- Email: [email protected]
Instructive clinical case reports
Operative Oral Surgery INSTRUCTIVE CLINICAL CASE REPORTS THEOI)OR BLUM, D.D.S., M.D.,* NEW YORK, N. Y. S A N a r d e n t a d v o c a t e of c o o p e r a t i o n b e t w e e n m e m b e r s of t h e p r o f e s s i o n s of t h e h e a l i n g a r t s , I a m g l a d f o r t h i s o p p o r t u n i t y to d e m o n s t r a t e i t s a d v a n t a g e s to m y a u d i e n c e , w h i c h c o n s i s t s l a r g e l y of g e n e r a l d e n t a l p r a c t i t i o n e r s . C o n s i d e r a t i o n of t h e case h i s t o r i e s w h i c h f o l l o w w i l l , I h o p e , i n d i c a t e t h e a d v a n t a g e s w h i c h a c c r u e to t h e p a t i e n t w h e n p h y s i c i a n s , d e n t i s t s , o r a l surgeons, and oral pathologists cooperate in the diagnosis, prognosis, and t r e a t m e n t of c l i n i c a l p r o b l e m s .
A
In my contact with the general practitioner, I have found too often that failure to consult with others in related areas of the healing arts has resulted in u n p l e a s a n t e x p e r i e n c e s f o r t h e p a t i e n t , u n n e c e s s a r i l y p r o l o n g e d t r e a t m e n t , a n d o c c a s i o n a l l y f a u l t y d i a g n o s i s a n d f a i l u r e of t r e a t m e n t . I a m p r e s e n t i n g these cases with the hope that they will serve the purpose of promoting more cooperation between members of the dental and medical professions. Through c o n s t r u c t i v e c r i t i c i s m o u r k n o w l e d g e is a d v a n c e d a n d t h e c a r e a n d t r e a t m e n t w e p r o v i d e f o r o u r p a t i e n t s is i m p r o v e d .
Case 1.--The first case is that of a boy, 111~ years old. Two and one-half years previously he met with an accident. Parts of the crowns of the maxillary central incisors were broken off and were repaired soon afterward by the dentist. Two weeks before the present examination an x-ray film revealed an area in the apical region of the right incisor which was diagnosed to be a cyst (Fig. 1). (Of course we all know that only a microscopic examination can determine the presence of a cyst or granuloma when the lesion is so small.) Initially a pulp test should have been done and repeated for a period of time until the exact status of the viability o~ the pulp was determined. Root canal ther~ apy could have been instituted as soon as the pulp was proved definitely nonvital. The area at the left incisor apex was entirely overlooked on the original x-ray picture and the tooth was now also found to be nonvital. I n t h i s case, t h e d e n t i s t , t h r o u g h c o n t a c t w i t h o t h e r s in t h e p r o f e s s i o n , might have kept up with its progress and employed the pulp test and thus p r e v e n t e d t h e d e v e l o p m e n t o f t h e s e a p i c a l lesions. Read before the Nov. 20, 1956. meeting of the Roekaway Dental Society. *The New York Institute of Clinical Oral Pathology. 1239
1240
BLUM
O S.. O. M.. & O. P. December, 1957
Case 2 . - - I n contradiction to the previous case, the diagnosis and t r e a t m e n t of a 34year-old woman in 1944 was based mostly on the pulp t e s t findings. The first (Fig. 2, A, Dec. 21, 1927) and second (Fig. 2, B, April 6, 1939) x-ray pictures, t a k e n elsewhere duringa period of t r a u m a t i c occlusion and orthodontic t r e a t m e n t , seemed normal. W h e n the p a t i e n t was first seen (Fig. 2, C, Dec. 5, 1944) the x-ray picture revealed an apical lesion at the m a n d i b u l a r l e f t central incisor approaching the lateral incisor and a pulp test of plus 50. I n Fig. 2, D, Nov. 13, 1951 i t responded only to plus 60 and the lesion now also reached the r i g h t central incisor. A few months l a t e r it finally became n o n v i t a ] and root canal therapy was instituted. The x-ray picture taken on Dec. 12, 1951 (Fig. 2, E ) illustrates the condition one week a f t e r completion of the filling, and the last one t a k e n three years l a t e r (Fig. 2, /~) exhibits an ideal result.
Fig. 1. I t is m y b e l i e f t h a t
every root-canal-filled tooth should be x-rayed
year, as there may be a recurrence retreatment amination
or difficulty indicating
of the canal or apicoectomy.
once a
the need for either
Even after apicoectomy,
annual
ex-
is i n d i c a t e d .
c a s e 3.--Because the practice of apicoectomy is often belittled, I wish to describe a case of acute purulent periostitis (usually called an alveolar abscess) o r i g i n a t i n g from a maxillary r i g h t second premolar in a young man, aged 18 years. The pus was drained, in duo time the canal was filled, and the operation was performed in 1926. The p a t i e n t was re-examined every y e a r u n t i l 1929. Thereafter, he disappeared. However, I contacted him by accident and took the last x-ray picture on Nov. 2, 1956. Even though the apex of the tooth was close to the floor of the a n t r u m and the condition was acute, the tooth had been saved and functioned perfectly now for nearly t h i r t y years (Fig. 3). Case 4.--Of course, recurrences are s as seen in this 46-year-old man. This is an i n t e r e s t i n g case because, instead of the very large area first operated upon, two smaller ones are now visible: one represents the recurrence at the resected apex and the other is scar tissue, so diagnosed b y microscopic e x a m i n a t i o n (Fig. 4).
