October 18, 2016
by Peter C. Fritz, BSc, DDS, FRCD(C), PhD (Perio), MBA, Certified Specialist in Periodontics; Assunta Piccini, CDAII; Stephanie Klok, BA, RDH
A 72-year-old female patient was referred to our office by her physician with the chief concern of a large granuloma on her lower lip. The patient had a medical history positive for hypertension, thyroid disease, hypercholesterolemia, osteopenia, sinusitis and eczema.
The patient reported that over the past two to three years, she had a re-occurring lump on the right side of her lower lip. She reported that it was not painful but it would become larger and smaller while sometimes completely disappearing all together.
The patient could not recall any prior injury to the area and the lump always returned in the same area, apparently spontaneously. She reported that the size of the lump was that of a green pea at it’s maximum.
At one of her regularly scheduled dental appointments, the patient’s general dentist suggested to her that he could easily remove the lump with laser surgery and she scheduled the laser treatment after her next recall appointment six months later.
On the day of her scheduled laser appointment, the patient reported that the lump was barely palpable. Her general dentist told her that she could continue with the treatment and it would be completed in less than 15 minutes. The patient reported that the procedure took thirty minutes to complete. The patient was upset about the pain and swelling she experienced post-operatively and reportedly her general dentist had not advised her of the risks associated with the procedure.
The patient experienced swelling and discomfort that lasted for two weeks. She had great difficulty eating and speaking. She noted that after the surgery a different lump was notable on her lip that in her estimation was continuing to grow. When the patient returned to the general dental office, she was prescribed a cortisone cream to apply to the site of the recurring lump and was told by her dentist that the area would slough off and that there must have been a salivary gland that was severed but it was not related to the laser procedure. As the lump continued to grow despite using the cream, the patient lost confidence in her general dentist and sought the care of her family physician who referred her to our office.
The patient presented to our clinic with a single, 12 x 4 x 5 mm, oval-shaped, well-defined, ulcerated, red, firm and well established mass on the lower right lip (Figs. A-C). The patient reported that the area was very painful and she reported tingling and numbness in the area. The patient reported that the pain was episodic and that it increased when lying on her side during the night.
Differential Diagnosis: Granulomatous mass, Pyogenic granuloma.
Patient presented with redness past vermillion border. The area was associated with pain and induration.
Intraoral view reveals a red mass that interferes with eating and speaking.
One week after the initial presentation the mass had grown. It bled upon provocation.
The treatment plan was a surgical excision of the mass using a scalpel under local anesthesia and submitting the mass for histopathological interpretation. To establish informed consent, the patient was informed of probable risks associated with surgery including post-operative pain, swelling, bruising and post-operative bleeding. The post-operative diet was planned for the patient as it was expected that she would have difficulty eating for several days after the surgery. We discussed the limitations of moving the lips during speech post-operatively as well as playing any musical wind instruments. We discussed that the probable post-operative wound healing sequence would limit her ability to participate in upcoming social events as well as speaking or singing commitments.
The patient was advised of possible risks including scarring, partial or permanent numbness, damage to adjacent salivary glands and a recurrence of the lesion.
Finally, I advised the patient to discontinue using the cortisone cream.
The surgery was uneventful and the mass was completely excised with a 15C scalpel blade under local anesthesia. Primary closure was achieved using 6-0 ethilon® (Ethicon) sutures and she was prescribed ibuprofen for post-operative pain management.
Post-operative Care Call
The day after the surgery, the patient reported moderate pain that was manageable with ibuprofen. The patient iced the area three times for 10 minutes during the first 12 hours following the surgery (after the area was no longer anaesthetized). The pain subsided after 48 hours. The swelling resolved after 72 hours. The patient reported some bruising of the lower lip that faded and then disappeared in two weeks. She was able to resume a normal diet after one week.
A three-week follow-up revealed that complete closure of the wound had been achieved and a small 2 x 3 mm area of firmness was present beneath the incision line (Fig. D). This firmness was likely scaring of the tissue and incomplete remodeling. There was no recurrence of either the first or second type of lesion. A follow-up is planned one year after the latest surgical visit.
The histopathological interpretation confirmed the clinical diagnosis of Pyogenic granuloma secondary to a surgical procedure with a laser surgery.
Three months post-operatively the lip mucosa has healed well. There is no recurrence of the mucocele or the granuloma.
Almost all conflict is attributable to a mismatch in expectations. This case report details of a conflict between the general dentist and the patient that could have been easily mitigated through better communication including a candid discussion regarding probable and possible complications of the proposed surgery. Every surgery carries risk of complications and no matter how minor the surgery seems to the surgeon, the procedure will affect the patient’s quality of life, at least in the short term. This is often referred to as “material risk” in legal parlance. It is the dentist’s duty to ensure the patient is aware of all the risks and is well prepared for the post-operative modifications they must endure during the wound healing. An understanding of complications pre-operatively can aid in the management of expectations and if proceeding via different clinical pathway is required. The discussion serves to educate the patient about the problem but is also the opportunity for a fair and balanced discussion regarding all treatment options. Being precise with the clinical issues is critical in guiding the patient; inevitably they will conduct their own online research about possible solutions, various options and often from uneducated or even nefarious sources.
