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Objective: The purpose of this contribution is to discuss how the subject of oral leukoplakia might be communicated among the various healthcare workers and also among patients. Material and Methods: The discussion is based on the available literature and on many decades of clinical and histopathological experience of the author. Results: The literature does not contain guidelines on what level of expertise can be expected from the various dental and medical healthcare workers in the field of oral leukoplakia, nor on how to communicate this disorder with patients. Based on personal experience, a number of suggestions have been proposed to overcome this shortcoming. Conclusion: Knowledge about oral leukoplakia varies among the various healthcare workers, depending on their level of expertise. Communication on this subject with patients should be in easy to understand wording, avoiding professional terminology as much as possible.

A series of 20 consecutive patients with an osteosarcoma of the jaws has been evaluated with regard to possible professional diagnostic delay. When set at an arbitrarily chosen period beyond three months, professional delay occurred in 15 patients, the mean being 21 months and the median 11 months. In five of the 15 patients a wrong diagnosis has been rendered on the biopsy specimen, being fibrous dysplasia (2x), osteoma (2x) and, in case of palatomaxillary swelling, pleomorphic adenoma (1x). In the other ten patients the initial clinicoradiographic features were misleading and apparently not indicative of a malignancy, except for one patient in whom a distinct widening of the periodontal ligament, as expressed on a periapical film, has been overlooked or not properly interpreted. It has not been possible to assess the possible influence of the delayed diagnosis on the prognosis. Key words:Osteosarcoma of the jaws, diagnostic delay.

Kwaadaardige processen komen relatief zelden in het bovenkaakbot of de kaakholte, de sinus maxillaris, voor. Het gaat daarbij om verschillende vormen van kwaadaardigheid, variërend van kanker in het bekledende slijmvlies van de sinus maxillaris, tot speekselklierkanker, botkanker, kanker van lymfoïd weefsel en een enkele maal zelfs een uitzaaiing van een elders in het lichaam gelegen kwaadaardig proces.De klinische en röntgenologische veranderingen kunnen zeer uiteenlopend zijn. Bij de meeste van de hier genoemde tumorsoorten betreft het oudere patiënten. Een uitzondering is het sarcoom van het kaakbot, waarbij kan het ook om jeugdige patiënten gaan.De klachten van met name bijholtekanker kunnen bestaan uit neusverstopping, hoogstand van één van de ogen, spontane neusbloedingen en soms uitval van de n. infraorbitalis. Soms gaat het om dentogeenachtige klachten, bestaande uit onverklaarbare kiespijn en mobiele gebitselementen.In de hierna te bespreken patiëntengeschiedenissen zal vooral worden stilgestaan bij de rol van de tandarts bij de diagnostiek.

Op tandheelkundige röntgenfoto’s worden soms onverwachte afwijkingen gezien die geen klachten veroorzaken en derhalve eigenlijk als toevalsbevinding moeten worden aangemerkt. Als het om een afwijkend beeld in de directe omgeving van de gebitselementen gaat, zullen tandartsen vermoedelijk meestal wel weten wat er aan de hand is. Mocht dat onverhoopt niet het geval zijn, ligt overleg met een meer deskundige voor de hand; vaak zal dat een MKA-chirurg zijn. Bij het toevalligerwijs aantreffen van een afwijking buiten het directe werkterrein van de tandarts, rijzen er toch wel wat vragen. Ligt het wel op de weg van de tandarts er nader aandacht aan te besteden? Moet de patiënt wel worden geïnformeerd en zorgt dat niet voor onnodige onrust? En, als er toch advies van een meer deskundige wenselijk is, wie moet dat dan zijn? Laten we maar eens een aantal casussen bespreken.

Background The literature hardly contains information on how patients suffering from oral lichen planus could be managed by dentists. Material and Methods Based on the limited available literature and particularly on the long-term clinical and histopathological experience of one of the authors, suggestions on how dentists could manage patients with oral lichen planus have been put forward. Results: In most cases, the dentist should be able to establish a correct diagnosis. Results In most cases, the dentist should be able to establish a correct diagnosis. Occasionally, the dentist may call upon a specialist, usually an oral medicine specialist or an oral and maxillofacial surgeon for confirmation of the diagnosis, possibly a biopsy procedure, and management of the patient in case of severe symptoms. Proper patient information is of utmost importance in the management. Conclusions General dentists can be expected to manage the majority of patients with oral lichen planus. Some patients may need to be referred for diagnostic purposes to a specialist; this is also the case for the rare patient with severe symptoms, possibly requiring systemic treatment. Key words:Oral mucosal disease, oral lichen planus.

