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D3 Fall OMS Final Review 2010 (Course #8240) Patterns of Horizontal Bone Loss (10/19/10) Only purpose of alveolar

lar one is !o "ol# !"e #en!i!ion o $i!"ou! alveolar one% #isuse a!rop"y o&&urs '(plan! sur)ery is ase# on an in&reasin) #ia(e!er of #rills es!a lis"e# y *rane(ar+ '((e#ia!e ,oa#in) '(plan!s o Mus! "ave a surfa&e &on#u&ive !o os!eoin!e)ra!ion (i-e- rou)"er surfa&e was foun# !o e e!!er an# s&rew s"ape o .a!ien! pressure on #o&!or !o as+ w"y !"ey "ave !o wai! so lon) o /se# !o e a rou!ine pro&e#ure 304 (on!"s for os!eoin!e)ra!ion in (an#i le 401 (on!"s for os!eoin!e)ra!ion in (a2illa (lon)er in!e)ra!ion !i(e for (a2illa) *e!!er resul!s in (an#i le (espe&ially an!erior (an#i le rela!ive !o an!erior (a2illa) Final res!ora!ion pla&e# 304 (on!"s af!er i(plan! pla&e(en! 'n!ernal an# 32!ernal roo! resorp!ion e2!ra&!ions are no! )oo# &an#i#a!es for i((e#ia!e loa# 4raf! w5 Free6e Drie# *one 7llo)raf! Resul!s #epen# on8 o 4raf! e# vas&ulari!y o Confine(en! wi!"in alveolar ar&"i!e&!ure envelope o 9u( er of ony walls surroun#in) )raf! o S!a ili!y of )raf! fro( (ove(en! o .ri(ary &losure an# "y)iene o .os!0)raf! (ana)e(en! of e#en!ulous area o Mana)e(en! of nu!ri!ion an# &o0(or i#i!ies

Grogan Impaction Lectures (10/26/10 an 11/2/10) '(pa&!ion8 a !oo!" !"a! is &o(ple!ely or par!ially unerup!e# an# posi!ione# so !"a! i! is a)ains! ano!"er !oo!"% one% or sof! !issue% so !"a! fur!"er erup!ion or fun&!ion is unli+ely Fre:uen&y of '(pa&!ion o Mos! fre:uen!8 ;"ir# (olars (Mn < M2) Cuspi#s (M2 < Mn) ,ess fre:uen!

*i&uspi#s Cen!rals% ,a!erals (se&on#ary !o (esio#ens) $"y !ee!" e&o(e i(pa&!e#= o Se:uen&e of erup!ion #is!ur an&es o 3arly loss of pri(ary #en!i!ion o C"an)in) s+ele!al pa!!erns Mo#ern (an "as a 10> #e&rease in ra(us "ei)"! 41> #e&rease in &oronoi# "ei)"! 21> in (an#i ular len)!"

11> #e&rease in si6e of #en!al ar&" ;"ir# Molar Con!roversy o Real pro le( is !"ere is no prospe&!ive s!u#ies availa le nor li+ely !o e&o(e availa le o ,a!e ?0@s an# early 80@s series of ar!i&les% non0s&ien!ifi& suppor!e# y (ana)e#0&are or)ani6a!ions (so(e (e( ers were DDS@s !"a! "a# never pra&!i&e#A !"ey were only poli&y (a+ers) 'n#i&a!e# !"a! !"ere was no reason !o re(ove i(pa&!e# !ee!" o 1B80 C 9'D Consensus Develop(en! Conferen&e for Re(oval of ;"ir# Molars o 9o &onsensus ase# on s&ien&e 77OMS