This procedure blo to study condensed
has been followed in a number
this scar tissue area surrounded
of other cases.
by the irregularly
b o n e w h i c h is so t y p i c a l o f s u c h a n a r e a .
It is valuaoutlined
and
It has been theorized
that
Volume 10
I N S T R U C T I V E CLINICAL CASE REPORTS
1241
N u m b e r 12
.O
r
t-
I
eq
1242
BLUM
o . s . , o. M., ~ O. P. December, 1957
r
Volume 10
Number 12
I N S T R U C T I V E CLINICAL CASE REPORTS
1243
in this region of the maxilla an operation may involve both the palatal and labial periosteum and so only dense connective tissue of a scar replaces the defect and the absence of periosteum prevents its calcification.
Fig. 4.--(From Blum:
ORAL SURG., ORAL ]~ED., • ORAL PATH., May, 1956.)
Case 5 . - - N o t all apical lesions are benign. Therefore, I wish to give as an example the case of a 50-year-old woman. The x-ray picture (Fig. 5) shows a defect in the apical region of a maxillary canine and premolar. A careful study gives the impression t h a t the bone is actually cut out, there being no dense bony periphery as seen in the average granuloma or cyst. Here we can see the importance of a complete intraoral series of x-rays as well as two extraoral films, since in this case many such lesions were present within the jawbones, which certainly must arouse the operator's suspicion. I do not think t h a t it is necessary to dwell on the consequences of either conservative t r e a t m e n t of the area found on the
Fig. 5 . - - ( F r o m B l u m :
ORAL SURG., ORAL MED., & ORAL PATH., May, 1956.)
first film or the extraction of the two teeth without a microscopic examination of the tissue in the periapical area. This defect proved to be a local lesion of a generalized plasma-cell myeloma. Case 6 . - - L e t us discuss a n o t h e r subject, namely, malposed teeth. A young girl, aged 14 years, showed a number of such t e e t h on both sides of the maxilla and mandible. In consultation with an orthodontist on Dec. 28, 1953 (Fig. 6, A and B), it was decided to
1244
BLUM
O.s., O. M., & O. P. December, 1957
Volume 10 Number 12
INSTRUCTIVE
CLINICAL
CASE
REPORTS
1245
o
t.O
o
o
~r
~o
1246
BLUM
o S., O. M., a O. P. December, 1957
remove first the mandibular third molars and then, by orthodontic means, to move the second molars into normal position (Fig. 6, C). Thereafter, it was decided to take care of the involved molars in the maxilla (Fig. 6, D). I t seemed best to remove the maxillary second molars and expose the two third molars. This procedure proved correct and successful, as seen by examination of the films taken about four months later, on Oct. ]1, 1956 (Fig. 6, E). This result could be obtained only by cooperation between the dentist, the orthodontist, and the oral surgeon.
Fig. 7.--(From Blum:
ORAL SURG., ORAL I~ED., • ORAL PATH., May, 1956.)
Case 7.--There are also instances when the removal of malposed teeth is contraindicated. A 43-year-old female patient, who for about three weeks complained of pain on the right side of the face, is an example. The pain started in the j a w and she thought t h a t she had neuralgia because she had a cold. The rhinologist found something in her ear and she was given penicillin. However, she awoke with a rash a f t e r that, so for about ten days was given other antibiotic drugs. While she f e l t better, she still had the pain. Her dentist examined her t e e t h and said t h a t she was cutting a wisdom tooth, which he felt should be removed. The pain seemed to be worse at night. "The tongue seemed to have a c o v e r i n g " after she took drugs. (These are the p a t i e n t ' s words.) Pain originating from a malposed mandibular third molar is rather unusual when tile clinical examination shows no inflammation of tile covering soft tissues. Therefore ex-
Volume 10 Number 12
I N S T R U C T I V E CLINICAL CASE REPORTS
1247
traoral, intraoral, and bite-wing films were taken and a pulp test was done (Fig. 7). I t was the pulp test which revealed the correct diagnosis. The right mandibular lateral incisor With a normal apical region and a p e r f e c t periodontal lamella was nonvital. Root canal therapy of this tooth relieved the p a t i e n t ' s discomfort. Case 8 . - - A similar case is t h a t of a woman, 29 years of age, who complained of discomfort on the l e f t side of the face, and slight pain for a few years. For nearly two weeks she had complained of trismus of undetermined origin. A malposcd mandibular third molar was thought to be the etiological f a c t o r and its removal was advised (Fig. 8). However, the tooth was unerupted and no inflammation or infection was discernible. Therefore, complete rest of the temporomandibular joints was ordered, followed in about a week with slowly increased exercise. Within four weeks the p a t i e n t was entirely well. In a few months the malposed tooth could safely be removed. I f the malposed third molar had been removed first in the former case the p a t i e n t ' s pains would have increased and the real cause of pain would not have been found until more a g g r a v a t i n g symptoms appeared. In the present case the trismus would have increased postoperatively and the period of recovery would have been very much delayed.
