Following Through

Alexander Frisbie, DMD

We hope to never fall short in our role in managing oral pathology. With modern education, awareness, and ubiquity of screening, general dentists generally do a good job of identifying concerning lesions at a new patient examination and giving appropriate treatment or referrals.

A less talked about responsibility is managing these conditions after that initial encounter. We are all taught to recognize zebras among the horses, but is there any room for improvement in the way we watch these zebras?

As general dentists, we have the unique role of treating a patient continuously beyond an acute treatment phase. Hygiene recall provides an opportunity to follow through on our treatment and recommendations. Am I happy with the margins of the crown I placed six months ago? Has the patient made any improvement in their oral hygiene? Drinking less soda? Are we starting to see relapse after orthodontics?

How about the leukoplakia that we referred for biopsy five years ago and was found to be benign? Have we taken measurements and photos since then, or are we relying on memory to determine if it has changed in size and appearance?

It can be a huge relief when a pathology report returns with a benign diagnosis. Patients view pathology as a pass/fail; “I had my biopsy and everything was fine.” Sometimes we may fall into this comfort zone as well when we feel we have done our job. It is important to remember that follow-up and long-term monitoring is an important part of managing oral disease.

The case pictured here is from a denture wearing 75 year old woman. About five years prior, a general dentist referred her for a biopsy of a much smaller lesion that was found to be normal squamous papilloma. At the time, the concern was low and the patient actually had forgotten that she even had a biopsy. Like many denture wearing patients, perhaps she may have not seen the need to continue to see a dentist regularly as she no longer had teeth.

Recently however, the lesion grew in size and began to feel different, perhaps causing her dentures to fit differently. She returned to a general dentist who immediately referred for a new biopsy, this time with the diagnosis of squamous cell carcinoma. Tragically, this will result in a maxillectomy and due to the size and age of the lesion has a high risk of secondary spread.

How easy would it be to mistake this lesion (when it was much smaller and less dramatic) for an epulis fissuratum, especially if the patient told you “it’s been there for years” or “I had a biopsy and it turned out to be nothing.” Anyone viewing this late-stage photograph will recognize a serious lesion, but perhaps fewer of us would notice subtle differences between an early carcinoma and a denture sore or a papilloma. It is important to trust your education, and at times intuition, to weed out the wolves dressed like sheep.

I think we all can admit we often breathe a sigh of relief and move on once a patient tells us that they previously had a biopsy. However, management and follow-up of pathology often falls on our shoulders, and we would do well to remember that general dentists treat patients not acutely but for life.

This case was provided by Dr. Kurt Summersgill, DDS, PhD of the University of Pittsburgh Department of Oral and Maxillofacial Pathology.