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Metal in bone and soft tissue
METAT,
IN BONE
AN11 SOFT TISSUE
I
HAVE observed metal in the tissues in about 3 per cent of the cases coming to me. It is ra.rely found in the soft tissue, but more often in the bone. The presence of metal usually results from pieces of amalgam which break off of a filling in a tooth when the tooth is removed or which may fall from the filling in an adjacent tooth into the socket of the one extracted before the socket has healed. Some of these foreign bodies with the appearance of a filling may be due to cement or gutta-percha. The bone heals around them, and they are cncased in cellular connective tissue without evidence of infection. Of course, in some of these cases there is definite evidence of infection, and it is necessary to remove the foreign body. I have observed metal in the bone in a large number of cases and in the soft tissues in some cases as a result of a gunshot wound where the metal has been in the tissue for as many as twenty-five years. X-ray and clinical examinations show no pathologic change in the tissue, and apparently the metal is encased in fibrous tissue with no evidence of infection. I hare also observed man)- cases of metal in the form of amalgam, gold fillings and needles that have been left in the tissue, have become fibrous, and have remained for long periods of t,ime without evidence of pathologic change. A good plan, of course, is to remove a foreign body, especially when it is found immediately after operative procedure while the wound is still open and in all cases where it does not involve drastic surgery. Even though drastic surgery is involved, it is well to remove a foreign body if there is an area of infection surrounding it, as shown by the clinical and roentgenographic appearance. Just because a piece of metad is found in the tissue does not warrant drawing t,he conclusion that it should be removed; in many cases it is very poor surgery to advise immediate removal. Surgery undertaken at a time when the tissues have healed incompletely may involve quite an operative procedure without any justified operative results. I have observed cases in which pieces of metal were present in the tissue, and in which acute infections developed upon the same side of the face from other causes. Consultants who were called in saw the metal and immediately attributed the infection to its presence. One of the main reasons for removing metal is to guard against misunderstanding on the part of the patient so that at no subsequent time will he think that he has a foreign body with infection. It is good practice t,o take preoperative and postoperative x-ray pictures and, where metal is found immediately after the operation, to remove it. When metal is found in an area that has completely healed and when no clinical or roentgenographic signs of infection or irritation are found, one should he some377
378
Sterling
I’.
Mecrcl
Surgery should be done only in those cases what hesitant in advising surgery. where the history, clinical manifestations, and other features of the ease indicate the need for it. I have observed some cases where metal left in the tissue caused an area of irritation. I have in mind the case of Mr. C., who had a gunshot wound and fracture taking away the entire angle of his jaw. In operating upon him a number of pieces of metal were left in the jaw. He later developed some soreness around a piece of metal along the lower border of the jaw. It caused tissue irritation and nerve irritation which gave him pain which was reflected over the entire side of his face. This metal was removed, and the symptoms of soreness disappeared. CLINICAL
EXAMINATION
In an examination of 713 cases clinically and with full mouth roentgenograms, there were twenty-seven of them with metal present in the tissue or 3.8 per cent. Two of these had more than one piece. In order to obtain an opinion from outstanding specialists in oral surgery in the leading cities of the United States with respect to their experience and observations of metal in the soft tissue and bone as a postoperative result, the following questionnaire was mailed to them: 1. Do you observe many cases of metal in the soft tissues or bone? 2. Approximately how many! 3. Do you think they may be safely left in place? 4. Do you recommend surgery in all cases? 5. Upon which cases do you operate? 6. Which cases do you leave alone! Answers to this questionnaire were received from fifty-six different cities representing the leading oral surgeons and the men who have the most experience in this type of work. In answer to the first question ten men answered, “No. ” The remaining men answered, “Yes.” In answer to question 2, the replies varied from 0.5 to 5 per cent, with such remarks as : “Maxillary jaw not more than 1 per cent, but mandibular jaw perhaps as much as 3 per cent’ ’ ; “this year we have had twenty-seven ca,ses”; “one in two to three hundred cases”; ‘(difficult to answer, but not an uncommon finding in the routine work in the clinic where full x-ray examinations are made”; “not so often as in former years; frequently see small fragments of shavings and bone alloy”; “observe cases of metal (amalgam fillings) in soft tissue and bone, the greater number in bone”; (‘frequently in full mouth roentgenogram examinations we observe evidence of metal in soft tissues and osseous structure ’ ’ ; “occasionally, the most common metal being amalgam which has been fractured loose from the adjacent teeth during extractions.” The answers to question 3 were in most cases, “Yes; most of them”; “sometimes ’ ’ ; and “generally”; four of the fifty-six answered, “No.” One of those who answered so stated, “No, with exceptions. ” In answer to question 4 all of the fifty-six answered, “No, ” with the exception of four who answered as follows: “AS a rule, yes”; “with few excep-
