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An 86-year-old woman visited her periodontist (M.F.) for diagnosis and treatment of a persistent palatal ulceration (Figure 1). At the time the patient first noted the palatal lesion, the periodontist believed that the ulceration represented a traumatized maxillary torus. He constructed a clear palatal stent to cover the lesion and prevent further trauma (Figure 2). The periodontist also prescribed triamcinolone ointment for topical application. During the ensuing four-month period, the lesion did not resolve, which prompted the periodontist to refer the patient to an oral medicine health care provider (M.A.S.) for a consultation. The patient was concerned about the possibility of having oral cancer. She reported that during the four-month period, she had a sharp area of bone that had resolved spontaneously. The patient had a complex medical history, but her medical conditions were well-controlled at the time of the consultation. She was ambulatory, lived alone and was able to carry out her daily activities Exposed bone in the palate

The Vanderbilt Head and Neck Symptom Survey (VHNSS) version 2.0 oral symptom subscale addresses underreported oral health issues. We report the associations of xerostomia, dental health, dentures and trismus questions with oral examination findings.Between May 2011 and April 2012, fifty head and neck cancer (HNC) patients treated with chemoradiotherapy completed the 50-item VHNSS survey, an oral health assessment by a dentist, salivary flow, and inter-incisal opening (IIO) measurements.Patient reported "problems with dry mouth" correlated with unstimulated salivary flow (-0.43, p=0.002). "Cracked teeth" (0.55, p=0.001) or "difficulty chewing due to teeth" (0.43, p=0.004) correlated with urgent/emergent dental issues identified on clinical exam. Scores of4 on any dental question identified 83% of patients with urgent or emergent needs. The ROC curve separated routine from urgent/emergent dental issues (0.89, p0.001). IIO correlated with reported jaw movement "limitations" (-0.43, p=0.002). Small numbers of patients with dentures precluded meaningful analysis of this subsample.Clinically significant oral health issues pertaining to xerostomia, dental health and trismus may be identified using the oral health subscale of the VHNSS version 2.0. MASCC guidelines should be followed by patients with xerostomia. The observation that a score of4 is highly predictive of dental issues is important and needs further validation. If confirmed, this would be a useful screening tool for identifying and referring HNC patients for dental care. Patients with trismus should receive physical therapy.

Pediatric cancer therapy has advanced to become curative for many types of cancer. The overall survival of patients treated for childhood cancer is now in the range of 90%. The May 2009 issue of the Journal of Clinical Oncology reported improved survival from about 30% in 1960 to 80% in 2004. An epidemiologic study (Mariotto et al. 2009) estimated that in the United States alone, there are more than 300,000 survivors of childhood cancer. However, this success has not come without a price. Pediatric cancer therapy is given during a time of growth, and late effects in the oral cavity can alter the growth and development of teeth and bones and affect overall health for the duration of a patient’s life. The severity of these clinical and anatomical complications depends on tumor diagnosis, therapy exposure (chemotherapy, radiation, hematopoietic stem cell transplantation or a combination of several therapies), patient age and developmental status at the time of therapy and the resulting toxicity. In this chapter we will discuss some of the most important oral complications in pediatric oncology, with a focus on late effects of cancer and its treatment. Early complications will also be briefly described. Although the emphasis of this book is neurologic malignancy, oral complications occur in association with such malignancies because of the type of cancer therapy used. The prevention and management of these complications will be discussed, as well as the need for collaboration between dental providers and the oncology team for the improvement of outcomes.

Histoplasmosis is a fungal infection caused by the organism Histoplasma capsulatum. Disseminated disease usually occurs in immunosuppressed patients or in patients with chronic illnesses. Although relatively uncommon, histoplasmosis has been reported in patients with AIDS, and oral lesions have been noted on multiple sites and in various clinical presentations. We present two HIV-positive cases with oral lesions as the initial signs of histoplasmosis. Both patients responded well to IV amphotericin B but later suffered recurrences despite being maintained on systemic antifungal therapy.

