Parameters of Care: Clinical Practice Guidelines for Oral ...Diagnosis and Management of...

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Parameters of Care: 12

Clinical Practice Guidelines 13

for Oral and Maxillofacial Surgery 14

(AAOMS ParCare 2017) 15 16 17 18 19 20 21

DIAGNOSIS AND MANAGEMENT OF 22

PATHOLOGICAL CONDITIONS 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37

©Copyright 2017 by the American Association of Oral and Maxillofacial Surgeons. 38 This document may not be copied or reproduced 39

without the express written permission of the 40 American Association of Oral and Maxillofacial Surgeons. 41

All rights reserved. 42 J Oral Maxillofac Surg 43

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THIS SECTION IS 1 OF 11 CLINICAL SECTIONS INCLUDED IN AAOMS 47 PARCARE 2017, WHICH IS VIEWED AS A LIVING DOCUMENT APPLICABLE 48

TO THE PRACTICE OF ORAL AND MAXILLOFACIAL SURGERY. IT WILL BE UPDATED 49 AT DESIGNATED INTERVALS TO REFLECT NEW INFORMATION CONCERNING THE 50

PRACTICE OF ORAL AND MAXILLOFACIAL SURGERY. 51 52 53

AAOMS ParCare 2017 Diagnosis and Management of Pathological Conditions ____________________________________________________________________________________________________

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INTRODUCTION 55 56 Diagnosis and Management of Pathological Conditions addresses the diagnosis and treatment of diseases of the 57 oral and maxillofacial region, including diseases of bone, soft tissue, and salivary glands. Cysts, benign and 58 malignant tumors, infections, and diseases of metabolism and function are discussed. Treatment of these diseases 59 involves ablation, functional alteration, nonsurgical management, and supportive care. Odontogenic infections, 60 including deep neck infections, are addressed in the Dentoalveolar Surgery chapter. 61

The parameters of care for pathological conditions have their foundation in knowledge that is continuing to 62 expand. Increased understanding of the nature of these diseases, their biologic behavior, and their response to 63 therapy form the basis for practice parameters. Evidence-based medicine demonstrates that treatment decisions 64 and their outcomes should be based on a definitive pathologic diagnosis obtained either by preoperative biopsy or 65 posttreatment submission of surgical specimens. When reasonable, submission of specimens to oral and 66 maxillofacial pathologists is encouraged because this increases the likelihood of diagnostic accuracy and, 67 therefore, appropriate management. This document does not replace existing biomedical knowledge; it merely 68 provides the basis for defining indications for therapy, parameters of therapy, goals of therapy, and the range of 69 outcomes. 70

This section will refer only to diagnostic and therapeutic surgical procedures for the management of the lesions 71 mentioned. Other areas of pathology, including temporomandibular disorders and congenital defects, are covered 72 in other sections. 73

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75

GENERAL CRITERIA, PARAMETERS, AND CONSIDERATIONS FOR 76

DIAGNOSIS AND MANAGEMENT OF PATHOLOGICAL CONDITIONS 77 78 INFORMED CONSENT: All surgery must be preceded by the patient's or legal guardian’s consent, unless an 79 emergent situation dictates otherwise. These circumstances should be documented in the patient’s record. 80 Informed consent is obtained after the patient or the legal guardian has been informed of the indications for the 81 procedure(s), the goals of treatment, the known benefits, and risks of the procedure(s), the factors that may affect 82 the risk, the treatment options, the outcomes if left untreated, and the favorable outcomes. 83 84 PERIOPERATIVE ANTIBIOTIC THERAPY: In certain circumstances, the use of antimicrobial rinses and 85 systemic antibiotics may be indicated to prevent infections related to surgery. The decision to employ 86 prophylactic perioperative antibiotics is at the discretion of the treating surgeon and should be based on well 87 researched treatment regimens including the patient’s clinical condition as well as other comorbidities which may 88 be present. 89 90 DEALING WITH NEUROLOGIC DEFECITS: Injuries to the terminal branches of the trigeminal nerve (eg, 91 lingual, inferior alveolar, long buccal nerves), as well as the facial nerve, are known risks of oral and maxillofacial 92 surgery. It should be noted that the presence of a pathologic craniomaxillofacial condition, dentoskeletal or 93 craniofacial abnormality, or traumatic craniomaxillofacial injury may result in nerve injury prior to surgical 94 management. In addition, the use of local anesthesia (eg, mandibular block) may increase the risk of nerve injury. 95 Most nerve injuries resolve spontaneously, but some do not, and these may require consideration for non-surgical 96 and/or surgical intervention. Microneurosurgical repair should be considered when the disability is of concern to 97 the patient, and there is clinical evidence of moderate, severe, or complete neurosensory impairment of various 98 areas of the orofacial region (eg, lips, chin, tongue); paresis or paralysis of facial muscles; loss, decreased, or 99 abnormal taste sensation; or neuropathic pain of peripheral origin. Surgical repair should incorporate specialized 100 microsurgical techniques (eg, operating magnification, nerve grafting), when indicated. Also see the 101 Reconstructive Surgery chapter. 102 103 USE OF IMAGING MODALITIES: Imaging modalities may include panoramic radiograph, periapical and/or 104 occlusal radiographs, maxillary and/or mandibular radiographs, computed tomography, cone beam computed 105 tomography, positron emission tomography, positron emission tomography/computed tomography, nuclear 106

AAOMS ParCare 2017 Diagnosis and Management of Pathological Conditions

____________________________________________________________________________________________________ isotope bone scans and magnetic resonance imaging. In determining studies to be performed for imaging 107 purposes, principles of ALARA (as low as reasonably achievable) should be followed. 108 109 DOCUMENTATION: The AAOMS ParCare 2017 includes documentation of objective findings, diagnoses, and 110 patient management interventions. The ultimate judgment regarding the appropriateness of any specific 111 procedure must be made by the individual surgeon in light of the circumstances presented by each patient. 112 Understandably, there may be good clinical reasons to deviate from these parameters. When a surgeon chooses 113 to deviate from an applicable parameter based on the circumstances of a particular patient, he/she is well advised 114 to note in the patient's record the reason for the procedure followed. Moreover, it should be understood that 115 adherence to the parameters does not guarantee a favorable outcome. 116 117 GENERAL THERAPEUTIC GOALS FOR DIAGNOSIS AND MANAGEMENT OF PATHOLOGICAL 118 CONDITIONS: 119 120

A. Provision of medical and/or surgical palliation or cure of the disease process 121 B. Restoration of function 122 C. Restoration of form 123 D. Preservation of vital structures 124 E. Prevention of recurrence 125 F. Limited period of disability 126 G. Appropriate understanding by patient (family) of treatment options and acceptance of treatment plan 127 H. Appropriate understanding and acceptance by patient (family) of favorable outcomes and known risks and 128

complications 129 I. Palliation of patient’s disease in the event of disseminated disease 130

131 GENERAL FACTORS AFFECTING RISK DURING DIAGNOSIS AND MANAGEMENT OF 132 PATHOLOGICAL CONDITIONS: 133 134

A. Degree of patient’s and/or family’s understanding of the origin and natural course of the condition or 135 disorder and therapeutic goals and acceptance of proposed treatment 136

