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To biopsy or not
LETTERS TO THE EDITOR
To biopsy or not To the editor: The defining characteristics of an editorial include showing some sensitivity to one's readers, providing no references, and addressed an interesting or even controversial topic. Dr Richard E. Walton has earned a respected position in the endodontic community for his honesty and courage; he uses his didactic voice to speak out on clinical issues in ways that sometimes conflict with the dominant positions. His evidence-based presentations at our annual sessions and in publications in refereed journals often challenge scientifically unfounded procedures. However, the opinion expressed in his editorial, "Routine histopathologic examination of endodontic periradicular surgical specimens-is it warranted?" (Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1998:86;505) is not supported by any authority other than the message itself. I feel that the message is misleading at best and a risk to patient health at worst. The American Association of Endodontists (AAE) provides guidelines to assure the appropriateness and quality of treatment for every patient receiving endodontic specialty care. These guidelines are generally accepted as defining the standard of care. The Appropriateness of Care and Quality Assurance Guidelines (3rd edition; AAE copyright 1998) states that it is appropriate to establish a diagnosis by microscopic examination any time a recoverable amount of tissue can be removed from a periradicu1ar surgical site. This is in addition to every clinical situation in which an unusual or persistent pathosis is noted on clinical or radiographic examination or the medical history indicates that a biopsy would have merit. A provisional diagnosis is always limited to the available clinical information and history and is many times complicated by previous treatment. Although it usually dictates the method of initial treatment, the behavior of a lesion and the ultimate prognosis can only be established through histologic diagnosis. The possibility of the occurrence of an aggressive lesion indicates a risk that justifies histologic diagnosis. Published case reports on malignancies manifesting as inflammatory disease are sufficient evidence that any risk is too great. Our patients deserve assurance and relief from the anxiety common with periapical disease that has not responded to conventional therapy.
Dr Walton has served dentistry many times before by being the first to make his opinion heard on a controversial issue. Now he has started a conversation that will challenge the wisdom of our profession to see that it is not the last word on the subject. Carl W Newton, DDS, MSD President American Association of Endodontists To the editor: In an editorial in the November 1998 issue of the Journal, Dr Richard Walton! argues that routine histopathologic examination of endodontic periradicular surgical specimens is unwarranted. I presume Dr Walton expected that this editorial would be controversial and would elicit comments. The recommendation not to submit surgically removed pathologic tissue for histopathologic examination seems so contrary to good dental practice that my initial reaction was that most readers would just ignore it. However, because of a concern that some readers may find Dr Walton's arguments compelling (especially in view of his position as Editor of the Endodontics Section of the Journal). I am, in turn, compelled to offer the following comments. Dr Walton begins his editorial by asking rhetorically whether histopathologic examinations of periapical tissues obtained during endodontic surgeries ever identify conditions more dangerous than endodontic periradicular pathosis secondary to pulpal necrosis and inflammation. The answer is an emphatic yes. 2-4 Most oral and maxillofacial pathologists can readily cite from their own experience in laboratory practice examples of more serious conditions, such as malignant lymphoma, leukemia, and primary and metastatic cancer (among others), masquerading as periapical inflammatory lesions. Dr Walton conditions his question by asking whether there are a meaningful number of such occurrences. Ah, how does one define "meaningful"? Any unexpected or potentially serious diagnoses are certainly meaningful to the affected patients, their families, and their healthcare providers. Dr Walton chooses an insurance company accountant's approach to health care when he states that the practice of routine histopathologic examination of surgically excised periapical tissues is not worth the cost to the patients or their insurance carriers. Although I believe that there is much more to good care and treatment of our patients
642 June 1999 ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY
To biopsy or not To the editor: The defining characteristics of an editorial include showing some sensitivity to one's readers, providing no references, and addressed an interesting or even controversial topic. Dr Richard E. Walton has earned a respected position in the endodontic community for his honesty and courage; he uses his didactic voice to speak out on clinical issues in ways that sometimes conflict with the dominant positions. His evidence-based presentations at our annual sessions and in publications in refereed journals often challenge scientifically unfounded procedures. However, the opinion expressed in his editorial, "Routine histopathologic examination of endodontic periradicular surgical specimens-is it warranted?" (Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1998:86;505) is not supported by any authority other than the message itself. I feel that the message is misleading at best and a risk to patient health at worst. The American Association of Endodontists (AAE) provides guidelines to assure the appropriateness and quality of treatment for every patient receiving endodontic specialty care. These guidelines are generally accepted as defining the standard of care. The Appropriateness of Care and Quality Assurance Guidelines (3rd edition; AAE copyright 1998) states that it is appropriate to establish a diagnosis by microscopic examination any time a recoverable amount of tissue can be removed from a periradicu1ar surgical site. This is in addition to every clinical situation in which an unusual or persistent pathosis is noted on clinical or radiographic examination or the medical history indicates that a biopsy would have merit. A provisional diagnosis is always limited to the available clinical information and history and is many times complicated by previous treatment. Although it usually dictates the method of initial treatment, the behavior of a lesion and the ultimate prognosis can only be established through histologic diagnosis. The possibility of the occurrence of an aggressive lesion indicates a risk that justifies histologic diagnosis. Published case reports on malignancies manifesting as inflammatory disease are sufficient evidence that any risk is too great. Our patients deserve assurance and relief from the anxiety common with periapical disease that has not responded to conventional therapy.
Dr Walton has served dentistry many times before by being the first to make his opinion heard on a controversial issue. Now he has started a conversation that will challenge the wisdom of our profession to see that it is not the last word on the subject. Carl W Newton, DDS, MSD President American Association of Endodontists To the editor: In an editorial in the November 1998 issue of the Journal, Dr Richard Walton! argues that routine histopathologic examination of endodontic periradicular surgical specimens is unwarranted. I presume Dr Walton expected that this editorial would be controversial and would elicit comments. The recommendation not to submit surgically removed pathologic tissue for histopathologic examination seems so contrary to good dental practice that my initial reaction was that most readers would just ignore it. However, because of a concern that some readers may find Dr Walton's arguments compelling (especially in view of his position as Editor of the Endodontics Section of the Journal). I am, in turn, compelled to offer the following comments. Dr Walton begins his editorial by asking rhetorically whether histopathologic examinations of periapical tissues obtained during endodontic surgeries ever identify conditions more dangerous than endodontic periradicular pathosis secondary to pulpal necrosis and inflammation. The answer is an emphatic yes. 2-4 Most oral and maxillofacial pathologists can readily cite from their own experience in laboratory practice examples of more serious conditions, such as malignant lymphoma, leukemia, and primary and metastatic cancer (among others), masquerading as periapical inflammatory lesions. Dr Walton conditions his question by asking whether there are a meaningful number of such occurrences. Ah, how does one define "meaningful"? Any unexpected or potentially serious diagnoses are certainly meaningful to the affected patients, their families, and their healthcare providers. Dr Walton chooses an insurance company accountant's approach to health care when he states that the practice of routine histopathologic examination of surgically excised periapical tissues is not worth the cost to the patients or their insurance carriers. Although I believe that there is much more to good care and treatment of our patients
642 June 1999 ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY