5: Guidelines for Observation and/or Referral of Patients’ Lesions

Guidelines for Observation and/or Referral of Patients’ Lesions

It is highly desirable and professionally responsible for the clinician to have a structured administrative plan for monitoring suspicious lesions of their patients. If accomplished, it simultaneously allows a favorable outcome and affords the clinician reasonable medicolegal protection. The following are guidelines for monitoring an area of suspicious clinical appearance or a lesion that yields an equivocal pathological diagnosis upon biopsy.

A look at the current dental literature mentions the standard diagnostic observation time span of 10–14 days for an undiagnosed lesion lacking a high degree of malignant suspicion; however, there is a paucity of recommendations for a lesion that continues to have a nonthreatening clinical appearance following a nonmalignant biopsy finding.1,2

We agree with others that although a dental hygienist is adequately trained to perform initial dental examinations the ultimate responsibility for diagnosis and follow-up rests with the dentist. If a general dentist confirms discovery of a lesion by a dental hygienist or personally discovers it and decides the lesion warrants referral to a specialist for a surgical biopsy, then, if at all possible, the referral appointment should be made while the patient is still at the dental office. In addition, a confirmation communication should be sent to the specialist describing the lesion and a requesting a written result; copies of both should be part of the patient’s permanent dental record.3 Whenever possible, surgical biopsy specimens should be submitted to oral and maxillofacial pathologists for interpretation since they are usually more familiar with the histopathological subtleties of the jaws and soft tissue of the oral tissues. It is important that any dental office that submits biopsies have an established protocol regarding biopsy documentation to ensure timely receipt and review of the written report and the follow-up action, if any is needed.3

If a biopsy is indicated, the patient should be counseled so that he or she understands its purpose is to achieve a precise, definitive diagnosis that will result in proper treatment and management.1–3

Previous authors have compiled a comprehensive list of indications for a soft tissue biopsy:

  • Any persistent or pathological condition that cannot be diagnosed clinically, including a lesion with no identifiable etiology that persists for more than 10–14 days despite local therapy
  • Any lesion that is felt to have malignant or premalignant characteristics, including growth or rapid growth for no apparent reason; any lesion that produces symptoms; any lesion that is red, white, or pigmented for which a cause or diagnosis is not evident
  • Any lesion that feels firmly attached or fixed to adjacent structures
  • Any unknown lesion in high-risk areas for development of oral cancer (e.g., floor of mouth, lateral tongue)
  • Confirmation of clinical diagnostic suspicions
  • Any lesion that does not respond to routine clinical management, such as antibiotic therapy or endodontic treatment, over a reasonable period of time
  • Any lesion that is a source of extreme concern to the patient (i.e., cancerphobia) such that the patient’s fear about the persistent lesion is greater than the concern about undergoing the minor surgical procedure

It would be an error in logic to continue to observe a patient’s soft tissue lesion as it continues to grow larger but not recommend a definitive diagnostic and therapeutic step to the patient. Even if the lesion proved to be benign upon biopsy, continued growth of a benign lesion can encroach upon normal anatomical structures and cause significant morbidity. Courts have ruled that a diagnostic biopsy needs to be performed as soon as possible by a prudent and reasonable dentist if the lesion’s clinical features do not improve or the clinical diagnosis becomes uncertain.

There are no consistent guidelines in the dental literature regarding the timing of appointments for reevaluation of suspicious lesions with or without histopathologic evaluation. Since the frequency and length of follow-up and management of oral pathology soft tissues is influenced by many factors, the guidelines can only be generalized. The clinician’s reasonable judgment and experience may, at times, cause modifications of the guidelines.1

Following discovery of an undiagnosed lesion the standard agreement of time for observation is 7–14 days, with or without local treatment. At the conclusion of this time period if the lesion has not responded to therapy or the lesion grows or alters its characteristics, then a biopsy is indicated.

If the lesion has not changed its appearance or surface characteristics after this observation time period, then a decision must be made whether to biopsy or continue to observe on a periodic basis. The patient, of course, has the ultimate decision by granting consent; the clinician should inform the patient of the risks and benefits so the patient understands that he or she shares the responsib/>

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Jan 14, 2015 | Posted by in Oral and Maxillofacial Surgery | Comments Off on 5: Guidelines for Observation and/or Referral of Patients’ Lesions
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