Abstracts of papers presented at the American Academy of Oral Medicine Annual Meeting, Clearwater, Fla., April 27–30, 1994

Abstracts

of papers presented at the American Medicine Annual Meeting, Clearwater, 1994

PAROTID PRESERVATION USING 3-DIMENSIONAL TREATMENT PLANNING IN HEAD AND NECK CANCER PATIENTS. Ship J, Jones R, Hazuka M. University of

Michigan School of Dentistry, University of Michigan Department of Radiation Oncology, Ann Arbor.

Permanent salivary gland dysfunction is a frequent complication of patients receiving head and neck irradiation. The parotid gland is a radiosensitive organ, and previous studies have demonstrated a doseresponse relatisonship between residual function after irradiation and1treatment volume. A new therapeutic modality (3-dimensional treatment planning) was developed that conforms the high-dose radiation volume to the shape of the tumor volume while minimizing irradiation to normal structures. Eighteen patients with unilateral head and neck tumors were entered into the study. Unstimulated and 2% citratestimulated bilateral parotid salivary gland flow rates were measured before radiation therapy, weekly during treatment, and 1, 3, 6, and 12 months after completion. The average total dose of radiation to tumor sites was 57 Gy (range 47-67), whereas the average dose to untreated sides was 3.5 Gy (range, 1.3 to 7.1). Data are available from eight persons who have underga’ne a 6-month postradiation evaluation. Salivary flow rates from treated glands decreased on average 99.6% (unstimulated) and 91% (stimulated) compared to pretreatment values. Conversely, average unstimulated flow rates from spared glands decreased only ll%, and stimulated flow rates increased 25%. These preliminary data suggest that the use of 3-dimensional treatment planning can help preserve contralateral parotid gland function in patients who receive radiation therapy for unilateral head and neck cancers. MUCOCUTANEOUS CYTOMECALOVIRAL ULCERS IN AIDS PATIENTS: A CLINICOPATHOLOCIC CORRELATION,, Flaitz C, Nichols CM, Hicks MJ. University of

Texas Health Science Center-Dental Branch; Bering Dental Clinic; Baylor College of Medicine-Houston.

Mucocutane.ous ulcerations in patients with human immunodeficiency virus represent a variety of disease entities. The purpose of this study was to characterize the clinical and microscopic features of oral ulcerations associat’ed with cytomegalovirus in AIDS paORAL

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tients. Thirty-one males (29 homosexuals, 1 heterosexual) with a mean CD4 count of 50/mm3 and an average of 2.8 ulcers/patient were included in this study. A single representative ulcer was biopsied from each patient. H&E, PAS, AFB and immunocytochemistry stains for cytomegalovirus (CMV) and herpes simplex virus (HSV) were performed on tissue sections. The most common sites of involvement were the buccal/labial mucosa (26%), tongue (26%), and gingiva (22%). The mean ulcer size was 1.9 cm in greatest dimension. The mean duration for the ulcers at the time of presentation was 6.4 weeks. Pneumocystic carinii pneumonia, candidiasis, and CMV were the most common opportunistic infections in this patient group. The majority (84%) of CMV-associated ulcers could be diagnosed on routine H&E stains. Combined CMV/HSV infection occurred in 35.5% of ulcers. Most pat.ients had been empirically treated with steroids or acyclovir before biopsy and were nonresponsive to this therapy. Treatment response to ganciclovir with or without topical steroids resulted in lesion resolution; however, recurrence or resistance was relatively high at 24%. In conclusion, CMV is associated with persistent mucocutaneous ulcers in AIDS patients that respond well to ganciclovir therapy but are difficult to differentiate from other ulcerogenie diseases, including aphthous major and necrotizing stomatitis without microscopic examination. ROLE OF INTRALESIONAL VINBLASTINE ADMINISTRATION IN TREATMENT OF INTRAORAL KAPOSI’S SARCOMA IN AIDS. Nichols CM, Flaitz CM, Hicks MJ.