Fig. 8. Case 9 . - - I n this group belongs also the case of a young girl, aged 12 years. X-ray examination revealed w h a t seemed to be a supernumerary tooth. In consultation w i t h the orthodontist, it was decided to remove the tooth at this time, as the apices of the adjoining teeth were fully formed (Fig. 9). During the discussion of the case with the family physician I particularly inquired about the s a f e t y of operating during the poliomyelitis season, even though she had received one polio vaccine injection some time before. He advised postponement until the l a t t e r part of October. The three regular intraoral films were taken from three different angles. Comparison of the three films revealed that there was very little change in the position of the supernumerary tooth so t h a t we had good reason to believe t h a t its position was palatal. To make certain, an occlusal exposure was procured; this confirmed our assumption. The supernumerary tooth turned out to be an odontoma, consisting of an enveloping membrane, and one larger and several smaller tooth buds.
N o w we come to the consideration of m a l i g n a n t lesions, since t h e y occur in p a t i e n t s who come to see the general dental practitioner. I n some cases, there will be no d o u b t as to the diagnosis. Others, which at first give the impression of a neoplasm, call f o r conservative t r e a t m e n t and observation. Case 10.--An example is the case of a 65-year-old woman. The area involved was in the cheek opposite the molar region (Fig. 10, A). The p a t i e n t was wearing full maxillary and mandibular dentures. The lesion was noticed by the p a t i e n t for only a f e w days a f t e r her d e n t i s t had adjusted the maxillary denture. She reported: " I t felt very t i g h t
1248
BLUM
o . s . , o. M., & O. P. December, 1957
Volume I0 Number 12
INSTRUCTIVE
CLINICAL
CASE
REPORTS
1249
A.
B.
C.
D.
E.
F.
Fig. 10.--A, Before treatment.
B, After treatment.
1250
BLUM
O.s., O. M., & O. P. December, 19.~7
and was i r r i t a t i n g the mouth and made it quite sore. Yesterday, glands in the neck swelled up." All this speaks for a recent lesion and led to my clinical impression t h a t I was dealing with an area of benign ulceration. This justified a conservative approach, namely, waiting a few days to observe the progress of the case. To prevent f u r t h e r irritation from influencing the diagnosis, the patient was advised not to wear the dentures. To make certain t h a t these orders were carried out, she was asked whether she had other dentures at home. She was told to avoid all i r r i t a t i n g food and drink (neither too hot nor too cold), and a mild alkaline mouthwash was prescribed for use a f t e r each meal. In this case, we were dealing with a traumatic ulcer which was well on the way to healing a f t e r three ,lays (Fig. 10, B).
l~ig". l l . - - E x t r a o r a !
films of a r e a s h o w n in Fig.
10, F.
C a ~ s 11 and 12.--In a number of malignant neoplasms the diagnostieian has no difficulty in recognizing the true nature of the lesion. Examples are a male patient, aged 68 years, afflicted with a carcinoma of the floor of the mouth (Fig. 10, C) and another male, aged 69, with the same type of lesion in the maxilla (Fig. 10, D). I never perform a biopsy if the p a t i e n t is referred to an oncologist. (I prefer, for obvious reasons, an oncologist who combines surgery with radiation therapy. He will perform the biopsy and the p a t i e n t is not subjected unnecessarily to the same procedure twice.) I t must be added that neither a physician nor a dentist should take a biopsy specimen unless he is well trained to do so. He should make certain t h a t the pathologist who studies the histologic sectiou is well qualified to diagnose oral tissue, in other words, an oral pathologist.
Case 1 3 . ~ I t is not always as simple as in the previous two eases. A 72-year-old male p a t i e n t had a loose molar in the left maxilla. When it was removed, granulations appeared at the mouth of the socket and an enlargement was noticed in this region, palatally a n d buceally (:Fig. t0, E). Three biopsies were performed bes a definite diagnosis of carcinoma could be established. I have had similar experiences previously, one in a p.~tient as young as 30 years.
One must not be satisfied with one negative biopsy if the clinical impression points toward a malignant lesion. In the above-mentioned case the three biopsies were made within a few days of each other. Case 14.--This was not so, however, in the ease of a male patient, aged 48 years (Fig.
10, 2').
The left maxilla was enlarged in the molar and the premolar region.