B. Presence of coexisting major systemic disease (eg, disease that increases a patient's American Society of 137 Anesthesiologists classification to II, III, or IV), as detailed in the Patient Assessment chapter 138

C. Age of patient 139 D. Presence of acute and/or preexisting infection 140 E. Accuracy and quality of pathologic diagnosis 141 F. Presence of local or systemic conditions that may interfere with the normal healing process and 142

subsequent tissue homeostasis (eg, previously irradiated tissue, diabetes mellitus, chronic renal disease, 143 liver disease, blood disorder, steroid therapy, contraceptive medication, immunosuppression, 144 malnutrition) 145

G. Presence of behavioral, psychological, neurologic, and/or psychiatric disorders, including habits (eg, 146 substance abuse, including tobacco and alcohol), seizure disorders, self-mutilation, or dementia, which 147 may affect surgery, healing, and/or response to therapy 148

H. Degree of patient's and/or family’s cooperation and/or compliance 149 I. Regulatory and/or third-party decisions concerning access to care, indicated therapy, drugs, devices, 150

and/or materials 151 J. Potential for risk to adjacent vital structures 152 K. Existing drug or alcohol intoxication 153

154 GENERAL FAVORABLE THERAPEUTIC OUTCOMES FOR DIAGNOSIS AND MANAGEMENT OF 155 PATHOLOGICAL CONDITIONS: 156 157

A. Cure or palliation of disease 158 B. Restored form 159 C. Restored function 160 D. Presence of intact adjacent structures (eg, no unanticipated loss or damage) 161


E. Limited period of disability 162 F. Patient (family) acceptance of procedure and understanding of outcomes 163

164 GENERAL KNOWN RISKS AND COMPLICATIONS OF DIAGNOSIS AND MANAGEMENT OF 165 PATHOLOGICAL CONDITIONS: 166 167

A. Unplanned admission to intensive care unit after elective surgery 168 B. Unplanned intubation for longer than 24 hours after surgery 169 C. Unplanned reintubation or tracheostomy after surgery 170 D. Use of parenteral drugs and/or fluids for longer than 72 hours after elective surgery 171 E. Failure to ambulate within an acceptable period (depending upon procedure) after surgery 172 F. Facial and/or trigeminal nerve dysfunction after surgery 173 G. Facial fracture during or after surgery (eg, pathologic fracture of mandible after marginal resection) 174 H. Unplanned Caldwell-Luc, bronchoscopy, or other exploratory procedures associated with surgery 175 I. Dental injury during surgery 176 J. Ocular injury during surgery (caused by surgery, anesthesia, or by the patient) 177 K. Repeat or unplanned oral and/or maxillofacial surgery (within 7 days following the initial procedure) 178 L. Postsurgical radiograph indicating presence of foreign body 179 M. Readmission of cancer patient for repeat ablative surgery within 12 months of primary surgery 180 N. Unplanned transfusion(s) of blood or blood components during or after surgery 181 O. Readmission for complications or incomplete management of problems on previous hospitalization 182 P. Respiratory and/or cardiac arrest 183 Q. Unanticipated residual functional deformity 184 R. Unanticipated residual structural deformity 185 S. Loss of or damage to adjacent vital structures (eg, neurosensory, dentition) 186 T. Local sequelae, with damage to or loss of vital structures 187 U. Loss of function 188 V. Loss of form 189 W. Death from tumor extension or as a result of tumor therapy 190 X. Death 191

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SPECIAL CONSIDERATIONS FOR DIAGNOSIS AND MANAGEMENT OF 194

PEDIATRIC PATHOLOGICAL CONDITIONS 195 196 The principles of management of pathological conditions in children and adults are similar. The differences are in 197 the types of pathologic entities encountered and their frequencies. The congenital epulis, for example, is by 198 definition a tumor found exclusively in neonates and newborns, and another example is the neuroectodermal 199 tumor of infancy found in infants and children. Lesions may also vary in rapidity of growth, aggressiveness, and 200 predictability with regard to biologic behavior when compared with those in adults. The biologic behavior of a 201 lesion (eg, rapid growth, effacement of the dental crypts, root destruction) must be considered in deciding the 202 therapeutic course. We assume for most pathologic entities and processes that the biologic behavior will mimic 203 that seen in adult patients; however, this may not always be the case. Lesions that more frequently occur in adults, 204 when found in children, may exhibit more aggressive behavior than seen in the adult equivalent. New therapies 205 and management protocols are evolving for some lesions previously managed primarily with surgery. Examples 206 are hemangiomas which respond and involute under the influence of beta blocker therapy, and some 207 mesenchymal tumors that respond to anti-angiogenesis and other treatments. The example of central giant cell 208 granulomas responding to interferon, or intra-lesional steroid injection, or calcitonin therapies, and even newer 209 monoclonal antibody therapy (denosumab) are current topics. Very likely more such examples will arise as 210 medical and targeted genetic treatments continue to be developed. 211

When managing tumors, the patient’s developmental stage must be considered. Radiation therapy for head and 212 neck malignant tumors may have devastating growth consequences, and the potential for secondary tumors 213 occurring years after the initial treatment is a concern. Although these and other concerns should be weighed in 214 the management of young patients, they may not always alter the recommended therapy for life-threatening or 215


____________________________________________________________________________________________________ aggressively destructive lesions. Anatomical variances from the adult, along with growth implications, present 216 significant considerations to surgical management and reconstruction in the growing child in whom abnormalities 217 of the face or jaws are to be removed. A condyle that is resected during surgical treatment, for example, should be 218 replaced with a graft that is responsive to growth. Dental development must be considered when planning implant 219 replacement for missing teeth. 220

A thorough physical evaluation, appropriate imaging studies, and vigilant monitoring of the clinical course are 221 required for management of infections in children. Airway and hydration status are paramount in the management 222 of severe pediatric infections because the margin of safety is less for the young patient. Also in children, it may be 223 difficult to differentiate infection from a rapidly expanding neoplasm. Decisions regarding hospital admission 224 must of necessity include consideration of the socioeconomic environment and the expected reliability of the 225 child’s support system. 226

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CYSTS OF BONE 229 230 This section includes all odontogenic and nonodontogenic cysts, including those lesions not thought to be true 231 cysts (eg, idiopathic bone cavity, traumatic bone cyst). 232 233 I. Indications for Therapy for Cysts of Bone 234 235

May include one or more of the following: 236 237

A. Clinical indications 238 1. Pain 239 2. Deformity (eg, swelling, expansion) 240 3. Altered sensation 241 4. Altered function 242 5. Drainage 243 6. Structures damaged or displaced from their normal position (eg, nerves, teeth, sinuses) 244 7. Altered hue 245 8. Crepitus 246 9. Clinical evidence of fracture 247 10. Secondary infection 248 11. Bony structural stability is questionable 249

B. Imaging indications (based on clinical and plain film assessment) 250 1. Change in bone density (eg, radiolucency) 251 2. Displacement of adjacent anatomical structures 252 3. Assessment of proximity to/invasion of adjacent structures 253 4. Evidence of pathologic fracture 254

C. Results of differential diagnosis 255 D. Results of additional studies, as indicated 256

1. Aspiration (eg, straw-colored fluid) 257 2. Fine-needle aspiration (eg, cytologic confirmation of cyst) 258 3. Core needle biopsy (self-directed or in association with an imaging study, eg, CT) 259 4. Biopsy: incisional or excisional, depending on lesion size, extent, character, and differential diagnosis 260

