Abstracts of papers presented at the 52nd annual meeting of the American Academy of Oral Medicine

Abstracts of papers presented at the 52nd annual meeting of the American Academy of Oral Medicine

VALIDATION OF THE RESEARCH DIAGNOSTIC CRITERIA FOR TEMPOROMANDIBULAR DISORDERS EMPLOYING MAGNETIC RESONANCE IMAGING. Petra Barclay, Lars Hollender,

Division of Oral Radiology, Department of Oral Medicine, School of Dentistry, Universi~. of Washington. This study was designed to compare clinical diagnoses that were obtained by head and neck examination and history according to the Research Diagnostic Criteria for Temporomandibular Disorders (RDC/TMD), with Magnetic Resonance imaging (MR/) diagnoses. The purpose was to validate the RDC/TMD for the diagnostic subgroup of Disk Displacement with Reduction (DD-R). Forty patients (35 female, 5 male; mean age, 34.9 years) clinically diagnosed with DD-R in at least one TMJ according to the RDC/TMD were recruited for this study. The condition of both joints in each patient was classified. Bilateral proton-density MR images in closed and open mouth position were obtained with a Signa 1.5 Tesla magnet (General Electric). For the coronaloblique imaging we used a new cut orientation not previously described in the literature. The consensus imaging diagnoses were achieved with two blinded observers. Thirty-nine patients (78 TMJs) were included in the final data analysis. One patient suffering from systemic rheumatoid arthritis had to be excluded from the study. Data analysis included the determination of the agreement between clinical and imaging diagnosis by kappa statistics and the predictive value of the RDC/TMD for DD-R. The MRI confirmed DD-R in 65.3% of the joints that had been clinically diagnosed as DD-R; 22.4% were found to have Disk Displacement without Reduction (DD-NR), 8.1% showed a norreal superior disk position, and in 2 TMJs (4%) the disk position could not be determined. The predictive value of the RDC/TMD examination for DD-R was 0.65, and the sensitivity to detect the DD-R proven by MRI was 78%. Considering all examined joints the RDC/TMD and MRI diagnoses agreed in 53.8% (42/78 imaged joints). For displacement of the disk vs no displacement the kappa value was 0.36. The predictive value of the RDC/TMD for disk displacement alone, including DD-R and DD-NR without considering the behavior of the disk on opening, is 0.92 (45149 joints). The two joints in which the disk position could not be determined were excluded from this analysis. Twenty-seven joints were clinically found not to have a disk displacement. In nine (33.3%) of these joints a normal disk position was confmned by MRI; in eight joints (29.6%) MRI revealed DD-R; and in seven joints (25.9%) MRI showed DD-NR. In an additional three joints the disk position could not be determined. The results of our study suggest that a positive RDC examination is predictive for internal derangement (predictive value, 0.92). However, no reliable conclusions about the degree of displacement and the reduction of the disk are possible. The agreement of only 54% between specific RDC/TMD diagnoses and MRI is poor (kappa value, 0.36). This is due to the high number of false negative diagnoses primarily in the asymptomatic contralateral joints. The clinical examination is therefore of only limited value in determining the true disk position in the TMJ. When

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treatment modalities are tailored to specific disk positions an MRI examination should be required; clinical examination alone can not provide sufficient information. Supported by Regional Clinical Dental Research Center (#DE09743) and the School of Dentistry Fund (#099208) at the University of Washington School of Dentistry. EFFECT OF INTRADENTAL CAPSAICIN AND IL-I(~ ON PERIAPICAL SUBSTANCE P IMMUNOREACTIVITY. D. Fischo~ D.

Sirois, UMDNJ-NJDS Division of Oral Medicine, Newark, N.J. Destruction of the nerves supplying the teeth is a very common therapeutic (endodontic) and pathologic (pulpal inflammation and necrosis resulting from dental caries) event. A subset of patients undergoing endodontic therapy develop significant persistent pain after amputation of the dental pulp. One cause for such chronic orofacial pain after pulpectomy may be aberrant local neural proliferation and neuroma-like formation. Recent investigations have demonstrated significant reciprocal influences between local immune and neural responses to tissue and nerve injury that could contribute to a pathologic outcome to pulp amputation. This study examined the effects of two substances present during tissue injury and inflammation that are known to influence the neuronal response to tissue injury: interleukin-lc~ (IL-I(~) and substance P (SP). Pulpectomy was performed on 48 molar teeth (2 maxillary and 2 mandibular first molars per animal) in 12 adult male Sprague Dawley rats either with immediate intradental placement of vehicle (control; n = 3) or with one of the following experimental compounds: IL-le~, anti-IL-lo~, or capsaicin (for each of which n = 3). In addition to the control group that received only vehicle, two teeth per animal in the experimental group also received vehicle (control) solution. Thus a total of 24 experimental teeth (8 for each compound) and 24 vehicle teeth were studied. Teeth were sealed during a 2-week post-pulpectomy period, with placement of supplemental compound on day 7. Two weeks after pulpectomy the molar teeth and stmounding bone were removed and prepared for HE and S100 staining and SP immunoreactivity (IR). Negative and positive control sections were used to identify signal; periapical and local neural S100 and SP IR was measured by means of a computerized morphometry system (BioMetrics, BioQuant). Differences between experimental and control values were determined with one-way analysis of variance (c~ = 0.05; Dunnett's Method) by means of Sigma Stat (Jandel Scientific). Intradental capsaicin resulted in (1) a significant increase in SP IR in the immediate periapical region (194% to 262%; p < 0.05) and nearby peripheral nerve (254% to 262%; p < 0.05) and (2) a significant increase in periapical (107%; p < 0.05) and decrease in peripheral nerve (-62%; p < 0.05) S100 labeling. IL- lo~ and antiIL-lc~ did not result in a significant effect on SP IR or $100 staining. There was no significant difference between maxillary and mandibular teeth. Capsaicin, but not IL-I ~ or its antagonist, sig-

nificantly alters neural and periapical SP levels and SIO0 stainingfollowingpulpectomy. Such local neural-immune interactions

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Volume 85, Number 4 may contribute to abnormal neural processing, though this possibility requires additional investigation. PAROTID SALIVARY GLAND PRESERVATION IN POST-RADIOTHERAPY HEAD A N D NECK CANCER PATIENTS. J. A. Ship, A.

Eisbruch, B. Henson, E. D'hondt, A. Madhava, University of Michigan School of Dentistry and Department of Radiation Oncology, Ann Arbor, Mich. Head mad neck cancers are frequently treated with radiotherapy (RT), which causes irreversible salivary dysfunction and persistent xerostomia. We have demonstrated that three-dimensional treatment planning and conformational dose-delivery techniques can minimize RT doses to contralateral parotid salivary glands while delivering therapeutic doses to ipsilateral tumors and tissues at high risk for cancer spread. This study's purpose was to determine whether spared contralateral parotid output in post-RT head and neck cancer patients can persist up to 2 years after completion of RT. Nine patients (age range, 53-82 years; mean age + standard deviation [SD] = 64 + 9.5 years) with unilateral cancers received parotid sparing treatment to contralateral glands. Unstimulated (UPFR) and 2% citrate stimulated parotid flow rates (SPFR) from spared and treated glands and responses to a standardized four-item xerostomia questionnaire (XQ) were assessed at baseline (pre-RT), completion of RT, and at 1 and 2 years post-RT. Treated and spared parotid flow rates were combined at each visit to yield total UPFR (TotUPFR) and total SPFR (TotSPFR). The results revealed that radiation doses to treated glands (mean + SD, 50.4 _+ 15.6 Gy), were higher than to spared glands (2.7 _+ 1.5 Gy; p < 0.001). UPFR from spared glands at the completion of RT and 1 year post-RT were similar to baseline values and were higher at 2 years in comparison with baseline (p = 0.06). SPFR from spared glands were 33% lower than baseline values at completion of RT (p = 0.02) yet were similar to baseline values at 1 and 2 years post-RT. Treated UPFR and SPFR were essentially zero at all post-RT visits. At the completion of RT, TotUPFR and TotSPFR were 22% (p > 0.05) and 58% (p < 0.001) lower than baseline values, respectively, but at 1 and 2 years they were similar to values obtained at baseline. Responses to three of the four XQ items were significantly worse than baseline at the completion of RT. At 1 and 2 years post-RT, all four XQ items were statistically indistinguishable from baseline responses.