A molar was
Volume 1o
Number 12
INSTRUCTIVE
CLINICAL CASE REPORTS
1251
r e m o v e d ; l a t e r on a b i o p s y w a s d o n e a t a h o s p i t a l a n d n e g a t i v e f i n d i n g s w e r e r e p o r t e d . T h e r e w a s a d i s c h a r g e o f p u s f r o m t h e s o c k e t , as well as p a i n i n t h i s r e g i o a a n d a n i r r i t a t i e r o f t h e eye. F o r f o u r m o n t h s t h e p a t i e n t w a s t r e a t e d b y a s p e c i a l i s t w h o w a s satisfied w i t h o n e b i o p s y . A f t e r f o u r m o n t h s of p r e c i o u s t i m e h a d e l a p s e d , t h e p a t i e n t w a s r e f e r r e d to a n o t h e r oral s u r g e o n ( F i g s . 11 a n d 12). A n u m b e r of b i o p s i e s w e r e p e r f o r m e d a n d finally a d i a g n o s i s o f c a r c i n o m a (oat-cell) was made. T h e p r o l o n g e d t r e a t m e n t s caused t h e
Fig. 12.--Intraora], blte-wfng, occlusal, and bird's-eye view of area s h o w n In Fig. 10, F.
1252
BLUM
o.s., o. M.. &O. P. December, I957
f o r m a t i o n of so m u c h i n f l a m m a t o r y tissue t h a t the n a t u r e of the lesion w a s difficult to d e m o n s t r a t e in t h e first biopsies. This case r e m i n d s me of a n o t h e r one w i t h a m e t a s t a t i c lesion in the mandible. The original t u m o r site in the sigmoid colon w a s f o u n d only at autopsy. C a s e 15.--One would not consider it possible t h a t a well-developed t u m o r occupying h a l f of the m a n d i b l e could be diagnosed as an osteomyelitis (Fig. ]3). The m o t h e r of a 31/~-year-old boy noticed a swelling of his f a c e and, w h e n looking into his mouth, saw t h a t the g i n g i v a e were red. H e r p h y s i c i a n advised h e r to see her dentist, who s u g g e s t e d h o s p i t a l i z a t i o n and various tests. Because t h e p a t i e n t h a d a fever, penicillin was prescribed. T h i s was not taken, as the p a t i e n t was to see a n oral surgeon. The specialist removed a tooth a n d f o u n d pus (?). T h e n e x t d a y he m a d e an incision. H e t h e n s u g g e s t e d c o n s u l t a t i o n a n d told the f a t h e r t h a t the boy had a benign t u m o r which could be removed.
Fig. 13.
The child was an early teether, and w h e n 4 m o n t h s old he had f o u r teeth. The f a m i l y h i s t o r y revealed m a l i g n a n t t u m o r s on both the f a t h e r ' s and m o t h e r ' s sides. Upon e x a m i n a tion, the child was f o u n d to be normal except for a swollen face. A description of the local lesion follows. Ext~aoral: The whole l e f t side w a s m a r k e d l y swollen. I t was s o f t and s o m e w h a t t e n d e r due to previous surgical interference. L y m p h nodes were about n o r m a l in size; the left s u b m a x i l l a r y region w a s sensitive. lntvaoral: There was a v e r y large m a s s covered b y normal mucous membrane, s o f t b u t firm, p a r t i c u l a r l y on the lingua] side which had n o t been interfered with. There w a s evidence of the removal of a tooth a n d also of an incision w h i c h w a s open b u t filled w i t h s o f t tisssue. This t u m o r e x t e n d e d f r o m t h e deciduous f r s t molar, inclusive, all the w a y b a c k to the a n t e r i o r pillars of t h e fauces.
I n t h i s 3 89 boy, a tooth w a s e x t r a c t e d and an incision w a s m a d e the n e x t d a y f o r the alleged purpose of finding and e v a c u a t i n g pus. T h e microscopic diagnosis w a s n e u r o b l a s t o m a . The p a t i e n t , who died w i t h i n a f e w m o n t h s , could h a v e been spared t h e unnecessary interference.
Summary In my introduction to this presentation I expressed the hope that the cases described will be of interest to you and assist you in the care of your patients. Even if you are aware of some or all of the points which I emphasized, they may still give you an idea of what others overlook. You, in turn, through
Volume l0 Number 12
INSTRUCTIVE
CLINICAL CASE REPORTS
1253
conversation and lectures, can help other practitioners to avoid such errors and, by adding to their knowledge, benefit their patients. It may seem to you that I have turned preacher. I will risk this accusation, because the thought that I wish to express is important. There were times when knowledge and experience were kept secret by the practitioners of the healing arts. For instance, for more than three generations (starting in the early part of the seventeenth century) the Chamberlen family in England kept to themselves the invention of an obstetrical forceps to be used in difficult labors. I do not think that this happens today. However, general practitioners and specialists in both the medical and dental professions do not cooperate sufficiently, and jealousy is often evident. The result is that the patient suffers. All my professional life I have endeavored to improve professional relations between the members of these professions, and I feel certain that meeting one's colleagues socially and at lectures and clinics helps a lot. Let us return now to our subject. We have dealt with disease and its treatment. However, this is not enough. Our aim today is prevention of disease and the maintenance of health. To accomplish it we recommend periodic health examination, which in our field means prophylaxis, routine x-ray examination, and pulp testing at regular intervals. In closing, i wish to quote from an interview entitled : "Prescription for ~edicine : Dr. Gregg, Lasker Award Winner, Outlines a Medical Philosophy" by Leonard Engel, which appeared in the New York Times Magazine Section (Nov. 4, 1956). In this article Dr. Alan Gregg, who was for twenty-six years first the director of the medical sciences division of the Rockefeller Foundation and then vice-president of the Foundation, said: "Recently, our way of referring to health and illness has begun to change. We hear less of 'disease' and more of health maintenance, health protection and the health professions. This change signifies a larger horizon, a larger task, but it also aims at a more positive and desirable goal for medicine than the mere absence of disease. The positive goal of maintaining health will be more nearly realized when the public has been educated to ask for i t . " Let us subscribe to this program, by coordinating more closely the efforts of the dental and medical professions.