The aim of this study was to review the available literature and define clinical practice guidelines for the use of laser and other light therapies for the prevention and treatment of oral mucositis. A systematic review was conducted by the Mucositis Study Group of the Multinational Association of Supportive Care in Cancer/International Society of Oral Oncology. The body of evidence for each intervention, in each cancer treatment setting, was assigned an evidence level. Based on the evidence level, one of the following three guideline determinations was possible: recommendation, suggestion, and no guideline possible. A new recommendation was made for low-level laser (wavelength at 650 nm, power of 40 mW, and each square centimeter treated with the required time to a tissue energy dose of 2 J/cm2 (2 s/point)) for the prevention of oral mucositis in adult patients receiving hematopoietic stem cell transplantation conditioned with high-dose chemotherapy, with or without total body irradiation. A new suggestion was made for low-level laser (wavelength around 632.8 nm) for the prevention of oral mucositis in patients undergoing radiotherapy, without concomitant chemotherapy, for head and neck cancer. No guideline was possible in other populations and for other light sources due to insufficient evidence. The increasing evidence in favor of low-level laser therapy allowed for the development of two new guidelines supporting this modality in the populations listed above. Evidence for other populations was also generally encouraging over a range of wavelengths and intensities. However, additional well-designed research is needed to evaluate the efficacy of laser and other light therapies in various cancer treatment settings.

A southeastern dental educational institution formalized a Percutaneous and Mucous Membrane Exposure Protocol in 1990. This article outlines the development, implementation, and administration of the protocol including risk assessment and rationale for testing health care workers and source persons. Pretest and posttest counseling for HIV testing is also discussed.

The Cytobrush Plus cell collector (cytobrush) was compared with the wooden tongue depressor during oral exfoliative cytology. The degree of patient discomfort, the convenience to the clinician, and the quantity and distribution of epithelial cells collected were evaluated. Two-factor analysis of variance and parametric and nonparametric analyses were performed. Because of the favorable findings revealed in this study, we recommend that the cytobrush be considered for use when obtaining diagnostic cytologic smears from the oral mucosa.

summary The aim of this study was to compare retrospectively the effect of three different treatments on the healing outcome of bisphosphonate-related osteonecrosis of the jaws (BRONJ) in cancer patients. Twenty-two cancer patients were treated for BRONJ with one of the following protocols: clinical (pharmacological therapy), surgical (pharmacological plus surgical therapy), or PRP plus LPT (pharmacological plus surgical plus platelet rich plasma (PRP) plus laser phototherapy (LPT). The laser treatment was applied with a continuous diode laser (InGaAlP, 660 nm) using punctual and contact mode, 40 mW, spot size 0.042 cm 2 ,6J / cm 2 (6 s) and total energy of 0.24 J per point. The irradiations were performed on the exposed bone and surrounding soft tissue. The analysis of demographic data and risk factors was performed by gathering the following information: age, gender, primary tumor, bisphosphonate (BP) used, duration of BP intake, history of chemotherapy, use of steroids, and medical history of diabetes. The association between the current state of BRONJ (with or without bone exposure) and other qualitative variables was determined using the chi-square or Fisher’s exact test. In all tests, the significance level adopted was 5%. Most BRONJ lesions occurred in the mandible (77%) after tooth extraction (55%) and in women (72%). A significantly higher percentage of patients reached the current state of BRONJ without bone exposure (86%) in the PPR plus LPT group than in the pharmacological (0%) and surgical (40%) groups after 1-month follow-up assessment. These results suggest that the association of pharmacological therapy and surgical therapy with PRP plus LPT significantly improves BRONJ healing in oncologic patients. Although prospective studies with larger sample sizes are still needed, this preliminary study may be used to inform a betterdesigned future study.

The possibility of diagnosing oral hairy leukoplakia by means of exfoliative cytology and the Papanicolaou stain was investigated. Exfoliative cytology and punch biopsy specimens were obtained from 10 lesions that demonstrated clinical features of hairy leukoplakia. All biopsy specimens demonstrated the characteristic histopathologic features of hairy leukoplakia whereas all Papanicolaou-stained cytologic smears demonstrated condensation and margination of the nuclear chromatin (nuclear beading). All biopsy specimens and cytologic smears displayed positive Epstein-Barr virus deoxyribonucleic acid in situ hybridization. We conclude that routine exfoliative cytology may be a reliable, noninvasive, and inexpensive technique for the diagnosis of hairy leukoplakia.

