Demystifying Your Initial Pathology Consultation
As oral & maxillofacial surgeons, fellow dentists and physicians commonly seek our expertise with “suspicious” findings in the mouth, on the face, or within deeper structures of the neck or facial bones (as may be evident on dental x-rays, CT scans, or other imaging tests). Medical and dental professionals may initially refer to these suspicious areas as “lesions,” “masses,” “growths,” “tumors,” “cysts,” or “ulcers” (just to name a few). Unfortunately, these terms are really only useful in a descriptive sense and offer very little information regarding treatment or prognosis. The purpose of this entry is to “clear the air” a bit and provide a logical, down-to-earth explanation of some of the confusing and often-redundant medical jargon you may encounter before your first consultation. Additionally, I will attempt to explain a little about what exactly a biopsy is and how it fits in with clarifying all this confusing terminology. Hopefully, if I can untangle some of these fundamentals, you’ll feel a little less intimidated by your first pathology consult and have a better underlying appreciation for the rationale we use in diagnosis and therapy.
What is a “lesion?”
A lesion is simply something that’s not supposed to be there. It could be anything. It could be an area of tissue that’s a different color, it could be an area of tissue that is raised up, it could be an area of tissue that looks raw, it could be a spot on an x-ray that looks out of place. The possibilities are nearly endless. When your doctor says, “you have a lesion,” it simply means they have noted something that’s not supposed to be there and they don’t know exactly what it is… yet. A lesion is not always bad; a lesion may go away on it’s own with time. For example, some patients may develop white areas on the sides of the tongue related to the tissues rubbing against a tooth or dental restoration over time – termed “frictional keratosis.” With proper adjustment of the teeth or dental restoration and correction of any related underlying habits (tongue biting for example) the white area will usually go away within a couple weeks. Thus, the original white lesion represented a case of frictional keratosis, a totally reversible process. By removing the original insult (mechanical rubbing on the tongue) and observing that it went away, we have arrived at the diagnosis. From then on, we no longer have to refer to that white spot as a lesion because we know exactly what it really was. By the same token, that same white lesion on the side of the tongue could also represent an early cancer or pre-cancer of the tongue. Even though the chances are much less likely, it’s still important not to neglect the possibility as we proceed. So, in conclusion, don’t lose sleep if you’re found to have a lesion. In most cases we see, the causes are relatively benign and amendable to simple therapy. The important thing to remember is that the term lesion does not necessarily imply malignancy although each new lesion needs to be treated with respect and attention to detail.
Bad lesions never go away… ever.
One of the most important aspects of our job as specialists is to determine when suspicious findings, or lesions, like the example above represent more serious problems. While we can gather a great deal of insight from the questions we ask you during our interview and from the findings we see during our exam, many times the only way to truly identify a lesion is to remove a sample of it, send it to a laboratory, and have it examined and analyzed under the microscope by a pathologist (a doctor specializing in the identification of disease processes from tissue samples). This is exactly what a biopsy is: removing a small sample of tissue with the intent of conclusively identifying exactly what the abnormality represents. Sometimes, based on the information available our first visit, we may get the impression that your lesion isn’t something worrisome. If that’s the case, we may elect to wait a bit and re-check the area before opting to perform the biopsy. However, if there’s any inclination the problem represents something more serious, we may elect to perform the biopsy early on, so as not to delay any further necessary treatment down the road. In general, any worrisome lesion (like an oral cancer, for example) will not go away with time. As such, if the problem persists after re-evaluating the area in a week, it may be time to really consider performing the biopsy.
What can I expect from a biopsy?
For most lesions of the tongue, cheek, gums, palate, or lip the amount of tissue removed during biopsy is very small. Oftentimes, just a few stitches after the sample is removed will suffice. In special situations, a small amount of adjacent bone may be removed when dealing with lesions around teeth, within the jaws, or the sinus. Depending on your level of anxiety and your general medical health, sedation may be an option to allow you to “sleep through” the entire procedure. For many of our patients, however, a simple biopsy can be performed successfully under local anesthesia in the office. Of course, this is a generalization, and we will always work with you to determine a plan with your best interests in mind. Sometimes, when dealing with lesions located in deeper tissues, it may be necessary to perform the procedure in the operating room to ensure 1) your maximal comfort and 2) our ability to obtain an adequate sample for diagnosis.
Growths, cysts, tumors, masses, and ulcers: what’s the difference?
Again, these are all really just descriptive terms we use to describe a little bit more about what a particular lesion looks like. Technically speaking, they just represent some of the different forms lesions may take, but really don’t describe much about the behavior of the lesion (i.e. likelihood to recur after treatment, ability to spread to other areas, possibility of damaging adjacent teeth or nerves, etc.). From a practical standpoint, “growth,” “tumor,” and “mass” are essentially synonymous terms used to indicate the abnormality’s solid through-and-through. These things tend to feel firm to the touch, and on advanced imaging, the solid nature may not always be clearly visible. In contrast, a “cyst” is essentially the same thing except the middle is filled with fluid (think “water balloon”). With “cysts,” it’s usually important to remove not only the fluid, but also the lining (the wall of the balloon), which produces the fluid center. An “ulcer” simply means there is some area of surface tissue that’s become eroded. Ulcers can occur on the skin, gums, cheek, tongue, or palate – basically anywhere there’s tissues that line the surface of the body. Because they usually occur in the outside layers of tissue, they’re often readily visible to the naked eye.
Again, the important thing to remember with all these terms is that they’re only descriptive. They can represent a wide spectrum of disease processes, some bad and some “not so bad.” The most important part is to figure out exactly what we’re dealing with first. Yes, while it’s true there’s always a possibility that any of these findings could ultimately represent an underlying cancer; fortunately, in the overwhelming number of cases that possibility is remote. Please don’t feel intimidated by the medical jargon you may encounter along the way. I’m never surprised by the number of patients who arrive on their first visit, having already scoured Google for information about the prognosis of their newly discovered “cyst” or “growth.” In most cases, without any information about the particular cyst or growth, this will often lead you astray (not to mention the unnecessary anxiety). In the end, just remember these terms don’t mean a whole lot until a final diagnosis is provided from biopsy. As definitive experts in all aspects of oral disease, we’re committed to talking you through the process of diagnosing and treating any newly discovered lesions. Hopefully this clarifies some of confusion we frequently encounter during new pathology consultations. Should you ever feel confused or overwhelmed, please don’t hesitate to ask. Ultimately, it’s our job and your right.
Nathan D. Lenox M.D., D.M.D.
Carolina Oral & Facial Surgery
*Specializing in general oral & maxillofacial surgery and oral oncologic and reconstructive surgery.