A
In my contact with the general practitioner, I have found too often that failure to consult with others in related areas of the healing arts has resulted in u n p l e a s a n t e x p e r i e n c e s f o r t h e p a t i e n t , u n n e c e s s a r i l y p r o l o n g e d t r e a t m e n t , a n d o c c a s i o n a l l y f a u l t y d i a g n o s i s a n d f a i l u r e of t r e a t m e n t . I a m p r e s e n t i n g these cases with the hope that they will serve the purpose of promoting more cooperation between members of the dental and medical professions. Through c o n s t r u c t i v e c r i t i c i s m o u r k n o w l e d g e is a d v a n c e d a n d t h e c a r e a n d t r e a t m e n t w e p r o v i d e f o r o u r p a t i e n t s is i m p r o v e d .
Case 1.--The first case is that of a boy, 111~ years old. Two and one-half years previously he met with an accident. Parts of the crowns of the maxillary central incisors were broken off and were repaired soon afterward by the dentist. Two weeks before the present examination an x-ray film revealed an area in the apical region of the right incisor which was diagnosed to be a cyst (Fig. 1). (Of course we all know that only a microscopic examination can determine the presence of a cyst or granuloma when the lesion is so small.) Initially a pulp test should have been done and repeated for a period of time until the exact status of the viability o~ the pulp was determined. Root canal ther~ apy could have been instituted as soon as the pulp was proved definitely nonvital. The area at the left incisor apex was entirely overlooked on the original x-ray picture and the tooth was now also found to be nonvital. I n t h i s case, t h e d e n t i s t , t h r o u g h c o n t a c t w i t h o t h e r s in t h e p r o f e s s i o n , might have kept up with its progress and employed the pulp test and thus p r e v e n t e d t h e d e v e l o p m e n t o f t h e s e a p i c a l lesions. Read before the Nov. 20, 1956. meeting of the Roekaway Dental Society. *The New York Institute of Clinical Oral Pathology. 1239
1240
BLUM
O S.. O. M.. & O. P. December, 1957
Case 2 . - - I n contradiction to the previous case, the diagnosis and t r e a t m e n t of a 34year-old woman in 1944 was based mostly on the pulp t e s t findings. The first (Fig. 2, A, Dec. 21, 1927) and second (Fig. 2, B, April 6, 1939) x-ray pictures, t a k e n elsewhere duringa period of t r a u m a t i c occlusion and orthodontic t r e a t m e n t , seemed normal. W h e n the p a t i e n t was first seen (Fig. 2, C, Dec. 5, 1944) the x-ray picture revealed an apical lesion at the m a n d i b u l a r l e f t central incisor approaching the lateral incisor and a pulp test of plus 50. I n Fig. 2, D, Nov. 13, 1951 i t responded only to plus 60 and the lesion now also reached the r i g h t central incisor. A few months l a t e r it finally became n o n v i t a ] and root canal therapy was instituted. The x-ray picture taken on Dec. 12, 1951 (Fig. 2, E ) illustrates the condition one week a f t e r completion of the filling, and the last one t a k e n three years l a t e r (Fig. 2, /~) exhibits an ideal result.
Fig. 1. I t is m y b e l i e f t h a t
every root-canal-filled tooth should be x-rayed
year, as there may be a recurrence retreatment amination
or difficulty indicating
of the canal or apicoectomy.
once a
the need for either
Even after apicoectomy,
annual
ex-
is i n d i c a t e d .
c a s e 3.--Because the practice of apicoectomy is often belittled, I wish to describe a case of acute purulent periostitis (usually called an alveolar abscess) o r i g i n a t i n g from a maxillary r i g h t second premolar in a young man, aged 18 years. The pus was drained, in duo time the canal was filled, and the operation was performed in 1926. The p a t i e n t was re-examined every y e a r u n t i l 1929. Thereafter, he disappeared. However, I contacted him by accident and took the last x-ray picture on Nov. 2, 1956. Even though the apex of the tooth was close to the floor of the a n t r u m and the condition was acute, the tooth had been saved and functioned perfectly now for nearly t h i r t y years (Fig. 3). Case 4.--Of course, recurrences are s as seen in this 46-year-old man. This is an i n t e r e s t i n g case because, instead of the very large area first operated upon, two smaller ones are now visible: one represents the recurrence at the resected apex and the other is scar tissue, so diagnosed b y microscopic e x a m i n a t i o n (Fig. 4).
This procedure blo to study condensed
has been followed in a number
this scar tissue area surrounded
of other cases.
by the irregularly
b o n e w h i c h is so t y p i c a l o f s u c h a n a r e a .