The initial pathology the patient sought treatment for was very likely an extravasation mucocele. Mucoceles are very common and there are many ways to treat them including cryosurgery, intralesional corticosteroid injection, micro-marsupilization, conventional surgical removal and laser ablation. There are two studies that compare treatment of oral mucoceles by surgical removal and laser ablation with a Diode and CO2 laser. Both studies suggest the laser removal is easier for the patient, has a lower recurrence rate and interestingly, in one study of 68 patients an absence of complications when using a laser. The complications and higher recurrence rate with the conventional surgical removal are likely highly dependent on the skill of the operator. Asgari et al. report that a disadvantage of the conventional surgical removal is that it “requires great precision….detailed knowledge of the mucocele and the surrounding anatomy. It also requires great control of the instrument, with accurate tactile awareness”. It would seem that these characteristics are fundamental of any surgical approach and not a reason to support any specific technique. The conventional surgical approach has a clear advantage in terms of the cost required to perform the procedure because it does not require expensive equipment. Nevertheless, irrespective of the technique chosen, the patient preparation should be the same. Preparing a patient for the complications of surgery is just as important, if not more important, than the surgery itself. Even with a complication rate of 1-2%, these events become points of stress for all involved and consume far more resources than the 98-99% of procedures that go as planned.
Cost to the Patient
The patient experienced a complication after laser surgery that resulted in the development of a pyogenic granuloma at the wound site. To determine the actual cost to the patient, one must calculate more than the cost of appointments required to have the complication resolved. There are a myriad of other costs that factor into the complication including time off work to attend additional appointments, travel expenses including gas and parking, additional prescriptions and communication expenses. In personal injury law these are sometimes referred to as “special damages.” There are lost opportunity costs due to the patient’s choice to prioritize the treatment of the complication over any other choice. There are also quality of life costs to the patient that include things like discomfort and physical pain as well as emotional distress, anxiety and stress that is associated with the complication. In law this is referred to as “general damages” and quantifying the pain and suffering and mental anguish can be a contentious calculation.
Cost to the Dentist
The financial cost of a complication to the dentist is also an intricate quantification. It is more than the cost of redoing the procedure or the time spent managing the complication over additional appointments. It also includes the time spent by the administrative staff in arranging the additional appointments as well as the cost of having the clinical staff prepare and take down the rooms after seeing the patient. Often complications are treated at no-charge to the patient and as such the lost opportunity of the dentist to treat other patients should also be considered. In this case report, the patient indicated that she would not return to her dentist as she lost confidence in him; a clear economic impact to the dentist of the long-term nature. Should she choose to encourage her family to leave the practice this cost expands. One other important cost to be considered is the value of the dentist’s reputational assets.
The possibility of an unsuccessful re-treatment should also be considered as a potential risk – after all, the procedure didn’t work for the first time and may be unsuccessful after retreatment in case the cause of the initial failure eludes the practitioner. Patients can very readily find many channels through social media or with conventional approaches that could damage the clinician’s reputation and impact the value of his or her practice. Finally, there is the cost of the collateral damage or the cost of the patient complications to the surgeon’s psyche and well being. In a similar vein, it is said every great surgeon remembers every bad outcome.
Avoiding conflict due to a mismatch in expectations requires communication. The clinician has to outline for the patient what the patient can expect as a clinical benefit from a proposed procedure. Also the clinician has to understand what the patient’s expectation of the clinical procedure is and if it is in fact reasonable and achievable. If there is a question regarding the expected outcome for either party, it is time to change the expectation so both sides are comfortable with all the potential outcomes. The time invested into understanding, clarifying and modifying expectations before surgery establishes a solid framework for informed consent and nearly all the possible outcomes. This is integral to the relationship between patient and surgeon. Those who offer “free consultations” should think again whether the time, expertise and vigilance required to fulfil an informed consent is adequately rewarded. OH
Peter Fritz is a certified specialist in periodontics practicing in Fonthill, ON. He is a global life-long learner with the goal of integrating international observations into the most predictable and cost-effective treatments for periodontal and implant patients. Center for Bone and Muscle Health, Faculty of Applied Health Sciences, Brock University, 1812 Sir Isaac Brock Way, St. Catharines, Ontario, Canada, L2S 3A1.
Stephanie Klok is a registered dental hygienist in Fonthill ON. She is also pursuing graduate studies in Applied Health Sciences at Brock University.
Assunta Piccini is a level II dental assistant with a special interest in periodontal surgery and oral pathology. She has trained in nine countries and has focused her learning on methods to optimize the patient experience.
Oral Health welcomes this original article.
1. Treatment of oral mucocele- scalpel versus CO2 laser. Yague-Garcia, J., Berini-Aytes, L, Gay-Escoda, C., Journal of Oral Surgery. 2009: Sep1:14(9); 469-74
2. Treatment of lower lip mucocele with diode laser- A novel approach. Sukhtankar, L.V., Mahajan, B., Agarwal P. Annals of Dental Research 2014; 2 Suppl1: 102-108.
3. Mucocele Resection: A Comparison of two techniques. Asgari, A., Kourtsiunis P., Jacobson B.L., Zhivago, P. Dentistry Today. 2008 Apr;27(4) 70-76