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ABSTRACT: Interventional carbon dioxide laser surgery is the preferred method to treat oral precancerous lesions and early invasive squamous cell carcinomas (SCCs). Little is known, however, about the complications that patients experience after such treatment. We retrospectively reviewed the hospital records of 82 patients with new dysplastic oral lesions or early invasive oral SCCs treated by laser surgery in the maxillofacial unit at Newcastle General Hospital. The most common postoperative complications were pain for more than two weeks after operation (n=28), bleeding (n=4), difficulties with speech (n=5), paraesthesia of the lingual nerve (n=17), difficulty swallowing (n=2), obstructive swelling of the submandibular gland (n=22), and tethering of the tongue (n=10). Overall, 78% of patients had one or more complication. In the absence of randomised controlled trials, this study provides the best available evidence for complication rates following interventional surgery. In addition to aiding in the preoperative counselling of patients, the data will help to inform and advise patients particularly during the immediate postoperative period.
British Journal of Oral and Maxillofacial Surgery 01/2012; 50(7):597-600. · 1.95 Impact Factor
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ABSTRACT: Management of oral precancerous lesions remains polarised between interventional surgery and conservative treatment. We have previously shown the efficacy of carbon dioxide laser excision for both diagnosis and treatment of oral precancerous lesions. The aim of this study was to review the clinicopathological details of a group of patients in whom pre-existing but occult invasive carcinoma was diagnosed histopathologically in specimens excised by laser. We retrospectively reviewed 169 patients who attended the Maxillofacial Dysplasia Clinic at Newcastle General Hospital with single, new oral premalignant lesions over a 5-year period (2004-2008). They were all treated by laser excision of lesions that were confirmed to be dysplastic from examination of preoperative incisional biopsy specimens. There was a significant correlation between the results of diagnostic incisional, and laser excision, biopsy specimens (p < 0.01), but 15 patients had signs of occult invasive carcinoma in the excision specimens (9%). In all cases the carcinomas were completely excised by the laser. Carbon dioxide laser excision is not only an effective treatment of precancerous lesions, but also facilitates early diagnosis and management of oral carcinoma at a stage when it is otherwise clinically undetectable.
British Journal of Oral and Maxillofacial Surgery 03/2011; 49(2):88-91. · 1.95 Impact Factor
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ABSTRACT: Dental practitioners will encounter patients who have been affected by cancer or who are current cancer patients. Dentists play an important role in the overall healthcare of such patients, particularly in those with head and neck malignancy. This paper gives an overview of the impact of cancer and its treatment on dental management.
British dental journal official journal of the British Dental Association: BDJ online 07/2010; 209(2):65-8. · 1.09 Impact Factor
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ABSTRACT: Alcohol is known to be a risk factor for oral precancerous lesions, but evidence has been weakened by subjective estimates of alcohol intake from patients, and confounded by their use of tobacco. Red cell macrocytosis, assessed by calculation of mean corpuscular volume (MCV), may be a useful objective indicator of chronic alcohol intake. The aim of this study was to compare subjective and objective measures of alcohol intake in patients with oral precancerous lesions and assess the use of reported alcohol intake and MCV on assessing the degree of dysplasia at presentation and their role as markers of the behaviour of such lesions by assessing clinical outcome after treatment. Fifty-four new patients were recruited. All were smokers and had histologically confirmed single dysplastic oral precancerous lesions, but had had no previous treatment. Subjective data about their alcohol consumption were recorded, and blood samples taken for the assessment of MCV. All patients had laser excision of their lesions, which were assessed histopathologically for signs of dysplasia. Patients were followed up for 2 years. The significance of differences was assessed using Fisher's exact test. Alcohol intake of more than 28 units/week and MCV of over 100 were associated with increased dysplasia at presentation (p=0.01 and p=0.03, respectively). Thirty-six patients were disease-free at 2 years, but 18 developed further disease, often at new sites. Alcohol intake of more than 28 units/week was significantly associated with an increased risk of further disease (p=0.03), particularly recurrence at the same site (p=0.02).