Bering Dental Clinic, University of Texas Health Science Center-Houston, Baylor College of Medicine-Houston.

The purpose of this clinical study was to determine the effect of intralesional vinblastine administration on intraoral Kaposi’s sarcoma (KS) in AIDS patients. A total of 144 KS lesions in 50 HIV-positive homosexual males (mean CD4 count 64/mm3) were treated periodically with intralesional vinblastine injection (0.1 mg/cm’) until lesion resolution or no further reduction in lesion area. The most frequent lesion sites were: palate 56% (hard palate 42%, soft palate 14%), gingiva 22% (maxillary 15%, mandibular 7%), and maxillary tuberosity 6%. Mean lesion area was 4.6cm2 MEDICINE

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(range, 0.1 to 35cm2). Complete resolution occurred in 13.6% (mean follow-up period, 14.1 weeks). Mean reduction in lesion area was 93% for all lesions. Lesions with only a partial response (26.4%) to vinblastine had a mean reduction in lesion area of 68.8%. Mean number of treatments was 2.4 (range, 1 to 6). Recurrence rate was 25.7% (mean disease-free period, 12.9 weeks). Recurrence rates were highest with purple macular lesions with focal nodularity (40.5%) and purple macular lesions (35.2%). No recurrences occurred with red macular lesions with focal nodularity. Most frequent complications were transient pain (72%), superficialmucosalulceration (22%), and transient parathesia (12%). Intralesional vinblastine administration produced complete resolution in a substantial number of intraoral KS lesions and represents a well-tolerated treatment regimen for localized control of intraoral KS lesions. Because of a 25% recurrence rate, reevaluation is necessary for treatment of recurrent and new Kaposi’s sarcoma lesions. A PHASE !/II NONBLINDED DETERMINE THE EFFICACY TO PREVENT ORAL MUCOSlTlS CONDITIONING REGIMEN TRANSPLANTATION Marc

LZED TRIAL TO -ENERGY LASER ULTINC FROM

coli-Filho WD, Lloid ME, Kelly J, Franquin JC, Hamdi M, Peterson D, Labbe R. Fred Hutchinson Cancer Research Center and University of Wushington, Seattle; Faculte D’OdontoEogie Laboratoire IMEB, Marseilles; Fradama, S.A., Geneva; and University of Connecticut, Farmington

Recent reports have implied that low energy laser (LEL) can reduce the severity and speed up the healing of oral mucositis associated with cancer therapy. We conducted a nonblind open Phase I/II pilot study to determine .the effects of LEL light (632 nm HeNe) on oral mucositis as a result of conditioning regimen toxicity and methotrexate. Seven patients were randomized to receive HeNe low-energy laser therapy. Patients were treated with laser therapy once a day starting on day 7 pre-bone marrow transplantation (BMT) through day 0 (total of seven.) During each laser session, six sites were treated: lower labial mucosa, upper labial mucosa, right buccal mucosa, left buccal mucosa, lateral surface of tongue, and ventral surface of tongue/floor of the mouth. Examinations for mucositis of the treated areas were done on days 0, 2, 5, 7,9, 11, 14, 18, 21 (*one day) post-BMT by personnel other than laser therapist. LEL subjects were then compared with a historic age/disease/ medical treatment matched control group. During after LEE therapy no apparent oral toxicities or adverse effects attributable to laser therapy were

noted. The mean mucositis score for HeNe laser was 22.0 on 53 mucositis examinations versus 29.7 on 110 mucositis examinations for the control group. There was a consistent trend for patients treated with laser to have lower mucositis scores on all exam days, and there was a distinct trend for patients to report less pain than controls on all days. Work to confirm these preliminary results is currently ongoing. THE EFFECT OF TUMOR NECROSIS FACTO INTERFERON--/ ON THE GROWTH OF A DUGAN SALIVARY GLAND CELL LINE. Wu AJ, Kurrasch RH, Katz

J, Fox PC, Baum BJ, Atkinson JC. CIPCB/NlDR/ NIH, Bethesda, Md.