Bisphosphonates changed the way cancer patients with bone cancer and cancer metastatic to bone are treated. They promote considerable improvement in patient’s quality of life, reduce pain and decrease the risk of skeletal adverse events like pathological fractures. However, for some patients, these improvements come with a high price when they develop bisphosphonate adverse events. One serious adverse event that has been recently described is osteonecrosis of the jawbones (BON). This complication may affect up to 10% of those patients taking an intravenous formulation of bisphosphonates, more commonly pamidronate and zoledronic acid. Risk factors, diagnostic procedures, patient management and prevention will be the main focus of the discussion. In addition, we will review what is known about the pathobiology of this oral cavity complication of bisphosphonate therapy and will identify areas for future research.

and Overview. In 2005, the American Dental Association (ADA) Council on Scientific Affairs convened an expert panel to develop clinical recommendations for dentists treating patients who are receiving oral bisphosphonate therapy. The Journal of the American Dental Association published the resulting report in 2006. This 2008 advisory statement is the first of projected periodic updates of the 2006 clinical recommendations.This 2008 advisory statement concludes, on the basis of a review of the current literature, that for patients receiving bisphosphonate therapy, the risk of developing bisphosphonate-associated osteonecrosis (BON) of the jaw apparently remains low. It also newly concludes that current screening and diagnostic tests are unreliable for predicting a patient's risk of developing the condition. This statement updates the 2006 recommendations regarding general dentistry, management of periodontal diseases, implant placement and maintenance, oral and maxillofacial surgery, endodontics, restorative dentistry and prosthodontics, and orthodontics.

More than half of all serious adverse reactions are identified 7 or more years after a drug receives approval from the US Food and Drug Administration (FDA). In 2002, 9 months after the intravenous bisphosphonate zoledronic acid received regulatory approval for marketing, the FDA received reports of nine patients with cancer, who were treated with zoledronic acid, who unexpectedly developed osteonecrosis of the jaw. During the next 2 years, three oral surgeons described 104 patients with cancer with osteonecrosis of the jaw in the medical literature and identified intravenous bisphosphonate therapy as being common to the care of these patients. In subspecialty medical, radiology, and dental journals, case reports and case series described clinical features of osteonecrosis of the jaw in patients with cancer who were treated with bisphosphonates. Manufacturer-sponsored epidemiological studies reported the first estimates of the incidence of this toxic effect, ranging from 0.1% to 1.8%. By contrast, independent epidemiological efforts from clinicians and the International Myeloma Foundation reported incidence estimates between 5% and 10%. Between 2003 and 2005, warnings about the risks of bisphosphonate-associated osteonecrosis were disseminated by national regulatory agencies, the manufacturers of bisphosphonates, and the International Myeloma Foundation. From 2006, independent clinical recommendations for diagnosis, prevention, and treatment of this toxic effect have been disseminated by manufacturers, national regulatory authorities, the International Myeloma Foundation, and medical specialty organisations. Furthermore, independent efforts by pharmaceutical manufacturers, dental and medical professionals, a non-profit organisation (the International Myeloma Foundation), patients, and regulatory authorities has led to the rapid identification and dissemination of safety information for this serious adverse reaction. Better coordination of safety-related pharmacovigilance initiatives is now needed.

Background Osteoporosis is a common disease in middle-aged and older Americans. The risk of sustaining fractures is a concern, and mortality rates after hip or vertebral fractures are high. Oral health maintenance for adults with osteoporosis is important. Types of Studies Reviewed The authors conducted a MEDLINE search of the medical and dental literature with the objective of reviewing osteoporosis, its effect on public health in the population in the United States and the implications in providing dental care for these patients. They selected studies by performing a content search with National Library of Medicine medical subject headings (epidemiology, public health impact, treatment, adverse drug reactions, cost-effectiveness of osteoporosis therapy, oral health, periodontal disease, adverse drug reactions, bisphosphonates and osteonecrosis of the jaw). They then performed a study design search with a filter so that only randomized clinical trials were included. Results Osteoporosis and related fractures are more common than coronary disease, stroke and breast cancer. Fractures resulting from osteoporosis can affect a patient's quality of life severely, and fractures result in functional impairment and increased health care cost and mortality. Medical management of osteoporosis includes diet control, with appropriate intake of calcium and vitamin D, weight-bearing exercise, discontinuation of tobacco and alcohol intake, and use of medications, including selective estrogen receptor modulators, calcitonin, anabolic agents and bisphosphonates. Bisphosphonates have been associated with the development of osteonecrosis of the jaws. Clinical Implications Oral health maintenance is important in patients with osteoporosis. Bisphosphonate therapy or other medical treatment for these people should be discontinued only after consultation with the patient's physician.