Overw"el(in) o#y of &lini&al evi#en&e s"ows !"a! pa!ien!s w5 i(pa&!e# !ee!" w"o wai! un!il sy(p!o(s !o appearEsuffer !"e ris+s of un#ue #is&o(for!% prolon)e# re&overy perio#s% in&rease# &os! of !rea!(en!% an# #an)er !o !"eir )eneral "eal!" ;i(ely re(oval of i(pa&!e# an# unerup!e# !ee!" is a vali# an# s&ien!ifi&ally soun# !rea!(en! ra!ionale F$"i!e .aperG on ;"ir# Molar Da!a (77OMS ;as+ For&e 200?) o Da!a ase# on review of li!era!ure on !"e re(oval of !"ir# (olars Ovi#% .u Me#% 4oo)le S&"olar% an# Co&"rane Da!a ase ;"e 9a!ural Dis!ory of ;"ir# Molars o Mos! si)nifi&an! varia le asso&ia!e# w5 !"ir# (olar i(pa&!ion is inadequate hard tissue space wi!" !"e vas! (aHori!y of i(pa&!e# !"ir# (olars "avin) space/crown width ratios of less than one o '! is possi le !o (easure spa&e for erup!ion !o !"e o&&lusal plane usin) a varie!y of ra#io)rap"i& !e&"ni:ues o /nerup!e# !ee!" &an &"an)e posi!ion even eyon# !"e (i##le of !"e !"ir# #e&a#e of life o *e&ause !"ere is no &o(ple!ely relia le way !o pre#i&! pa!"olo)i& &"an)es asso&ia!e# w5 i(pa&!e# !ee!"% !"e life &y&le of i(pa&!e# !ee!" s"oul# e (oni!ore# perio#i&ally w5 ra#io)rap"s o 3rup!ion !o !"e o&&lusal plane #oes no! ensure proper perio#on!al suppor!% !"a! is% a#e:ua!e osseous spa&e #oes no! )uaran!ee a#e:ua!e p"ysiolo)i& spa&e for !"e (ain!enan&e of a !oo!" in )oo# "eal!" Con&lusionE o $"ile i! is no! possi le !o pre#i&! erup!ion of !"ir# (olars in all &ases% adequate space between the anterior border of the ramus of the mandible and the distal of the mandibular second molar seems to be necessary to allow successful eruption to the occlusal plane- 7ssess(en! of !"is spa&e &an e #e!er(ine# usin) a varie!y of ra#io)rap"i& !e&"ni:ues32!ra&!ion of !"e Man#i ular ;"ir# Molars w5 3vi#en&e of 32is!in) .erio#on!al Disease o ;"e re(oval of i(pa&!e# !"ir# (olars &an ne)a!ively i(pa&! !"e perio#on!iu( an# &an ne)a!ively i(pa&! !"e perio#on!iu( of a#Ha&en! se&on# (olars- ;"e preopera!ive e2is!en&e of an intrabony defect, age of the patient, and level of plaque control (ay serve !o pre#i&! a#verse ou!&o(es Does Flap Desi)n an# 32!ra&!ion ;e&"ni:ue 'nfluen&e ,on)0!er( .erio#on!al 'ssues= o 9o sin)le sur)i&al approa&" !o !"e re(oval of !"ir# (olars !"a! will (ini(i6e loss of perio#on!al a!!a&"(en! was i#en!ifie# o 4ui#e# ;issue Re)enera!ion (4;R) an# 5or De(inerali6e# *one .ow#er (D*.) (ay e enefi&ial in ins!an&es w"ere !"ere is evi#en&e of si)nifi&an! pre0e2is!in) a!!a&"(en! loss o S&alin)% roo! plannin)% an# pla:ue &on!rol "ave !"e po!en!ial !o re#u&e pos!0opera!ive loss of a!!a&"(en! o Fur!"er resear&" is nee#e# !o &larify un#er w"a! &on#i!ions 4;R an#5or D*. &an &on!ri u!e !o

(ini(i6in) pos!0opera!ive perio#on!al #efe&!s3ffe&! of 7)e on 32is!in) ;"ir# Molars o .erio#on!al #efe&!s% as assesse# y po&+e! #ep!"s% #e!eriora!e w5 in&reasin) a)e in !"e presen&e of re!aine# !"ir# (olars o Caries in erup!e# !"ir# (olars in&reases in prevalen&e w5 in&reasin) a)eo ;"e in&i#en&e of pos!opera!ive (or i#i!y followin) !"ir# (olar re(oval is "i)"er in pa!ien!s <21 years o 4er(e&!o(y (ay e asso&ia!e# w5 a lower in&i#en&e of pos!opera!ive (or i#i!y Or!"o#on!i& Consi#era!ion for Re(oval of ;"ir# Molars o Despi!e )oo# in!en!ions% we are no! a le !o e2plain% pre#i&!% or preven! #en!al &row#in)% no (a!!er w"a! !"e &ause o $"ile i! is li+ely !"a! !"ir# (olars play a role in !"e e!iolo)y of &row#in)% !"ey are only one fa&!or !o &onsi#er in (a+in) a &lini&al #e&ision a ou! !"ir# (olar (ana)e(en!o Ew"ile !"ir# (olars (ay play a si)nifi&an! role in so(e pa!ien!s% !"e &urren! s!a!e of +nowle#)e #oes no! allow us !o i#en!ify wi!" a&&ura&y w"o is a! ris+ .ros!"o#on!i& Consi#era!ions an# !"e Re(oval of ;"ir# Molars o ;"e na!ural &ourse of an asy(p!o(a!i& !"ir# (olar is un&er!ain% wi!" &"an)e in posi!ion or erup!ion repor!e# even w5 a#van&in) a)e o ;"e po!en!ial for !"e #evelop(en! of pa!"olo)y asso&ia!e# w5 i(pa&!e# !ee!" is well #o&u(en!e# o 9o! all asy(p!o(a!i& i(pa&!e# !ee!" un#er re(ova le pros!"esis will #evelop pa!"olo)y if lef! in pla&e o ;"ere is in&rease# #iffi&ul!y an# ris+ of &o(pli&a!ions asso&ia!e# w5 re(oval of i(pa&!e# !ee!" if #eferre# un!il la!er in life o *e&ause !"ere is no relia le way !o pre#i&! pa!"olo)i& &"an)es asso&ia!e# w5 i(pa&!e# !ee!"% !"ey s"oul# e (oni!ore# wi!" perio#i& &lini&al an# ra#io)rap"i& e2a(ina!ion Iali# 'n#i&a!ions for ;"ir# Molar Re(oval o .ar!ial erup!ion C peri&oroni!is o Malpose# w5 early folli&le &"an)es o Caries o .erio#on!al en#an)er(en! of 2n# (olars o 'nfe&!ions or "is!ory of infe&!ions o Supererup!e#% (alposi!ione#% (alo&&lu#e# o .reven!ion of spor!s inHuries o Or!"o5.ros!" ;rea!(en! plans o .reirra#ia!ion% pre!ransplan!% an# i((unosuppresse# o ;oo!" in line of fra&!ure 'nvali# Reasons for ;"ir# Molar Re(oval o Causin) or!"o#on!i& !rea!(en! !o relapse Mul!iple ar!i&les on o!" si#es of !"e issue% u! !"e ar!i&les w5 !"e es! s&ien!ifi& evi#en&e s"ow no i(pa&! on or!"o relapse Si!ua!ions !"a! &all for .ru#en! Ju#)(en! o Re(oval of M2 3r# (olars in pa!ien!s K 14 years ol# o Re(oval of 3r# (olars in pa!ien!s < 10 years o Re(oval of 3r# (olars in asso&ia!ion w5 lar)e &ys!s or o!"er pa!"olo)i& lesions Refer