Oral lichen planus (OLP) is a rather common oral disease, mainly affecting adults, occurring more often in women than in men. The etiopathogenesis is still unclear. The diagnosis may be cumbersome, even in the presence of a biopsy. In addition, there are several lesions that may resemble lichen planus (lichenoid lesions) both clinically and histopathologically. Treatment of OLP can only be symptomatic and usually consists of topical application of corticosteroids. The disease is characterized by remissions and exacerbations and may persist in some patients lifelong. There is an ongoing debate in the literature as whether OLP is a potentially malignant disease. Because of this uncertainty, annual follow-up is advised.DOI: 10.14693/jdi.v22i3.979

Background In view of the many white or predominantly white lesions of the oral mucosa it is a challenge for dentists to clinically identify a leukoplakia, being a potentially (pre)malignant lesion. Material and Methods Based on the available literature and experience of the authors the parameters of a clinical diagnosis of oral leukoplakia have been studied. Results A guide has been presented that should help dentists to establish a clinical diagnosis of leukoplakia as accurate as possible. Conclusions Probably in most parts of the world dentists will need the help of a specialist for confirmation or exclusion of the clinical diagnosis of oral leukoplakia and for further management of the patient, including patient information. Key words:Oral diseases, oral leukoplakia.

Op de tong kunnen verschillende soorten ulceraties voorkomen, varierend van onschuldig tot levensbedreigend. Sommige ulceraties van de tong berusten op een onderliggend lijden, terwijl ook bepaalde medicijnen tot ulceraties op de tong kunnen leiden. Het is voor de tandarts en de mondhygienist een uitdaging om bij ulceraties van het slijmvlies in het algemeen en bij die van de tong in het bijzonder, alert te zijn en niet te schromen om een patient voor advies naar de kaakchirurg te verwijzen. Alle redenen voor een nadere toelichting.

(Ziekenhuis)tandartsen en mondziekten-, kaak- en aangezichtschirurgen worden regelmatig geconfronteerd met een odontogeen focusonderzoek bij patiënten die in het medisch centrum behandeld (gaan) worden en bij wie de gebitssituatie van belang is voor de medische behandeling of situatie. Dit betreft doorgaans onbegrepen koorts, hartchirurgie, chemotherapie, orgaantransplantaties en gewrichtsprothesen, bisfosfonaatgebruik en radiotherapie in het hoofd-halsgebied. In de praktijk is er behoefte aan een duidelijk, eenvoudig te hanteren beslissingsmodel voor beoordeling en behandeling van odontogene foci voor de verschillende medische indicaties. De beschreven medische omstandigheden hebben met elkaar gemeen, dat subklinische infecties in bijzondere omstandigheden tot complicaties kunnen leiden. De invloed en de wijze van optreden van een odontogene infectie is bij elk van de genoemde situaties verschillend. Dit laatste heeft consequenties voor de noodzaak van het elimineren van odontogene foci. De beoordeling en behandeling van odontogene foci in relatie tot verschillende medische situaties behoeven daarbij een genuanceerde benadering.

The aim was to evaluate the management strategies of Dutch oral and maxillofacial surgeons when performing invasive dental or oral surgery in patients using oral antithrombotic medication (OAM). In November 2009 a survey was mailed to all 213 members of the Dutch Society for Oral and Maxillofacial Surgery. A response rate of 57% was achieved with 79 surveys returned through mail and 38 surveys answered through the Internet. The results show that many different treatment strategies are advocated by Dutch oral and maxillofacial surgeons, regarding preferred international normalised ratio (INR) value and continuation or discontinuation of OAM prior to invasive dental or oral surgery. The risk of bleeding during or after an invasive dental procedure was overestimated. A need for a practice guideline on this topic was expressed by 73% of respondents.

