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Carcinoma and the mandibular staple
LETTERS TO THE EDITOR J Oral Maxtllofac
Surg
42.1. 1984
CONCERNSANDCONFLICTS TO r/w E&or:-1
Dr. Friedman reported. He was a resident on service and participated in the patient’s care. I also personally saw the patient with the residents when he returned with his carcinoma two years after the placement of the staple. The patient was a prime candidate for the development of an oral carcinoma. He was sixty-five years of age, had smoked two packs of cigarettes a day for 40 years, and was known to have been a significant alcohol abuser for a protracted period of time. Furthermore, the patient developed a carcinoma in the mid-portion of the anterior floor of the mouth. The carcinoma then spread to the mucosa on the lingual side of the mandible. Finally and most importantly, the histologic sections of the cuff of tissue around the posts and the alveolar crestal bone did not demonstrate carcinoma. It is my opinion that the carcinoma would have developed regardless of the placement of the mandibular staple. The author, however, does have a valid point when he stresses the importance of close follow up of all patients who have had implants placed. STUART N. KLINE, DDS Miami, Florida
OVER DISC SURGERY
applaud the courage Dr. Ernie Small
showed by stating his opinions in a letter to the editor of this journal (J Maxillofac Surg 41:485. 1983) concerning the value of TMJ arthrography. computerized tomography, and surgery. I share his concern about the large numbers of TMJ cases being treated surgically throughout the country. Our specialty must be made aware of the fact that much of the current information concerning diagnosis and treatment of internal derangements of the TMJ has not been clearly proven. Many questions remain to be answered; in fact, we have many more questions than we do answers. These questions include: 1) The natural history of the disorder, i.e., does disc displacement eventually lead to degenerative joint disease with accompanying pain and dysfunction? If so, how often? 2) What is the etiology of disc displacement? 3) What is the relationship of muscle hyperactivity disorders, such as bruxism and MPD, to disc displacement? 4) What are the appropriate diagnostic procedures, i.e., electromyography, arthrography, CT? 5) When is nonsurgical management appropriate? 6) What are the indications for surgery and for the appropriate surgical procedure, (i.e.. disc repair, meniscectomy, condylar and eminence reduction, etc.) and what are the long-term results of these procedures? The rediscovery of internal derangements, the introduction of new diagnostic procedures such as arthrography, and the development of new surgical procedures have been significant advancements in oral and maxillofacial surgery. However, until the many unanswered questions regarding disc derangement are clearly answered, it seems prudent to be somewhat cautious and conservative in our approach to these patients. On the other hand, I must also state that I found Dr. Small’s letter void of factual information, potentially damaging to patients, and personally insulting. His letter, clearly implies that everyone who lectures and writes about internal derangements (which includes myself) is an opportunist conducting traveling road shows. Additionally, anyone who does TMJ surgery is also an opportunist doing unnecessary surgery. This certainly indicts a large number of our specialty. I feel sorry for the patients who have legitimate surgical problems and may be denied treatment because insurance carriers use Dr. Small’s statements as reason to stop all coverage. I also feel sorry for the ethical, caring doctors who will be sued without reason because lawyers pick up his statements. I, too, am concerned about many issues involving TMJ diagnosis and management, but I believe we should support our statements with scientific evidence and refrain from such severe generalized indictments.
Reference I. Friedman KE, Vernon SE: Squamous Cell Carcinoma Developing in Conjunction with a Mandibular Staple Bone Plate. J Oral Maxillofac Surg 41:265. 1983 The Author responds-I am grateful to have an opportunity to respond to Dr. Kline’s letter. In this letter it is implied that I suggested the development of the carcinoma had a direct relationship to the irritation surrounding the post of the staple implant. One may also find in this letter a hypothesis implying that to be a prime candidate to develop an oral carcinoma, one must smoke Two packs of cigarettes a day and engage in significant alcohol abuse for an extended period of time. While one can accept this as a reasonable theory, the criteria must be extended to include patients with chronic irritation, syphilis, nutritional deficiencies, trauma, exposure to heat, sepsis, and irritations from sharp teeth and dentures.’ In my discussion of this case it is clearly stated that the staple acted as a nidus of continued irritation (“Although irritation is not a proven cause of cancer, it can be a contributory factor.“) It appears that this statement was misconstrued. The purpose of the article was to simply report a case in which a squamous cell carcinoma developed in conjunction with a staple bone implant. The article was not intended to be a statement on what factors contribute to the development of cancer-our intention was simply to warn our colleagues to be cautious in the long-term follow up of staple-implant patients and to look for signs of tissue irritation and poor prosthetic design. If tissue inflammation does develop, the care must include a biopsy of the area as well as a prompt correction of the inflammatory condition. It is my expressed aim to commend the staple bone implant for treatment of the atrophic mandible. Its reliability and success rate speak for themselves. If, in fact, one may get the wrong impression from reading my paper, let me state that I draw no direct causal relationship between staple implants and mandibular carcinoma.