o o

Re(oval of 2n# (olars !o allow 3r# (olars !o erup! Re(oval of 3r# (olars in presen&e of a&u!e infe&!ions

De a!a le o Re(oval in i((unosuppresse# or (e#i&ally &o(pro(ise# pa!ien!s o Re(oval of 3r#s in e2!re(e ana!o(i& lo&a!ions Classifi&a!ion Sys!e(s of '(pa&!e# ;ee!" o ;o #e!er(ine !"e #e)ree of #iffi&ul!y preopera!ively o Ra#io)rap"i& analysis De)ree of #iffi&ul!y is pri(arily #e!er(ine# y a&&essi ili!y 3ase of e2posure *one re(oval (avoi#in) a#Ha&en! #en!i!ion)

De!er(inin) pa!"way for #elivery Me&"ani&al a#van!a)e (pur&"ase poin!s) *asis of Classifi&a!ion Sys!e( Rela!ions"ip !o an!erior or#er of ra(us Rela!ions"ip !o o&&lusal plane 7n)ula!ion Roo! Morp"olo)y Si6e of folli&ular sa& Rela!ions"ip !o '7 n Densi!y of surroun#in) one Rela!ions"ip !o 2n# (olar .ell an# 4re)ory Sys!e( *ase# on !"e a(oun! of (an#i ular !"ir# (olar !"a! is &overe# y !"e one of !"e (an#i ular ra(us ;oo!" !o an!erior or#er of ra(us Ier!i&al posi!ion in rela!ion !o !"e a#Ha&en! !ee!" Rela!ions"ip !o o&&lusal plane 7n)ula!ion Mesioan)ular Dis!oan)ular Ier!i&al Dori6on!al ' Crown &o(ple!ely an!erior !o !"e an!erior or#er !o !"e (an#i ular ra(us 7ppro2i(a!ely one0"alf of !"e &rown is &overe# y !"e ra(us ;oo!" is &o(ple!ely lo&a!e# wi!"in !"e ra(us O&&lusal surfa&e level or nearly level w5 !"e o&&lusal plane of !"e 2n# (olar O&&lusal surfa&e e!ween !"e o&&lusal surfa&e an# C3J of 2n# (olar O&&lusal surfa&e elow !"e C3J of 2n# (olar

Rela!ions"ip !o 7n!erior *or#er of Ra(us

'' ''' 7

Rela!ions"ip !o !"e O&&lusal .lane

* C

Less !ifficult "actors Mesioan)ular Class ' ra(us Class 7 #ep!" Roo!s 153 !o 253 for(e# Fuse# &oni&al roo!s $i#e .D, ,ar)e folli&le 3las!i& one Separa!e# fro( 2n# (olar Separa!e# fro( '7 n Sof! ;issue '(pa&!ion $left Lip an Palate (11/9/10 an 11/16/10)

