The incidence of oral metastasis is one percent of all oral malignancies, a low but significant number considering the implications of the diagnosis. Metastasis to the jaw usually indicates a stage four diagnosis. This group of patients has a poor five year survival rate and generally do not survive beyond one year. On occasion these lesions are the first indication of primary neoplasms elsewhere in the body.
The indications for apicoectomy are technical and biological (El-Swiah JM, Walker RT) and the biological symptoms closely mimic metastasis to the jaws. The radiographic appearance is usually osteolytic although metastasis from breast, prostate and lung (the most common metastasis to the jaws) may give a sclerotic appearance (Zachariades). Most cases occur in the mandibular premolar molar areas. The symptoms may mimic abscess and include hypoesthesia, mobility of teeth, swelling, hemorrhage, periodontitis, pathologic fracture and trismus. The most common diagnosis of periradiuclar pathology is granuloma followed by periradicular cyst. Other jaw lesions include odontogenic cysts, tumors and inflammatory/reactive lesions.
Dentists need to be aware of the other possibilities when treating a persistent apical lesion that has not responded to conventional root canal therapy. A cracked tooth, virulent bacteria warranting culture sensitivities and unusual pulp anatomy and finally cysts or neoplasms should be included in the differential diagnosis. Any tissue or material recovered during surgery in these areas should routinely be sent for pathologic examination to rule out other pathologies that may warrant different treatments.
The majority of biopsies I see in my biopsy service are fibromas, mucoceles and pyogenic granulomas to name a few of the more common lesions. Although benign, you should convince your patients these lesions are not supposed to be there, will not go away on their own and could get worse with time. And a small percentage of these lesions turn out to be neoplasms with the most common oral malignancy being squamous cell carcinoma. Any suspicious white or red lesions should be biopsied to rule out dysplasia (a precancerous lesion) or squamous cell carcinoma. Inform your patients you can’t tell just by looking at the lesion (you don’t have microscopic eyes) it needs to be biopsied and examined under a microscope for a definitive diagnosis.
The adjunct screening methods available today that are offered to dentists to screen their patient population have questionable utility. A recent study (Patton, Epstein, Kerr) in the Journal of the American Dental Association says the positive predictive value and cost effectiveness of these adjunct screening devices has still not been determined.
“There remains uncertainty as to whether the use of adjuncts for identifying and assessing oral mucosal abnormalities results in a meaningful reduction in morbidity and mortality.”
So, the jury is still out on the use of Oral CDx, Vizilite, Velscope, Microlux and the recently introduced Identifi3000. Toluidine blue as a vital stain has shown some evidence as a valuable diagnostic adjunct for use in high risk populations (smokers) and suspicious oral lesions. Finally, just do a thorough head and neck exam and you will be providing a high standard of care for your patient. If you see something that isn’t supposed to be there and you don’t know what it is: biopsy it and find out. Don’t get caught playing the wait and see game only to find out you have been watching the development of an oral cancer for the last six weeks to see if it will go away!
Most dental practices have intraoral cameras, don’t hesitate to take a picture of a lesion and e-mail it to your oral pathologist or oral surgeon for an opinion on whether or not it needs to be biopsied. You are only alone if you chose to be; reach out to your colleagues for expert opinions if you are in doubt and provide the highest standard of care for your patient.
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Dr. Dovigi obtained his DDS from the University of Toronto and his MS in Oral Pathology from the University of North Carolina/ Chapel Hill. He started the biopsy service in 2006 and is also Associate Professor of Oral Pathology at Midwestern University College of Dental Medicine in Glendale, AZ. Dr. Dovigi is Board Certified and a Fellow of the American Academy of Oral and Maxillofacial Pathology.www.nationaloralpathology.comadovig@midwestern.edu
Oral Health welcomes this original Viewpoint
References
1. Adjunctive techniques for oral cancer examination and lesion diagnosis. Patton, Epstein, Kerr, JADA July 2008 896-905.
2. Reasons for apicectomies. A retrospective study, JM El-Swiah, RT Walker. Endod Dent Traumatol 1996; 12: 185-191
3. Neoplasms Metastatic to the Mouth, Jaws and Surrounding Tissues, Nicholas Zachariades J. Cranio-Max-Fac Surg. 17 (1989) 283-290
4. Oral and Maxillofacial Pathology, Neville, Damm. Allen , Bouquot
