Lymphoid organisation in labial salivary gland biopsies is a possible predictor for the development of malignant lymphoma in primary Sjögren's syndrome

Objective The development of non-Hodgkin's lymphoma (NHL) confers a high risk of mortality in primary Sjogren's syndrome (pSS) patients, but the sensitivity and specificity of proposed lymphoma predictors are insufficient for practical use. The performance of lymphoid organisation in the form of germinal centre (GC)-like lesions was evaluated in labial salivary gland biopsies taken at pSS diagnosis as a potential lymphoma-predicting biomarker. Methods Labial salivary gland tissue biopsies available from two Swedish pSS research cohorts (n = 175) were re-evaluated by light microscopy in a blind study in order to identify GC-like structures as a sign of ectopic lymphoid tissue formation and organisation. A linkage study was performed with the Swedish Cancer Registry for lymphoma identification. The risk of developing NHL in GC-positive patients in comparison with GC-negative patients was evaluated using Kaplan-Meier statistics and log-rank test. Associations between GC-like structures and clinical and/or laboratory disease markers were also determined using. 2 or Fisher's exact tests. Results At diagnosis, 25% of pSS patients had GC-like structures in their salivary glands. Seven of the 175 patients studied (14% GC+ and 0.8% GC-) developed NHL during 1855 patient-years at risk, with a median onset of 7 years following the initial diagnostic salivary gland biopsy. Six of the seven patients had GC-like structures at diagnosis; the remaining patient was GC negative at the time of diagnosis (p=0.001). Conclusions The detection of GC-like structures by light microscopy in pSS diagnostic salivary biopsies is proposed as a highly predictive and easy-to-obtain marker for NHL development. This allows for risk stratification of patients and the possibility to initiate preventive B-cell-directed therapy

Mandibular third molar removal : patient preferences, assessments of oral surgeons and patient flows