#ore !ifficult "actors Dis!oan)ular Class ''' ra(us Class C #ep!" ,on)% !"in roo!s Diver)en! &urve# roo!s 9arrow .D, ;"in folli&le Dense% inelas!i& one Con!a&! w5 2n# (olar &lose !o '7 nCo(ple!e ony i(pa&!ion

Di)" Liel# Fa&!s o Clef! lip an# pala!e affe&!s 18?00 live ir!"s o IL .us" a&+ fi2es !"e pala!e o ,ip is fi2e# a! 10 wee+s or 10 l s or 10 )5#, D (Rule of 10 C any of !"e 3 &an apply !o #o sur)ery) o ,ip is fi2e# firs!% followe# y !"e pala!e% followe# y !"e alveolar &res! 3( ryolo)y o %&'( )H* PI$)+,*- '" .LL )H* -).G*- '& )H* -LI!*- .&! B* .BL* )' I!*&)I"/ 0*,/ (*LL111 o Du(an e( ryo "as 1 pairs of p"aryn)eal ar&"es w"i&" are &o(pose# of Mus&le &o(ponen!s Car!ila)e &o(ponen!s Cranial nerves 7r!eries s! 1 7r&" (Ma2illo0Man#i ular) C9 I (;ri)e(inal) Ma2illary pro&ess Mus&les of Mas!i&a!ion% an!erior #i)as!ri&s% (ylo"yoi#% !ensor veli pali!ini% !ensor !y(pani Me&+el@s Car!ila)e ( e&o(es sp"eno(an#i ular li)a(en!)% in&us% an# (alleus Clef! ,ip an# .ala!e is pri(arily #ue !o pro le(s of 1s! ar&"MMM n# 2 7r&" (Dyoi# 7r&") C9 I'' (Fa&ial) Mus&les of fa&ial e2pression% pos!erior elly of #i)as!ri&s% s!ape#ius% an# s!ylo"yoi# Rei&"ar!@s Car!ila)e (s!yloi# pro&ess of !e(poral one)% lesser "orn of !"e "yoi# one an# por!ion of !"e "yoi# o#y% s!apes S!yloi# pro&ess of !"e &raniu( an# s!ylo"yoi# li)a(en! 7uri&ular ((r# 3 7r&" (pro#u&es s!ylop"aryn)eus (-) C9 'N (4lossop"aryn)eal) 4rea!er "orn of "yoi# one 'nferior par! of "yoi# one

's !"e &o((on &aro!i# an# roo!s of !"e 'n!ernal Caro!i# aa4 7r&"
!"

C9 N (Ia)us) Mus&les of !"e laryn2 an# lower p"aryn2 (inferior &ons!ri&!ors)% &ri&o!"yroi#% leva!or veli pala!ine ,aryn)eal Car!ila)es% !"yroi# &ar!ila)e Right su &lavian a- an# !"e ar&" of !"e aor!a

1!" $ee+ o ;wo fas! )rowin) ri#)es8 la!eral an# (e#ial nasal swellin)s ,a!eral for( alae of nose Me#ial for(8 (i##le par! of nose% (i##le upper lip% (i##le of (a2illa% an# en!ire pri(ary pala!e

O!" $ee+ o Si(ul!aneously !"e Ma2illary swellin)s will approa&" !"e (e#ial an# la!eral nasal swellin)s% u! re(ain separa!e# fro( !"e( y well (ar+e# )rooveso .ala!ine s"elves appear in !"e O!" wee+ an# are #ire&!e# o li:uely #ownwar# on ei!"er si#e of !"e !on)ue !" ? $ee+ o Ma2illary swellin)s &on!inue !o )row in a (e#ial #ire&!ion an# &o(press !"e (e#ial nasal swellin)s !owar# !"e (i#line- Su se:uen!ly !"ese swellin)s si(ul!aneously (er)e wi!" ea&" o!"er an# wi!" !"e Ma2illary swellin)s la!erally- ;"e upper lip is for(e# y !"e !wo (e#ial nasal swellin)s an# !"e !wo (a2illary swellin)s y !"e 10!" wee+ "ailure of fusion of t2e lateral an me ial nasal s3ellings uring 4t2 3ee5 is 32at causes cleft lip an palate111 o ;"e pala!ine s"elves as&en# !o a!!ain a "ori6on!al posi!ion a ove !"e !on)ue an# fuse w5 ea&" o!"er for(in) !"e se&on#ary pala!e ;"e pri(ary pala!e for(s as a s"elf% )rowin) pos!eriorly fro( !"e in!er(a2illary pro&ess !o for( !"e floor of !"e pri(i!ive nasal &avi!y ;"e an!erior por!ion of !"e se&on#ary pala!e ossifies !o for( !"e "ar# pala!e 10!" wee+ o $"ole pala!e is fuse# .ala!e o .ri(ary .ala!e (.re(a2illa) Superior ,ip 7lveolar one Dar# pala!e (an!erior !o fora(en) Se&on#ary .ala!e Dar# pala!e (pos!erior !o fora(en) Sof! pala!e .ri(ary .ala!e Clef! 2n# (on!" of )es!a!ion Failure of (eso#er( !o pene!ra!e in!o )rooves 5w !"e (e#ial nasal an# (a2illary pro&esses w"i&" pro"i i!s !"eir (er)in) w5 one ano!"er Se&on#ary .ala!e Clef! 3r# (on!" of )es!a!ion Failure of !"e pala!ine s"elves !o fuse w5 one ano!"er

