Académique Documents
Professionnel Documents
Culture Documents
February 2016
Intraoral Lesions
Oropharyngeal Cancer
Oral Cancer Chemoprevention
C A L I F O R N I A D E N TA L A S S O C I AT I O N
ORAL CANCER:
NOVEL CONCEPTS
FOR THE ORAL
HEALTH CARE
PRACTITIONER
Diana V. Messadi,
DDS, MMSc, DMSc
You are not a sales goal.
Protecting dentists. Its all we do.
800.733.0633 | tdicsolutions.com | CA Insurance Lic. #0652783
Feb. 2016 C D A J O U R N A L , V O L 4 4 , N 2
D E PA R T M E N T S
F E AT U R E S
82 Oral Cancer: Novel Concepts for the Oral Health Care Practitioner
An introduction to the issue.
Diana V. Messadi, DDS, MMSc, DMSc
85 Managing Intraoral Lesions in Oral Cancer Patients in a General Dental Practice: An Overview
Patients with active cancer or a history of cancer may present with multiple side effects that dental practitioners
can manage or prevent. The authors discuss some of these concerns and provide management strategies.
Reuben Han-Kyu Kim, DDS, PhD; Paul Yang, BS, MS; and Eric C. Sung, DDS
F E B R U A R Y 2 0 1 6 71
C D A J O U R N A L , V O L 4 4 , N 2
CDA Classieds.
JournaC A L I F O R N I A D E N TA L A S S O C I AT I O N
Volume 44, Number 2
February 2016
Free postings. published by the Editorial Upcoming Topics Letters to the Editor
Priceless results. California
Dental Association
Kerry K. Carney, DDS, CDE
EDITOR-IN-CHIEF
March/Integrated Health
Systems
www.editorialmanager.
com/jcaldentassoc
1201 K St., 14th Floor Kerry.Carney@cda.org April/Changing Landscape
Sacramento, CA 95814 of Practice Subscriptions
Ruchi K. Sahota, DDS, CDE
800.232.7645 May/Student Research
ASSOCIATE EDITOR Subscriptions are available
cda.org only to active members of
Brian K. Shue, DDS, CDE Advertising the Association. The
CDA Ocers ASSOCIATE EDITOR Doug Brown subscription rate is $18 and
Kenneth G. Wallis, DDS ADVERTISING SALES is included in membership
PRESIDENT Diana V. Messadi, DDS, Doug.Brown@cda.org dues. Nonmembers can
president@cda.org MMSc, DMSc 916.554.7312 view the publication online
GUEST EDITOR at cda.org/journal.
Clelan G. Ehrler, DDS Permission and
PRESIDENT-ELECT Andrea LaMattina Manage your subscription
presidentelect@cda.org PUBLICATIONS SPECIALIST Reprints online: go to cda.org, log in
Andrea LaMattina and update any changes to
Natasha A. Lee, DDS Blake Ellington PUBLICATIONS SPECIALIST your mailing information.
VICE PRESIDENT TECH TRENDS EDITOR Andrea.LaMattina@cda.org Email questions or other
vicepresident@cda.org 916.554.5950 changes to membership@
Courtney Grant cda.org.
R. Del Brunner, DDS COMMUNICATIONS
Manuscript
SPECIALIST
SECRETARY
secretary@cda.org
Submissions
Jack F. Conley, DDS www.editorialmanager.
Kevin M. Keating, DDS, MS EDITOR EMERITUS com/jcaldentassoc
TREASURER
treasurer@cda.org Robert E. Horseman, DDS
CDA classieds work harder to HUMORIST EMERITUS
Craig S. Yarborough, DDS, Stay Connected cda.org/journal
bring you results. Selling a practice
MBA
Production
or a piece of equipment? Now you SPEAKER OF THE HOUSE
speaker@cda.org Val B. Mina
can include photos to help buyers SENIOR GRAPHIC DESIGNER
Walter G. Weber, DDS Go Digital cda.org/apps
see the potential. IMMEDIATE PAST PRESIDENT Randi Taylor
Look for this symbol, noting additional video
pastpresident@cda.org SENIOR GRAPHIC DESIGNER
content in the ePub version of the Journal.
And if youre hiring, candidates
anywhere can apply right from Management
Peter A. DuBois
the site. Looking for a job? You can EXECUTIVE DIRECTOR
Journal of the California Dental Association (ISSN 10432256) is published monthly by the
post that, too. And the best part California Dental Association, 1201 K St., 14th Floor, Sacramento, CA 95814, 916.554.5950.
Jennifer George
Periodicals postage paid at Sacramento, Calif. Postmaster: Send address changes to Journal
its free to all CDA members. CHIEF MARKETING OFFICER
of the California Dental Association, P.O. Box 13749, Sacramento, CA 95853.
Cathy Mudge The California Dental Association holds the copyright for all articles and artwork published
All of these features are designed to VICE PRESIDENT herein. The Journal of the California Dental Association is published under the supervision of
help you get the results you need, PUBLIC AFFAIRS CDAs editorial sta. Neither the editorial sta, the editor, nor the association are responsible for
any expression of opinion or statement of fact, all of which are published solely on the authority
faster than ever. Check it out for Alicia Malaby of the author whose name is indicated. The association reserves the right to illustrate, reduce,
COMMUNICATIONS revise or reject any manuscript submitted. Articles are considered for publication on condition
yourself at cda.org/classieds. DIRECTOR that they are contributed solely to the Journal.
72F E B R U A R Y 2 01 6
Assoc.
Editor
Editor C D A J O U R N A L , V O L 4 4 , N 2
W
hen was the last time
someone asked you,
How can I make Time and time again, organized
your life easier? dentistry has helped me be a better
It was incredibly
reassuring to hear this from a member of our leader and a better person.
CDA Executive Committee. She asked me
what CDA could do to ensure that parents
of young children, like me, felt supported
and able to serve in leadership positions at 9-to-5 schedule. At times, involvement Dr. Dugoni alluded to the many
our association. Long emails in paragraph in organized dentistry takes us away from benefits of getting involved in his speech.
form ensued. We discussed challenges, our normal day-to-day lives. Arthur A. But he repeatedly went back to the same
including difficulty attending face-to- Dugoni, DDS, MSD, dean emeritus of piece of advice. Dr. Dugoni reminded
face meetings while nursing a baby. We the University of the Pacific, Arthur A. us to smile. He reminded us to laugh as
re-examined processes that were already Dugoni School of Dentistry, recently much as possible. More often than not,
in place. We reviewed other options. spoke at CDA Presents in San Francisco. we smile and laugh when we are amongst
At the same time, she brought He encouraged attendees to step out of friends and family when we are with
a few other young mothers into the their comfort zone, saying, You have to those who wish us joy and happiness.
conversation. We swapped stories. We live beyond the nine-by-nine operatory We belong to a magnificent profession
strengthened connections. We confirmed and your high-speed handpiece. with some pretty amazing colleagues
that one thing that always makes a The volunteer life cycle starts off many of whom are kind, virtuous and
person feel better we confirmed that as we apply for positions in our dental ultimately inspirational. We will never
we were not alone. There were other society or maybe a CDA council. We know them unless we step outside
young mother CDA volunteers out there. may aim to represent our personal the comfort zone and get involved. We
In that moment, I realized organized demographic, voice our opinions will have more of a chance to follow Dr.
dentistrys sincere intentions to help. Here and share our experiences. Slowly Dugonis advice if we leave our nine-by-
was another tangible member benefit. This leadership in organized dentistry nine operatories. We will have more of
isnt anything new. Time and time again, enhances our ability to see. Within a a chance to laugh and smile when we
organized dentistry has helped me be a short period of time, volunteering starts connect with other dentists in organized
better leader and a better person. It giving back. Motivation seeps into dentistry. They will restore our sense
continues to renew its special place in my the consciousness. It makes us want of purpose in our profession. They will
heart. CDA has become like family. When to do better in our own offices. We connect with us, share their experiences
organized dentistry connected me to other are inspired to find ways to give back and inevitably remind us that we are not
young mother leaders, I was filled with to our communities at home. And we alone. There are others out there going
emotions. I felt relief there were others become more productive in our overall through many of the same challenges.
out there trying to balance work, family, lives. What started as a mission to serve And there are others out there who we
volunteerism, friends and all things life. I transforms itself into a generous gift. will meet through organized dentistry who
felt pride there were others out there Many may not apply for volunteer will offer to make your life easier.
trying to set an example of strength, poise positions because of the lack of monetary
and diligence for their little ones. And I compensation. Napoleon Hill said, The Ruchi K. Sahota, DDS, CDE, practices
felt support there were other dentists [wo]man who does more than [s]he is paid family dentistry in Fremont, Calif., and serves
from around the state willing to lend me for will soon be paid for more than [s]he as faculty at the University of the Pacific,
their time, experience and encouragement. does. Volunteer leadership gives us the Arthur A. Dugoni School of Dentistry. She
After almost 15 years of volunteering, opportunity to be a part of something is also a certified dental editor, a consumer
I can value how much it has given back to bigger than ourselves. Volunteering advisor for the American Dental Association,
my life. So it is natural to wonder: Why are involves us in the movement to bring past president of the Southern Alameda County
there not more young parents involved? positive change to the oral health of the Dental Society and a fellow of the American
Of course, it may be simpler to stay general public isnt that a part of the College of Dentists, International College of
within the confines of the office walls and Hippocratic Oath we take? Dentists and the Pierre Fauchard Academy.
F E B R U A R Y 2 0 1 6 73
You are the protector of the smile. You enable people to
laugh without shame, eat their favorite foods and experience
the dignity of aging with grace. Thats why this association
tirelessly advocates for the profession and stands up for those
in need of care. Because the world is a better place when
people are smiling, and thats thanks to you.
Renew today.
cda.org/member
Impressions C D A J O U R N A L , V O L 4 4 , N 2
F E B R U A R Y 2 0 1 6 75
F E B . 2 0 16 IMPRESSIONS
C D A J O U R N A L , V O L 4 4 , N 2
How Teeth Find Their Way to the Right Spot in the Jaw
Led by scientists at the University of The authors report that by
California, San Francisco, researchers combining lineage tracing, genetic cell
recently showed in mice that molar ablation and confocal live imaging,
progenitor cells migrate to their final they were able to identify a migratory
locations during development, rather population of Fgf8-expressing epithelial
than forming the teeth in place, as cells in the embryonic mandible.
researchers had previously thought. These findings are published in the
According to a news release from the journal Developmental Cell and suggest
university, this is the first time researchers that the progenitor cells that produce
have captured on video how teeth find other organs could also exhibit as-
their way to the right spot in the jaw. yet unrecognized wanderlust, and
F E B R U A R Y 2 0 1 6 77
F E B . 2 0 16 IMPRESSIONS
C D A J O U R N A L , V O L 4 4 , N 2
80F E B R U A R Y 2 01 6
C D A J O U R N A L , V O L 4 4 , N 2
F E B R U A R Y 2 0 1 6 81
introduction
C D A J O U R N A L , V O L 4 4 , N 2
GUEST EDITOR
O
Diana V. Messadi, ral cancer is a significant oral side effects that are associated
DDS, MMSc, DMSc, global health concern, with multiple cancer therapies.4
is a professor and chair
responsible for more This issue includes insightful
of the section of oral
medicine and orofacial than 600,000 new cases articles related to oral cancer emerging
pain and the associate per year worldwide and technologies in early intervention,
dean for education and approximately 42,000 annual incident potential therapies and dental
faculty development at the cases in the U.S. Most cases are diagnosed management of cancer survivors. The
University of California,
at a late stage, resulting in poor five- first article by Reuben Kim, DDS, PhD,
Los Angeles, School of
Dentistry. year survival rates between 30 and 60 Paul Yang, BS, MS, and Eric Sung, DDS,
Conict of Interest percent.1,2 Hence, the need is high for describes the most common oral effects of
Disclosure: None reported. early detection and development of new associated cancer therapies and discusses
management strategies to reduce the how general dental practitioners can
mortality and morbidity of late-stage manage and treat these conditions.
diagnosis.3 The disease burden of oral The increasing incidence of human
cancer is significant; patients require papillomavirus-positive head and neck
intensive multimodality treatments and cancers highlights the need to better
prolonged rehabilitation with long- understand the role of HPV in the
term support to achieve an adequate development of these cancers. Fariba
recovery. General dental practitioners Younai, DDS, focuses on the role of HPV
frequently encounter cancer survivors in head and neck cancer development
for their routine dental care and these especially among HIV-seropositive
patients are likely to present with individuals. More specifically, she
F E B R U A R Y 2 0 1 6 83
introduction
C D A J O U R N A L , V O L 4 4 , N 2
describes the epidemiologic trends for Progress toward identifying an effective Cancer stem cells (CSCs) may be
HPV-related oropharyngeal squamous chemopreventive agent to reduce the involved in oral cancer progression,
cell carcinoma and provides an update incidence of oral cancer has been limited metastasis, treatment resistance, and
on the HPV life cycle, oncogenic by poor efficacy and intolerable toxicity recurrence. In their article, Anh Le,
properties and prognostic role in profiles. Kazumichi Sato, DDS, PhD, DDS, and Qilin Xu, MD, PhD, discuss
carcinogenesis. Furthermore, she and I review the current status of cancer the biological properties of CSCs and
emphasizes the role of dental health chemoprevention and its effectiveness their implication in oral carcinogenesis,
care providers in prevention, early in treatment of oral premalignant which could lead to the development of
detection and expert referral for this lesions (OPL) and prevention of their novel antitumor drugs that specifically
category of head and neck cancers. progression to oral cancer. Unfortunately, target oral cancer stem cells.
Cancer chemoprevention is defined despite the significant efforts over Nanodiamonds are promising
as the use of a systemic agent to halt the past decades and the substantial biomedical agents that have markedly
the carcinogenesis process. This has gain in knowledge of the biology of enhanced theefficacy and safety of
been an attractive topic in head oral premalignant lesions, no tangible drug delivery and imaging. They
and neck squamous cell carcinoma indications for chemoprevention combine several properties that
(HNSCC) for the past three decades. have emerged for this disease. include uniquely faceted surfaces,
biocompatibility, and scalable
manufacturing parameters, making
them applicable toward oncology and
dentistry. Dean Ho, PhD, et al. explore
the potential use of nanodiamond-
chemotherapeutic agents to increase
intratumoral retention while markedly
reducing dose-limiting toxicity in an
experimental cancer mouse model.
These advancements have opened the
doors to developing nanodiamond-based
therapies for oral health indications.
I would like to extend my deepest
appreciation to all the authors for sharing
their expertise and knowledge on the
topic of oral cancer. I hope that you, the
readers, find this issue educational and
useful in your dental practice in regard
to the current roles of HPV, stem cells,
nanodiamonds and chemoprevention in
oral cancer detection and management.
RESOURCES
1. American Cancer Society. Cancer Facts and Figures 2014.
Atlanta: American Cancer Society, 2014.
2. Ferlay J, Soerjomataram I, Dikshit R, Eser S, Mathers C,
Rebelo M, et al. Cancer incidence and mortality worldwide:
Sources, methods and major patterns in GLOBOCAN 2012.
Int J Cancer 2015;136:E359-8.
3. Messadi DV. Diagnostic aids for detection of oral
precancerous conditions. Int J Oral Sci 2013; 5:59-65.
4. Jawad H, Hodson NA, Nixon PJ. A review of dental
treatment of head and neck cancer patients, before, during and
after radiotherapy: Part 1. Br Dent J 2015; 218, 65-68.
84F E B R U A R Y 2 01 6
intraoral lesions
C D A J O U R N A L , V O L 4 4 , N 2
AUTHORS
A
Reuben Han-Kyu Kim, pursuing oral maxillofacial recent study showed in the U.S.1 While some of these patients
DDS, PhD, is an associate and facial surgery training that nearly 14.5 million may seek a large cancer center where
professor, vice chair in the and oral medicine after his
Americans had experiences their dental needs can be addressed in a
section of restorative dentistry DDS/PhD training.
and the course chair for Conict of Interest
with cancers as of 2014, hospital-based setting before, during or
direct restorations for Disclosure: None reported. and almost 1.7 million after cancer therapy, significant numbers
predoctoral students at the new cancer cases were expected to of these patients are being referred to
University of California, Los Eric C. Sung, DDS, is a be diagnosed in 2015.1 Among them, local general dental practitioners for
Angeles, School of Dentistry. professor of clinical
2 percent is attributed to oral and their dental care.3 With progressive
He is actively engaged in dentistry, chair in the
research related to oral section of special needs
oropharyngeal cancers, ranking them increase in life expectancy due to the
diseases including wound patients and the program as the sixth most commonly occurring advancement in medical technology,
healing and oral cancers. director of the general cancer in the U.S. with 63 percent and these cancer patients seeking general
Conict of Interest practice residency program 51 percent of overall five- and 10-year dentists to address their dental needs
Disclosure: None reported. at the University of
survival rates, respectively. A similar will only escalate. Therefore, as a general
California, Los Angeles,
Paul Yang, BS, MS, is a School of Dentistry. His
trend can also be seen worldwide,2 dental practitioner it is important to
rst-year student in the DDS/ background is in training suggesting that oral and oropharyngeal know about, and to be better prepared
PhD combined program at and providing cancers in the oral cavity impose for, any disease or pathology that may
the University of California, comprehensive treatment significant health issues not only in the specifically develop in the oral cavity
Los Angeles, School of for medically, physically
U.S., but also throughout the world. in patients who are undergoing or who
Dentistry. Mr. Yang earned and psychologically
his bachelors and masters complex individuals.
Approximately 45,780 new have undergone therapy for their cancer.
degrees in biology from Conict of Interest diagnoses of oral and oropharyngeal Depending on the treatment
UCLA. He is interested in Disclosure: None reported. cancers alone were expected in 2015 modality, the side effects commonly
F E B R U A R Y 2 0 1 6 85
intraoral lesions
C D A J O U R N A L , V O L 4 4 , N 2
found in the oral cavity are diverse, cancers. However, this approach is often
ranging from xerostomia, oral mucositis, limited due to compromised functions and
opportunistic infection and trismus esthetics.5 Surgical removal of a cancer
to osteoradionecrosis (ORN). These mass in the oral cavity often creates large
side effects may be overlooked because structural defects, and the outcomes
some of them are asymptomatic in may be disfiguring. In addition, intraoral
nature, but can be severe such that surgical removal may result in significantly FIGURE 1. Mucositis covered by a pseudomembranous
normal functioning in daily life may altered oral functions for speech and layer with areas of erythema and ulceration.
be significantly compromised. Detailed mastication. Therefore, patients may opt
descriptions of screening and examining out of this therapeutic modality because
oral cancers in patients can be found of these functional and esthetic concerns. Oral Complications Associated
on the Foundation for Oral-Facial With Cancer Therapy
Rehabilitations website (ffofr.org) and Radiation Therapy Although these treatment modalities
in other reviews.4 We primarily focus Radiation therapy has the advantage are specifically formulated to reduce
on the etiology, clinical presentation, of inducing DNA damage in highly the cancer burden by inducing cancer
treatment and management of these proliferating cancer cells by ionizing cell death, normal cells responsible
oral lesions in patients who are radiation via generating reactive for maintaining body homeostasis by
undergoing or underwent therapy for oxygen species (ROS).6 Because cancer continually proliferating, differentiating
their cancers. The use of adjuvant cells constantly replicate DNA for and replenishing tissue structures and
cancer therapeutic agents such as their continual proliferation, DNA functions are also affected. As such, there
antiresorptive (e.g., bisphosphonates damage by ionizing radiation through are multiple complications associated
and denosumab) or anti-angiogenic radiation therapy leads to cell death. with cancer therapy, such as nausea,
(e.g., sunitinib or bevacizumab) drugs is Radiation is delivered to the tumor vomiting, hair loss, myelosuppression and
increasingly common to treat metastatic sites by fractionating the doses with stomatotoxicity. Among them, several side
cancers. These patients are at risk of different radiation paths in multiple effects are observed in the oral-specific
developing oral-specific lesions called visits. Typically, an average of 2 gray manner and compromise the quality
medication-related osteonecrosis of (Gy) per fraction is delivered over a of patients lives. These complications
the jaw (MRONJ). We also discuss course of six to seven weeks, resulting include oral mucositis, xerostomia,
the management of MRONJ lesions. in a total dose of 60-72 Gy. ORN, trismus and secondary infection.
Xerostomia
General description: Xerostomia is
another commonly occurring side effect
FIGURE 2A . Xerostomia causing gross decay FIGURE 2B . Gross decay leading to fracture at the in cancer patients undergoing radiation
(arrows). gumline (arrow). therapy or concomitant chemotherapy.
FIGURES 2 . Rampant caries secondary to xerostomia. Xerostomia occurs because of partial or
complete damages, which may be either
for replenishing the tissues, leading to Topical anesthetics in the form of sprays, recoverable or irreversible to the salivary
oral mucosal damages.8,9 Ironically, this ointments, gels or rinses, such as lidocaine, glands (e.g., parotid, submandibular
is also the basic principle behind the benzocaine, dyclonine or capsaicin, can and sublingual glands) especially when
use of radiation and/or chemotherapy be used. The practitioner should examine these glands are in the radiation path.
to target cancer cells. The severity of loss of oral function, weight loss and Histologically, early changes at the tissue
mucosal reaction is more evident in the secondary infection.10 It should be noted level include interstitial fibrosis, progressive
less keratinized oral mucosa, such as under that patients with severe mucositis may loss of the fine vasculature and vacuolization
the tongue. The ulceration escalates in require hospitalization. Patients should of serous acinar cells. Of note, serous acinar
patients with chronic alcoholism, liver be instructed to avoid hot, spicy or acidic cells seem to be more readily affected by
cirrhosis and insulin-dependent diabetes. foods or beverages. Any sharp or hard radiation when compared to the mucous
Clinical manifestation: Mucositis food intake should be curtailed, as they cells, presumably because of the relatively
initially presents as an erythematous lesion can be traumatic to the oral mucosal rapid turnover rate and profuse vasculature
as early as seven to 10 days after the initial tissues. If oral mucositis is generalized of serous cells. As such, saliva is more acidic
treatment dose. These initial erythematous throughout the oral cavity, analgesics and viscous with less buffering capacity.
mucositis will soon develop into ulcerative can be administered systemically, which During the late stages of radiation therapy,
mucositis that is typically covered by may require hospitalization. Emphasizing glands become progressively fibrotic,
pseudomembranes (FIGURE 1 , arrows). good oral hygiene practices to patients leading to almost complete loss of acinar
These lesions are usually confined to the is important to reduce the chances elements and the striated duct system.
tissues associated with the initial tumor of developing infection secondary Ultimately, no saliva may be present.
site. Ulcerative mucositis lasts throughout to mucositis. Fungal and bacterial Because such environmental alterations
the treatment period, but the lesions infections are common with these lesions make the oral cavity more susceptible to
are usually self-limiting after two to four and antifungal and/or antibacterial rampant caries, acute and chronic fungal
weeks following the completion of therapy medications may be prescribed as needed. infections and compromised tolerance
during which they are re-epithelialized and Some of these patients may have to prosthesis such as dentures, early
covered by normal-appearing oral mucosa. already undergone preventive therapeutic detection and management of xerostomia
Caution should be taken when treatment, such as cryotherapy, palifermin in these patients are critical to alleviate
managing the irradiated oral mucosal or amifostine, so practitioners should discomforts and possible permanent
tissues as they can be easily perforated be aware of these methods. Palifermin, structural damage in the oral cavity.
by trauma, resulting in secondary a truncated human keratinocyte Clinical manifestation: Practitioners
ulceration that could take months to growth factor (KGF) recombinant should actively look for signs and symptoms
heal. The practitioner should carefully protein, is FDA approved and currently related to salivary hypofunction including
examine the localized ulcerative mucositis available to use in the clinic; however, fissures at the lip commissures, difficulties
in oral mucosal tissues particularly recent clinical trials demonstrated in swallowing or chewing as well as with
around the metallic crown that is in the modest effects of palifermin.11,12 speech. Salivary reduction up to 80 percent
the path of the radiation beam due Amifostine, a radioprotectant, can of its original flow13 and xerostomia can
to backscatter effects of radiation. be administered intravenously or be specifically noted in cancer patients
Management: As these lesions are subcutaneously before therapy to reduce two weeks after initial radiation therapy
often self-limiting, the primary goal of the severity of oral mucositis, but it or at a cumulative dose of 20 Gy. The
managing patients with oral mucositis may induce several side effects such as diminished salivary flows bring changes
should be focused on alleviating pain. headaches, nausea or hypotension. to the oral flora, increasing the chances
F E B R U A R Y 2 0 1 6 87
intraoral lesions
C D A J O U R N A L , V O L 4 4 , N 2
FIGURE 3A . Custom trays for maxillary and FIGURE 3B . Custom trays on the maxillary and FIGURE 4 . Osteoradionecrosis lesion with exposed
mandibular dentition. mandibular dentition. bone in the lower right mandibular arch. Note plaque
accumulation around the exposed bone.