These findings suggest that despite parotid-sparing RT techniques, contralateral (spared) parotid glands can undergo diminished function during RT, with concomitant complaints of xerostomia. However, 1 and 2 years post-RT, parotid-sparing techniques can preserve contralateral parotid funetion, which may protect patients from xerostomic complaints. THE NEVOID BASAL CELL CARCINOMA SYNDROME (NBCCS) A N D MUTATIONS IN THE H U M A N PATCHED GENE. P. J.

Shahani, University of Missouri-Kansas City School of Dentistry. The purpose of this study was to analyze DNA obtained from five patients with the Nevoid Basal Cell Carcinoma Syndrome (NBCCS) and five patients with sporadic medulloblastomas for mutations in the gene PATCHED, which is thought to be aberrant in both of these conditions. The five persons (three families) with NBCCS used in this study were patients at the UMKC School of Dentistry. The diagnosis of the disease was based on the fact that these patients had at least two major features of the syndrome, one of which was multiple odontogenic keratocysts. Each patient was given a sire-

ple explanation of the purpose of the study; questions were answered; and the patient was then asked to give written consent for 10 mt of blood to be drawn from the antecubital fossa. The specimen from each patient was collected in two ethylenediamine tetraacetic acid tubes (approximately 5 mt in each tube) and immediately transported to the laboratory. DNA from medulloblastomas in 5 nonrelated patients had been stored as archival material at the laboratory where this study was being conducted. Two of these tumors were of the desmoplastic histologic variety, two were non-desmoplastic, and one was of unknown type. This study made use of the basic technique of the polymerase chain reaction (PCR), modified by the use of a thermostable DNA polymerase purified from the thermophilic bacterium Thermus aquaticus, PCR was used to amplify the PATCHED gene one exon at a time from each patient's DNA, after which the PCR products were purified, quantitated, and sequenced. The sequence data were then manually analyzed for mutations in the gene. The nature of the study did not lend itself to statistical analysis. A total of 20 exons have been examined and several polymorphisms have been found, but there have been no deleterious mutations. Exons 1, 2, and 4 have yet to be amplified and sequenced, and DNA from one additional patient with NBCCS may be analyzed before the period of research is terminated. The results may be explained by the localization of mutations in intronic PATCHED sequence or in upstream promoter regions of the genome. In addition, genes whose products may be involved in the PATCHED protein biochemical pathways may themselves be mutated. Hence the activity of the PATCHED protein may be modified, resulting in phenotypic expression of the NBCCS in the absence of germline mutations in this gene. Supported by the Reinhart Foundation. C H R O N O B I O L O G I C VS CONVENTIONAL BLOOD PRESSURE M O N I T O R I N G OF DENTAL PATIENTS. N. Rhodus, E Raab, G.

Cornelissen, J. Little, E. Schaffer, E Halberg, University of Minnesota. Approximately daily (circadian), half-weekly (circasemiseptan), and weekly (circaseptan) components characterize human blood pressure (BP) and heart rate (HR). This variability contributes a large error in episodic diagnosis from single BP measurements taken at arbitrary times of day. This study aimed at comparing BPs obtained conventionally in dental patients with those assessed by the rhythm-adjusted mean (MESOR) and a circadian BP amplitude (A) by a continuous ambulatory blood pressure monitor (ABPM, Colin Corp.) for a minimum of 7 days. A total of 46 subjects (22 female and 24 male; mean age, 42.7 years) were evaluated. The results indicated that 14/45 (31%) of the subjects exceeded the 95% prediction limit of age- and sex-matched peers for mean amplitude (A) of SBP and DBR Furthermore, of the 23 subjects (one half of the subject population) presenting for surgery, 35% demonstrated excessive BR Although there were individual variations, the mean values for the study group were as follows:

SBP DBP HR

M +_SE

2A +_SE

f +_SE

136.2 _+ 1.4 78.7 + 1.0 67.1 _+ 1.0

40.3* _+4.0 24.7* +_2.9 24.8* _+2.9

11:23 _+00:24 1 t:26 +_00:28 13:47 _+00:28,

where M = MESOR, 2A = double amplitude (SBP and DBP are expressed in mm Hg and HR is expressed in beats/minute; values

4 1 6 Abstracts

ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY

April 1998 marked with an asterisk are above normal range), and f = acrophase (timing of overall high values occurring each day), These values indicate a significant variation in both SBP and DBP (*p < 0.05) in comparison with conventional episodic measurements. An excessive BP amplitude is a risk factor for adverse vascular outcomes and emergencies in the dental clinic. The chronobiologic approach provides new endpoints for the dentist's screening and diagnosis of hypertension and for the indications and the timing of systemic treatment. THE ROLE OF ORAL MANIFESTATIONS OF HIV AND BODY SIGNS IN SUSPICION OF POSSIBLE HIV INFECTION. L. L.

Patton, R. G. McKaig, D. Rogers, R. P. Strauss, J. J. Eron, Jr., University of North Carolina, Chapel Hill, N.C. Oral manifestations of HIV, such as oral candidiasis (OC) and oral hairy leukoplakia (OHL), are important prognostic indicators of HIV progression and are included in various classification and staging schemes. They have been suggested as early indicators of possible H1V infection in undiagnosed individuals. The purpose of this study was to document the role of oral manifestations of HIV in arousing suspicion of possible HIV infection before HIV testing and to identify characteristics associated with persons who are suspicious of possible HIV infection or who report oral or systemic signs of possible infection before HIV testing. The study population consisted of 452 HIV-infected adults receiving HIV care at the University of North Carolina who enrolled in a longitudinal study of oral disease; 77.2% of the subjects were male, 62.8% were black, and the mean age at diagnosis was 34 years. Subjects were queried by a trained interviewer; 49.1% reported that at the time they tested positive they were already suspicious of possible HIV infection, and 40.5% had body signs and 8.4% had oral signs that made the subjects (or their doctors) think that they might have HIV. Of oral signs reported, most (60.5%) were episodes of. pseudomembranous OC. Suspicion or oral signs alone did not result in progression to development of an AIDSindicator condition in a shorter time, but those with body signs at diagnosis developed AIDSzindicator conditions in significantly less time than those who were tested before development of body signs. Multivariate logistic regression indicated that suspicion of HIV-positive serostatus was significantly more likely among whites (odds ratio [OR] = 1.67; 95% confidence interval [CI] 1.06,2.61), men who have sex with men (OR = 2.55, 95% CI 1.66,3.91), those with higher socioeconomic status (OR = 1.70, 95% CI 1.07,2.70) and lower income at the time of the interview (OR = 0.63, 95% CI 0.45,0.97), and those reporting oral signs (OR = 2.23, 95% CI 1.02,4.87) or body signs (OR = 2.47, 95% CI 1.64,3.75) before HIV testing. The report of body signs was significantly associated in a multivariate model only with being suspicious (OR = 2.42, 95% CI 1.64,3.57) and having oral signs (OR = 2.64, 95% CI 1.29,5.39). Multivariate logistic regression modeling revealed that subjects with oral signs have a significantly higher likelihood of being suspicious (OR = 2.14, 95% CI 1.04,4.57), having body signs (OR = 2.80, 95% CI 1.36,5.78), being of a higher socioeconomic status (OR = 2.03, 95%CI 1.01,4.08) and not currently living in a city (OR = 0.28, 95% CI 0.11,0.70). Although oral manifestations of HIV appear to have aroused suspicion of possible HIV infection in undiagnosed individuals less often than did body signs, the presence of these oral signs, especially OC, was important in detecting HIV infection in 38 persons in this population and aroused sufficient suspicion alone in the patient or the doctor to result in the diagnosis of HIV

