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Oral and Maxillofacial Surgery (OMFS) is among the newest established medical specialties and its full scope is not fully known by other specialties. The aim of the present study is to record the perception of OMFS scope by general medical practitioners (GMPs) of the National Health Service in Greece. A cross-sectional study was conducted in GMPs via a structured questionnaire. Questions involved various head and neck disorders and possible referring medical specialties. 66 answered questionnaires were included in this study. Participants were established to regional health practices, health centres or hospitals. 77.2% of the participants would refer a facial laceration to a plastic surgeon and only 7.2% to an OMFS. 89.3% would refer a zygoma fracture to an OMFS and 10.6% to an ENT. The vast majority would refer a tongue cancer, a neck mass and a mouth lesion to an ENT (74.8%, 81.8%, and 48% respectively). OMFS scope awareness of GMPs can be considered low. Thus, widening the knowledge of OMFS practice in primary grade medical practitioners is of high importance. Early exposure of medical students to the specialty could be a valid option to achieve this target.

Introduction Few data on possible local factors that can influence the achievement of response in nonsegmental vitiligo (NSV) treated with narrowband ultraviolet B (Nb-UVB) phototherapy are available. Our objective is to evaluate possible correlations between therapeutic outcomes and dermoscopic and local (lesional) clinical findings of vitiligous lesions undergoing Nb-UVB phototherapy to find positive and/or negative response predictor factors to such treatment. Methods For each target patch, we calculated the extension area using a computer-aided method and assessed dermoscopic and local (lesional) clinical findings at baseline. After 30 phototherapy sessions (twice weekly), surface area of the lesions was reevaluated to assess clinical improvement, correlating the therapeutic outcome with initial clinical and dermoscopic features. Results A total of 70 lesions were finally included in the study. At the end of therapy, 18 patches (25.7%) achieved improvement, and the presence of perifollicular pigmentation on baseline dermoscopic examination was found to be associated with a 12-fold higher probability of having a positive therapeutic outcome. Similarly, face localization was also correlated with clinical amelioration, with a sevenfold higher probability for improvement. No association (p > 0.05) between therapeutic outcomes (either good or poor) and other dermoscopic or local clinical variables (including leukotrichia) was observed. Conclusions Therapeutic response of vitiligo to Nb-UVB phototherapy may be positively affected by local features of the lesions, i.e., face localization and presence of perifollicular pigmentation on baseline dermoscopic examination, which might be considered as positive response predictor factors to optimize treatment of vitiligo.

Hidradenitis suppurativa/acne inversa is a disease with deep-seated chronic painful nodules, abscesses, and draining sinus tracts, which manifests on the apocrine gland-rich skin areas of the body. Observational findings demonstrate that the disease usually appears after puberty, exhibits pre-menstrual flares in women, improves in pregnancy, and worsens post-partum, which indicates a role of hormones and particularly of androgens in its pathophysiology. Because increased androgen levels in serum have not been widely reported, an end-organ androgen hypersensitivity has been postulated. The aim of this systematic review was to identify and present evidence for antiandrogen therapeutic options for the treatment of hidradenitis suppurativa/acne inversa. A literature search was conducted in different medical electronic databases using the keywords “hidradenitis”, “suppurativa”, “acne inversa”, and “antiandrogen” on 1 December, 2018. The main therapeutic options were subsequently used as separate keywords with the disease terms in a separate search. The main therapeutic options yielded were cyproterone acetate, spironolactone, finasteride, and metformin. One randomized controlled crossover trial and seven case series were identified following use of a standard extraction form for eligibility. The existing studies do not allow a robust evidence-based recommendation for the use of antiandrogens in the treatment of hidradenitis suppurativa/acne inversa. Further randomized controlled trials are needed to define the role of hormonal treatment as an alternative or concomitant therapy together with antibiotics or biologics.

Dysphagia is a symptom associated with significant morbidity and mortality, with profound impact on physical ability and quality of life. Many questionnaires have been used to assess patient-reported dysphagia, but issues related to developmental and measurement properties affect their wide applicability. The purpose of this study was to assess the validity and reliability of the Eating Assessment Tool-10 (EAT-10, Greek adaptation) in neurogenic and head and neck cancer-related dysphagia. The study consisted of: item generation in the Greek language, internal consistency and reliability analysis, normative data generation, and validity analysis. Data were collected prospectively from 421 participants: 144 asymptomatic subjects, 146 patients with dysphagia, and 131 patients with dysphagia-related diagnoses. Validity was assessed by comparing scores of healthy and dysphagic participants, by comparing pre- and post-treatment scores, and by correlating the Greek-EAT-10 with fibreoptic endoscopic evaluation of swallowing (FEES). The mean participants’ age was 52.85 years (ranging from 18 to 85 years). All questionnaires were completed in less than 3 min. The overall internal consistency (assessed with Cronbach’s alpha) was 0.963. The test–retest reliability was excellent with Spearman’s rho ranging from 0.937 to 1. Dysphagic patients had a significantly higher score compared to healthy participants (p