FIGURES 3 . Stannous uoride gel application with custom tray.
of bacterial and/or fungal infection. Osteoradionecrosis (ORN) care may lead to the accumulation of
These changes predispose the patient to General description: Osteoradionecrosis plaque that covers the exposed bone.
radiation caries, which is typically located (ORN), as the name implies, means bone Management: In one study, tooth
at the incisal edge and cervical third of death because of radiation. The incidence extractions were found to be responsible
the teeth. Rampant caries progress rapidly of ORN ranges from 8 percent to 35 percent, for 50 percent of all ORN cases.14
and extensively such that teeth become largely depending on observational periods Therefore, invasive dental procedures
nonrestorable (FIGURE 2A ) or fractured that range from months to years.14,15 Most should be reserved. Periodontal procedures
at the gingival margin (FIGURE 2B ); of ORN (about 75 percent) occurs within such as deep scaling and flap surgery
therefore, early detection and immediate the first three years of radiation therapy are also contraindicated particularly in
restorations are highly recommended. treatment.16 ORN is more prevalent in the heavily irradiated patients. Instead, more
Management: Early symptoms of mandible than the maxilla, owning to the conservative treatment approaches, such as
xerostomia include thick or ropey saliva in poor vascularization and increased density endodontic therapy with or without coronal
the oral cavity. Carboxymethylcellulose-, that allows for absorbing more radiation restorations, are preferable (FIGURE 6 ).
mucin-, water- or glycerin-based saliva in the mandible. The cause of ORN is When bone exposure is evident, a patients
substitutes may be used, although the still unclear although there are several chief complaint is typically pain associated
effectiveness of these agents is somewhat hypotheses, such as bacterial infection, with bacterial infection secondary to
questionable. In mild cases, a simple hypoxia and fibroatrophy.17-19 Risk factors exposed bone. Prescribing antibiotics may
increase in the frequency of water intake include location of primary tumor, cancer help resolve the pain. Regular checkups and
is helpful. If salivary glands are spared from staging, dose of radiation (> 60 Gy), poor dental prophylaxis every four months are
complete eradication by radiation therapy, oral hygiene, alcohol and tobacco use and highly recommended to maintain optimal
salivary stimulants such as pilocarpine or invasive dental procedures such as tooth conditions in the oral cavity along with
cevimeline may be used. Xylitol-based extraction.20 It is noteworthy that, once giving the clinician ample opportunity to
chewing gum that has a nonfermentable radiation therapy is delivered, cancer patients catch dental disease at the early stages.
sugar alcohol may also be used to increase have the risk of developing ORN that is Hyperbaric oxygen (HBO) therapy that
salivary flow. The early use of stannous lifelong and does not decrease over time. provides high contents of oxygen has
fluoride gel applied with custom carriers Therefore, thorough examination at each been used to manage ORN conditions
(FIGURE 3A ) and five-minute daily visit for periodic examination is essential. but without drastic improvement.21 If
applications is highly recommended to Clinical manifestation: ORN is clinically possible, it is highly encouraged to remove
reduce caries risk (FIGURE 3B ). If significant defined as an area of exposed bone that any sources of dental diseases including
numbers of rampant caries are noted, persists for more than three months advanced caries, periapical infection and
dental treatment should be performed (FIGURE 4 ). However, radiographic pathologic periodontal bone loss before
without any delay. Due to the high caries findings of irregular radio-opacity that is a patient undergoes radiation therapy.
risk, fluoride-releasing glass ionomers indicative of sequestrum formation without New alternatives to HBO treatments
and/or amalgam restorations are more breached overlaying mucosal closure is have been introduced, such as the use of
predictable when compared to composite also common (FIGURE 5 ). Ulcerative pentoxifylline and/or tocopherol,22,23 and
restorations. Patients should be counseled or necrotic soft tissues can also be seen the use of these medications may hold
about eliminating sucrose from their diet frequently around the exposed area. promising results in reducing the risk of
and reducing the frequency of meals. Long-term exposure without proper oral and managing patients with ORN.
88F E B R U A R Y 2 01 6
C D A J O U R N A L , V O L 4 4 , N 2
FIGURE 5A . Sclerotic changes around No. 31 area FIGURE 5B . After two years, sequestrum was FIGURE 6 . Endodontically treated Nos. 18 and 19
(arrows) after radiation therapy. pushed out spontaneously. that are domed with amalgam restoration.
FIGURE 9. MRONJ
A lesions induced by long-
term bisphosphonate use.
(A) Note radiolucency
around the aected area
(arrows), which is an
indicative of nonviable subcutaneously, to prevent the cancer from
bone. (B) A typical spreading to bone. As such, practitioners
MRONJ lesion with
should keep in mind that osteoporosis
plaque formation induced
by the long-term use of patients also take these drugs orally, and
bisphosphonates on the that although the incidence of MRONJ
B C lower left mandibular arch. occurring by this route is relatively less, these
(C) Bony sequelae that fell patients may still develop MRONJ lesions
out spontaneously from when they have been on these medications
the upper right maxillary for more than four years.37 Practitioners
arch (A, arrowhead)
should also be aware of the risk factors
that the patient brought
to the clinic. associated with MRONJ, such as high (e.g.,
IV or subcutaneous administration) and
long duration (e.g., > four years) of doses,
Prolonged use of antifungal medications antiresorptive (e.g., bisphosphonates or pre-existing inflammatory dental diseases
is discouraged because of the risk of denosumab) or anti-angiogenic (e.g., (e.g., periodontal disease or periapical
developing fungal resistance to these drugs. sunitinib or bevacizumab) drugs. The use lesions), dentoalveolar surgery (e.g., tooth
of these medications is associated with extraction), age and corticosteroids,37-43 all
Altered Taste Buds MRONJ that specifically occurs in the oral of which may exacerbate ONJ lesions.
Alterations in taste acuity are first cavity. Therefore, general practitioners Clinical manifestation: A typical
noticed as early as the second week of should be aware of these MRONJ clinical presentation is very similar to
radiation therapy (approximately 30 Gy lesions when managing patients who are that of ORN. Long-term exposure of
of radiation). Perception of bitter and acid receiving such adjuvant chemotherapy. bone is almost inevitably accompanied
flavors is more susceptible to impairment by plaque accumulation (FIGURE 9B ).
than salt and sweet. The architecture MRONJ Practitioners should consider this for
of the taste buds is almost completely General description: The first formal patients who have pain with unidentifiable
eliminated at 50 Gy. However, taste report on osteonecrosis of the jaw (ONJ) origin as it may indicate stage 0 MRONJ.
generally returns to normal two to four by bisphosphonates was published in Abnormal findings (e.g., sclerosis) from
weeks after the completion of therapy 2003,34 but the etiology is still unknown. radiography and computed tomography
as long as salivary flow is reasonable. In Multiple hypotheses have been suggested, (CT) should also be noted, but interpreted
the case of severe xerostomia following including suppression of bone remodeling, with caution, as it may be suggestive of
radiation therapy, the number of buds inflammation, inhibition of angiogenesis MRONJ.44,45 Bone exposure is likely to
are significantly decreased and their and soft tissue toxicity.35 The terminology be seen in previously extracted areas but
morphology is altered. The perception of bisphosphonate-related osteonecrosis can also occur spontaneously in thin oral
of taste may be permanently altered. of the jaw, or simply BRONJ, was recently mucosal areas such as tori. Spontaneous
updated to MRONJ in order to be more bone exposure may be associated with
Oral Complications Associated With inclusive of medications other than chronic inflammation (e.g., periodontal
Adjuvant Chemotherapy bisphosphonates, such as denosumab or or periapical diseases) and previously
Cancers in advanced stages typically bevacizumab.36 MRONJ is clinically defined traumatized areas. Radiographically,
metastasize to other parts of the body. as patients with a history of treatment with nonviable bone can be predicted based on
In particular, some cancers, including antiresportive or anti-angiogenic agents, radiolucent periphery around the affected
breast, prostate, lung, thyroid and kidney, exposed bone for more than eight weeks area (FIGURE 9A ). A periodontal probe
are more prone to metastasize to other and no history of radiation therapy to instrument can be used to detect bony
areas including bone. These lesions the head and neck regions.36 A detailed surface through mucosal fistulas, which is
may also lead to high calcium levels in classification of MRONJ can be found indicative of MRONJ at the stage 1, 2 or 3.
the blood stream called hypercalcemia. elsewhere.36 Individuals with advanced- Management: Similar to ORN, invasive
Medications commonly prescribed for stage cancers that invade bone may take dental procedures should be refrained
the management of metastasis include these medications, usually intravenously or from, but conservative approaches are
90F E B R U A R Y 2 01 6
C D A J O U R N A L , V O L 4 4 , N 2
TABLE
recommended. It is important to know without signs/symptoms of MRONJ, the occlusal plane can be reduced as
whether cancer patients are taking the routine oral hygiene including scaling and needed to eliminate occlusal contacts and
aforementioned medications, as dental root planning should be continued. For contact-associated pain until the tooth
treatment options are significantly limited stage 0 patients with the chief complaint falls out spontaneously. In certain instance,
due to increased risk of MRONJ after of pain with unidentifiable origins, the use patients may present with bony sequelae
invasive dental treatment. Once identified, of medication to control pain is helpful. In that naturally sequester out (FIGURE 9C ),
patients with MRONJ should be managed stage 1 or 2 patients with exposed bone, the and such a sign is usually accompanied by
according to the MRONJ staging. As a use of oral antimicrobial rinses (e.g., 0.12% reepithelialization at the healing site. These
general practitioner, the primary goals of chlorhexidine) is recommended. Although sites should be continuously monitored.
managing these patients are to maintain infection as a primary etiological factor
good oral hygiene in a nonsurgical manner in causing MRONJ is still controversial, Conclusion
in patients with stage 2 or less and to the use of antibiotics is also recommended Once established, the relationship
monitor progression of lesions such that, in order to reduce bacterial colonization between dentists and patients can last for
when the lesions meet the stage 3 criteria, particularly at the area with exposed many years. As life expectancy increases
the patients can be referred to oral surgeons bone. It is not uncommon to observe a and advancement of medical technology
for possible surgical interventions. For tooth with class 3 mobility. In such cases, continues to grow, these relations may
patients who are taking these mediations extraction should be avoided; instead, potentially be lifelong. During that time,
F E B R U A R Y 2 0 1 6 91
intraoral lesions
C D A J O U R N A L , V O L 4 4 , N 2
dentists are likely to encounter patients protection for improving radiotherapy: Where are the gaps? Transl Acta Oncol 2014;53(4):502-9.
Cancer Res 2012;1(1):35-48. 29. Brown LR, Dreizen S, Handler S, Johnston DA. Eect of
who are undergoing or who have a history
9. Villa A, Sonis ST. Mucositis: Pathobiology and management. radiation-induced xerostomia on human oral microora. J Dent Res
of cancer therapy. As general dental Curr Opin Oncol 2015;27(3):159-64. 1975;54(4):740-50.
practitioners, knowing different cancer 10. Eilers J, Epstein JB. Assessment and measurement of oral 30. Bensadoun RJ, Patton LL, Lalla RV, Epstein JB. Oropharyngeal
mucositis. Semin Oncol Nurs 2004;20(1):22-9. candidiasis in head and neck cancer patients treated with radiation:
therapeutic modalities (e.g., surgical,
11. Henke M, Alfonsi M, Foa P, et al. Palifermin decreases Update 2011. Support Care Cancer 2011;19(6):737-44.
radiation, chemo, or combination severe oral mucositis of patients undergoing postoperative 31. Ramirez-Amador V, Silverman Jr. S, Mayer P, Tyler M, Quivey J.
therapies) is essential for assessing radiochemotherapy for head and neck cancer: A randomized, Candidal colonization and oral candidiasis in patients undergoing
placebo-controlled trial. J Clin Oncol 2011;29(20):2815-20. oral and pharyngeal radiation therapy. Oral Surg Oral Med Oral
and managing these cancer patients.
12. Le QT, Kim HE, Schneider CJ, et al. Palifermin reduces severe Pathol Oral Radiol Endod 1997;84(2):149-53.
Many side effects from cancer therapy, mucositis in denitive chemoradiotherapy of locally advanced head 32. Groll AH, Piscitelli SC, Walsh TJ. Clinical pharmacology of
including oral mucositis, xerostomia, and neck cancer: A randomized, placebo-controlled study. J Clin systemic antifungal agents: A comprehensive review of agents in
Oncol 2011;29(20):2808-14. clinical use, current investigational compounds and putative targets for
ORN, trismus and secondary infection,
13. Burlage FR, Coppes RP, Meertens H, Stokman MA, Vissink A. antifungal drug development. Adv Pharmacol 1998;44:343-500.
are inevitable but manageable, and to a Parotid and submandibular/sublingual salivary ow during high 33. Haveman CW. Xerostomia management in the head and neck
certain degree, treatable (TABLE ). This dose radiotherapy. Radiother Oncol 2001;61(3):271-4. radiation patient. Tex Dent J 2004;121(6):483-97.
14. Reuther T, Schuster T, Mende U, Kubler A. Osteoradionecrosis 34. Marx RE. Pamidronate (Aredia) and zoledronate (Zometa)
holds true for MRONJ lesions in cancer
of the jaws as a side eect of radiotherapy of head and neck induced avascular necrosis of the jaws: A growing epidemic. J Oral
patients undergoing adjuvant therapy tumour patients a report of a 30 year retrospective review. Int J Maxillofac Surg 2003;61(9):1115-7.
with bisphosphonates and denosumab. As Oral Maxillofac Surg 2003;32(3):289-95. 35. Reid IR, Cornish J. Epidemiology and pathogenesis of
15. Rice N, Polyzois I, Ekanayake K, Omer O, Stassen LF. The osteonecrosis of the jaw. Nat Rev Rheumatol 2012;8(2):90-6.
such, it is of paramount importance for the
management of osteoradionecrosis of the jaws a review. Surgeon 36. Ruggiero SL, Dodson TB, Fantasia J, et al. American Association
general dental practitioner to know how 2015;13(2):101-9. of Oral and Maxillofacial Surgeons position paper on medication-
cancer therapy can affect oral health and 16. Thorn JJ, Hansen HS, Specht L, Bastholt L. Osteoradionecrosis related osteonecrosis of the jaw 2014 update. J Oral Maxillofac
of the jaws: Clinical characteristics and relation to the eld of Surg 2014;72(10):1938-56.
to manage these patients accordingly in
irradiation. J Oral Maxillofac Surg 2000;58(10):1088-93; 37. Lo JC, ORyan FS, Gordon NP, et al. Prevalence of osteonecrosis
order to provide the full spectrum of dental discussion 93-5. of the jaw in patients with oral bisphosphonate exposure. J Oral
services. Because managing cancer patients 17. Delanian S, Lefaix JL. The radiation-induced broatrophic Maxillofac Surg 2010;68(2):243-53.
process: Therapeutic perspective via the antioxidant pathway. 38. Thumbigere-Math V, Michalowicz BS, Hodges JS, et al.
successfully in the general dental practice
Radiother Oncol 2004;73(2):119-31. Periodontal disease as a risk factor for bisphosphonate-related
is a team effort, it is equally important for 18. Marx RE. A new concept in the treatment of osteoradionecrosis. osteonecrosis of the jaw. J Periodontol 2014;85(2):226-33.
general practitioners to communicate not J Oral Maxillofac Surg 1983;41(6):351-7. 39. Malden N, Lopes V. An epidemiological study of alendronate-
19. Meyer I. Infectious diseases of the jaws. J Oral Surg related osteonecrosis of the jaws. A case series from the southeast
only with the patients but also with medical
1970;28(1):17-26. of Scotland with attention given to case denition and prevalence. J
practitioners to determine the optimal 20. ODell K, Sinha U. Osteoradionecrosis. Oral Maxillofac Surg Bone Miner Metab 2012;30(2):171-82.
management plan for each patient. Clin North Am 2011;23(3):455-64. 40. Henry D, et al. Delaying skeletal-related events in a randomized
21. Bennett MH, Feldmeier J, Hampson N, Smee R, Milross phase 3 study of denosumab versus zoledronic acid in patients with
ACKNOWLEDGMENT
C. Hyperbaric oxygen therapy for late radiation tissue injury. advanced cancer: An analysis of data from patients with solid tumors.
This study was supported by grants R01DE023874 and
Cochrane Database Syst Rev 2012;5:CD005005. Support Care Cancer 2014;22(3):679-87.
R01DE023348 from the National Institute of Dental and
22. Delanian S, Chatel C, Porcher R, Depondt J, Lefaix JL. Complete 41. Saad F, Brown JE, Van Poznak C, et al. Incidence, risk factors and
Craniofacial Research/National Institutes of Health.
restoration of refractory mandibular osteoradionecrosis by outcomes of osteonecrosis of the jaw: Integrated analysis from three
REFERENCES prolonged treatment with a pentoxifylline-tocopherol-clodronate blinded active-controlled phase III trials in cancer patients with bone
1. Society AC. Cancer Facts and Figures 2015. Atlanta: American combination (PENTOCLO): A phase II trial. Int J Radiat Oncol Biol metastases. Ann Oncol 2012;23(5):1341-7.
Cancer Society 2015. Phys 2011;80(3):832-9. 42. Vahtsevanos K, Kyrgidis A, Verrou E, et al. Longitudinal cohort
2. Warnakulasuriya S. Global epidemiology of oral and 23. Hayashi M, Pellecer M, Chung E, Sung E. The ecacy study of risk factors in cancer patients of bisphosphonate-related
oropharyngeal cancer. Oral Oncol 2009;45(4-5):309-16. of pentoxifylline/tocopherol combination in the treatment of osteonecrosis of the jaw. J Clin Oncol 2009;27(32):5356-62.
3. Barker GJ, Epstein JB, Williams KB, Gorsky M, Raber-Durlacher osteoradionecrosis. Spec Care Dentist 2015. 43. Fehm T, Beck V, Banys M, et al. Bisphosphonate-induced
JE. Current practice and knowledge of oral care for cancer patients: 24. Rapidis AD, Dijkstra PU, Roodenburg JL, et al. Trismus in patients osteonecrosis of the jaw (ONJ): Incidence and risk factors in patients
A survey of supportive health care providers. Support Care Cancer with head and neck cancer. Etiopathogenesis, diagnosis and with breast cancer and gynecological malignancies. Gynecol Oncol
2005;13(1):32-41. management. Clin Otolaryngol 2015. 2009;112(3):605-9.
4. Beumer J, Marunick MT, Esposito SJ. Maxillofacial 25. Ichimura K, Tanaka T. Trismus in patients with malignant tumours 44. Khan AA, Morrison A, Hanley DA, et al. Diagnosis and
Rehabilitation: Prosthodontic and Surgical Management of in the head and neck. J Laryngol Otol 1993;107(11):1017-20. management of osteonecrosis of the jaw: A systematic review and
Cancer-related, Acquired and Congenital Defects of the Head and 26. Dijkstra PU, Huisman PM, Roodenburg JL. Criteria for international consensus. J Bone Miner Res 2015;30(1):3-23.
Neck. Quintessence Publishing; 2011. trismus in head and neck oncology. Int J Oral Maxillofac Surg 45. Bedogni A, Fedele S, Bedogni G, et al. Staging of osteonecrosis
5. Biglioli F. Surgical therapy of oral cancer. Minerva Stomatol 2006;35(4):337-42. of the jaw requires computed tomography for accurate denition
2009;58(4):157-80. 27. Lee LY, Chen SC, Chen WC, Huang BS, Lin CY. Postradiation of the extent of bony disease. Br J Oral Maxillofac Surg
6. Orth M, Lauber K, Niyazi M, et al. Current concepts in clinical trismus and its impact on quality of life in patients with head and 2014;52(7):603-8.
radiation oncology. Radiat Environ Biophys 2014;53(1):1-29. neck cancer. Oral Surg Oral Med Oral Pathol Oral Radiol
7. Seiwert TY, Salama JK, Vokes EE. The chemoradiation paradigm 2015;119(2):187-95. THE CORRESPONDING AUTHORS, Reuben Han-Kyu Kim, DDS, PhD,
in head and neck cancer. Nat Clin Pract Oncol 2007;4(3):156-71. 28. Pauli N, Fagerberg-Mohlin B, Andrell P, Finizia C. Exercise and Eric C. Sung, DDS, can be reached at
8. Prasanna PG, Stone HB, Wong RS, et al. Normal tissue intervention for the treatment of trismus in head and neck cancer. rkim@dentistry.ucla.edu and esung@dentistry.ucla.edu.
92F E B R U A R Y 2 01 6
oropharyngeal cancer
C D A J O U R N A L , V O L 4 4 , N 2
AUTHOR
A
Fariba S. Younai, DDS, is new global pattern of (HIV) who, in recent years, have also
a professor of clinical oropharyngeal cancer started to present with an increased
dentistry in the section of epidemiology started to incidence of head and neck and
oral medicine and
orofacial pain in the
emerge in the 1990s. oropharyngeal squamous cell carcinomas.3
division of oral biology and An increased incidence
medicine at the University of malignant lesions, specifically Oropharyngeal Cancer Epidemiology
of California, Los Angeles, squamous cell carcinomas, was being Every year, more than 600,000 new
School of Dentistry, where noted to occur mostly in the posterior cases of head and neck cancer (HNC) are
she currently serves as the
vice chair of the division of
region of the oropharynx and among reported worldwide.7 As the sixth most
oral biology and medicine. younger individuals who did not have common type of cancer, the incidence
Dr. Younai earned her the traditional oral cancer risks such rates of HNC have great variations across
dental degree from the as smoking and excess alcohol use.1 the globe it is the most common form
School of Dental Medicine Since then, the scientific evidence has of cancer in India while its incidence
at the State University of
New York at Stony Brook
increasingly shown that this subset rates in the United States and in northern
and completed her training of head and neck cancers is a distinct Europe are lower than in countries in
in hospital dentistry at Long entity connected to an infection with Latin America.8 The majority of head
Island Jewish Medical human papillomavirus (HPV) and, in and neck cancers are of the squamous
Center in New York. fact, exhibits better overall survival cell carcinoma (SCC) type involving the
Conict of Interest
Disclosure: None reported.
rates and response to treatment.2-6 This oral cavity, oropharynx, hypopharynx,
association between HPV and oral larynx, sinonasal tract and nasopharynx.7
malignancy is even more pronounced The term oral cavity cancer (OCC)
among individuals seropositive for typically refers to a malignant lesion
the human immunodeficiency virus in the anterior part of the oral cavity,
F E B R U A R Y 2 0 1 6 93
oropharyngeal cancer
C D A J O U R N A L , V O L 4 4 , N 2
including gingivae, floor of the mouth, and Slovakia.15 The striking finding in It is not entirely clear if the increase
buccal mucosa, retromolar trigone, hard this analysis was that the increased OPC in the incidence of head and neck
palate and the anterior two-thirds of incidence among men corresponded cancers among HIV-infected individuals
the tongue, while the oropharyngeal with a reduction in the incidence of is related to behavioral factors such
cancer (OPC) designation is for those both OCC and lung cancer, but among as tobacco and alcohol use, immune
lesions located in any of four distinct women, a reverse pattern was observed suppression, long-term use of cART,
subsites: the posterior pharyngeal wall, where the increased OPC incidence other infectious agents or results from
the soft palate, the tonsillar complex occurred with concomitant increases in the a combination of all these factors.
and the base of the tongue.9,10 incidence of OCC and lung cancer. These
Several studies have provided findings suggested significant differences HPV Infection and Oropharyngeal
overwhelming evidence for the increasing between the OPC risk factors and those Cancer
incidence of oropharyngeal cancer of OCC and lung cancer, differences Globally, smoking, alcohol
worldwide. In the U.S., an assessment of that may be more influential in cancer consumption and betel nut chewing
the incidence data from the Surveillance, development among men than women. are traditional risk factors for the SCC
Epidemiology and End Results (SEER) type of HNC and OCC.20 In fact, aside
Program of the National Cancer Institute from cases of oral dysplasia seen related
(NCI) showed that between 1973 and to betel nut chewing that is common
1995, the incidence of tonsillar SCC in Asia and the tropical Pacific region,
among men younger than 60 years of age
Several studies have traditional patients with OCC have been
increased by about 2 to 3 percent per year.11 provided overwhelming older men with a significant smoking
Another analysis of the data from the evidence for the increasing and drinking history. As noted before,
SEER Program and the mortality data from incidence of oropharyngeal there has been a significant reduction
the National Center for Health Statistics in the rates of OCC among older male
(NCHS) further revealed that from the cancer worldwide. smokers, mostly due to reductions in the
late 1980s to 2001, the risk for tonsillar global smoking and alcohol consumption
SCC increased for males age 40-64 years rates.21,22 At the same time, there has
while the incidence for this type of cancer been a dramatic increase in incidence
and progression to death decreased for After the introduction of effective rates of oropharyngeal cancer among
those age 65 years and older.12 A parallel combination antiretroviral therapies middle-aged white men who are often
pattern was reported from Sweden and (ART or cART) in the mid-1990s, the nonsmokers or former/light smokers, a
Finland during the same approximate incident rates for the AIDS-defining phenomenon now attributed to infection
time period.13,14 Looking at the global cancers, such as Kaposis sarcoma, was with HPV.23-26 In the U.S., by 2010,
statistics, one study using data from the dramatically reduced, while a trend toward the rate of OPC among men became
Cancer Incidence in Five Continents increased incidence of other types of higher than the rate of cervical cancer
database, maintained by the International cancer, like lung cancer, invasive anal in women and if this trend continues,
Agency for Research on Cancer (IARC), SCC, head/neck cancers and Hodgkin by the year 2020 the annual number
constructed age-period-cohort models lymphoma, started to emerge.16-18 Pooled of HPV-positive OPC will surpass the
to examine the incidence trends for data from the North American AIDS annual number of cervical cancers.27 An
OPC and OCC across 23 countries Cohort Collaboration on Research and analysis of the SEER data from three
around the world.15 This comprehensive Design (NA-ACCORD) studies between regions (Hawaii, Iowa and Los Angeles)
analysis showed that between 1983 1996 and 2009 showed that the HIV- showed that while the incidence rate for
and 2002, significant increases in OPC infected individuals risk of development HPV-negative OPC dropped from 2.0
incidence were observed among both of HNC, specifically SCC, was threefold per 100,000 in 1988 to 1.0 per 100,000
men and women, predominantly among higher than that of the general U.S. in 2004, the rates for HPV-positive
individuals younger than 60 years and in population.19 This report also showed a tumors increased by more than threefold,
economically developed countries such modest role for immunosuppression (low from 0.8 per 100,000 in 1988 to 2.6
as the U.S., Australia, Canada, Japan CD4 count) prior to cancer diagnosis. per 100,000 in 2004 (F I G U R E 1 ).27
94F E B R U A R Y 2 01 6
C D A J O U R N A L , V O L 4 4 , N 2
3.5
3
these viral gene products, early or late
Rates per 100,000
2.5
in the transcription process during viral
2 replication. The HPV genome contains
segments referred to as open reading frames
1.5 (ORF codons or sequence of nucleotides
with the potential to be transcribed into
1 Oropharynx (overall) RNA) that encode early proteins E1
HPV-negative oropharynx through E8 and late proteins L1 and L2.34
.5
HPV-positive oropharynx
Of all the regulatory proteins, E1 and E2
0 are necessary for viral replication and,
19881990 19911992 19951996 19992000 20032004
therefore, the genes encoding for these
Surveillance Period as well as the capsid proteins L1 and L2
are called the core genes, while the
FIGURE 1. Incidence rates for overall HPV-positive and HPV-negative OPC (SEER data from Hawaii, Iowa and genes encoding for the other proteins that
Los Angeles 1988-2004). Adopted from J Clinical Oncology 2011;29(32):4294-4301.