It is valuaoutlined
and
It has been theorized
that
Volume 10
I N S T R U C T I V E CLINICAL CASE REPORTS
1241
N u m b e r 12
.O
r
t-
I
eq
1242
BLUM
o . s . , o. M., ~ O. P. December, 1957
r
Volume 10
Number 12
I N S T R U C T I V E CLINICAL CASE REPORTS
1243
in this region of the maxilla an operation may involve both the palatal and labial periosteum and so only dense connective tissue of a scar replaces the defect and the absence of periosteum prevents its calcification.
Fig. 4.--(From Blum:
ORAL SURG., ORAL ]~ED., • ORAL PATH., May, 1956.)
Case 5 . - - N o t all apical lesions are benign. Therefore, I wish to give as an example the case of a 50-year-old woman. The x-ray picture (Fig. 5) shows a defect in the apical region of a maxillary canine and premolar. A careful study gives the impression t h a t the bone is actually cut out, there being no dense bony periphery as seen in the average granuloma or cyst. Here we can see the importance of a complete intraoral series of x-rays as well as two extraoral films, since in this case many such lesions were present within the jawbones, which certainly must arouse the operator's suspicion. I do not think t h a t it is necessary to dwell on the consequences of either conservative t r e a t m e n t of the area found on the
Fig. 5 . - - ( F r o m B l u m :
ORAL SURG., ORAL MED., & ORAL PATH., May, 1956.)
first film or the extraction of the two teeth without a microscopic examination of the tissue in the periapical area. This defect proved to be a local lesion of a generalized plasma-cell myeloma. Case 6 . - - L e t us discuss a n o t h e r subject, namely, malposed teeth. A young girl, aged 14 years, showed a number of such t e e t h on both sides of the maxilla and mandible. In consultation with an orthodontist on Dec. 28, 1953 (Fig. 6, A and B), it was decided to
1244
BLUM
O.s., O. M., & O. P. December, 1957
Volume 10 Number 12
INSTRUCTIVE
CLINICAL
CASE
REPORTS
1245
o
t.O
o
o
~r
~o
1246
BLUM
o S., O. M., a O. P. December, 1957
remove first the mandibular third molars and then, by orthodontic means, to move the second molars into normal position (Fig. 6, C). Thereafter, it was decided to take care of the involved molars in the maxilla (Fig. 6, D). I t seemed best to remove the maxillary second molars and expose the two third molars. This procedure proved correct and successful, as seen by examination of the films taken about four months later, on Oct. ]1, 1956 (Fig. 6, E). This result could be obtained only by cooperation between the dentist, the orthodontist, and the oral surgeon.
Fig. 7.--(From Blum:
ORAL SURG., ORAL I~ED., • ORAL PATH., May, 1956.)
Case 7.--There are also instances when the removal of malposed teeth is contraindicated. A 43-year-old female patient, who for about three weeks complained of pain on the right side of the face, is an example. The pain started in the j a w and she thought t h a t she had neuralgia because she had a cold. The rhinologist found something in her ear and she was given penicillin. However, she awoke with a rash a f t e r that, so for about ten days was given other antibiotic drugs. While she f e l t better, she still had the pain. Her dentist examined her t e e t h and said t h a t she was cutting a wisdom tooth, which he felt should be removed. The pain seemed to be worse at night. "The tongue seemed to have a c o v e r i n g " after she took drugs. (These are the p a t i e n t ' s words.) Pain originating from a malposed mandibular third molar is rather unusual when tile clinical examination shows no inflammation of tile covering soft tissues. Therefore ex-
Volume 10 Number 12
I N S T R U C T I V E CLINICAL CASE REPORTS
1247
traoral, intraoral, and bite-wing films were taken and a pulp test was done (Fig. 7). I t was the pulp test which revealed the correct diagnosis. The right mandibular lateral incisor With a normal apical region and a p e r f e c t periodontal lamella was nonvital. Root canal therapy of this tooth relieved the p a t i e n t ' s discomfort. Case 8 . - - A similar case is t h a t of a woman, 29 years of age, who complained of discomfort on the l e f t side of the face, and slight pain for a few years. For nearly two weeks she had complained of trismus of undetermined origin. A malposcd mandibular third molar was thought to be the etiological f a c t o r and its removal was advised (Fig. 8). However, the tooth was unerupted and no inflammation or infection was discernible. Therefore, complete rest of the temporomandibular joints was ordered, followed in about a week with slowly increased exercise. Within four weeks the p a t i e n t was entirely well. In a few months the malposed tooth could safely be removed. I f the malposed third molar had been removed first in the former case the p a t i e n t ' s pains would have increased and the real cause of pain would not have been found until more a g g r a v a t i n g symptoms appeared. In the present case the trismus would have increased postoperatively and the period of recovery would have been very much delayed.
