Nonsyndromic cleft palate only (nsCPO) is a facial malformation that has a livebirth prevalence of 1 in 2,500. Research suggests that the etiology of nsCPO is multifactorial, with a clear genetic component. To date, genome-wide association studies have identified only 1 conclusive common variant for nsCPO, that is, a missense variant in the gene grainyhead-like-3 (GRHL3). Thus, the underlying genetic causes of nsCPO remain largely unknown. The present study aimed at identifying rare variants that might contribute to nsCPO risk, via whole-exome sequencing (WES), in multiply affected Central European nsCPO pedigrees. WES was performed in 2 affected first-degree relatives from each family. Variants shared between both individuals were analyzed for their potential deleterious nature and a low frequency in the general population. Genes carrying promising variants were annotated for 1) reported associations with facial development, 2) multiple occurrence of variants, and 3) expression in mouse embryonic palatal shelves. This strategy resulted in the identification of a set of 26 candidate genes that were resequenced in 132 independent nsCPO cases and 623 independent controls of 2 different ethnicities, using molecular inversion probes. No rare loss-of-function mutation was identified in either WES or resequencing step. However, we identified 2 or more missense variants predicted to be deleterious in each of 3 genes (ACACB, PTPRS, MIB1) in individuals from independent families. In addition, the analyses identified a novel variant in GRHL3 in 1 patient and a variant in CREBBP in 2 siblings. Both genes underlie different syndromic forms of CPO. A plausible hypothesis is that the apparently nonsyndromic clefts in these 3 patients might represent hypomorphic forms of the respective syndromes. In summary, the present study identified rare variants that might contribute to nsCPO risk and suggests candidate genes for further investigation.

This chapter discusses a selection of genetic syndromes associated with structural heart disease sorted by type of genetic alteration, with specific exposition of dysmorphology, cardiac and noncardiac phenotype, and their genetic testing. In addition it discusses the arrhythmia prone long-QT syndromes.

Purpose: Advanced or recurrent intraorbital sarcomas usually result in mutilating operative procedures. An interdisciplinary group of brachytherapy, head & neck surgery, neurosurgery, and ophthalmology experts formed a team for performing successful treatments with visual function preservation. The long-term results were analyzed in terms of feasibility, outcome and toxicity.

Chronic infections of bone such as osteomyelitis are frequent events, especially in immunocompromised or diabetic patients, and costly on a national level. Incorrect treatment or delayed diagnosis may lead to loss of the affected extremity or mandible. The aim of this study was to assess the possible value of urinary lysylpyridinoline (LP) and hydroxylysylpyridinoline (HP) concentrations in the monitoring of mandibular osteomyelitis. Patients were assigned to the following groups: group 1 (n=85), control; group 2a (n=38), patients with active disease; group 2b (n=25), patients of group 2a 6 months after successful treatment; group 2c (n=7), patients of group 2a with ongoing osteomyelitis 6 months after treatment. The range and upper limit of normal values (HPmax and LPmax) were determined in group 1. Levels of LP and HP were measured by high-performance liquid chromatography and fluorescence detection. There was a significant decrease (mean 45.43% for HP and 32.12% for LP) in samples of group 2b compared to 2a (P<0.001 for HP and LP). There was a significant increase in HP values in samples from group 2c compared to 2a (P=0.018). The urinary concentrations of HP and LP appear to act as a marker of disease activity, with a decrease reflecting treatment success and an increase or stable values indicating persistent disease. An inexpensive tool (US$5 per analysis) for the monitoring of osteomyelitis is described.

The purpose of this study was to investigate the expression of human beta-defensins (hBD-1, -2) in dental pulps by reverse-transcription polymerase chain reaction (RT-PCR) and immunohistochemistry. The mRNA transcripts of human beta-defensin-1 and human beta-defensin-2 could be detected by performing RT-PCR. With immunohistochemical staining of pulp tissue using antisera to hBD-1 and -2 it was possible to demonstrate cytoplasmic expression in odontoblasts. The results demonstrate that not only oral keratinocytes at the epithelial surface but also odontoblasts express human beta-defensins. Thus odontoblasts take part in the innate immune system and human beta-defensins may play an important role in the innate host defense of human dental pulp.