mainly affect the cellular environment of
the virus are called accessory genes.34,35
HPV-positive squamous cell include cutaneous and genital warts and The viral infection of the epithelial
carcinoma is a genetically, clinically recurrent respiratory papillomatosis.34 In basal cells and HPV entry into the cells
and epidemiologically distinct subtype the anogenital tissues specifically, a number nucleus is thought to ensue a series of
of HNC with a predilection for the of HPV genotypes are connected to steps that include: a) microtrauma to the
oropharyngeal tissues, referred to by premalignant and malignant lesions such as epithelium, b) an interaction between
many as HPV-associated oropharyngeal squamous intraepithelial lesions (SILs) and the viral L1 capsid protein and the
squamous cell carcinoma (OPSCC).28 anal, vaginal and cervical cancers. Of more extracellular matrix (ECM) or the cell
The first reports of a potential role for than 15 high-risk HPV subtypes, HPV surface of basal layer keratinocytes and
HPV in the HNC development were 16 and 18 are best known for their role c) an interaction between the L2 capsid
published almost 35 years ago.29-31 in anogenital cancers and were initially protein and the host lysosomal membrane
However, it was not until the surge in the targeted for vaccine development.35 for viral endocytosis.34-37 After entry into
HNC incidence that the role of HPV in the host cell, papillomaviruses replicate
OPC carcinogenesis became subject to The HPV Life Cycle and assemble exclusively in the nucleus
intense scientific research for its natural Human papillomavirus is a small, non- in a fashion that is regulated by the
history, transmission patterns and primary encapsulated virus consisting of a core with patterns of keratinocyte maturation and
and secondary prevention approaches. an 8,000 base pair long circular DNA and differentiation across the epithelial cell
Human papillomavirus has more an outer capsid that contains two main layers. For instance, the expression of the
than 320 different subtypes found in proteins, L1 and L2.34 The L1 protein is the early regulatory proteins occurs in the
many vertebrae, of which more than 200 highly conserved main capsid component, lower undifferentiated or intermediately
genotypes have been fully sequenced and because of an ability to elicit virus- differentiated keratinocytes while
in humans.32 HPV has five different neutralizing antibodies in humans, it has the transcription of the late capsid
genera (alpha, beta, gamma, mu and nu) been the basis for the currently available proteins takes place in the upper layer
and although each group has a specific HPV vaccines; the L2 protein along with of keratinocytes undergoing terminal
anatomic site predilection, they all share L1 interacts with a number of cellular differentiation.36 Of all the viral proteins,
great epithelial tropism and are found in proteins during the viral entry process E1 and E2 actively function in viral DNA
either skin, mucosa or both, even when into the host cell.35 The virus has six main replication,36 E4 facilitates virion release
nonpathogenic.33 In their pathogenic form nonstructural regulatory proteins, E1, E2, into the environment,38 and E5, E6 and E7
in the skin, the anogenital tissues and E4, E5, E6 and E7, each with a specific facilitate the transformation of regularly
the tracheobronchial and oral mucosa, function related to viral replication and/ maturing keratinocytes into malignant
several HPV subtypes lead to benign or oncogenesis.34 The E and L designations cells. More specifically, E5 protein activates
hyperproliferative epithelial lesions that are based on the order of expression of the cell growth-promoting signaling of
F E B R U A R Y 2 0 1 6 95
oropharyngeal cancer
C D A J O U R N A L , V O L 4 4 , N 2
TABLE
younger age of individuals at diagnosis, of the tissue can be a good prognostic common sexually transmitted infection
lower rates of smoking and alcohol- marker for the level of HPV biological worldwide.70Although HPV is known
related morbidities and more sensitivity activity.65 The clinical relevance of this to be transmitted through direct skin
to treatment because of HPV-induced was shown in one study that compared or mucosa contact, its transmission
P53 dysfunction and better apoptotic the prognostic value of HPV-16 DNA patterns and the exact determinants
response of cancer cells to radiation and viral load with p16 protein expression, of susceptibility and infectivity are less
chemotherapy.61 In addition to these showing the most favorable prognosis established. In one recent study, a per-
factors, HPV-positive OPSCC has a more for patients whose tumors were HPV- person transmission probability of about
indolent clinical behavior with a clinical 16-positive/p16 expressive.66 It should 20 percent during a six-month period was
staging that is in an earlier T-category and be noted that continuous smoking and shown among discordant couples.71 In this
a more advanced N-category but lymph alcohol use can change the behavior of study, the transmission rates from women
node metastasis that is often cystic in HPV-positive tumors, as both smoking to men and men to women were the same,
nature.62 Based on these properties inferred and alcohol can induce mutational varied little with the circumcision status
by HPV infection, HPV testing of the loss of p53 and p16INK4A.59 Currently, of the men and showed a trend toward
cancer tissues is becoming the standard higher rates for HPV 16. Because of its
of care at many cancer treatment centers. relationship with cancer development
Molecular detection of HPV DNA, the in cervical tissues, HPV malignant
gold standard for the identification of Based on these properties subtypes have been targeted for vaccine
HPV in tissues, can be accomplished inferred by HPV infection, development. In the U.S., a quadrivalent
by methods such as Southern transfer HPV vaccine (4vHPV) that targets HPV
HPV testing of the cancer
hybridization, dot blot hybridization, in 6, 11, 16 and 18 has been available since
situ hybridization (ISH), hybrid capture tissues is becoming the 2006 and a 9-valent vaccine (9vHPV)
and polymerase chain reaction (PCR).63,64 standard of care at many targeting additional HPV subtypes 31,
Although identifying the presence cancer treatment centers. 33, 45, 52 and 58 was licensed for use in
of HPV in the cancer tissue samples is females and males in December 2014.72
important to predicting its prognosis, In addition, a bivalent HPV vaccine
it has become exceedingly clear that against HPV subtypes 16 and 18 has also
even among HPV-positive OPSCC several other molecular mechanisms been available since 2009.73 According
lesions, there is a great degree of are being investigated for their possible to the U.S. Advisory Committee on
heterogeneity that is driven by the level contributions to the overall prognosis Immunization Practices (ACIP), the
of HPV biological activity, offering of HPV-positive tumors. Some of these HPV vaccines are recommended to be
an opportunity for specific prognostic include the role of HPV in the Wnt used routinely for females and males
molecular markers that may further and Notch signaling pathways involved at age 11 or 12 years (can be started
enhance outcomes of these cancers in in keratinocyte differentiation, the beginning at age 9) up to age 26 years.74
the future.59 For instance, the level of role of epigenetic factors such as the Each HPV vaccine is delivered through
expression of p16INK4a (a cyclin-dependent differences in the methylation profile a series of three intramuscular injections
kinase inhibitor that promotes cell cycle of HPV-positive and HPV-negative over a six-month period and is not
arrest) in the HPV-positive SCC tissues tumors and the contribution of recommended for pregnant women;
may be a good molecular proxy for this angiogenesis factors such as vascular if the vaccine schedule is interrupted,
level of activity. It turns out that the endothelial growth factor (VEGF) and the vaccination series does not need to
suppressive effect of HPV E7 protein on endothelin-1 in tumor progression.67-69 be restarted and there are no booster
pRb leads to an over expression of the doses recommended.74 These vaccines
INK4a, a tumor suppressor gene and Prevention Strategies are now available in most countries
its protein product p16INK4A and hence With an estimated life-long risk in the world and are recommended
improves the overall cancer prognosis. of cervical HPV infection up to by the World Health Organization to
Therefore, immunostaining for p16INK4A 80 percent among sexually active be used in young women after age 9
in conjunction with HPV DNA testing women, HPV is considered the most and in two doses six months apart.75
98F E B R U A R Y 2 01 6
C D A J O U R N A L , V O L 4 4 , N 2
There is no doubt that vaccination REFERENCES Head and Neck Squamous Cell Carcinoma in HIV-infected
of females, despite low vaccine coverage, 1. Gillison ML. Current topics in the epidemiology of oral cavity individuals. North American AIDS Cohort Collaboration on
and oropharyngeal cancers. Head Neck 2007; 29:779-792. Research and Design (NA-ACCORD) of IeDEA. Oral Oncol
has contributed to a reduction in the 2. Nsman A, Attner P, Hammarstedt L, et al. Incidence of 2014;50(12):1169-76.
prevalence of cervical infections of the human papillomavirus (HPV) positive tonsillar carcinoma in 20. Licitra L, Bernier J, Grandi C, et al. Cancer of the
targeted HPV subtypes. One U.S. study Stockholm, Sweden: An epidemic of viral-induced carcinoma? oropharynx. Crit Rev Oncol Hematol 2002;41:107-122.
Int J Cancer 2009;125(2):362-6. 21. Ng M, Freeman MK, Fleming TD, et al. Smoking Prevalence
showed an HPV positivity rate of 5.1 3. Chaturvedi AK, Engels EA, Pfeier RM, et al. Human and Cigarette Consumption in 187 Countries, 1980-2012.
percent of cervicovaginal specimens from papillomavirus and rising oropharyngeal cancer incidence in JAMA 2014;311(2):183-192.
2007 to 2010 compared to 11.5 percent the United States. J Clin Oncol 2011;29:4294-4301. 22. Pytynia KB, Dahlstrom KR, Sturgis EM. Epidemiology of
4. Jemal A, Simard EP, Dorell C, et al. Annual Report to the HPV-associated oropharyngeal cancer. Oral Oncol 2014;
of the specimen in 2003-2006.76 What Nation on the Status of Cancer, 1975-2009, featuring the 50(5):380-386.
is not clear is the extent to which HPV burden and trends in human papillomavirus (HPV)-associated 23. Gillison ML, Koch WM, Capone RB, et al. Evidence
vaccination has impacted the incidence cancers and HPV vaccination coverage levels. J Natl Cancer for a causal association between human papillomavirus
Inst 2013;105:175-201. and a subset of head and neck cancers. J Natl Cancer Inst
of cervical cancer, and even less is 5. Chaturvedi AK, Anderson WF, Lortet-Tieulent J, et al. 2000;92:709-720.
known about its impact on other types of Worldwide trends in incidence rates for oral cavity and 24. Dahlstrand HM, Dalianis T. Presence and inuence of
HPV-related cancers. A recent Centers oropharyngeal cancers. J Clin Oncol 2013;31:4550-4559. human papillomaviruses (HPV) in tonsillar cancer. Adv Cancer
6. Gillison ML, Alemany L, Snijders PJ, et al. Human Res 2005;93:59-89.
for Disease Control and Prevention papillomavirus and diseases of the upper airway: Head 25. Kreimer AR, Cliord GM, Boyle P, Franceschi S. Human
study used about 2,700 cancer archival and neck cancer and respiratory papillomatosis. Vaccine papillomavirus types in head and neck squamous cell
tissues collected from 1993 to 2005 2012;30(Suppl 5):F34-54. carcinomas worldwide: A systematic review. Cancer Epidemiol
7. Ramqvist T, Dalianis T. Oropharyngeal Cancer Epidemic and Biomarkers Prev 2005;14(2):467-75.
from seven U.S. cancer registries and, Human Papillomavirus. Emerg Infect Dis 2010; 16(11):1671-1677. 26. Chaturvedi AK, Engels EA, Pfeier RM, et al. Human
after HPV DNA testing of the samples, 8. Parkin DM, Bray F, Ferlay J, Pisani P. Global cancer statistics, papillomavirus and rising oropharyngeal cancer incidence in
provided estimates for the impact of HPV 2002. CA Cancer J Clin 2005;55:74-108. the United States. J Clin Oncol 2011;29(32):4294-4301.
9. Rethman MP, Carpenter W, Cohen EE, et al. American 27. Chaturvedi AK, Engels EA, Anderson WF, Gillison ML.
vaccines in reducing the HPV-related Dental Association Council on Scientic Aairs Expert Panel on Incidence Trends for Human PapillomavirusRelated and
cancers.77 The study estimated that the Screening for Oral Squamous Cell Carcinomas. Evidence- Unrelated Oral Squamous Cell Carcinomas in the United
quadrivalent vaccine can potentially based clinical recommendations regarding screening for States. J Clin Oncol 2008;26:612-619.
oral squamous cell carcinomas. J Am Dent Assoc 2010 28. Edwards BK, Noone AM, Mariotto AB, et al. Annual
prevent the majority of invasive cervical, May;141(5):509-520. Report to the Nation on the status of cancer, 1975-2010,
anal, oropharyngeal and vaginal cancers, 10. Cohan DM, Popat S, Kaplan SE, et al. Oropharyngeal featuring prevalence of comorbidity and impact on survival
almost 25,000 cases annually, and the cancer: Current understanding and management. Curr Opin among persons with lung, colorectal, breast or prostate cancer.
Otolaryngol Head Neck Surg 2009;17:88-94. Cancer 2014;120(9):1290-314.
9-valent vaccine has the potential to 11. Frisch M, Hjalgrim H, Jaeger AB, Biggar RJ. Changing 29. Syrjnen KJ, Surjnen SM. Histological evidence for the
prevent an additional 4,000 cases.77 patterns of tonsillar squamous cell carcinoma in the United presence of condylomatous epithelial lesions in association with
These estimates are very encouraging States. Cancer Causes Control 2000;11(6):489-95. laryngeal squamous cell carcinoma. J Otorhinolaryngol Relat
12. Golas SM. Trends in palatine tonsillar cancer incidence Spec 1981;43(4):181-94.
and call for improved vaccination and mortality rates in the United States. Community Dent Oral 30. Syrjnen K, Syrjnen S, Pyrhnen S. Human papilloma
coverage for both young men and women, Epidemiol 2007;35:98-108. virus (HPV) antigens in lesions of laryngeal squamous cell
before they become sexually active. 13. Hammarstedt L, Dahlstrand H, Lindquist D, et al. The carcinomas. J Otorhinolaryngol Relat Spec 1982;44(6):323-
incidence of tonsillar cancer in Sweden is increasing. Acta 34.
Otolaryngol 2007;127(9):988-92. 31. Syrjnen K, Syrjnen S, Lamberg M, et al. Morphological
Conclusion 14. Syrjnen S. HPV infections and tonsillar carcinoma. J Clin and immunohistochemical evidence suggesting human
HPV-related oropharyngeal Pathol 2004 May;57(5):449-55. papillomavirus (HPV) involvement in oral squamous cell
cancers are increasing, and while HPV 15. Chaturvedi AK, Anderson WF, Lortet-Tieulent J, et al. carcinogenesis. Int J Oral Surg 1983;12(6):418-24.
Worldwide Trends in Incidence Rates for Oral Cavity and 32. PaVE: The papillomavirus knowledge source.
vaccination can reduce the incidence Oropharyngeal Cancers. J Clin Oncol 2013;31(36):4550-9. Papillomavirus Episteme. pave.niaid.nih.gov. Accessed Aug.
of these cancers, early clinical detection 16. Bruyand M, Ryom L, Fatkenheuer G, et al. Cancer risk and 9, 2015.
and lower cancer staging is key to use of protease inhibitor or nonnucleoside reverse transcriptase 33. de Villiers EM. Crossroads in the classication of
inhibitor-based combination antiretroviral therapy: The D: A: D papillomaviruses. Virology 2013;445(1-2):2-10.
patient survival after diagnosis. Focused study. J Acquir Immune Dec Syndr 2015;68(5):568-77. 34. Egawa N, Egawa K, Grin H, Doorbar J. Human
scientific research has started to produce 17. Pinzone MR, Berretta M, Cacopardo B, Nunnari G. Epstein- Papillomaviruses; Epithelial Tropisms and the Development of
reliable prognostic molecular markers Barr virus- and Kaposi sarcoma-associated herpesvirus-related Neoplasia. Viruses 2015;7(7):3863-90.
malignancies in the setting of human immunodeciency virus 35. June 8, 2006 Approval Letter Human Papillomavirus
and novel treatment approaches that, infection. Semin Oncol 2015;42(2):258-71. Quadrivalent (Types 6, 11, 16, 18) Vaccine, Recombinant.
once clinically validated and adopted in 18. Robbins HA, Pfeier RM, Shiels MS, et al. Excess cancers www.fda.gov/BiologicsBloodVaccines/Vaccines/
everyday practice, can forever transform among HIV-infected people in the United States. J Natl Cancer ApprovedProducts/ucm111283.htm. Accessed Aug. 8, 2015.
Inst 2015;107(4):dju503. 36. Zheng ZM, Baker CC. Papillomavirus genome structure,
the landscape of oropharyngeal cancer 19. Beachler DC, Abraham AG, Silverberg MJ, et al. expression and post-transcriptional regulation. Front Biosci
detection, staging and treatment. Incidence and risk factors of HPV-related and HPV-unrelated 2006;11:2286-2302.
F E B R U A R Y 2 0 1 6 99
oropharyngeal cancer
C D A J O U R N A L , V O L 4 4 , N 2
37. Richards KF, Mukherjee S, Bienkowska-Haba M, et al. staging.pdf. Accessed Aug. 12, 2015. 73. FDA Licensure of Bivalent Human Papillomavirus
Human papillomavirus species-specic interaction with the 55. Osborne RF, Brown JJ. Carcinoma of the oral pharynx: An Vaccine (HPV2, Cervarix) for Use in Females and Updated
basement membrane-resident non-heparan sulfate receptor. analysis of subsite treatment heterogeneity. Surg Oncol Clin N HPV Vaccination Recommendations from the Advisory
Viruses 2014;6(12):4856-79. Am 2004;13(1):71-80. Committee on Immunization Practices (ACIP). MMWR
38. Doorbar J. The E4 protein; structure, function and patterns 56. Stupp R, Weichselbaum RR, Vokes EE. Combined modality 2010;59(20):626-629.
of expression. Virology 2013;445(1-2):80-98. therapy of head neck cancer. Semin Oncol 1994;21:349-58. 74. Petrosky E, Bocchini Jr. JA, Hariri S, et al. Use of 9-Valent
39. Ramakrishnan S, Partricia S, Mathan G. Overview of high- 57. Adelstein D, Sharan V, Earle AS, et al. Long-term results Human Papillomavirus (HPV) Vaccine: Updated HPV
risk HPVs 16 and 18 infected cervical cancer: Pathogenesis to after chemoradiation for locally conned squamous cell head Vaccination Recommendations of the Advisory Committee on
prevention. Biomed Pharmacother 2015;70:103-10. and neck cancer. Am J Clin Oncol 1990;13:440-7. Immunization Practices. MMWR 2015;64(11):300-304.
40. Rampias T, Sasaki C, Psyrri A. Molecular mechanisms of 58. Vermorken JB, Remenar E, van Herpen C, et al., EORTC 75. World Health Organization. Weekly epidemiological
HPV induced carcinogenesis in head and neck. Oral Oncol 24971/TAX 323 Study Group. Cisplatin, uorouracil and record. Human papillomavirus vaccines. WHO position paper
2014;50(5):356-63. docetaxel in unresectable head and neck cancer. N Engl J 2014;89:465-492.
41. Goodwin EC, DiMaio D. Repression of human Med 2007;357(17):1695-704. 76. Markowitz LE, Hariri S, Lin C, et al. Reduction in human
papillomavirus oncogenes in HeLa cervical carcinoma cells 59. Wirth LJ, Allen AM, Posner MR, et al. Phase I dose- papillomavirus (HPV) prevalence among young women
causes the orderly reactivation of dormant tumor suppressor nding study of paclitaxel with panitumumab, carboplatin following HPV vaccine introduction in the United States,
pathways. Proc Nat Acad Sci USA 2000;97(23):12513-8. and intensity-modulated radiotherapy in patients with locally National Health and Nutrition Examination Surveys, 2003-
42. Beachler DC, Guo Y, Xiao W, et al. High Oral Human advanced squamous cell cancer of the head and neck. Ann 2010. J Infect Dis 2013;208(3):385-93.
Papillomavirus Type 16 Load Predicts Long-Term Persistence in Oncol 2010;21(2):342-7. 77. Saraiya M, Unger ER, Thompson TD, et al. HPV Typing of
Individuals With or at Risk for HIV Infection. J Infect Dis 2015 60. Mourad WF, Hu KS, Shasha D, et al. Long-term outcome Cancers Workgroup. U.S. assessment of HPV types in cancers:
Nov 15;212(10):1588-91. of seropositive HIV patients with head and neck squamous cell Implications for current and 9-valent HPV vaccines. J Natl
43. Gillison ML, Broutian T, Pickard RK, et al. Prevalence of carcinoma treated with radiation therapy and chemotherapy. Cancer Inst 2015;107(6):djv086.
Oral HPV Infection in the United States, 2009-2010. JAMA Anticancer Res 2013;33(12):5511-6.
2012;307(7):693-703. 61. Guihard S, Ramolu L, Macabre C, et al. The NEDD8 THE AUTHOR,Fariba S. Younai, DDS, can be reached at
44. Kreimer AR, Pierce CM, Lin HY, et al. Incidence and conjugation pathway regulates p53 transcriptional activity and fyounai@dentistry.ucla.edu.
clearance of oral human papillomavirus infection in men: The head and neck cancer cell sensitivity to ionizing radiation. Int J
HIM cohort study. Lancet 2013;382(9895):877-87. Oncol 2012 Oct;41(4):1531-40.
45. King EM, Gilson R, Beddows S, et al. Oral human 62. Goldenberg D, Begum S, Westra WH, et al. Cystic
papillomavirus (HPV) infection in men who have sex with men: lymph node metastasis in patients with head and neck
Prevalence and lack of anogenital concordance. Sex Transm cancer: An HPV-associated phenomenon. Head Neck 2008
Infect 2015;91(4):284-6. Jul;30(7):898-903.
46. DSouza G, Agrawal Y, Halpern J, et al. Oral sexual 63. Zaravinos A. An updated overview of HPV-associated
behaviors associated with prevalent oral human papillomavirus head and neck carcinomas. Oncotarget 2014;5(12):3956-69.
infection. J Infect Dis 2009;199(9):1263-9. 64. Zaravinos A, Mammas IN, Sourvinos G, Spandidos DA.
47. Kreimer AR, Alberg AJ, Daniel R, et al. Oral Molecular detection methods of human papillomavirus (HPV).
human papillomavirus infection in adults is associated Int J Biol Markers 2009;24(4):215-22.
with sexual behavior and HIV serostatus. J Infect Dis 65. Liang C, Marsit CJ, McClean MD, et al. Biomarkers of
2004;189(4):686-98. HPV in head and neck squamous cell carcinoma. Cancer Res
48. Heck JE, Berthiller J, Vaccarella S, et al. Sexual behaviours 2012;72(19):5004-13.
and the risk of head and neck cancers: A pooled analysis 66. Weinberger PM, Yu Z, Haty BG, et al. Molecular
in the International Head and Neck Cancer Epidemiology classication identies a subset of human papillomavirus
(INHANCE) consortium. Int J Epidemiol 2010;39(1):166-81. associated oropharyngeal cancers with favorable prognosis. J
49. Beachler DC, Weber KM, Margolick JB, et al. Risk factors Clin Oncol 2006;24(5):736-47.
for oral HPV infection among a high prevalence population of 67. Rampias T, Sasaki C, Psyrri A. Oral Oncol
HIV-positive and at-risk HIV-negative adults. Cancer Epidemiol 2014;50(5):356-63.
Biomarkers Prev 2012;21(1):122-33. 68. van Kempen PM, Noorlag R, Braunius WW, et al.
50. Beachler DC, Sugar EA, Margolick JB, et al. Risk factors Dierences in methylation proles between HPV-positive
for acquisition and clearance of oral human papillomavirus and HPV-negative oropharynx squamous cell carcinoma: A
infection among HIV-infected and HIV-uninfected adults. Am J systematic review. Epigenetics 2014;9(2):194-203.
Epidemiol 2015;181(1):40-53. 69. Baruah P, Lee M, Wilson PO, et al. Impact of p16 status on
51. Chen CH, Chung CY, Wang LH, et al. Risk of cancer pro- and anti-angiogenesis factors in head and neck cancers.
among HIV-infected patients from a population-based nested Br J Cancer 2015;113(4):653-659.
case-control study: Implications for cancer prevention. BMC 70. Veldhuijzen NJ, Snijders PJ, Reiss P, et al. Factors aecting
Cancer 2015;15:133. transmission of mucosal human papillomavirus. Lancet Infect
52. Castel AD, Young H, Akiwumi AM, et al. Trends in cancer Dis 2010 Dec;10(12):862-74.
diagnoses and survival among persons with AIDS in a high HIV 71. Burchell AN, Coutle F, Tellier PP, et al. Genital transmission
prevalence urban area. AIDS Care 2015;27(7):860-9. of human papillomavirus in recently formed heterosexual
53. Cohan DM, Popat S, Kaplan SE, et al. Oropharyngeal couples. J Infect Dis 2011;204:1723.
cancer: Current understanding and management. Curr Opin 72. Food and Drug Administration. Highlights of prescribing
Otolaryngol Head Neck Surg 2009;17(2):88-94. information. Gardasil 9 (human papillomavirus 9-valent vaccine,
54. Patel SG, Shah JP. TNM Staging of Cancers of the Head recombinant). Silver Spring, Md.: U.S. Department of Health
and Neck: Striving for Uniformity Among Diversity. CA Cancer and Human Services, Food and Drug Administration; 2014.