(eg, microscopic confirmation of cyst) 261 5. Enucleation and curettage 262

a. Simple, mandible 263 b. Complex, mandible 264 c. Maxilla 265

6. Decompression/Marsupialization 266 a. Mandible 267 b. Maxilla 268

7. Resection (eg, recurrent cyst) 269


a. Mandible 270 b. Maxilla 271

E. Additional presurgical studies may include: 272 1. Imaging 273

a. Office-based scans (panoramic and/or cone beam computed tomography) 274 b. Conventional plain films or computed tomography (CT) (depending on size and character) 275

2. Evaluation for nevoid basal cell carcinoma syndrome in patients with multiple keratocystic 276 odontogenic tumors (eg, complete cutaneous examination, imaging studies as indicated) 277

II. Specific Therapeutic Goals for Cysts of Bone 278 279

The goal of therapy is to restore form and/or function. However, risk factors and potential complications may 280 preclude complete restoration of form and/or function. 281

282 A. Presence of a general therapeutic goal, as listed in the section entitled General Criteria, Parameters, and 283

Considerations for Diagnosis and Management of Pathological Conditions 284 B. Eradication of cyst 285

III. Specific Factors Affecting Risk in the Treatment of Cysts of Bone 286 287

Severity factors that increase risk and the potential for known complications: 288 289

A. Presence of a general factor affecting risk, as listed in the section entitled General Criteria, Parameters, 290 and Considerations for Diagnosis and Management of Pathological Conditions 291

B. Associated teeth 292 C. Proximity to/invasion of adjacent structures 293 D. Type of cyst, recurrence-prone cysts (eg, keratocystic odontogenic tumor, botryoid odontogenic cyst, 294

glandular odontogenic cyst) 295 E. Fracture or weakening of bone due to cyst expansion 296 F. Status post removal of prior cyst or tumor in same area of bone 297

IV. Indicated Therapeutic Parameters for Cysts of Bone 298 299

The presurgical assessment includes, at a minimum, a comprehensive history, a physical examination, and an 300 imaging evaluation. Also see the Patient Assessment chapter. 301

302 The following procedures for the management of cysts of bone are not listed in order of preference: 303

304 A. Diagnosis by aspiration or biopsy 305 B. Primary treatment 306

1. Observation, including clinical examination and serial radiographs (eg, presumptive diagnosis of 307 idiopathic bone cavity, traumatic bone cyst unicameral bone cavity], Stafne cyst, and periapical 308 radiolucency in the endodontically treated tooth) 309

2. Marsupialization and/or decompression for patients with large cysts or those unable to undergo 310 enucleation or extirpation or for those in whom the potential for damage to adjacent vital structures is 311 high 312

3. Enucleation for lesions not prone to recurrence 313 4. Enucleation and curettage for lesions in which complete removal by enucleation alone is known to be 314

inadequate (curettage can be mechanical, physical, chemical, or a combination of each) 315 5. Marginal or segmental resection for aggressive or recurrent cysts 316

317 All specimens must be submitted for pathologic assessment. 318

319 C. Adjunctive treatment (Also see the Reconstructive Surgery chapter) 320

1. Fixation to reduce the potential for fracture and/or preserve function (eg, maxillomandibular, bone 321 plates) 322

2. Management of bone defect for defects likely to persist or break down (eg, packing; autogenous, 323 allogeneic, or alloplastic grafting) 324


____________________________________________________________________________________________________ 3. Secondary reconstruction for cases with potential for infection or recurrence, if primarily 325

reconstructed, or those with systemic or local contraindications 326 D. Posttreatment follow-up 327

1. Baseline imaging in the initial postoperative period 328 2. Determination of restoration of form and function and absence of recurrence 329

a. Clinical and imaging examination for non-recurrence-prone cysts (dentigerous) until form and/or 330 function are restored 331

b. Clinical and imaging examination for recurrence-prone cysts (odontogenic keratocyst) for the 332 patient's lifetime, annually for 5 years, then biannually if no recurrence 333

3. Instructions to return if signs or symptoms recur before regularly scheduled follow-up appointment 334 E. Instructions for posttreatment care and follow-up 335

V. Outcome Assessment Indices for Cysts of Bone 336 337

Indices are used by the specialty to assess aggregate outcomes of care. Outcomes are assessed through 338 clinical evaluation and may include an imaging evaluation. 339

340 A. Favorable therapeutic outcomes 341

1. General favorable therapeutic outcomes, as listed in the section entitled General Criteria, Parameters, 342 and Considerations for Diagnosis and Management of Pathological Conditions 343

2. Patient remains free of disease 344 B. Known risks and complications associated with therapy 345

1. Presence of a general known risk and/or complication, as listed in the section entitled General 346 Criteria, Parameters, and Considerations for Diagnosis and Management of Pathological Conditions 347

2. Recurrence of cyst 348

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MALIGNANT TUMORS OF BONE 351 352 This section includes primary and metastatic lesions. 353 354 I. Indications for Therapy for Malignant Tumors of Bone 355 356


A. Clinical indications 359 1. Pain 360 2. Deformity (eg, swelling, expansion) 361 3. Altered sensation 362 4. Altered function 363 5. Drainage 364 6. Structures damaged or displaced from their normal position (eg, nerves, teeth, sinuses) 365 7. Altered hue 366 8. Crepitus 367 9. Clinical evidence of fracture 368 10. Secondary infection 369 11. Pulsation, bruit, or thrill 370 12. Ulceration 371 13. Hemorrhage 372 14. Evidence of local tumor extension, regional lymphadenopathy, or metastasis 373 15. Boney structural stability is questionable 374

B. Imaging indications (based on clinical and plain radiograph assessment) 375 1. Change in bone architecture and/or density 376 2. Displacement of adjacent anatomical structures 377 3. Assessment of proximity to/invasion of adjacent structures 378


4. Evidence of pathologic fracture 379 5. Abnormal bone scan 380 6. Altered vascularity 381 7. Positron emission tomography (PET) or positron emission tomography/computed tomography 382

(PET/CT) scan demonstrating intense hypermetabolic focus or foci 383 C. Results of differential diagnosis 384 D. Results of additional studies, as indicated 385

1. Aspiration to rule out vascular lesions 386 2. Incisional biopsy 387 3. Core needle biopsy 388 4. Fine-needle aspiration biopsy (self-directed or in association with imaging, eg, CT) 389 5. Microbiologic assessment (eg, culture and sensitivity for secondarily infected lesions) 390


a. Office-based scans (panoramic and/or cone beam computed tomography) 393 b. Conventional film imaging or computed tomography (depending on size and character) 394 c. Magnetic resonance imaging 395 d. Nuclear medicine scan (bone scan, SPECT, PET or PET/CT scan) 396 e. Plain radiographs, including chest radiograph and skeletal survey, as necessary 397 f. Angiography including MRA, CTA if indicated 398

2. Laboratory studies (eg, complete blood cell count, liver function tests, serum electrophoresis) 399 II. Specific Therapeutic Goals for Malignant Tumors of Bone 400 401



Considerations for Diagnosis and Management of Pathological Conditions 406 B. Eradication of tumor 407

