A brief review of cytology in dentistry Srinivasan Rajsri, Kritika; K Durab, Safia; A Varghese, Ida ...
British dental journal,
02/2024, Letnik:
236, Številka:
4
Journal Article
Recenzirano
Odprti dostop
Oral cytology is a non-invasive adjunctive diagnostic tool with a number of potential applications in the practice of dentistry. This brief review begins with a history of cytology in medicine and ...how cytology was initially applied in oral medicine. A description of the different technical aspects of oral cytology is provided, including the collection and processing of oral cytological samples, and the microscopic interpretation and reporting, along with their advantages and limitations. Applications for oral cytology are listed with a focus on the triage of patients presenting with oral potentially malignant disorders and oral mucosal infections. Furthermore, the utility of oral cytology roles across both expert (for example, secondary oral medicine or tertiary head and neck oncology services) and non-expert (for example, primary care general dental practice) clinical settings is explored. A detailed section covers the evidence-base for oral cytology as a diagnostic adjunctive technique in both the early detection and monitoring of patients with oral cancer and oral epithelial dysplasia. The review concludes with an exploration of future directions, including the integration of artificial intelligence for automated analysis and point of care 'smart diagnostics', thereby offering some insight into future opportunities for a wider application of oral cytology in dentistry.
An 83-year-old male presented to a community oral maxillofacial surgeon with a tender, pink, pedunculated exophytic tumor measuring 2 × 1.5 cm involving the right anterior mandible adjacent to tooth ...#27 (Figure 1A). His medical history was significant for hypertension, congestive heart failure, atrial fibrillation, and prostate cancer treated with radiation and androgen deprivation chemotherapy. The patient had been taking amiodarone, metoprolol, digoxin, rivaroxaban, furosemide, bicalutamide, and leuprorelin injections. The patient reported that the lesion had been present for at least four months and had recently started growing rapidly, resulting in pain and increased mobility of tooth #27. Tooth #27 exhibited localized advanced bone loss with class IV mobility. An ill-defined, moth-eaten, peri-radicular radiolucency was noted in the panoramic and periapical radiographs (Figures 1B and 2). The oral maxillofacial surgeon excised the tumor, extracted tooth #27, and submitted the excisional biopsy to UTHealth Houston School of Dentistry with the clinical diagnosis of “Pyogenic granuloma.” The patient's prostate cancer history was unknown at the time of the biopsy specimen submission to the pathology laboratory.
Considering the clinical and radiographic characteristics of the lesion, the broad spectrum of potential differential diagnoses for our case can be grouped into three categories according to their biological behavior: benign, intermediate (locally aggressive), and malignant tumors. Our differential diagnostic consideration for benign exophytic gingival growth was the widely recognized three "Ps," encompassing reactive lesions such as pyogenic granuloma, peripheral ossifying fibroma, and peripheral giant cell granuloma 1. Pyogenic granuloma usually presents in patients in their second to fourth decades with a tendency to bleed readily 1, 2. Peripheral ossifying fibroma (POF) presents as a sessile or pedunculated red to pink nodular mass with frequent surface ulceration. POF is frequently encountered in young patients with a predilection for females. It frequently involves the anterior maxillary and mandibular gingiva. POF exhibits proliferative fibrous connective tissue with bone, cementoid, and dystrophic calcifications 1, 3. Peripheral giant cell granulomas present as dusky red to purple-colored lesions, with approximately 60% of the cases occurring in the anterior mandibular gingiva 4. They may bleed, and radiographically saucerization of the underlying bone may be detected. Peripheral odontogenic fibroma and peripheral ameloblastoma are the two extraosseous odontogenic neoplasms that are clinically indistinguishable from the above-mentioned three “Ps.” Peripheral odontogenic fibroma is a benign odontogenic neoplasm of ectomesenchymal origin with a predilection to the anterior maxillary gingiva 5. Peripheral ameloblastoma microscopically resembles intraosseous ameloblastoma with a predilection to the mandibular premolar region. Peripheral ameloblastoma exhibits a benign nonaggressive course and does not invade the underlying bone 6.