J Clin 2005;55;242-258. American Cancer Society. www. www.fda.gov/downloads/BiologicsBloodVaccines/Vaccines/
oralcancerfoundation.org/discovery-diagnosis/pdf/TNM- ApprovedProducts/UCM426457.pdf. Accessed Aug. 12, 2015.
100F E B R U A R Y 2 01 6
chemoprevention
C D A J O U R N A L , V O L 4 4 , N 2
Oral Cancer
Chemoprevention: Current
Status and Future Direction
Diana V. Messadi, DDS, MMSc, DMSc, and Kazumichi Sato, DDS, PhD
AUTHORS
C
Diana V. Messadi, DDS, Kazumichi Sato, DDS, ancer chemoprevention transformation and the difficulty in
MMSc, DMSc, is a PhD, is an associate is defined as the use patient recruitment. The most common
professor and chair of the professor in the department
of natural, synthetic OPLs are leukoplakia, erythroplakia
section of oral medicine of oral medicine and oral
and orofacial pain and the and maxillofacial surgery or biological chemical and erosive lichen planus. These lesions
associate dean for at Tokyo Dental College in agents to suppress, are very heterogeneous, varying in
education and faculty Sugano, Ichikawa, Chiba, reduce or prevent the progression of color, size, texture and anatomic site,
development at the Japan. During the carcinogenesis. The term was first with studies showing a wide percentage
University of California, Los preparation of this
coined by Sporn et al.1 It is defined as progressing to malignancy ranging from
Angeles, School of manuscript he was a
Dentistry. research scholar in the drugs that have an effect of slowing 1.1 to 25 percent. This variability arises
Conict of Interest section of oral medicine or stopping cancer development and partly because of the differences in study
Disclosure: None reported. and orofacial pain at the preventing malignant transformation populations (i.e., clinic-based versus
University of California, Los of premalignant lesions. Clinicians population-based), tobacco history and
Angeles, School of
have considered that the best durations of follow-up after leukoplakia
Dentistry.
Conict of Interest target populations for oral cancer diagnosis.5-6 Oral leukoplakia, the most
Disclosure: None reported. chemoprevention are patients with common OPL, is clinically defined as a
oral premalignant lesions (OPLs) and/ white patch or plaque on the oral mucosa
or postoperative oral cancer patients that cannot be removed by scraping
without tumor bearing for prevention and cannot be classified clinically or
of secondary primary tumors.2-4 microscopically as another disease entity.
One of the major obstacles in Biopsy and histopathologic analysis
chemoprevention studies to date has is required to definitively diagnose as
been the inability to identify oral leukoplakia and erythroplakia lesions.
lesions with a high risk of malignant Under the microscope, these lesions
F E B R U A R Y 2 0 1 6 101
chemoprevention
C D A J O U R N A L , V O L 4 4 , N 2
intervention periods when administrating term clinical testing of green tea extract oral rinse in oropharyngeal leukoplakia,
low-dose isotretinoin.17,19 In general, for oral cancer prevention. On the other unfortunately, their study demonstrated
the balance of dose and side effects has hand, a cross over clinical trial of green that ketorolac did not cause leukoplakia
been important for retinoids and beta- tea was reported with a focus on dropout regression as compared to placebo.37
carotene when studying their potential cases. The study showed that the rates of Similarly, Papadimitrakopoulou et al.
use as chemopreventive agents for oral drop out were significantly higher among also reported no effective results of COX-2
cancer (TA BLE 3 ). Although clinical smokers than nonsmokers.31 Only a few inhibitor as a chemopreventive agents in
or histological regression were seen in of the dropout cases were interviewed, OPL (TABLES 1 and 2 ).21 They also
short-term periods of observation, the with bitter taste and teeth staining as the reported some adverse reactions observed
response was reversed when the treatment main reasons for their drop out. Green by patients such as dizziness and oral pain,
was terminated and this resulted in tea extract does not cause bitter taste and including one patient with a grade three
posttreatment lesional recurrences.17,27 teeth staining, but absorption of caffeine cerebrovascular accident (cerebral
should be considered according to patient infarction) (TABLE 3 ). They concluded that
Green Tea preference. Studies are being conducted these results discouraged their
Similar to retinoids and beta- pursuit of this agent as an oral cancer
carotene, green tea has been studied as a chemopreventive agent. These studies
chemopreventive agent for an extensive confirm that using COX-2 inhibitor solely
period. The background for its use stems as a chemopreventive agent for oral cancer
from the idea that drinking green tea
This potential benet is still will unlikely be available in clinical practice.
reduces cancer risk.28 In Japan, with its not strong enough for a
large population of tobacco users (around universal recommendation Bowman-Birk Inhibitor Concentrate
20 percent of adults) and drinking green to drink green tea in order Bowman-Birk inhibitor concentrate
tea as part of its culture, reports show that (BBIC) is defined as a serine protease
oral cancer patients are about 1 percent to prevent oral cancer. inhibitor isolated from soybeans possessing
of all cancer patients and the prevalence domains with trypsin and chymotrypsin
of OPL is 2.5 percent, which is lower than inhibitory activity.38 Although BBIC has
other countries.25,30 The leading compound been shown in some cell culture and animal
in the mechanism of green tea cancer to enhance the bioavailability and studies to inhibit oral carcinogenesis,
chemoprevention is a type of polyphenol, potency of green tea by manufacturing a the specific inhibitory mechanism is still
specifically, epigallocatechin-3-gallate prodrug formulation of EGCG. Another unknown.39-42 It is considered that BBIC
(EGCG). Studies showed that multiple promising approach is to formulate may be acting as a tumor suppressor
signal pathways are involved in the nanoparticles for effective delivery.32-33 similar to the serine protease inhibitors.
inhibitory effect of polyphenols on cancer Despite the promising evidence on It also has anti-inflammatory properties,
cell growth.29-32 A phase II study reported the benefits of green tea in preventing inhibiting free radical production and
by Tsao et al. used three green tea dosages oral and other cancers in animal models altering the levels of several oncogenes
including a 1,000 mg/m2 of green tea and cell cultures, this potential benefit (TABLES 1 and 2 ).22 BBIC has few side
extract based on a previous phase I study.20 is still not strong enough for a universal effects because it is prepared from natural
The clinical response in this phase II study recommendation to drink green tea food and is a common ingredient in
did not reach statistical significance in in order to prevent oral cancer.33 Japanese foods (soybean-based foods
all green tea extract arms versus placebo. such as miso and tofu). Therefore, BBIC,
However, the two higher-dose green tea Cyclooxygenase-2 (COX-2) Inhibitor just like green tea, was expected to be
extract arms had higher responses (clinical The anticarcinogenic properties of an effective chemopreventive agent for
response), confirming dose-response effect COX-2 inhibitor have been thoroughly oral cancer. Recently, Armstrong et al.
(TA BLE 1 ). Although some side effects investigated in multiple experimental performed a phase IIb double-blinded
were observed, the therapy was well and clinical studies.34-37 In case of OPL, placebo controlled study that showed no
tolerated and safe. They concluded that Mulshine et al. reported the use of the difference between the placebo and the
these promising results supported longer- cyclooxygenase inhibitor ketorolac as an BBIC arm in oral cancer prevention.22, 42-43
F E B R U A R Y 2 0 1 6 103
chemoprevention
C D A J O U R N A L , V O L 4 4 , N 2
TABLE 1
Summary of the Nine Studies (eligible participants, study design, control, location of study, sample size, registration period) 1524
Summary of the study
Author Agents Eligible participants Study design Control Location
Year (RCT: randomized
control trial)
Jyothirmayi Vitamin A Head and neck cancer treated with surgery RCT Placebo India
1996 and/or radiation therapy (disease free) two-arm
Khuri Isotretinoin Head and neck cancer treated with surgery RCT (pilot phase III) Placebo USA
2006 (13-cis retinoic acid) and/or radiation therapy (stage 1 or 2) two-arm
multicenter
Papadimitrakopoulou Isotretinoin Premalignant lesions two-arm (open-label Beta-carotene + retinyl USA
2009 (13-cis retinoic acid) trial) single-center palmitate
or retinyl palmitate
alone
Freeze-Dried Black Raspberry and pathway.46 A clinical study using a statistical decrease of histologic grading,
ZengShengPing topical 10% BRB gel applied daily for a whereas placebo gel application did not
Freeze-dried black raspberry (BRB) three-month period demonstrated have a significant impact.23
contains natural ingredients such as statistical significant regression of OPL, ZengShengPing (ZSP) is a registered
vitamin A, vitamin E, beta-carotene, where 41 percent of participants achieved trademark and herbal mixture composed
multiple anthocyanins and phytosterols. a decrease in lesional dysplastic grade of six herbs (Sophora tonkinensis,
These ingredients have been shown to when compared to patients using placebo23 Polygonum bistorta, Prunella vulgaris,
exhibit a chemopreventive effect both in (TABLE 1 ). The authors attributed the Sonchus brachyotus, Dictamnus dasycarpus
an in vitro model using oral cancer cell BRBs chemopreventive effect to its and Dioscorea bulbifera). Although the
lines and in vivo in a pilot study with oral primary phenolic compounds, effective compounds of ZSP have not
leukoplakia patients.44-47 BRB has many anthocyanins. In addition, the comparison yet been identified, individual herbs of
functions, including the suppression of of the histological grade and loss of ZSP are known to contain bioactive
redox-mediated intracellular signaling, heterozygosity (LOH) in the pretreatment chemicals with anti-inflammatory
reducing production of pro-angiogenic versus posttreatment tissues demonstrated and anticancer activities.48 Preclinical
cytokines and stimulating an apoptotic that application of BRB resulted in a studies have shown that ZSP inhibited
104F E B R U A R Y 2 01 6
C D A J O U R N A L , V O L 4 4 , N 2
TABLE 2
Administration Method (period, route of administration); Effects (evaluation point, endpoints, results of endpoints) in Nine Studies 1524
Tsao 12 weeks Oral administration 12 weeks #0 Clinical and histological response (primary endpoint)
2009 500mg/m2, 750mg/m2, #1 Qualitative and quantitative toxicities of GTE
1000mg/m2 #2 Eects of treatment on the expression of biomarkers
(3x daily) (VEGF, p53, Ki-67, Cyclin D1, The p16 promoter methylation)
#3 Any potential correlation between treatment ecacy and/
or toxicity with plasma concentrations of EGCG or caeine
Papadimitrakopoulou 12 weeks Oral administration 12 weeks #0 Clinical response rate (primary endpoint)
2008 100mg or 200mg #1 Histological improvement rate
Armstrong 6 months Oral administration 6 months #0 Percent change in total lesion area (primary endpoint)
2013 (PR,CR ) add 12 (powder + water) #1 Change in clinical impression
months 600 C.I. units of BBIC/day #2 Central pathology review
(2x daily) #3 Change in buccal-cell Neu protein
#4 Change in serum Neu protein
#5 Change in buccal cell protease activity
Mallery 3 months Application 3 months #0 Change in lesional size
2014 (4x daily) #1 Change in histological grade
#2 Change in LOH events
#3 Cumulative responsiveness score
Sun 812 months Oral administration 3.6mg 3 months #0 clinical response (primary endpoint)
2010 (3x daily) (after cessation of #1 AgNOR and PCNA - labeling index
treatment)
vit A: Vitamin A; N.S: not statistically signicant; GTE: Green tea extract; EGCG: epigallocatechin 3-gallate; PR: partial response; CR: complete response;
BBIC: Bowman-Birk inhibitor concentrate; LOH: loss of heterozygosity; BRB: black raspberry
106F E B R U A R Y 2 01 6
C D A J O U R N A L , V O L 4 4 , N 2
Results of endpoints
TABLE 3
Effects (side effects and adverse effects); Qualities of the Nine Studies 1524
13cRA: 13-cis retinoic acid; GTE: green tea extract; BRB: black raspberry
108F E B R U A R Y 2 01 6
C D A J O U R N A L , V O L 4 4 , N 2
to examine the incidence of oral cancer low bioavailability, which results in Side Eects and Adverse Eects
in patients who received the HPV subtherapeutic concentrations at the It is well documented that not all
vaccine. Unfortunately, none of the target site. To overcome the bioavailability OPL lesions progress to oral squamous cell
studies presented in this review had issues, advanced drug delivery systems, carcinoma. Therefore, the justification to
HPV vaccines as one of the variables. designed to provide localized or targeted use chemopreventive agents in all patients
Limitations (Risk of Bias) and delivery of these agents, may represent with OPL is controversial, as these
Intervention of Pharmaceutical Companies. a more viable therapeutic option. treatments will be unnecessary for more
Risk of bias was evaluated for each Nanoparticles has emerged as one of than half of the affected patients. This
mentioned study. These biases the viable delivery systems but caution is the reason that all chemopreventive
included selection bias, performance should be taken when using large amounts agents should have minimal side effects
bias, detection bias, attrition bias and of these particles as neurotoxicity and adverse reactions. One of the most
reporting bias. Although most of them induced by solid lipid nanoparticles severe side effects was reported by
had no serious problems with regard to due to their lipophilicity, may result in Papadimitrakopoulou et al. using COX-2
risk of bias, some studies showed selection crossing of the blood-brain barrier.73 inhibitor as chemopreventive agents in
bias, in regard to bias of allocation which they observed cerebral infarction
and concealment of participants and during the clinical study (TA BLE 3 ).19,27
six of nine studies did not mention They also mentioned that subsequent
the method of randomization. data from other studies indicated adverse
TA B L E 3 illustrates company-
Drug delivery systems for cardiovascular effects of the same agent,
sponsored clinical trials for chemopreventive agents which raised the possibility that it was
commercialized chemopreventive have recently evolved as drug related.19 In addition, EGFRtargeted
agents and agents under production. an important factor in therapy has been shown to include several
In general, companies provide the side effects, such as severe acneiform
pharmaceutical products, so it is chemoprevention success. exanthema or seborrheic dermatitis,
imperative for these studies to show and interstitial pneumonia.49 This is
conflict of interest and independent why most investigators prefer the use
third-party assessments for the of well-tolerated natural compounds
purpose of publication bias.69 Among nine studies summarized in chemopreventive agents.76
in TA B L E 2 , the study by Mallery et
Drug Delivery System al.23 is the only clinical trial that Best Approach for Designing Clinical
Drug delivery systems for used local application as opposed Trials, Systematic Review and Clinical
chemopreventive agents have recently to oral administration. Based on Practice Guidelines
evolved as an important factor in the characteristics of each agent, it In designing clinical practice
chemoprevention success. The is important to consider the agent guidelines, systematic review along with
experiment using solid lipid nanoparticles concentration in tissue and duration documentation of undesirable side effects,
encapsulated curcumin and aspirin for of agents action when choosing an gender, adverse reactions, costs and
chemoprevention of pancreatic cancer administration route. For patients patient preference should be considered.
in a carcinogen-induced hamster model with OPL, topical application has Age should also be considered as well,
is recognized as the new starting point an advantage in that patients can because the administration period and
for cancer chemoprevention.70-72 This apply the agent directly. However, desirable control period of malignant
administration method changed not some agents have a bad taste and transformation differ in elderly people who
only the property of absorption and unpleasant stickiness, so patients may have difficulty in undergoing surgical
metabolism of agents, but also the side deliberately forget to apply them to intervention than in middle-aged people
effects due to dose reduction. The limited avoid the unpleasant taste. Still some who have OPL with wide distribution or
efficacy of several chemopreventive studies consider topical application multiple occurrences. It is also important to
agents in preclinical and clinical as a better alternative due to the prepare the answers for patients inquiries
studies is attributed largely to their direct effect on the oral mucosa.74 such as Will I continue to take this
F E B R U A R Y 2 0 1 6 109
chemoprevention
C D A J O U R N A L , V O L 4 4 , N 2
110F E B R U A R Y 2 01 6
C D A J O U R N A L , V O L 4 4 , N 2
apoptosis in epithelial cells overexpressing prostaglandin road to clinical translation. Caner Prev Res 2011; 4:296-298. regimen demonstrates signicant suppression of pancreatic
endoperoxide synthase 2. Cell 1995; 83:493-501. 52. Cheng AL, Hsu CH, Lin JK, et al. Phase I clinical trial of cancer neoplastic lesions. Cancer Prev Res (Phila) 2013;
35. Learhy KM, Ornberg RL, Wang Y, et al. Cyclooxygenase-2 curcumin, a chemopreventive agent, in patients with high-risk or 6:1015-1025.
inhibition by celecoxib reduces proliferation and induces premalignant lesions. Anticancer Res 2001; 21:2895-2900. 71. Yang CS, Wang H, Hu B. Combination of chemopreventive
apoptosis in angiogenic endothelial cells in vivo. Cancer Res 53. Kim SG, Veena MS, Basak SK, Han E, et al. Curcumin agents in nanoparticles for cancer prevention. Cancer Prev Res
2002; 62:625-631. Treatment Suppresses IKKb Kinase Activity of Salivary Cells (Phila) 2013; 61011-1014.
36. Caponigro F, Milano A, Basile M, et al. Recent advances of Patients With Head and Neck Cancer: A Pilot Study. Clin 72. Sharma D, Sukumar S. Big punches come in nanosizes for
in head and neck cancer therapy: The role of new cytotoxic Cancer Res 2011Sep 15;17(18);5953-61. chemoprevention. Cancer Prev Res (Phila) 2013; 6:1007-
and molecular-targeted agents. Curr Opin Oncol 2006; 54. Bansal SS, Goel M, Aqil F, et al. Advanced drug delivery 1010.
18:247-252. systems of curcumin for cancer chemoprevention. Cancer Prev 73. Helson L. Curcumin (diferuloylmethane) delivery methods:
37. Mulshine JL, Atkinson JC, Greer RO, et al. Randomized, Res (Phila) 2011; 4:1158-1171. A review. Biofactors 2013; 39:21-26.
double-blind, placebo-controlled phase IIb trial of the 55. Brewster AM, Patterson SL, Forman MR, et al. Conference 74. Brown RS, Edwards D, Walsh-Chocolaad T, et al. Topical
cyclooxygenase inhibitor ketorolac as an oral rinse in Report: Eighth Annual AACR International Conference on tacrolimus with custom trays in the treatment of severe oral
oropharyngeal leukoplakia. Clin Cancer Res 2004;10:1565- Frontiers in Cancer Prevention Research. Cancer Prev Res chronic graft-versus-host disease refractory to a potent topical
1573. 2010; 3:1044-1048. steroid therapy: A case report. Oral Surg Oral Med Oral
38. Birk Y. The Bowman-Birk inhibitor. Trypsin- and 56. William WN Jr. Oral premalignant lesions: Any progress Pathol Oral Radiol 2013; 115:e26-e30.
chymotrypsin-inhibitor from soybeans. Int J Pept Protein Res with systemic therapies? Curr Opin Oncol 2012; 24,205-210. 75. Iqbal Z, Jain N, Jain GK, et al. Dental therapeutic systems.
1985; 25:113-131. 57. Burotto M, Szabo E. PPAR in head and neck cancer Recent Pat Deliv Formul 2008; 2:58-67.
39. Messadi DV, Billings P, Shklar G, et al. Inhibition of oral prevention. Oral Oncol 2014; 50:924-929. 76. Saba NF, Haigentz M Jr, Vermorken JB, et al. Prevention
carcinogenesis by a protease inhibitor. J Natl Cancer Inst 58. Reid JM, Walden CA, Qin R, et al. Phase 0 clinical of head and neck squamous cell carcinoma: Removing the
1986; 76:447-452. chemoprevention trial of the Akt inhibitor SR13668. Cancer chemo from chemoprevention. Oral Oncol 2015; 51:112-
40. Armstrong WB, Wan XS, Kennedy AR, et al. Development Prev Res 2011; 4:347-353. 118.
of the Bowman-Birk inhibitor for oral cancer chemoprevention 59. Casto BC, Knobloch TJ, Galioto RL, et al. Chemoprevention
THE CORRESPONDING AUTHOR, Diana V. Messadi, DDS, MMSc,
and analysis of Neu immunohistochemical staining of oral cancer by lyophilized strawberries. Anticancer Res
intensity with Bowman-Birk inhibitor concentrate treatment. 2013; 33,4757-4766. DMSc, can be reached at dmessadi@dentistry.ucla.edu.
Laryngoscope 2003; 113:1687-1702. 60. Martinez VD, MacAulay CE, Guillaud M, et al. Targeting
41. Wan XS, Meyskens FL Jr, Armstrong WB, et al. Relationship of chemoprevention to high-risk potentially malignant oral
between protease activity and neu oncogene expression in lesions: Challenges and opportunities. Oral Oncol 2014;
patients with oral leukoplakia treated with the Bowman-Birk 50:1123-1130.
inhibitor. Cancer Epidemiol Biomarkers Prev 1999; 8:601- 61. Mao L, Lee JS, Fan YH, et al. Frequent microsatellite
608. alterations at chromosomes 9p21 and 3p14 in oral
42. Armstrong WB, Kennedy AR, Wan XS, et al. Single-dose premalignant lesions and their value in cancer risk assessment.
administration of Bowman-Birk inhibitor concentrate in patients Nat Med 1996; 2:682-685.
with oral leukoplakia. Cancer Epidemiol Biomarkers Prev 62. Warnakulasuriya S, Dietrich T, Bornstein MM, et al. Oral
2000; 9:43-47. health risks of tobacco use and eects of cessation. Int Dent J
43. Armstrong WB, Kennedy AR, Wan XS, et al. Clinical 2010; 60:7-30.
modulation of oral leukoplakia and protease activity 63. Gupta PC, Murti PR, Bhonsle RB, Mehta FS, Pindborg JJ.
by Bowman-Birk inhibitor concentrate in a phase IIa Eect of cessation of tobacco use on the incidence of oral
chemoprevention trial. Clin Cancer Res 2000; 6:4684-4691. mucosal lesions in a 10-year follow-up study of 12,212 users.
44. Shumway BS, Kresty LA, Larsen PE, et al. Eects Oral Dis 1995;1(1):54-58.
of a topically applied bioadhesive berry gel on loss of 64. Syrjnen S, Lodi G, von Bltzingslwen I, et al. Human
heterozygosity indices in premalignant oral lesions. Clin Cancer papillomaviruses in oral carcinoma and oral potentially
Res 2008; 14:2421-2430. malignant disorders: A systematic review. Oral Dis 2011; 17
45. Wang LS, Stoner GD. Anthocyanins and their role in Suppl 1:58-72.
cancer prevention. Cancer Lett 2008; 269:281-90. 65. Saulle R, Semyonov L, Mannocci A, et al. Human
46. Xue H, Aziz RM, Sun N, Cassady JM, Kamendulis LM, Xu papillomavirus and cancerous diseases of the head and
Y, et al. Inhibition of cellular transformation by berry extracts. neck: A systematic review and meta-analysis. Oral Dis 2014;
Carcinogenesis 2001; 22:351-6. doi:10.1111/odi.12269.
47. Kresty LA, Morse MA, Morgan C, Carlton PS, Lu J, Gupta 66. Friedman JM, Stavas MJ, Cmelak AJ. Clinical and scientic
A, et al. Chemoprevention of esophageal tumorigenesis by impact of human papillomavirus on head and neck cancer.
dietary administration of lyophilized black raspberries. Cancer World J Clin Oncol 2014; 10:781-791.
Res 2001; 61:6112-9. 67. Beachler DC, Abraham AG, Silverberg MJ, et al. Incidence
48. Ding Z, Gao F, Lin P. Long-term eect of treating patients and risk factors of PV-related and HPV-unrelated Head and
with precancerous lesions of the esophagus. Zhonghua Zhong Neck Squamous Cell Carcinoma in HIV-infected individuals.
Liu Za Zhi 1999; 21(4):275-277. Oral Oncol 2014; 50:1169-1176.
49. Mak MP, William WN Jr. Targeting the epidermal growth 68. Zaravinos A. An updated overview of HPV-associated
factor receptor for head and neck cancer chemoprevention. head and neck carcinomas. Oncotarget 2014; 30:3956-
Oral Oncol 2014; 50:918-923. 3969.
50. Park W, Amin AR, Chen ZG, et al. New perspectives of 69. Mulshine JL, Ondrey FG. Not signicant but important.
curcumin in cancer prevention. Cancer Prev Res 2013; 6: Cancer Prev Res 2013; 6:371-374.
387-400. 70. Grandhi BK, Thakkar A, Wang J, et al. A novel
51. Shureiqi L, Baron JA. Curcumin chemoprevention: The long combinatorial nanotechnology-based oral chemopreventive
F E B R U A R Y 2 0 1 6 111
stem cells
C D A J O U R N A L , V O L 4 4 , N 2
AUTHORS
C
Qilin Xu, MD, PhD, is a Anh D. Le, DDS, PhD, is ancer that forms in the However, cancer is widely understood to
clinician scientist who the Norman Vine professor tissues of the oral cavity or be a heterogeneous disease and there is
studies stem cells and and chair of the
the oropharynx is referred increasing awareness that intratumoral
cancer. She has extensive department of oral and
expertise in tumor maxillofacial surgery at the
to as oral cancer, which is heterogeneity contributes to treatment
microenvironment, cancer University of Pennsylvania among the 10 most common failure and disease progression.3 It is
metastasis and cancer stem School of Dentistry. She is cancers worldwide. It was estimated becoming increasingly clear that cancer
cells. Dr. Xu currently a diplomate of the that in 2014 there would be 45,780 new cells display features of normal tissue
directs independent American Board of Oral
cases affecting the oral cavity of both organization, whereby cancer stem cells
research projects in the oral and Maxillofacial Surgery
and maxillofacial surgery and fellow of the American
sexes with an estimated death rate of (CSCs) can drive tumor growth. Like
research lab at the Association of Oral and 8,390 in the U.S. alone.1 Among all oral other forms of cancer, oral cancer also
University of Pennsylvania Maxillofacial Surgeons. mucosal origins, about 90 percent are exhibits the property of heterogeneity
School of Dentistry. Conict of Interest oral squamous cell carcinoma (OSCC).2 and majorly comprises three different
Conict of Interest Disclosure: None reported.