III. Specific Factors Affecting Risk in the Treatment of Malignant Tumors of Bone 408 409



B. Associated teeth 414 C. Proximity to/invasion of adjacent structures 415 D. Extent of primary tumor 416 E. Presence and extent of regional and/or distant metastasis 417 F. Fracture or weakening of mandible or maxilla due to presence of tumor 418 G. Compromised airway 419

IV. Indicated Therapeutic Parameters for Malignant Tumors of Bone 420 421


424 The following procedures for the management of malignant tumors of bone are not listed in order of 425 preference: 426


1. Observation (eg, unresectable tumors, indolent lesions in compromised patients, patients or families 430 unwilling to give consent informed or otherwise) 431

2. Marginal resection when a margin of normal bone can be removed without creating a segmental 432 defect 433


____________________________________________________________________________________________________ 3. Segmental resection of bone with adjacent structures 434 4. Composite resection of bone, including surrounding soft tissues and regional lymph nodes for 435

squamous cell carcinoma or similar malignant tumors 436 5. Radiation therapy and/or neoadjuvant chemotherapy 437


440 C. Adjuvant therapy and reconstruction 441

1. Radiation therapy and/or chemotherapy 442 2. Reconstruction bone plates to bridge segmental defects or prevent pathologic fractures in extensive 443

marginal resections 444 3. Primary reconstruction to restore form and/or function for defects likely to persist, for weakened 445

underlying structures with low potential for infection, or for recurrence in the absence of systemic or 446 local contraindications 447 a. Bone grafts 448 b. Skin grafts and soft tissue flaps (eg, local, pedicled, free) 449 c. Composite grafts 450 d. Alloplasts (bone plates) 451 e. Implant reconstruction (rarely primary in malignancies) 452

4. Secondary reconstruction to restore form and/or function for cases with high potential for infection or 453 recurrence or with systemic or local contraindications to primary reconstruction 454 a. Bone grafts 455 b. Skin grafts and soft tissue flaps (eg, local, pedicled, free) 456 c. Composite grafts 457 d. Alloplasts (bone plates) 458 e. Implant reconstruction 459

D. Posttreatment follow-up 460 1. Baseline plain radiography in the initial postoperative period 461 2. Plain film radiographs of the chest at regularly scheduled intervals 462 3. Special imaging studies (CT, magnetic resonance imaging, bone scans, PET or PET/CT, according to 463

tumor type and location and the clinician’s level of suspicion for recurrent and metastatic disease) 464 4. Clinical and imaging examination for malignant tumors for the patient's lifetime, depending on tumor 465

type, likely site of metastasis, and likely length of time to recurrence 466 5. Instructions to return if signs or symptoms recur before regularly scheduled follow-up appointment 467

E. Instructions for posttreatment care and follow-up 468 V. Outcome Assessment Indices for Malignant Tumors of Bone 469 470






2. Local recurrence of tumor or regional and/or distant metastasis 481 3. Death from regional extension of tumor, metastasis, or as a result of therapy 482 4. Excess morbidity from radiation and/or chemotherapy (eg, tissue necrosis, radiation caries) 483

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BENIGN TUMORS OF BONE 486 487

AAOMS ParCare 2017 Diagnosis and Management of Pathological Conditions ____________________________________________________________________________________________________ I. Indications for Therapy for Benign Tumors of Bone 488 489


A. Clinical indications 492 1. Pain 493 2. Deformity (eg, swelling, expansion) 494 3. Altered sensation 495 4. Altered function 496 5. Drainage 497 6. Structures damaged or displaced from their normal position (eg, nerves, teeth, sinuses) 498 7. Altered hue 499 8. Crepitus 500 9. Clinical evidence of fracture 501 10. Secondary infection 502 11. Pulsation, bruit, or thrill 503 12. Ulceration 504 13. Hemorrhage 505 14. Incidence of local tumor extension 506 15. Boney structural stability is questionable 507

B. Imaging indications (based on clinical and plain film radiograph assessment) 508 1. Change in bone architecture and/or density 509 2. Displacement of adjacent anatomical structures 510 3. Assessment of proximity to/invasion of adjacent structures 511 4. Evidence of pathologic or impending pathologic fracture 512 5. Abnormal bone scan 513 6. Altered vascularity 514


1. Aspiration to rule out vascular lesions 517 2. Biopsy (incisional or excisional, depending on lesion size, extent, character, and differential 518

diagnosis) 519 3. Fine-needle aspiration biopsy 520 4. Core needle biopsy (self-directed or associated with imaging, eg, CT) 521

E. Additional presurgical studies may include 522 1. Imaging 523

a. Office-based scans (panoramic and/or cone beam computed tomography) 524 b. Conventional tomography or medical-grade CT (depending on size and character) 525 c. Magnetic resonance imaging 526 d. Nuclear medicine scan 527 e. Angiography including CTA or MRA for presumptive arteriovenous malformation 528 f. Plain radiographs of the jaws 529

2. Laboratory studies (eg, complete blood cell count) 530 II. Specific Therapeutic Goals for Benign Tumors of Bone 531 532




III. Specific Factors Affecting Risk in the Treatment of Benign Tumors of Bone 539 540



____________________________________________________________________________________________________ A. Presence of a general factor affecting risk, as listed in the section entitled General Criteria, Parameters, 543

and Considerations for Diagnosis and Management of Pathological Conditions 544 B. Associated teeth 545 C. Proximity to/invasion of adjacent structures 546 D. Extent of primary tumor 547 E. Fracture or weakening of mandible due to presence of tumor 548 F. Compromised airway 549 G. Histologic type and character of tumor 550

IV. Indicated Therapeutic Parameters for Benign Tumors of Bone 551 552

The presurgical assessment includes, at a minimum, a comprehensive history, a physical examination, an 553 imaging evaluation, and a histologic analysis (if indicated). Also see the Patient Assessment chapter. 554

555 The following procedures for the management of benign tumors of bone are not listed in order of preference: 556

557 A. Diagnosis by aspiration or biopsy 558 B. Primary treatment (management modified by local or systemic factors) 559

1. Observation (eg, unresectable tumors, indolent lesions in compromised patients, patients or families 560 unwilling to give consent informed or otherwise) 561

2. Therapeutic injection or systemic therapy (eg, steroid injection, calcitonin or interferon therapy for 562 central giant cell lesions) 563

3. Enucleation for well-demarcated lesion with low potential for recurrence (eg, adenomatoid 564 odontogenic tumor, odontoma, ossifying fibroma) 565

4. Enucleation and curettage for lesions in which complete removal by enucleation alone is known to be 566 inadequate (curettage can be mechanical, physical, or chemical) 567

5. Marginal resection for tumor with propensity for recurrence (eg, ameloblastoma) and when a margin 568 of normal bone can be removed without creating segmental defect 569

6. Segmental resection of bone with adjacent structures for benign tumors with propensity for 570 involvement, extension to adjacent structures, or when size or location mitigates a marginal resection 571

7. Embolization and/or vessel ligation for vascular lesions with the possibility of secondary surgical 572 removal 573


576 C. Adjunctive treatment 577

1. Reconstruction bone plates to bridge segmental defects or prevent pathologic fractures in extensive 578 marginal resections 579

2. Adjunctive chemotherapy as with interferon or calcitonin for post-enucleation/resection adjuvant 580 treatment of aggressive giant cell lesions 581

