A Biopsy-ing We Will Go

Back to Dr W's office for the biopsy. Basically the plan is to drill into the bone and remove, as much as possible, the lesion and then send that material off to the pathologist to find out what it is. If it is a simple cyst, scraping it out is all that would be needed to get rid of the issue. If it is something more significant, more surgery might be needed. My vote is for the simple cyst.

I was given the choice of local anesthetic injection alone, with laughing gas, or IV sedation. I've never had a problem with dental work so I chose injection with the gas as a backup.  First, however are the photos. Dr. W is definitely old school on this. Lot's of photos both before, during and after. All photos both inside and outside looked normal for my age. No overt sign of my little friend.

Right

Left

View from the inside. The asterisk is where the lesion is.

 Next the numbing. I guess is was about 4-5 injections. Pretty quickly my entire right jaw, lip and chin were completely numb. A rubbery bumper goes in between the left molars to block my mouth open and a gauze sponge over my tongue. "All set?" Yep. Incision time...not feeling at all. Dr. W cut along the teeth at the gum line on the inside of my mouth. Cut. Suck. Cut. Suck. Peel the gum tissue off of the bone down to the floor of my mouth. I can't feel a thing.

The gum line is peeled down. This photo is reversed because he used a mirror to take it.

"So do you remember Dr. X during residency? Let me tell you a story..." Dr. W is very efficient with motion and can keep up both surgical progress and a steady flow of stories about people and experiences we both knew. It brings me back to a great time of life and keeps my mind off of what he is doing.

Now for the drill. Since the lesion is fully contained in the bone (...which is good thing. Lesions that erode through the bone into the soft tissue often require more extensive treatment.) he has to drill through the bone to get to it. From the panorex and CT scan he knows that it is centered at the roots of #28. Drill, drill, suck, suck, drill, drill. "There it is". More drilling. No pain, my nerves are ok too.

A view of the lesion. It is solid tissue, not a cyst. That needs to come out.

"It's a solid tumor rather than a cyst." The next step is to get that tissue out by picking and scraping (called currettage) in order to get as much of it out as possible. If this ends up being a minor issue, currettage will be the cure. The hole will fill in with bone fairly rapidly. If it is a more sinister problem, it will need further work. Dr. W is very careful not to scrape or pick at the roots of the teeth to protect each individual nerve.

The empty cavity

The tissue came out easily and according to Dr. W, it looked benign to the naked eye. Scrape, pick again until the cavity was empty of all the tissue he could see.

Irrigation (saline) was used to clear it out and the hole was stuffed with gelfoam (a collagen sponge that helps things clot). The gum tissue was then sutured back together. This was actually a really cool part from my surgeons eye. The suture weaved around the teeth and slings the gum back where it came from. From the outside, I couldn't tell anything had been done.

My little friend in the flesh

All back together after suturing

"The pathology will go to Louisville. They are the best at this type of stuff. They can take a while to get a result, so I'll call you with the results. See you in a week. Oh, and if you feel like it, grab a Werther's candy on the way out. They are really good."

Immediately after, I felt great...other than the big wound on my lip from biting it because it was numb. Unfortunately, the long acting local anesthetic did not last as long as expected. I was feeling great for about 3 hours, then the floor of my mouth REALLY started to hurt.

Clearly swelling from the hematoma in the soft tissues and the biopsy site was causing pain. I thought I would get by with ibuprophen, but I was glad he gave me the hydrocodone.

Jargon Alert:
hematoma /he·ma·to·ma/ (he″mah-to´mah) a localized collection of extravasated blood, usually clotted, in an organ, space, or tissue.

After a couple of days, however, my pain was well controlled with ibuprofen. The hardest part was avoiding that gum when I ate or brushed my teeth. After about 5 days, the sutures started coming apart (as they are supposed to) and I kept spitting out pieces of fishing line. Fun.

My follow-up in a week showed that my incision was healed and all looked good. The remaining sutures were removed. It's amazing how big such a small suture feels inside the mouth. True to form, the pathologists had not finished their report. "I'll call you just as soon as I know something" Dr. W says. "Grab a Werther's. Not the same family but they are really good."

And so we wait....



Research, Research, Research

Like any good doctor, I have an insatiable curiosity regarding health issues, diseases, pathology and treatments. Medicine is often like a puzzle. First find the pieces, then see where they fit. Sometimes we have to try one thing to see if it works. If it does...great. If not, we look to something else. Art based on science rather than the reverse.

Ok, I have a lytic lesion in my jaw. What could it be? Infection? Cancer? A cyst? Some sort of benign neoplasm? A space alien or retained twin? News of the weird, here I come.