Interferon-y (IFN-y) is a product of activated T-lymphocytes, and tumor necrosis factor-a (TNF-a) is a product of both lymphocytes and macrophages. These cell types are often present at sites of tissue damage as a result of chronic inflammation or autoimmune disease. Sjogren’s syndrome (SS) is an inflammatory autoimmune disease that is characterized by a progressive inflammatory infiltrate of the salivary glands, loss of acinar secretory epithelium, and ultimately diminution of secretory function. We and others have hypothesized that IFN-7 and TNF-a may play a role in the pathogenesis of SS by means of upregulation of surface proteins such as intracellular adhesion molecule type- 1 (ICAM- 1) and histocompatibility antigen (HLA-DR) that can exacerbate the inflammatory process. As it is currently not possible to reliably maintain acinar or ductal epithelial cells in primary culture for extended periods of time, we have chosen to work with a cell line obtained from an histologically benign submandibular gland that had been irradiated. The human submandibular cell line (HSG) has been widely studied and is thought to be derived from the intercalated duct region of the submandibular gland. Cells from this region are believed to be pluripotential with the ability to give rise to other glandular cell types. In principle, if the proliferative abilities of this cell type were impaired, it would follow that the long-term integrity of the gland would be compromised. This represents another potential means by which cytokines could be involved in the exocrinopathy of SS. The purpose of this study was to characterize the ability of TNF-a and IFN-7 to affect the growth and surface molecule expression of the HSG cell line. Ten thousand cells per we11were plated on 12 well tissue culture plates. Growth of these cells was monitored daily for up to 15 days by determining total cell number and viability, using a hemocytometer and the 0.4% trypan blue exclusion test. IFN-7 caused a dra-

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Volume 78, Number 6 matic, dose-dependentdecreasein cell number. HSG cell growth was reduced -70% by day 6. TNF-a had little (effect on the growth of these cells; a slight dose effect was seen1 on day 3 only. A combination of cytokines (20 U/ml TNF-a! and 1000 U/ml of IFN-7) resulted in a decreasein cell number that was significantly greater than that predicted from cells treated with each cytokine. The antiproliferative effect of IFN-*y alone
Armstrong R, Khalifa A. Faculty of Medicine, University of Western Ontario and Victoria Hospital, London, Ontario, Canada Only eight casesof multifocal adult rhabdomyoma have previously been reported. We present a ninth case of this exceedingly rare tumor, which in this instance was a bilateral multifocal recurrence of a previousl:y diagnos#edsolitary adult rhabdomyoma. The patient was a ‘71-year-old retired machine operator with multiple massesin his neck. Fourteen years before this visit, he had been diagnosed with benign rhabdomyoma in this area. Since that time, these masseshad increased in size and were now involving both sides of the upper neck. The submandibular gland was displaced anteriorly by a tumor coming from above. Thle tumor had the appearance and the

consistency of engorged thyroid tissue, was not encapsulated, and bled profusely on incision. Histologic staining included H & E and PAS with and without diastase. These showed that the tumor was a benign adult rhabdomyoma composed of polygonal cells of varying sizes with small peripherally placed nuclei and occasional intracellular vacuoles filled with glycogen. Immunoperoxidase for actin, myoglobin, and S-100 confirmed that the tumor was of muscle origin. Electron microscopy showed abundant mitochondria with linear cristae and glycogenfilled vacuoles. There were also structures consistent with myofilaments, exhibiting condensation of disorganized Z-band material. There is a number of interesting similarities among casesof multifocal adult rhabdomyoma reported in the literature. All have occurred in older patients, ranging in age from 59 to 82 years; our patient was 71. Our patient was white; all other cases that reported racial data also reported white patients. All cases,including ours, occurred in males. Finally, every casehas occurred in the anterior neck, oropharynx, or oral cavity, areas of branchial arch origin. These intriguing similarities point to an emerging pattern that will slowly gain detail as more casesof this exceedingly rare tumor are reported. SELF ESTEEM AND DAILY HASSLE STRESS ASSESSMENT IN FEMALES SUFFERING FROM TMD. AZ-Khatib AQ,