3. Primary reconstruction to restore form and/or function for defects likely to persist, for weakened 582 underlying structures with low potential for infection, or for recurrence in the absence of systemic or 583 local contraindications 584 a. Bone grafts 585 b. Skin grafts and soft tissue flaps (eg, local, pedicled, free) 586 c. Composite grafts 587 d. Alloplasts (bone plates) 588 e. Implant reconstruction (primary or secondary) 589

4. Secondary reconstruction to restore form and/or function for cases with high potential for infection if 590 primarily grafted, recurrence, or with systemic or local contraindications 591 a. Bone grafts 592 b. Skin grafts and soft tissue flaps (eg, local, pedicled, free) 593 c. Composite grafts 594 d. Alloplasts (bone plates) 595 e. Implant reconstruction 596

D. Posttreatment follow-up 597


1. Baseline imaging in the initial postoperative period 598 2. Clinical and imaging examination until form and/or function is restored for non-recurrence-prone 599

tumors 600 3. Clinical and imaging examination for recurrence-prone benign tumors for the patient's lifetime, 601

annually for 5 years, then biennially (eg, ameloblastoma) 602 4. Instructions to return if signs or symptoms recur before regularly scheduled follow-up appointment 603

E. Instructions for posttreatment care and follow-up 604 V. Outcome Assessment Indices for Benign Tumors of Bone 605 606






2. Death from regional extension of tumor or as a result of therapy 617 3. Local recurrence of tumor 618

619

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OSTEOMYELITIS 621 622 I. Indications for Therapy for Osteomyelitis 623 624


A. Clinical indications 627 1. Pain 628 2. Swelling 629 3. Altered sensation 630 4. Altered function 631 5. Diaphoresis 632 6. Fever 633 7. Trismus 634 8. Chills 635 9. General malaise 636 10. Swelling 637 11. Erythema 638 12. Purulence 639 13. Exposed bone 640 14. Fetor oris 641 15. Soft tissue induration 642 16. Fluctuance 643 17. Sinus tract (fistula) 644 18. Malocclusion 645 19. Tooth mobility 646 20. Lymphadenitis 647 21. Sequestration 648 22. Evidence of fracture 649 23. Skin Mottling 650 24. Granulation tissue formation 651


____________________________________________________________________________________________________ B. Imaging indications (based on clinical and plain film radiograph assessment) 652

1. Destruction of bone (radiolucency or other evidence of osteolytic process) 653 2. Evidence of sequestrum and/or involucrum formation 654 3. Reactive hyperplasia (sclerosis) of bone 655 4. Abnormal bone scan 656 5. Abnormal location and extent of radiopacity or radiolucency 657 6. Antral or nasal wall destruction or thickening 658 7. Evidence of pathologic fracture 659 8. Evidence of boney expansion 660


1. Surgical procedures 663 a. Biopsy 664 b. Incision and drainage with productive result 665 c. Removal of bone sequestrum 666 d. Lateral decortication 667 e. Resection 668

2. Laboratory evidence 669 a. Gram stain 670 b. Histopathology (special stains identifying organisms) 671 c. Culture and sensitivities 672 d. Complete blood cell count, differential count, and sedimentation rate 673


a. Nuclear scans (eg, technetium, gallium, indium) 676 b. Office-based scans (panoramic and/or cone beam computed tomography) 677 c. CT (Computed Tomography 678 d. MRI (Magnetic Resonance Imaging) 679

II. Specific Therapeutic Goals for Osteomyelitis 680 681



Considerations for Diagnosis and Management of Pathological Conditions 686 B. Elimination of infection 687 C. Prevention or treatment of pathologic fractures 688

III. Specific Factors Affecting Risk in the Treatment of Osteomyelitis 689 690



B. Associated nonvital teeth 695 C. Periodontal disease 696 D. Presence of impending airway obstruction 697 E. Extent of infection (eg, localized, diffuse) 698 F. Identification of organism (eg, known, classified) 699 G. Virulence of organism and/or responsiveness to antibiotics 700 H. Degree of vascularity in region (eg, prior injury or surgery) 701 I. Presence of associated fracture 702 J. Presence or absence of disseminated disease (eg, Chronic recurrent multifocal osteomyelitis (CRMO)) 703

IV. Indicated Therapeutic Parameters for Osteomyelitis 704 705



708 The following procedures for the management of osteomyelitis are not listed in order of preference: 709

710 A. Diagnosis by imaging, biopsy, and culture (if indicated) 711 B. Nonsurgical treatment 712

1. Antibiotic or antifungal therapy 713 2. Nutritional support 714 3. Hydration 715 4. Irrigation 716 5. Control of systemic disease 717 6. Consideration for hyperbaric oxygen therapy 718

C. Surgical treatment 719 1. Incision and drainage 720 2. Debridement and sequestrectomy 721 3. Stabilization of fracture 722 4. Removal of involved teeth 723 5. Saucerization 724 6. Lateral decortication of mandible 725 7. Marginal resection of mandible 726 8. Segmental resection of mandible 727 9. Partial or complete maxillectomy 728

729 All specimens must be submitted for pathologic and microbiologic assessments. 730

731 D. Posttreatment follow-up 732

1. Baseline imaging in the initial postoperative period 733 2. Antibiotic/antifungal therapy 734 3. Posttreatment assessment (bone scan, eg, gallium, indium) 735 4. Determination of adequate restoration of form and/or function 736 5. Instructions to return if signs or symptoms recur before regularly scheduled follow-up appointment 737

E. Instructions for posttreatment care and follow-up 738 V. Outcome Assessment Indices for Osteomyelitis 739 740




2. Complete absence of infection 747 B. Known risks and complications associated with therapy 748


2. Persistent infection 751 3. Pathologic fracture 752 4. Airway impairment 753 5. Draining fistulae 754

755

756

NON-ODONTOGENIC SOFT TISSUE INFECTIONS OF THE HEAD AND 757

NECK 758 759


____________________________________________________________________________________________________ I. Indications for Therapy for Non-Odontogenic Soft Tissue Infections of the Head and Neck 760 761


A. Clinical or physical findings 764 1. Pain 765 2. Swelling 766 3. Soft tissue induration 767 4. Erythema 768 5. Lymphadenitis 769 6. Trismus 770 7. Purulence 771 8. Fistula 772 9. Malaise 773 10. Fever 774 11. Chills 775 12. Diaphoresis 776 13. Dyspnea 777 14. Dysphagia 778 15. Altered function 779 16. Altered sensation 780 17. Soft tissue necrosis (eg, necrotizing fasciitis) 781 18. Systemic sepsis 782 19. Disseminated infection (eg, prosthetic cardiac valve) 783 20. Skin ulceration 784 21. Vesicular skin eruption 785 22. Skin mottling 786

B. Diagnostic imaging findings 787 1. Gas spaces in soft tissue 788 2. Soft tissue mass, fluid loculation, and/or abscess cavity 789

C. Laboratory findings 790 1. Abnormal complete blood cell count, differential count, sedimentation rate, serum electrolytes, 791

glucose, arterial blood gas 792 2. Positive microbiologic culture (eg, blood, purulence) 793 3. Positive Gram stain 794 4. Elevated temperature 795

