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Applied pathology in oral surgery
APPLIED
PATHOLOGY
CAR,J.. W. WALDROK, D.D.S.,
M.D.,
IN ORAL mn
NIXN~AEAPOLIS,
CHARLES
SURGERY 9.
WALEPROS!
D.D.S.,
J~JXN.
UBIKG the past seven years, I have devoted a great amount of time to the D over-all problems of graduate training in oral surgery. Realizing that the basic requirements are similar to those of general surgery and its various specialties, thorough study was made of the graduate training program of the American College of Surgeons of which I am a Fellow. This formal, more or less standardized program is about ten years old; the first list of approved hospitals was published in 1939. It is of interest to note that one of the greatest problems confronting the Committee on Graduate Training in Surgery of the American College of Surgeons is that of securing adequate training in the basic sciences as applied to the practice of surgery in nonuniversity hospitals. The purely academic or advanced courses in a basic science subject without clinical application are not fully acceptable to the College. Some such courses are, of course, necessary for a graduate degree. It has been suggested that wherever possible the graduate students, fellows, or residents in surgery be instructed in the basic sciences by staff members of the departments of surgery who had majored in the respective basic sciences in their graduat.e training, rather than receive such instruction solely from the staffs of the respective basic science departments. This premise, based on the’objective of better care for the surgical patient, is worthy of careful consideration with reference to the graduate training program in oral surgery. One must, however, go farther back to discover t,he basic defects of graduate training in oral surgery and thus meet our present problems. Chief among these is the curricular difficulty to be overcome in order to include the application of the basic sciences, particularly pathology, to the clinical years in den.tistry in order to assure that the graduates in dentistry have more than just a restorative concept of their professional activities. The heads of the departments of oral pathology must exert every effort to sell this concept to the teachers in the clinical branches of the schools of dentistry. How many departments of oral medicine and periodontia have wellselected, enlarged photomicrographs of pathologic conditions of their field conDo the veniently arranged in sight or immediately available in the clinic? teachers of these subjects have a basic knowledge of the pathology of their field and maintain a continued interest in it in order to impress upon the student that his basic study of oral pathology has a definite purpose ? The pathologist --_ Ill.,
~~~~~ at the second Feb. H, 1948.
Annual
Meeting
of the American 807
Acadamy
of Oral
Patholog~T,
Chicago,
should be a frequent visitor to the clinic in oral medicine in order to lend his assistance to the objectives ant1 to emphasize the importance of live clinical i~~*alpathology in relation to sound arid ef?ective therapy. Teachers in all the restorative branches of dentistry should r~lost certainI> know the histopathologic changes in the periodontiuin and alveolar process that may be produced by various stresses, occlusal trauma from poorly designed restorations. This background knowledge, plus available photomicrographs for demonstration, would impress the st,udent with his great responsibility in his restorative work. It is obvious that the more effective t,he teaching of clinical oral pathology, the greater is the demand for a higher standard of restorative dentistry in all its branches. Even greater cooperation in teaching is indicated in the department of oral surgery. A fundamental knowledge of the processes of inflammation and repair, the more intimate understanding of the normal, the dela,ved and pathologic healing of tooth sockets; and repair of bone are essential. It is highly desirable that at least one teacher should be a member of both the oral pathology and oral surgery staffs. Ample demonstration material should be at hand, including abstracts of case reports with accompanying pre- and postoperative roentgenograms, photographs, gross specimens, and microscopic slides. When a patient returns to the clinic for interval or final postoperative checkup after the removal of tumors, the demonstration of the complete records of the patient and the examination of the slides under the microscope will impress the student regarding the proper routines in handling such cases. I can assure 3-0~ that students show greater interest when this is done. Observation by the student of the preparation and diagnosis of a biopsy from a clinical patient is most worth while and will impress him with the importance and necessity One can hardly conof having such facilities available in future practice. demn the dentist or oral surgeon for neglectin, 0 to have examinations made of tissues he removes if his only conhact with microscopic slides was in the earlier years of his dental course. Clinical oral surgical ‘pathology must be given greater prominence. In schools undertaking graduate training in oral surgery, the graduate student workin g on applied pathology will find the demonstration of such material to the undergraduate student a worth-while task and in a basic experience. The success of the graduate training of an individual and teach science is largely dependent upon his ability to dl,‘0’ out information supplemented by frequent himself under expert guidance and supervision. discussions and consultations. The pathologist should be the key man in both undergraduate and gradua.te programs, to correlate basic and clinical work in the interest of better professional care of the patient. Until this is accomplished in our dental schools, purely academic basic research might well be abandoned or delegated to institutions financed by foundations. As already intimated, the lack of understanding of the basic sciences! notably pathology, on the part of many oral surgeons is lamentable. While a greater proporbioll are men who graduated many years ago, a considerable