M. FRANKLINDOLWICK,DMD, PHD San Antonio, Texas
CARCINOMA
AND THE MANDIBULAR
STAPLE
To The Editor-In
a case report published in the April 1983 issue of the Journal, Friedman and Vernon’ suggest that the development of an oral carcinoma was related to the irritation surrounding the post of a staple implant. One is hard-pressed to see the validity of this suggestion, especially when all the facts are known. As chief of the oral surgery section at the University of Miami School of Medicine, I was responsible for the implant surgery that
KURT E. FRIEDMAN, DDS, MS Miami Beach, Florida
Reference I. Shafer WG, Hine MK, Levy BM: Textbook of Oral Pathology. Philadelphia, W. B. Saunders, 1963, p 97 1
Surg
42.1. 1984
CONCERNSANDCONFLICTS TO r/w E&or:-1
Dr. Friedman reported. He was a resident on service and participated in the patient’s care. I also personally saw the patient with the residents when he returned with his carcinoma two years after the placement of the staple. The patient was a prime candidate for the development of an oral carcinoma. He was sixty-five years of age, had smoked two packs of cigarettes a day for 40 years, and was known to have been a significant alcohol abuser for a protracted period of time. Furthermore, the patient developed a carcinoma in the mid-portion of the anterior floor of the mouth. The carcinoma then spread to the mucosa on the lingual side of the mandible. Finally and most importantly, the histologic sections of the cuff of tissue around the posts and the alveolar crestal bone did not demonstrate carcinoma. It is my opinion that the carcinoma would have developed regardless of the placement of the mandibular staple. The author, however, does have a valid point when he stresses the importance of close follow up of all patients who have had implants placed. STUART N. KLINE, DDS Miami, Florida
OVER DISC SURGERY
applaud the courage Dr. Ernie Small
showed by stating his opinions in a letter to the editor of this journal (J Maxillofac Surg 41:485. 1983) concerning the value of TMJ arthrography. computerized tomography, and surgery. I share his concern about the large numbers of TMJ cases being treated surgically throughout the country. Our specialty must be made aware of the fact that much of the current information concerning diagnosis and treatment of internal derangements of the TMJ has not been clearly proven. Many questions remain to be answered; in fact, we have many more questions than we do answers. These questions include: 1) The natural history of the disorder, i.e., does disc displacement eventually lead to degenerative joint disease with accompanying pain and dysfunction? If so, how often? 2) What is the etiology of disc displacement? 3) What is the relationship of muscle hyperactivity disorders, such as bruxism and MPD, to disc displacement? 4) What are the appropriate diagnostic procedures, i.e., electromyography, arthrography, CT? 5) When is nonsurgical management appropriate? 6) What are the indications for surgery and for the appropriate surgical procedure, (i.e.. disc repair, meniscectomy, condylar and eminence reduction, etc.) and what are the long-term results of these procedures? The rediscovery of internal derangements, the introduction of new diagnostic procedures such as arthrography, and the development of new surgical procedures have been significant advancements in oral and maxillofacial surgery. However, until the many unanswered questions regarding disc derangement are clearly answered, it seems prudent to be somewhat cautious and conservative in our approach to these patients. On the other hand, I must also state that I found Dr. Small’s letter void of factual information, potentially damaging to patients, and personally insulting. His letter, clearly implies that everyone who lectures and writes about internal derangements (which includes myself) is an opportunist conducting traveling road shows. Additionally, anyone who does TMJ surgery is also an opportunist doing unnecessary surgery. This certainly indicts a large number of our specialty. I feel sorry for the patients who have legitimate surgical problems and may be denied treatment because insurance carriers use Dr. Small’s statements as reason to stop all coverage. I also feel sorry for the ethical, caring doctors who will be sued without reason because lawyers pick up his statements. I, too, am concerned about many issues involving TMJ diagnosis and management, but I believe we should support our statements with scientific evidence and refrain from such severe generalized indictments.
Reference I. Friedman KE, Vernon SE: Squamous Cell Carcinoma Developing in Conjunction with a Mandibular Staple Bone Plate. J Oral Maxillofac Surg 41:265. 1983 The Author responds-I am grateful to have an opportunity to respond to Dr. Kline’s letter. In this letter it is implied that I suggested the development of the carcinoma had a direct relationship to the irritation surrounding the post of the staple implant. One may also find in this letter a hypothesis implying that to be a prime candidate to develop an oral carcinoma, one must smoke Two packs of cigarettes a day and engage in significant alcohol abuse for an extended period of time. While one can accept this as a reasonable theory, the criteria must be extended to include patients with chronic irritation, syphilis, nutritional deficiencies, trauma, exposure to heat, sepsis, and irritations from sharp teeth and dentures.’ In my discussion of this case it is clearly stated that the staple acted as a nidus of continued irritation (“Although irritation is not a proven cause of cancer, it can be a contributory factor.“) It appears that this statement was misconstrued. The purpose of the article was to simply report a case in which a squamous cell carcinoma developed in conjunction with a staple bone implant. The article was not intended to be a statement on what factors contribute to the development of cancer-our intention was simply to warn our colleagues to be cautious in the long-term follow up of staple-implant patients and to look for signs of tissue irritation and poor prosthetic design. If tissue inflammation does develop, the care must include a biopsy of the area as well as a prompt correction of the inflammatory condition. It is my expressed aim to commend the staple bone implant for treatment of the atrophic mandible. Its reliability and success rate speak for themselves. If, in fact, one may get the wrong impression from reading my paper, let me state that I draw no direct causal relationship between staple implants and mandibular carcinoma.
M. FRANKLINDOLWICK,DMD, PHD San Antonio, Texas
CARCINOMA
AND THE MANDIBULAR
STAPLE
To The Editor-In
a case report published in the April 1983 issue of the Journal, Friedman and Vernon’ suggest that the development of an oral carcinoma was related to the irritation surrounding the post of a staple implant. One is hard-pressed to see the validity of this suggestion, especially when all the facts are known. As chief of the oral surgery section at the University of Miami School of Medicine, I was responsible for the implant surgery that
KURT E. FRIEDMAN, DDS, MS Miami Beach, Florida
Reference I. Shafer WG, Hine MK, Levy BM: Textbook of Oral Pathology. Philadelphia, W. B. Saunders, 1963, p 97 1