Fotos PG, Logan HL, Jackobson JR. University of Iowa College of Dentistry, Iowa City. Temporamandibular joint syndrome and myofacial pain (TMD) is due to multifactorial causes,and psychological factors are suspected to be particularly important in many cases.The majority of casesaffect females (3:l) in the 3rd to 5th decade of life. Previous research has suggested positive correlations between chronic TMD and critical attitudes towards self and coping with daily hassles(DH). Becausein some cases stress may be a precipitating factor, past research has investigated personality traits that may identify those personspredisposedto developing such symptoms. Low self-esteem (SE) and DH may contribute to stress through a person’s attempts to: maintain unrealistically high standards, tolerate deviations from some standard, interpret specific failures as reflective of one’s self-worth (self criticism), and deal with specific stressful daily events. Inadequaciesin SE and difficulties encountered in daily life can produce inordinate amounts of stressthrough perceptions of loss of control. Women suffering from chronic TMD (group 1) were asked to complete a confidential survey including questionson SE and DH (N = 79). An age-matched control population of

Abstracts women with no history of TMD (group 2) completed the same survey (N = 29). Although some differences were found between groups for total SE, these were not significant. However, group 1 desired significantly more control over DH when compared with group 2 (P < 0.04). That data suggest the need for further investigations into the premise that SE and DH may be important in women with TMD. If these studies are supported by expanded studies underway, it may prove beneficial to include psychological intervention with current TMD therapies to improve attitude toward self and Goping with daily stress as alternatives to psychotherapeutic drugs. IDIOPATHIC ATROPHIC CHEILITW ME: A SUBSET OF BURNlNG MO

Brown RS, Flaitz CM, Hays GL, Bottomiey WK. UTHSCH-DB, Howard University, Houston, Tex. and Washington, D.C. Purpose. A prospective study was undertaken to evaluate an intraoral pain disorder characterized by burning lips, atrophic secondary salivary glands, and a particular histopathologic appearance consistent with sialoadenitis. Methods. Six patients were referred to the stomatology clinic of the University of Texas Health Science Center at Houston, Dental Branch for evaluation and management of an oral condition associated with burning mouth/lips. Medical histories, oral examinations, laboratory and histopathologic tests were obtained or performed. Clinical and histopathologic assessments helped to define the condition. Medications were prescribed in an attempt to develop a treatment regimen. Treatment was evaluated with the use of patient response to alternative treatment approaches. Patients either presented with blood studies or were referred back to their physicians for general baseline blood studies. Patient progress and an assessment of pharmacotherapeutic therapy was evaluated on follow-up patient visits and progress reports by telephone. Results. The mean age at presentation was 65.2 years with a standard deviation of 10.5 years of age. The study population consisted of three males and three females, five whites and one black. Clinically, there was decreased function of the secondary salivary glands on all the subjects. 0ne patient was noted for a positive reaction to Sjogren’s syndrome antigen B. One patient was noted for borderline decreased T3 (thyroid) uptake. All other blood studies were within normal limits. The treatment regimen consisted of topical corticosteroid therapy. Treatment outcomes were generally favorable with all patients reporting improvement.

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Conclusion. A condition separate from burning mouth syndrome with specific clinical and histopathologic characteristics has been presented. Future investigations are in order. PREVALENCE OF HIV I TERMINED BY ELISA. Ghufar KAA, Cutler CW, Brown