To the Editor: We report a case of linear squamous cell papilloma of the oral mucosa associated with the sebaceous nevus syndrome in a 7-year-old boy. He had a linear sebaceous nevus on the right half of his face that did not cross the midline. He also had epileptic seizures. The sebaceous nevus extended from his forehead to the tip of his nose, continuing over the philtrum of the upper aspect of his right lip and across to the alveolar ridge in the region of teeth 12 and 13 (Fig 1). From here it continued onto the right side of his palate (Fig 2). A biopsy of the palatal lesion demonstrated mucosal squamous cell papilloma (Fig 3). Fig 2Linear papilomatous lesions representing intraoral manifestation of sebaceous nevus may be found in Schimmelpenning-Feuerstein-Mims (SFM) syndrome. They do not cross midline and may represent intraoral counterpart of Blaschko's lines of head and neck. Intraoral lesion involves right palate and alveolar mucosa (arrows) of boy with SFM syndrome. (View over mirrow.) View Large Image Figure Viewer Fig 3Biopsy specimen taken from palatal lesion shows squamous cell–derived papilloma. Sebaceous cells are absent on oral mucosa. (Hematoxylin-eosin stain; original magnification: ×250.) View Large Image Figure Viewer

Antimicrobial peptides, like human beta-defensins, play an important role in the epithelial innate defense response. The aim of the present study was to investigate the quantitative expression of human beta-defensin-1, -2, and -3 in inflammatory gingival diseases. Gingival biopsies were obtained from patients with healthy gingiva (n = 10), patients with gingivitis (n = 10), and patients with periodontitis (n = 10). The clinical diagnosis was verified by histology. Gingival tissues were used for RNA extraction followed by reverse transcription. Gene expression was quantified by real-time polymerase chain reaction (normalization with GAP-DH). Comparing the tissues with different clinical stages of health and disease, no significant differences in mRNA expression were found for any of the beta-defensins studied. Similar levels of expression were found in healthy gingiva, whereas in gingivitis samples there was a significantly higher expression of hBD-2 compared to hBD-1 (P = 0.004) and hBD-3 (P = 0.016). Likewise, in periodontitis samples, hBD-2 expression was significantly higher than hBD-1 (P = 0.016); however, hBD-2 expression was comparable to hBD-3. In conclusion, the results of the present study showed a differential expression of human beta-defensins (hBD-1, -2, -3) in tissues with inflammatory gingival disease.

Lysylpyridinoline (LP) and hydroxylysylpyridinoline (HP) are collagen crosslink residues of which the urinary concentration reflects the level of connective-tissue turnover. HP is ubiquitous in tissue, whereas LP is specific for bone. The purpose of this investigation was to assess the sensitivity and specificity of an increased urinary concentration of both HP and LP in indicating infiltration of mandibular bone by an oral squamous cell carcinoma (OSCC) or recurrence of the disease after successful therapy. We investigated the history and urine levels in 116 adult patients, who were divided into the following groups. Group 1: patients with OSCC with bone infiltration ( n =17); group 2: patients with confirmed OSCC ( n =12) without evidence of bone infiltration; group 3: patients with recurrence of an OSCC ( n =13); group 4: patients without clinical evidence of disease ( n =74). The range and upper limit of normal values (HP max and LP max ) were measured from the normal controls in group 4. Levels of LP and HP were measured by HPLC and fluorescence detection. There was a significant difference in the average urinary levels of LP and HP between groups 1–4 ( P <0.001). The presence of mandibular bone infiltration could be detected with a sensitivity and specificity of 100% when comparing groups 1 and 2. Presence of tumour tissue could be detected with a sensitivity of 90%. In conclusion, a normal LP concentration in patients with an OSCC strongly suggests that bone invasion by the disease has not taken place. If both urinary HP and LP are elevated, disease recurrence is highly likely.