Clef! ,ip an# .ala!e O&&urren&e o Di)"er in Japanese o /nila!eral is (ore &o((on !"an ila!eral an# (ore #iffi&ul! !o fi2 o More &o((on in (ales o More &o((on on lef! si#e o 'sola!e# &lef! on pala!e is )rea!er in fe(ales 3!iolo)y o 4ene!i&s < 40> C,. an# < 20> C. o .osi!ion of !on)ue% environ(en!al fa&!ors% &i)are!!es% #ru)s% vi!a(ins% al&o"ol% viral infe&!ions% &or!i&os!eroi#s% e!&Classifi&a!ion o /nila!eral5*ila!eral 'n&o(ple!e5Co(ple!e Repair o Rule of 10 o Lip 7S7. (10 wee+s) o -oft palate6 a! 8018 (on!"s !o pro#u&e velop"aryn)eal (e&"anis( w"en or efore spee&" s+ills are #evelopin) o Har palate8 no! un!il all of !"e #e&i#uous #en!i!ion "as erup!e# e&ause a si)nifi&an! por!ion of (a2illary )row!" "as alrea#y o&&urre# y 401 years o Or#er of sur)ery for a 0/ Pus27ac5 for pala!e (Pnow !"e se:uen&e)

1- Close nasal (u&osa 2- Close (us&les 3- Close (u&osa of pala!e Principles of Biops8 (11/90/10 an 12/4/10) Many #iseases5lesions loo+ &lini&ally si(ilar *iopsy8 !"e re(oval of sa(ple !issue for !"e purpose of #ia)nosis o 'n&isional o 32&isional $"y *iopsy= o Confir( eni)ni!y or (ali)nan&y of suspi&ious lesions o Confir( a #ia)nosis e!ween 2 si(ilar lesions o De!er(ine &lear (ar)ins o Me#i&ole)al #o&u(en!a!ion ;"e Clini&ian@s Dile((a o ;"ere are (any oral a nor(ali!ies o Mos! are eni)n% u! (any are no! o Clini&al inspe&!ion &anno! #ifferen!ia!e e!ween eni)n an# (ali)nan! &an&erous an# pre&an&erous lesions o .ra&!i!ioners are of!en relu&!an! !o su (i! pa!ien!s !o s&alpel iopsy% relu&!an! !o a#(i! !"ey #o no! +now% an# relu&!an! !o refer !o so(eone else o On !"e o!"er "an#E o '! is illo)i&al !o &on!inue wa!&"in) a lesion pro)ressively )e! lar)er an# lar)er w"ile no! re&o((en#in) #efini!ive #ia)nos!i& an# !rea!(en! s!eps !o !"e pa!ien!o '! is &ri!i&al !o !"e pa!ien!@s survival &"an&es !"a! (ali)nan! lesions are #e!e&!e# an# (ana)e# 7S7.M