II. Specific Therapeutic Goals for Non-Odontogenic Soft Tissue Infections of the Head and Neck 796 797



Considerations for Diagnosis and Management of Pathological Conditions 802 B. Prevention of recurrence 803

III. Specific Factors Affecting Outcomes from Non-Odontogenic Soft Tissue Infections of the Head and 804 Neck 805

806 Severity factors that increase risk and the potential for known complications: 807

808 A. Presence of a general factor affecting risk, as listed in the section entitled General Criteria, Parameters, 809

and Considerations for Diagnosis and Management of Pathological Conditions 810 B. Extent of infection (eg, localized, diffuse) 811 C. Direction and/or rate of extension of infection 812 D. Presence of impending airway obstruction 813 E. Susceptibility of organism to antibiotics 814


F. Virulence of organism 815 G. Proximity to contiguous structures 816 H. Presence of foreign bodies or implanted materials 817

IV. Indicated Therapeutic Parameters for Non-Odontogenic Soft Tissue Infections of the Head and Neck 818 819


822 The following procedures for the management of non-odontogenic infections are not listed in order of 823 preference: 824

825 A. Establishment of airway (intubation, emergency tracheostomy, cricothyroidotomy), if compromised 826 B. Elimination of infection source 827 C. Incision and drainage 828 D. Aspiration 829 E. Pain control 830 F. Irrigation and debridement 831 G. Fasciotomies (if indicated) 832 H. Identification of organism (eg, Gram stain, aerobic and anaerobic organism culture and sensitivity testing, 833

culture acid-fast bacilli, methicillin-resistant Staphylococcus aureus [MRSA] and fungi) when indicated 834 I. Assessment and support of host defenses (eg, local measures, antipyretics, nutritional support, and 835

hydration, hyperbaric oxygen treatment) 836 J. Antimicrobial therapeutic management, if indicated (systemic or local therapy) 837 K. Assessment and management of systemic involvement (eg, sepsis) 838 L. Assessment and management of coexisting systemic disease (eg, diabetes mellitus) 839 M. Instructions for posttreatment care and follow-up 840

V. Outcome Assessment Indices for Non-Odontogenic Soft Tissue Infections of the Head and Neck 841 842




2. Absence of local or systemic signs and/or symptoms of infection 849 3. Absence of unanticipated tissue loss 850 4. Restored form and function 851 5. Improved host defenses 852 6. Limited period of disability 853

B. Known risks and complications associated with therapy 854 1. Presence of a general known risk and/or complication, as listed in the section entitled General 855

Criteria, Parameters, and Considerations for Diagnosis and Management of Pathological Conditions 856 2. Persistence or extension of infection (intracranial extension, eg, sinusitis, cavernous sinus thrombosis, 857

osteomyelitis, mediastinitis) 858 3. Airway impairment 859 4. Tissue loss or damage to adjacent vital structures 860 5. Adverse systemic sequelae (eg, septicemia, endocarditis), which could lead to organ failure and death 861 6. Adverse drugs reactions or interaction with existing therapeutic drug regimens 862 7. Facial, neck scarring, or keloid formation with need for secondary revision surgery 863 8. Nerve injury secondary to the infection or the surgical intervention 864 9. Injury to organ systems approximate to areas of prior infection (eg, salivary duct) that need secondary 865

revision surgery 866

867

868


____________________________________________________________________________________________________

OSTEORADIONECROSIS 869 870 I. Indications for Therapy for Osteoradionecrosis 871 872


A. Clinical indications 875 1. History of radiotherapy 876 2. Pain 877 3. Exposed bone 878 4. Sequestrum 879 5. Orocutaneous fistula 880 6. Oronasal fistula 881 7. Oroantral fistula 882 8. Tissue hypoxia (eg, thin skin, beard loss, oximetry evidence) 883 9. Soft tissue dehiscence 884 10. Evidence of pathologic fracture 885 11. Tooth mobility 886 12. Altered sensation 887 13. Swelling 888 14. Induration 889 15. Secondary infection 890 16. Fetor oris 891

B. Imaging indications (based on clinical and plain radiograph assessment) 892 1. Destruction of bone (radiolucency or other evidence of osteolytic process) 893 2. Sequestrum formation 894 3. Sclerosis of bone 895 4. Evidence of pathologic fracture 896 5. Altered uptake on bone scan 897


1. Surgical 900 a. Biopsy to rule out presence of tumor and confirm nonvital bone, as indicated 901


a. Office-based scans (panoramic and/or cone beam computed tomography) 904 b. CT 905 c. Nuclear scans 906

2. Transcutaneous oxygen concentration measurements (optional) 907 II. Specific Therapeutic Goals for Osteoradionecrosis 908 909



Considerations for Diagnosis and Management of Pathological Conditions 914 B. Pain control 915 C. Provision of full mucosal coverage of remaining, viable bone 916 D. Preparation of the patient for bony reconstruction, as necessary 917 E. Reconstruction of quantitatively deficient soft tissue bed as necessary 918

III. Specific Factors Affecting of Risk in Treatment of Osteoradionecrosis 919 920


A. Presence of a general factor affecting risk, as listed in the section entitled General Criteria, Parameters, 923


and Considerations for Diagnosis and Management of Pathological Conditions 924 B. Associated teeth 925 C. Associated nonvital teeth 926 D. Periodontal disease 927 E. Potential for risk to adjacent structures 928 F. Extent of osteoradionecrosis clinically present (staging) 929 G. Dose, portals, fractionation, and tissue response of radiotherapy 930 H. Airway status 931

IV. Indicated Therapeutic Parameters for Osteoradionecrosis 932 933


936 The following procedures for the management of osteoradionecrosis are not listed in order of preference: 937

938 A. Supportive, nonsurgical treatment 939

1. Ruling out of recurrent tumor 940 2. Local wound care 941 3. Nutritional support 942 4. Optimal therapy of concomitant systemic disease 943 5. Antibiotic therapy for secondary infections 944 6. Hyperbaric oxygen therapy before and after surgical treatment) 945 7. Vitamin E and Trental® 946

B. Surgical treatment (with adjunctive hyperbaric oxygen therapy when appropriate) 947 1. Removal of affected bone 948

a. Sequestrectomy 949 b. Saucerization to bleeding bone 950 c. Partial or complete maxillectomy 951 d. Marginal resection of mandible 952 e. Segmental resection of mandible 953 f. Removal of all exposed radiated bone 954

2. Vascularized soft tissue flap with bone resection 955 956

All specimens must be submitted for pathologic assessment. 957 958

C. Primary or secondary bony reconstruction to restore form and/or function 959 D. Posttreatment follow-up 960

1. Baseline imaging in the initial postoperative period 961 2. Repeat biopsy, when indicated by clinical or radiographic changes 962 3. Instructions to return if signs or symptoms recur before regularly scheduled follow-up appointment 963

E. Instructions for posttreatment care and follow-up 964 V. Outcome Assessment Indices for Osteoradionecrosis 965 966




2. Elimination of clinically active osteoradionecrosis and associated signs and symptoms 973 B. Known risks and complications associated with therapy 974


2. Clinically persistent osteoradionecrosis (eg, pain, fistula, exposed bone, pathologic fracture) 977 3. Systemic sequelae (eg, septicemia, endocarditis) 978