Oral lichenoid reactions resemble oral lichen planus clinically and histologically and may arise in the vicinity of amalgam fillings, frequently. 108 out of 122 patients with oral lichenoid reactions were patch tested against a variety of dental materials. Patients were screened for cutaneous lichen planus by a dermatologist. The local relation of lesions to fillings in question was documented. 33 patients had positive patch test reactions to amalgam or inorganic mercury components. Amalgam fillings were replaced in 105 patients, which led to a benefit in 94 patients regardless of patch test results. In 31 patients lesions cleared completely, in 8 patients subtotally. An improvement was observed in 63 patients, no change at all in 3 patients. 17 patients refused replacement of amalgam fillings. In one of these patients lesions cleared subtotally while lesions remained unchanged in 16 patients. Amalgam removal had very little impact on intraoral lesions in patients with cutaneous lichen planus as compared to patients without cutaneous lesions. Oral lichenoid reactions may have a multifactorial etiology. We suggest that removal of amalgam restorations can be recommended in all patients with symptomatic OLR associated with amalgam fillings if no cutaneous LP is present.

BACKGROUND:The pathogenetic relationship between oral lichenoid reactions (OLR) and dental amalgam fillings is still a matter of controversy.OBJECTIVES:To determine the diagnostic value of patch tests with amalgam and inorganic mercury (INM) and the effect of amalgam removal in OLR associated with amalgam fillings.METHODS:In 134 consecutive patients 467 OLR were classified according to clinical criteria. One hundred and fifty-nine biopsies from OLR lesions were histologically diagnosed according to the World Health Organization criteria for oral lichen planus (OLP) and compared with 47 OLP lesions from edentulous patients without amalgam exposure. One hundred and nineteen patients were patch tested with an amalgam series. In 105 patients (357 of 467 lesions) the amalgam fillings were removed regardless of the patch test results and OLR were re-examined within a follow-up period of about 3 years. Twenty-nine patients refused amalgam removal and were taken as a control group.RESULTS:Eleven patients with OLR (8.2%) had skin lesions of lichen planus (LP). Histologically, the lesions in the OLR group could not be distinguished from those seen in the OLP group. Thirty-three patients (27.7%) showed a positive patch test to INM or amalgam. Amalgam removal led to benefit in 102 of 105 patients (97.1%), of whom 31 (29.5%) were cured completely. Of 357 lesions, 213 (59.7%) cleared after removal of amalgam, whereas 65 (18.2%) did not improve. In the control group without amalgam removal (n = 29) only two patients (6.9%) showed an improvement (P < 0.05). Amalgam removal had the strongest impact on lesions of the tongue compared with lesions at other sites (P < 0.05), but had very little impact on intraoral lesions in patients with cutaneous LP compared with patients without cutaneous lesions (P < 0.05). Patients with a positive patch test reaction to amalgam showed complete healing more frequently than the amalgam-negative group (P < 0.05). After an initial cure following amalgam removal, 13 lesions (3.6%) in eight patients (7.6%) recurred after a mean of 14.6 months.CONCLUSIONS:Of all patients with OLR associated with dental amalgam fillings, 97.1% benefited from amalgam removal regardless of patch test results with amalgam or INM. We suggest that the removal of amalgam fillings can be recommended in all patients with symptomatic OLR associated with amalgam fillings if no cutaneous LP is present.

The presence of an oral squamous cell carcinoma (OSCC) may be associated with increased urinary excretion of the markers of collagen degradation, hydroxylysylpyridinoline (HP) and lysylpyridinoline (LP). We investigated the possibility of these markers predicting the presence of active disease. Patients from a current study on HP and LP were included as follows: Group 1a (OSCC with confirmed mandibular bony infiltration, n =12), group 1b (group 1a patients >6 months after successful treatment), group 2a (OSCC without evidence of mandibular bone infiltration, n =8), group 2b (group 2a patients >6 months after successful treatment), group 3a (recurrent OSCC, n =8), group 3b (group 3a patients >6 weeks later, symptoms unchanged) and group 4 (control group, n =74). Tissue samples from tumour tissue and adjacent healthy mucosa were additionally investigated for HP and LP concentrations ( n =8). The decrease in the urinary concentrations of HP and LP was statistically significant between groups 1a and 1b ( P <0.001 for HP and LP), but not between groups 2a and 2b ( P =0.07 for HP and LP), while values in groups 1b and 2b were within the normal range. When comparing groups 3a and 3b, a significant increase was observed for LP ( P =0.050), but not HP ( P =0.208). In conclusion, successful treatment of OSCC with bony involvement may be associated with a reduction of urinary HP and LP, whereas ongoing disease may result in an increase of LP. HP and LP may both be useful markers of tumour progression in patients with OSCC.