The focus of this review is to highlight the need for improved communication between medical and dental professionals in order to deliver more effective care to patients. The need for communication is increasingly required to capitalise on recent advances in the biological sciences and in medicine for the management of patients with chronic diseases. Improvements in longevity have resulted in populations with increasing special oral-care needs, including those who have cancer of the head and neck, those who are immunocompromised due to HIV/AIDS, advanced age, residence in long-term care facilities or the presence of life-long conditions, and those who are receiving long-term prescription medications for chronic conditions (e.g., anti-hypertensives, anticoagulants, immunosuppressants, antidepressants). These medications can cause adverse reactions in the oral cavity, such as xerostomia and ulceration. Patients with xerostomia are at increased risk of tooth decay, periodontal disease and infection. The ideal management of such individuals should involve the collaborative efforts of physicians, nurses, dentists and dental hygienists, thus optimising treatment and minimising secondary complications deriving from the oral cavity.

A breast cancer patient with skeletal metastases was treated with only one i.v. dose of ibandronate in March of 2005 and subsequent doses of oral ibandronate 50 mg daily. One year after the i.v. infusion, the patient complained of oral pain under her lower denture. After several negative attempts from her dentist to control the pain and adjust the denture, the patient was diagnosed with bisphosphonate-associated osteonecrosis (BON) of the mandible. The use of ibandronate, a potent bisphosphonate, is increasing worldwide. Prescribing oncologists should be aware of the potential for the development of new cases of BON in a similar fashion as with zoledronic acid.

Reports of osteonecrosis of the jaw (ONJ) in patients receiving long-term bisphosphonate therapy have appeared in the literature since 2003. This condition involves avascular necrotic bone in the area of maxilla or mandibula and there may be a secondary infection. Most cases of ONJ have been reported in cancer patients receiving the intravenous aminobisphosphonates zoledronic acid and pamidronate monthly or q 3 week; of note these are also the two most commonly used agents of this class. Risk factors for ONJ include a history of trauma, dental surgery or dental infection and intravenous bisphosphonate administration; in addition, the extent and duration of exposure to bisphosphonates also seem to correlate with the risk. Although a direct causal relationship with bisphosphonates cannot be assumed, these agents may possibly contribute to the development of ONJ by suppression of bone remodeling in the jaw which leads to increased rates of bone mineralisation and accumulation of microfractures. Clodronate, a non-aminobisphosphonate, appears to have a different mechanism of suppressing bone remodeling compared with aminobisphosphonates, and this may explain why few cases of ONJ have been reported with clodronate despite extensive use over the past 20 years; however, the potential of clodronate to reduce the risk of ONJ while providing equivalent clinical benefit to the aminobisphosphonates needs to be substantiated in controlled clinical trials. Use of bisphosphonate therapy should be carefully planned in patients with metastatic bone disease who have risk factors for ONJ, and appropriate preventive measures taken to avoid the development of this condition.

Considerable progress in research and clinical application has been made since the original guidelines for managing mucositis in cancer patients were published in 2004, and the first active drug for the prevention and treatment of this condition has been approved by the United States Food and Drug Administration and other regulatory agencies in Europe and Australia. These changes necessitate an updated review of the literature and guidelines. Panel members reviewed the biomedical literature on mucositis published in English between January 2002 and May 2005 and reached a consensus based on the criteria of the American Society of Clinical Oncology. Changes in the guidelines included recommendations for the use of palifermin for oral mucositis associated with stem cell transplantation, amifostine for radiation proctitis, and cryotherapy for mucositis associated with high-dose melphalan. Recommendations against specific practices were introduced: Systemic glutamine was not recommended for the prevention of gastrointestinal mucositis, and sucralfate and antimicrobial lozenges were not recommended for radiation-induced oral mucositis. Furthermore, new guidelines suggested that granulocyte-macrophage-colony stimulating factor mouthwashes not be used for oral mucositis prevention in the transplantation population. Advances in mucositis treatment and research have been complemented by an increased rate of publication on mucosal injury in cancer. However, additional and sustained efforts will be required to gain a fuller understanding of the pathobiology, impact on overall patient status, optimal therapeutic strategies, and improved educational programs for health professionals, patients, and caregivers. These efforts are likely to have significant clinical and economic impact on the treatment of cancer patients. Cancer 2007;109:820-31. (c) 2007 American Cancer Society.