Jargon Alert:
neoplasm /neo·plasm/ (ne´o-plazm) tumor; any new and abnormal growth, specifically one in which cell multiplication is uncontrolled and progressive. Neoplasms may be benign or malignant.

Orthopaedic Surgery is the study and care of maladies of the skeleton and musculoligamentous structures. The bones and the soft stuff attached to the bones is my baliwick...that is EXCEPT when it comes to bones of the skull, face or jaw. This is the realm of the Oral Surgeon, the Maxillofacial Surgeon, the Plastic Surgeon, or the Otolaryngologist. The teeth, in particular are interesting structures stemming from very specialized cells found nowhere else in the body. Special cells mean special problems. We DID NOT learn about odontogenic tumors and the like in medical school or residency. I get to learn something new.

When a doctor or scientist is looking for information about a problem, we must first narrow down the possibilities of what the issue might be because the world of medical problems is huge. When it comes to tumors/lesions etc. any clues to it's behavior is helpful. Where is it? What does it look like? How is it acting? In my case, the first step in making a diagnosis was to identify the lesion. Where it is and what it looks like are important in narrowing down the possibilities. What the lesion is doing to the bone is very important when trying to decide if it is bad (malignant) or not so bad (benign). In this case the smooth oval look on the panorex and x-rays suggest that this is likely a benign process.

Next we have to look at what possible causes of a lytic lesion in the jaw is. My job began with Google. Searching "Lytic Lesion Mandible"gave me 107,000 results. For medical conditions I first look for medical journal references, online journals and case reports. Peer reviewed journals are best for the quality of studies and reports, but may be over the head of most lay people. I stay away from (at least at first) forums, blogs, aggregators and the like. There is a lot of garbage or recycled information out there. Forums and blogs have their place, but not for collecting accurate information. Wikipedia is a good start BUT always be leery of the accuracy of the information.

Jargon Alert:
odontogenic /odon·to·gen·ic/ (-jen´ik) 1. forming teeth. 2. arising in tissues that give origin to the teeth.

Since my lesion has the appearance of a cyst (a hole in my jaw), is in the mandible/jaw, and is near my teeth, we can narrow down the focus when it comes to searching for information.

I found these two journal articles helpful in reviewing from a radiographic point of view, what the possibilities are:

 Cystic and Cystic-Appearing Lesions of the Mandible: Review

Imaging Characteristics of Benign, Malignant and Infectious Jaw Lesions: A Pictorial Review 

These references speak more to the actual pathology of the various lesions:

 

Odontogenic Tumors: The Short Version

Clinical Pathology: Odontogenic and Non-Odontogenic Tumors of the Jaws

And then this page, which is essentially a Wikipedia like site for Radiologists:

Radiopedia.org - Mandibular Lesions

Ok, there are few malignant tumors of the jaw. Good. There are a lot of cysts, and other issues that are essentially minor problems. Excellent. There are a few bad actors both in the benign and the malignant world that we must look out for. Yep, there's always a catch.

With a good couple of steps towards understanding the lay of the land, so to speak, (The x-rays, the Panorex, the CT, and a review of the possible causes) there really is only one step left...BIOPSY. We need to get a sample of my little friend to send to the pathologist. They will cut it, stain it, and look at it under the microscope in order to determine the origin and it's identity. The pathologist is the CSI of neoplasm care.

Let's go get a biopsy.

Here Kitty Kitty - Time For A CAT Scan

 Ok, sorry for the pun.

A CAT scan is an advanced anatomical imaging tool also known as Computerized Axial Tomography. These are 2 dimensional x-ray slices that allow us to re-create a 3 dimensional view of anatomy. CAT (or CT) is excellent for looking at the bone and skeleton. Technology these days makes CT fast and accurate (Although a single CT scan of the face exposes the patient to the same quanity of radiation as he/she gets over a 16 month period due to background radiation. Not something to ignore. Link for more information.)

The CT was NOTHING. It took literally 5 minutes. The contrast injection, however was...interesting. After the initial scan was taken, the dye was injected into my arm and another scan was done. Shortly after the injection, it felt like my butt was hot. Weird. The tech said that some people also say that it feels like they are peeing on themselves. Wish she had told me that beforehand.

Next step, back to Dr. W's office to go over the CT. Meow ;-)

So the scan confirmed that the lesion was contained in the jaw bone. No destruction of the teeth. It also showed that the lesion is on the lingual side of my jaw (the tongue side). This is important because the approach for biopsy needs to be on the side where the lesion is.

