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Letter to the editor
4
Letters to the Editor
ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY
Januq~ I994
cases are popping up in different geographic areas of the country, obviously treated by different surgeons. The statement by Chuong et al. that foreign body inflammatory reactions may occur even in the asymptomatic person is patently true and has also been reported by our group at the University of Connecticut.’ Magnetic resonance (MR) imaging has clearly demonstrated how in numerous cases, significant inflammatory reactions have occurred in patients who had none of the usual indications for Proplast-Teflon implant removal, such as pain, occlusal change, or radiographic evidence of bone erosion. All patients who have had these implants inserted should undergo MR scans. Given the now well-established possibility of recurrence of the giant cell inflammatory reaction, it is difficult to imagine leaving the Proplast-Teflon implants within the joints of human beings even if such MR scans are negative. After removal of Proplast-Teflon implants, patients should undergo repeat MR imaging even in the absence of symptoms for at least 5 years, on the basis of the very slow progressive development of this pathologic entity. I would like to go a step further. There may be more recurrent giant cell inflammatory reactions than we realize. I invite any oral and maxillofacial surgeon who has treated a patient with a recurrent ProplastTeflon granuloma that developed after removal of the implant to write to me. You may not have an article to present, but I am willing to count up the numbers and report them in this space by the end of this year so that we may have a better idea of the incidence of recurrent giant cell granulomas associated with this type of implant. Joseph F. Piecuch, DMD,
MD
Associate Clinical Professor University of Connecticut Health Center Mailing address: 34 Dale Road Avon, CT 06001 REFERENCES
1. Feinerman DM, Piecuch JF. Long-term retrospective analysis of twenty-three Proplast-Teflon temporomandibular joint interpositional implants. Int J Oral Maxillofac Surg 1993;22:1116. 2. Ryan DE. The Proplast-Teflon dilemma. J Oral Maxillofac Surg 1989;47:22.
To the Editor:
The comments of Dr. Piecuch are appreciated and reiterate the principles delineated in the recent report Recurrent giant cell reaction to residual Proplast in the temporomandibular joint ( 1993;76: 16-9) I agree
wholeheartedly with the need for long-term follow-up of all patients who have had Proplast-Teflon implants placed even after implant removal, and it is clear that all such implants should be removed regardless of the presence or absence of symptoms. Although Dr. Piecuch suggests 5 years as a minimum period, the recommendation should perhaps be for a lifetime. The answer is not known at this time. At the 1992 annual meeting of the American Society of Temporomandibular Joint Surgeons held in Scottsdale, Arizona, I presented an abstract on this very same subject. On the basis of the comments of some of the other distinguished surgeons at the meeting this is a phenomenon that has been seen by other experienced TMJ surgeons. I agree with Dr. Piecuch that further case examples should be reported and tabulated. Robert Chuong, DMD, MD
Maxillofacial Surgery Institute of Florida St. Petersburg, Fla. To the Editor:
I read with interest Dr. Eversole’s editorial in the September 1993 issue of ORAL SURGERY, ORAL MEDICINE, ORAL PATHOLOGY; his comments require a response. Oral Pathology is the recognized specialty of dentistry and disciplineof pathology that deals with the diagnosis and management of diseases affecting the oral and maxillofacial region. Although many would prefer we restrict ourselves to histopathology, that action is not our heritage. It is inconsistent with our training and would be detrimental to the many patients who need our unique expertise. When patients have pathoses of the soft tissues of the oral and maxillofacial regions, oral pathologists are uniquely qualified to interpret the clinical presentations. The appearance of every lesion is immediately correlated with the possible histologic patterns capable of producing the noted alterations. A pathologist’s knowledge is not superficial and restricted only to the clinical appearance. An intimate knowledge of both the histologic patterns and the associated clinical presentations of oral soft tissue pathology results in a level of excellence in clinical practice that is difficult to achieve by one who is experienced only in the superficial appearance of lesions. Even patterns of soft tissue disease that have not been seen previously can be figured out with an appropriate knowledge of histopathology and the ability to make the correlation. In response to Dr. Eversole’s question, “Can one individual be expert in both clinical and histopathologic diagnosis?” the answer is a resounding YES! As a very active clinical oral pathologist, it is obvious the
