From time to time, a physician has a patient present with certain symptoms and must determine if the situation calls for a referral to an oral or maxillofacial surgeon. The following write-ups have been developed by Dr. Pitts to assist doctors in making an informed decision about when to refer patients.
When to recommend a biopsy or evaluation of a lesion
During the course of any soft tissue examination, if a white lesion, red lesion, mass, or non-healing ulceration is discovered it should be followed up with appropriate treatment as soon as possible. The usual treatment for small lesions (less than 5 mm) is complete excisional biopsy, and submission of the lesion for pathologic evaluation. If the lesion is large, or unusual in appearance, incisional biopsy can be performed to obtain a pathologic diagnosis, and the appropriate treatment options would then be discussed with the patient.
To help distinguish between highly suspicious lesions versus lesions which are most likely benign in nature, a Toluidene Blue stain can be performed at the time of evaluation in my office. This technique is also valuable in assessing the areas which most likely represent dysplastic epithelium in a large lesion at the time of biopsy, to help obtain a specimen from the area of highest risk of dysplasia.
Options for treatment of benign lesions following incisional biopsy include close observation and follow-up, removal of precipitating factors, complete excision, or Laser ablation.
When to recommend evaluation or extraction of wisdom teeth
Wisdom teeth should almost always be recommended for removal and referred to a qualified Oral Surgeon for removal if they are symptomatic, carious, infected, periodontally involved/compromised, or impacted. Also, if any impaction is noted to have a surrounding radiolucent or radiopaque lesion, or an associated intrabony lesion of any kind, it must be removed as soon as possible and the lesion must be submitted for pathologic evaluation. Dysplastic lesions are uncommon with impacted teeth, however, aggressive benign lesions, such as an Ameloblastoma, should always be considered and must be surgically excised.
Contrary to what most people believe, wisdom teeth can be removed at almost any age after they become visible on the Panorex x-ray. Removing the impactions at an earlier age often makes the procedure less traumatic, reduces overall risk to the patient, and allows for quicker healing. Most wisdom teeth are removed between the ages of 12 and 16, and before they are fully developed, if it has been determined that there is inadequate space for them to erupt normally.
When to consider referral of implant evaluation and what to expect
Many patients present to your office with missing teeth. As you know, there are many options for replacement of missing teeth, and intraosseous titanium implants allow you to provide the highest standard of care possible for your patients. They are also very popular amongst many types of patients, and consideration of implants in a patient’s care always gives them the feeling that you are trying to provide the best care possible for them.
Any patient who is missing teeth and is considering a fixed prosthesis (single crown or bridge), or needs implants for stabilization of a removal prosthesis can be referred for an implant evaluation. A referral form should be sent with the patient or e-mailed to me explaining your goals and considerations/concerns. At the evaluation, a full clinical exam will be performed, and xrays will be taken to assess the bony anatomy. Usually, a Cone Beam CT scan is performed of the proposed implant site(s) to allow for thorough and accurate treatment planning. The patient will be informed at the consultation appointment if they are a good candidate for implants, what may be necessary to allow for proper placement of the implants and proper osseointegration of the implants, and if any other procedures, such as bone grafting or a sinus lift, will be necessary.
Following the initial implant evaluation, I will contact you to discuss the case. If needed, we can review the CT scan and other xrays or models together and discuss the best treatment options. We can also discuss your preference in type of implant to be placed, and any other special considerations, such as soft tissue or esthetic concerns. If it is decided that a surgical stent needs to be fabricated, the patient can return to your office prior to the surgery for impressions and fabrication of the stent.
The implant or implants can then be surgically placed as treatment planned. If the patient is having a single tooth replaced with an implant, a flipper can be fabricated to wear at the site until the implant is fully osseointegrated. The flipper must be adjusted prior to insertion to assure that it is not placing any pressure on the implant or adjacent soft tissue. A temporary restoration attached to the implant can be considered, but only in the best candidates (usually young, healthy patients with dense bone at the implant site and very good stability of the implant after insertion), and only if the restoration can be maintained out of occlusion and in a non-functional position. This would need to be discussed and decided upon prior to placement of the implant, so that during surgery, a temporary abutment can be placed, or the patient can be sent to your office immediately following placement of the implant for placement of the abutment and fabrication of the temporary.
Also, immediate placement of implants can be performed at the time of extraction of the teeth, if the patient meets certain criteria. Whether or not the patient is a candidate for immediate insertion of an implant must be determined prior to extraction of the tooth. Periodontal disease or infection at the extraction site are absolute contraindications to immediate implant placement.
If the patient wears a partial or denture, following about 1 or 2 weeks of soft tissue healing, the removable prosthesis can be adjusted to fit over the implant(s) and a soft reline can be placed. The removable prosthesis can be worn, as necessary, over the implant(s) until they are fully osseointegrated.
Usually, after 3 or 4 months of healing, the implant(s) are re-evaluated. If there is clinical and radiographic evidence of osseointegration, the patient will be released, and will return to your office. The implant(s) can then be restored.
Throughout this process, I am always willing to be of assistance in any way possible. The American Dental Implant Corporation also has a very strong customer service department that will assist you and your dental laboratory in choosing and obtaining the necessary components to allow for easy and proper restoration of the implant(s).