Several therapeutic agents have been investigated for the treatment of oral lichen planus (OLP). Among these are corticosteroids, retinoids, cyclosporine, and phototherapy, in addition to other treatment modalities. A systematic review of clinical trials showed that particularly topical corticosteroids are often effective in the management of symptomatic OLP lichen planus. Systemic corticosteroids should be only considered for severe widespread OLP and for lichen planus involving other mucocutaneous sites. Because of the ongoing controversy in the literature about the possible premalignant character of OLP, periodic follow-up is recommended. There is a spectrum of oral lichen planus-like ("lichenoid") lesions that may confuse the differential diagnosis. These include lichenoid contact lesions, lichenoid drug reactions and lichenoid lesions of graft-versus-host disease. In regard to the approach to oral lichenoid contact lesions the value of patch testing remains controversial. Confirmation of the diagnosis of an oral lichenoid drug reaction may be difficult, since empiric withdrawal of the suspected drug and/or its substitution by an alternative agent may be complicated. Oral lichenoid lesions of graft-versus-host disease (OLL-GVHD) are recognized to have an association with malignancy. Local therapy for these lesions rests in topical agents, predominantly corticosteroids.

Article Title and Bibliographic Information Bisphosphonates-induced exposed bone (osteonecrosis/osteopetrosis) of the jaws: risk factors, recognition, prevention and treatment. Marx RE, Sawatary Y, Fortin M, Broumand V. J Oral Maxillofac Surg 2005;63:1567-75. Level of Evidence 4 Purpose/Question To determine type, dosage, and duration of bisphosphonate therapy; indication of use; clinical findings; comorbidities present; and the event that initiated the bone exposure. Source of Funding None disclosed Type of Study/Design Retrospective case series review

We present current knowledge of bisphosphonate-associated osteonecrosis, a new oral complication in oncology. It was first described in 2003, and hundreds of cases have been reported worldwide. The disorder affects patients with cancer on bisphosphonate treatment for multiple myeloma or bone metastasis from breast, prostate, or lung cancer. Bisphosphonate-associated osteonecrosis is characterised by the unexpected appearance of necrotic bone in the oral cavity. Osteonecrosis can develop spontaneously or after an invasive surgical procedure such as dental extraction. Patients might have severe pain or be asymptomatic. Symptoms can mimic routine dental problems such as decay or periodontal disease. Intravenous use of pamidronate and zoledronic acid is associated with most cases. Other risk factors include duration of bisphosphonate treatment (ie, 36 months and longer), old age in patients with multiple myeloma, and a history of recent dental extraction. We also discuss pathobiology, clinical features, management, and future directions for the disorder.

The Multinational Association for Supportive Care in Cancer/International Society of Oral Oncology (MASCC/ISOO) Mucositis and Patient and Professional Education Study Groups are collaborating to improve the promulgation of the updated mucositis management guidelines. The initial step in the collaboration was to survey cancer care health professionals to determine their awareness of the original 2004 guidelines and their opinions on the usefulness of patient educational materials based on the guidelines. The authors surveyed four samples (three US and one European) of cancer health care professionals attending three cancer-related professional conferences between May and July 2005 using a ten-item questionnaire in both paper-and-pencil and web-based formats. Data were compiled and analyzed using descriptive statistics. All respondents were generally aware of the importance of mucositis as a treatment-limiting toxicity with life-threatening complications and endorsed regular oral assessment and dental care practices. Only about one third of the US respondents were aware of the 2004 guidelines in contrast to 80% of the European respondents. A majority of respondents across all four surveys (66–93%) felt strongly that educational materials based on the guidelines were needed and that they would use them, while a smaller number (7–29%) indicated they might use them if a patient had a problem with mucositis. Awareness of the guidelines remains limited in the US, and use of the guidelines worldwide is minimal. The Mucositis and Patient and Professional Education Study Groups have developed a set of strategies to enhance dissemination, awareness, and use of the updated guidelines and to promote patient education based on the guidelines. Future work will focus on implementation and evaluation of the guidelines in clinical practice.