in 13 persons. Appropriate vigilance for oral signs of possible HIV infection during oral examination is important for the dentist and physician treating not only patients with known risk behaviors but also those who are less likely to be suspicious of possible HIV infection, such as blacks, heterosexuals, and individuals of lower socioeconomic status. IDIOPATHIC FAILURE TO ERUPT OF PRIMARY AND PERMANENTTEETH. Anne C. O'Connell, NIDR, NIH, Bethesda, Md.

A girl appeared for treatment at our clinic with a history of delayed eruption of primary teeth. Physical evaluation revealed her to be a well-proportioned person with no craniofacial, dermal, or skeletal dysmorphologies. She displayed age-appropriate development. There were no abnormalities noted in hair, skin or nails. At age 4 years she had only 8 teeth erupted and underwent an extensive endocrine evaluation. No abnormalities were noted in thyroid function, and calcium, phosphorus, and alkaline phosphatase levels were within normal range. Bone age corresponded to chronologic age at 4 years 2 months. An oral examination at 6 years revealed that a total of 13 primary teeth had erupted. The teeth that had erupted displayed normal size, shape, and quality of enamel. Radiographically all primary teeth were present, and the permanent tooth buds of all teeth except the upper second premolars were identified. The nonerupted teeth were covered with bone and had well-circumscribed follicles. The developing lower second premolar tooth buds were ectopically placed. Root development or dental maturity was assessed by tlae method of Demirjian et al. (1973) and revealed age-appropriate dental maturity. Previous radiographs revealed continued root development without progress toward the alveolar crest in the developing dentition. This patient was evaluated extensively at the initial visit and at subsequent visits. All laboratory values were within the normal range for a growing child, including parathyroid, thyroid, and growth hormone levels. Bone age at 6 years 10 months corresponded to chronologic age. No abnormalities were noted on radiographic examination of the clavicles. High-resolution karyotyping was performed and no abnormalities were noted. In the absence of significant clinical findings our working diagnosis is idiopathic failure of eruption. This case represents a unique clinical situation and appears to reflect a severe generalized disturbance in the eruptive process, inasmuch as (1) both deciduous and permanent dentitions are affected, (2) incisors, molars, and premolars are involved in all quadrants, and (3) skeletal and craniofacial growth are within normal limits. HUMAN PAPILLOMAVIRUS-INDUCED ORAL WARTS IN HIV INFECTION: ASSESSMENT OF TREATMENT OUTCOMES. C. M.

Nichols, (2. M. Flaitz, K. H. Allen, 3. Hicks, Bering Dental Clinic, University of Texas, Houston, Tex. The purpose of this study was to evaluate the clinical features of human papillomavirus (HPV)-induced oral warts and correlate these findings with treatment outcomes in patients with HIV infection. A set of 100 consecutive HIV-infected persons with biopsy-woven oral HPV infection was studied; of these, 94 were male and 6 were female; 54% were white, 30% were black, 14% were Hispanic, and 2% were of some other race; 72% were homosexual, 10% were homosexualand were intravenous drug users, 8% were heterosexual, 5% were heterosexual and were intravenous drug users, and 5% were "Other"; the mean age was 38 years; the mean CD4 cell count was 223. Anogenital warts were reported in 28%, with 4% of these patients having infected

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Volume 85, Number 4 partners and 12% having concurrent cutaneous warts. Oral HPV involved the lips and buceal and labial mucosa (69%), tongue and/or floor of the mouth (17%), gingiva (11%), palate/tonsillar pillars (9%), and perioral skin (9%). Clinical appearances included flat/stippled (36%), nodular/stippled (31%), papillary (17%), flat/corrugated (6%), conical/spiky (2%), and combinations (8%). Oral wart distribution was evenly grouped into single (50%) and multiple (50%) lesions. Treatments included biopsy only (34%), podophyllin resin alone (15%), laser ablation alone (14%), and laser ablation in combination with podophyllin resin (13%). Intralesional interferon was used in combination with surgery in 13%; intralesional cidofovir was administered in 5%. Cimetidine or vitamin A was added to the multimodality therapy in 6%. Complete resolution was documented in 80%; partial resolution (>_ 50%) in 10%, and minimal response or no response in 10%. Despite treatment, there was a 35% recurrence rate. With recurrence, 80% were in the multiple lesion group, with 43% described as flat/stippled, and 20% were single lesions with a variety of clinical appearances. Oral warts in HIV-infected patients fre-

quently require multimodality therapy and are associated with a moderate recurrence rate, despite aggressive management approaches. ROLE OF LANGERHANS' CELLS IN PATHOGENESIS OF ORAL LICHEN PLANUS: A PRELIMINARY STUDY. N. Narayana,

UMKC School of Dentistry. The exact role of Langerhans' cells (LC), in the pathogenesis of lichen planus (LP), is not fully understood. An increase or no change in density of LC but with an increase in class II major histocornpatibility complex expression has been reported in affected oral mucosa. Although steroids are the mainstay of therapy, the effect of topical steroid rinses on LC and LP has not been studied. The aim of this investigation was to study the effects of a 0.05% fluocinonide rinse in clinical management and location, density, and state of activity of LC in oral LP. Material and methods. Buccal mucosal incisional biopsy specimens were obtained from eight patients with LP and five agematched healthy controls. Each patient with LP used 5 ml of 0.05% fluocinonide rinse twice daily for 4 weeks and was subjected to a second biopsy on completion of treatment. Frozen sections were single-labeled with C D l a (LC marker) and doublelabeled with CDla and HLA-DR (marker for functional activity) through use of immunoperoxidase techniques. Clinical, histologic features, and LC density were compared in control subjects, patients with LP pretreatment, and patients with LP posttreatment by means of the t test for independent analysis and a two-factor repeated measure analysis of variance. Results. Six of eight (75%) patients with LP exhibited clinical and histologic healing. There was concordance in location and density of LC in sections double-labeled with CDla and HLADR and single-labeled with CDIa. Summary of results. The total LC density (epithelium + lamina propria) was similar in the control and pretreatment LP groups. However, there was a significant reduction (p < 0.01) in the density of LC in the epithelium and increased density (p < 0.05) in the lamina propria in the pretreatment LP group in comparison with the controls. After treatment there was a significant reduction (p < 0.05) in total LC density (epithelium + lamina propria) in the LP group in comparison with the controls, whereas the density in the epithelial LC remained significantly lower (p < 0.01). Overall numbers of LC in the lamina propria decreased, returning

to levels similar to that observed in controls. These results appear to indicate a redistribution of LC in LR facilitating them to perform their function of antigen presentation to T-lymphocytes. The activated T-lymphocytes in turn release cytotoxic agents, which results in basal epithelial cell damage and clinical disease. The results also indicate that a steroid rinse is inhibitory to both LC and T-lymphocytes. Funding source: Rinehart Foundation. GIANT CELL LESION OF THE JAWS: REPORT OF A CASE TREATED WITH INTRALESIONAL STEROIDS. M. Kurtz, M. Mesa, P.