.re0*iopsy Moni!orin) o /n#ia)nose# lesions s"oul# e o serve# for ?014 #ays% !"en iopsie# o ,esions wi!" #ysplasia s"oul# e a la!e#% no! o serve# o 'f no! iopsie#% pa!ien!s (us! e fully infor(e# of !"e ris+s 7ssure .roper Follow0up o Ma+e appoin!(en!s for follow0up evalua!ion o 'f lesion s!ill presen! an#5or lar)er appoin! or refer for iopsy o 4e! a##i!ional pi&!ures% ra#io)rap"s as in#i&a!e# a! follow0up visi!s o Consi#er wri!!en pro!o&ol (pla&e a &opy in pa!ien!@s &"ar!) ;"orou)" Do&u(en!a!ion o Measure% s+e!&"% an# re&or#MM o ,a!er you won@! re(e( er o /se a! leas! 2 #i(ensions o ."o!os o .i&!ures wi!" la els 3le(en!s of 3ffe&!ive Do&u(en!a!ion o 7nno!a!e# "eal!" "is!ory (!o a&&o5al&o"ol) o De!aile# ini!ial e2a( no!es o Dia)nos!i& !es! resul!s o S+e!&"% p"o!o% (easure(en!s of lesion o Differen!ial i(pression #2 o 9o!es on #is&ussion wi!" p! o De!ails of plans for follow0up o Re&or# of any se&on# opinion p"one &alls o Su se:uen! pro le(s o Se&on# opinion re:ues!s5referrals in wri!in) o 7u2iliary en!ries s"oul# e si)ne# y !"e( *iopsy or Refer= o Do you "ave !"e !rainin)5e2perien&e= o 's !"ere &ri!i&al ana!o(y involve#= o Do you "ave !"e ins!ru(en!s= o Do you reasona ly feel i! is eni)n= o Do you "ave arran)e(en!s wi!" an oral pa!"olo)is!= o Do you "ave spe&i(en &on!ainers% e!&-= *enefi!s (us! ou!wei)" !"e ris+s ;"e ;ene!s of .roper Referral o 9o! #is&usse# in (os! pa!"olo)y oo+s o 'f i! isn@! in wri!in)% i! #i#n@! "appen o Don@! e afrai# !o see+ se&on# opinion if unsure o 7ny!"in) !"a! #oesn@! )o away in an e2pe&!e# perio# of !i(e s"oul# &ause &on&ern o Don@!@ follow lesions in#efini!ely% espe&ially if !"ey enlar)e% e&o(e fi2e#% e!&.a!"olo)y Referrals o 7rran)e !"e appoin!(en! now (unless pa!ien! o He&!s) o Don@! Hus! )ive a lis! of spe&ialis!s C #is&uss an# arran)e o 'nsis! on )oo# #o&!or0!o0#o&!or &o((uni&a!ion

Follow0up all appoin!(en!s wi!" le!!er5fa25e0(ail

.u! &opy in pa!ien! &"ar! o Ma+e sure referral sur)eons un#ers!an# you e2pe&! a repor! a&+ !"a! you will pla&e in !"e pa!ien!@s &"ar! o 'f repor! #oesn@! &o(e a&+% &"e&+ i! ou!M o Co((on sense #oesn@! o&&ur &o((onlyM o $"en you refer% you #on@! relin:uis" &on!rol C you are s!ill !"e )a!eway DDS 'n#i&a!ions for *iopsy o 7ny persis!en! pa!"olo)i&al &on#i!ion !"a! &an@! e #ia)nose# &lini&ally 3nlar)in) in!ra ony lesions 7ny lesion wi!" no i#en!ifia le e!iolo)y% !"a! persis!s for 10014 #ays or (ore% #espi!e !ypi&al lo&al !"erapy ;o &onfir( &lini&al #ia)nos!i& suspi&ions ;o #efini!ely i#en!ify lesions !"a! are a &on&ern !o !"e pa!ien! 7ny lesion wi!" (ali)nan! or pre0(ali)nan! &"ara&!eris!i&s% in&lu#in)8

o o o

Rapi#ly )rowin) lesions Re#5w"i!e5pi)(en!e# lesions or &o( ina!ions of sa(e 7ny lesion asso&ia!e# wi!" "ar#ene#% fi2e#% or enlar)e# ly(p" no#es 7ny un+nown lesion in "i)" ris+ area (la!eral !on)ue% "ar#5sof! pala!e) o *e suspi&iousEw"en in #ou ! C !a+e i! ou!M So(e .rin&iples o *iopsies are no! foolproof .a!"olo)is!s &an only rea# w"a! you sen# in $"en in #ou ! C #o i! a)ainM Dile((a8 s"oul# all !issues e su (i!!e#=

7&a#e(i&ally8 yes Clini&ally5pra&!i&ally8 no! ne&essarily o *iopsy !"e perip"ery% no! !"e &en!erM o Consi#er iopsyin) fro( (ore !"an one area w"en #ealin) wi!" lar)er lesions *iopsy 7voi#sMMM o Cri!i&al ana!o(y areas o Cen!ral areas of ne&rosis o .i)(en!e# lesions o Mis"an#lin) spe&i(ens o ;a+in) ina#e:ua!e sa(ple ;ypes o 32folia!ive Cy!olo)y *rus" For (ass s&reenin)s% for lesions wi!" a low in#e2 of suspi&ion 9o! as relia le as a iopsy in +era!ini6e# !issue 9o! a su s!i!u!e for iopsy ;"e a&!ion is a! !"e ase(en! (e( rane Cy!olo)y !e&"s no! e2perien&e# wi!" oral pa!"olo)y $"a! a ou! !"e new oral CDN +i!s= Only surfa&e &ells are &ap!ure# S&reenin) !ool for oral &an&er