In Scandinavia, as in many European countries, most patients consult their general dentist once a year or more. This gives the dentist a unique opportunity and an obligation to make an early diagnosis of oral diseases, which is beneficial for both the patient and the society. Thus, the dentist must have knowledge of clinical symptoms, local and systemic signs and clinical differential diagnoses to make an accurate diagnosis. The dentist must be competent in selecting appropriate diagnostic tests, for example, tissue biopsy and microbiological samples, and conducting them correctly, as well as in interpreting test results and taking appropriate action accordingly. Furthermore, the dentist must be aware of diseases demanding multidisciplinary cooperation and be able to recognise his/her professional limitation, and to refer to other specialists when required. The dental curriculum changes over time as new approaches, treatments and diagnostic possibilities develop. Likewise, the role of the dentist in the community changes and may vary in different countries. As members of the Scandinavian Fellowship for Oral Pathology and Oral Medicine and subject representatives of oral pathology and oral medicine, we feel obliged to contribute to the discussion of how the guidelines of the dental curriculum support the highest possible standards of dental education. This article is meant to delineate a reasonable standard of oral pathology and oral medicine in the European dental curriculum and to guide subject representatives in curriculum development and planning. We have created an advisory topic list in oral pathology and oral medicine.

Een 16-jarige jongen bleek na diagnostisch onderzoek met computertomografie en een skeletscan de monostotische verschijningsvorm van fibreuze dysplasie in de maxilla te hebben. De diagnose is bevestigd aan de hand van een botbiopt. Tijdens een periode van 8 jaar afwachtend beleid hebben zich geen tekenen van progressie van de afwijking voorgedaan. Fibreuze dysplasie is een enigszins onbegrepen, benigne botafwijking die overal in het skelet kan voorkomen. Om de diagnose met zekerheid te kunnen stellen, wordt over het algemeen geadviseerd een botbiopt te nemen. Er wordt onderscheid gemaakt tussen 3 verschijningsvormen: 1. monostotisch, 2. polyostotisch en 3. polyostotisch met endocriene problemen. In de meeste gevallen kan worden volstaan met een afwachtend beleid. Maligne ontaarding is uiterst zeldzaam en doet zich vrijwel uitsluitend voor bij de polyostotische verschijningsvorm.

Oral verrucous carcinoma (OVC) is a low-grade variant of squamous cell carcinoma (SCC) with a distinctive morphology and specific pattern of behaviour that is often diagnosed in elderly patients. Resection is the treatment of choice, with radiotherapy as a reasonable alternative. In this retrospective case review we present our experience and outcomes in a group of 12 patients with various stages of OVC who had not been treated conventionally because of the extent of their lesions and their poor general condition. All patients were given chemotherapy with methotrexate, which was given by various routes and in different doses during the period 1972-2010. In 11 patients treatment with methotrexate alone was beneficial. One patient failed to respond. Methotrexate used alone as chemotherapy may minimise morbidity and improve quality of life, particularly among elderly patients.

Er kunnen in en rond de mond diverse aandoeningen van bloedvaten en een enkelemaal ook van lymfevaten voorkomen. Soms zijn deze reeds bij of vlak na de geboorte aanwezig, terwijl andere pas later in het leven zichtbaar worden. Hetmerendeel van deze afwijkingen is onschuldig, maar kunnen soms wel ontsierend zijn of anderszins klachten veroorzaken, bij voorbeeld door secundaire ontsteking. Kwaadaardige hemangiomen (angiosarcomen) en lymfangiosarcomen komen zelden in de mond voor.

Het uit gewoonte kauwen op het mondslijmvlies, hetzij op de wangen, de lippen of de tong wordt aangeduid met de Latijnse benaming morsicatio (respectievelijk buccarum, labiorum en linguarum). Morsicatio lijkt vaker bij vrouwen dan bij mannen voor te komen. In een bekend Amerikaans leerboek is vermeld dat dit fenomeen vooral boven het 35e jaar voorkomt. Mijn eigen ervaring sluit daar niet bij aan. Het merendeel van de patienten betreft jongvolwassenen. Dat was ook het geval in een Zweeds bevolkingsonderzoek uit de jaren zeventig van de vorige eeuw. In dat onderzoek werd een prevalentie van ongeveer 5% vermeld. Het is dus bepaald geen zeldzame aandoening en iedere tandarts en mondhygienist heeft meerdere patienten met morsicatio in zijn/haar praktijk.