Alberto, UMDNJ-New Jersey Dental School, Newark, N.J. The giant cell lesion of the jaws accounts for approximately 7% of all benign tumors of the jaws. Most occur within the first 3 decades of life with a female predilection, and the mandible is more commonly affected than the maxilla, usually anterior to the first molar. With respect to their behavioral spectrum, giant cell lesions range from those that respond well to conservative surgical procedures to those that are very aggressive and recur. Factors that appear to predict the behavior of a lesion include pain, swelling, root resorption, cortical perforation, increased size, and young patient age (these are more characteristic of the aggressive variants). The treatment modalities for the central giant cell lesion of the jaws have been mostly surgical and range from simple enucleation and curettage with or without peripheral ostectomy to resection. Recently treatment of central giant cell lesions with intralesional injections of corticosteroids has been described as a treatment alternative in a number of cases. A case of central giant cell lesion of the jaws treated with intralesional injections of corticosteroids will be presented. An 11year-old girl appeared for treatment with a 4.0 × 2.5 cm multilocular radiolucent lesion associated with an unerupted left mandibular cuspid. The lesion was curetted and submitted for pathologic examination, which revealed a central giant cell granuloma. The patient returned 5 months later with a large muhilocular radiolucency extending from left mandibular second bicuspid to the right mandibular cuspid. The lesion caused displacement and loosening of the mandibular central incisors and buccal expansion. Because of the extent of expansion and destruction of the mandible (which would require an extensive resection) and the young age of the patient, careful consideration was given to the use of intralesional injections of corticosteroids (as described by Terry and Jacoway in 1994). The protocol consisted of a series of 6 injections of triamcinolone acetonide (10 mg/ml) at a suggested dose of 2 ml/2 cm of radiolucency for a total dose of 15 ml per injection weekly. Within 6 months there was considerable evidence of remineralization and other signs of continued resolution, such as tightening of mobile teeth and reduction in discomfort. One year later an area of persistent radi01ucency was noted in the left mandibular cuspid region, and the protocol described was repeated; this resulted in rernineralization of that area. Our experience supports the previous findings that intralesional corticosteroids may cause resolution of central giant cell lesions of the jaws. Further clinical trials including a larger number of cases should be developed to determine the value of this therapeutic approach. SEVERE PALATAL NECROSIS IN COCAINE ABUSERS. A.

Majorana, E Facchetti, G. Gregorini, M. L. Morassi, P. Gigola, M. Trimarchi, P. L. Sapelli, Department of Odontostomatology-School of Dentistry, University of Bresci a, Italy. The destructive effects of cocaine abuse on the nasal cavity and

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nasal septum are well recognized, whereas oral complications, particularly palate perforations, are much less emphasized. Of six patients presenting themselves to our Departments between 1994 and 1997 with nasal lesions resulting from cocaine abuse, four showed palate perforation; of these, three were female and one was male. The mean age of these four patients was 37.5 years (_+ 7.5 years); their histories of cocaine abuse ranged from 4 to 8 years. Two patients displayed systemic cardiovascular effects of cocaine--cardiomyopathy with cardiac failure in one and severe hypertension in the other. None of the patients showed pulmonary or kidney diseases or systemic vasculitis. All patients manifested severe nasal crusting; this was associated with either isolated septurn perforation (one patient) or complete septum destruction involving the middle and lower turbinates (three patients). Only one patient showed a typical saddle nose. The palate perforation developed after the nasal lesions, and it involved the hard palate in three patients and the hard and soft palate in one patient. The diameters of the palate perforations ranged from 0.5 to 4 cm. In three of the four patients for whom a close follow-up was possible, persistence of cocaine abuse was documented; in all these patients persistence or progression of the destructive lesions was found. Multiple biopsies (nasal and/or palatal) revealed similar anomalies: (1) dense inflammatory infiltrate involving the lamina propria and composed of mature lymphocytes, histiocytes, and variable numbers of neutrophils and eosinophils; (2) transmural inflammatory cells within the walls of blood vessels--primarily venules and arterioles--occasionally associated with deposition of fibrinoid material; and (3) lack of deep tissue necrosis, multinucleated giant cells, or granulomas. In some biopsy specimens, the inflammatory infiltrate was minimal and reparative fibrosis was found. Stainings for fungi or acid-fast bacilli were negative. Inmmnostaining of the infiltrate revealed a prevalence of phenotypically normal T cells, associated with macrophages, with an absence of CD56+ cells. This study indicates that oral complications in individuals who abuse cocaine are common. In these patients palate perforation can be much more troublesome than nasal septum perforation because of its early association with rhinolalia and oral cavity incontinence; the subsequent passage of fluids and solids into the nasal cavity may further complicate the nasal discomfort. Moreover, the oral specialist faces problems with prosthetic rehabilitation of the palate perforation. Severe palatal and nasal necrosis resulting from cocaine abuse adds to other causes of midline facial destruction, including Wegener's granulomatosis and non-Hodgkin's lymphomas. Nongranulomatous vascular inflammation is regularly observed on biopsy, but lack of tissue necrosis and granulomas, as well as cell atypia, can be helpful in the differential diagnosis. A careful history of drug abuse should be obtained in any patient seeking care for a necrotizing midfacial disease. TH1/TH2 CYTOKINE EXPRESSION IN SALIVA OF HIV-NEGATIVE A N D HIV-POSITIVE INDIVIDUALS WITH OROPHARYNGEAL CANDIDIASIS. J. Leigh, C. Steele, F. Wormley, L. Wei, R.

Clark, W. Gallaher, P. Fidel, Louisiana State University School of Dentistry. Oropharyngeal candidiasis (OPC) is a common mucosal infection in HIV-infected individuals. Although there is a paucity of information on host defense mechanisms at the oral mucosa, recent studies suggest that local cell-mediated immunity (CMI) is more important than systemic CMI for host defense against mucosal Candida albicans infections. The purpose of this study

ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY April 1998 was to evaluate the potential presence of oral-associated CMI through the expression of Th 1/Th2-type cytokines in the saliva of immunocompetent and immunocompromised persons. Forty-five subjects were enrolled, of whom 25 were HIV-negative (12 male and 13 female; age range, 21 to 52 years) and 20 were HIV-positive (14 male and 6 female; age range, 26 to 46 years; mean CD4+ cell count, 197/mm3); of the latter, 8 were OPC-positive (mean CD4+ cell count, 107/ram 3) and 12 were OPC-negative (mean CD4+ cell count, 249/mm3). Ten ml of unstimulated saliva and 30 ml of blood were collected from each patient. The Thl-type cytokines (IL-2, IFN-g, IL-12) and Th2-type cytokines (IL-4 and IL-10) in the saliva were quantitated by enzyme-linked immunosorbent assay and expressed as pg/mg protein in saliva. The functional competence of the peripheral blood mononuclear cells was tested by response to C. albicans antigens. Analysis of saliva showed a constitutive Th0 cytokine expression in HIVpersons; IL-10 had the highest median concentration, and it was followed by IFN-g, IL-12, IL-4 and IL-2. All HIV+ patients demonstrated a Th2-type cytokine profile with IL-4 and IL-10 concentrations that were significantly greater than the concentrations of IL-2, IL-12, and IFN-g (p < 0.001), which was suggestive of susceptibility to Candida infections. This Th2-type cytokine profile was observed in all HIV+ patients regardless of CD4+ cell count. Comparison of salivary IL-4 and IFN-g levels between OPC+ and OPC- subjects revealed decreased levels of IFN-g in comparison with 1L-4 in the OPC+ group; the reciprocal relationship was observed for the OPC- group. Every subject, irrespective of CD4 count, had some level of positive peripheral blood lymphocyte response to C. albicans antigen. The ratio of mean mitogen to Candida antigen proliferation indices of the HIV-, HIV+/OPC-, and HIV+/OPC+ with >200 CD4 cells/ram were similar, with ratios ranging from 1.77:1 and 1.0:1. The HIV+ OPC+ individuals with <200 CD4+ cells/ram 3 had a higher ratio---13.3:l--as a result of lower responses to C. albicans antigen. These results suggest that local CMI may play an important role in resistance/susceptibility to oral C. albieans infections. AN UNUSUAL CASE OF SALIVARY DUCT CARCINOMA INTHE BODY OF THE MANDIBLE. A. Lee, R. Gier, C. G. Cumming,

UMKC School of Dentistry. During a course of routine dental treatment it was noticed that the anterior mandibular teeth of a 63-year-old male patient became progressively loose over a period of 1 month. Radiologic findings indicated an irregular radiolucent area in the body of the mandible, with no other site apparently affected. Biopsy of mandibular tissue revealed" an underlying glandular tumor with a distinct comedocarcinoma-like appearance. This pattern has been reported in "salivary duct" carcinoma, a tumor characterized by aggressive behavior and early metastasis that is locally recurrent and has a significant mortality rate. Histologically, such tumors feature the presence of intraductal, circumscribed epithelial nests, with a diverse cellular arrangement and the presence of an infiltrative component. The patient was subsequently transferred to a regional cancer center for further examination and treatment. O U T C O M E OF TREATMENT OF MODERATE MYOFASCIAL PAIN: A GENDER SPECIFIC RETROSPECTIVE STUDY. P. Hanian,

T. P Sollecito, S. F. Silverton, M. S. Greenberg, School of Dental Medicine, University of Pennsylvania, Philadelphia, Pa. Myofascial pain (MFP) is a common complaint with variable treatment outcomes. Management of MFP of the masticatory

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Volume 85, Number 4 muscles is controversial. To study patient outcomes, the departmerit of Oral Medicine has initiated a database for patients with MFR Patients were seen and assessed between July 1, 1996, and June 30, 1997. We now report on outcomes from the first 43 of 150 patients identified with moderate MFP. Our analysis focused on gender presentation and multimodal treatment of MFR Patients were evaluated for tenderness of muscles of mastication and for maximal interincisal opening. Each muscle of mastication was palpated and assigned a value on a qualitative tenderness scale. The scale ranged from 0 to 3, with 0 representing no tenderness and 3 representing maximal tenderness. Treatments assigned by two calibrated faculty clinicians included exercise, appliance therapy, oral anti-inflammatory agents, trigger point injections, and tricyclic antidepressants. Tenderness scores were summed for each muscle bilaterally on initial presentation and after treatment. Cases with tenderness scores totaling either >6 or >2 in two or more muscles of mastication were defined as moderate MFR Patients h a d pain histories ranging from 2 weeks to 10 years. Maximal interincisal opening was recorded for each patient on initial evaluation and after treatment. Improvement was based on either a decrease in the tenderness score in comparison with initial presentation, an increase in maximal interincisal opening, or changes in both indices. Success rates for combined treatment modalities were collected. Gender specific success rates were analyzed. The age distribution showed a range of initial presentation from 16 to 82 years. Twenty-six (60%) of the 43 patients were between the ages of 20 and 39. Ten (23%) of the forty-three were male. The proportion of male patients was similar in the age ranges sampled. The proportion of female patients was also similar in the age ranges sampled. Male patients had a superior success rate for treatment; 90% percent were improved at the time of follow-up. For female patients, 73% were improved at the time of follow-up. To confirm that this difference in outcome is statistically significant, approximately 100 more patients will need to be added to the database. We next examined the number of therapies that were assigned to each patient. There were five treatments offered. The numbers of patients receiving one, two, and three treatment modalities were approximately equal. One patient received four treatment modaliries, and none received five. Success rates varied between the number of treatments received; patients receiving three treatment modaliries appeared more likely to have a successful outcome than patients receiving only one. Confirmation of this observation would require a prospective enrollment in one or three treatments for approximately 80 patients. Several questions are raised by this study. First, it appears that outcome of treatment of moderate MFP is better in male patients; further prospective data are needed to clarify this possible association. Second, it may be that multimodal therapy has some advantage in the treatment of moderate MFP; a prospective look at this hypothesis with a prospective randomized patient sample would be helpful. MORSICATIO BUCCARUM / LINGUAGRAM: CASE REPORT & REVIEW OF LITERATURE. C. Gokool, R~ Gier, C. G. Cumming,

UMKC School of Dentistry. Morsicario is a condition caused by chronic irritation of the tongue or buccal or labial mucosa as a result of chronic mucosal chewing. It occurs mostly in females and is prevalent among people who are stressed or psychologically impaired. The lesions are usually bilateral and may occur simultaneously on all three

mucosal areas (tongue, lips, cheek), or it can be isolated to one location depending on the parafunctional habits of the patient. Clinically the lesions appear as thickened white areas with an irregular ragged surface. Case Report. A 27-year-old woman appeared for treatment at the UMKC dental clinic with the complaint of a white growth on her cheeks and tongue that had been present for 3 months, Her medical history was unremarkable except for frequent vaginal candidiasis. She had been unsuccessfully treated for her oral lesions with nystarin and ketoconazole agents by a previous denfist. She described being able to scrape off some of the white areas occasionally. She denied mucosal biting or chewing. A biopsy of the lesion revealed histologic features commonly encountered in hairy leukoplakia. Results of HIV testing were negative, and the laboratory results of a complete blood count and white cell differential count were within normal limits. On the basis of the pathology report she was treated with acyclovir, but this also was unsuccessful. A diagnosis of morsicatio was made, and an acrylic shield was constructed to prevent buccal mucosa and tongue chewing. Conclusion. Clinically and histologically, morsicatio mimics hairy leukoplakia. This case therefore suggests that because of the social implications and the difference in management of hairy leukoplakia, care must be taken in making such a diagnosis. PAPILLON-LEFfZVRE SYNDROME: NEUTROPHIL FUNCTION IN FIFTEEN CASES FROM FOUR FAMILIES FROM EGYPT. K. A.