RS. University of Cairo, University of Texas-DentaE Branch, Cairo, Egypt and Houston, Tex. Purpose. The purpose of this study is to detect the prevalence of HIV among Egyptian dentists from 1988-89 with the use of ELISA blood studies. Methods. Five groups of 100 persons each representing final-year dental students, and dentists with 0 to 5, 5 to 10, 10 to 15, and more than 15 years of practice experience were evaluated for NIV. Three mls of blood was collected from each subject, and serum was separated and frozen until evaluated with ELISA with the use of the technique described by Weiss et al. (1985). Social, drug, and health histories were taken on all subjects. The Abbott Recombinanat HIV assaywas used (Abbott Laboratories, Chicago, Ill.) Results. In all five groups, no antibodies were detected against HIV infection. There were zero cases of HIV found among the 500 dental students/de~t~sts in the study population. As detected by the guideline questionnaire, 90% of the study group were not following any international protective infectious disease guidelines. Discussion. Dentists are among the health care workers at risk for occupational exposure to HIV infection. This is especially so in Egypt where bare fingers often expose dentists to blood and saliva. In a study of Egyptian dentists, the exposure rate for hepatitis B virus among 104 dentists was determined to be 31.7% (El-Refai and El-Shawy, 1987) Other surveys of dental and medical healthcare workers also demonstrate a low incidence of HIV infection, (Klein et al., 1988; Weiss et al., 1985; Marcus et al., 1993; Tokars et al., 1992) Conclusion. The negative findings among Egyptian dentists demonstrate a low incidence of HIV infection within a particular population of dentists at a particular time. Moreover, the relative risk of infectivity from patients to dentists appears low even in an environment with less than rigorous infection control procedures. HEALTH SURVEY OF A UNIVERSITY DENTAL EMERGENCY CLINIC PATIE T POPULATION. Johnson CD,

Eaught KS, Brown RS, Koh S. University of TexasHouston., Dental Branch and School of Public Health. Purpose. The purpose of this study was to survey a university emergency dental clinic patient population

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Volume 78, Number 6 with respect to ASA (a measure of physical health) status, age, gender, ethnicity, blood pressure levels, dental diagnoses,and dental treatment. Methods. A survey was distributed to fourth-year dental students treating emergency patients from August 1, 1993 to October 30, 1993. Surveys were completed and returned to one of the investigators (C.D.J.). Surveys were evaluated with respect to ASA status,,age, gender, ethnicity, blood pressurevalues, diagnoses,and treatment. Survey data were entered onto alLOTUS 123 spreadsheetprogram with regard to percentages and linear regression analysis. Results. From a total population of approximately 800 elmergencypatients seenduring the study period, 442 (55.3% of the population) surveys were returned with acceptable completeness(age, ASA status, gender, and ethnicity) and 334 were returned with further information including blood pressure values, diagnosesand treatment. Demographics were as follows: ASA status, 73.5% ClassI, 20.9% ClassII, 4.8% Class III, 0.9% Class IV; gender, 57.5% female, 42.5% male; ethnicity, 61.3% whites, 18.3% Hispanics, 15.6% blacks, and 3.1% Asian. Age was considered as continuous variable. Mean ages(and SD) are as follows: AS14 classification and age, 34.6 ( f 14.6) years for ASA I; 47.0 (+ 17.4) years for ASA II; 48.7 (+ 13.4) years for ASA III; 4’7.5 (? 7.9) years for ASA IV; gender, -36.8 (+ 15.3) years for males and 38.8 I(? 16.7) years for females. Mean ages for all ethnicity classifications ranged from between 34.9 to 39.3 years with large standard deviations. The diagnostic catagorilesand percentageswere asfollows: (1) reversible pulpitis, 9.8%; (2) irreversible pulpitis, 47.7%; (3) tooth-non-pulpal (such as periodontitis), 9.5%; (4) other, 22.6%; and (5) trauma, 0.3%. The treatment categories and percentageswere asfollows: (1) pulpectomy, 17.6%; (2) extraction, 54.8%; (3) seditive restoration, 18.0%; (4) periodontal therapy, 1.9%; (5) other, 5.4%; (6) occlusal adjustment, 1.9%; and (‘7) no treatment, 0.4%. Hypertensive categories (as defined by The Joint National Committee on Detection, Evaluation, and Treatment of High Blood Pressure [JNC V], 1993) and percentages were as follows: (1) normal, 53.7%; (2) high-normal, 17.9%; (3) mild, 23.8%; (4) moderate, 3.3%; (5) severe, 1.3%; (4) very severe, 0%. The only positive correlation that was revealed by linear regression analysis was an expected relationship between diastolic and systolic values in which R2 was equal to 0.35. Conclusions. The vast majority of emergency patients seenat the UT Dental Branch emergency clinic are in relative good -health. The majority of the emergency patient population accepted the treatment of tooth extractiosn.