Cysten van de kleine speekselklieren, slijmcysten, komen vooral bij kinderen en jongvolwassenen voor. Ze worden veroorzaakt door bij herhaling bijten op het weefsel, resulterend in obstructie van een uitvoergangetje. Soms is er sprake van een recente chirurgische behandeling die heeft geleid tot verlittekening van de uitvoeropening van een speekselkliertje. Slijmcysten kunnen op alle plaatsen in de mond voorkomen waar kleine speekselkliertjes aanwezig zijn. In de praktijk blijken ze echter vooral voor te komen op de onderlip en worden daar aangeduid als ‘mucocele’, de mondbodem (‘ranula’), een enkel keer de onderkant van de tong en het wangslijmvlies, en zelden of nooit de bovenlip, het gehemelte en de regio van het trigonum retromolare van de onderkaak. Aangezien tandartsen en mondhygienisten een belangrijke rol spelen bij het onderkennen van slijmcysten, zullen de diverse slijmcysten hier kort worden toegelicht. Daarbij zal ook een enkel woord worden gewijd aan de behandeling.

There is an ongoing debate about the predictive value of histopathological parameters in oral cancer. In the past decades, the emphasis was on the possible added value of the so-called malignancy grading system. In a retrospective study on 128 previously untreated patients with a T1 or T2 squamous cell carcinoma of the tongue and the floor of the mouth, the value of the classical Broders' grading system and the malignancy grading system were compared with regard to various outcome measures such as regional metastasis, local recurrence and 5-year survival. The results show that neither of the histological grading systems has a strong predictive value and that none is superior to the other.

Oral squamous cell carcinomas develop in precancerous fields consisting of genetically altered mucosal epithelial cells. These precancerous fields may appear as clinically visible lesions, in particular, oral leukoplakia, but the large majority remains clinically undetectable. The aim of this study was to assess the potential value of a noninvasive screening approach to detect precancerous fields. As a first step, we developed a suitable assay and investigated 25 leukoplakia patients and 20 noncancer control subjects. Exfoliated cells were removed by a brush from multiple small areas of the oral mucosa, including the leukoplakia. Brushed samples were investigated for allelic imbalance (AI) at chromosomes 3p, 9p, 11q, and 17p using microsatellite markers known to show frequent alterations in oral precancer. AI was absent in all (137) of the samples of the 20 control subjects, yielding a specificity of 100%. AI was detected in exfoliated cell samples of 40% (10 of 25) of the leukoplakia lesions studied. Genetic changes were also found outside the leukoplakia lesions. Most frequent was AI at 9p (9 of 10). The noninvasive assay was validated against the biopsy results of the leukoplakia lesions yielding an estimate of sensitivity of 78% (7 of 9) and a positive predictive value of 100% (7 of 7). Altogether, these results show the feasibility of a noninvasive genetic screening approach for the detection and monitoring of oral precancer. This assay could therefore contribute to the secondary prevention of oral squamous cell carcinoma. The assay also shows promise for the detection of precancerous changes that are not macroscopically visible.

Rendu-Osler-Weber disease, also known as hereditary hemorrhagic telangiectasia (HHT), is an autosomal dominant inherited disorder characterized by an aberrant vascular development. The reported prevalence is approximately 1 per 5,000-10,000. The clinical manifestations consist of recurrent spontaneous nosebleeds, telangiectasias characteristically at the lips, oral cavity, fingers, and nose, and visceral arteriovenous malformations. Timely recognition of this syndrome makes screening for complications, preventive measurements, and genetic counselling possible. The important role of the dental profession in the recognition of this genetic disease is emphasized. In addition, a brief overview of the current literature is presented.

This study was designed to investigate the effect of compression with ice and compression alone on pain and quality of life after surgical removal of mandibular third molars. A prospective, single-blind, randomized controlled study design was chosen. Participants in group A applied 45 min of repeated compression with ice; those in group B applied 45 min of repeated compression without ice (control); and those in group C did not apply any compression. Pain intensity was measured on a visual analogue scale (VAS) three times a day for seven days. At day seven, overall pain reduction was scored on a global perceived effect (GPE) scale and a quality-of-life questionnaire was completed. Ninety-five patients completed the trial.The VAS scores demonstrated a significant pain decrease in groups A and B three days postoperatively. No significant differences were observed between groups A and B. Based on the GPE ratings, in groups A and B more patients indicated that pain was reduced successfully, but this was not statistically significant. Quality of life was significantly better for patients in groups A and B. These results demonstrate that compression after surgical removal of mandibular third molars is a valuable method for preventing pain.