Ghaffar, E M. Zahran, H. M. Fahmy, R. S. Brown. Our purpose was to compare neutrophil function among probands in four families in Egypt with Papillon-LeF~vre syndrome (PLS), the unaffected siblings of the probands, and ageand gender-matched control subjects. Methods. Family histories of PLS subjects were evaluated. All subjects were examined for dermal and oral manifestations of PLS. Fifteen subjects in four fmnilies with the manifestations of PLS, 11 siblings of the probands, and 16 age- and gender-matched control subjects were evaluated. Phagocytic and intracellular killing (lyric activity) of polymorphonuclear nentrophils (PMNs) were evaluated for all subjects according to a modification of the Wilkinson (1978) method. Opsonization was evaluated according to the methods of Cutler et al. (1991). Data were evaluated by paired t test analysis, with p < 0.05 demonstrating significance. Results. Family pedigrees were plotted, and the prevalence of consanguinity was noted in the families with PLS. The means + SDs for phagocytosis, lytic activity, and opsonization were as follows: probands, 4.75 _+2.06, 0.45 _+0.18, and 0.84 _+0.09; unaffected siblings, 10.4 -+ 1.3, 3.5 + 0.46, and 0.85 _+ 0.05; control subjects, 10.8 _+ 1.3, 3.3 + 0.3, and 0.84 _+0.07. The phagocytosis and lytic indices showed significance between the probands and both siblings and controls (p < 0.05), whereas the opsonization index did not demonstrate significance between groups. Conclusion. Significant decreased neutrophil function in PLS subjects was demonstrated with respect to neutrophil phagocytotic and lyric activity but not with respect to opsonization. Therefore specific neutrophil dysfunction appears to be involved in the causation of this disorder. HEPATITIS C VIRUS INFECTION OF ORAL MUCOUS TISSUES IN PATIENTS WITH ORAL LICHEN PLANUS. Giovanni Maria

Gaeta, Department of Oral Medicine II, University of Naples, Italy.

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April 1998 In recent years many case control studies have confirmed the association between oral lichen planus (OLP) and chronic hepatitis C but have been unable to clarify any biological correlation between them. Hepatitis C vires genome (HCV-RNA) has been detected in the whole saliva of chronically infected patients. However, contamination of the tissues by plasma or blood cells was not excluded by the previous reports. The aim of this study was to assess the HCV-RNA in oral mucous tissues of patients with OLP. Methods. Thirty unselected patients with OLP (24 erosive, 6 reticular; histologically confirmed) and with aminotransferase levels above the upper normal level (>40 U/L) were enrolled in this study. Twenty patients were HCV+; of these, 14 had chronic active hepatitis and 6 had chronic cirrhosis. All 20 HCV+ patients had the erosive kind of OLP. The remaining 10 patients with OLP (6 reticular, 4 erosive) were HCV-. Serum and saliva samples (2 ml of each, collected by micropipette without stimulation) and mucous samples were obtained from each patient, Polymerase chain reaction (PCR) for virus C genome was performed on RNA extracted from serum, saliva, and oral epithelial cells. The cells were obtained after separation with collagenase of the whole mucous tissues. By means of gel chromatogralShy and enzymelinked immunosorbent assay testing, the presence of secretory IgA anti-HCV was also detected in the saliva samples. Results. HCV-RNA was detected in all HCV+ patients with titers ranging from 4.32 x 105 genome equivalents/ml to 140.48 x 105 genome equivalents/ml. Low-titer HCV-RNA (<1.5 x 25 genome equivalents/rnl) was detected in 15 of 30 saliva samples from highly viremic patients; however, it is not possible to exclude the possibility of contamination of the saliva by the bleeding of the erosive lesions. RNA extracted from oral epithelial cells tested negative for HCV-RNA. Moreover all saliva samples tested negative for secretory IgA anti-HCV. The PCR for virus C was negative in the HCV- group in all specimens (serum, saliva~ and epithelial cells). In this group also the test for secretory IgA anti-HCV was negative. Conclusions. The absence of detectable HCV-RNA in oral epithelial ceils and detectable IgA anti-HCV in saliva specimens of patients with OLP indicated that HCV is not actively propagating in the oral mucous tissues of our patients. The relationship between OLP and hepatitis C is probably not restricted to a specific etiologic agent. ICHTHYOSIS VULGARIS AND ORAL LESIONS: A CLINICAL AND HISTOPATHOLOGICAL STUDY IN TWO BROTHERS.

Giovanni Maria Gaeta, Department of Oral Medicine II, University of Naples, Italy. Ichthyosiform dermatoses are a heterogeneous group of hereditary disorders all of which are characterized by the accumulation of large amounts of scale on the cutaneous surface. It is possible to distinguish on clinical appearance, histologic findings, and genetic background four different dermatoses: ichthyosis vulgaris (IV), X-linked ichthyosis, lamellar ichthyosis, and epidermolytic hyperkeratosis. IV, the most common of these disorders, begins early in childhood. It is transmitted as an autosomal dominant trait. Often there is family history of dry skin. The incidence of IV is approximately 1 per 300 persons. The lesions involve the extremities and the trunk; the foreheads and cheeks, as well as the scalp, are also frequently involved. Flexural surfaces appear normal. Sometimes there are associate findings such as urticaria, asthma, hay fever, eczema, and atopy. The disorder is lifelong; it

is exacerbated in cold, dry weather and improves in the summer. One etiopathogenetic hypothesis in IV is the absence of filaggrin, which correlates with the lack of keratohyaline granules histologically. This absence could increase adherence of the stratum corneum cells to each other and reduce the hydration of the stratum corneum as the basic protein is broken down to materials of low molecular weight that bind water. The oral lesions are normally related to the reduction of movements of the arms and hands because of the stiffness of the skin. It is therefore possible to find lesions that are associated with reduction of the normal hygiene procedures, such as dental caries and parodontopathy. Sometimes it is also possible to find an amelogenesis imperfecta. In this report we present the cases of two brothers, age 2 and 5 years, in whom the lesions were absent at birth; IV manifestations began at about three months. There was no evidence of the disease in the parents, but one of the grandmothers had a history of dry and scaly skin. The patients show severe involvement of the extensor surfaces of the extremities and trunk and involvement of the forehead, cheeks, and scalp. Hyperkeratosis of the palms and soles is present. Flexural surfaces appear normal. The history for atopy and asthma was positive. The oral lesions are characterized by severe caries with the loss of the teeth crowns, and it is also possible to recognize the signs of amelogenesis imperfecta. All lesions are more accentuated in the 2-year-old. Biopsy specimens were taken from the skin of the legs with a small (6 mm) biopsy punch. Histologic examination shows the absence of the granular layer and an augmentation of the corneum stratum. INTRAORAL PSORIASIS: A CASE PRESENTATION AND REVIEW. D. K. Fleming, R. Gier, C. G. Cumming, School of

Dentistry, University of Missouri-Kansas City, Mo. Psoriasis is a chronic inflammatory skin disease affecting 1% to 2% of the population and is usually discovered during the second or third decade of life. Clinically, psoriasis is characterized by erythernatous papules and plaques covered with fine silvery scales, and it may be found on any part of the body. This presentation describes the clinical and histologic characteristics and management of a case of intraoral psoriasis. A 78-year-old woman appeared for treatment with a chief complaint of a burning sensation of the tongue. She also complained of cutaneous psoriasis affecting the limbs, which had been present for a period of 7 years. On examination the patient's tongue manifested a red, depapillated, glossy dorsal surface that was interrupted by a fine, shiny network of white lines and patches. An incisional biopsy was performed; it led to a diagnosis of intraoral psoriasis. Treatment with Lidex (fluocinonide 0.05%) for 1 month resulted in significant improvement. The literature relating to this uncommon condition will be reviewed. MANAGEMENT OF ORAL MUCOUS MEMBRANE PEMPHIGOID: A RETROSPECTIVE STUDY OF THE USE OF DAPSONE. K. Ciarracca, M. S. Greenberg, Universi~. of

Pennsylvania Department of Oral Medicine, Philadelphia, Pa. The use of dapsone as the most effective first-line therapy for ocular lesions of cicatricial pemphigoid is well documented in the literature. There are few data, however, regarding the response of oral lesions of mucous membrane pemphigoid to dapsone. The