Article Title and Bibliographic Information Incidence of osteonecrosis of the jaw in patients with multiple myeloma and breast or prostate cancer on intravenous bisphosphonate therapy Wang EP, Kaban LB, Strewler GJ, Raje N, Troulis MJ. J Oral Maxillofac Surg 2007;65:1328-31 Strength of Recommendation C Purpose/Question To determine the incidence of ONJ in a cohort of patients with multiple myeloma (MM), breast cancer (BC), or prostate cancer (PC) who were receiving intravenous bisphosphonate therapy for an established period of time. Source of Funding American Association of Oral and Maxillofacial Surgeons Student Training Award; Office of Enrichment Programs, Harvard Medical School; and the Department of Oral and Maxillofacial Education and Research Fund. Type of Study/Design Retrospective chart review

Article Title and Bibliographic Information Safety of oral bisphosphonates: controlled studies on alveolar bone Jeffcoat MK. Int J Oral Maxillofac Implants 2006 May-Jun;21(3):349-53 Level of Evidence 4 Purpose/Question To determine if oral bisphosphonates cause osteonecrosis of the jaw Source of Funding Proctor and Gamble & Merck Research Type of Study/Design 2 cohort studies

6040 Background: The Vanderbilt Head and Neck Symptom Survey (VHNSS) version 2.0 oral symptom subscale was developed to address potentially overlooked and underreported oral health issues. We report the validation of questions pertaining to xerostomia (4 items), dental health (4 teeth), dentures (1 item) and trismus (1 item). Methods: Between May 2011 and April 2012, 50 patients treated with chemoradiotherapy for head and neck cancer completed the 50-item VHNSS survey, underwent an oral health assessment by a dentist, salivary flow and inter-incisal opening (IIO) measurements. Results: Patient reported “problems with dry mouth” correlated with unstimulated salivary flow rates (-0.43, p = 0.002). “Cracked teeth” (-0.55, p = < 0.001) or “difficulty chewing due to teeth” (-0.43, p = 0.004) correlated with urgent or emergent dental care issues identified on exam. Using a cut off of >4 on any of four the dental questions, we were able to identify 83% of patients with urgent or emergent dental issues. The ROC curve was useful (0.89, p< 0.001) for separating patients with and without urgent/emergent dental issues. “Limitations” in jaw movement correlated with IIO (-0.43, p = 0.002). Small numbers of patients with dentures precluded meaningful analysis of this subsample. Conclusions: Clinically significant oral health issues pertaining to xerostomia, dental health and trismus may be identified using the oral health subscale of the VHNSS version 2.0. Patients who score > 4 on any of the teeth related items should be referred for immediate dental evaluation; and for trismus should be referred for physical therapy.

We studied the reactivity of monoclonal antibodies (MAbs) 17.13 and 63.12 with normal and diseased human oral mucosa by means of the immunoperoxidase technique. The specimens included: 22 normal oral tissues, 20 benign tumors, 17 lichen planus, 23 focal keratosis and epithelial hyperplasias, 18 proliferative verrucous leukoplakias, 20 dysplasias, and 21 squamous cell carcinomas. In most cases of normal mucosa and benign lesions, MAb 17.13 stained basal epithelial cells only, whereas MAb 63.12 stained all cell layers above the basal cells. In the premalignant and malignant lesions MAb 17.13 stained above the basal cells and MAb 63.12 either stained areas not stained by MAb 17.13 or the staining was absent. Based on the different staining patterns observed, there appears to be a potential value of these new reagents in diagnostic histopathology regarding specimens with equivocal cellular morphology.

Numerous publications have reviewed the oral manifestations of HIV infection and AIDS. Although uncommon, herpetic infections and histoplasmosis are among the diseases reported. The case that follows presents the first description of the simultaneous occurrence of oral herpes simplex virus, cytomegalovirus, and histoplasmosis in an HIV-infected person. These infections appeared as extensive oral ulcerations and were the only clinical manifestation of HIV infection. Eleven months after the initial presentation, the patient died of complications of AIDS.

Since our first description and profile of patients with Kaposi's sarcoma (KS) in 1984, the relative rate of KS in patients with the acquired immunodeficiency syndrome has dropped from 34% to 20%. However, the absolute number is increasing. The pathogenesis of KS is still obscure, and its interaction with the human immunodeficiency virus infection remains unclear. Cause of death is usually opportunistic infections in both endemic and epidemic KS. The most common intraoral site is the palate, which is involved in 95% of our cases. The oral cavity may be the only or first site of KS, and therefore, becomes important in the diagnosis. More than 20% of our current patient population had the oral cavity as the initial site of manifestation. Because of functional impairment, bleeding, pain, or cosmetic reasons, treatment is frequently required. There are many modalities used, including chemotherapy, radiation, and laser resection. Radiation appears to be a most effective and practical control measure for oral KS.