Fig. 8. Case 9 . - - I n this group belongs also the case of a young girl, aged 12 years. X-ray examination revealed w h a t seemed to be a supernumerary tooth. In consultation w i t h the orthodontist, it was decided to remove the tooth at this time, as the apices of the adjoining teeth were fully formed (Fig. 9). During the discussion of the case with the family physician I particularly inquired about the s a f e t y of operating during the poliomyelitis season, even though she had received one polio vaccine injection some time before. He advised postponement until the l a t t e r part of October. The three regular intraoral films were taken from three different angles. Comparison of the three films revealed that there was very little change in the position of the supernumerary tooth so t h a t we had good reason to believe t h a t its position was palatal. To make certain, an occlusal exposure was procured; this confirmed our assumption. The supernumerary tooth turned out to be an odontoma, consisting of an enveloping membrane, and one larger and several smaller tooth buds.
N o w we come to the consideration of m a l i g n a n t lesions, since t h e y occur in p a t i e n t s who come to see the general dental practitioner. I n some cases, there will be no d o u b t as to the diagnosis. Others, which at first give the impression of a neoplasm, call f o r conservative t r e a t m e n t and observation. Case 10.--An example is the case of a 65-year-old woman. The area involved was in the cheek opposite the molar region (Fig. 10, A). The p a t i e n t was wearing full maxillary and mandibular dentures. The lesion was noticed by the p a t i e n t for only a f e w days a f t e r her d e n t i s t had adjusted the maxillary denture. She reported: " I t felt very t i g h t
1248
BLUM
o . s . , o. M., & O. P. December, 1957
Volume I0 Number 12
INSTRUCTIVE
CLINICAL
CASE
REPORTS
1249
A.
B.
C.
D.
E.
F.
Fig. 10.--A, Before treatment.
B, After treatment.
1250
BLUM
O.s., O. M., & O. P. December, 19.~7
and was i r r i t a t i n g the mouth and made it quite sore. Yesterday, glands in the neck swelled up." All this speaks for a recent lesion and led to my clinical impression t h a t I was dealing with an area of benign ulceration. This justified a conservative approach, namely, waiting a few days to observe the progress of the case. To prevent f u r t h e r irritation from influencing the diagnosis, the patient was advised not to wear the dentures. To make certain t h a t these orders were carried out, she was asked whether she had other dentures at home. She was told to avoid all i r r i t a t i n g food and drink (neither too hot nor too cold), and a mild alkaline mouthwash was prescribed for use a f t e r each meal. In this case, we were dealing with a traumatic ulcer which was well on the way to healing a f t e r three ,lays (Fig. 10, B).
l~ig". l l . - - E x t r a o r a !
films of a r e a s h o w n in Fig.
10, F.
C a ~ s 11 and 12.--In a number of malignant neoplasms the diagnostieian has no difficulty in recognizing the true nature of the lesion. Examples are a male patient, aged 68 years, afflicted with a carcinoma of the floor of the mouth (Fig. 10, C) and another male, aged 69, with the same type of lesion in the maxilla (Fig. 10, D). I never perform a biopsy if the p a t i e n t is referred to an oncologist. (I prefer, for obvious reasons, an oncologist who combines surgery with radiation therapy. He will perform the biopsy and the p a t i e n t is not subjected unnecessarily to the same procedure twice.) I t must be added that neither a physician nor a dentist should take a biopsy specimen unless he is well trained to do so. He should make certain t h a t the pathologist who studies the histologic sectiou is well qualified to diagnose oral tissue, in other words, an oral pathologist.
Case 1 3 . ~ I t is not always as simple as in the previous two eases. A 72-year-old male p a t i e n t had a loose molar in the left maxilla. When it was removed, granulations appeared at the mouth of the socket and an enlargement was noticed in this region, palatally a n d buceally (:Fig. t0, E). Three biopsies were performed bes a definite diagnosis of carcinoma could be established. I have had similar experiences previously, one in a p.~tient as young as 30 years.
One must not be satisfied with one negative biopsy if the clinical impression points toward a malignant lesion. In the above-mentioned case the three biopsies were made within a few days of each other. Case 14.--This was not so, however, in the ease of a male patient, aged 48 years (Fig.
10, 2').
The left maxilla was enlarged in the molar and the premolar region.
A molar was
Volume 1o
Number 12
INSTRUCTIVE
CLINICAL CASE REPORTS
1251
r e m o v e d ; l a t e r on a b i o p s y w a s d o n e a t a h o s p i t a l a n d n e g a t i v e f i n d i n g s w e r e r e p o r t e d . T h e r e w a s a d i s c h a r g e o f p u s f r o m t h e s o c k e t , as well as p a i n i n t h i s r e g i o a a n d a n i r r i t a t i e r o f t h e eye. F o r f o u r m o n t h s t h e p a t i e n t w a s t r e a t e d b y a s p e c i a l i s t w h o w a s satisfied w i t h o n e b i o p s y . A f t e r f o u r m o n t h s of p r e c i o u s t i m e h a d e l a p s e d , t h e p a t i e n t w a s r e f e r r e d to a n o t h e r oral s u r g e o n ( F i g s . 11 a n d 12). A n u m b e r of b i o p s i e s w e r e p e r f o r m e d a n d finally a d i a g n o s i s o f c a r c i n o m a (oat-cell) was made. T h e p r o l o n g e d t r e a t m e n t s caused t h e
Fig. 12.--Intraora], blte-wfng, occlusal, and bird's-eye view of area s h o w n In Fig. 10, F.