____________________________________________________________________________________________________ 4. Masticatory or airway impairment 979 5. Further bone loss causing facial deformity 980

981

982

MEDICATION-RELATED OSTEONECROSIS OF THE JAWS 983 984 I. Indications for Therapy for Medication-Related Osteonecrosis of the Jaws 985 986


A. Clinical indications 989 1. History of exposure to antiresorptive or antiangiogenic medications 990 2. Pain 991 3. Exposed bone 992 4. Sequestrum 993 5. Orocutaneous fistula 994 6. Oronasal fistula 995 7. Oroantral fistula 996 8. Soft tissue retraction 997 9. Evidence of pathologic fracture 998 10. Tooth mobility 999 11. Altered sensation 1000 12. Swelling 1001 13. Induration 1002 14. Secondary infection 1003 15. Fetor oris 1004

B. Imaging indications (based on clinical and plain radiograph assessment) 1005 1. Destruction of bone (radiolucency or other evidence of osteolytic process) 1006 2. Sequestrum formation 1007 3. Sclerosis of bone 1008 4. Evidence of pathologic fracture 1009 5. Altered uptake on bone scan 1010


1. Surgical 1013 a. Biopsy to rule out presence of tumor and confirm nonvital bone, as indicated 1014

2. Microbiologic assessment 1015 E. Additional presurgical studies may include: 1016

1. Imaging 1017 a. Office-based scans (panoramic and/or cone beam computed tomography) 1018 b. CT scan 1019 c. Bone scans 1020

II. Specific Therapeutic Goals for Medication-Related Osteonecrosis of the Jaws 1021 1022



Considerations for Diagnosis and Management of Pathological Conditions 1027 B. Limited pain 1028 C. Provision of full mucosal coverage of remaining, viable bone 1029

III. Specific Factors Affecting Risk in the Treatment of Medication-Related Osteonecrosis of the Jaws 1030 1031

Severity factors that increase risk and the potential for known complications: 1032

AAOMS ParCare 2017 Diagnosis and Management of Pathological Conditions ____________________________________________________________________________________________________ 1033


B. Associated teeth 1036 C. Associated nonvital teeth 1037 D. Periodontal disease 1038 E. Potential for risk to adjacent structures 1039 F. Extent of osteonecrosis clinically present (staging) 1040 G. Airway status 1041 H. Overall health of patient (active malignancy, metastatic disease, immunosuppression) 1042

IV. Indicated Therapeutic Parameters for Medication-Related Osteonecrosis of the Jaws 1043 1044


1047 The following procedures for the management of bisphosphonate-related osteonecrosis of the jaws are not 1048 listed in order of preference: 1049

1050 A. Supportive, nonsurgical treatment 1051

1. Local wound care 1052 2. Nutritional support 1053 3. Optimal therapy of concomitant systemic disease 1054 4. Antibiotic therapy for secondary infections 1055

B. Surgical treatment 1056 1. Removal of affected bone 1057

a. Sequestrectomy 1058 b. Saucerization to bleeding bone 1059 c. Marginal resection of mandible 1060 d. Segmental resection of mandible 1061 e. Partial or complete maxillectomy 1062


1065 C. Primary or secondary bony reconstruction to restore form and/or function 1066

1. Alloplast reconstruction (bone plates) 1067 2. Primary or secondary bony reconstruction to restore form and/or function 1068

D. Posttreatment follow-up 1069 1. Baseline imaging in the initial postoperative period 1070 2. Repeat biopsy, when indicated by clinical or radiographic changes 1071 3. Instructions to return if signs or symptoms recur before regularly scheduled follow-up appointment 1072

E. Instructions for posttreatment care and follow-up 1073 V. Outcome Assessment Indices for Medication-Related Osteonecrosis of the Jaws 1074 1075




2. Elimination of clinically active osteonecrosis of the jaws and associated signs and symptoms 1082 B. Known risks and complications associated with therapy 1083


2. Clinically persistent osteonecrosis of the jaws (eg, pain, fistula, exposed bone, pathologic fracture) 1086 3. Systemic sequelae (eg, septicemia, endocarditis) 1087


____________________________________________________________________________________________________ 4. Masticatory or airway impairment 1088 5. Further bone loss causing facial deformity 1089

1090

1091

METABOLIC AND DYSTROPHIC DISEASES OF BONE 1092 1093 I. Indications for Therapy for Metabolic and Dystrophic Diseases of Bone 1094 1095


A. Clinical indications 1098 1. Pain 1099 2. Swelling 1100 3. Altered sensation 1101 4. Altered function 1102 5. Facial deformity (hard and/or soft tissue) 1103 6. Loss of bone 1104 7. Alteration of bone quality (eg, fibrous dysplasia) 1105 8. Deposition of bone 1106 9. Evidence of secondary infection 1107 10. Evidence of pathologic fracture 1108 11. Evidence of exposed bone 1109 12. Mobility or displacement of teeth 1110

B. Imaging indications (based on clinical and plain film radiograph assessment) 1111 1. Mass effect 1112 2. Altered bone density (radiolucency and/or radiopacity) 1113 3. Displaced adjacent structures 1114 4. Expansion into adjacent structures and regions 1115 5. Evidence of fracture and/or infection 1116

C. Results of differential diagnosis 1117 D. Additional presurgical studies may include: 1118

1. Surgical procedures 1119 a. Biopsy (with or without guidance imaging) 1120

i. Incisional 1121 ii. Excisional 1122

iii. Trephine 1123 iv. Core 1124

2. Imaging 1125 a. Three-dimensional (eg, conventional tomography or CT, depending on size and character) 1126 b. Magnetic resonance 1127 c. Nuclear medicine scan 1128 d. Plain radiographs, including chest radiograph and skeletal survey 1129

E. Laboratory evidence 1130 1. Abnormal laboratory values (eg, serum calcium, phosphorus, alkaline phosphatase, parathyroid 1131

hormone assay) 1132 II. Specific Therapeutic Goals for Metabolic and Dystrophic Diseases of Bone 1133 1134



Considerations for Diagnosis and Management of Pathological Conditions 1139 B. Elimination of disease 1140 C. Controlled disease progression 1141

AAOMS ParCare 2017 Diagnosis and Management of Pathological Conditions ____________________________________________________________________________________________________ III. Specific Factors Affecting Risk in the Treatment of Metabolic and Dystrophic Diseases of Bone 1142 1143



B. Associated teeth, vital and/or nonvital 1148 C. Presence of acute and/or preexisting infection 1149 D. Proximity to/invasion of adjacent structures 1150 E. Fracture or weakening of jaw and facial skeleton due to extension of disease 1151 F. Compromised airway 1152

IV. Indicated Therapeutic Parameters for Metabolic and Dystrophic Diseases of Bone 1153 1154


1157 The following procedures for the management of metabolic and dystrophic diseases of bone are not listed in 1158 order of preference: 1159

1160 A. Diagnosis by aspiration or biopsy 1161 B. Supportive, nonsurgical treatment 1162

1. No immediate treatment but deferred periodic reassessment and possible treatment for such 1163 conditions as fibrous dysplasia, osteogenesis imperfecta 1164

2. Medical management (eg, calcium supplements for osteoporosis, chemotherapy for Paget disease) 1165 3. Therapeutic injection of lesion (eg, corticosteroids) 1166