The aforementioned benign gingival tumors are unlikely contenders for our case, as the clinical and radiographic presentation of the current case is more compatible with locally aggressive or malignant tumors. Our differential diagnostic considerations for the locally aggressive neoplastic process were central giant cell granuloma and ameloblastoma. The central giant cell granuloma/giant cell lesion occurs predominantly in children and young adults, frequently involving the mandible 7. Central giant cell granuloma (CGCG) presents as a solitary radiolucent lesion producing a painless expansion of the affected jaw 7. However, perforation of the cortical plate and extension into the gingiva is extremely rare except for the aggressive variants of CGCG 7. An aggressive variant of CGCG exhibits rapid growth, causing root resorption, displacement of teeth, and cortical perforation with extension into the adjacent gingiva 7, 8. The patient's age and the clinical and radiographic presentations of the current case are not compatible with a central giant cell lesion. Ameloblastoma is the most common odontogenic tumor of the jaws, which is a slow-growing, locally infiltrative neoplasm. Ameloblastomas predominantly occur in the posterior mandible, causing displacement of teeth, bony expansion and perforation of the cortical plate, and gingival involvement as late events 9. Rapid growth and the destructive behavior of the current case are not compatible with either the central giant cell lesion or ameloblastoma.
Our differential diagnostic considerations for malignant processes include squamous cell carcinoma, lymphoma, and metastatic carcinoma. Squamous cell carcinoma (SCC) of the head and neck is the 8th most common malignancy impacting males in the United States, with 70% of the cases observed in older adults aged 60 years and over 10. Clinical presentation can vary from leukoplakia, erythroplakia to an exophytic fungating/ papillary mass or may present as a nonhealing ulcerated mass 10. While the ventral surface of the tongue and the floor of the mouth are high-risk sites, the gingiva is also a common location for SCC 10. Depending on the stage of diagnosis, paresthesia, tooth mobility, and perineural invasion may be observed. Given our patient's demographic information and clinical presentation, SCC is a plausible differential diagnosis. Non-Hodgkin lymphoma (NHL) is the third most common malignancy in the oral cavity, ranking just after squamous cell carcinoma and salivary gland malignancies 11. Despite being the third most common malignancy noted in the oral cavity, it is rare, representing only 3.5% of all malignancies in the oral cavity12. Diffuse large B-cell lymphoma (DLBCL) is the most common extranodal lymphoma involving the jawbone and gingiva 12. Typically, it presents in older patients, although it can occur in younger immunocompromised patients. Patients often present clinically with a distinct mass involving intraosseous and extraosseous sites with a strong predilection to gingiva 12. It may or may not be ulcerated, along with variable levels of pain, dysesthesia, or paresthesia accompanied by increasing tooth mobility.
Metastatic carcinomas involving the jaws are relatively uncommon and typically signify an advanced stage with widespread dissemination of the primary cancer 13, 14. While metastatic lesions can present in any location in the oral cavity, the mandible and gingiva are the most common sites13, 14 . Among men, the primary malignancies most frequently associated with oral metastases are from the lung, kidney, liver, and prostate 13, 14. Patients often clinically present with an exophytic lesion accompanied with rapidly progressing swelling, pain and paresthesia 13, 14. Early lesions, particularly those in the gingiva, may resemble hyperplastic or reactive lesions such as the earlier discussed “3 Ps”. Radiographically, metastatic tumors to the jaw do not have a distinct pathognomonic appearance; however, generally, destruction of the cortical bone and radiolucency is noted 13, 14.