Background: The prognosis of adenoid cystic carcinoma (ACC), a malignant salivary gland tumour, depends on clinicopathological parameters. To decipher the biological behaviour of ACC, and to identify patients at risk of developing metastases, additional markers are needed.Methods: Expression of the cell cycle proteins p53, cyclin D1, p16INK4a, E2F1 and Ki-67, together with the Polycomb group (PcG) proteins BMI-1, MEL-18, EZH2 and EED wasinvestigated immunohistochemically 21 formalin-fixed, paraffin-embedded primary ACCs in relation to tumour characteristics.Results: ACC revealed significantly increased expression of the cell cycle proteins compared to normal salivary tissue (n=17). Members of the two PcG complexes displayed mutually exclusive expression in normal salivary gland tissue, with BMI-1 and MEL-18 being abundantly present. In ACC, this expression pattern was disturbed, with EZH2 and EED showing significantly increased expression levels. In univariate analysis, presence ofrecurrence, poor differentiation and high EZH2 levels (.25% immunopositivity) significantly correlated with unfavourable outcome. ACCs with high proliferative rate (.25% Ki-67 immunopositivity) significantly correlated with high levels of EZH2 and p16. Only the development of recurrence was an independent prognostic factor of survival in multivariate analysis.Conclusions: Expression of PcG complexes and ofessential cell cycle proteins is highly deregulated in ACC.Also, EZH2 expression has prognostic relevance in thismalignancy.

Aims: Myoepithelial salivary gland tumours are uncommon and follow an unpredictable biological course. The aim was to examine their molecular background to acquire a better understanding of their clinical behaviour.Methods and results: Expression of protein (E2F1, p16INK4a, p53, cyclin D1, Ki67 and Polycomb group proteins BMI-1, MEL-18 and EZH2) was investigated in 49 benign and 30 primary malignant myoepithelial tumours and five histologically benign recurrences by immunohistochemistry and the findings correlated with histopathological characteristics. Benign tumours showed a higher percentage of cells with expression of p16INK4a pathway members [p16INK4a and E2F1 (both P < 0.001), and cyclin D1, P = 0.002] compared with normal salivary gland. Furthermore, malignant tumours expressed p53 (P = 0.003) and EZH2 (P = 0.09) in a higher percentage. Recurrences displayed more p53 + tumour cells (P = 0.02) than benign primaries. Amongst the benign tumours, the clear cell type had the highest proliferation fraction (P = 0.05) and a higher percentage of EZH2 was detected in the plasmacytoid cell type (P = 0.002).Conclusions: This study is the first to demonstrate that deregulation of the p16INK4a senescence pathway is involved in the development of myoepithelial tumours. We propose that additional inactivation of p53 in malignant primaries and benign recurrences contributes to myoepithelial neoplastic transformation and aggressive tumour growth.

Pijn in het aangezicht, waarbij geen duidelijke oorzaak is vast te stellen en causale behandeling dan ook onmogelijk is. Komt meestal voor bij vrouwen van middelbare leeftijd of ouder. Aet. Mogelijk onderliggende psychoneurotische oorzaken, o.a. depressiviteit. Sympt. Pijn bestaat gewoonlijk al jaren, zeurend van aard, wisselende intensiteit.

At a workshop coordinated by the WHO Collaborating Centre for Oral Cancer and Precancer in the UK issues related to terminology, definitions and classification of oral precancer were discussed by an expert group. The consensus views of the Working Group are presented here. The term, 'potentially malignant disorders', was recommended to refer to precancer as it conveys that not all disorders described under this term may transform into cancer. Critically evaluating all definitions proposed so far for oral leukoplakia, the Working Group agreed that the term leukoplakia should be used to recognize 'white plaques of questionable risk having excluded (other) known diseases or disorders that carry no increased risk for cancer'. An outline was proposed for diagnosing oral leukoplakia that will prevent other oral white disorders being misclassified as leukoplakia. The Working Group discussed the caveats involved in the current use of terminology and classification of oral potentially malignant disorders, deficiencies of these complex systems, and how they have evolved over the past several decades. The terminology presented in this report reflects our best understanding of multi-step carcinogenesis in the oral mucosa, and aspires to engender consistency in use.