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Volume 85, Number 4 purpose of this study was to analyze the effectiveness of dapsone to treat oral lesions of mucous membrane pemphigoid. Patients and Methods'. We reviewed the charts of 29 patients who were referred to the Department of Oral Medicine between 1993 and 1997 and subsequently diagnosed with mucous membrane pemphigoid by routine histologic examination and direct immunofluorescence. Seventeen of the patients were followed for at least 6 months and qualified for the study; this group consisted of 15 women and 2 men ranging in age from 17 to 86 years (mean age, 62.5 years). All 17 patients had desquamative gingivitis. In addition, nine had buccal mucosal lesions, two had nasal lesions, and two had vaginal lesions. The disease severity of each patient was graded on a scale from i to 4: I represented localized disease; 2, generalized desquamative gingivitis; 3, multiple sites or moderate disease; and 4, generalized severe disease. According to his or her response to treatment, each patient was also assigned to one of the following groups: complete resolution, significant reduction (75% improved), partial response (50% improved), and unchanged. Complications to dapsone were also recorded. Results. Five patients with moderate disease were treated with topical steroids alone; in two of these patients there was complete control of lesions, and in three control was partial. Eleven patients with moderate to severe disease were treated initially with topical steroids, with minimal improvement. Dapsone therapy (75-175 mg daily) was then added after a G6PD screen and a baseline hemoglobin were taken. Seven (64%) of these 11 patients had a total resolution of the lesions, whereas 4 (36%) experienced significant improvement (>75% resolution). A major complication to dapsone therapy is a decrease in hemoglobin. Among the 11 patients the decrease in hemoglobin ranged from 1.8 to 4.7 gin% (mean, 2.96 gin%). Two patients had to discontinue dapsone because of signs or symptoms associated with anemia, although G6PD was normal. Conclusions. In this group of patients with moderate to severe mucous membrane pemphigoid, dapsone caused significant to complete remission of oral lesions. A larger study that is underway includes the use of vitamin E to decrease dapsone-related anemia. PRIMARY SJOGREN'S SYNDROME IN MEN: CLINICAL AND SEROLOGIC FEATURES. M. T. Brennan, P. C. Fox, NIDR/NIH,

Bethesda, Md. Primary Sjtgren's Syndrome (SS) is an autoimmune exocrinopathy mainly affecting the salivary and lacrimal glands. Xerostomia and xerophthalmia result from disease to these exocrine glands. Extraglandular manifestations may also occur in patients with SS; these include organ-specific disease, tissue-specific disease, monoclonal gammopathies, hematologic and serologic abnormalities, and mediator-induced disease. Primary SS affects women to men at a ratio of 9:1. Differences in clinical and laboratory features for men and women with SS have been examined by 3 groups. Collectively the results from these 3 studies do not provide uniform findings; it is thus difficult to draw conclusions with respect to whether actual gender differences exist in SS. The purpose of the current study was to examine the clinical and serologic characteristics of 12 men with primary SS, compare them to the characteristics of 24 women with primary SS, and then compare these findings to those of previous studies that evaluated gender differences in primary SS. Patient information was collected from patients with primary SS at the National Institutes of Health Salivary Gland Dysfunction Clinic from 1987 to 1997.

A total of 12 male patients were diagnosed during this period. The control group consisted of 24 female patients matched according to focus score of the labial minor salivary gland biopsy. Results. In terms of glandular manifestations, men had significantly (p = 0.05) lower stimulated submandibular salivary flow (men, 0.002 ml/min/gland; women, 0.042 ml/min/gland), but there were no gender differences in stimulated parotid salivary flow. A significant (p = 0.01) gender difference was noted in extraglandular manifestations, with more women than men reporting fatigue (71% vs 25%, respectively). Other extraglandular manifestations did not demonstrate gender specificity. Women also had significantly higher anti-nuclear antibody and rheumatoid factor titers than men. Although other parameters such as anti-SSA, anti-SSB, sedimentation rate, IgG, IgA, and IgM failed to achieve statistically significant differences between men and women, the women tended to have more extensive systemic involvement. The current study indicates that women may have more positive serologic findings than men; this is in agreement with earlier work. The current study also found a higher prevalence of fatigue in women; this has not been reported previously. No gender differences could be established with other extraglandnlar manifestations of SS. Inconsistent reports of extraglandular manifestations in studies evaluating gender differences may be due to small patient samples. Analysis of a large number of male patients with SS would more clearly establish possible gender differences in extraglandular manifestations. FURTHER EVALUATION OF DEBACTEROL FOR THE TREATMENT OF RECURRENT APHTHOUS STOMATITIS. N. L. Rhodus,

J. Bereuter, University of Minnesota, Minneapolis, Minn. Recurrent aphthous stomatitis (RAS) is a common condition. Current treatment for RAS includes anti-inflammatory and other agents that palliate the symptoms. The purpose of this continuing clinical trial was to further compare two topical medications used for RAS treatment, Debacterol (D) and Kenalog-in-Orabase (KO). Continuing an investigation previously reported by this taboratory (JDR, 1997; abstract no. 3487), the present study involved the comparison of a larger subject population of 40 persons (n = 20 [14 female and 6 male; mean age, 37.3 years] in each treatment arm) with a control population (n = 20). After the diagnosis of RAS, a clinical examination of each subject was performed; this involved measurements of ulcer size (×4) as well as a subjective evaluation of symptoms (VAS). The subjects did not use any other medications. Both agents were applied topically (the frequency varied depending on the arm of the subject) in specified intervals. Ulcer size and erythema measurements and subjective (100-ram VAS) evaluations of pain were made at days 0, 3, 6, and 10. The results indicated that 100% of the ulcers clinically healed and caused no pain in both groups by day 10. A significant decrease in the VAS in the D group at 3 days indicated a significant improvement in pain (>70% reduction) in comparison with the KO group. After day 6, 70% of the ulcers had clinically disappeared, with no symptoms in the D group as compared to 30% in the KO group. In some subjects in the KO group there was a decrease in the clinical measures over the D group, but the VAS revealed no significant change. These results indicate significant relief of symptoms accompanying RAS with the application of D, which may or may not correspond to clinical improvement. MULTIFOCAL ORAL PIGMENTATION LEDTOTHE DIAGNOSIS

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OF HIV INFECTION. K. H. M. Behjat, R. E. Geir, UKMC School

of Dentistry. Progressive hyperpigmentation of the skin and oral mucosa have been reported in patients with HIV. In many such cases the cause could be identified as adrenocortical deficiency or the use of medications; in some seropositive HIV cases, the cause of hyperpigmentation onset remains undetermined. The purpose of this report is to present a case of multifocal oral pigmentations that provided a basis for the diagnosis of HIV infection. A 49-year-old woman appeared for treatment at the emergency clinic of the UMKC School of Dentistry complaining of severe pain and swelling in the left mandibular region. Dental examination revealed that the source of the pain was the mandibular left second molar, which was severely decayed and had a large periapical lesion radiographically. Intraoral soft tissue examination showed a bilateral multifocal reacular pigmentation on the patient's buccal mucosa and soft palate and on both lips. She was unaware of the existence of these areas of pigmentation and their onsets. Her medical history was positive for hysterectomy, gall bladder surgery, and high blood pressure, which had been controlled with a dally dose of 50-mg Atenolol. A history of possible causative factors, such as adrenocortical deficiency, HIV, AIDS, or having taken medications to which the pigmentations could be attributed, was not reported by the patient. After treatment of her dental infection, the patient consulted with her physician. Clinical signs of Addison's disease--weakness, weight loss, hypotension and abdominal pain--were not identified. HIV-associated pigmentation is microscopically characterized by basilar melanin pigment with incontinence into underlying submucosa. The patient declined our request to have a biopsy specimen taken from a pigmented area of the buccal reucosa. A review of the patient's medical history, along with the proper medical tests, will help to establish a diagnosis of progressive pigmented conditions. These measures will permit differentiation between idiopathic acquired pigmentation and pigmentation that is caused by hormonal disturbances, chronic inflammation, or use of medication. STOMATOLOGIC AND SKELETAL FINDINGS IN FABRYANDERSON'S SYNDROME. L. Baccaglini, M. T. Brennan, 1-I. E.