APPLIED
PATHOLOGY
IN
ORAL
SURGERY
so9
nnmber graduating within the past fifteen years show a marked lack of interest and comprehension of the importance of the subject. Among several reasorrs for this are the absence of short courses organized and designed for th.e oral surgeon, and the failure to include a sufficient number of worth-while papers on the subject in the programs of the special surgical societies and in current literature. There is an apparent failure of authors of texts on oral pathology to understand the needs and problems of the practitioners in the This is obviously the primary diagnosis and treatment of the sick patient. objective of all the basic sciences and clinical branches of the healing art. MOST of the texts are far too academic and basic to the extent that the busy oral surgeon finds great. difficulty in flncling the help he needs. The two most serious defects are the lack of uniform classification and the failure to consider It is my firm belief and arrange tumors from a topographical standpoint. that by adequate cross references and indexin,, r no sacrifice of purely academic scientific considerations will result; then the oral surgeon will be provided with texts that he will find of great service t,o him in the office rather than confuse him when in need of assistance. For example, the jaws are affected by practicadly a.11of the tumors affecting other bones of the body. The Codman Registry Classification with its minor modifications was brought out to clarify the confusion of classifications of tumors of bone. It is commonly used in surgical literature but is notable for its absence in dental texts and literature. It should at least be mentioned. Robinson made a worth-while effort to establish a workable classification of cysti,c tumors. This or some other should be accepted by this Academy, and texts ;and articles should be made to conform to it. This does not deny an author t,he right to use another term he may prefer, but the chapter heading or title should conform to an agreed classification. Another point I might stress is t,he fact that many of the candidates for certification by the Eoard of Oral Surgery had no knowledge and’ apparently but little interest in the types of tumors that appear on the gum (the so-called epulis ) . It is my feeling that this term should not as yet be discarded but rather used along with the designation of the pathology of the growth until such time as oral surgeons show a more proper interest in clinical oral pathology. It would seem that many oral surgeons have too little interest in the. types of tumors they are called upon to remove and not infrequently fail to send the tissue to the pathologist for examination. Furthermore, they do not seem too interested in the pathology of the tumors they remove so long as they ase benign and do not recur. Definite steps should be taken to interest oral surgeons in the larger centers by organizin g clinicopathologic conferences or seminars which might correspond to the similar hospital staff conferences that are mandatory for approval of the hospital by the American College of Surgeons. There might be a possibility that t,his Academy could, with the assistance of the Army Institute of Pathology, interest the full-time pathologists in hospitals in various parts of the country to take a little more than casual inThe pathologist in the general terest in the oral surgeons of the community. hospital unassociated with a medical school has even greater opportunities to
stimulalte the interests of all surgical specialists and thus improve the stall(lar& of treatment. The histopathologist can be of service to the oral surgeon ill clarifying Sd number of points that are subject to controversy. For example, many oral surgeons advocate the elevation of the gingiyal tissues of several teeth on either side of a cystic area or the side of an embedded tooth rather than an incision that would provide an adequate approach but would preserve several millimeters of gingiva undisturbed. It. is their contention t.hat after resuturing or simply repositioning the gingival papilla flaps, subsequent healing restores the I appreciate gingiva, papilla, and crevice to a perfectly norma. condition. that nature is wonderful, but I feel that the histopathologist should give us an answer to this question. and repair of fraeCollective studies and reviews of the histopathology tured teeth, apicoectomies, the prognosis of vital teeth encroached upon by cystic tumors after Partsch conservative procedures or enucleation would be of great service to the busy oral surgeon. 1 am attempting to pick out of the case reports of the candidates for the Board of Oral Surgery those reported as leaving apparently involved teeth in situ after the enucleation of the cyst wall. I ~1 hoping to contact all of these surgeons to secure re-examination and ritalitJ7 tests of these teeth several years after regeneration of the jaw has taken place. It is my sincere hope that this headem) 7 and its members individuall\7 will take an active par% in improving the teaching in applied oral pathology Likewise, I trust that LOU in the undergraduate program in oral surgery. o oral surgeons and therebv raise the standmake every efit’ort to aid praeticin, ards of oral surgical care.