British Journal of Oral and Maxillofacial Surgery 12/2009; 48(7):507-10. · 1.95 Impact Factor
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British dental journal official journal of the British Dental Association: BDJ online 11/2009; 207(9):407-8. · 1.09 Impact Factor
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ABSTRACT: Oral precancerous lesions may be solitary or multifocal, the latter being difficult to manage because of extensive field change. The aim of this study was to characterise differences in clinicopathological features, proliferative labelling indexes for cyclin A, cyclin B1, and Ki67, and clinical outcome 5 years after laser resection in a group of patients presenting with single and multiple oral precancerous lesions. Ninety-six patients with 132 lesions (78 single and 18 multiple) were recruited, and there were no significant differences between those with single and multiple lesions with respect to age, sex, smoking, or alcohol consumption, although multiple lesions were significantly more common in smokers who ate little fruit and vegetables (p=0.02). Clinically, most lesions were leukoplakia, with ulcerated or exophytic lesions appearing singly. There were significant differences in site, single lesions being most common on the floor of the mouth and the ventrolateral tongue, and multiple lesions preferring the buccal mucosa (p=0.0002). The most severe dysplasia was seen in single lesions (p=0.001) with labelling indexes for cyclin A and Ki67 being significantly higher in these (p=0.04 and p=0.01, respectively). Oral squamous cell carcinoma developed in 3/78 single lesions and 4/18 multiple ones. There are distinct differences between single and multiple lesions that have implications for the prophylaxis and management of oral cancer.
British Journal of Oral and Maxillofacial Surgery 10/2009; 48(7):503-6. · 1.95 Impact Factor
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ABSTRACT: Although the benefits of CO(2) laser surgery in oral precancer management have been evaluated, little consideration has been given to the factors which may influence treatment outcome, especially amongst patients developing recurrence or malignant transformation.
Seventy eight patients (51 males, 27 females; mean age 57.8 years) undergoing CO(2) laser excision of single, new dysplastic oral precancer lesions (OPLs) were followed up for a minimum of 2 years and the influence of clinico-pathological parameters, socio-demographic factors and the presence or absence of residual dysplasia in excision margins upon clinical outcome were examined.
Seventy three percent of patients were smokers and 78% consumed alcohol regularly. The majority of lesions were leukoplakias arising in the floor of mouth and ventro-lateral tongue and moderate or severe dysplasia accounted for 86% of histopathological diagnoses. Patient follow up ranged from 24 to 119 months (mean 58 months). Sixty four percent of patients were disease free at most recent clinical follow up, whilst 32% developed local recurrent dysplasia or new site dysplasia with 4% developing oral squamous cell carcinoma (but at sites distinct from their initial OPL). Excision margins were clear in 55% of cases, but 19% showed mild, 21% moderate and 5% severe dysplasia on histopathological examination. No statistically significant associations were seen between patients' age, gender, lesion appearance, site of origin, histopathological grading, presence of dysplasia in resection margins, or alcohol consumption and clinical outcome. Smokers, however, were at significantly higher risk of dysplasia recurrence compared to ex-smokers or non-smokers (P = 0.04).
In the absence of agreed treatment protocols for OPLs, we recommend CO(2) laser surgery as an effective treatment modality offering precise lesion excision, full histopathological assessment, minimal post-operative morbidity and a 64% disease free clinical outcome. Regular patient follow up is encouraged due to the persistence of field cancerisation effects.
Lasers in Surgery and Medicine 02/2009; 41(1):17-25. · 2.75 Impact Factor
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ABSTRACT: Prediction of the behaviour of oral precancerous lesions (OPLs) is unreliable in clinical practice. The aim of this study was to analyse the efficacy of cell cyclin markers A and B1, and the proliferative marker Ki67, in predicting clinical outcome for patients with OPLs. A cohort of previously-treated patients with single OPLs were retrieved from the MaxilloFacial Dysplasia database and reviewed. All had dysplastic lesions excised by laser and were followed up for 5 years post-treatment. Outcome was determined as no recurrence or further disease. Excision specimens were re-examined immunohistochemically and labelling indices (LIs) for cyclin A, B1 and Ki67 determined. Forty patients, aged between 31 and 91 years, were recruited. There were no differences in age or sex. OPLs were predominantly leukoplakias on the floor of mouth or ventro-lateral tongue (65%), most of which exhibited moderate or severe dysplasia. Cyclin A LIs ranged from 3.9% to 31.3%, B1 0 to 28.3% and Ki67 3.5% to 54.5%. Using median LIs as 'cut off points' (12% cyclins; 22% Ki67) Kaplan-Meier survival analysis showed a significant risk of further progression of disease in patients with OPL LIs exceeding median values (Cyclin A p=0.02, Cyclin B1 p=0.01, Ki67 p=0.025). By combining analysis of both Cyclin A and B LI, the significance of the difference was increased (p<0.01). Cell cycle analysis is effective in identifying patients at risk of further progression of disease following treatment of OPLs. Multi-centre, longitudinal trials are needed to assess the precise role of cell cycle markers in their management.