Bij klachten of afwijkingen van de bovenof onderlip zullen de meeste patiënten vermoedelijk als eerste hulp zoeken bij hun huisarts. Anderzijds kunnen er op de lippen afwijkingen voorkomen die niet direct klachten veroorzaken en waarvoor niet altijd de gang naar de huisarts zal worden gemaakt. Vooral in die situatie is het van belang, dat tandartsen op de hoogte zijn van afwijkingen die zich op de lippen kunnen voordoen en weten wanneer verwijzing naar de kaakchirurg is geïndiceerd.In deze bijdrage zal worden ingegaan op enkele zwellingen van de lippen. Daarbij wordt onderscheid gemaakt in lokale, circumscripte zwellingen en diffuse zwellingen. Een aantal patiënten zal worden besproken met een lokale of diffuse zwelling van de lippen zonder dat wordt beoogd een overzicht te geven van alle op de lippen denkbare afwijkingen.

De niet-infectieuze afwijkingen van het mondslijmvlies worden in deze bijdrage behandeld naar aspect en naar lokalisatie. Afwijkingen van het mondslijmvlies dienen bij het mondonderzoek niet alleen op hun aspect beoordeeld, maar ook gepalpeerd te worden. Veel slijmvliesafwijkingen in de mond hebben een dermate kenmerkend klinisch beeld dat weefselonderzoek alleen nodig is wanneer men een maligniteit vermoedt.

In de afgelopen jaren werden twee patiënten, hier mevrouw A en mevrouw B te noemen, naar de afdeling mondziekten, kaak- en aangezichtschirurgie verwezen wier casus aanvankelijk niet, maar bij nadere bestudering toch relevante informatie voor de behandelend tandarts in zich bleken te hebbendie ik hier graag doorgeef.

Een 63-jarige vrouw wordt door haar tandarts verwezen in verband met leukoplakische veranderingen van de buccale gingiva in vrijwel de gehele onderkaak. Ongeveer 25 jaar geleden is door een andere tandarts de diagnose gesteld op lichen planus. Door een enkele jaren geleden elders geconsulteerde kaakchirurg is de diagnose op het toenmalige klinische beeld eveneens gesteld op lichen planus en is een proefexcisie verricht. Uit het verslag van de patholoog bleek sprake van hyperkeratose zonder ongunstige, dysplastische veranderingen in het epitheel. Er werd geen ondersteuning gezien voor de diagnose lichen planus. Mede gelet op afwezigheid van klachten is geen behandeling voorgesteld en is de tandarts geadviseerd patiente jaarlijks te controleren. Er zijn geen etiologische momenten. Patiente vertelt nooit te hebben gerookt. Hoewel patiente nog steeds klachtenvrij is en het klinische aspect van de leukoplakie in de loop van de jaren niet wezenlijk veranderd lijkt te zijn, was er nu toch behoefte aan hernieuwd advies voor het te voeren beleid.

Binnen enkele weken tijds zag ik op een van mijn spreekuren twee patiënten, beiden verwezen door de tandarts. De ene patiënt betrof een 14jarig meisje, dat zich om esthetische redenen stoorde aan een al van jongs af aan aanwezige blauwe verkleuring van de onderlip links, dichtbij de linker mondhoek (afbeelding 1). De andere patiënt betrof een 70-jarige man met een sinds zijn kinderjaren bestaande diffuse blauwrode zwelling van zijn onderlip en tevens een soortgelijke afwijking van zijn tong (afbeelding 2). Hij stoorde zich niet aan het aspect van de onderlip. Hem was vele jaren geleden verteld dat daar eigenlijk niets aan te doen was. Zijn vraag was of de zwelling van zijn tong te maken kon hebben met zijn slaapapneuklachten.

INTRODUCTION: Confirmation of a clinical diagnosis of oral lichen planus (OLP) by means of histopathologic study of a biopsy specimen is generally advised. However, hardly any data exist about the correlation between clinical and histopathologic diagnoses of OLP. The aim of the present investigation was to study the correlation between the clinical and histopathologic assessment of OLP, and to propose diagnostic refinements, if appropriate. METHODS: Clinical and histopathologic data of two previously published studies were used for this purpose. The number of clinical cases in which all clinicians agreed as well as the number of microscopic slides on which all reviewing pathologists agreed were calculated and compared with each other in order to assess the clinicopathologic correlation. RESULTS: In 42% of the cases in which all clinicians agreed about the clinical diagnosis being diagnostic of OLP, there appeared to be no consensus on the histopathologic diagnosis. Conversely, in 50% of the cases in which all pathologists agreed about the histopathologic diagnosis being diagnostic of OLP there was a lack of consensus on the clinical diagnosis. CONCLUSION: Based on the findings of the present study, there appears to be a lack of clinicopathologic correlation in the diagnostic assessment of OLP. We therefore propose a set of revised diagnostic criteria of OLP and oral lichenoid lesions, based on the WHO definition of OLP, including clinical as well as histopathologic aspects.