That's right....I said biopsy. Surgery to get a sample of the lesion. In many cases, the biopsy procedure actually removes the entire lesion. One and done. There may be a possibility that the biopsy shows something more serious, and more surgery would be required. Not likely, I am told.

We will do the biopsy in the office under any anesthesia that I preferred. I've never had a problem with dental procedures so I decided to start with local anesthetic (Lidocaine and Marcaine. Novocaine is no longer used, I learned) with nitrous oxide gas as a backup. (Laughing gas...common in the 1800's for recreational use, also the primary propellant in whipped cream cans. Ask me how I know!) "Any questions?" Nope. "Ok, we will see you next week."

"Oh, and grab a Werther's candy on the way out. They are really good."

A biopsy we will go...

It started innocently enough...

City House Menu

About 2 months ago, after a really good meal at City House here in Nashville, a couple of my teeth in my lower right jaw became a little sore. Not really painful...more just an ache. I thought to myself...you need to do a better job flossing. You probably have some retained meat from the awesome Pork Belly pizza the other night. Flossing, however, produced no offending porcine products, just a little blood between the two.  Are those teeth wiggly? Hmmm.

As it happened, my regularly scheduled dental appointment was the next week and when I talked to my hygienist, I mentioned that my chompers were still a bit sore. She found no sign of infection, no hidden foodstuffs, no pit or other dire finding. Whew, that would have been embarassing. We mentioned it to my dentist who decided to get some x-rays.

Something looks a little funny. More x-rays. These images showed a well circumscribed oval dark area around the roots of teeth #28 and #29. Hmmm. This was not there when they took x-rays 18 months ago. Hmmmmmmmmmmm.

"Does this ice on your tooth feel cold?" No "Well I think you might have internal resorption" (some form of internal deterioration with damage to the nerve going to the tooth.) my dentist tells me.  A sidewalk consult with one of his partners confirmed that I likely needed a root canal. Great. I've heard bad stories about those.

I was lucky enough to be able to get an appointment with a well regarded endodontist the next day. Good, I can get this over with and get on with life. Nice guy, modern office. The digital x-ray technology for dentistry is phenomenal...clear pictures and fast. Yep, there is a lytic lesion in my right jaw. "It really does not look like internal resorption, more like a bone cyst" he tells me. Cold test again clearly shows all of my teeth have normal sensation. "Good news...no root canal. Bad news...I need to send you to an oral surgeon because I dont know what that lesion is. It doesn't look bad, but we need to find out what it is." Now I was getting a little concerned.

Jargon Alert:
lytic /lyt·ic/ (lit´ik) - Having to do with destruction. It looks like a hole on x-ray.

Fortunately, he wanted to send me to Dr. W, an oral surgeon whom I know well and respect highly. We were both in residency at Vanderbilt University at the same time, me in Orthopaedic Surgery, he in Oral/Maxillofacial Surgery. Dr. W. is a very busy guy (as you would want the best guys to be) but luck had it that I could see him the next day...he had a cancellation. Thank you sir. I appreciate your insight.

Dr. W is a whirlwind of intelligence, dry sarcastic wit, and plain talk. I like him tremendously as he and I are cut from very similar cloth. First order of business is my history....2 weeks duration, not trauma, just sore...especially with biting down or pressure. Yes, they do throb with my heartbeat. No swelling, fever....etc. Next step the exam. A lot of fingers in my mouth with his scribe noting my occlusion (how my teeth fit together), my dental hygiene ("Good +"), "no masses" etc. "Does it hurt if I tap here on your jaw? Nope. How about tapping on these teeth?" Uh Huh (somewhat garbled because his fingers were still in my mouth) All the time relating stories about all the folks we trained with and under while in residency. Funny. Off to get a panorex.

Jargon Alert:
panorex - A panorex is a two-dimensional dental x-ray that displays both the upper and lower jaws and teeth, in the same film. 

Can you spot my new little friend?

There was clearly a lesion in the front half of the right side of my mandible (Jaw bone). It is well circumscribed (It has a definite outline), oval appearance without any evidence of tooth or root destruction. Good. It looked benign (meaning that it was not terribly destructive), but "it could be a problem". Okay, what now?

In order to determine the extent of the lesion, and it's specific location, we needed to get a CAT scan. This is an x-ray scan that "slices" the body up in multiple planes so that the anatomy of the bone can be more clearly and completely evaluated.

"Oh and have a Werther's candy on the way out. I'm not related, but they are really good. I'll see you next week."

And off I went...