OSCC occurs most commonly on the soft types of tumor cells, including bulk tumor
Disclosure: None reported.
palate, roof or floor of the mouth, gingiva, cells with a high degree of differentiation,
tongue and other areas of the oral cavity. transit amplifying cells with maximum
Despite advances in cancer treatment, proliferation and a small population of
many patients still fail in therapy, resulting cells with elevated plasticity (self-renewal
in disease progression, recurrence and capacity) that may contribute to the
reduced overall survival. Historically, tumor diversity.4-6 The growth and spread
a lot of attention has been directed of oral cancer is driven by these so-called
toward understanding the genetic and cancer stem-like cells or tumor-initiating
biochemical mechanisms that cause cells (TICs), which are capable of long-
resistance to chemo- and radiotherapies. term self-renewal and generation of the
112F E B R U A R Y 2 01 6
C D A J O U R N A L , V O L 4 4 , N 2
Normal cells
Cancer stem
cells (CSC) Self-renewal
Major genetic/epigenetic event
Transient
amplifying cells
FIGURE 1A . The stochastic model indicates a clonal evolution of cancer and FIGURE 1B. The cancer stem cell model postulates that cancer is organized in
postulates that cancer cell phenotypes are primarily dened by intrinsic factors, a hierarchical structure that, at least in part, resembles that of the tissue of origin.
in particular, driver mutations. The tumorigenic potential is limited to the cancer stem cell subpopulation and its
cellular heterogeneity is a product of multipotent cancer stem cells.
FIGURES 1. Models of tumor heterogeneity.
phenotypically diverse populations of CSCs Hypothesis in Oral Cancer these states are, at least in part, reversible.
tumor cells. Accumulating evidence has There are two models that account Intrinsic properties and extrinsic selection
implicated an important role of CSCs for heterogeneity and inherent pressure allow some mutant subclones with
in cancer progression, invasion, distant differences in tumor-regenerating survival advantages to become dominant
metastasis and recurrence, the reasons capacity: the stochastic or clonal while others become extinct or remain
behind the high morbidity and mortality of evolution and the hierarchy or cancer dormant (FIGURE 1A ).5,10,11,13 Based on
the majority of patients with oral cancer.7-9 stem cell model (FIGURE 1 ).10-12 the stochastic model and the assumption
In this narrative review, we will discuss In the stochastic model, malignant that the vast majority of tumor cells
the CSCs hypothesis in oral cancer and transformation arises from a random are able to propagate and drive tumor
the traits displayed by CSCs. Specifically, mutation that can affect any cell. Cancers growth, the goal of cancer treatment has
we will focus on the markers of CSCs and evolve by a reiterative process of clonal traditionally been to kill all cancerous cells.
how they are linked to metastasis and expansion of mutant cell progeny This theory has been challenged
resistance to chemo- and radiotherapies. with proliferative advantage, genetic recently by the CSCs hypothesis, which
Finally, we will discuss the novel approach diversification and clonal selection due to proposes that, similar to the hematopoietic
for developing new strategies to overcome intrinsic (e.g., activated signaling pathways, system, only one cell type, the CSCs, can
therapeutic resistance through specific etc.) and extrinsic factors (e.g., hypoxia, initiate tumors.5 The CSC model posits that
elimination of CSCs in oral cancer. stress, drug treatment, etc.), and that some cancers are organized into a hierarchy
F E B R U A R Y 2 0 1 6 113
stem cells
C D A J O U R N A L , V O L 4 4 , N 2
of subpopulations of tumorigenic CSCs CSCs are responsible for maintaining tumor The identification and formulation
and their nontumorigenic progeny. And growth is also based on the findings that of new methods for CSCs in oral cancer
cellular heterogeneity of the cancer is a CSCs transplanted into nonobese diabetic/ remains a challenge for targeting oral
product of multipotent CSCs (FIGURE 1B ). severe combined immunodeficiency (NOD/ cancer. CSCs in OSCCs have been
CSCs exhibit self-renewal and multilineage SCID) mice not only displayed significant defined by diverse methodologies using
differentiation potentials, which are self-renewal ability but also promoted cell lines, primary tumor specimens and
achieved by symmetric and asymmetric tumor growth through their aberrant patient-derived xenografts (PDX).24
divisions, respectively. The asymmetric differentiation capacity, thus reproducing A number of assays, such as sphere
division leads to a generation of transient the heterogeneity of the original tumor.19 In formation, side population (SP) by
amplifying cells with more restricted lineage vitro culture of purified CD133+ oral CSCs Hoechst dye exclusion, Aldefluor and
potential, which eventually produces in a serum-free culture condition generated the expression of different cell surface
the most differentiated progenies. Tumor only about 60 percent CD133+ cells, also markers (e.g., CD44, CD133) have been
cells lacking stem cell properties, or indicating that CSC-formed sphere-like used to identify, isolate and subsequently
nontumorigenic cancer cells, will not be bodies are still heterogeneous by nature.20 characterize CSCs populations in
able to initiate self-propagating tumors, squamous cell carcinomas. Specific
regardless of their differentiation status markers like aldehyde dehydrogenase
or proliferative capacity. In these cases, 1 (ALDH1), CD44 and Bmi-1 have
CSCs are thought to drive tumor growth shown early promising results both in
and disease progression perhaps because
The identication and CSCs detection and in guiding treatment
of their intrinsic capabilities of metastasis formulation of new protocols. Long-surviving cells in the oral
and resistance to therapies.14,15,16 However, methods for CSCs in oral mucosa can be identified through labeling
the cellular and molecular mechanisms cancer remains a challenge and flow cytometry. Interestingly, oral
that govern the dynamic transition from CSCs populations show upregulation of
CSCs to transient amplifying cells and for targeting oral cancer. the stem cell-related genes such as Oct-4,
vice versa are still poorly understood, Nanog, Nestin, CK19, BMI-1, CD117
although some key embryonic and (c-kit), CD44 and CD133 with depressed
developmental pathways, such as Hedgehog expression of genes associated with
or Wnt pathways that are active in Identication of CSCs differentiation.25 Moreover, the CD117
noncancerous stem cells, have also been By definition, both CSCs and normal (c-kit), CD44 and CD133 are highly
demonstrated to be active in CSCs.17 tissue stem cells possess self-renewal capacity; expressed within the poorly differentiated
The paradigm of tumor heterogeneity however, self-renewal is typically deregulated metastatic stages of oral cancer
and CSCs hypothesis also apply to oral in CSCs. For many cancers, CSCs represent patients, thus contributing to invasion,
cancer.8,18 The existence of CSCs in a distinct population that can be prospec- malignancy and worse prognosis.21
head and neck squamous cell carcinoma tively isolated from the remainder of the Once the unique subpopulation of
(HNSCC) was first described in 2007 tumor cells and can be shown to have tumor cells has been isolated, functional
by Prince et al., which were isolated and long-term clonal repopulation and self- xenotransplantation assay, the gold
identified according to the expression of the renewal capacity the defining features of a standard for CSCs identification, is used to
cell surface marker CD44.19 A subsequent CSC. CSCs are defined by their ability to: assess the tumorigenicity and self-renewal
study on OSCC reported that about 60 Generate a xenograft that is potential of putative CSCs populations in
percent of cells were positive for stem cell representative of the parent tumor. vivo.25,26 Interestingly, the CD44+ CSC-like
markers Oct-4, Nanog, CD133, CD117 and Self-renew as demonstrated by oral cancer cells are more commonly found
ABCG2.20 Later on, other studies attempted serial passages in a xenograft to be less than 10 percent and have the
to isolate CSCs from oral squamous cell assay at clonal cell doses. potential to form tumors when transplanted
carcinomas according to the expression Give rise to daughter cells that may into NOD/SCID immunocompromised
of distinct stem cell-related markers like possess proliferative capacity but are mice.19 These tumors are responsible for
CD44, CD133, CD117, OCT-4 and unable to establish or maintain the a tumors cellular heterogeneity and can
aldehyde dehydrogenase.21,22 The idea that tumor clone upon serial passages.23 be serially subcultured while maintaining
114F E B R U A R Y 2 01 6
C D A J O U R N A L , V O L 4 4 , N 2
the properties of CSCs. In contrast, the been explored extensively, the detection CSCs and Metastasis
CD44 counterparts are incapable of of CSC markers in the tumor-adjacent Mortality in oral cancer often results
inducing tumor formation. In certain tumor normal mucosa has provided evidence from metastasis to regional lymph
cases, a small subset of cancer cells that to support their possible role in field nodes and distant organs, and CSCs
are CD133+ possess higher clonogenicity, cancerization. Recent studies revealed that may be critical players of metastasis.
invasiveness and increased in vivo tumor-adjacent normal tissues showed an Because CSCs have been isolated from
tumorigenicity as compared to CD133 increased expression of the CSC markers primary tumors as well as metastatic
counterparts. Meanwhile, these CD133+ ATR and ABCG1.30,31 Studies in rat oral sites, an important question is whether
CSC-like cells displayed significantly carcinogenesis models have also shown there are distinct subsets of CSCs that
increased resistance to conventional expression of CSC-related markers, are either stationary or migratory.33 If
chemotherapy both in vitro and in vivo.27 OCT4 and SOX2, in the clinically these are two distinct pools, it will be
normal and dysplastic oral mucosa.32 necessary to therapeutically target both.
CSCs and Field Cancerization These results were further validated by Preliminary work in HNSCC cell lines
OSCC has a high propensity for the findings that these CSC-related shows that the highly metastatic cell
local failure, which is attributed to lines have almost 20 times more SP cells
recurrence at the primary site or the as compared to their weakly metastatic
development of second primary tumors parental cell line.34 However, additional
(SPT). Field cancerization that refers to work is required to assess the in vivo
the existence of transformed cells in areas Recent studies revealed metastatic ability of these populations and
adjacent to the primary tumor has been that tumor-adjacent normal answer the questions mentioned above.
one of the probable reasons underlying tissues showed an increased These SP populations did show stem-
disease relapse. The concept of field like characteristics of chemoresistance,
cancerization, coined by Slaughter in
expression of the CSC increased in vitro invasiveness and an
1953, proposes that the normal tissue markers ATR and ABCG1. activation of signaling pathways that
adjacent to the tumor harbors certain are involved in stem cell self-renewal,
preneoplastic genetic fingerprints, which as compared to non-SP cells.34
can eventually lead to development Epithelial-mesenchymal transition
of local recurrence or second primary markers were also highly expressed in (EMT) is a developmental program
tumors. Slaughter and his group based this the clinically normal mucosa adjacent to that, when activated in cancer cells,
concept on the following observations: tumors and in the precancerous lesions increases invasiveness and motility.35
Tumor-adjacent mucosa being of oral cancer patients.32 Apart from the Given the importance of EMT in
molecularly abnormal. possible role of CSCs in the development facilitating dissemination of cancer
Multifocal areas of precancerous of the neoplastic field associated with cells, a relevant question appears as to
changes develop due to a oral carcinogenesis, the expression of what is the contribution of EMT to the
prolonged and widespread these markers (OCT4 and SOX2) in the process of self-renewal of metastatic
exposure to carcinogens. normal tissues adjacent to tumors also CSCs. The answer to this important
Oral cancer often consists of suggests a de-differentiation-mediated question comes from the landmark
multiple independent lesions origin of these CSCs. Taken together, work by Mani and colleagues, who
that sometimes coalesce. establishment and experimental validation showed that the induction of the EMT
The formation of second of this concept will provide new insights program in immortalized mammary
primary tumors and recurrences into the mechanism of loco-regional epithelial cells caused them to acquire
can be explained by the recurrence and development of SPTs. stem-like properties in addition to the
presence of residual abnormal Identification of CSC-specific molecules mesenchymal phenotype.16 Subsequently,
tissue after surgery.28,29 that drive the filed cancerization process their work cemented this connection
Even though the concept of the may be useful for early diagnosis, prognosis by showing the EMT promoter ZEB1
CSCs potentially being responsible for and development of novel targets for also promotes stemness by repressing the
field cancerization in OSCC has not the prevention and treatment of SPTs. miRNAs that target stemness factors.36
F E B R U A R Y 2 0 1 6 115
stem cells
C D A J O U R N A L , V O L 4 4 , N 2
The connection between EMT and divide again and finally differentiate to HPV-positive HNSCC responded more
self-renewal has also been explored in oral become proliferating cells in order to form favorably to treatment than did patients
cancer. CSCs isolated from tumors of oral the epithelium. Studies showed that the with HPV-negative HNSCC because
cancer patients have features consistent HPV-positive cells can express oncogenic HPV-positive tumors might harbor fewer
with EMT, namely loss of expression of proteins E6 and E7, which target important CSCs. Nevertheless, in vivo limiting
epithelial markers like E-cadherin and proteins including p53, pRb, Notch-1, cell dilution experiments revealed that
acquisition of mesenchymal markers p16, cyclinD1 and EGFR.41,47 A positive CSC frequency is greater in HPV-positive
such as Vimentin and Snail.37 Snail is a correlation has also been established tumors than in HPV-negative tumors.50
master regulator of EMT and controls between HPV infection and carcinoma Indeed, data from a large cohort of patients
invasiveness and metastasis in many of the tonsil and oral tongue cancer. HPV indicates that HPV16-positive HNSCC
cancers.38 The stem-like properties of these initially produces a premalignant lesion is associated with increased ALDH1
CSCs are dependent on Snail expression, of heterogeneous cells with different staining in tumor cells.50 Therefore,
suggesting a causal link between EMT states of the viral genome and persistent this study suggested that patients with
and stemness.37,39 In a recent study, it was infection then progresses toward malignant HPV-positive HNSCC have a better
proven that the EMT regulator, Twist, prognosis and respond more favorably to
directly regulates the stemness factor Bmi1 chemotherapy and radiation therapy than
in head and neck cancer.40 These studies do patients with HPV-negative HNSCC,
further demonstrate the link between EMT likely due to CSC phenotype or quality.51
and stemness in head and neck cancer.
With the decline of tobacco In addition, CSCs from HPV-positive and
use in the U.S., smoking- HPV-negative HNSCC cell lines are very
HPV and Its Role in CSCs related (HPV-negative) resistant to cisplatin therapy.52 Moreover,
Human papillomavirus (HPV), a oropharyngeal malignancy in vivo studies indicated that cells on
sexually transmitted infection, has been the bulk of HPV-positive HNSCC might
identified as an etiologic agent for an cases have decreased. respond better to platinum-based cancer
overwhelming majority of OSCCs in therapy.52 Further studies are warranted to
the U.S.41 With the decline of tobacco elucidate the relation of HPV infection
use in the U.S., smoking-related (HPV- and CSC formation in HNSCC.
negative) oropharyngeal malignancy transformation. A study showed that
cases have decreased.42 The proportion HPV E6 and E7 activated Wnt signaling CSCs and Resistance to Therapy
of oropharyngeal cancers attributable to pathway in HPV16-positive oropharyngeal As for most types of cancers,
HPV (HPV-positive OSCC) has risen squamous carcinoma cells and might be conventional treatment for oral
substantially in the U.S. Indeed, while involved in de-differentiation to CSCs cancer includes surgery, radiation and
only 16 percent of OSCCs in the 1980s from oral cancer cells.48 Moreover, recently chemotherapy, which can be used alone
were HPV-positive, approximately 73 a new HPV-positive UM-SCC-104 or in combination. Chemotherapy, apart
percent of tumors in the 2000s were HNSCC cell line has been identified that from antibody treatment, remains the
HPV-positive.42 Patients with HPV-OSCC has a subpopulation of ALDH+ CSCs, only systemic treatment option that can
have significantly better prognosis than which is highly tumorigenic, that can at anytime be combined with surgery and
those with HPV-negative OSCC.43-45 self-renew and has the capacity to recreate radiation. Clinically, the use of radiation
A significant carcinogenesis has been tumor heterogeneity.49 However, it is not and high-dose chemotherapy, in many
associated with high-risk HPV 16 and clear whether the CSCs are originated instances, results in good initial responses
18 infections to oral epithelium. During from infected epithelial stem cells that of tumors, unless the dosage is limited
skin abrasions, infection occurs with have transformed to become CSCs or by co-morbidities. Unfortunately, the
basal stem cells, which is the only site from differentiated epithelial cells that frequent development of unresponsiveness
of HPV infection, in the host through a will subsequently give rise to new CSCs. to further treatment raises the question
disturbed epithelial wall.46 After infection, To date, the effects of HPV16 on pertaining to the underlying causes.
the viral DNA is retained in basal stem CSCs are not well understood. One Advances in CSC research may provide
cells. These HPV-positive stem cells then idea in the field was that patients with some explanation to these phenomena.
116F E B R U A R Y 2 01 6
C D A J O U R N A L , V O L 4 4 , N 2
Tumor
degenerate
Tumorigenesis CSC-targeted Tumor regression
therapy
Elimination of CSCs
Heterogeneous
tumor cells
Conventional
Cancer stem cell (CSC) cancer therapy
CSCs lead to tumor regrowth/metastasis
Transient amplifying cell
Recurring tumor/
Dierentiated tumor cell disseminated malignancy
FIGURE 2. Therapeutic implications of cancer stem cells. Cancer stem cells (red) self-renew and dierentiate within the tumors to form additional cancer stem cells as well as transient
amplifying cells (green) and dierentiated tumor cells (blue), which have limited proliferative potential. Conventional therapy that kills primarily nontumorigenic cancer cells can shrink
tumor size, but is not able to eliminate cancer stem cells (CSCs), which are the potential players in recurring tumor and metastasis. Targeting CSCs can lead to tumor regression.
In the past few years, studies have relative to CD44low cells after treatment is unknown, but it does hold promise for
begun to investigate the role of CSCs with a panel of cytotoxic drugs including novel therapeutic strategies. Oral CSCs
in the therapeutic resistance of cancers. 5-FU, docetaxel, paclitaxel, cisplatin also express high levels of ATP binding
In these studies, cell surface markers and carboplatin as well as radiation.55 cassette (ABC) transporters that can
were used to identify and purify CSCs Cisplatin-resistant HNSCC cells express actively efflux drugs and shield them from
from tumors. These studies showed that high levels of stem cell surface markers the adverse effects of chemotherapeutic
the fraction of CSCs is enriched in (CD133 and c-Kit) as well as stemness insult. For example, oral CSCs upregulate
tumor samples or cancer cell cultures markers Oct4, Nanog, Nestin and Bmi1.56 different types of ABC transporters and
after treatment with radiation or Likely, radiation resistance has been confer chemoresistance and the detail
chemotherapeutic drugs, and it was shown to increase CSC subpopulations mechanism needs to be explored.27,62,63
therefore proposed that CSCs are in SCC cell lines and primary tumors.37,53 In addition to an increased drug efflux
particularly resistant to radiotherapy37,53 Most recently, a study showed that oral capacity, CSCs also exhibit intrinsic
and chemotherapy.54,55,56 This resistance CSCs undergoing EMT represent the resistance to apoptosis and play an
could then possibly contribute to majority of invasive cells and are more important role in therapy resistance in
treatment failure and, consequently, radioresistant than any other populations oral cancer. For example, the CD44high/
CSCs could represent a novel target for in reconstructed 3-D tissues.59 EGFRlow population exhibits an EMT
therapeutic treatment.57,58 The therapy Acquired therapy resistance in phenotype and resistance to radiotherapy,
response and sensitivity of oral CSCs CSCs can arise by different mechanisms cisplatin and EGFR-targeted therapies.64
is measured through sphere-forming that confer survival advantage during Survivin, a member of the inhibitor
capacity, SP status and ALDH activity to treatment. The DNA protection of apoptosis proteins (IAP) family,
a variety of chemotherapeutic drugs and and damage repair pathways lead to has been identified as one of the most
radiations. For example, cells from tumor momentous resistance to radiation and crucial biomarkers in the recognition of
spheres of esophageal cancer (EC) showed chemotherapy, which has been shown drug resistance. Knockdown of survivin
greater resistance to cisplatin than to in glioblastoma.57,60 Another mechanism by siRNA could induce apoptosis and
EC cells grown under differentiating of CSC radioresistance is increased free enhance radiosensitivity in OSCC cells
conditions.54 Other studies have shown radical scavenging and reduced levels of in vitro and in vivo.65 Livin, one of the
therapy resistance in CSCs defined reactive oxygen species (ROS), which has most important members of the IAP
by cell surface markers. A CD44high been shown in breast cancer.61 Whether family, is associated with invasive and
subpopulation from oral cancer cells radioresistance of oral cancers is mediated oncogenic phenotypes such as tumor
showed increased viability and survival through similar molecular mechanisms cell invasion, tumor cell migration,
F E B R U A R Y 2 0 1 6 117
stem cells
C D A J O U R N A L , V O L 4 4 , N 2
tumor cell proliferation and resistance CD44v6 was not exclusively targeting the recently described CD8 defined T-cell
to apoptosis in human OSCC cells.66 CSCs. In later dose-escalation studies, epitope of ALDH177 or the development
Recent studies showed that increased the antibody was coupled to mertansine, of a CSC-dendritic cell vaccine.78 Success
expression of survivin in breast and a cytotoxic drug, but toxic effects were of these potential therapies will depend
colon CSCs represent one of the major severe,70,71 indicating that the drug may on how well immunological responses
factors involved in increased resistance to not be selective enough for this approach. to CSCs can be modulated, for example,
apoptosis and chemotherapy.67,68 Future This observation is experimentally by vaccine adjuvants upregulating
studies are required to investigate whether supported by immunohistologic studies antigen-processing and presentation.
oral CSCs have an increased expression showing that the expression of CD44v6 is An alternative immunotherapeutic
of survivin that may also contribute not exclusively restricted to the tumor.72 approach to target OSCC is the use
to their increased resistance to both Swaminathan and colleagues developed of monoclonal antibodies. Different
chemotherapy and radiation therapy. polymeric nanoparticles (CD133NPs) strategies have thus far entered the clinic:
consisting of a monoclonal antibody Antibodies directed against
Targeting CSCs in Current Cancer against CD133, paclitaxel (a conventional tumor surface antigens trigger
Treatment immune effector cells that
The increasing knowledge of the cause tumor cell death.
existence and biology of CSCs has led Antibodies that are conjugated
to the study of their specific elimination, These strategies have to cytotoxins or radiation
which can be of clinical benefit because resulted in various degrees emitters causing cell damage
an eradication of the root of cancer directly upon binding.
of improved prognosis and
would stop tumor growth and ultimately Antibodies blocking or inhibiting
lead to tumor involution as bulk tumor survival but have not yet cellular pathways after binding
cells die off or succumb to therapy displayed equal success to the respective receptor.
(FIGURE 2 ). The characteristics of a in regards to a cure. These strategies have resulted
given CSC population for their marker in various degrees of improved
gene expression and their proliferative prognosis and survival but have not
state or drug resistance may support the yet displayed equal success in regards
decision for certain treatment options. chemo-agent) and a fluorescence probe.73 to a cure. This variable success can be
As CSCs can be identified based on The effectiveness of CD133NPs as explained by tumor immune-escape
their cell surface molecules, developing anti-CSC agents was demonstrated in (e.g., downregulation of the target)
specific antibodies/immunotoxins against a remarkable reduction in the ability of and a heterogeneous expression of
these antigens will be a useful way to mammosphere and colony formation as the antibody targets in the tumor.
eradicate CSCs selectively. Akin to many compared to the untreated control or A number of studies investigating
solid tumors, OSCCs are histologically paclitaxel-only treated cells. Also, in vivo the use of antibodies to target CSCs
heterogeneous for the expression of the tumor growth was reduced significantly in of solid cancers are underway.79,80
CD44 marker. CD44v6 antibodies either the CD133NP-treated animal groups.73 Heterogeneous signals from tumor
radiolabeled or coupled with a cytotoxic Several lines of evidence have microenvironments nurture cancer stem
drug entered phase I clinical testing in shown that different mechanisms can cells.81 Pharmacological interruptions of
head and neck cancer patients. However, protect CSCs from T-cell-mediated these paracrine-signaling systems thus
the use of CD44 as a specific marker to immunosurveillance and NK-cell- have therapeutic potential to eradicate
identify CSCs in head and neck cancer mediated cytotoxicity.74-76 Therefore, CSCs in the tumor bulk. Epidermal
remains controversial. In a phase I dose- immunotherapies specifically targeting growth factor receptor (EGFR) is
escalation study, the treatment with a CSCs are very promising approaches to overexpressed in approximately 90
radiolabeled antibody showed promising overcome the therapeutic resistance. percent of tumors. Recent research
antitumor effects.69 One patient, however, CSCs can be eliminated selectively by results implicated a possible role of
developed toxic epidermal necrolysis developing antitumor T-cell vaccines. EGFR in regulating OSCC-CSCs.82
and died, indicating that perhaps anti- One potential target in HNSCC is the Several EGFR-targeted drugs are FDA
118F E B R U A R Y 2 01 6
C D A J O U R N A L , V O L 4 4 , N 2
antibodies cetuximab and panitumumab interplay. Taking into account the 1. Siegel R, et al. Cancer statistics, 2014. CA Cancer J Clin 2014
64(1):9-29.
and small molecule inhibitors erlotinib complex modalities of activation of these 2. Vokes EE, et al. Head and neck cancer. N Engl J Med 1993
and afatinib. A specific affinity of pathways, the identification of predictive 328(3):184-94.
these antibodies toward CSCs has biomarkers remains a challenge, ideally 3. Hanahan D, Weinberg RA. Hallmarks of cancer: The next
generation. Cell 2011 144(5):646-74.
not been described in in vitro testing; requiring biomarker measurement within 4. Wicha MS, Liu S, Dontu G. Cancer stem cells: An old idea a
however, it has been revealed that the a microenvironmental context. It is also paradigm shift. Cancer Res 2006. 66(4): p. 1883-90; discussion
EGFR-targeting monoclonal antibody, worth considering that the therapeutic 1895-6.
5. Wang JC, Dick JE. Cancer stem cells: Lessons from leukemia.
cetuximab, offers clinical benefits for potential of self-renewal pathway Trends Cell Biol 2005 15(9):494-501.
patients with head and neck tumors.83 antagonists could be counterbalanced by 6. Meacham CE, Morrison SJ. Tumour heterogeneity and cancer
Moreover, other anti-EGFR therapies potential serious adverse events because cell plasticity. Nature 2013 501(7467):328-37.