o o

32folia!ive &y!olo)y no! all !"a! useful e&ause un#erlyin) &ells are no! &ap!ure# *rus" iopsy allows for !ransepi!"elial &ap!ure *rus" is ro!a!e# over !"e suspe&!e# area un!il sli)"! lee#in) o&&urs *lee#in) ensures &ap!ure of ase(en! (e( rane /seful only as a s&reenin) !ool Cos! effe&!ive *roa# s&ope% li!!le sur)i&al s+ill re:uire# in !e&"ni:ue 'f a!ypi&al &ells are foun#% in&isional iopsy follow up is ne&essary Oral CDN +i!s Pi! in&lu#es8 s!erile rus"% )lass sli#es% fi2a!ive% (ailin) o2% paperwor+ ;e&"ni:ue o 1) .la&e !opi&al o 2) Mois!en rus" wi!" wa!er5saliva o 3) .la&e rus" on lesion o 4) Ro!a!e rus" on lesion o 1) S(ear rus" on sli#eA fi2a!ive o O) Sen# !o &o(pany ;"e Repor! o 9e)a!ive8 no a nor(ali!ies no!e#A follow &lini&ally o .osi!ive8 #efini!ive &ellular evi#en&e of epi!"elial #ysplasia or &an&er presen!A refer or iopsy o 7!ypi&al8 a nor(al &"an)es presen! (pre0&an&erous or infla((a!ory) (i-eli&"en planusA refer or iopsy) o 'na#e:ua!e Sa(ple8 #en!is! nee#s !o re#o pro&e#ure (an# you ea! !"e &os!) .ros an# Cons of Oral CDN o 1011> of pa!ien!s e2a(ine# (ay "ave suspi&ious lesions o Solves !"e #ile((a wi!" !"ese lesions8 wa!&" or iopsy= o May en&oura)e fur!"er #ia)nos!i& s!eps y relu&!an! DDSs o 'n s!u#y of B41 pa!ien!s% !e&"ni:ue &orre&!ly i#en!ifie# 100> of &an&erous lesionsA foun# unsuspe&!e# &an&er in 4-1> of Finno&en!G lesions o Suspi&ious lesions in "i)" ris+ areas s!ill nee# !o e iopsie# o ;"e &os! is "i)" o 'nsuran&e won@! pay #ia)nos!i& pro&e#ures !wi&e o S!ill possi le !o (iss areas of (ali)nan&y o ;"e rus" a rasion &oul# e (ore painful !"an su!ure# in&ision 'n&isional8 re(oval of a por!ion or sa(ple of !issue 32&isional8 re(oval of !"e en!ire lesion 'f !"e #ifferen!ial #ia)nosis in&lu#es as !"e four (os! realis!i& possi ili!ies% lesions !"a! are &ura le y re(oval s"oul# e e2&ise# (Mar2) Marsupiali6a!ion For lar)e &ys!s espe&ially ranula Cys! linin) su!ure# !o oral (u&osa w"i&" &rea!es per(anen! #e&o(pression pa!" On&e &ys! is s(aller% #e&ision &an e (a#e a ou! iopsy Disa#van!a)e8 i((e#ia!e iopsy is no! #one 7spira!ion5.un&"59ee#le