British Journal of Oral and Maxillofacial Surgery 08/2008; 46(5):370-5. · 1.95 Impact Factor
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ABSTRACT: To assess and observe the development of competence in oral surgical skills during a 3-year undergraduate programme.
Over a 3-year period 75 students were followed through from the beginning of their clinical course to their Bachelor of Dental Surgery graduation and their surgical experience monitored by the use of logbooks. Their development of competence was assessed objectively through structured assessments and subjectively by a single tutor responsible for each year. Assessments were made of their ability in exodontia, pre-surgical assessment and the surgical extraction of teeth/roots.
Seventy-three students completed the course (97%). Successful completion rates for the objective testing were 100% for both exodontia and pre-surgical assessment. The surgical assessment, (surgical extraction of a tooth or root) had a successful completion rate of only 23% and the caseload for students was low with a mean of four teeth removed surgically upon graduation. Relationships were examined between total numbers of teeth extracted, total number of minor oral surgical procedures completed and the successful completion of the surgical competence assessment, but no significant relationships were found.
This study demonstrates that it is possible to achieve objectively measurable levels of competence in undergraduates undertaking oral surgery procedures. It is however, a labour and time intensive process and appropriate clinical and teaching resources are required. National co-operation towards agreed standardised competencies should be encouraged to allow data to be pooled and more powerful analyses to occur.
European Journal Of Dental Education 12/2007; 11(4):200-7. · 1.18 Impact Factor
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ABSTRACT: Smoking is the commonest risk factor for oral cancer and precancer. The objective of this study was to characterize smoking behaviour and attitude in a cohort of oral precancer patients in Newcastle upon Tyne, UK, and to determine changes in behaviour during diagnosis, treatment and follow-up. Twenty-seven consecutive, smoking patients with dysplastic oral lesions were recruited to the study and a detailed smoking history obtained, quantifying types and numbers of cigarettes smoked, length of smoking history, and changes in smoking behaviour during treatment episodes and long-term follow-up. All patients underwent an interventional management protocol comprising risk-factor education, histopathological diagnosis by incisional biopsy and laser excision of lesions. Patients were followed up for 5 years. Whilst there was a significant decrease in the number of cigarettes smoked at patients' most recent follow-up compared with initial presentation (p<0.001), 74% continued to smoke. Patients received advice from a smoking cessation adviser on support available to them from the local NHS (National Health Service) Stop Smoking services. Six out of 10 patients who set a 'quit date' and attended a programme had quit at the 4-week follow-up but only 5 remained non-smokers. Smoking remains a considerable problem in oral precancer patients even after interventional treatment, with the risk of further precancerous lesions and malignant transformation.
International Journal of Oral and Maxillofacial Surgery 08/2007; 36(8):706-11. · 1.51 Impact Factor
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ABSTRACT: Field cancerisation within the oral cavity risks multiple primary tumour development. Whilst multi-focal disease may ultimately affect up to 24% of oral cancer patients, a particular management problem is encountered with those patients presenting with pan-oral dysplasia. In an attempt to characterise the extent of dysplasia and to quantify the risk of malignant change, examination under anaesthesia (EUA) and multiple, 'field mapping biopsies' were carried out for 16 consecutive patients presenting with pan-oral disease. Seventy lesions, predominantly homogenous leukoplakias, were biopsied primarily showing hyperkeratosis or mild dysplasia histologically. More significant dysplasia was seen to affect the faucial pillars, floor of mouth and ventral tongue. Interventional CO(2) laser surgery was used to excise 11 severely dysplastic lesions in six patients. Field mapping appears effective in the initial identification and treatment of the most significant areas of dysplasia in patients with multi-focal precancer. Longitudinal, multi-centre trials are now required.
Oral Oncology 02/2007; 43(1):20-6. · 2.86 Impact Factor
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Oral Oncology Supplement 01/2007; 2(1):141-141.