7. Wicha MS. Cancer stem cells and metastasis: Lethal seeds. Clin
based on tyrosine kinase inhibitors have of interference with crucial mechanisms Cancer Res 2006 12(19):5606-7.
been designed to bind covalently and of tissue homeostasis. Therefore, a 8. Costea DE, et al. Cancer stem cells new and potentially
irreversibly to their targets. Afatinib, an deeper understanding of adult stem important targets for the therapy of oral squamous cell carcinoma.
Oral Dis 2006 12(5):443-54.
oral small molecule ErbB family blocker cell biology is required to determine a 9. Zhang Z, Filho MS, Nor JE. The biology of head and neck
that irreversibly binds to ErbB1 (EGFR), therapeutic window for anti-CSC agents. cancer stem cells. Oral Oncol 2012 48(1):1-9.
ErbB2 (HER2) and ErbB4 (HER4),84 is 10. Reya T, et al. Stem cells, cancer and cancer stem cells. Nature
2001 414(6859):105-11.
being investigated in HNSCC treatment Conclusion 11. Campbell LL, Polyak K. Breast tumor heterogeneity: Cancer stem
with encouraging phase II results and The cancer stem cells hypothesis cells or clonal evolution? Cell Cycle 2007 6(19):2332-8.
several ongoing phase III trials. opens up a wide field for future research 12. Kreso A, Dick JE. Evolution of the cancer stem cell model. Cell
Stem Cell 2014 14(3):275-91.
It is becoming increasingly clear that and further validation is needed to obtain 13. Greaves M, Maley CC. Clonal evolution in cancer. Nature
the CSC population consists of not just better understanding. An important 2012 481(7381):306-13.
one particular CSC phenotype but a aspect is the reliability of identifying and 14. Oravecz-Wilson KI, et al. Persistence of leukemia-initiating
cells in a conditional knockin model of an imatinib-responsive
plasticity of interchangeable states and a characterizing CSCs based on the cell myeloproliferative disorder. Cancer Cell 2009 16(2):137-48.
variety of different clones. Therefore, it surface markers. This would offer a more 15. Balic M, et al. Most early-disseminated cancer cells detected
should be taken into consideration that precise knowledge of the type of cells that in bone marrow of breast cancer patients have a putative breast
cancer stem cell phenotype. Clin Cancer Res 2006 12(19):5615-
even though certain drugs can eradicate generate a tumor, their tissue distribution, 21.
a certain cohort of cancer stem-like cells, the relationships with their progenies 16. Mani SA, et al. The epithelial-mesenchymal transition generates
a variety of CSC clones with different and the implications of their proliferative cells with properties of stem cells. Cell 2008 133(4):704-15.
17. Clevers H. The cancer stem cell: Premises, promises and
properties within the same tumor as well activity and invasive capacity for challenges. Nat Med 2011 17(3):313-9.
as from different patients with the same the prognosis of cancer patients. A 18. Prince ME, Ailles LE. Cancer stem cells in head and neck
cancer type may not be treatable with the greater understanding of the biological squamous cell cancer. J Clin Oncol 2008 26(17):2871-5.
19. Prince ME, et al. Identication of a subpopulation of cells
same compound. Therefore, considerable properties of CSCs could also lead to with cancer stem cell properties in head and neck squamous cell
attention has to be paid to the selection the development of novel antitumor carcinoma. Proc Natl Acad Sci U S A, 2007 104(3):973-8.
of drug compounds, or a combination, drugs that can specifically target these 20. Chiou SH, et al. Positive correlations of Oct-4 and Nanog
in oral cancer stem-like cells and high-grade oral squamous cell
to effectively target the CSC pool, cells. The optimal therapy should aim at carcinoma. Clin Cancer Res 2008 14(13):4085-95.
including quiescent cells, which appear targeting not only those cells undergoing 21. Margaritescu C, et al. The utility of CD44, CD117 and CD133
to be able to escape most treatments. differentiation (bulk tumor population) in identication of cancer stem cells (CSC) in oral squamous
cell carcinomas (OSCC). Rom J Morphol Embryol 2011 52(3
A deeper understanding of molecular but also those resistant CSCs and Suppl):985-93.
mechanisms governing the biology concomitantly destroying the CSC niche 22. Reers S, et al. Stem cell proling in head and neck cancer
of tumorigenic cells should also be for the survival. Thus, it is hoped that reveals an Oct-4 expressing subpopulation with properties of
chemoresistance. Oral Oncol 2014 50(3):155-62.
considered a priority for optimal this novel strategy will result in a rapid 23. Clarke MF, et al. Cancer stem cells perspectives on current
development of innovative anti- exclusion of all tumor cell subpopulations status and future directions: AACR Workshop on cancer stem cells.
CSC drugs. It is conceivable that and avoid the possible repopulation of Cancer Res 2006 66(19):9339-44.
24. Facompre N, et al. Stem-like cells and therapy resistance in
pharmacological inhibition of paracrine- the tumor mass by tumor-initiating cells squamous cell carcinomas. Adv Pharmacol 2012 65:235-65.
acting pathways results in cytostatic or by originally differentiated tumor cells 25. Zhang P, et al. Side population in oral squamous cell carcinoma
effects correlated with the disruption that have regained renewal activity. possesses tumor stem cell phenotypes. Cancer Lett 2009
F E B R U A R Y 2 0 1 6 119
stem cells
C D A J O U R N A L , V O L 4 4 , N 2
277(2):227-34. literature. Head Neck Pathol 2011 5(2): 108-16. and reduced apoptosis in breast cancer stem cells. J BUON 2015
26. Loebinger MR, et al. Squamous cell cancers contain a side 48. Rampias T, et al. Activation of Wnt signaling pathway by 20(5):1287-94.
population of stem-like cells that are made chemosensitive by ABC human papillomavirus E6 and E7 oncogenes in HPV16-positive 68. Lee MR, et al. Chemoresistance of CD133(+) colon cancer
transporter blockade. Br J Cancer 2008 98(2):380-7. oropharyngeal squamous carcinoma cells. Mol Cancer Res 2010 may be related with increased survivin expression. Biochem Biophys
27. Zhang Q. et al. A subpopulation of CD133(+) cancer stem-like 8(3):433-43. Res Commun 2015 463(3):229-34.
cells characterized in human oral squamous cell carcinoma confer 49. Tang AL, et al. UM-SCC-104: A new human papillomavirus-16- 69. Borjesson PK, et al. Phase I therapy study with (186) re-labeled
resistance to chemotherapy. Cancer Lett 2010 289(2):151-60. positive cancer stem cell-containing head and neck squamous cell humanized monoclonal antibody BIWA 4 (bivatuzumab) in patients
28. Bianchini C, et al. Targeted therapy in head and neck cancer. carcinoma cell line. Head Neck 2012 34(10):1480-91. with head and neck squamous cell carcinoma. Clin Cancer Res
Tumori 2011 97(2):137-41. 50. Zhang M, et al. Elevated intrinsic cancer stem cell population 2003 9(10 Pt 2):3961S-72S.
29. Slaughter DP, Southwick HW, Smejkal W. Field cancerization in human papillomavirus-associated head and neck squamous cell 70. Riechelmann H, et al. Phase I trial with the CD44v6-targeting
in oral stratied squamous epithelium; clinical implications of carcinoma. Cancer 2014 120(7):992-1001. immunoconjugate bivatuzumab mertansine in head and neck
multicentric origin. Cancer 1953 6(5):963-8. 51. Pullos AN, Castilho RM, Squarize CH. HPV Infection of the squamous cell carcinoma. Oral Oncol 2008 44(9):823-9.
30. Suresh A, et al. Resistance/response molecular signature Head and Neck Region and Its Stem Cells. J Dent Res 2015 71. Tijink BM, et al. A phase I dose escalation study with anti-
for oral tongue squamous cell carcinoma. Dis Markers 2012 94(11):1532-43. CD44v6 bivatuzumab mertansine in patients with incurable
32(1):51-64. 52. Tang AL, et al. Head and neck cancer stem cells: The eect of squamous cell carcinoma of the head and neck or esophagus. Clin
31. Gallmeier E, et al. Inhibition of ataxia telangiectasia- and Rad3- HPV an in vitro and mouse study. Otolaryngol Head Neck Surg Cancer Res 2006 12(20 Pt 1):6064-72.
related function abrogates the in vitro and in vivo tumorigenicity 2013 149(2):252-60. 72. Mack B, Gires O. CD44s and CD44v6 expression in head
of human colon cancer cells through depletion of the CD133(+) 53. Oliveira-Costa JP, et al. Topoisomerase expression in oral and neck epithelia. PLoS One 2008 3(10):e3360.
tumor-initiating cell fraction. Stem Cells 2011 29(3):418-29. squamous cell carcinoma: Relationship with cancer stem cells 73. Swaminathan SK, et al. CD133-targeted paclitaxel delivery
32. Qiao B, et al. The expression prole of Oct4 and Sox2 in proles and lymph node metastasis. J Oral Pathol Med 2012 inhibits local tumor recurrence in a mouse model of breast cancer. J
the carcinogenesis of oral mucosa. Int J Clin Exp Pathol 2014 41(10):762-8. Control Release 2013 171(3):280-7.
7(1):28-37. 54. Zhang G, et al. Esophageal cancer tumorspheres 74. Jachetti E, et al. Tenascin-C Protects Cancer Stem-like Cells From
33. Brabletz T, et al. Opinion: Migrating cancer stem cells an involve cancer stem-like populations with elevated aldehyde Immune Surveillance by Arresting T-cell Activation. Cancer Res
integrated concept of malignant tumour progression. Nat Rev dehydrogenase enzymatic activity. Mol Med Rep 2012 6(3):519- 2015 75(10):2095-108.
Cancer 2005 5(9):744-9. 24. 75. Wang B, et al. Metastatic consequences of immune escape
34. Song J, et al. Characterization of side populations in HNSCC: 55. Okamoto A, et al. Expansion and characterization of cancer from NK cell cytotoxicity by human breast cancer stem cells.
Highly invasive, chemoresistant and abnormal Wnt signaling. PLoS stem-like cells in squamous cell carcinoma of the head and neck. Cancer Res 2014 74(20):5746-57.
One 2010 5(7): e11456. Oral Oncol 2009 45(7):633-9. 76. Volonte A, et al. Cancer-initiating cells from colorectal cancer
35. Thiery JP, et al. Epithelial-mesenchymal transitions in 56. Tsai LL, et al. Markedly increased Oct4 and Nanog expression patients escape from T cell-mediated immunosurveillance in vitro
development and disease. Cell 2009 139(5):871-90. correlates with cisplatin resistance in oral squamous cell carcinoma. through membrane-bound IL-4. J Immunol 2014 192(1):523-32.
36. Wellner U, et al. The EMT-activator ZEB1 promotes J Oral Pathol Med 2011 40(8):621-8. 77. Visus C, et al. Identication of human aldehyde dehydrogenase
tumorigenicity by repressing stemness-inhibiting microRNAs. Nat 57. Bao S, et al. Glioma stem cells promote radioresistance by 1 family member A1 as a novel CD8+ T-cell-dened tumor antigen
Cell Biol 2009 11(12):1487-95. preferential activation of the DNA damage response. Nature 2006 in squamous cell carcinoma of the head and neck. Cancer Res
37. Chen YC, et al. Aldehyde dehydrogenase 1 is a putative marker 444(7120):756-60. 2007 67(21):10538-45.
for cancer stem cells in head and neck squamous cancer. Biochem 58. Li X, et al. Intrinsic resistance of tumorigenic breast cancer cells 78. Xu Q, et al. Antigen-specic T-cell response from dendritic cell
Biophys Res Commun 2009 385(3):307-13. to chemotherapy. J Natl Cancer Inst 2008 100(9):672-9. vaccination using cancer stem-like cell-associated antigens. Stem
38. Batlle E, et al. The transcription factor snail is a repressor of 59. Gemenetzidis E, et al. Invasive oral cancer stem cells display Cells 2009 27(8):1734-40.
E-cadherin gene expression in epithelial tumour cells. Nat Cell Biol resistance to ionising radiation. Oncotarget 2015 Nov 2. doi: 79. Schatton T, et al. Identication of cells initiating human
2000 2(2):84-9. 10.18632/oncotarget.6268. [Epub ahead of print] melanomas. Nature 2008 451(7176):345-9.
39. Ota I, et al. Snail-induced EMT promotes cancer stem cell-like 60. Chang CJ, et al. Enhanced radiosensitivity and radiation- 80. Park CY, Tseng D, Weissman IL. Cancer stem cell-directed
properties in head and neck cancer cells. Oncol Rep 2015. induced apoptosis in glioma CD133-positive cells by knockdown therapies: Recent data from the laboratory and clinic. Mol Ther
40. Yang MH, et al. Bmi1 is essential in Twist1-induced epithelial- of SirT1 expression. Biochem Biophys Res Commun 2009 2009 17(2):219-30.
mesenchymal transition. Nat Cell Biol 2010 12(10):982-92. 380(2):236-42. 81. Hanahan D, Coussens LM. Accessories to the crime: Functions
41. Syrjanen S. The role of human papillomavirus infection in head 61. Diehn M, et al. Association of reactive oxygen species of cells recruited to the tumor microenvironment. Cancer Cell 2012
and neck cancers. Ann Oncol 2010 21 Suppl 7:vii243-5. levels and radioresistance in cancer stem cells. Nature 2009 21(3):309-22.
42. Chaturvedi AK, et al. Human papillomavirus and rising 458(7239):780-3. 82. Chen JS, et al. EGFR regulates the side population in head and
oropharyngeal cancer incidence in the United States. J Clin Oncol 62. Grimm M, et al. ABCB5 expression and cancer stem cell neck squamous cell carcinoma. Laryngoscope 2006 116(3):401-
2011 29(32):4294-301. hypothesis in oral squamous cell carcinoma. Eur J Cancer 2012 6.
43. Ang KK, et al. Human papillomavirus and survival of patients 48(17):3186-97. 83. Bernier J. Drug Insight: Cetuximab in the treatment of recurrent
with oropharyngeal cancer. N Engl J Med 2010 363(1):24-35. 63. Yanamoto S, et al. Isolation and characterization of cancer and metastatic squamous cell carcinoma of the head and neck. Nat
44. Semrau R, et al. Prognostic impact of human papillomavirus stem-like side population cells in human oral cancer cells. Oral Clin Pract Oncol 2008 5(12):705-13.
status, survivin and epidermal growth factor receptor expression Oncol 2011 47(9):855-60. 84. Solca F, et al. Target binding properties and cellular activity
on survival in patients treated with radiochemotherapy for very 64. La Fleur L, Johansson AC, Roberg K. A CD44high/EGFRlow of afatinib (BIBW 2992), an irreversible ErbB family blocker. J
advanced nonresectable oropharyngeal cancer. Head Neck 2013 subpopulation within head and neck cancer cell lines shows an Pharmacol Exp Ther 2012 343(2):342-50.
35(9):1339-44. epithelial-mesenchymal transition phenotype and resistance to
45. Fakhry C, et al. Improved survival of patients with human treatment. PLoS One 2012 7(9):e44071. THE CORRESPONDING AUTHOR, Anh D. Le, DDS, PhD, can be reached
papillomavirus-positive head and neck squamous cell carcinoma in 65. Sun HB, Zheng HY, Yan X. Survivin silencing enhances at anhle@dental.upenn.edu.
a prospective clinical trial. J Natl Cancer Inst 2008 100(4):261-9. radiosensitivity in oral squamous cell carcinoma cell. Eur Rev Med
46. Evander M, et al. Identication of the alpha6 integrin as a Pharmacol Sci 2014 18(18):2678-86.
candidate receptor for papillomaviruses. J Virol 1997 71(3):2449- 66. Lee DH, et al. Relationship between expression of Livin and the
56. biological behavior of human oral squamous cell carcinoma. Oncol
47. Masand RP, et al. Adenosquamous carcinoma of the head Rep 2014 32(6):2453-60.
and neck: Relationship to human papillomavirus and review of the 67. Yu CJ, et al. Elevated survivin mediated multidrug resistance
120F E B R U A R Y 2 01 6
nanodiamonds
C D A J O U R N A L , V O L 4 4 , N 2
A Chemopreventive
Nanodiamond Platform
for Oral Cancer Treatment
Albert Yen, BS; Kangyi Zhang, PhD; Giulia Daneshgaran, BS; Ho-Joong Kim, PhD;
and Dean Ho, PhD
AUTHORS
A
Albert Yen, BS, is in the Ho-Joong Kim, PhD, is in pproximately 45,780 Recent advances in nanomedicine
department of the department of Americans were diagnosed have driven the development of
bioengineering, Henry chemistry at Chosun
with oral cancer in 2015.1 novel treatment modalities for a
Samueli School of University in Gwangju,
Engineering and Applied Republic of Korea. Treating oral cancer usually multitude of diseases, including oral
Science at the University of Conict of Interest requires surgical resection cancer. Among these advances are
California, Los Angeles. Disclosure: None reported. with postoperative chemotherapy and/ drug-loaded nanoparticles designed to
Conict of Interest or radiotherapy.2,3 Although the five- mitigate the shortcomings associated
Disclosure: None reported. Dean Ho, PhD, is a
year survival rate from 2004 to 2010 with chemotherapy. Though such
professor in the division of
Kangyi Zhang, PhD, is in oral biology and medicine for oral cancer patients was 66 percent, nanoparticles come in all sizes, shapes
the division of oral biology and department of modern treatments for oral cancer and compositions, their overarching
and medicine at the bioengineering and is are not without obstacles.1 Surgery is purpose is the same: sustained and
University of California, Los co-director of the Jane and physically traumatic, and radiotherapy targeted delivery of therapeutic agents
Angeles, School of Jerry Weintraub Center for
often leads to adverse physiological to a tumor site.4 By modulating their
Dentistry. Reconstructive
Conict of Interest Biotechnology at the effects, including infection and oral material properties, nanoparticles can
Disclosure: None reported. University of California, Los mucositis.3 Chemotherapy subjects be designed to release their therapeutic
Angeles. patients to drug toxicity, and the payload over a long period of time,
Giulia Daneshgaran, Conict of Interest effectiveness of chemotherapy is often eliminating toxicity associated with bolus
BS, is in the department of Disclosure: None reported.
hampered by poor drug bioavailability, injections.4 Nanoparticle drug carriers
integrative biology and
physiology at the University
drug resistance and limited cellular are also passively targeted to tumors
of California, Los Angeles. uptake. Furthermore, close to one- because of the enhanced permeability
Conict of Interest third of oral cancer patients undergo and retention (EPR) effect, augmenting
Disclosure: None reported. a disease relapse after treatment.2 treatment specificity and improving
F E B R U A R Y 2 0 1 6 121
nanodiamonds
C D A J O U R N A L , V O L 4 4 , N 2
therapeutic efficacy.4 Functionalization carrier.10,16 NDs also contain nitrogen to oral cancer lesions. One drug that
of nanoparticles with targeting moieties vacancy (NV) centers, which occur could benefit from the implementation
can further enhance this specifity.4 as natural defects or are introduced by of this platform is celecoxib (Cxb), a
One such nanoparticle drug carrier chemical modification.17,18 These NV commonly prescribed nonsteroidal anti-
is the nanodiamond (ND), a truncated centers imbue NDs with fluorescent inflammatory drug. Cxb is a selective
octahedral nanocarbon that is 4-5 nm in properties, making NDs not only a drug inhibitor of cyclooxygenase-2 (COX-2),
diameter (FIGURE 1 ).5-7 NDs are usually carrier but also a biological probe.17,18 an enzyme implicated in tumorigenesis
generated as a byproduct of industrial Although the scalability and versatility and cancer progression.21,22 COX-2 has
detonation processes involving carbon- of NDs render them a suitable candidate been found to be overexpressed in oral
based materials.6,7 Because NDs are for various clinical applications, the squamous cell carcinomas (OSCCs) and
a waste byproduct of these industrial most critical indicator of NDs clinical is a promising target for chemopreventive
processes, ND synthesis is highly scalable. potential is their biocompatibility. A Cxb therapies.23-26 However, a randomized
The surface composition of the ND series of in vitro and in vivo studies have phase II clinical trial of Cxb in patients
is also variable and easily modified, demonstrated the biocompatibility of NDs with oral premalignant lesions returned
serving as a foundation for electrostatic in their functional form, be it that of an inconclusive results, as only a small
adsorption or chemical conjugation of imaging agent or a drug carrier.12,19,20 Both fraction of patients had a partial or
small-molecule drugs, genes, targeting fluorescent and detonation NDs were complete response to Cxb treatment.27
motifs and other therapeutic compounds proven to be nontoxic toward HepG2 In this paper, ND-polyethyleneimine-
(FIGURE 2 ).6-15 Anthracylines are one and HeLa cell lines.20 Furthermore, poly(ethylene glycol) conjugate
class of drug that bind potently but an in vivo study conducted on grafted (ND-PEI-PEG) was synthesized as
reversibly to NDs through electrostatic chemoresistant mammary mice tumors a proof-of-concept drug carrier for
interactions and pi stacking, allowing showed that mice could tolerate a Cxb (FIGURE 3A ). This ND-polymer
for the synthesis of ND-anthracycline lethal dose of doxorubicin delivered conjugate sequestered and released Cxb
complexes that release their payload over by NDs, and that NDs alone induced in a sustained, pH-dependent manner.
time.11-13 Because NDs are endocytosed no systemic inflammatory response.12 Arginylglyclaspartic acid (RGD), a
into cells via macropinocytosis and Taken together, the advantageous tripeptide that binds preferentially
clathrin-mediated endocytosis, any therapeutic and diagnostic properties to integrins often overexpressed on
attached therapeutic payload will readily of NDs motivate the development OSCCs, can also be conjugated to ND-
enter a target cell along with its ND of an ND platform for drug delivery PEI-PEG to create an actively targeted
122F E B R U A R Y 2 01 6
C D A J O U R N A L , V O L 4 4 , N 2
FIGURE 3A .
variant, ND-PEI-PEG-RGD, without generated from stock ND after heat- RGD Functionalization for Active
compromising Cxb loading and release.28,29 treating at 475 degrees Celsius for three Targeting. To confer active targeting
This multimodal ND-Cxb platform has hours and resuspended in deionized functionality to ND-PEI-PEG, an
the potential to enhance cellular uptake water. Coupling reagents 1-ethyl-3-(3- additional EDC/NHS coupling reaction
of drug while prolonging therapeutic dimethylaminopropyl)-carbodiimide was used to conjugate RGD (Sigma-
release, enhancing the chemopreventive (EDC) and N-hydroxysuccinimide Aldrich, St. Louis) onto the terminal
effects of Cxb without compromising (NHS) were used to facilitate a carboxylic groups of PEG. The reaction was
the drugs therapeutic window. series of two consecutive EDC/NHS performed in water at pH 5.5-6.0. A water
coupling reactions, performed in wash was performed after the coupling
Materials and Methods water at pH 5.5-6.0: conjugation of reaction to remove excess reagents.
Synthesis of ND-PEI-PEG. All polyethyleneimine 800 (PEI) to carboxyl Qualitative Model of Drug Loading and
chemical reagents were purchased groups on the surface of ND-COOH Release. Fluorescein diacetate (Sigma-
from Sigma-Aldrich (St. Louis). ND and conjugation of poly(ethylene Aldrich, St. Louis) was solvated in
hydrogel was purchased from Nanocarbon glycol) diacid 600 (PEG) to terminal acetonitrile (Sigma-Aldrich, St. Louis)
Institute Co. Ltd. (Nagano, Japan) and amine groups on PEI. A water wash at a concentration of 1 mg/mL. The
lyophilized to obtain stock ND powder. was performed between each coupling fluorescein diacetate solution was then
Carboxylated ND (ND-COOH) was reaction to remove excess reagents. added to an equal volume of 10 mg/mL
F E B R U A R Y 2 0 1 6 123
nanodiamonds
C D A J O U R N A L , V O L 4 4 , N 2
A B 50
45
FIGURE 5B .
ND-PEI-PEG (or ND-PEI-PEG-RGD). FIGURES 5 . Cxb release from ND-Cxb complexes (no RGD) (5A ) is measured over a period of 24 hours (1,440
minutes) under pH 1 (red) and pH 5 (blue) conditions. A greater initial burst release is observed under pH 1 conditions,
The mixture was probe sonicated for
but average Cxb concentrations gradually decrease to similar baseline levels (n = 4, error bars = standard deviation). The
30 minutes and spun down at 18,000 g. high pKa of the amine groups on PEI (5B ) may lead to preferential celecoxib release from the ND-Cxb at low pH, possibly
The precipitate was then resuspended in triggering the proton sponge eect. Under acidic conditions like those found in the cell endosome, the amine groups
aqueous buffer solutions of pH 4 and pH on PEI are protonated, dissociating the ND-Cxb complex due to electrostatic repulsion. The dissociation of the ND-Cxb
7.5. Fluorescein diacetate release under complex subsequently releases Cxb into the endosome. The PEI also acts as a proton sponge, removing protons from the
differing pH conditions was observed for endosome and generating a negative proton gradient. This negative proton gradient could initiate an inux of protons (and
30 days by illuminating the pH 4 and pH therefore intracellular medium) from the intracellular space, rupturing the endosome and releasing Cxb into the cell.
7.5 solutions under ultraviolet light.