Ano-genital granulomatosis encompasses the previously recognized clinical entities of vulvitis granulomatosa, posthitis granulomatosa, and ano-perineitis granulomatosa. We report three patients with ano-genital granulomatosis. The pathological features of the disease are lymphoedema and the presence of non-caseating giant cell granulomas. These granulomas are histologically indistinguishable from those found in both Crohn's disease and sarcoidosis, therefore, patients with ano-genital granulomatosis with accompanying gastro-intestinal or pulmonary symptoms should be investigated for the presence of Crohn's disease or sarcoidosis, respectively. The value of ano-genital granulomatosis as a unifying clinicopathologic concept is to provide a label for the affliction as well as to stimulate a careful search for possibly underlying systemic disorders, thus also permitting a more specific approach to therapy.

Aim: To study patients with oral metastatic tumours for the distribution of sex and age, the oral site and histopathological type of the metastasis, the primary tumour site and length of follow-up. Patients and methods: All patients who had an oral metastasis diagnosed during the period January 1970–January 2001 at the Department of Oral and Maxillofacial Surgery/Oral Pathology, VU University Medical Centre, Amsterdam, The Netherlands, were included in this retrospective case study. Results: Of 1537 patients with newly diagnosed oral cancers, 24 had metastatic tumours. There was an equal sex distribution and age at the time of diagnosis ranged from 8 to 90 years (median 60). The metastatic tumours most commonly involved the bone (18/24), the mandible being the most common (15/18). The predominant histological type was adenocarcinoma. In most patients (n=16) the primary tumour was already known before the oral metastatic lesion appeared. The most common primary tumours were breast, lung, kidney, and prostate, in that order. Prognosis was poor (median survival 6 months, range 1–60). Conclusions: Oral metastases are rare and may present at any age in both sexes and predominantly involve bony structures, particularly the mandible. A third of oral metastases appeared to be the first indication of an occult malignant process elsewhere.

A general dental practitioner can, in the daily practice, be confronted with a patient with a swelling in the head and neck region. For such swellings an extensive differential diagnosis exists. Often such a swelling is caused by one or more enlarged lymph nodes due to a bacterial or viral infection. If a swelling in the head and neck region has been present for some time--longer than 4 weeks--then there is a considerable chance, especially in adults, that it is the result of the metastasizing of a malignancy, such as a squamous cell carcinoma in the oral mucosa or another mucosal site in the head and neck region. In addition to lymph node swellings resulting from a malignancy, diseases are now more frequently encountered which were previously uncommon in the Netherlands, due in part to the growing number of people with a non-Western ethnic background. Tuberculosis is such a rare disease, which can in the first instance express itself in the form of a lymph node swelling in the head and neck region.

Een 13-jarige meisje wordt door haar tandarts verwezen in verband met achterblijvende doorbraak van 46. Een door de tandarts vervaardigde tandfoto laat periapicaal van 47 een radiolucentie zien. Het meisje heeft geen klachten. Zij is verder gezond.

Een 32-jarige vrouw wordt door haar tandarts verwezen in verband met een door patiënte enige maanden geleden opgemerkte ‘ruwe plek’ op haar gehemelte (afbeelding 1). Zij heeft er verder weinig last van, maar wil toch graag weten wat hier aan de hand is. De medische voorgeschiedenis is blanco. Patiënte rookt niet en gebruikt geen medicijnen. Gelet op de titel van deze bijdrage zal het niet verbazen, dat het hier om een melanoom blijkt te gaan.

Een 33-jarige vrouw wordt door haar tandarts verwezen in verband met een sinds enkele jaren bestaande, uiterst langzaam in omvang toegenomen, niet pijnlijke zwelling aan de binnenzijde van de bovenlip, paramediaan links. De tandarts had patiënte al eens eerder geadviseerd naar de kaakchirurg te gaan, maar dat advies is destijds niet opgevolgd. Ditmaal had patiënte zich echter gewonnen gegeven.