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ABSTRACT: Accurate, predictive assessment of the behaviour of oral cancers and precancers remains elusive. Increasing dysregulation of cell proliferation is a feature of carcinogenesis, and alterations in cyclin proteins regulating cell cycle progression are involved in enhanced cell proliferation. The authors of the present study have previously demonstrated increased proliferative activity in oral dysplastic lesions and poorly differentiated carcinomas, and hypothesize that cell proliferation can be used as a predictive agent in clinical management. In this preliminary study, immunohistochemical quantification of cyclin A expression was carried out for 33 excised oral lesions (ranging from mild dysplasia to invasive squamous cell carcinoma, SCC). Clinical outcome was determined as: no disease after 2 years follow-up, persistent disease, or further disease presentation. Labelling Indices (LIs) ranged from 5.5 to 32.1%, and whilst a trend to increased labelling in increasingly dysplastic and neoplastic tissue was seen, this was not statistically significant (P=0.06). High LIs were related to poor clinical outcome (P=0.003), suggesting a definite role for cyclin A measurement as a predictive tool in clinical management.
International Journal of Oral and Maxillofacial Surgery 12/2006; 35(11):1041-6. · 1.51 Impact Factor
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ABSTRACT: The objective is to investigate whether sedation techniques for oral surgery can be improved by combining the use of inhalation of nitrous oxide/oxygen with intravenous Midazolam. Prospective, randomized controlled clinical trial: Patients requiring extractions or surgery were randomly allocated to subgroups receiving either intravenous Midazolam or nitrous oxide/oxygen or a combined technique using nitrous oxide/oxygen and intravenous Midazolam. Safety parameters, amount of sedative agents administered, recovery time and co-operation scores were recorded. Patients receiving the combined sedation technique were initially titrated with 10% nitrous oxide, increasing by increments of 10% up to a maximum of 40% nitrous oxide and 60% oxygen. Midazolam was then titrated (initially 2 mg wait 2 min with increments of 1mg every minute until appropriately sedated) whilst still administering 40% nitrous oxide. When a combined technique of N(2)O/O(2) and Midazolam was used there was a statistically significant reduction in the amount of Midazolam required to achieve effective sedation (P<0.001), an overall significant reduction in recovery time (P<0.001) and a significant improvement in co-operation (P<0.01) and arterial oxygen saturation (P<0.001). This combined technique was found to be safe and reliable, requiring reduced doses of Midazolam and demonstrable improvement in patient recovery and co-operation.
International Journal of Oral and Maxillofacial Surgery 06/2006; 35(6):522-7. · 1.51 Impact Factor
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ABSTRACT: Regional variations in the incidence of oral cancer may be related in some cases to material deprivation. The main aim of this study was to identify in cases (and controls matched for age and sex) an index of material deprivation, employment history, smoking and alcohol habits. This prospective study comprised 100 subjects in each group and was questionnaire based. Previous studies in relation to material deprivation in oral cancer have been population based. There was a statistically significant trend for patients to come from the most deprived groups. Sixty-six per cent of the cases had experience of long-term unemployment. Although a high proportion, this was not statistically significant after multi-variable analysis due to the confounding effects of smoking and alcohol use. Such a high proportion of cases with a history of long-term unemployment requires further study to examine in detail if there is a definite link with oral cancer once the confounding effects of smoking and alcohol are removed.
International Journal of Oral and Maxillofacial Surgery 03/2003; 32(1):74-7. · 1.51 Impact Factor
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ABSTRACT: Computer simulation has been carried out to help to determine the cell-proliferative mechanisms underlying data gathered from a double-labelling experiment on the dorsal tongue of the mouse. Good fits to the data have been obtained by assuming that there is a high degree of synchrony in the stem cells, which have a 24-h cell cycle time, and that daughters of these cells undergo two further divisions, with mean cell cycle times of 48 h, before differentiating. This results in one-seventh of proliferative cells being stem cells, which ties in well with the concept of epidermal proliferative units. There is no need to assume that S-phase duration changes diurnally. The administration of epidermal growth factor seems to increase the degree of synchrony. In such systems, the influx to S-phase and the efflux from it have very sudden short peaks, which it is impossible to observe unless observations are taken very frequently. There are therefore implications for the designs of experiments that attempt to study diurnal rhythms or the effect of factors that disturb the normal proliferative pattern of cells.