Fro6en /se# #urin) sur)ery !o assess (ar)ins of rese&!e# !issue Can e use# !o &onfir( a suspe&!e# #ia)nosis or rela!e !o !"e sur)eon !"e !ype of !issue (i-e- nerve vs- s&ar) Fro6en se&!ions (ay e o !aine# fro( one u! #e&al&ifi&a!ion (us! e #one prior !o pro&essin) Mos! oney !u(ors a#van&e !"rou)" !"e (arrow &avi!y ra!"er !"an !"e &or!e2% !"erefore !"is area is (os! useful for iopsy Cure!!a)e is )enerally a#e:ua!e% no #e&al&ifi&a!ion is re:uire# .ro&essin) .araffin lo&+ Fi2a!ive% usually 10> for(alin% lar)e se&!ions s"oul# e se&!ione# in 0-1 &( in&re(en!s Spe&i(en prepare# !"rou)" #e)ra#e# al&o"ols (?0> !o a solu!e) !o #e"y#ra!e 7f!er 24 "r pro&essin) in 7u!o0!e&"ni&ian% (i&ro!o(e se&!ions paraffin !o 10O (i&ro(e!ers S!ainin) wi!" "e(a!o2ylin ( asop"ili& i-e- D97) an# eosin (a&i#op"ili& i-e&olla)en% (us&le% an# nerve) DQ3 are a:ueous% paraffin in !issues (us! e re(ove# Nylene an# al&o"ols Dar# !issues #one in a si(ilar (anner u! DCl #e&al&ifi&a!ion is ne&essary af!er fi2a!ion Dis!olo)i& 'n!erpre!a!ion .ri(ary (e!"o# of in!erpre!a!ion is DQ3 s!ainin) wi!" li)"! (i&ros&ope 7llows for 'D of &ells y pa!!ern% su s!an&e pro#u&e# an# s"ape an# si6e ,ow power R pa!!ern (i-e- s!ra!ifie# s:ua(ous epi!"eliu() Di)" power R &ell (orp"olo)y '((unofluores&en&e /seful #ia)nos!i& !ool in i((une ase# #iseases (vesi&ulo ul ous) Dire&! '((unofluores&en&e8 perilesional !issue is e2&ise# an# in&u a!e# wi!" fluores&en! la ele# an!i o#ies a)ains! "u(an i((uno)lo ulins% &o(ple(en!% an# fi rin Fi2a!ive8 Mi&"ael@s 90e!"yl (ale(i#e an# M)SO4 in a &i!ra!e uffer 7n!i o#ies usually &o(e fro( ra i!s !"a! "ave een i((uni6e# wi!" i((uno)lo ulins !a+en fro( "u(an (yelo(as Dire&! is (ore sensi!ive !"an in#ire&! 'n#ire&!8 presen&e an# &on&en!ra!ion of &ir&ula!in) an!i o#ies wi!"in !"e pa!ien!@s seru( are assaye# Seru( is in&u a!e# wi!" a !issue su s!ra!e fro( ano!"er spe&ies Of!en "u(an lip or (on+ey esop"a)us is &"osen% an!i o#ies fro( !"e pa!ien!s seru( !"a! !ar)e! spe&ifi& an!i)ens in !"e su s!ra!e will in# 9e2! s!ep is !o a## fluores&en! la ele# an!i0"u(an i((uno)lo ulin so !"e oun# )lo ulin &an e seen un#er !"e (i&ros&ope /seful in #iseases li+e pe(p"i)us Mis!a+es Sa(ple nee#s !o e sen! in Mi&"ael@s (e#iu( Dalf life of Mi&"ael@s is s"or!% i((une ase# #iseases no! as &o((on% (any

sur)eons sen# sa(ples in for(alin ins!ea# Re0appoin! pa!ien! an# &all pa!" la !o "ave !"e( supply you wi!" Mi&"ael@s for proper s!u#y

o F97 Mis!a+es o $"en !a+in) sa(ples fro( areas wi!" !"in (u&osa li+e FOM% sa(ple will s"rin+ an# roll up on i!self (a+in) i! "ar# !o orien!- ;a+e !issue sa(ple an# pla&e on &ar# oar# (fro( su!ure &on!ainer) for 1 (inu!es !"en pla&e in fi2!ure o 'na#e:ua!e sa(ple si6e o 'n&isin) lesion an# sen#in) a se&!ion fro( !"e (i##le an# !"en su!urin) ;"is s"ows pa!"olo)is! only !"e !u(or o Sen# sa(ple wi!" nor(al !issue in !"e sa(ple ((isse# !"e lesion) o Desi&&a!ion wi!" ele&!ro0sur)ery or laser o Crus" inHuries Di)" Ris+ ,o&a!ions o Lateral 7ase of tongue (90:) o "loor of mout2 (29:) o 'rop2ar8n; (24:) o 4in)iva (8>) o *u&&al (u&osa (1>) o ,ips (4>) o .ala!e (3>) $ays you &an (ess up a spe&i(enE o ,os! spe&i(en o '(proper (ailin) o Free6in) ar!ifa&!s o 'nsuffi&ien! wri!!en infor(a!ion Dan#lin) (ul!iple spe&i(ens5si!es o ;"e use of 75*5C spe&i(ens an# o!!les o ;"e use of su!ure !a)s S!a)es of .a!"olo)y $or+up o 1) ;"e Dis!ory o o o 4eneral survey% vi!als% "is!ory !a+in) 2) ;"e Clini&al 32a( Sys!e(a!i& DQ9 e2a( (#o i! !"e sa(e way every !i(eM) 3) ,a S!u#ies5N0rays 4) Clini&al '(pression Dia)nosis

;en!a!ive #ifferen!ial Co((on !"in)s o&&ur &o((only /se an oral pa!"olo)is! if possi le o 1) Dis!opa!"olo)i& Dia)nosis 'n!ra ony *iopsies o 'n&isional iopsy (soli# !u(ors) o 3nu&lea!ion (&ys!i& lesions) Re#5$"i!e Mi2e# ,esions o *ewareM .o!en!ially worse !"an w"i!eM

o 40O> or (ore &an e (ali)nan! or pre0&an&erousA "i)"er in s(o+ers5#rin+ers o Re# lesions a! "i)" ris+ C up !o 30> &oul# !ransfor( !o &an&er o Mos! of !"ese lesions are seen in (ales (M8F 281) ol#er !"an 11 years ol# .i)(en!e# ,esions re:uire wide (ar)ins on e2&ision