Chapter 5: Oral Surgery Introduction



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Performing Biopsies

Introduction


You must have a good understanding of oral pathology before performing a biopsy of the oral cavity. There are over 700 pathological conditions of the oral cavity. Many of these lesions are benign and present no life threatening danger if left alone; however, malignant lesions in the oral cavity require early diagnosis and treatment to prevent an early death.

Responsibility


Simple oral biopsies of the oral cavity can be performed under local anesthesia in the dental office by a general dentist with some surgical training. The anatomic site and malignant characteristics of the lesion may determine whether or not a general dentist should attempt a biopsy.

Types of Lesions


The following types of lesions may be found in the oral cavity:

  • benign soft tissue lesions

  • malignant lesions

  • bone lesions

Benign Soft Tissue Lesions


The following soft tissue lesions, if in non-critical anatomic areas, could be biopsied by the general dentist:

  • fibroma

  • papilloma

  • mucocele

  • gingival hyperplasia

  • amalgam tattoo

  • epulus fissuratum

Malignant Lesions

Ninety percent of all oral malignancies are squamous cell carcinomas. Since they are surface lesions involving the soft tissues of the oral cavity and the lips, they are readily visualized on oral exam. Any ulcerated lesions that do not heal after a two to four week duration must be biopsied. Any reddish or white lesion that exists for more than two to four weeks should be biopsied even though there is no fresh ulceration.



Early diagnosis will save lives. A patient with any squamous cell carcinoma:

  • less than 1 cm in diameter and with no lymph node involvement may have a 90 percent 5-year survival rate if totally surgically removed

  • larger than 4 cm in diameter may have only a 10 percent 5-year survival rate if completely surgically removed


Warning: If you suspect a patient has a squamous cell carcinoma, immediately refer the patient to an Oral and Maxillofacial Surgeon for evaluation and biopsy.

Bone Lesions


Most bone lesions, especially if a malignancy is suspected, should be referred to an oral and maxillofacial surgeon.

Anatomical Considerations


The following areas in the oral cavity may be difficult for the general practitioner because of probable injury to vital structures:

Types of Biopsy Procedures


Biopsy procedures are divided into either:

Excisional Technique


Lesions that are less than 1 cm in diameter may be biopsied using the excisional technique. The biopsy is performed by:

  • removing the entire lesion

  • submitting it for histological examination

A band of normal tissue should be included with the lesion specimen in this biopsy technique.

Note: There should be enough normal tissue included with the specimen to indicate that the total lesion was removed.

Incisional Technique


The incisional biopsy is performed by:

  • removing a representative section from the lesion

  • submitting it for histological examination

The representative section must include, if possible, the junction with the surrounding normal tissue. Necrotic areas should be avoided since they are seldom diagnostic. Superficial sections should be avoided since they are seldom diagnostic and may only show mucosal reactions and inflammation rather than the regions of primary concern.

Pathology Report


Any biopsy submitted to a pathologist must be accompanied by appropriate paper work. The pathology department that you deal with will provide the proper forms. Generally, any pathology report must include the following information:

  • an adequate history of the lesion

  • a complete clinical description of the lesion including color, size, and location

  • your preliminary diagnosis

Considerations for Submitting a Biopsy


When submitting a biopsy the following factors must be considered:

  • Submit the specimen to the pathologist the same day it is received.

  • When appropriate, submit x-rays, photographs, and in some cases, study models.

  • Do not use coloring agents on incisional biopsies, because they may affect the various stains employed in preparing the histologic sections.

  • Inject local anesthesia around the lesion since a direct injection may distort the specimen.

  • Electrosurgery is not indicated since this procedure may cause a severe alteration in the margins of the specimen.

  • Immediately place the specimen(s) in an adequate volume of formalin.

  • Always warn the pathologist if a calcified body is enmeshed with a soft tissue lesion. The presence of a calcified body will damage a microtome or ruin the remaining specimen during the sectioning procedure.

Submission of Specimens


If your local facility does not have a pathology department available, send your specimens to the following Naval Hospital:

Naval Medical Center

Laboratory Department EDA 13

34800 Bob Wilson Drive, Suite 305

San Diego, CA 92134-1305

(619) 532-9340


Performing SBE Prophylaxis

Introduction


The administration of antibiotics to endocarditis-prone patients is a universal standard of practice. The benefits of preventing subacute bacterial endocarditis (SBE) are readily apparent since the treatment of this disease requires prolonged hospitalization and supportive care, followed by a long recovery period for those who survive.

Indications for SBE Prophylaxis


Endocarditis prophylaxis is recommended for dental procedures known to induce gingival or mucosal bleeding (including professional cleaning).

Contraindications for SBE Prophylaxis


Endocarditis prophylaxis is not recommended for:

  • dental procedures not likely to induce gingival bleeding such as simple adjustment on orthodontic appliances or fillings above the gum line

  • injection of local intraoral anesthetic (except intraligamental injections)

  • shedding of primary teeth

Recommended SBE Prophylaxis Regimen for Adult Patients at Risk


The recommended standard prophylactic regimen for dental, oral, or upper respiratory tract procedures in adult patients who are at risk are as follows:

  • Amoxicillin 2 grams orally 1 hour before procedure.

For amoxicillin/penicillin allergic patients, any of the following:

  • Clindamycin 600 mg orally 1 hour before procedure

  • Keflex 2.0 g orally 1 hour before procedure.

  • Azithromycin or clarithromycin 500 mg orally 1 hour before procedure.

Recommended SBE Prophylaxis Regimen for Pediatric Patients At Risk


The recommended standard prophylactic regimen for dental, oral or upper respiratory tract procedures in pediatric patients who are at risk are amoxicillin 50 mg/kg orally 1 hour before procedure.

For amoxicillin/penicillin allergic pediatric patients, any of the following:



  • Clindamycin 20 mg/kg orally 1 hour before procedure.

  • Keflex 50 mg/kg orally 1 hour before procedure.

  • Azithromycin or clarithromycin 15 mg/kg orally 1 hour before procedure.
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