Loading of Celecoxib Onto Nanodiamond
Carriers. Cxb (Sigma-Aldrich, St. Louis) The ND carrier was separated from with a Zetasizer Nano-ZS (Malvern
and ND-PEI-PEG (or ND-PEI-PEG- the DMSO solution by centrifuging for Instruments, Worcestershire, United
RGD) was solvated in dimethyl sulfoxide 20 minutes at 14,000 rpm and a UV-Vis Kingdom). The hydrodynamic size and
(DMSO) at a 1:5 mass ratio of Cxb to spectrophotometer was used to measure -potential of loaded ND-Cxb complexes
ND carrier. The DMSO suspension was the absorbance of the Cxb-containing were also measured in this manner.
added drop-wise to twice the volume of supernatant at 260 nm. The concentration Quantitative Evaluation of Celecoxib
deionized water. The resultant mixture of loaded Cxb was determined by Release From ND-Cxb. Cxb was loaded
was shaken on a rotator for one hour and converting the final supernatant onto ND-PEI-PEG as previously
then centrifuged for 20 minutes at 14,000 absorbance value to a concentration described. The ND-Cxb complexes were
rpm. After removing the supernatant, value with a Cxb standard curve. resuspended in 1 mL of pH 1 aqueous
the ND-Cxb precipitate was probe Characterization of ND-Cxb. Carrier buffer solution and 1 mL of pH 5 aqueous
sonicated in 1 mL of DMSO at high intermediates were solvated in deionized buffer solution (four replicates for each
amplitude to dissociate the ND-Cxb water and the hydrodynamic size and pH). The ND-Cxb solutions were rotated
complex, releasing Cxb into the DMSO. -potential measurements were taken continuously over a period of 24 hours.
124F E B R U A R Y 2 01 6
C D A J O U R N A L , V O L 4 4 , N 2
0
PBS
Dox 100 g
100
Relative tumor volume (V/Vo)
12 NDX 100 g
Dox 200 g
NDX 200 g 80
solvating FDA in acetonitrile and mixing The preferential release of Cxb from
this water-miscible organic phase with an ND-Cxb under acidic conditions is
Anti-EGFR-
NDLP-Epi
aqueous phase containing the ND carrier. critical for its therapeutic efficacy. Upon
Because of its hydrophobicity, FDA is endocytosis by OSCCs, ND-Cxb will enter
thought to preferentially complex with the the acidic cell endosome, triggering Cxb
FIGURE 7. The ecacy of nanodiamond-lipid
ND carrier upon mixing with the aqueous release via protonation of amine groups
hybrids loaded with epirubicin (NDLP-Epi) was phase, becoming embedded in the polymer on PEI.31 The rapid protonation of these
evaluated using a triple negative breast cancer mice network on the surface of the ND carrier. amine groups removes protons from the
model. The ecacy of a targeted NDLP-Epi variant The ND carriers were subsequently endosome, generating a negative proton
functionalized with antibodies against epidermal suspended in pH 4 and pH 7.5 buffer gradient that induces an influx of protons
growth factor receptor (anti-EGFR-NDLP-Epi) was solutions. The fluorescent signature of from the intracellular space. This influx of
also investigated in this study. Tumor growth was
the pH 4 buffer solution increased more intracellular fluid lyses the endosome, thus
visualized weekly by measuring the luciferase signal.
Mice treated with epirubicin alone succumbed
quickly than that of the pH 7.5 buffer releasing Cxb into intracellular medium.
to drug toxicity after week three (second row), solution, indicating a pH-dependent In this way, PEI is not only utilized as
while mice treated with a PBS control showed little release mechanism that favors FDA a pH-sensitive trigger for Cxb release,
inhibition of tumor growth (rst row). Treatment with release at lower pH (FIGURE 4A ). After but it also acts as a proton sponge that
untargeted NDLP-Epi slowed tumor growth relative 30 days, the fluorescent signature of both creates the proton gradient necessary for
to the PBS control (third row), but near-complete buffer solutions were identical, confirming endosomal rupture and subsequent release
tumor regression was achieved with anti-EGFR-
that FDA was loaded onto the ND carriers of Cxb throughout the target cell.30
NDLP-Epi treatment (bottom row). (Reprinted with
permission from Wiley-VCH, 2013.)
and gradually released over a month-long
period, albeit, more quickly under acidic Therapeutic Outlook
conditions (FIGURE 4B ). Cxb loading was Preclinical studies conducted with
achieved with a similar loading method. similar ND-based delivery systems have
(FIGURE 3B ). An additional size increase pH-Dependent Celecoxib Release. already returned promising results. The first
is observed upon Cxb incorporation, After loading ND-PEI-PEG with Cxb, of these preclinical studies involved the
indicating successful drug loading. The the resultant ND-Cxb complexes were treatment of highly chemoresistant mice
-potential also fluctuates throughout the suspended in pH 1 and pH 5 buffer mammary tumors with ND-doxorubicin
synthesis procedure, reflecting changes solutions. Again, a pH-dependent conjugates (NDX).12 NDX was able
in the surface charge of the ND (FIGURE release mechanism is observed, with to overcome drug efflux transporters
3B ). For instance, ND-COOH exhibits a greater initial burst release of Cxb commonly found in chemoresistant tumor
negative -potential ( 46.70 6.83 mV) at pH 1 (FIGURE 5A ). After 1,440 strains, ensuring drug retention, whereas
due to the deprotonated carboxyl groups minutes (24 hours), Cxb levels in both free drug would be effluxed out of the cell.12
on its surface. Upon PEI conjugation, pH 1 and pH 5 solutions decrease to Mice treated with NDX were also able
the -potential becomes positive (52.70 similar baseline concentrations. to tolerate a double dose of doxorubicin,
4.45 mV), indicating that the surface The pH-dependent release mechanism showing significantly improved tumor
carboxyl groups were replaced by of both FDA and Cxb from the ND regression compared to a free doxorubicin
protonated amine groups found on PEI. carrier may be attributed to the high pKa control (FIGURE 6A ).12 In fact, when
Cxb incorporation into either ND- of amine groups found in PEI. Under delivered in its free form, this double dose
PEI-PEG or ND-PEI-PEG-RGD also acidic conditions, the proton transfer of doxorubicin killed the mice before the
gives rise to a change in -potential. equilibrium shifts in favor of amine end of the treatment period (FIGURE 6B ).
Validation of Carrier Loading and Release protonation (NH2 to NH3+). The greater The efficacy of NDX was also
of Payload. To determine whether the number of positively charged species studied in a mice model of glioblastoma
completed ND carrier could sequester in the PEI layer of ND-Cxb (or ND- multiforme, an aggressive brain cancer
hydrophobic molecules like Cxb, ND- FDA) generates electrostatic repulsions with high mortality rates.32 NDX and
PEI-PEG (or ND-PEI-PEG-RGD) was that dissociate the ND-Cxb complex free doxorubicin were delivered directly
126F E B R U A R Y 2 01 6
C D A J O U R N A L , V O L 4 4 , N 2
to mice gliomas through a convection- and properties of ozone-puried detonation nanodiamonds. J expression in oral squamous cell carcinoma. Int J
Immunopathol Pharmacol 2004;17(3):273-282.
enhanced delivery system. On average, Phys Chem C 2011;115(20):9827-9837.
25. Kim Y-Y, Lee E-J, Kim Y-K, et al. Anti-cancer eects
6. Mochalin VN, Shenderova O, Ho D, Gogotsi Y. The
mice treated with NDX survived almost properties and applications of nanodiamonds. Nat of celecoxib in head and neck carcinoma. Mol Cells.
20 days longer than mice treated with free Nanotechnol 2012;7(1):11-23. 2010;29(2):185-194.
26. Feng L, Wang Z. Chemopreventive eect of
doxorubicin. NDX also induced greater 7. Vaijayanthimala V, Lee D-K, Kim SV, et al. Nanodiamond-
celecoxib in oral precancers and cancers. Laryngoscope
mediated drug delivery and imaging: Challenges and
tumor regression and apoptotic cancer cell opportunities. Expert Opin Drug Deliv 2015;12(5):735-749. 2006;116(10):1842-1845.
death than free doxorubicin (FIGURE 6C ).32 8. Krueger A. New carbon materials: Biological applications 27. Papadimitrakopoulou VA, William WN, Dannenberg AJ,
et al. Pilot randomized phase II study of celecoxib in oral
Targeted variants of ND-drug of functionalized nanodiamond materials. Chem A Eur J
premalignant lesions. Clin Cancer Res 2008;14(7):2095-
2008;14(5):1382-1390.
conjugates have also been implemented 9. Krueger A, Stegk J, Lu L, et al. Biotinylated nanodiamond: 2101.
successfully in preclinical mice models. Simple and ecient functionalisation of detonation diamond. 28. Thomas GJ, Nystrm ML, Marshall JF. v6 integrin in
wound healing and cancer of the oral cavity. J Oral Pathol
The efficacy of an epirubicin-loaded Langmuir 2008;8(24):4200-4204.
Med 2006;35(1):1-10.
10. Chu Z, Miu K, Lung P, et al. Rapid endosomal escape of
ND-liposome hybrid (NDLP-Epi) was prickly nanodiamonds: Implications for gene delivery. Sci Rep 29. Ruoslahti E. RGD and other recognition sequences for
compared to that of anti-EGFR-NDLP- 2015;5:11661. integrins. Annu Rev Cell Dev Biol 1996;12:697-715.
30. Behr J. The proton sponge: A trick to enter cells the viruses
Epi, an NDLP variant functionalized 11. Adnan A, Lam R, Chen H, et al. Atomistic simulation and
did not exploit. Chim Int J Chem 1997;2(1):34-36.
measurement of pH dependent cancer therapeutic interactions
with antibodies targeted to epidermal with nanodiamond carrier. Mol Pharm 2011;8(2):368-374. 31. Murphy RF, Powers S, Cantor CR. Endosome pH measured
growth factor receptor (EGFR).33 Both the 12. Chow EK-H, Zhang X-Q, Chen M, et al. Nanodiamond in single cells by dual uorescence ow cytometry: Rapid
acidication of insulin to pH 6. J Cell Biol 1984;98(5):1757-
untargeted and targeted variants were used therapeutic delivery agents mediate enhanced chemoresistant
1762.
tumor treatment. Sci Transl Med 2011;3(73):73ra21.
to treat mice models of triple negative 13. Wang X, Low XC, Hou W, et al. Epirubicin-absorbed 32. Xi G, Robinson E, Mania-Farnell B, et al. Convection-
breast cancers, which often overexpress nanodiamonds kill chemoresistant hepatic cancer stem cells. enhanced delivery of nanodiamond drug delivery platforms for
intracranial tumor treatment. Nanomedicine 2014;10(2):381-
EGFR. Free epirubicin killed the mice ACS Nano 2014;8(12):12151-12166.
391.
14. Ho D, Wang C-HK, Chow EK-H. Nanodiamonds:
after three weeks of treatment (FIGURE The intersection of nanotechnology, drug development 33. Moore L, Chow EK-H, Osawa E, Bishop JM, Ho D.
7 ).33 Although mice treated with NDLP- and personalized medicine. Science Advances Diamond-lipid hybrids enhance chemotherapeutic tolerance
and mediate tumor regression. Adv Mater 2013;25(26):3532-
Epi survived the seven-week treatment 2015;1(7):e1500439-e1500439.
3541.
15. Lee D-K, Kim SV, Limansubroto AN, et al. Nanodiamond-
period, tumor growth was only impeded gutta percha composite biomaterials for root canal therapy.
to some degree (FIGURE 7 ). In contrast, ACS Nano. 2015. doi:10.1021/acsnano.5b05718. THE CORRESPONDING AUTHOR, Dean Ho, PhD, can be reached at
dean.ho@ucla.edu.
anti-EGFR-NDLP-Epi treatment resulted 16. Liu K-K, Wang C-C, Cheng C-L, Chao J-I. Endocytic
carboxylated nanodiamond for the labeling and tracking
in almost full tumor regression by the of cell division and dierentiation in cancer and stem cells.
end of the treatment period (FIGURE 7 ). Biomaterials 2009;30(26):4249-4259.
Comprehensive in vitro and in 17. Havlik J, Petrakova V, Rehor I, et al. Boosting nanodiamond
uorescence: Towards development of brighter probes.
vivo studies are required to validate Nanoscale 2013;5(8):3208-3211.
the safety and therapeutic efficacy of 18. Chang B-M, Lin H-H, Su L-J, et al. Highly uorescent
ND-Cxb. Nonetheless, our current nanodiamonds protein-functionalized for cell labeling and
targeting. Adv Funct Mater 2013;23(46):5737-5745.
data highlights a proof-of-concept ND 19. Schrand AM, Huang H, Carlson C, et al. Are diamond
platform for chemopreventive oral nanoparticles cytotoxic? J Phys Chem B 2007;111(1):2-7.
cancer applications. Given the prior 20. Moore L, Grobarova V, Shen H, et al. Comprehensive
interrogation of the cellular response to uorescent, detonation
success of ND-drug systems, NDs may and other functionalized nanodiamonds. Nanoscale
soon carve out their own niche amongst 2014;6(20):11712-11721.
modern oral cancer treatments. 21. Williams CS, Mann M, DuBois RN. The role of
cyclooxygenases in inammation, cancer and development.
REFERENCES
Oncogene 1999;18(55):7908-7916.
1. Siegel RL, Miller KD, Jemal A. Cancer statistics, 2015. CA 22. Greenhough A, Smartt HJM, Moore AE, et al. The COX-2/
Cancer J Clin 2015;65(1):5-29. PGE2 pathway: Key roles in the hallmarks of cancer and
2. Montero PH, Patel SG. Cancer of the oral cavity. Surg Oncol adaptation to the tumour microenvironment. Carcinogenesis
Clin N Am 2015;24(3):491-508. 2009;30(3):377-386.
3. Devi S, Singh N. Dental care during and after radiotherapy 23. McCormick DL, Phillips JM, Horn TL, Johnson WD, Steele
in head and neck cancer. Natl J Maxillofac Surg VE, Lubet RA. Overexpression of cyclooxygenase-2 in rat
2014;5(2):117. oral cancers and prevention of oral carcinogenesis in rats by
4. Chow EK-H, Ho D. Cancer nanomedicine: From drug selective and nonselective COX inhibitors. Cancer Prev Res
delivery to imaging. Sci Transl Med 2013;5(216):216rv4. 2010;3(1):73-81.
5. Shenderova OA, Vlasov II, Turner S, et al. Surface chemistry 24. Pannone G, Bufo P, Caiaa MF, et al. Cyclooxygenase-2
F E B R U A R Y 2 0 1 6 127
^
>K^E'>^KhEdz KZE'KhEdz
^E/'KKhEdz
KtEz'W^ D/^^/KEs/:K>/
KD >EdZK'Wd
^W< ,
<W/ Z W<
W/ <W/
hZdd<
WWK D/^^/KEs/:K>/ K'W/
W/ K W
> </
'>E>'W
yE,DK<D WKtz'W,
'W/
ZW/ W</
6 2/ '
,hEd/E'dKEWZ<'W ^E/'K'W
EtWKZd,'W
WD
^E<W/ Ed<W/
WWKW<
<W/
>tE>d
, KZE''W
, K
E<W/
Z/sZ^/^EZEZ/EKKhEdz
>'
W WW>s>>z^
KZE'>/
6 2/ '
E,K>>ztKK'W
KD D<E<W
WWK
WW t /
/ KW/
,/EK>/
E,K>>ztKK
Z& ZE,K^dDZ'Z/d^
d
6 2/ '
W
<W/ W/
W<Ed
/E/Et>>^'WD
<W/
W^E>/ /
K ^EdEd'W W/
>W/ EK
6 2/ '
,DKW<W/ DhZZ/dt
WWK
WKDKE>/ hzZ^EdK&<W/
KD
W/ W>D^Zdt
d
dKZZE'W
W /
<E<W/ <ZEsEdhZKhEdz^E>h/^K/^WK EdK&<W/
<Z^&/>WZ'Wd W>D^WZ/E'^'
t^dKs/E>/
K ^^
& W<
hzZ^EdK&<W/
D' W/
W/ Z/sZ^/'W
^E>h/^K/^WKKhEdz
6 2/ '
t^dKs/E'W
, ,
<W/
y^ W</
<W/
st^D
WWs
I
ts been a long day, but a good day, at the course of four years, the patient
your practice. When you finally head suspended his anticoagulant regimen
home for dinner, its getting dark and It takes thoughtful before every dental appointment.
traffic is not on your side. Red lights coordination between Following this protocol, the patient
flash ahead. Two cars speed through the dentist and patients had stopped taking his Coumadin
the crossing before the gates come down, prior to a recall appointment at which
but you slow to a stop and wait. The bell
physician prior to dental the dentist diagnosed a needed root
rings loudly, the striped gate arm lowers treatment, especially when canal and crown. The procedure was
and the warning light glows. Theres no it comes to medically scheduled one week after, which resulted
mistaking that a train is coming. And, compromised patients. in the patient resuming Coumadin for
once it passes, the ringing stops, the only three days and then suspending it
gates rise and the light goes out. You again for another five. At the time the
have the all-clear signal to drive ahead.
Wouldnt it be nice if these
signals were as clear in dentistry?
In a perfect world, all the elements
for a patients total health would come
together seamlessly to make care easy
and stress-free. In the real world,
though, it takes thoughtful coordination
between the dentist and patients You are not a statistic.
physician prior to dental treatment,
especially when it comes to medically
compromised patients. And the key to
getting the all-clear to proceed with
treatment is a medical clearance form.
Take, for instance, the case of a
66-year-old patient whose medical
history included open-heart surgery
and high blood pressure. His dentist You are also not a sales goal or a market segment. You are a dentist.
started the medical clearance process And we are The Dentists Insurance Company, TDIC. Its been 35 years
the right way she sent a form since a small group of dentists founded our company. And, while times
requesting more information to the may have changed, our promises remain the same: to only protect
patients physician. The physician dentists, to protect them better than any other insurance company and to
shared that the patient was taking be there when they need us. At TDIC, we look forward to delivering on
Coumadin for atrial fibrillation and these promises as we innovate and grow.
was, therefore, subject to bleeding.
Contact the Risk Management Advice Line at 800.733.0634.
Unfortunately, heres where
signals got crossed. Based on the form
response, and without seeking further
clarification from the physician, the Protecting dentists. Its all we do.
dentist instructed her patient to 800.733.0634 | thedentists.com | CA Insurance Lic. #0652783
discontinue taking Coumadin five
days prior to any treatment. Over
F E B R U A R Y 2 0 1 6 129
F E B . 2 0 16 RM MAT TERS
C D A J O U R N A L , V O L 4 4 , N 2
patient presented for treatment, local According to the ADA, there is Further clarification prior to treatment
anesthetic was administered and he strong evidence that typical dental and clear communication between dentists
appeared to fall asleep. However, when patients do not need to discontinue and physicians can truly save lives.
the dentist attempted to wake him, he anticoagulant use; local measures can
was unresponsive. Paramedics transported be used to control bleeding. For patients What is your role in the medical
the patient to the hospital and it was with a higher risk of bleeding, any clearance process?
determined he had suffered a massive suggested modification to the medication The following preventive measures can
stroke during the dental procedure. regimen prior to dental treatment protect your practice and your patients:
Medical experts who reviewed the should only be done with advice from 1. Obtain health history.
case stated Coumadin takes time to reach the patients physician. In the event a Every new patient should complete a
therapeutic levels in the bloodstream. physician refuses to provide medical health history form. The form should
By following the dentists instruction to clearance for dental treatment, The be reviewed, signed and dated by the
stop the regimen five days prior to any Dentists Insurance Company (TDIC) patient at each appointment, as well
treatment, the patient was placed at recommends getting the patient involved as initialed and dated by the dentist.
increased risk of stroke. Once therapeutic in contacting his or her physician directly. Both signatures serve as evidence
levels of anticoagulant were decreased, a The dentist in this case should that the information is current and
stroke could have occurred at any time. have explored the options thoroughly the patients health was discussed.
Starting and stopping Coumadin in with the patients physician and Additionally, TDIC recommends
succession for two dental appointments discussed alternatives to stopping checking with your carrier or local
likely increased the patients risk. the anticoagulation regimen. CONTINUED ON 132
130F E B R U A R Y 2 01 6
SELL YOUR PRACTICE . . . . .
LEE SKARIN
3. Bank financing or Seller financing, with proper agreements to adequately protect
the Seller and make the deal close - realistically and expeditiously.
6. Lease negotiations.
Your calls are invited. Put our thirty years of experience to work for you!
818.991.6552
Visit our website for current listings: www.LeeSkarinandAssociates.com 800.752.7461
F E B . 2 0 16 RM MAT TERS
C D A J O U R N A L , V O L 4 4 , N 2
132F E B R U A R Y 2 01 6
Specialists in the Sale and Appraisal of Dental Practices
How much is your practice worth?? Practices
Selling or Buying, Call PPS today! Wanted
2016 marks PPS 50th Year Anniversary
of Serving California Dentists
NORTHERN
NORT RN CALIFORNIA SOUTHERN CALIF
CALIFORNIA
(415) 899-8580 (800) 422-2818 (714) 832-0230 (800) 695-2732
Raymond and Edna Irving Thomas Fitterer and Dean George
Ray@PPSsellsDDS.com PPSincnet@aol.com
www.PPSsellsDDS.com www.PPSDental.com
California DRE License 1422122 California DRE License 324962
6097 SAN FRANCISCOS PARKSIDE DISTRICT Part-time ARROWHEAD Absentee Owner. Grosses $450,000. Hi Identity
practice collected $130,000+ in 2015. 2-ops with separate digital Lake Drive Building. Practice $350,000. RE $250,000.
x-ray room. 3rd op available. Great opportunity for someone DANA POINT Grossed $950 in 2013 with ortho. No longer
looking to enter private practice with low start-up costs. doing ortho. Absentee Owner. Full price $650,000
6096 FRESNO Long established. 4-days per week of hygiene. EAST LOS ANGELES - EMERGENCY SALE Huge Latino
Realized collections of $450,000 in 2015. 4-ops. population within 3 radial miles. Long established. Million Dollar
6095 WEST CONTRA COSTA COUNTYS PINOLE Located Potential Hi Identity office. Full Price $330,000.
off Interstate 80 in Dental Village alongside Appian Way. 3-days of GRANADA HILLS Location. Seeks Specialists.
Hygiene. 2015 tracking $425,000 in collections. Delivery systems HEMET Grosses $850,000 with opportunity to increase substantially.
in ops were upgraded 11-years ago. Seller will work back as will associates. Great opportunity for Oral
6094 PERIO PRACTICE - SAN FRANCISCO BAY AREA Surgeon or Corporate Group.
This offering shall appeal to the Periodontist who wants a high-end INDIO DENTAL OFFICE Next to City Hall. 2 ops in 4,000 sq.ft. hi
practice in aQH[WUHPHO\desirable area. 2015 trending $700,000 in identity building includes real estate. Asking $650,000. Make Offer.
Available Profits. ,59,1( Great location. Busy Lady DDS will Solo Group her 5 ops or
6093 CENTRAL MARIN COUNTY Located in hub of Marin partner into acquiring building with Specialists.
SOLDoffice.
County. Consistent $700,000+ per year performer with strong LOS ANGELES HMO Grossing $4 Million. In Escrow. Back-Up
Profits. 3-days of hygiene. Digital Offers requested.
6092 ROSEVILLE 2015 trending $350,000. 3-ops with 4th MISSION VIEJO Freeway location. Solo Group. New DDS with
S LD
available. Convenient locationOon Douglas Boulevard. End cap patients will be paid 40%. Join Million Dollar state-of-art office.
suite in strip center with fantastic exposure. Membership $30,000.
6089 MOUNT SHASTA Small town living renowned for outdoor NORCO - CORONA Recently renovated. Gorgeous 8 ops and digital
living. Perfect escape from Rat Race and corporate intrusion. On includes cone beam. Grossing near $100K/month. Hi identity building
3-day week, 2015 trending $850,000 with $450,000 in Profits. apprx 3,000 sq.ft. Great for Absentee Buyer or Specialist as Seller will
6088 SANTA CRUZ Well established, lots of patients. Strong work back on contract. Full Price for practice $1.1 Million and Building
Hygiene Department with 6.5 days Dof hygiene per week. Collected
SOL$675,000+.
$900,000.
REDLANDS Full Price $50,000 Established 27 years. Connect with
$600,000 in 2014. 2015 trending
3,000 employee Employer. Rent $850/mth year one, $1,250/mth next
6087 LAKE TAHOE - NEVADA'S STATELINE
5-years and then $1,450/mth 5 more years.
"Fee-for-Service as practice is "out-of-network with insurance
companies. Collections lastSyear D $600,000 with Profits of
OLtopped
REDLANDS 5 Ops and digital. Rent $2,400. 900 Patients. Absentee
Owner. Full Price $250,000
$220,000. 3.5 days of hygiene per week. Nevada State Board of
RIVERSIDE Divorce Sale. Full Price $31,000 includes 4 ops in
Dental Examiners accepts the Western Boards.
historic professional location. Includes all charts seen prior to 2014.
6081 SANTA CLARA El Camino Real location. 2015 tracking Rent negotiable.
$775,000 with Profits of $325,000. Management is on "cruise SAN FERNANDO VALLEY Grossed $550,000 in 2014. Will do
control." New Doc who is ambitious and extends hours shall push $650,000 in 2015. Full Price $550,000.
practice over the $1 Million bar very quickly. 5-ops in 1,700 sq.ft. SAN FERNANDO VALLEY Long established. Renovated in 2010 at
6080 SAN RAMON 8+ days of Hygiene per week. $450,000
SOLD$900,000+ per year performer.
cost of $350,000+. Gorgeous 2,000 sq.ft. 6 ops. Digital includes
invested in 6-Op office. Consistent Panorex. Full Price $500,000.
Attractive transition arrangements available. TUSTIN BUILDING 2,000 sq.ft. available at best intersection.
6071 CHICO Strength is 4-day Hygiene schedule. Retiring DDS
S OS,LD
60,000 autos pass daily.
focuses on restorative. Endo, O Perio & Pedo referred. 2014 TUSTIN DENTAL BUILDING 5 ops in 1,875 sq.ft. office in Tustin
collected $450,000. Beautiful 4-Op office. Full Price $150,000. Hills. $1.4 Million.
6070 VISALIA Strong foundation and well-positioned for VALENCIA - SANTA CLARITA 60,000-to-70,000 autos pass this
successor. Strong Hygiene Department, beautiful facility, well intersection daily. 8 ops plumbed, 4 equipped. 2,000 sq.ft. Full Price
equipped. Digital throughout. Not a Delta Premiere practice. $220,000.