Metal
in Bone und soft
T&SW
379
tions, yes ’ ’ ; “I think they should all be removed as I have had a number of patients receive health benefit after removing metal from the tissue” ; “yes.” In answer to question 5, such answers as the following were received: “Depends on patient’s general condition, complaint, location, etc.“; “those indicating pathologic change in tissue, only such as may be a source of mechanical irritation ’ ’ ; “I operate when no greater damage may result, or when no im‘(where infection is present or there is nerve portant structures are involved”; pressure”; “where there is evidence of irritation to soft tissue and structural change in bone”; “usually to satisfy patients”; “where there is clinical or radiographic evidence of pathologic areas”; “those cases which have been rcferred to me after immediate extraction.” The consensus appears to be to remove metal in the following conditions: as a prophylactic or preventive method when detected before healing of a wound; when it causes irritation of nerve or tissue; when pat,hologic change in tissue is indicated or if there is evidence of infection. In answer to question 6, such answers were received as : (‘The average case of fractured or shattered amalgam or gold filling”; “those showing no evidence of pathologic change ” ; “needles in the aged and ill if there is no infection present “; “those not showing local or general disturbances”; “where there is no complaint and the areas radiograph negative”; “most of them”; ‘Lcases of long standing in which no abnormality exists surrounding the foreign body and patient complains of no disturbance.” The consensus is that most of them do not give trouble, and are left alone where they are not giving trouble as indicated by roentgenographic or clinical evidence. SUMMARY
Metal may be found in the tissues in from 1 to 3 per cent of t,he cases. Most of them may be safely left alone, and surgery is not recommended in all cases. It is well to remove metal from open or new wounds when possible and in those cases where there is evidence of suppuration, irritation, nerve pressure or roentgenographic evidence of bone change. 1149
SIXTEENTII
STREET,
N.
W.
IN BONE
AN11 SOFT TISSUE
I
HAVE observed metal in the tissues in about 3 per cent of the cases coming to me. It is ra.rely found in the soft tissue, but more often in the bone. The presence of metal usually results from pieces of amalgam which break off of a filling in a tooth when the tooth is removed or which may fall from the filling in an adjacent tooth into the socket of the one extracted before the socket has healed. Some of these foreign bodies with the appearance of a filling may be due to cement or gutta-percha. The bone heals around them, and they are cncased in cellular connective tissue without evidence of infection. Of course, in some of these cases there is definite evidence of infection, and it is necessary to remove the foreign body. I have observed metal in the bone in a large number of cases and in the soft tissues in some cases as a result of a gunshot wound where the metal has been in the tissue for as many as twenty-five years. X-ray and clinical examinations show no pathologic change in the tissue, and apparently the metal is encased in fibrous tissue with no evidence of infection. I hare also observed man)- cases of metal in the form of amalgam, gold fillings and needles that have been left in the tissue, have become fibrous, and have remained for long periods of t,ime without evidence of pathologic change. A good plan, of course, is to remove a foreign body, especially when it is found immediately after operative procedure while the wound is still open and in all cases where it does not involve drastic surgery. Even though drastic surgery is involved, it is well to remove a foreign body if there is an area of infection surrounding it, as shown by the clinical and roentgenographic appearance. Just because a piece of metad is found in the tissue does not warrant drawing t,he conclusion that it should be removed; in many cases it is very poor surgery to advise immediate removal. Surgery undertaken at a time when the tissues have healed incompletely may involve quite an operative procedure without any justified operative results. I have observed cases in which pieces of metal were present in the tissue, and in which acute infections developed upon the same side of the face from other causes. Consultants who were called in saw the metal and immediately attributed the infection to its presence. One of the main reasons for removing metal is to guard against misunderstanding on the part of the patient so that at no subsequent time will he think that he has a foreign body with infection. It is good practice t,o take preoperative and postoperative x-ray pictures and, where metal is found immediately after the operation, to remove it. When metal is found in an area that has completely healed and when no clinical or roentgenographic signs of infection or irritation are found, one should he some377
378
Sterling
I’.