BACKGROUND:In 97% of all patients with oral lichenoid reactions (OLR) associated with dental amalgam a removal of the fillings leads to a decline of the lesions, as a minimum.OBJECTIVES:The aim of this study was to determine if contact allergic or local toxic effects or both may contribute to OLR using an animal model with mercury-sensitive and non-sensitive rats.METHODS:Twenty Brown Norway rats, which have a genetic predisposition for an autoimmune syndrome after exposure to mercury and 20 Lewis rats, not mercury sensitive, were treated as follows: 10 animals of each group were sensitized with a low dose of mercuric chloride. Half of all animals received local exposure of the right buccal mucosa to amalgam (left: control), the others to amalgam alloy free of mercury. All rats were patch tested with an amalgam series.RESULTS:After 20 days of exposure 96% of all animals showed white mucosal lesions restricted to the contact zone of the alloy on the treated side, but only up to 25% had a positive patch test reaction to amalgam or inorganic mercury (INM). The lesions showed no relation to species, alloy, sensitization or patch test reaction.CONCLUSIONS:While allergic mechanisms may contribute to mucosal contact lesions in Brown Norway rats, this is less probable in Lewis rats. Mercury in general appears to be irrelevant in the development of ORL in this study. If this holds true for humans as well, patch testing with an amalgam series may be helpful in a minor fraction of all patients with OLR.

BACKGROUND:Unicystic ameloblastomas (UAs) and dentigerous cysts (DCs) have an identical clinical and radiographic appearance. Some subtypes of UAs have a better prognosis than solid or multicystic ameloblastomas, and simple enucleation is the adequate treatment. The present study was designed to test the hypothesis that UAs with small islands of ameloblastomatous epithelium may be misdiagnosed as a DC or keratocyst if no more than two histologic sections are examined. METHODS:A total of 101 resection specimens from 22 women and 73 men (mean age: 46.5 years) were selected, all showing the clinical and radiographic features of a DC. Only cysts with a minimum diameter of 15 mm in the panoramic X-ray were considered for the present investigation. The histopathologic diagnosis had been routinely established by examining two sections. For our study, the specimens were investigated by step sections at 50 microm and by staining of 5 microm thin sections with hematoxylin and eosin (H&E) at 1 mm levels. An average of 15 slides were evaluated per case. RESULTS:Microscopic examination of the step sections did not reveal ameloblastomatous epithelium in the cyst lining epithelium of the 101 cases. Thus, every primary diagnosis of a dentigerous cyst was confirmed. In four cases, additional rather large odentogenic cell nests were detected with palisading of basaloid cells, while there was a lack of other signs of ameloblastic differentiation. All lesions were completely resected, and no additional treatment was performed. CONCLUSIONS:Step sectioning of larger DCs may reveal associated odontogenic cell nests in some cases but does not lead to the detection of formerly missed ameloblastic cells. Thus, unicystic ameloblastomas are not misdiagnosed if only two slides are prepared for routine diagnosis of DCs.

Cerebriform giant melanocytic nevus of the scalp is an extremely rare malformation. Clinical appearance with maceration and fetor within the crypts and the risk of malignant transformation may require surgical therapy. We report two cases with different methods of surgical management. A 27-year-old woman noticed a swelling of the parietal scalp that developed over a period of 4 years into a gyrus-like tumor measuring 12 cm x 18 cm. The crypts between the gyri could not be inspected. Serial excisions under subcutaneous infusion anesthesia were performed to reduce the size of the nevus and to flatten the surface of the scalp. The second patient, a 26-year-old man, demonstrated a giant 10 cm x 10 cm cerebriform nevus on the occiput. The nevus also contained areas of fetid maceration. After implanting a tissue expander under general anesthesia the nevus was excised. The defect was closed using a rotation flap.

Hintergrund. Die sekundäre Kieferspaltosteoplastik (KSO) ist ein Kompromiss zwischen möglichst spätem Spaltverschluss und Schaffung eines optimalen Knochenangebots zum vollständigen Durchbruch des Eckzahns oder des seitlichen Schneidezahns. Ziel dieser Studie ist eine retrospektive Analyse des Konzepts der sekundären KSO, das in unserer Klinik kontinuierlich über 20 Jahre angewendet wurde. Die Zahlen werden mit sporadischen Fällen der tertiären KSO desselben Zeitraums verglichen.