Fifty-three homosexual men with Kaposi's sarcoma (KS) were studied. Twenty-seven had biopsy-proved oral KS, the palate being the most common site. Past or present infections with cytomegalovirus, hepatitis, venereal diseases, and gastrointestinal microorganisms occurred in more than 70%. Oral candidiasis was confirmed in 57%. Heavy marijuana smoking was the most common habit. Transmission of AIDS is thought to be by a viral agent. Precautions involving the use of gloves, eyeglasses, and masks, similar to those recommended for the management of patients with hepatitis B, are urged.

One hundred thirty-two consecutive patients suspected of having malignant or precancerous oral lesions were studied by comparing toluidine blue dye uptake clinically with a simultaneous biopsy. The histopathologic diagnosis confirmed 57 squamous carcinomas, 42 epithelial dysplasias, and 33 benign mucosal changes. Overall accuracy of the toluidine blue uptake was 91%. In the dysplastic and malignant lesions the false negatives were 2%, and there were 30% false positives in the benign lesions. It was concluded that toluidine blue staining is a useful adjunct to careful examination, clinical judgment, and biopsy.

To explore the nature and importance of mononuclear cells of different phenotypes in oral premalignant lesions and oral cancer, we studied biopsy specimens from 21 oral red and/or white lesions (6 hyperkeratosis, 3 mild dysplasia, 4 severe dysplasia and 8 squamous cell carcinoma), using monoclonal antibodies and avidin-biotin-peroxidase complex staining. Peripheral blood samples (PB) from 4 normal subjects and 5 reactive lymph nodes (LN) were used as controls for the technique. T11-positive cells were the predominant phenotype (74-78%) in all cases examined. The T4/T8 ratio in severe dysplasia was significantly lower than that in mild dysplasia (p less than or equal to 0.05). These observations support the hypothesis of a role for cellular immune responses in oral premalignant lesions and oral cancer. The predominance of T cells may represent the local expression of immunity against antigens (viral or other). The decreased T4/T8 ratio observed in severe dysplasia may represent a transitory stage of local immunosuppression, which may be of critical importance for the progression into carcinoma. Phenotypic variations in mononuclear cell infiltrates in these conditions could be diagnostic value.

An objective evaluation of 55 patients with chronic vesiculoerosive oral diseases was made to compare the beneficial and adverse effects of prednisone treatment. Patients were divided into groups of high, intermediate, and low drug dosages, as well as short and long periods of administration. Prednisone benefited 49 patients in spite of the fact that 55% had some adverse side effects. The duration of prednisone administration appeared to have a larger impact on side effects than the daily amount given. The most common side effects were gastrointestinal disturbances, mood alterations, polyuria and insomnia. There were no significant changes in blood pressure, blood sugar level, weight, or white blood cell counts. This study confirmed that systemic prednisone is a useful and beneficial treatment modality for patients with chronic oral inflammatory diseases.

A total of 375 consecutively identified homosexual, males were studied to assess dental findings, needs, and risks. The oral signs and symptoms that may be used to recognize people infected with the AIDS virus are defined to help dental professionals participate in health care delivery. A total of 375 homosexual males were studied to assess the dental findings, life-style, and risk factors during a 4-year period. At baseline, 136 of the patients were diagnosed as having AIDS, 116 were considered at risk for AIDS, and 123 were considered healthy. In a mean follow-up time of 23 months, nine of the patients at risk for AIDS and five of the patients considered healthy were diagnosed as having AIDS. Kaposi’s sarcoma was the most common oral neoplasm, and candidiasis was the most frequent oral infection. Hairy leukoplakia was found in 28% of the patients, and periodontal disease was found in 17% of the patients. Carriers of the AIDS virus may not be identified easily and control measures in the dental office must be followed.

Systemic glucocorticoids in the form of prednisone have been effective in reducing signs and symptoms in a variety of acute and chronic oral inflammatory diseases. In the 101 patients prospectively studied, the benefits from prednisone treatment far outweighed the adverse side effects, which occurred in 61 patients. However, none of the adverse side effects was severe enough to require cessation of the prednisone. The adverse effects, which could be minimized by reducing the dosage in most instances, were primarily related to treatment that persisted for more than two weeks. Fluid retention or bloating was the most common symptom, and insomnia was the chief side effect in those patients receiving short-term treatment (less than two weeks). Blood sugar, blood pressure, weight, and white blood cell counts were not meaningfully altered. Variables in patients' drug response and side effects precluded formulation of precise prednisone dosages that would allow predictive outcomes.