Mecrcl
Surgery should be done only in those cases what hesitant in advising surgery. where the history, clinical manifestations, and other features of the ease indicate the need for it. I have observed some cases where metal left in the tissue caused an area of irritation. I have in mind the case of Mr. C., who had a gunshot wound and fracture taking away the entire angle of his jaw. In operating upon him a number of pieces of metal were left in the jaw. He later developed some soreness around a piece of metal along the lower border of the jaw. It caused tissue irritation and nerve irritation which gave him pain which was reflected over the entire side of his face. This metal was removed, and the symptoms of soreness disappeared. CLINICAL
EXAMINATION
In an examination of 713 cases clinically and with full mouth roentgenograms, there were twenty-seven of them with metal present in the tissue or 3.8 per cent. Two of these had more than one piece. In order to obtain an opinion from outstanding specialists in oral surgery in the leading cities of the United States with respect to their experience and observations of metal in the soft tissue and bone as a postoperative result, the following questionnaire was mailed to them: 1. Do you observe many cases of metal in the soft tissues or bone? 2. Approximately how many! 3. Do you think they may be safely left in place? 4. Do you recommend surgery in all cases? 5. Upon which cases do you operate? 6. Which cases do you leave alone! Answers to this questionnaire were received from fifty-six different cities representing the leading oral surgeons and the men who have the most experience in this type of work. In answer to the first question ten men answered, “No. ” The remaining men answered, “Yes.” In answer to question 2, the replies varied from 0.5 to 5 per cent, with such remarks as : “Maxillary jaw not more than 1 per cent, but mandibular jaw perhaps as much as 3 per cent’ ’ ; “this year we have had twenty-seven ca,ses”; “one in two to three hundred cases”; ‘(difficult to answer, but not an uncommon finding in the routine work in the clinic where full x-ray examinations are made”; “not so often as in former years; frequently see small fragments of shavings and bone alloy”; “observe cases of metal (amalgam fillings) in soft tissue and bone, the greater number in bone”; (‘frequently in full mouth roentgenogram examinations we observe evidence of metal in soft tissues and osseous structure ’ ’ ; “occasionally, the most common metal being amalgam which has been fractured loose from the adjacent teeth during extractions.” The answers to question 3 were in most cases, “Yes; most of them”; “sometimes ’ ’ ; and “generally”; four of the fifty-six answered, “No.” One of those who answered so stated, “No, with exceptions. ” In answer to question 4 all of the fifty-six answered, “No, ” with the exception of four who answered as follows: “AS a rule, yes”; “with few excep-
Metal
in Bone und soft
T&SW
379
tions, yes ’ ’ ; “I think they should all be removed as I have had a number of patients receive health benefit after removing metal from the tissue” ; “yes.” In answer to question 5, such answers as the following were received: “Depends on patient’s general condition, complaint, location, etc.“; “those indicating pathologic change in tissue, only such as may be a source of mechanical irritation ’ ’ ; “I operate when no greater damage may result, or when no im‘(where infection is present or there is nerve portant structures are involved”; pressure”; “where there is evidence of irritation to soft tissue and structural change in bone”; “usually to satisfy patients”; “where there is clinical or radiographic evidence of pathologic areas”; “those cases which have been rcferred to me after immediate extraction.” The consensus appears to be to remove metal in the following conditions: as a prophylactic or preventive method when detected before healing of a wound; when it causes irritation of nerve or tissue; when pat,hologic change in tissue is indicated or if there is evidence of infection. In answer to question 6, such answers were received as : (‘The average case of fractured or shattered amalgam or gold filling”; “those showing no evidence of pathologic change ” ; “needles in the aged and ill if there is no infection present “; “those not showing local or general disturbances”; “where there is no complaint and the areas radiograph negative”; “most of them”; ‘Lcases of long standing in which no abnormality exists surrounding the foreign body and patient complains of no disturbance.” The consensus is that most of them do not give trouble, and are left alone where they are not giving trouble as indicated by roentgenographic or clinical evidence. SUMMARY
Metal may be found in the tissues in from 1 to 3 per cent of t,he cases. Most of them may be safely left alone, and surgery is not recommended in all cases. It is well to remove metal from open or new wounds when possible and in those cases where there is evidence of suppuration, irritation, nerve pressure or roentgenographic evidence of bone change. 1149
SIXTEENTII
STREET,
N.
W.