Summary Diagnosis in the Mail Today

This came in the mail today:

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[Patient] is 31 years old and presented for evaluation of radiolucent area in his posterior left mandible on December 4, 2008, as referred by his dentist, [Dentist]. A multi-centimeter diameter lesion was noted in the left ramus and was not associated with pain or anesthesia. There was notable expansion of the mandibular ramus and external oblique region. An incisional biopsy of the area was performed under local anesthesia on December 8, 2008, and submitted to Baylor College of Dentistry Oral Pathology Services for evaluation. The pathology report revealed an ameloblastoma within his mandible. A cone-beam image CT scan was performed on December 12, 2008, and I have reviewed that scan today. The lesion is large and extends from the anterior portion of the mandible in the distal first molar region to the posterior extent of it in the mid ramus below the mandibular condyle. There is significant expansion of the mandible, thinning of the cortices and root resoprtion of tooth #18. There is a possible perforation to the soft tissues on some of the lingual areas. There inferior alveolar nerve appears to be within very thin bone and displaced to the inferior quarter of the mandible.

[Patient] enjoys excellent general health. He is GI intolerant to erythromycin. Otherwise, he received a tonsillectomy at 8 years old, wisdom teeth extraction at 18 and partial gingivectomy for periodontal maintenance during the past year.

IMPRESSION:

1. Patient is a 31-year-old man in good general health
2. Ameloblastoma, large, left posterior mandible.

TREATMENT RECOMMENDATIONS

1. Inform patient regarding the clinical findings and nature of his lesion. We have discussed this prior and we will do so more in great detail in the near future.
2. Obtain articulated study models for a reference guide for his dental occlusion. This may be performed by his dentist.
3. Surgery, left mandible:
   1. Partial mandibulectomy with removal of tooth #19 and tissue distal with maintenance of the mandibular condyle
   2. Autologous, cortical cancellous bone graft from the iliac crest to mandible with rigid bone plate fixation
   3. These procedures will be performed in a hospital operating room while the patient receives general anesthesia. An orthopedic surgeon will be consulted for harvesting of the bone graft.

Aspects of the details of the surgery will be discussed with the patient in the near future. Such topics will include the expected permanent anesthesia of the inferior alveolar nerve due to its ablation as well as aspects of reconstruction, limitation of function and need for long term rehabilitation. In the long term, dental implants maybe be used to replace the #19 and #18. Complex vestibuloplasty as well as other bone graft augmentation may be performed after the patient has healed over 1 year following these surgeries. He will need follow up care and the discussion of possible recurrence of the ameloblastoma cannot be ruled out.

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Dental Cleaning and They Listen to Me

So today I went in to get my 6 month dental cleaning. I get pretty good service there. The hygienist I see is great. She seems to pay attention to what she’s doing and to notice things that are wrong.

So I brought up my jaw discomfort again. The whole “feels like a day old bruise” spiel. And they did X-rays. Local and panoramic.

And they found a subtle lesion-like area back around my molars on the left side.

Normally, X-rays (high energy photons) don’t penetrate bone (at least at the energy levels they use, higher energy ones would). Thus the film is not exposed where bone is. That would normally be “black”, but it gets inverted at some point – probably to increase the contrast since clinicians are usually more interested in the bones rather than that spaces. Anyways, black=no bone/space/thinner bone, white=dense bone/teeth/etc.

And if you compare the right and left sides of my jaw, you can see that on the left side:

1. you cannot see the subtle outline where my inferior alveolar nerve should be
2. you can see a region where it is not as white as the other side, corresponding to roughly where I have discomfort
3. the roots of my lower left back most molar are rounded, unlike the teeth in the rest of my mouth

My dentist thinks it could just be a cyst, but wants me to go to the oral surgeon because he’s more specialized. And that he wants me to get seen Thursday or Friday, ASAP.

He also said that if the underlying bone was diseased, he might have to do a root canal. Oh joy.

They gave me print outs of my panoramic X-ray and the local X-ray around that tooth to carry over, because they were having email problems, but they were just on regular 8.5″ x 11″ paper. And I shall photocopy them. They are mine after all. I hate it when medical professionals keep things from you.

I also brought up my insurance woes. My insurance says, “we won’t cover the gingivectomy unless you provide updated X-rays”. I guess this will cover that requirement 🙂 I mentioned this too them, they said they’d take care of it. I partly suspect they won’t.

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Gingevectomy deferred

Today, I went in to see my dentist.  The gum in my left lower back part of my mouth grows up over the molar in the back and food gets trapped up under it.  Then it gets infected, which causes the gum to swell up.  And no matter how much I brush, I’ve never been able to get back there an floss behind it – it’s just too tight and the gum is always in the way.

So I went in today, just to get the excess gum tissue cauterized away.  This is called a gingevectomy.  Jaw numbed up, electro-cautery pen (kind of like a soldering iron), no big deal.

This isn’t the first time I’ve had this same procedure done.  It is in fact the fourth.  It seems like I just need to get this done every few years or so.  I get some pain relievers, after the novocain wears off it hurts for a few hours then it’s okay.  After a few days, all healed up.  And my mouth invariable tastes like teriyaki chicken for the rest of the day.

But today I went in expecting to get my gingevectomy right then and there (just like every previous time I’d had this done), only to be given a quick exam and sold a 16oz bottle of chlorhexidine for $32 and told to come back next week.  Couldn’t I have gotten this at the pharmacy with my prescription insurance for $5?  At least it has all of the doctor notes on the side.  Even has stick diagrams!  I hate the consumer version, I want to know all the details.  Like how that they think this works by disrupting the membrane potentials of bacteria and how that in their tests, no bacteria was able to evolve an immunity to chlorhexidine.  These things I relish.

I also complained about how the left side of my jaw had a wonky feeling.  You know how you get a bruise and the next day it’s kind of tender, but maybe not terribly.  Well, my left jaw feels that way too.

Well, till next week then.

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