Lancaster, J. S. Brahim, NIH-NIDR, Bethesda, Md. Fabry-Anderson's syndrome, also known as angiokeratoma corporis diffusum, is an X-linked metabolic disease caused by the deficiency of the lysosoreal enzyme c~-galactosidase A. The deficit of this catabolic enzyme causes a progressive accumulation of glycosphingolipids in multiple organs. There have been only a few reports in the literature that describe the oral findings associated with this syndrome. The purpose of this study was to identify oral and extraoral findings in a group of patients with Fabry-Anderson's syndrome to facilitate the early recognition and proper treatment of subjects affected by this condition. Methods and Materials. The subjects were 13 patients seen at the National Institutes of Health. They were 11 white and 2 Hispanic men, age 21 to 51 years (mean age, 36 years). Data were collected by means of a questionnaire, clinical examinations, panoramic and cephalometric radiographs, and magnetic resonance images of the head. The SNA, SNB, and ANB cephalometric angles were calculated for 8 subjects. Results. Numerous hard and soft tissue abnormalities were noted frequently. All dentate subjects without histories of orthodontic treatment had malocclusion; diastemas, particularly among

the anterior teeth, were present in 5 of these 7 persons. Maxillary and/or mandibular prognathism with secondary skeletal class I, II, and III abnormalities was seen on 6 of the 8 cephalograms. Anomalies of dental development and eruption were found in 23 % of the cases; these included a retained primary incisor, a second molar irepaction, and a history of delayed eruption. Vascular abnormalities were common; telangiectasias of the labial, buccal, alveolar, and/or palatal movable mucosa were seen in 77% of the cases, lntraoral and/or perioral angiokeratomas were found in 8 of the 13 subjects; in one subject the angiokeratoreas extended to the gingiva. The dorsal surface of the tongue had generalized (23%) or localized (62%) fissuring; the fungiform papillae appeared erythematous in 69% of the subjects. Single or multiple mucous retention cysts of the maxillary sinuses were seen in 38% of the patients. Conclusions. To our knowledge the increased prevalence of recurrent mucous retention cysts of the maxillary sinuses and the presence of maxillary prognathism in Fabry-Anderson's syndrome have not been previously reported in the literature. Given the high prevalence of oral and dental abnormalities, we recommend a thorough stomatologic evaluation of these patients. ORAL LESIONS AND MORTALITY IN MINORITY CHILDREN WITH H U M A N IMMUNODEFICIENCY VIRUS INFECTION.

Winston Patrick Kuo, Andrei Barasch, UMDNJ Dental School Division of Oral Medicine, New Jersey. HIV infection in pediatric populations is of public concern; it is reported that an estimated 10 million children will be born infected by the year 2000. Oral manifestations are common in HIVinfected patients and were reported to predict disease progression and related mortality. The purpose of this longitudinal project was to study the prevalence of oral soft tissue lesions in a racial-minority, HIV-infected pediatric population and assess the prognostic value of these lesions for disease-related mortality. One hundred five HIVinfected minority children were enrolled in a 3-year study. Each child was evaluated for oral soft tissue lesions at baseline and at 6-month intervals by two experienced oral medicine clinicians. Oral lesions were noted in 68 (64.8%) of the patients, Twentyseven (25.7%) patients died during the course of the study; of these, 11 (40.7%) were diagnosed with various oral lesions. Significantly fewer lesions were diagnosed in the deceased group than in the surviving group (p < 0.002). Oral candidiasis was the most frequent lesion type diagnosed in the whole population (n = 27); it was followed by linear gingival erythema (n = 23), median rhomboid glossitis (n = 13), necrotizing gingivitis (n = 4), and parotitis (n = 1). All of these lesion types had similar frequencies in both the deceased and surviving groups of children. However, conventional gingivitis (n = 14) was diagnosed only in the surviving group (p < 0.02). These data suggest that oral lesions, particularly conventional gingivitis in HIV-infected children, may be associated with increased survival and that the absence of oral lesions may in fact represent immunologic abnormalities (low CD4 count) rather than a state of relative health. CASE REPORT OF AIDS PATIENT PRESENTING WITH "SUSPICIOUS" LESION ON LIE J. Pannebaker, V. Meeks, University of

Maryland. Current research regarding renal transplant patients on potent immunosuppressive therapy is showing this population to be at a

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Volume 85, Number 4 significantly greater risk of developing squamous cell carcinoma of the lip, as well as oral lesions such as hairy leukoplakia and candidiasis. Whereas the causation of oral squanlous cell carcinoma (SCC) is multifactorial, actinic damage appears to be a pri= mary cause of SCC of the lip. Infection by certain fungi and viruses has also been implicated. Exposure to sunlight and tobacco use are respectively the first and second most important risk factors in the increased incidence of SCC of the lip in the immunosuppressed renal transplant patient. It is unclear whether these malignant changes are directly related to the medications or are rather a result of drug-induced immunosuppression. However, as one researcher explains, the "purposeful" immunosuppression of the long-term solid organ transplant survivor can be compared to the HIV-induced immunosuppression of the long-term AIDS survivor with respect to the development of malignancies. SCC of the lip usually occurs in the fifth to eighth decade of life; its earlier appearance in the immunocompromised patient may indicate a link between immunosuppression and SCC. Previous research has stated that although there is no increased incidence of SCC in HIV-infected individuals, it has been reported to appear to occur more frequently than expected in the third decade of life in HIVinfected homosexual men. This case presentation describes a 35year-old HIV+ man who appeared for treatment at an urban dental school clinic for comprehensive dental, care. The patient had

been diagnosed with HIV disease 2 years before initial presentation; a history of hepatitis B and a functional heart murmur were the only other significant findings of the medical history. His social history included heavy cigarette smoking and substance abuse; he denied any current substance use or abuse. During the clinical examination, the dentist questioned the patient about a 0.6 x 0.5 cm crusty, ulcerated lesion on the right side of his lower lip. The patient stated that he had ftrst noticed the lesion 2 years previously after an episode of chapped lips and that as a result of continuously "picking" at the area with his fingers the lesion had never healed completely. The patient also felt that the lesion was growing. A wide excisional biopsy was performed. The biopsy diagnosis was byperorthokeratosis and moderate dysplasia. Epithelial dysplastic changes were consistent with premalignant changes. Continued monitoring of the oral mucosal tissue in this patient is essential. Further study and data collection in this area is warranted to determine whether a relationship exists between HIV-induced immunosuppression and SCC. Findings regarding "AIDS-related" and "immune suppression therapy-related" oral cancer indicate not only that oral soft tissue examinations should be completed on a regular basis by dental professionals on every immunosuppressed patient but also that biopsies of suspicious lesions may need to be performed for the sake of identifying early oncologic changes.