Introduction Several authors have expressed the view that patients with oral lichen planus (OLP) are at increased risk of developing oral cancer. Since OLP cannot be effectively treated, regular screening for the possible development of oral cancer might be considered. Objectives (i) To calculate costs and effectiveness of screening for oral cancer in OLP patients with a decision model; (ii) to compare the cost-effectiveness of different screening scenarios; and (iii) to perform a sensitivity analysis of several variables used in this model. Methods Costs and effectiveness of a population of 100,000 OLP patients, being either screened or not screened for oral cancer, were calculated for the period of 1 year. Health gain was expressed as quality adjusted live years (QALY's) and equivalent lives saved (ELS). Cost-effectiveness was expressed as extra costs (costs of screening minus costs of no screening) per ELS. Then, the outcome was compared with the cost-effectiveness of a different screening scenario. Finally, the effect of varying the variables: (i) costs of cancer treatment; (ii) annual malignant transformation rate (MTR); (iii) sensitivity and specificity of an oral examination; and (iv) proportion of cancers found in stage I on extra costs per ELS were assessed in a sensitivity analysis. Results The health gain from screening was 592 QALY's or the equivalent of 23.68 lives saved, costing 1,265,229 dollars, meaning that one ELS costed 53,430 dollars. Increase of cancer-treatment costs will significantly decrease the costs per ELS. When the MTR is lower than 0.4% per year, extra costs per ELS will increase exponentially. The effect of sensitivity and specificity of an oral examination in detecting oral cancer on cost-effectiveness seems to be substantial. When the proportion of cancers found in stage I can be increased from 40% (without screening) up to at least 60% after screening, extra costs per ELS will decrease exponentially. Conclusions Screening for oral cancer in OLP patients, based on the presently used model, seems attractive. However, varying the several variables in the decision model has a significant impact on the final costs and effectiveness. Only, when additional information about these variables will become available, a more precise and realistic calculation can be performed.

Background: The clinical relevance of the presence of epithelial dysplasia in the margins of surgically removed oral squamous cell carcinoma is still unclear. Method: In a retrospective study, the presence of mild or moderate epithelial dysplasia in the surgical margins of tongue and floor of mouth squamous cell carcinoma was examined histologically. Patients with tumor cells within 0.5 cm of the surgical margins were excluded. Also patients with severe dysplasia were excluded, as this is usually regarded as carcinoma in situ. Patients that received postoperative irradiation were also excluded. Only patients who completed a follow-up period of five years were included. All together, a total number of 37 patients fulfilled the inclusion criteria. Results: Epithelial dysplasia was observed in 7 out of the 37 patients. Five of these patients, and two of the 30 patients with no dysplasia, had a local recurrence (P

Aims: To identify immunostaining patterns that are predictive for p53 mutations and to investigate whether p53 mutations are associated with established risk factors for oral squamous cell carcinoma (OSCC). Methods: Fifty five OSCCs were investigated for p53 protein expression by immunohistochemistry (IHC). Ten of these cases, including five p53 immunopositive and five p53 immunonegative cases, were subjected to microdissection of representative tumour areas followed by sequence analysis for the detection of TP53 mutations. Results: Paired IHC and sequence analysis revealed that p53 immunoexpression in more than 25% of tumour cells was indicative of TP53 mutations, whereas p53 immunonegativity was not informative. Therefore, for p53 immunohistochemical interpretation, p53 immunonegative cases were excluded from the analysis and the cut off value for p53 immunoexpression was set at 25%. Of the OSCCs showing any p53 immunoexpression, 64% revealed staining in more than 25% of the tumour cells. p53 immunoexpression in more than 25% of the neoplastic cells was significantly associated with smoking but not with alcohol consumption. No significant association with smoking habits was found when OSCCs were dichotomised into p53 immunonegative and p53 immunopositive. Conclusions: In OSCCs the following conclusions can be made: (1) p53 immunonegativity is not informative for TP53 mutations; (2) 25% p53 immunopositive cells appears to be a good cut off value to predict TP53 mutations; (3) p53 immunostaining patterns that appeared to be predictive for TP53 mutations were associated with the smoking habits of the patients.