Operativt avlägsnande av visdomständer i underkäken utgör en stor del av verksamheten vid landstingens specialistkliniker i käkkirurgi i Sverige. Under 1980- och 1990-talen beräknades årligen 20-25.000 visdomständer ha avlägsnats vilket utgjorde ca 60 % av operationsvolymen vid dessa kliniker. Därtill kommer ett stort antal operationer av visdomständer som har utförts av privata specialister och allmänpraktiserande tandläkare. Mot den här bakgrunden har målsättningen varit, avseende visdomstandskirurgi i underkäken, att: 1. Studera patienters preferenser för möjliga konsekvenser efter operativt avlägsnande jämfört med att man avstår från operation, d.v.s. att visdomstanden får sitta kvar. 2. Jämföra patienters preferenser i två olika länder, Sverige och Wales. 3. Studera käkkirurgers bedömning av indikationens styrka för tänder, med och utan sjukdom, som skall operativt avlägsnas. 4. Beskriva och analysera vårdprocessen för patienter som remitterats till käkkirurgiska specialistenheter för operativt avlägsnande av visdomstanden. I de två första studierna presenterades resultaten av den svenska undersökningen som sedan jämfördes med resultaten från motsvarande undersökning utförd i Wales. Patienternas preferenser vid behandlingsbeslut att operativt avlägsna visdomstanden alternativt att avstå från operation, visade att trots att kulturer och ekonomiska system kan skilja sig åt, så var patienternas preferenser i de båda länderna likartade. Samstämmigt föredrog patienterna de konsekvenser som kan uppstå om visdomstanden får vara kvar (perikoronit, karies, rotresorption, follikularcysta) jämfört med de konsekvenser som kan uppstå vid operativt avlägsnande av visdomstanden (värk, svullnad, känselstörningar på näraliggande nerver, postoperativ infektion). I den tredje studien konstaterades att käkkirurger som opererade visdomständer på patienter som var remitterade till specialistklinik visade stor variation då man skattade styrkan för indikationen att utföra ingreppet. En Visual Analog Scale (VAS) användes, där 0 indikerade mycket svag indikation och 100 mm mycket stark indikation, för att käkkirurgerna skulle registrera hur de värderade styrkan på indikationen för planerad operation. Dessutom registrerades antalet sjukdomstillstånd i anslutning till aktuell visdomstand, patientens ålder, tandens läge i käken samt om tanden helt eller delvis var täckt med slemhinna/benvävnad. Andelen tänder i det undersökta materialet som avlägsnades utan att ha någon associerad sjukdom (s.k. profylaktiskt indikation) var 18 %. Styrkan på indikationen att operativt avlägsna denna grupp visdomständer var lägre än för de med associerad sjukdom. Patientens ålder var den enda faktor, av de registrerade, som påverkade indikationen för profylaktisk operation. Indikationen var högre i de yngre åldersgrupperna jämfört med de äldre. I den fjärde studien följdes det faktiska förloppet i vårdprocessen för 361 patienter som var remitterade för visdomstandsoperation i underkäken, vid fyra käkkirurgiska specialistenheter. Detta innebar att olika patientflöden identifierades. Dessa beskrev antalet patientbesök och dess innehåll, från remissmottagande till utförd operation. Åtta olika patientflöden kunde identifieras. Antalet patientbesök varierade mellan ett och tre. För majoriteten av patienterna bedömdes den röntgenundersökning som bifogades remissen vara otillräcklig som underlag för operationen. Kompletterande röntgenundersökning utfördes för drygt 10 procent av patienterna på specialistklinik för odontologisk röntgen. Resterande kompletterande röntgenundersökningar utfördes på den käkkirurgiska kliniken. Behovet av kompletterande röntgenundersökning hade med få undantag ingen påverkan på antalet besök för den planerade visdomstandsoperationen. Konklusionerna från resultaten i avhandlingen visar att: • Patienter föredrar de konsekvenser som kan inträffa om visdomstanden får vara kvar jämfört med de konsekvenser som kan inträffa vid ett operativt avlägsnande av visdomstanden • Patienters behandlingspreferenser är stabila i jämförelse mellan två olika länder som tycks ha olika kulturer och ekonomiska system • Behandlingsbeslut fattade av patienter visar mindre variation än behandlingsbeslut fattade av kliniker • Olika patientflöden kan påverka kostnadseffektiviteten.Mandibular third molar removal is one of the most common treatments conducted at oral and maxillofacial surgery clinics in Sweden. During the 1980’s and 1990’s, 20-25,000 mandibular third molars were removed annually which represents about 60% of the total operation volume. Removals performed in private specialist clinics and general dental clinics are not included in these figures. The aims of the present studies on mandibular third molars were to: 1) study values that reflect patients’ preferences about possible outcomes of removal and non-removal; 2) make comparisons between Sweden and Wales with respect to patient’s preferences; 3) study assessments of oral surgeons’ indications for molars to be removed ; 4) describe patient flows in the care process of removal. The multi-attribute utility (MAU) method was used to quantify patients’ preferences about outcomes following removal and non-removal. Whilst there were clear cultural and economic differences between the Swedish and the Welsh, there was a high degree of correlation in patients’ ranking of the different outcomes for patients from the two countries (rs= 0.93, P<0.001). Generally, situations describing the outcomes of non-removal had a higher ranking than those describing the outcomes of removal i.e. patients seemed to prefer non-removal. Oral surgeons at seven specialist clinics registered data for 666 patients i.e. patient age and sex, the angular position and extent of eruption of the molar and whether or not there was an associated disease related to the molar proposed for removal. The indication for the removal was assessed on a Visual Analogue Scale (VAS), and the recorded results found to show a great variety. The mean VAS for removal of molars without disease was significantly lower than that for molars with associated disease. The differences between the mean VAS for molars with one disease compared with molars with two or three diseases were not significant. The patients´ age was the only factor that had a significant effect on the assessment of the indication for molars without disease. The indication was higher for patients of the youngest age group than for patients of the oldest age group (P< 0.05). In four specialist units in southern Sweden, the patient flows (the number of visits and what the visits comprise of) was registered for 361 patients. All details were recorded from arrival of the referral to the unit to performed mandibular third molar surgery. Eight different patient flows were found. The number of patient visits varied from one to three. For about 60 percent of the patients, attached radiographs to the referral were considered not appropriate and had to be completed, e.g. to be retaken. For a minority of the patients, the radiographic examination was completed at the radiological clinic included in the specialist unit and, in the oral and maxillofacial clinic for the others. The number of patient visits seemed not to depend on whether the attached radiographs were judged to be appropriate or not. In conclusion: • Patient preferences seem to be more stable than the preferences of oral surgeons across the boundaries. • Patients prefer outcomes of third molar non-removal as compared to outcomes following removal. • Different patient flows may influence the cost-effectiveness in mandibular third molar surgery