Letters to the Editor
ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY
Januq~ I994
cases are popping up in different geographic areas of the country, obviously treated by different surgeons. The statement by Chuong et al. that foreign body inflammatory reactions may occur even in the asymptomatic person is patently true and has also been reported by our group at the University of Connecticut.’ Magnetic resonance (MR) imaging has clearly demonstrated how in numerous cases, significant inflammatory reactions have occurred in patients who had none of the usual indications for Proplast-Teflon implant removal, such as pain, occlusal change, or radiographic evidence of bone erosion. All patients who have had these implants inserted should undergo MR scans. Given the now well-established possibility of recurrence of the giant cell inflammatory reaction, it is difficult to imagine leaving the Proplast-Teflon implants within the joints of human beings even if such MR scans are negative. After removal of Proplast-Teflon implants, patients should undergo repeat MR imaging even in the absence of symptoms for at least 5 years, on the basis of the very slow progressive development of this pathologic entity. I would like to go a step further. There may be more recurrent giant cell inflammatory reactions than we realize. I invite any oral and maxillofacial surgeon who has treated a patient with a recurrent ProplastTeflon granuloma that developed after removal of the implant to write to me. You may not have an article to present, but I am willing to count up the numbers and report them in this space by the end of this year so that we may have a better idea of the incidence of recurrent giant cell granulomas associated with this type of implant. Joseph F. Piecuch, DMD,
MD
Associate Clinical Professor University of Connecticut Health Center Mailing address: 34 Dale Road Avon, CT 06001 REFERENCES
1. Feinerman DM, Piecuch JF. Long-term retrospective analysis of twenty-three Proplast-Teflon temporomandibular joint interpositional implants. Int J Oral Maxillofac Surg 1993;22:1116. 2. Ryan DE. The Proplast-Teflon dilemma. J Oral Maxillofac Surg 1989;47:22.
To the Editor:
The comments of Dr. Piecuch are appreciated and reiterate the principles delineated in the recent report Recurrent giant cell reaction to residual Proplast in the temporomandibular joint ( 1993;76: 16-9) I agree
wholeheartedly with the need for long-term follow-up of all patients who have had Proplast-Teflon implants placed even after implant removal, and it is clear that all such implants should be removed regardless of the presence or absence of symptoms. Although Dr. Piecuch suggests 5 years as a minimum period, the recommendation should perhaps be for a lifetime. The answer is not known at this time. At the 1992 annual meeting of the American Society of Temporomandibular Joint Surgeons held in Scottsdale, Arizona, I presented an abstract on this very same subject. On the basis of the comments of some of the other distinguished surgeons at the meeting this is a phenomenon that has been seen by other experienced TMJ surgeons. I agree with Dr. Piecuch that further case examples should be reported and tabulated. Robert Chuong, DMD, MD
Maxillofacial Surgery Institute of Florida St. Petersburg, Fla. To the Editor:
I read with interest Dr. Eversole’s editorial in the September 1993 issue of ORAL SURGERY, ORAL MEDICINE, ORAL PATHOLOGY; his comments require a response. Oral Pathology is the recognized specialty of dentistry and disciplineof pathology that deals with the diagnosis and management of diseases affecting the oral and maxillofacial region. Although many would prefer we restrict ourselves to histopathology, that action is not our heritage. It is inconsistent with our training and would be detrimental to the many patients who need our unique expertise. When patients have pathoses of the soft tissues of the oral and maxillofacial regions, oral pathologists are uniquely qualified to interpret the clinical presentations. The appearance of every lesion is immediately correlated with the possible histologic patterns capable of producing the noted alterations. A pathologist’s knowledge is not superficial and restricted only to the clinical appearance. An intimate knowledge of both the histologic patterns and the associated clinical presentations of oral soft tissue pathology results in a level of excellence in clinical practice that is difficult to achieve by one who is experienced only in the superficial appearance of lesions. Even patterns of soft tissue disease that have not been seen previously can be figured out with an appropriate knowledge of histopathology and the ability to make the correlation. In response to Dr. Eversole’s question, “Can one individual be expert in both clinical and histopathologic diagnosis?” the answer is a resounding YES! As a very active clinical oral pathologist, it is obvious the