References in Surgery, Bull. Am. Uoll. G. H. : Basic Medical Sciences in Graduate Training Surgeons 30: 103-109, 1945. in Surgery and Surgical Specialties, Bull. Am. Coil. Reynolds, C. R.: Gradua.te Training Surgeons 30: 9510.2, 1945. and Oral Burg. of Cysts of the J2ws, Am. J. Orthodontics Robinson, H. B. 6.: Classification (Oral Surq. Fe&) 31: 370-375, 19+3. TValdron, C. W.: Graduate Training in Oral Surgery, J. Oral Xurg. 3: 265-269, 1945. Sciences in Graduate Training in Oral Surgery, J. Waldron, C. TV’.: The Basic Medical Oral Surg. 4: 179-187, 1946. Miller,
960
MEDICAI,
ARTS
BUILDING.
PATHOLOGY
CAR,J.. W. WALDROK, D.D.S.,
M.D.,
IN ORAL mn
NIXN~AEAPOLIS,
CHARLES
SURGERY 9.
WALEPROS!
D.D.S.,
J~JXN.
UBIKG the past seven years, I have devoted a great amount of time to the D over-all problems of graduate training in oral surgery. Realizing that the basic requirements are similar to those of general surgery and its various specialties, thorough study was made of the graduate training program of the American College of Surgeons of which I am a Fellow. This formal, more or less standardized program is about ten years old; the first list of approved hospitals was published in 1939. It is of interest to note that one of the greatest problems confronting the Committee on Graduate Training in Surgery of the American College of Surgeons is that of securing adequate training in the basic sciences as applied to the practice of surgery in nonuniversity hospitals. The purely academic or advanced courses in a basic science subject without clinical application are not fully acceptable to the College. Some such courses are, of course, necessary for a graduate degree. It has been suggested that wherever possible the graduate students, fellows, or residents in surgery be instructed in the basic sciences by staff members of the departments of surgery who had majored in the respective basic sciences in their graduat.e training, rather than receive such instruction solely from the staffs of the respective basic science departments. This premise, based on the’objective of better care for the surgical patient, is worthy of careful consideration with reference to the graduate training program in oral surgery. One must, however, go farther back to discover t,he basic defects of graduate training in oral surgery and thus meet our present problems. Chief among these is the curricular difficulty to be overcome in order to include the application of the basic sciences, particularly pathology, to the clinical years in den.tistry in order to assure that the graduates in dentistry have more than just a restorative concept of their professional activities. The heads of the departments of oral pathology must exert every effort to sell this concept to the teachers in the clinical branches of the schools of dentistry. How many departments of oral medicine and periodontia have wellselected, enlarged photomicrographs of pathologic conditions of their field conDo the veniently arranged in sight or immediately available in the clinic? teachers of these subjects have a basic knowledge of the pathology of their field and maintain a continued interest in it in order to impress upon the student that his basic study of oral pathology has a definite purpose ? The pathologist --_ Ill.,
~~~~~ at the second Feb. H, 1948.