Abstracts 741 ORAL ULCERS IN HIV-INFECTED PATIENTS: A STUDY OF 42 CASES Piluso S, Ficarra G, Eversole LR, Orsi

A, Lucatorto F, UCLA, Florence, Italy. Introduction. Oral ulcers of various origin are often described in HIV-infected patients. We evaluated 42 HIV-positive subjects with oral ulcers. Possibly etiologic factors and clinical characteristics of these lesionsare discussed. Methods. A thorough oral exam was performed in all patients. Cultures for viruses, bacteria, and fungi were taken in 39 patients, biopsies from the lesions were obtained in 20 patients in whom deep longstanding or treatment-resistent ulcers were observed, in situ hybridization was performed in 10 cases.In the absenceof histologic examination, a presumptive diagnosiswas made on the basisof the clinical appearance, location of ulcers, culture results, and treatment response. Results, Patient’s median age was 34 years, CD4 T-cell level ranged from 3 to 454 with a median of 2 1 cells/mm3. Aphthous-like ulcers were observed in 18 patients (43%) and herpetic ulcers in 18 patients (43%). Among patients with oral herpetic ulcers, the contemporary presence of two herpes-group viruses were reported in five cases.Aphthous-like ulcers occurred on nonkeratinized mucosa in 77% of cases, herpetic ulcers on keratinized mucosain 78% of cases. Four personshad non-Hodgkin’s lymphoma. Atypical ulcers were expression of Kaposi’s sarcoma and lues maligna in two patients. Major ulcers (> 10 mm) were observed in 18 patients, multiple ulcers in 14 patients. Severe pain was a common symptom. Discussion. Oral ulcers in HIV patients may be a diagnostic and therapeutic challenge to the clinician because of multifactorial causes.Biopsies should be performed on severe and long-standing ulcers to exclude rare infections or tumors. SEROTYPE AND ANTIFUNGAL SUSCEPTIBILITY-RELATED DIFFERENCES IN ORAL CANDIDA ALBICANS ISOLATES FROM TWO IMMUNOSUPPRESSED POPULATIONS: A PILOT STUDY. Hovan A, Schubert M.

Department of Oral Medicine, University of Washington and Fred Hutchinson Cancer Research Center, Seattle. Methods. Oral C. albicans isolates were collected from 32 bone marrow transplant (BMT) patients pre-BMT, weekly from day 0 until ANC > 1000, and at day 80 post-BMT. Isolates were also collected bimonthly from 32 HIV patients with T4 <500. All isolateswere sero’typedwith Iatron antiserum. In vitro antifungal susceptibilities of selected “early” and “late” isolatesfrom each group were determined to a panel of four antifungal agents (amphotericin-B

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(AmB), 5FC, fhrconazole (FLZ), and ketoconazole (KTZ)) and results compared with isolates from healthy controls. Results. It appears that serotype carriage is similar in immunosuppressedand immunocompetent personsand that simultaneous carriage of both serotypes is not uncommon in both BMT and HIV patients. Infections were more often due to type B candida (27 of 50) in HIV patients and were significantly higher in patients with T4 <200 (p = 0.005). Infections in MT patients were most common during the period

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of profound neutropenia (ANC < 1000). Isolates obtained from healthy controls did not differ in MICs or MFCs from early isolates obtained from HIV and BMT patients. Serotype A and B strains appear similar in susceptibility to AmB, FLZ and KTZ. Treatment with azole antifungals may increase resistance to AmB in BMT patients (p = 0.09). IIIV patients showed a trend toward KTZ resistance over time (p = 0.07). Serotype B strands showa significant rate of innate resistance to 5-FC in all populations, most significantly in the WIV group 0, = 0.002).