1252
BLUM
o.s., o. M.. &O. P. December, I957
f o r m a t i o n of so m u c h i n f l a m m a t o r y tissue t h a t the n a t u r e of the lesion w a s difficult to d e m o n s t r a t e in t h e first biopsies. This case r e m i n d s me of a n o t h e r one w i t h a m e t a s t a t i c lesion in the mandible. The original t u m o r site in the sigmoid colon w a s f o u n d only at autopsy. C a s e 15.--One would not consider it possible t h a t a well-developed t u m o r occupying h a l f of the m a n d i b l e could be diagnosed as an osteomyelitis (Fig. ]3). The m o t h e r of a 31/~-year-old boy noticed a swelling of his f a c e and, w h e n looking into his mouth, saw t h a t the g i n g i v a e were red. H e r p h y s i c i a n advised h e r to see her dentist, who s u g g e s t e d h o s p i t a l i z a t i o n and various tests. Because t h e p a t i e n t h a d a fever, penicillin was prescribed. T h i s was not taken, as the p a t i e n t was to see a n oral surgeon. The specialist removed a tooth a n d f o u n d pus (?). T h e n e x t d a y he m a d e an incision. H e t h e n s u g g e s t e d c o n s u l t a t i o n a n d told the f a t h e r t h a t the boy had a benign t u m o r which could be removed.
Fig. 13.
The child was an early teether, and w h e n 4 m o n t h s old he had f o u r teeth. The f a m i l y h i s t o r y revealed m a l i g n a n t t u m o r s on both the f a t h e r ' s and m o t h e r ' s sides. Upon e x a m i n a tion, the child was f o u n d to be normal except for a swollen face. A description of the local lesion follows. Ext~aoral: The whole l e f t side w a s m a r k e d l y swollen. I t was s o f t and s o m e w h a t t e n d e r due to previous surgical interference. L y m p h nodes were about n o r m a l in size; the left s u b m a x i l l a r y region w a s sensitive. lntvaoral: There was a v e r y large m a s s covered b y normal mucous membrane, s o f t b u t firm, p a r t i c u l a r l y on the lingua] side which had n o t been interfered with. There w a s evidence of the removal of a tooth a n d also of an incision w h i c h w a s open b u t filled w i t h s o f t tisssue. This t u m o r e x t e n d e d f r o m t h e deciduous f r s t molar, inclusive, all the w a y b a c k to the a n t e r i o r pillars of t h e fauces.
I n t h i s 3 89 boy, a tooth w a s e x t r a c t e d and an incision w a s m a d e the n e x t d a y f o r the alleged purpose of finding and e v a c u a t i n g pus. T h e microscopic diagnosis w a s n e u r o b l a s t o m a . The p a t i e n t , who died w i t h i n a f e w m o n t h s , could h a v e been spared t h e unnecessary interference.
Summary In my introduction to this presentation I expressed the hope that the cases described will be of interest to you and assist you in the care of your patients. Even if you are aware of some or all of the points which I emphasized, they may still give you an idea of what others overlook. You, in turn, through
Volume l0 Number 12
INSTRUCTIVE
CLINICAL CASE REPORTS
1253
conversation and lectures, can help other practitioners to avoid such errors and, by adding to their knowledge, benefit their patients. It may seem to you that I have turned preacher. I will risk this accusation, because the thought that I wish to express is important. There were times when knowledge and experience were kept secret by the practitioners of the healing arts. For instance, for more than three generations (starting in the early part of the seventeenth century) the Chamberlen family in England kept to themselves the invention of an obstetrical forceps to be used in difficult labors. I do not think that this happens today. However, general practitioners and specialists in both the medical and dental professions do not cooperate sufficiently, and jealousy is often evident. The result is that the patient suffers. All my professional life I have endeavored to improve professional relations between the members of these professions, and I feel certain that meeting one's colleagues socially and at lectures and clinics helps a lot. Let us return now to our subject. We have dealt with disease and its treatment. However, this is not enough. Our aim today is prevention of disease and the maintenance of health. To accomplish it we recommend periodic health examination, which in our field means prophylaxis, routine x-ray examination, and pulp testing at regular intervals. In closing, i wish to quote from an interview entitled : "Prescription for ~edicine : Dr. Gregg, Lasker Award Winner, Outlines a Medical Philosophy" by Leonard Engel, which appeared in the New York Times Magazine Section (Nov. 4, 1956). In this article Dr. Alan Gregg, who was for twenty-six years first the director of the medical sciences division of the Rockefeller Foundation and then vice-president of the Foundation, said: "Recently, our way of referring to health and illness has begun to change. We hear less of 'disease' and more of health maintenance, health protection and the health professions. This change signifies a larger horizon, a larger task, but it also aims at a more positive and desirable goal for medicine than the mere absence of disease. The positive goal of maintaining health will be more nearly realized when the public has been educated to ask for i t . " Let us subscribe to this program, by coordinating more closely the efforts of the dental and medical professions.