Revenues trending $750,000 for 2015 on part-time schedule. YUCCA VALLEY Small dental building on .4 acres. Land Value
Extend hours and be busier. Best location! $150,000.
**FOUNDERS OF PRACTICE SALES** Wall Street Investor seeks small Groups to manage. PPS is banding
120+ years of combined expertise and experience! practices together of Owners retiring in near future. Cash in and work
3,000+ Sales - - 10,000+ Appraisals back for growing Group. Enjoy working with team spirit. Register your
**CONFIDENTIAL** interest with Tom Fitterer.
PPS Representatives do not give our business name when returning your calls.
DENTAL PRACTICE BROKERAGE
Making your transition a reality.
Dr. Lee Dr. Thomas Dr. Dennis Dr. Russell Jim Kerri Mario Jaci Steve Thinh
Maddox Wagner Hoover Okihara Engel McCullough Molina Hardison Caudill Tran
LIC #01801165 LIC #01418359 LIC #0123804 LIC #01886221 LIC #01898522 LIC #01382259 LIC #01423762 LIC #01927713 LIC #00411157 LIC #01863784
(949) 675-5578 (916) 812-3255 (209) 605-9039 (619) 694-7077 (925) 330-2207 (949) 566-3056 (949) 675-5578 (949) 675-5578 (951) 314-5542 (949) 675-5578
25 Years in Business 40 Years in Business 36 Years in Business 33 Years in Business 42 Years in Business 35 Years in Business 35 Years in Business 26 Years in Business 25 Years in Business 11 Years in Business
OLD
Microscopes, and PBS Endo in approx. 1,200 WEST HOLLYWOOD: 4 Ops, Intra-Oral
BEVERLY HILLS: 5 Ops. EagleSoft,
S
GREATER SACRAMENTO: 7 Ops, sq. ft. 2014 GR $672K. #CA284 Camera, Digital, Laser, 5 yr. old equip. 2014
Digital, CEREC. Long-term staff, newer GR of $613K . #CA212
3,079 sq. ft. (Shared w/2nd DDS Separate ROSEVILLE/GRANITE BAY: 1,320 Equipment. 2014 GR 1.07MM, Adj. Net
Practices), 2013 GR $974K. #CA140 sq. ft., 3 equip. Ops, 1 addl Plumbed. Dexis of $406K. #CA210 WHITTIER: General Dentistry. 4 Ops,
Digital X-ray. 2014 GR $434K. #CA296 3 Equipped. Dentrix, Dexis. Est for 50+ yrs.
LIVERMORE: Practice & Building. 1,100 CARSON: 3 Ops. Paperless, EagleSoft, on main street. 2014 GR $217K. #CA276
sq. ft., 4 Ops, Digital Pan & X-ray, Laser, SACRAMENTO: 1,684 sq. ft., 6 equip. Digital, Pano. All equip. <3 yrs. old. 2014
Dentrix. 2014 GR $740K. #CA300 stations in bay, 2 addl Plumbed. 2014 GR GR $143K. #CA280 SAN DIEGO
$590K. #CA269 CHULA VISTA: Est. 50+ yrs. 4 Ops, 3
MARIN COUNTY: Mill Valley 1,260 sq. CYPRESS: 5 Ops, 35 yrs. of Goodwill.
ft. 3 Ops, 1 addl Plumbed. Dentrix, Digital, SACRAMENTO: Russian-speaking. 4 Ops, days of Hygiene, Dentrix. $493K GR in 2013.
7 days Hygiene per week. $948K GR. #CA109
Intra-Oral. #CA224 1,500 sq. ft.. All new Equipment, practice
#CA257 - IN ESCROW!
started recently. $1M over last 12 months. CHULA VISTA EAST: New Listing!
MARIN COUNTY: 3 Op practice w/views #CA290 GREATER LOS ANGELES: Perio General Dentistry. 3 Ops. Est. 19 years.
of Corte Madera Creek. 2014 GR$315K. Practice. 5 Ops, 34 Yrs. of Goodwill. Dentrix,
SACRAMENTO: 2,500 sq. ft., 6 equip. Ops, Professional bldg. 2014 GR $454K. #CA304
Paperless charts, Schick, Eaglesoft. #CA286 Digital, Laser, great referral base. #CA173
1 addl Plumbed. Dentrix software, Digital COLLEGE AREA: Very busy 6 Ops with
MARIN COUNTY: 1,250 sq. ft. X-ray, Pano. 2014 GR $788K. #CA297 HACIENDA HEIGHTS: General Dentistry, room to expand to 9 Ops. PPO, Dentrix,
3 Ops. Fee for service 2014 GR $370k. On SAN FRANCISCO: Periodontal Practice 5 Ops, 3 Equipped, retail center, Digital, Digital. 2014 GR $1.7MM #CA231
pace for same in 2015. #CA302 & Condo Unit. 1,160 sq. ft. w/4 Ops, 2014 Pano. PPO. #CA295 DOWNTOWN: LEASEHOLD SALE.
MILLBRAE:VTIWOHDVHGRIFH GR $714K w/$363K adj. net. #CA274 0RGHUQDQGFKLFGRZQWRZQRIFHLQSULPH
HUNTINGTON BEACH: 5 Ops, 28 yrs.
with 5 Ops, 1 addl Plumbed, state-of-the-art SAN RAMON: FACILITY ONLY, 1,654 sq. of Goodwill, Digital, Pano, Laser, 12 days location. 3 Ops + room to expand. #CA232
D
Equipment. 2014 GR $670K. #CA262 ft., 4 Ops. Pelton & Crane Equipment, Digital
SOL
of hyg./wk. GR of $1.1MM+. #CA263 ESCONDIDO: 4 Ops, 3 Chairs, Central
X-ray, Digital Pan, I.O. cameras. #CA306 Escondido, Doctor Retiring Excellent
N. COAST: Endo Practice. 6 Ops, INLAND EMPIRE: Endo Practice. 4 Ops,
5 Plumbed 3,300 sq. ft. Digital, Microscopes, SANTA ROSA: General Dentistry & Opportunity to merge/grow. #CA292
3-yr. new equip., Digital, Cone Beam CT.
EndoVision. #CA214 Building. 3 Ops. 2013 GR $542K w/Adj. Net LA JOLLA: 3 Ops, FFS and Delta Premier.
2014 GR $739K with low overhead. #CA281
$182K. #CA200 2014 GR of $559K. Owner retiring. #CA278
N. EAST OF SACRAMENTO: 2,500 sq. INLAND EMPIRE: 7 Ops, Dentrix, Digital,
ft, 7 Ops with intra-oral, Digital X-ray, and SONOMA:6WDQGDORQHVTIWRIFH MID-TOWN: New Listing! 4 Ops+ 1
w/4 Ops. Digital X-rays, Lasers, CAD/CAM. Pano, 30 yrs. goodwill. 4 days surgical Op, Modern & Bright. HMO/
Eaglesoft. 2014 GR $1.5MM. #CA268 of Hygiene. #CA283
2014 GR $675K on 3 day/week. #CA270 PPO/FFS, Digital Pan/Ceph, Convenient
NORTHERN CALIFORNIA: Endo INLAND EMPIRE: General Dentistry, Location. #CA309
YOLO COUNTY: Pediatric practice, 2
Practice. 3 Ops, 1 Plumbed, 1,200 sq. ft.
D
SOL
equip. Ops, 1,000 sq. ft., Intra-oral, Open 4 Ops, Camera, Digital, Pano, 2014 GR NORTH COUNTY INLAND: General
2 Microscopes, Digital. 2013 GR $319K+ $534K, Adj. Net $196K. #CA285
Dental software. 2014 GR $245K. #CA301 Dentistry, 6 Ops, FFS/PPO. Free-standing
#CA158
bldg. also available to buy. #CA271
CENTRAL CALIFORNIA LAGUNA BEACH: New Listing! General
NORTHERN CALIFORNIA: Perio Practice, Dentistry. 5 Ops, 3 Equipped. Great Location. NORTH COUNTY, VISTA: New
Partnership Position. 6 Ops, 1,500 sq. ft. CALAVERAS COUNTY: 4 Ops, 1,752
2014 GR $503K. #CA303 Listing! Beautiful and modern 5 Ops
Dentrix. Owner Financing Available. #CA168 sq. ft., Dexis Digital X-ray, Eaglesoft, Cerec,
FFS/PPO, Digital X-rays & Pano, Most
Pano. Av. GR last 3 years $450K. #CA294 LOS ANGELES: General Dentistry, 6 Ops,
N. OF SACRAMENTO: 1,750 sq. ft. w/4 Specialty work referred out. Seller retiring
CENTRAL COAST: General Dentistry. 5 Equipped, Est. 50+ yrs., SoftDent, Digital. due to health. #CA308
Ops. Intra-Oral, Digital, Pano, Laser, CAD/
6 Ops, 8 days Hygiene/wk. GR over $2MM 2014 GR $591K. #CA255 - IN ESCROW!
CAM, Dentrix. 2014 GR $1MM. #CA260
D
S. BAY AREA, SAN DIEGO: General
SOL
for last 3 yrs. Est. 30+ yrs. #CA208 Dentistry, 3 Ops, 4 days hyg/wk. Retail
PALM DESERT: 5 Ops, Est. for 32 yrs.,
N. OF SACRAMENTO:VTIWRIFH KINGS COUNTY: General Dentistry. center, Dentrix, Digital Pano, PPO & FFS.
6 days of Hygiene/week. GR of $824K and
w/4 Ops, Dentrix, Pano. Owner worked 39 4 Ops, Pano, established for 50+ yrs. GR GR 2014 $524K. #CA206
$339K adj. net. #CA245 - IN ESCROW!
weeks in 2014. #CA267 of $246K in 2014. #CA265
PASADENA AREA: General Dentistry. SOUTH BAY AREA: New Listing! 4
N. OF SACRAMENTO: 1,800 sq. ft., 4 MADERA: Building & practice. 6 Ops, Ops, PPO/FFS, EagleSoft, Digital, Modern
3 Ops, Dentrix, Dexis, CEREC, established
Ops, Eaglesoft software, laser. 2014 GR 3000 sq. ft., Dentrix software, Dexis software, and Spacious. Practice & Building for Sale.
for 50+ yrs. #CA282
$289K. #CA307 Pano. 2014 GR $850K. #CA289 #CA313
PICO RIVERA: General Dentistry,
NORTH SACRAMENTO: 3 Ops in a PORTERVILLE: General Dentistry, 6 Ops.
6 Ops, Est. in 1960. DentiSoft, Pano, 4
OUT OF CALIFORNIA
leased space with <1,000 sq. ft., PPO, 2 days 2014 GR $555K, 7 year old Equipment, retail
days of Hygiene per week. 2014 GR of MAUI, HAWAII: New Listing! 7 Ops,
Hygiene, Digital, Easy Dental. #CA266 center. #CA223
$690K. #CA258- IN ESCROW! 5 Equipped, Modern Design, CEREC. 2014
NORTH SACRAMENTO: Practice & SOUTHERN CALIFORNIA GR $1.4MM+. #HI101
S. ORANGE COUNTY: Pedo Practice with
OLD
condo. 2,500 sq. ft., 5 Ops, Dexis Digital ANAHEIM HILLS: with 4 Ops, est. for CENTRAL OAHU, HAWAII:
X-ray, Pano, Laser, Dentrix. 2014 GR $673K. 4 Ops, 1 year new Equipment, Digital, Pano.
S
34 yrs. Dentrix, 6 days Hygiene per week. $236K GR with room to grow. #CA222 New Listing! General Dentistry. 3 Ops in
#CA305 #CA279 Central Oahu. Dentrix, Dexis, Pano. 2014
OAKLAND: Appx. 1,500 sq. ft. w/4 Ops, SANTA BARBARA: New Listing! GR $454K #HI102
BAKERSFIELD: General Dentistry with General Dentistry. 4 Ops. Est. 40+ yrs. 8
Dentrix software, Dexis Digital X-ray. 2014 4 Ops, Dentrix, Dexis, Pano, PPO/FFS. 2014 HONOLULU, HAWAII:New Listing!
GR $869K, adj. net $370K. #CA293 days hyg./wk. Long term staff. GR of $827K.
GR $329K #CA299 - IN ESCROW! #CA291 3 Ops, Dentrix, Digital, FFS/PPO. #HI100
Following are answers to questions which is mandated by Cal/OSHA. PPE must be worn over the scrubs
asked in recent months by dental A declination form and additional when treating patients. In responding
practices about infection control. information on HBV vaccination, to the question, What type of PPE
including recommendations, is should be used by employees in a
A new employee is joining our staff. available on cda.org/practicesupport. dental office? Cal/OSHA states:
She used to work at another dental Staff attended different infection PPE will be considered
practice. What is our practices obligation control courses recently and heard appropriate only if it does not
with regard to providing the hepatitis B conflicting information about scrubs. permit blood or other potentially
vaccination to the new employee? What are Cal/OSHAs rules? infectious material (OPIM)
Cal/OSHA requires an employer to The blood-borne pathogens to pass through employees
offer the hepatitis B (HBV) vaccination regulation does not address the use of underlying garments, or to
to employees who are occupationally scrubs or even uniforms. The regulation reach the skin, eyes, mouth or
exposed to blood-borne pathogens. The requires the use of personal protective other mucous membranes under
offer must be made within 10 working equipment (PPE). Consider this normal conditions of use. PPE
days of initial assignment to the job question: In your office, are scrubs must retain this capability during
and after the employer has provided used as PPE or are they uniforms? If the entire course of its use by
the employee with information on the they are uniforms, then appropriate the employee. This allows the
vaccines efficacy, safety, method of
administration and the benefits of being
vaccinated. An employer need not
make the HBV vaccination available to
employees who have previously received When Looking To Invest In Professional
the vaccination series, who are already
immune as revealed by appropriate tests Dental Space Dental Professionals Choose
for HBV antibodies or who are prohibited
from receiving the vaccine for medical
reasons. However, an employer may not
make any of these three exemptions a
condition of employment. The HBV
Linda Brown
series received as a child does not count
for the purpose of this requirement. 30 Years of Experience Serving
Employers can request documentation of the Dental Community Proven
previous vaccination from employees.
The employer must provide for Record of Performance
postvaccination testing one to two
months after the last shot and another Dental Office Leasing and Sales
vaccination series and testing for the
employee if the postvaccination test For your next move, Investment Properties
results are negative. If the second contact: LINDA BROWN Owner/User Properties
postvaccination test is negative, the
Locations Throughout
employer must refer the employee
Direct: (818) 466-0221 Southern California
to a health care provider for
counseling on infection prevention. Office: (818) 593-3800
An employee who tests negative Email: LindaB@TOLD.COM
need not be excluded from work. Web: www.TOLD.com
If an employee refuses the offer Cal BRE: 01465757
of vaccination, the employee must
sign a declination, the wording of
F E B R U A R Y 2 0 1 6 135
F E B . 2 016 R E G U L ATO RY C O M P L I A N C E
C D A J O U R N A L , V O L 4 4 , N 2
136F E B R U A R Y 2 01 6
C CARROLL
& C O M P A N Y
Complete Evaluation of Dental Practices & All Aspects of Buying and Selling Transactions
Matching the Right Dentist
to the Right Practice
5. Use and limitations of engineering 11. Employers requirements for post- the internal portions of some low-speed
controls, work practices and exposure evaluation and follow-up. handpiece motors have the potential to
personal protective equipment. 12. Signs and labels. become contaminated when used with
6. Type, use, location, handling, Is it true that the motors of low- both disposable and reusable prophylaxis
decontamination and disposal of speed handpieces must be sterilized? angles. The studies also have shown
personal protective equipment. The subject is addressed in the CDC that there is the potential for internal
7. Explanation of basis for selection 2003 Guidelines for Infection Control contamination to be released through
of personal protective equipment. in Dental Health-Care Settings. All the prophylaxis angle into the mouth
8. HBV vaccine information: handpieces and attachments, including of a patient during subsequent uses.
efficacy, safety, method of motors, must be heat sterilized between In summary, unless all components of
administration, benefits, offered patients unless they are single-use disposable handpieces are properly heat sterilized
at no cost to employees. items. This includes, but is not limited to, all between patients, there is the potential
9. Actions to take and who handpiece attachments, handpiece motors, for microorganisms to enter, remain and
to contact in an emergency reusable prophy angles, reusable air and then be released during use on patients.
involving infectious materials. water syringe tips and ultrasonic scaler tips. The 2003 CDC guidelines provide
10.Post-exposure procedures including CDA contacted the CDC Oral Health the following recommendations for
reporting, medical follow-up and Division, which provided additional dental handpieces and other devices
sharps injury log recording. information. Recent studies have shown attached to air and waterlines:
1. Clean and heat sterilize handpieces
and other intraoral instruments
that can be removed from the
air and waterlines of dental
RESOURCES
CDC. Guidelines for infection control in dental health-care
settings 2003. MMWR 2003; 52 (No. RR-17):1-66. www.
cdc.gov/mmwr/PDF/rr/rr5217.pdf.
Chin JR, Miller CH, Palenik CJ. Internal contamination of air-
driven low-speed handpieces and attached prophy angles. J
Am Dent Assoc 2006;137:12751280.
Available for iPad, iPhone, Android or Kindle Fire. Chin JR, Westerman AE, Palenik CJ, Eckert SG. Contamination
Check it out at cda.org/apps. of handpieces during pulpotomy therapy on primary teeth.
Pediatr Dent 2009;31:7175.
Herd S, Chin J, Palenik CJ, Ofner S. The in vivo contamination
of air-driven low-speed handpieces with prophylaxis angles. J
Am Dent Assoc 2007;138:13601365.
138F E B R U A R Y 2 01 6
Periscope C D A J O U R N A L , V O L 4 4 , N 2
F E B R U A R Y 2 0 1 6 139
BAY AREA BAY AREA CONTINUED
Largest AC-335 SAN FRANCISCO: Great Practice! 2100 DC-406 SAN JOSE: Amazing opportunity in
sf, 8ops in desirable location. Call for Details Westgate Shopping Center. 6 ops + 80 mall
Broker in $475k!
AG-511 SAN FRANCISCO: Trendy, tony West
hours per week $400k
DC-522 PLEASANTON: Location, Location, Loca-
Portal neighborhood. 800+ sf w 3 ops $315k tion! Do not pass this opportunity! 2ops in
Northern AN-490 SAN FRANCISCO: This is an opportunity
of a lifetime! 1,000 sf w/ 4 ops. $795k
712sf office $149k
DG-499 SARATOGA Facility: 2 fully equipped
AN-514 SAN FRANCISCO Facility: Located in the ops & room for 1 addl w 1,178sf . Move-In
California bustling financial district! 1,007 sf w/4 ops.
$150k
Ready NOW ONLY $99.5k
DN-447 SUNNYVALE: Quality, family-oriented
BN-183 HAYWARD: Kick it up a notch by in- opportunity awaits your talent and skill. 1,200
creasing the current very relaxed work sched- sf w/ 3 ops + 1 addl. $395k
ule! 1,300 sf w/ 3 ops $150k DN-467 GILROY Facility: This traditionally
Extensive Buyer BN-279 CONTRA COSTA COUNTY: Excellent styled practice is perfectly situated! 1,325 sf
Merger Opportunity! 2-story. 1,350 sf w/ 3 w/ 3 ops + 1 addl. $75k
Database & ops +1 addl $60k DN-497 PLEASANTON Facility: Great Location!
BC-361 OAKLAND: Established for over 23+ 870 sf w/ 3 ops + 1 addl. Owner Financing
Unsurpassed years! 2,200 sf w/ 7 ops. Now Only: $330k
BC-381 PLEASANT HILL Facility: Open Floor
w/10% Down! Reduced! $95k
DG-519 SANTA CLARA Facility: Move In Ready!
Exposure allows Plan! 1,852 sf w/ 6 equipped ops! $80k
BC-509 SAN LEANDRO: Facility Only, 800 sf,
2240 sf w 6 fully equipped ops $225k
us to offer you 3ops w/ xray in each op. Call for Details $60k
BG-407 SAN LEANDRO: Prof bldg. Great sign-
NORTHERN CALIFORNIA
800.641.4179 WPS@SUCCEED.NET
Timothy Giroux, DDS Jon B. Noble, MBA Mona Chang, DDS John M. Cahill, MBA Edmond P. Cahill, JD
EN-484 FOLSOM Facility: Come live, practice and grow here! HN-280 NO EAST CA: Only Practice in Town 900 sf w/ 2 ops $110k
1,934 sf w/ 4 Ops. $150k HN-290 PLACERVILLE: Excellent Merger Op! FFS. 1,400 sf w/ 4 ops
EN-503 FOLSOM Facility: Take a close look at this opportunity! $210k
2,150 sf w/5 ops. Reasonable Offers Considered! HG-448 LAKE TAHOE AREA: Upscale Family Practice. 3400sf w 6 ops
EG-508 FOLSOM Facility: Youll want to spend your days here! $725k
1,500 sf w/ 4 ops + 1 addl. $60k CENTRAL VALLEY
EN-516 CITRUS HEIGHTS: well-established, quality prac ce is load-
ed w/30+ years of goodwill. 1,358 sf w/ 3 ops + 2 addl $140k IC-468 SAN JOAQUIN VLY: 2500+sf, 6 ops, Mo vated Seller, Price
EG-521 FOLSOM Facility: Stands out above the rest! Dont Miss Reduced. All oers considered! $350k
this one! 1,200 sf w 3 ops. Well Equipped! $115k IG-367 MERCED: Newly Remodeled, Paperless. 1,550 sf w/4 ops
EG-523 SACRAMENTO: Spacious practice and Real Estate Available REDUCED! $305k
NOW! Call for Details! IN-397 FRESNO/MADERA: Focused on quality dental care & pa-
FN-299 FERNDALE: Live and practice on the beautiful North tient comfort! 2,000 sf w/5ops. Seller Motivated: $440k
Coast! 1,300 sf w/ 3 ops $195k (Real Estate: $309k) IN-429 TRACY Facility: Move-in ready Hesitate and you might
FC-334 NORTHERN CA: Emphasis on prevention. 1,200 sf w/ 4 ops miss out! 2,488 sf, 5 ops $245k/RE: $650k
$480k / Real Estate Also Available! IN-474 STOCKTON: Too good to be true? Absolutely not! 1,600 sf
FC-415 FT. BRAGG: Excellent practice in peaceful, family-oriented w/ 3 ops. $95k
community! 1,800 sf w/ 5 ops + 1 hyg. Op. $425k IC-468 SAN JOAQUIN VALLEY: High-End Restorative Practice! Dont
GC-472 ORLAND: Live & Practice in charming small town community. miss out! 2,500 sf w/ 6ops. $425k
1,000 sf w/ 2ops. Seller Retiring. $160k IN-506 TURLOCK: Practice in the heart of the Central Valley!
GG-386 REDDING: Amazing Practice. Lease or Buy Real Estate! 2,000 sf w/ 5ops + 1 addl. $425k
2,860 sf w/ 4 ops. Plumbed for 2 addl! ONLY $275k IN-512 Merced: This immaculate practice is an absolute jewel!
GG-453 CHICO: 5,000 sf 7 ops Perfect for 1 or more dentists! $395k 1,200 sf w/ 4ops + 1 addl. $140k
GG-454 PARADISE: ~2,550 sf w 9 ops. 40 yrs goodwill! Amazing Op- JC-349 FRESNO Facility: Mo vated Seller re ring! Step right in and
portunity! $595k make yours! Call for Details!
GN-201 CHICO: Beautiful practice, major thoroughfare, stellar JG-491 FRESNO: Well-established. 40-50 new Pt/mo. 1,452 sf w/
reputation! 1,400 sf w/ 4 ops & room for another $425k 4 fully equipped ops $425k
GN-244 OROVILLE: Must See! Gorgeous, Spacious. 2,500 sf w/5
ops! Collections over $450k in 2013. Only $315k SPECIALTY PRACTICES
GN-258 REDDING: Pristine and attractive! Conveniently located!
2,100 sf w/ 3 ops + 2 addl. Now Only $300k! I-9461 CENTRAL VALLEY Ortho: 1,650 sf w/5 chairs/bays & plumbed
GN-399 REDDING: Loyal patient base and relaxed workweek sched- for 2 addl $180k
ule. 1,440 sf w/3 ops. $150k CC-346 SO MARIN CO Perio: 1,142 sf w/ 3 ops. Meticulously main-
GN-418 REDDING: Goodwill Galore! Established for ~37 years. Seller tained! No reasonable oer will be refused! REDUCED! $199k
is retiring! 3,200 sf w/6 ops +2 addl. $495k CG-424 NAPA Prostho: Office has Digital X-ray & NEW 3D Imaging
GN-507 CHICO: It just doesnt get any better than this! 3,000 sf w/ Unit! Ready for Experienced, high-end Prosthodontist! On track to
7ops. Practice $535k Real Estate $750k collect just under $1m $725k
HC-461 SONORA: In the beautiful Sierra Foothills, 4ops, 1350sf, free CC-405 SOLANO CO. Endo: Endodontic Practice in a vibrant commu-
-standing bldg.. Practice $700k & Real Estate Also Available! nity! 1,250 sf w/ 4 ops. $485k
HG-298 REDDING FOOTHILLS: HEALTH FORCES SALE! Includes Cerec! DC-459 SF PENINSULA Perio) 50% Partnership Buy In! Call for De-
2,000 sf w/ 5 ops. Practice $75k & Real Estate Also Available! tails! $580k
HN-213 ALTURAS: Close to Oregon Border. FFS practice is 2,200 CG-481 S SONOMA CO Ortho: 2070 sf w 7 chairs + 1 exam in Med/
sf w/ 3ops +1 addl $115k Prof Plaza $295k
BG-517 NORTH EAST BAY Endo: Coming Soon! Call for Details!
800.552.5512 | ultradent.com
2016 Ultradent Products, Inc. All Rights Reserved.