The patient underwent an excisional biopsy of the lesion, which revealed a submucosal basaloid tumor with an organoid growth pattern with sheets and nests of infiltrative tumor cells. The larger tumor cells exhibited a characteristic “salt and pepper chromatin” pattern with prominent nucleoli with peripheral palisading (Figures 3, 4, 5). The smaller round cells revealed nuclear molding and crush-artifact without visible nucleoli. Histomorphologic examination of the lesion appeared to be indicative of a possible metastatic neuroendocrine tumor, prompting a panel of immunohistochemical studies based on the patient's demographics. Epithelial membrane antigen (EMA) staining was diffusely positive (Figure 6). CK-7 and CK-20 staining were negative, excluding neuroendocrine carcinoma of the lung and GI tract, respectively, from the list of possible differentials of metastatic neuroendocrine tumors. Staining for prostate-specific antigen (PSA) was negative, while the tumor cells reacted focally positive for prostate-specific alkaline phosphatase (PSAP) and neuron-specific enolase (NSE), leading to the diagnosis of high-grade metastatic neuroendocrine carcinoma of the prostate (Figure 7).
At this point, the biopsy contributor was contacted and confirmed that the patient had a known history of stage IV prostate cancer with multifocal skeletal and lung metastases, which the oral surgeon failed to mention at the time of biopsy submission. It was ascertained that the primary tumor originated in the peripheral zone of the left hemisphere of the prostate, and the patient had known metastases to the right lateral wall of the bladder, left seminal vesicle, right and left lung, liver, as well as multiple osseous, retroperitoneal, mediastinal and cervical lymph node metastases. The PET-CT findings on the patient also revealed a hypermetabolic mass in the proximal ascending colon, which was suspected to be primary colon carcinoma versus metastatic prostatic carcinoma. Subsequent colonoscopic examination confirmed primary adenocarcinoma of the ascending colon. At the time of presentation to the oral surgeon, the patient was undergoing hormonal (androgen-deprivation) therapy for his prostate cancer and taking the medications bicalutamide and leuprorelin. Subsequent treatment could not be ascertained from the oncologist, however, ultimately, the patient died of treatment failure with disseminated metastatic prostate cancer.
Prostate cancer is the most prevalent cancer in men globally, characterized by a relatively slow progression course and a more favorable prognosis in comparison to other significant cancers affecting males 15, 16. Neuroendocrine prostate carcinoma (NE-PC) is a rare and aggressive form of prostate cancer, representing less than 1% of all prostate cancer cases 17. However, a significant
Purpose/objectives
Social media platforms (SMPs) have become a popular portal for the acquisition and dissemination of dentistry‐related information. The study aims to identify the pattern and ...influence SMPs for education and practice among dental trainees and professionals.
Method and materials
A cross‐sectional study involving dental trainees and clinical professionals was conducted based on a structured 20‐item survey instrument among dental trainees and professionals. The validated questionnaire was circulated among six dental training institutions in India through the internet‐based application Google form and achieved a response rate of 60%. The questionnaire focused on identifying the usage of social media in disseminating dentistry‐related content. The data from responders were extracted, sorted, and analyzed for descriptive analysis of various factors.
Result
The survey revealed the most common SMP used for dentistry‐related content as YouTube. The second most commonly used SMP was Facebook for professionals whereas it was Instagram for younger trainees. There was a highly significant difference between professionals and trainees concerning their sources of new information and the most commonly used SMP for dental education (p < 0.001).
Conclusions
There is a growing consensus among young dental trainees and professionals on SMPs being an effective open access knowledge center. The survey results call for the need for a scientific journal and dental schools to have verified pages in social media to act as flagbearers of evidence‐based dental practices. The potentials of SMPs in providing open access information collection to wider viewership across the globe and being a digital archive in attractive audio‐visual forms can be used to strengthen the conventional educational model and improvise clinical practice.
Chronic Ischemic medullary disease (CIMD) is now known to occur in 50-80% of femoral heads with osteoarthritis. It occurs, moreover, so frequently before cartilage damage that some have suggested ...that poor medullary blood flow may be a major cause of desiccation of overlying hard tissues.
