are needed to confirm these results, the review authors wrote.

In a 2015 study, researchers focused on the possible relationship between circadian clock dysfunction and BMS.3 Of particular relevance is the link between circadian rhythm and pain perception, mood, and sleep, all of which are altered in patients with BMS, the authors wrote.4,5

The role of neuroendocrine and hormonal disturbances in BMS is also explored in this review. In particular, plasma adrenaline levels are significantly lower in patients with BMS. Cortisol levels are slightly increased, while dehydroepiandrosterone, the precursor of testosterone and estradiol, is decreased significantly among patients. Emerging data suggest that decreased dehydroepiandrosterone levels are indicative of hypothalamic-pituitary-adrenal dysfunction. Because of the importance of the immune-neuroendocrine axis in maintaining health, dysregulation of these systems likely contributes to chronic pain conditions such as BMS, the authors wrote.

Determining optimal treatments for patients with BMS is challenging, and further placebo-controlled double-blinded studies are needed to establish evidence-based approaches. Treatments can be grouped into topical therapies, systemic therapies, and behavioral strategies. Topical therapies include clonazepam, capsaicin, and low-level laser treatment. Systemic therapies consist of systemic clonazepam, alpha-lipoic acid, gabapentin, and amitriptyline.

In addition, cognitive behavioral therapy has been shown to be effective in treating patients with BMS. Specific techniques include biofeedback, relaxation, exposure, and cognitive restructuring. Those that emphasize the reduction of dysfunctional cognitive factors, especially pain catastrophizing, are particularly effective in alleviating BMS symptoms, the authors wrote.

BMS is a chronic pain condition that diminishes patients’ quality of life. The authors stress the need for well-designed studies to elucidate the causes of this condition and establish evidence-based treatments.

Read the original article.

1. Lopez-Jornet P, Molino-Pagan D, Parra-Perez P, Valenzuela S. Neuropathic pain in patients with burning mouth syndrome evaluated using painDETECT. Pain Med. 2017;18(8):1528-1533.
2. Braud A, Descroix V, Ungeheuer MN, Rougeot C, Boucher Y. Taste function assessed by electrogustometry in burning mouth syndrome: a case-control study. Oral Dis. 2017;23(3):395-402.
3. Lopez-Jornet P, Molino Pagan D, Andujar Mateos P, Rodriguez Agudo C, Pons-Fuster A. Circadian rhythms variation of pain in burning mouth syndrome. Geriatr Gerontol Int. 2015;15(4):490-495.
4. Bortolato B, Berk M, Maes M, McIntyre RS, Carvalho AF. Fibromyalgia and bipolar disorder: emerging epidemiological associations and shared pathophysiology. Curr Mol Med. 2016;16(2):119-136.
5. Anyan J, Verwey M, Amir S. Individual differences in circadian locomotor parameters correlate with anxiety- and depression-like behavior. PLoS One. 2017;12(8):e0181375.


Product Spotlight

American Academy of Oral & Maxillofacial Pathology logo

2019 AAOMP Annual Meeting
Join AAOMP at our Annual Meeting, June 7-June 12, 2019 in Miami, Florida.

Join us for our annual AAOMP Seminar panel session moderated by Dr. Indraneel Bhattacharyya, Division Head, University of Florida Oral and Maxillofacial Pathology. Learn about interesting cases from the University of Florida Oral Pathology team.

Earn additional CE credits by attending the following sessions:

• Symposium—HPV & Oro-pharyngeal and Oral Cancer, by Dr. Gypsyamber D’Souza, Division of Cancer Epidemiology Johns Hopkins University.
• Slide seminar—Head and Neck Pathology, by Dr. Bruce Wenig, Section Head of Anatomic Pathology External Network Consultation Services and Head and Neck–Endocrine Pathology Program Moffitt Cancer Hospital.
• Slide seminar—Hematopathology: Lymphoid lesions of the Head and Neck, by Dr. L. Jeffrey Medeiros, Chief of the Lymphoma Section in the Department of Hematopathology at the University of Texas M.D. Anderson Cancer Center.
• Founders Seminar—Newly Defined (and Recently Refined) Head and Neck Tumors, by Dr. Justin Bishop, Associate Professor of Pathology, Otolaryngology-Head and Neck Surgery, and Oncology at Johns Hopkins Hospital

Learn more


News You Can Use

Oral pathology courses are in high demand at ADA 2018

ADA 2018 Meeting logoMake the most of your training at ADA 2018. Register for Oral Pathology courses, like Following the Path of Oral Cancer Diagnosis and Treatment to further you knowledge and response to possible cancerous lesions. The course will guide oral health care providers the basics of the oral cancer screening process and what to do when a lesion is suspected to be cancerous. Take advantage of this free course and learn more about what can be done to give the necessary care to patients. Earn 1.5 CE hours upon completion.

Free CE over here!

ADA CE Online logoADA CE Online has a wide selection of on-demand courses that are free for all, including this course by Dr. Sebastian Cianco, Baking Soda Dentifrices: Benefits for Oral Health. Benefit your patients’ smiles by learning all about the clinical, esthetic, and antimicrobial benefits of baking soda.

This course is sponsored by Arm & Hammer.



What's in this issue?

Assessing electronic cigarette use and self-reported
oral symptoms among adolescents>>

Screening for oral cancer >>

Diagnostic delays among patients
with autoimmune blistering
diseases of the mouth >>

An overview of the etiology
and treatment of burning mouth syndrome >>

Product Spotlight:
2019 AAOMP Annual Meeting>>

News You Can Use:
Oral pathology courses are in high
demand at ADA 2018 >>


Faizan Alawi D.D.S.

The consulting editor for JADA+ Specialty Scan — Oral Pathology is Faizan Alawi D.D.S.; Associate Dean for Academic Affairs and Associate Professor of Pathology, School of Dental Medicine; Associate Professor of Dermatology, Perelman School of Medicine; Director, Penn Oral Pathology Services; University of Pennsylvania


Bruno C. Jham, DDS, MS, PhD

The associate consulting editor for JADA+ Specialty Scan — Oral Pathology is Bruno C. Jham, DDS, MS, PhD; Associate Professor and Associate Dean for Academic Affairs; College of Dental Medicine – Illinois, Midwestern University


JADA+ Specialty Scans and JADA+ Scans
JADA+ Specialty Scans and JADA+ Scans are quarterly newsletters updating dentists on the latest research in selected specialties and disciplines in dentistry. ADA Publishing and the consulting editors from the represented specialties and disciplines aggregate and summarize research from previously published materials, each item attributed to its publication of origin. JADA+ Scan specialties and disciplines include endodontics, healthy aging, oral pathology, orthodontics, pediatric dentistry, periodontics, prosthodontics, radiology, cosmetic/esthetic and osseointegration. View past issues here.

Editorial and Advertising Policies
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.

All matters pertaining to advertising should be addressed to the advertising sales manager, Sales and Marketing Department, American Dental Association, Publishing Division, 211 E. Chicago Ave., Chicago, Ill 60611, 1-312-440-2740, fax 1-312-440-2550. All advertising appearing in ADA publications must comply with official published standards of the American Dental Association, a copy of which is available on request.