Cell Proliferation 09/2002; 35 Suppl 1:68-77. · 2.52 Impact Factor
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ABSTRACT: Accurate, predictive assessment of the behaviour and progression of oral cancers and precancers remains elusive in clinical practice. Archival tissue specimens from 10 previously treated patients with oral lesions of known clinical outcome (3 years post-treatment) were re-examined histopathologically, and proliferative cell labelling indices (LIs) determined for Ki67, cyclin A and histone mRNA cell cycle markers. While histone mRNA labelling ultimately proved unreliable, both Ki67 and cyclin A LIs demonstrated a clear trend for enhanced labelling to occur in increasingly dysplastic and neoplastic tissue, with particular emphasis on suprabasal labelling in abnormal tissue. Perhaps of greatest significance was the observation of increased LIs and suprabasal labelling in lesions with poor clinical outcome, such as patients developing recurrent disease or cervical lymph node metastasis. Measurement of cell proliferative activity in individual oral epithelial dysplastic lesions or invasive squamous cell carcinomas may thus provide unique, predictive information on clinical outcome.
Cell Proliferation 09/2002; 35 Suppl 1:110-20. · 2.52 Impact Factor
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P J Thomson
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ABSTRACT: Patients with oral squamous cell carcinoma (OSCC) are at risk of developing second or multiple primary cancers as a result of field cancerization in the upper aerodigestive tract. In order to quantify the incidence of field change observable in oral mucosa, 26 consecutive new (untreated) patients presenting with a unilateral OSCC (18) or a premaligant lesion (eight) underwent 'mirror image' biopsies from clinically normal-looking mucosa at corresponding anatomical sites. A total of 15 patients (58%) demonstrated histologically abnormal tissue upon microscopic examination: six showed reactive change/cellular atypia associated with chronic irritation, seven exhibited frank dysplasia, whilst two displayed carcinoma-in-situ (CIS) or microinvasive SCC. Although not statistically significant, there was an observable trend for the lateral/ventral tongue and floor of mouth to display increased vulnerability to dysplastic change.
International Journal of Oral and Maxillofacial Surgery 07/2002; 31(3):262-6. · 1.51 Impact Factor
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ABSTRACT: Invasive oral squamous cell carcinomas (OSCCs) are often preceded by precancerous lesions, the management of which remains controversial, polarized between active surgical excision to try to prevent malignant change or more conservative, medical or observational techniques. In order to determine the efficacy of interventional CO2 laser surgery in oral precancer management, the records of 57 consecutive laser-treated patients presenting over a 4-year period, with histologically confirmed dysplastic lesions, were reviewed. Leukoplakias were the commonest clinical lesions (69%), whilst the floor of the mouth was the most frequent anatomical site (42%). Laser surgery successfully excised 55 precancerous lesions, 11 of which exhibited more severe dysplasia or neoplasia compared with initial biopsy. Postoperative scarring and morbidity were minimal. After surgery, patients were followed for between 1 and 44 months (mean 18 months). Of these patients, 76% remained disease-free, whilst 24% developed new dysplastic lesions at distinct or multiple sites, often exhibiting increased dysplasia. Of the patients experiencing recurrence, 7% developed OSCC, whilst a further 3.5% presented with other aerodigestive tract cancers. Neither initial lesion appearance nor histological diagnosis predicted clinical behaviour. Interventional laser surgery is thus advised, in contradistinction to conservative management of oral precancers, to facilitate efficacious, low-morbidity treatment and to establish definitive histological diagnosis. As a consequence of field change carcinogenesis, regular follow up of treated precancer patients is mandatory for effective tertiary prevention.
International Journal of Oral and Maxillofacial Surgery 05/2002; 31(2):145-53. · 1.51 Impact Factor
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ABSTRACT: Samples (110) of human mandibular gingiva and buccal mucosa, harvested from patients undergoing third-molar surgery, were subjected to in vitro labelling with tritiated thymidine, bromodeoxyuridine, or a sequential double-labelling technique comprising tritiated thymidine followed by bromodeoxyuridine, in order to determine the efficacy of a new incubation labelling technique, and to characterize S-phase labelling indices in human oral mucosa. Whilst, there were no demonstrable differences in labelling indices obtained by single thymidine, single bromodeoxyuridine or double labelling, there was a significant difference between anatomical sites, with higher S phase labelling observed in buccal mucosa (mean LI 11.7) than mandibular gingiva (mean LI 8.5; P<0.01). There was, however, no significant correlation between individual labelling indices and patient age, sex or the time of day when tissue was harvested. The in vitro labelling technique provides a reliable and quantifiable method of characterizing proliferative labelling indices in the human oral cavity. Further investigation is being carried out to profile wider age and anatomical ranges and to utilize the double-labelling technique to calculate S-phase durations and cell-cycle times. These profiles may have a future role in the assessment of oral mucous membrane disease.
Archives of Oral Biology 01/2002; 46(12):1157-64. · 1.60 Impact Factor
