Referral and Management Considerations for a Biopsy

Traditional oral and maxillofacial surgeon office practice spans the full scope of patient management. Most surgeons practicing in the United States dedicate their primary focus to the needs of patients referred by our dental colleagues. Dentoalveolar surgical practice remains the mainstay of office-based care. Oral cavity disease typically occurs from chronic bacterial infections of carious teeth, chronic periodontitis, fractured teeth. Recognition of oral disease patterns occurs by medical and dental clinicians. Oral and maxillofacial surgeon practice is uniquely designed to provide choice for the diagnosis and management of oral cavity disease, including neoplastic oral cavity and maxillofacial mucocutaneous disease.

Key points

  • Current trends in the diagnosis and treatment of oropharyngeal neoplasms.

  • Coordinating comprehensive anesthesia and surgical treatment planning.

  • Choosing an oral and maxillofacial surgeon based on training for place of service (office, outpatient, inpatient).

  • Coordinating benefits for a combined dental and medical treatment plan.

General patient evaluation

Patients referred to the oral and maxillofacial surgeon (OMS) are divided into the pediatric and adult categories for purposes of discussing a general overview of incidence and prevalence of disease. Children referred by pediatricians typically require care that can be assessed by the pediatric dentist, general dentist, or in some cases directly by the OMS. In contrast, many adult patient referrals may come from the general dentist, dental specialist (periodontist, endodontist, orthodontist), or a medical provider such as the primary care physician, nurse practitioner, or a medical specialist such as an otolaryngologist, ophthalmologist, neurologist, and dermatologist. The training and education of the OMS allows for the formulation of a focused and coordinated plan to recognize, assess, and manage the pathology and needs of the patient.

Aerodigestive lesion general considerations

Oropharyngeal neoplasia can be described primarily as benign or malignant. They can arise as a primary lesion related to disorders of amelogenesis, odontogenesis, inflammatory, developmental, and metastatic disease. Their biologic behavior of local and distant destruction has been well-documented in the medical literature.

The epidemiology of neoplasia has been followed by the American Cancer Society for decades. The statistical analysis of the rate of cancer is a complex formula. Oral cancer malignancy survival rates are generally reported in developed countries approximating a 5-year survival rate of 50%. Delays in diagnosis and subsequent treatment can contribute to advanced stage tumors to be encountered. Treatment modalities for oral cancer include combinations of surgical, chemotherapeutic and radiotherapy. Traditional medical and radiation oncology practice uses a team approach to coordinate surgical intervention as indicated. Comorbid conditions can ultimately guide the care of the patient in a palliative nature.

Odontogenic oral cavity lesions can be categorized based on the rates of incidence and prevalence. Pediatric or growing individuals and adults have differing trends or patterns of disease. Typically, an odontogenic neoplastic lesion is diagnosed radiographically by a dentist ( Box 1 ). In addition to radiographic investigation, a soft tissue incision or excision biopsy allows for a histopathologic examination and diagnosis. Odontogenic malignancy is exceedingly rare and often complex and confusing. Odontogenic benign lesions are more common and can also create confusion related to differentiation between a hamartoma or a true neoplasm.

Box 1
Odontogenic neoplasms

  • Child

    • Odontoma, ameloblastoma, ameloblastic fibroma, cementoma, odontogenic myxoma

  • Adult

    • Ameloblastoma, calcifying odontogenic cysts/tumors, cementoma, odontogenic myxoma

Nonodontogenic oral cavity lesions, which include inflammatory, developmental, and neoplastic lesions, can also be categorized into generally accepted rates of incidence and prevalence and have specific biologic behavior. These lesions can be discovered and diagnosed by dentists and physicians alike ( Table 1 ).

Table 1
Nonodontogenic oropharyngeal neoplasms
Benign Malignant
Child
Mucosal Traumatic fibroma, papilloma Rhabdomyosarcoma, squamous cell carcinoma
Salivary Vascular tumors, neural tumors, pleomorphic adenoma Mucoepidermoid carcinoma, adenoid cystic carcinoma
Bony Giant cell, fibro-osseous, Osteogenic sarcoma, chondrosarcoma, fibrosarcoma
Adult
Mucosal Fibroma, papilloma Squamous cell carcinoma
Salivary Pleomorphic adenoma Mucoepidermoid carcinoma
Bony Fibrous-osseous lesions Osteogenic sarcoma

Demographics of health care and oral pharyngeal cancer

A review of the 2017 US census statistics estimate the current civilian population to be roughly 320,775,000. Population growth from 2009 to 2017 rate was roughly 1%. Health insurance coverage analysis of these statistical demographics 2009 to 2017 demonstrates a decrease in the uninsured health care rate of 91% to 85%. In 2009, roughly 45 million individuals were uninsured in contrast with 2017, where it is estimated that 28 million individuals were uninsured. A review of these statistics presents a general numerical consideration to access for health care. Access to health care can be further discussed with regard to limitations, such as geographic distances, wait time to office visits, coordination in benefits, and primary care considerations.

Statistical analysis of oral pharyngeal cancer shows the incidence and prevalence to account for 3% of all cancers. The oral cancer locations include the lip, tongue, salivary glands and other sites in the mouth; whereas pharyngeal cancer includes the nasopharynx, oropharynx and hypopharynx. The overwhelming majority of cancers are squamous neoplasms, accounting for more than 90% in total.

Early detection of oral pharyngeal cancer presents a dilemma to the general population. The choice of who is the appropriate health care provider to assess the oral cavity is a topic of debate. The roles of the health care professionals who are not physicians or dentists in oral cancer screening remains poorly defined. Participants such as dental hygienists, physician’s assistants, and nurses can contribute to delays in the diagnosis of oral cancers. Patient education to self-examination techniques requires knowledge, experience, and an understanding of the limitations. Self-examination is reasonable and practical for breast cancer; however, for the oral cavity self-examination is complex and requires manipulations of structures with illumination for visual inspection, which cannot be accomplished.

The general population receives information about cancer through various methods. Few individuals can identify 1 sign of oral cancer. The dangers of tobacco and alcohol related to lung cancer and cardiovascular disease dominate patient education from health care providers and the media. Less of an emphasis exists related to aerodigestive cancer. Smokeless tobacco with its risks, along with human papilloma virus, remain topics that are often discussed minimally or not at all.

The public has little interest in considering their risk of oral cancer. As the lay public receives health care, it is assumed that the history taking and examination techniques are provided by educated and trained health care providers. The assumption is that the examination will adequately screen for all types of disease, cancer included. Often, an office visit to a primary care physician excludes an examination of the mouth. Oral cancer screening requires a head, neck, and oral cavity examination, and many patients are unclear who should be responsible for screening them for oral cancer.

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Jan 7, 2020 | Posted by in General Dentistry | Comments Off on Referral and Management Considerations for a Biopsy
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