Dear Editors, Denosumab is a human monoclonal IgG2 antibody that binds selectively and with high affinity to the receptor activator of nuclear factor-κB ligand(RANK-L) and pharmacologically mimics the effect of osteoprotegerin on RANK-L [1, 2] thereby blocking the binding of RANK-L to the receptor activator of nuclear factor-κB(RANK) [1]. Denosumab rapidly decreases bone turnover markers resulting in a significant increase in bone mineral density and reduction in fracture risk [3]. Osteonecrosis of the jaws (ONJ) was initially erroneously ascribed to being a later chemotherapy effect [2, 4]. ONJ became one of the most discussed adverse events in advanced malignancy [5]. Importantly, ONJ has never been reported to be associated with other pharmaceutical agents, except bisphosphonates [2, 4]. The case of a cancer patient who developed ONJ without previous history of irradiation or bisphosphonate administration has been published [6]. In this patient, ONJ was reported to have healed completely following sequestration, 15 months after drug discontinuation [6]. Despite the fact that this is the only case published to date, additional evidence published in scientific meeting proceedings suggest that the condition of ONJ may not be solely associated to bisphosphonates [7, 8]. Results from two randomized clinical trials (RCTs; NCT00321464 [8], NCT00330759 [7]) of denosumab in cancer patients with bone metastases report that ONJ occurred infrequently [7, 8] (Table 1). Both studies have current or prior intravenous or oral bisphosphonate administration in their exclusion criteria [7, 8], thus bisphosphonates as an etiopathological factor for ONJ in those participants who received denosumab can be ruled out. Since ONJ has not been previously described to be associated with other drugs agents administered to cancer patients [2], it can be suggested that these cases of ONJ are related to denosumab administration. The role of dosing interval and cumulative dose appears to be important regarding development of denosumabrelated ONJ. All denosumab RCTs published to date include a dosing interval longer than 3 months and a cumulative dose of not more than 210 mg per 6 months [3]. None of these studies does report any cases of ONJ. On the contrary, preliminary results of both RCTs studying denosumab for the treatment of bone metastases in cancer patients include a monthly dosing interval and a dose of 120 mg per month [7, 8]. It is evident that denosumabrelated ONJ could be a dose-related adverse effect. This latter argument has also been reported to apply to bisphosphonate administration [4, 9]. ONJ has been reported to be a much more common event in those patients receiving bisphosphonates for the treatment and prevention of cancer-related skeletal events (mainly intravenously), rather than in those patients receiving bisphosphonates (mainly orally) for non-malignancy indications [10, 11]. Similar to bisphosphonate-related ONJ pharmacosurveillance and reporting history [4], one could anticipate that broad introduction of denosumab into clinical practice, would allow for the recognition of the denosumab-related ONJ adverse effect in a much wider spectrum of prescription indications, including those for non-malignancy [10]. A. Kyrgidis (*) Department of Oral and Maxillofacial Surgery, School of Dentistry, Aristotle University of Thessaloniki, 3 Papazoli St, Thessaloniki 546 30, Greece e-mail: akyrgidi@gmail.com

One should read with great interest the paper of Mauri et al. [1] in the Online First section of Breast Cancer Research and Treatment. The paper presents a meta-analysis of the existing randomized clinical trials (RCTs) for the overall incidence of bisphosphonates-induced jaw osteonecrosis (ONJ) in adjuvant treatment of breast cancer. This is a well-conducted meta-analysis, which is definitely going to be cited several times in the near future. However, important information may be missing from the discussion. In their introduction, Mauri et al. characterize ONJ uncommon, with a reported incidence of 5–7.7%. In their discussion, the authors report that ONJ during the adjuvant treatment of breast cancer is a rare event with an incidence of 0.24%. The authors attribute this difference in incidence to the dose intensity of bisphosphonates regimens used in the treatment of primary breast cancer. The low ONJ incidence reported by this metaanalysis of RCTs could be attributable to the following

Sir, We read with considerable interest the review by RE Coleman (2008) discussing the latest clinical aspects of bisphosphonates (BP) use and their side effects. Coleman reports that 75% of BP-related osteonecrosis of the jaw (ONJ) occurs following a dental extraction or jaw surgery. This might be true, however, in a case–control study that we recently published, in which the percentage of breast cancer patients under zolendronic acid (ZA) treatment who developed ONJ after having experienced tooth extraction was found to be 50% (Kyrgidis et al, 2008). In this study, patients who experienced tooth extraction were reported to have an at least 16 times higher risk of developing ONJ. Nonetheless, tooth extraction and alveolar surgery may not be the only important clinical factor for ONJ development. In our study, we also report the use of dentures to account for an almost five-fold higher risk for ONJ development. A recent paper (Landesberg et al, 2008) provides evidence that the oral mucosa can actually be defective. We hypothesised that potentially ill-fit dentures could cause breaches to the defective underlying mucosa, thereby providing an entry point to the bone for oral flora (Kyrgidis and Vahtsevanos, 2008; Kyrgidis et al, 2008). Coleman notes that the reported frequency of ONJ varies considerably between 10% among different populations. This fact has also been emphasised by other authors, especially in regard to the Greek and US population (Raje et al, 2008). We have suggested that it could be an issue of differential susceptibility to ONJ in the Greek population (Kyrgidis and Andreadis, 2008), although careful pretreatment, dental assessment and avoidance of invasive dental procedures, as suggested by the author (Coleman, 2008), could partly account for this difference. The latter hypothesis is supported by the evidence we provide (Kyrgidis et al, 2008) that tooth extractions may amplify the risk for ONJ development. In accordance with Coleman, we believe that prospective research is definitely required to assess potential risk factors, effect modifiers and confounders. In this regard, we currently carry out a prospective cohort study with breast, prostate cancer and multiple myeloma patients receiving BP treatment (ZA and ibandronate). In this study, the type, dose and duration of treatment is monitored. Results will be published when the study is concluded (Kyrgidis et al, 2008). Coleman has suggested that until solid evidence is available, patients receiving BP should have regular inspection of the mouth, undergo dental check-ups every 6–12 months and avoid invasive dental surgery unless no alternative is available (Coleman, 2008). Our study provides substantial evidence supporting that suggestion, at the same time raising the current ASCO level of evidence linking ONJ to tooth extractions from V to III. We further suggest, on the basis of evidence (Kyrgidis et al, 2008), that additional dental and medical attention should be paid to BP patients using removable dentition to avoid mucosal breaches caused by dentures.