Annual
Meeting
of the American 807
Acadamy
of Oral
Patholog~T,
Chicago,
should be a frequent visitor to the clinic in oral medicine in order to lend his assistance to the objectives ant1 to emphasize the importance of live clinical i~~*alpathology in relation to sound arid ef?ective therapy. Teachers in all the restorative branches of dentistry should r~lost certainI> know the histopathologic changes in the periodontiuin and alveolar process that may be produced by various stresses, occlusal trauma from poorly designed restorations. This background knowledge, plus available photomicrographs for demonstration, would impress the st,udent with his great responsibility in his restorative work. It is obvious that the more effective t,he teaching of clinical oral pathology, the greater is the demand for a higher standard of restorative dentistry in all its branches. Even greater cooperation in teaching is indicated in the department of oral surgery. A fundamental knowledge of the processes of inflammation and repair, the more intimate understanding of the normal, the dela,ved and pathologic healing of tooth sockets; and repair of bone are essential. It is highly desirable that at least one teacher should be a member of both the oral pathology and oral surgery staffs. Ample demonstration material should be at hand, including abstracts of case reports with accompanying pre- and postoperative roentgenograms, photographs, gross specimens, and microscopic slides. When a patient returns to the clinic for interval or final postoperative checkup after the removal of tumors, the demonstration of the complete records of the patient and the examination of the slides under the microscope will impress the student regarding the proper routines in handling such cases. I can assure 3-0~ that students show greater interest when this is done. Observation by the student of the preparation and diagnosis of a biopsy from a clinical patient is most worth while and will impress him with the importance and necessity One can hardly conof having such facilities available in future practice. demn the dentist or oral surgeon for neglectin, 0 to have examinations made of tissues he removes if his only conhact with microscopic slides was in the earlier years of his dental course. Clinical oral surgical ‘pathology must be given greater prominence. In schools undertaking graduate training in oral surgery, the graduate student workin g on applied pathology will find the demonstration of such material to the undergraduate student a worth-while task and in a basic experience. The success of the graduate training of an individual and teach science is largely dependent upon his ability to dl,‘0’ out information supplemented by frequent himself under expert guidance and supervision. discussions and consultations. The pathologist should be the key man in both undergraduate and gradua.te programs, to correlate basic and clinical work in the interest of better professional care of the patient. Until this is accomplished in our dental schools, purely academic basic research might well be abandoned or delegated to institutions financed by foundations. As already intimated, the lack of understanding of the basic sciences! notably pathology, on the part of many oral surgeons is lamentable. While a greater proporbioll are men who graduated many years ago, a considerable
APPLIED
PATHOLOGY
IN
ORAL
SURGERY
so9
nnmber graduating within the past fifteen years show a marked lack of interest and comprehension of the importance of the subject. Among several reasorrs for this are the absence of short courses organized and designed for th.e oral surgeon, and the failure to include a sufficient number of worth-while papers on the subject in the programs of the special surgical societies and in current literature. There is an apparent failure of authors of texts on oral pathology to understand the needs and problems of the practitioners in the This is obviously the primary diagnosis and treatment of the sick patient. objective of all the basic sciences and clinical branches of the healing art. MOST of the texts are far too academic and basic to the extent that the busy oral surgeon finds great. difficulty in flncling the help he needs. The two most serious defects are the lack of uniform classification and the failure to consider It is my firm belief and arrange tumors from a topographical standpoint. that by adequate cross references and indexin,, r no sacrifice of purely academic scientific considerations will result; then the oral surgeon will be provided with texts that he will find of great service t,o him in the office