A convenience sample of 7 condylar heads surgically removed because of severe, painful osteoarthritis, were histopathologically assessed for features of ischemic disease in the marrow immediately beneath the damaged hard tissues. Changes looked for were the same as those found in affected hips and bone marrow edema: 1) ischemic myelofibrosis; 2) dilated medullary capillaries; 3) oil cysts (large bubbles of liquefied fat) or fatty microvesicles, as evidence of past fat necrosis; 4) osteocavitations; 5) ischemic marrow atrophy (denuded trabeculae); 6) intramedullary fibrous scar tissue; 7) stagnant immature bone; 8) osteosclerosis; 9) reticular fatty degeneration; 10) focal osteoporosis; 11) plasmostasis (serous ooze); 12) mast cell presence.
Of 7 temporomandibular joints examined, 6 showed evidence of CIMD: one severe, 4 moderately severe and 1 mildly damaged. Three joints showed CIMD consistent with a diagnosis of bone marrow edema, while 5 showed marrow voids or cavitations; 3 showed areas of focal osteoporosis; all showed either oil cysts or fatty microvesicles. Five affected condyles showed focal fibrosis, and none demonstrated osteosclerosis. Very few lymphocytes were seen, but small numbers of mast cells were found in areas of wispy fibrosis. Four of the specimens showed multiple, usually small areas of ischemic damage, separated by normal marrow. Surface cartilage was fissured, broken or missing in all condyles, while underlying bone was only focally nonviable (focal areas of empty lacunae).
As with femoral heads, condylar heads affected by osteoarthritis show ischemic medullary damage beneath the damaged cartilage/bone (6 of 7 condylar heads).
Single-drug oral etoposide daily for 5 days or more in 3-week cycles is commonly used as palliative chemotherapy for small-cell lung cancer (SCLC). However, there have been no randomised trials to ...compare this treatment with standard intravenous multidrug chemotherapy. Our objective was such a comparison in patients with poor performance status. However, before the planned intake of 450 patients had been completed the trial was stopped on the recommendation of an independent data monitoring committee, because of the inferiority of oral etoposide. We report the interim findings of the trial.
Patients of either sex and any age were entered into the trial if they had: previously untreated, microscopically confirmed SCLC; WHO grade performance status 2–4; no contraindications to either treatment regimen; normal renal function; and plasma bilirubin concentrations of less than 35 μmol/L. Patients with grade 4 performance status were likely to benefit from chemotherapy. Between September, 1992, and August, 1995, 339 patients were randomly allocated four cycles of 50 mg oral etoposide twice daily for 10 days (171 patients) or a standard intravenous regimen of etoposide and vincristine (EV), or cyclophosphamide, doxorubicin, and vincristine (CAV, 168 controls). The intake was stopped in September, 1995. Patients were assessed by clinicians before the start of treatment, at each attendance for treatment, at 3 months after randomisation, every month to 6 months, every 2 months to 1 year, then every 3 months thereafter. The primary endpoint was the palliation of major symptoms at 3 months after randomization—ie, a reduction in cough, pain, anorexia, and shortness of breath scores. Secondary endpoints were quality of life, clinical and radiographic tumour response, and survival.
The palliative effects of treatment were similar in the etoposide group and control group (41%
vs 46%). Grade 2 or worse haematological toxicity occurred in 35 (29%) etoposide-treated patients and 26 (21%) controls. Controls had a higher overall response rate than etoposide-treated patients (51%
vs 45%). There was a small disadvantage in survival associated with oral etoposide (hazard ratio 1·35 95% Cl 1·03–1·79, p=0·03). Median survival was 130 days in the etoposide group and 183 days in the controls; survival rates were 35% and 49% at 6 months and 11% and 13% at 1 2 months, respectively.
Oral etoposide 50 mg twice daily for 10 days every 3 weeks for four cycles is inferior to standard intravenous multidrug chemotherapy in the palliative treatment of patients with SCLC and poor performance status. Oral etoposide alone should no longer be used in the treatment of such patients.