Economic aspects of mandibular third molar surgery

Objective. The aim of this study was to make estimates from a dental care and societal perspective on costs of mandibular third molar surgery. Material and methods. A total of 64 patients were recruited from three Swedish oral and maxillofacial specialist clinics. Calculations were made prospectively on utilization of labor time, specific medical services and materials, and standardized utilization of other direct costs. Indirect costs were identified from patient surveys. Results. The base case average direct cost of surgery was 217 Euro. Adding the patient's average cost due to absence from work and transportation of 333 Euro increased overall costs to 550 Euro per patient. About 86% of the patients reported some absence following surgery. Conclusions. The indirect costs were on average higher than the direct costs, i.e. the patient's loss of time caused higher costs than the intervention per se. Appropriate indications for mandibular third molar removal can minimize the risks of complications and individual or societal costs

PREDICTION OF POSTOPERATIVE PAIN AFTER LOWER THIRD MOLAR SURGERY

Introduction Severe acute pain after lower third molar surgery (L3MS) has been reported in 16-20 % of the patients. The objective of the present study was to evaluate the predictive potential of a combination of preoperative psychological and psycho-physiological variables in estimating severity of postoperative pain, following this high volume, out-patient surgical procedure. Methods Following ethical committee approval and informed consent, 40 consecutive patients scheduled for L3MS were studied. Preoperative psychometric indicators of anxiety, depression and vulnerability were evaluated by patient questionnaires. Quantitative sensory testing was performed with a Modular Sensory Analyzer (Somedic AB, Sweden) using a contact thermode applied to the skin. Thermal thresholds and supra-threshold heat pain perception (1 s: 44, 45, 46, 47 and 48°C [VAS]) were evaluated. Standardized surgery was performed (LE) during local anesthesia. Postoperative pain management was with rescue acetaminophen 1 g and ibuprofen 600 mg. The patients were instructed to daily record pain (VAS) at rest, and, during mouth-opening, eating and drinking and requirement of analgesics for 14 days following surgery. Results Thirty-eight patients completed the study. Median duration of surgery was 11 min (range 2-21 min). Eight patients returned to the clinic because of pain. Total rescue doses of acetaminophen and ibuprofen were 13.5 g (6.5-22.2 g [median (IQ range)]) and 7 g (3.9-13.8 g), respectively. Moderate to severe pain (VAS > 30) was reported by 23/38 at rest, 25/38 during mouth-opening, 24/38 during drinking and 29/38 during eating. In a multiple regression model the combination of psychological vulnerability and heat pain perception rendered a predictive model that could account for 20 to 40 % of the variance in postoperative pain during resting and dynamic conditions following L3MS (P = 0.001). Implementation of clinically relevant preoperative screening methods may offer more efficacious pain therapies to pain susceptible individuals undergoing lower third molar surgery

Prediction of Postoperative Pain After Mandibular Third Molar Surgery

Aims: To evaluate the predictive potential of preoperative psychological and psychophysiological variables in estimating severity of postoperative pain following mandibular third molar surgery (MTMS). Methods: Following ethical committee approval and informed consent, 40 consecutive patients scheduled for MTMS were included. Preoperative psychometric indicators of anxiety, depression, and vulnerability were evaluated by patient questionnaires. Thermal thresholds and heat pain perception (1 second phasic stimuli: 44 degrees C to 48 degrees C) were evaluated with quantitative sensory testing techniques. Standardized surgery was performed during local anesthesia. Postoperative pain management was with rescue paracetamol and ibuprofen. The patients were instructed to record each day their pain at rest and during dynamic conditions, and their requirement of analgesics for 14 days following surgery. Results: Thirty-eight patients completed the study. Eight patients were readmitted because of pain. During the postoperative period, one or more episodes of moderate to severe pain (>30 on a visual analog scale) was reported by 60% (23/38) at rest, 63% (24/38) during mouth-opening, and 73% (28138) during eating. In a multiple regression model, the combination of psychological vulnerability and beat pain perception rendered a predictive model that could account for 15 to 30% of the variance in postoperative pain during resting and dynamic conditions (P = .03 to.001).Conclusion: Implementation of clinically relevant preoperative screening methods may offer more efficacious postoperative pain therapies to pain-susceptible individuals undergoing mandibular third molar surgery. J OROFAC PAIN 2010;24:189-19

Contact allergies to potential allergens in patients with oral lichen lesions.

OBJECTIVE: The aim of the present controlled study was to investigate a possible relationship between contact allergies to potential allergens and oral lichen lesions. METHODS: Eighty-three patients with oral lichen lesions (OLL) and control groups of age- and gender-matched dermatitis patients (DP, n = 83) and patch-tested dermatitis patients randomly selected from files (PSFF, n = 319) were included in the study. OLL and DP groups were patch-tested epicutaneously and examined intraorally. RESULTS: The frequencies of contact allergy to mercury and carvone were statistically higher in the OLL group than in the DP group. Surfaces of amalgam and composite restorations were statistically more frequent in the OLL group compared to the DP group. Contact allergy to nickel and colophony, the latter with a statistically significant difference, was more common in the DP group. The numerical difference found for nickel allergy was, however, not significant comparing the OLL and PSFF groups. CONCLUSION: Contact allergy to mercury was overrepresented in patients with OLL and has been reported in previous studies, but the present finding of an overrepresentation of contact allergy to carvone in patients with oral lichen lesions has not been reported previously. CLINICAL RELEVANCE: Carvone, in addition to mercury and gold, as previously suggested, can be one of the causative or maintenant factors for oral lichen lesions. Carvone-hypersensitive patients with oral lichen lesions should therefore avoid carvone-containing products for oral use

The necessity of a test reading after 1 week to detect late positive patch test reactions in patients with oral lichen lesions.

Establishing the clinical relevance of contact allergy to dental materials in patients with oral lichen lesions (OLL) may be difficult, and tests are often read only on day 3 or day 4; also, concentration of the tested allergens may vary. Several studies on dermatitis patients have shown that additional positive patch test reactions can be found after day 4. Therefore, the aim of the present study was to analyse the frequency of late positive reactions to potential allergens in patients with OLL

Contact Allergy to Gold in Patients with Oral Lichen Lesions.

The aetiology of oral lichen lesions is obscure. In this study the frequency of contact allergy to gold in 83 patients with oral lichen lesions was compared with that in two control groups, comprising 319 age- and gender-matched patients with dermatitis selected from files and 83 clinically examined dermatitis patients. All patients were tested epicutaneously with gold sodium thiosulphate. The two control groups tested were under examination for a tentative diagnosis of allergic dermatitis not related to oral problems. The frequency of contact allergy to gold was 28.9% in the patients with oral lichen lesions, 18.2% in patients selected from files, and 22.9% in the clinically examined control patients. The difference in frequency between patients with oral lichen lesions and those taken from files was statistically significant

Contact allergy to gold is correlated to dental gold.

Questionnaire studies have indicated that patients with dental gold will more frequently have contact allergy to gold. This study aimed at investigating the relationship between contact allergy to gold and the presence and amount of dental gold alloys. A total of 102 patients were referred for patch testing because of suspicion of contact allergy. Patch tests were performed with gold sodium thiosulphate 2% and 5%. The patients underwent an oral clinical and radiological examination. Contact allergy to gold was recorded in 30.4% of the patients, and of these 74.2% had dental gold (p=0.009). A significant correlation was found between the amount of gold surfaces and contact allergy to gold (p=0.008), but there was no statistical relationship to oral lesions. It is concluded that there is a positive relationship between contact allergy to gold and presence and amount of dental gold alloys