rather than confuse him when in need of assistance. For example, the jaws are affected by practicadly a.11of the tumors affecting other bones of the body. The Codman Registry Classification with its minor modifications was brought out to clarify the confusion of classifications of tumors of bone. It is commonly used in surgical literature but is notable for its absence in dental texts and literature. It should at least be mentioned. Robinson made a worth-while effort to establish a workable classification of cysti,c tumors. This or some other should be accepted by this Academy, and texts ;and articles should be made to conform to it. This does not deny an author t,he right to use another term he may prefer, but the chapter heading or title should conform to an agreed classification. Another point I might stress is t,he fact that many of the candidates for certification by the Eoard of Oral Surgery had no knowledge and’ apparently but little interest in the types of tumors that appear on the gum (the so-called epulis ) . It is my feeling that this term should not as yet be discarded but rather used along with the designation of the pathology of the growth until such time as oral surgeons show a more proper interest in clinical oral pathology. It would seem that many oral surgeons have too little interest in the. types of tumors they are called upon to remove and not infrequently fail to send the tissue to the pathologist for examination. Furthermore, they do not seem too interested in the pathology of the tumors they remove so long as they ase benign and do not recur. Definite steps should be taken to interest oral surgeons in the larger centers by organizin g clinicopathologic conferences or seminars which might correspond to the similar hospital staff conferences that are mandatory for approval of the hospital by the American College of Surgeons. There might be a possibility that t,his Academy could, with the assistance of the Army Institute of Pathology, interest the full-time pathologists in hospitals in various parts of the country to take a little more than casual inThe pathologist in the general terest in the oral surgeons of the community. hospital unassociated with a medical school has even greater opportunities to
stimulalte the interests of all surgical specialists and thus improve the stall(lar& of treatment. The histopathologist can be of service to the oral surgeon ill clarifying Sd number of points that are subject to controversy. For example, many oral surgeons advocate the elevation of the gingiyal tissues of several teeth on either side of a cystic area or the side of an embedded tooth rather than an incision that would provide an adequate approach but would preserve several millimeters of gingiva undisturbed. It. is their contention t.hat after resuturing or simply repositioning the gingival papilla flaps, subsequent healing restores the I appreciate gingiva, papilla, and crevice to a perfectly norma. condition. that nature is wonderful, but I feel that the histopathologist should give us an answer to this question. and repair of fraeCollective studies and reviews of the histopathology tured teeth, apicoectomies, the prognosis of vital teeth encroached upon by cystic tumors after Partsch conservative procedures or enucleation would be of great service to the busy oral surgeon. 1 am attempting to pick out of the case reports of the candidates for the Board of Oral Surgery those reported as leaving apparently involved teeth in situ after the enucleation of the cyst wall. I ~1 hoping to contact all of these surgeons to secure re-examination and ritalitJ7 tests of these teeth several years after regeneration of the jaw has taken place. It is my sincere hope that this headem) 7 and its members individuall\7 will take an active par% in improving the teaching in applied oral pathology Likewise, I trust that LOU in the undergraduate program in oral surgery. o oral surgeons and therebv raise the standmake every efit’ort to aid praeticin, ards of oral surgical care.
References in Surgery, Bull. Am. Uoll. G. H. : Basic Medical Sciences in Graduate Training Surgeons 30: 103-109, 1945. in Surgery and Surgical Specialties, Bull. Am. Coil. Reynolds, C. R.: Gradua.te Training Surgeons 30: 9510.2, 1945. and Oral Burg. of Cysts of the J2ws, Am. J. Orthodontics Robinson, H. B. 6.: Classification (Oral Surq. Fe&) 31: 370-375, 19+3. TValdron, C. W.: Graduate Training in Oral Surgery, J. Oral Xurg. 3: 265-269, 1945. Sciences in Graduate Training in Oral Surgery, J. Waldron, C. TV’.: The Basic Medical Oral Surg. 4: 179-187, 1946. Miller,
960
MEDICAI,
ARTS
BUILDING.