C. Surgical treatment 1167 1. Recontouring and correction of secondary deformities 1168 2. Enucleation and curettage 1169 3. Resection of involved bone 1170


1173 D. Reconstruction to restore form and/or function (Also see the Reconstructive Surgery chapter) 1174 E. Posttreatment follow-up 1175

1. Periodic clinical, laboratory, and imaging evaluation, as indicated 1176 2. Instructions to return if signs or symptoms recur before regularly scheduled follow-up appointment 1177

F. Instructions for posttreatment care and follow-up 1178 V. Outcome Assessment Indices for Metabolic and Dystrophic Diseases of Bone 1179 1180




2. Control or elimination of disease 1187 a. Reduction in number and severity of symptoms 1188 b. Reversal of damage to anatomical structures 1189 c. None or minimal progression of disease 1190


Criteria, Parameters, and Considerations for Diagnosis and Management of Pathological Conditions 1193 2. Deterioration of clinical status 1194 3. Uncontrolled progression of disease 1195

1196


____________________________________________________________________________________________________

1197

CYSTS OF SOFT TISSUE 1198 1199 This section excludes the management of salivary cysts. 1200 1201 I. Indications for Therapy for Cysts of Soft Tissue 1202 1203


A. Clinical indications 1206 1. Pain 1207 2. Deformity (eg, swelling, expansion) 1208 3. Altered sensation 1209 4. Altered function 1210 5. Drainage 1211 6. Erythema 1212 7. Movable discrete swelling 1213 8. Fistula 1214

B. Results of differential diagnosis 1215 C. Additional presurgical studies may include: 1216

1. Fine-needle aspiration or incisional biopsy for confirmation of cyst 1217 2. Microbiologic assessment for secondarily infected lesions 1218 3. Imaging 1219

a. CT, magnetic resonance imaging, or ultrasonography for large lesions possibly impinging on vital 1220 structures 1221

b. Nuclear scans as dictated by clinical examination 1222 II. Specific Therapeutic Goals for Cysts of Soft Tissue 1223 1224



Considerations for Diagnosis and Management of Pathological Conditions 1229 B. Eradication of cyst 1230

III. Specific Factors Affecting Risk in the Treatment of Cysts of Soft Tissue 1231 1232



B. Presence of acute and/or preexisting infection 1237 C. Proximity to/invasion of adjacent structures 1238

IV. Indicated Therapeutic Parameters for Cysts of Soft Tissue 1239 1240


1243 The following procedures for the management of cysts of soft tissue are not listed in order of preference: 1244


1. Enucleation of cyst 1248 2. Excision of adjacent skin/mucosa if indicated 1249


AAOMS ParCare 2017 Diagnosis and Management of Pathological Conditions ____________________________________________________________________________________________________ 1252

C. Adjunctive treatment 1253 1. Primary repair 1254 2. Repair with adjacent soft tissue transfer 1255

D. Posttreatment follow-up 1256 1. Clinical follow-up until form and/or function are restored 1257 2. Instructions to return if signs or symptoms recur before regularly scheduled follow-up appointment 1258

E. Instructions for posttreatment care and follow-up 1259 V. Outcome Assessment Indices for Cysts of Soft Tissue 1260 1261






2. Recurrence of cyst 1272

1273

1274

BENIGN TUMORS OF SOFT TISSUE 1275 1276 I. Indications for Therapy for Benign Tumors of Soft Tissue 1277 1278


A. Clinical indications 1281 1. Pain 1282 2. Deformity (eg, swelling, expansion) 1283 3. Altered sensation 1284 4. Altered function 1285 5. Induration 1286 6. Elevated temperature 1287 7. Red, white, discolored, or pigmented lesions 1288 8. Ulceration 1289 9. Secondary infection 1290

B. Imaging indications 1291 C. Results of differential diagnosis 1292 D. Results of additional studies, as indicated 1293

1. Biopsy (incisional or excisional, depending on lesion size, site, extent, character, and differential 1294 diagnosis) 1295

2. Fine-needle aspiration 1296 3. Microbiologic assessment for secondarily infected lesions 1297

II. Specific Therapeutic Goals for Benign Tumors of Soft Tissue 1298 1299





____________________________________________________________________________________________________ III. Specific Factors Affecting Risk in the Treatment of Benign Tumors of Soft Tissue 1306 1307

Severity factors that increase risk and the potential for known complications: 1308 1309 A. Presence of a general factor affecting risk, as listed in the section entitled General Criteria, Parameters, 1310

and Considerations for Diagnosis and Management of Pathological Conditions 1311 B. Presence of acute and/or preexisting infection 1312 C. Proximity to/invasion of adjacent structures 1313 D. Extent of tumor or malformation (eg, limited to primary site, beyond primary site) 1314 E. Degree of mobility of normally mobile organ/structure (eg, tongue, mandible) 1315

IV. Indicated Therapeutic Parameters for Benign Tumors of Soft Tissue 1316 1317


1320 The following procedures for the management of benign tumors of soft tissue are not listed in order of 1321 preference: 1322

1323 A. Diagnosis by aspiration or biopsy 1324

1. Primary treatment 1325 a. Local surgical (including laser, cryotherapy, and radiofrequency ablation) or chemical excision 1326


1329 B. Adjunctive treatment 1330

1. Primary or secondary reconstruction 1331 a. Vascularized or non-vascularized bone grafts 1332 b. Soft tissue flaps (eg, local, pedicled, free) 1333 c. Skin grafting or acellular dermal matrices 1334 d. Alloplasts (bone plates) 1335

2. Access osteotomies 1336 C. Posttreatment follow-up 1337

1. Clinical examination until form and/or function are restored 1338 2. Instructions to return if signs or symptoms recur before regularly scheduled follow-up appointment 1339

D. Instructions for posttreatment care and follow-up 1340 V. Outcome Assessment Indices for Benign Tumors of Soft Tissue 1341 1342




2. No evidence of disease 1349 B. Known risks and complications associated with therapy 1350


2. Local recurrence of tumor 1353

1354

1355

MALIGNANT TUMORS OF SOFT TISSUE 1356 1357

AAOMS ParCare 2017 Diagnosis and Management of Pathological Conditions ____________________________________________________________________________________________________ Malignant tumors are managed only in part by surgery. Management is frequently comprehensive and involves 1358 an interdisciplinary team that includes specialties of Oral and Maxillofacial Surgery, radiation therapy, medical 1359 oncology, dentistry, and various support services. 1360 1361 I. Indications for Therapy for Malignant Tumors of Soft Tissue 1362 1363


A. Clinical indications 1366 1. Pain 1367 2. Deformity (eg, swelling, expansion) 1368 3. Altered sensation 1369 4. Altered function 1370 5. Induration 1371 6. Hemorrhage 1372 7. Elevated temperature 1373 8. Red, white, discolored, or pigmented lesions 1374 9. Ulceration 1375 10. Evidence of tumor and/or regional lymphadenopathy 1376 11. Secondary infection 1377

B. Imaging indications 1378 1. Proximity to/invasion of adjacent bony or soft tissue structures 1379


1. Biopsy (incisional or excisional, depending on lesion size, site, extent, character, and differential 1382 diagnosis) 1383

2. Fine-needle aspiration 1384 3. Microbiologic assessment for secondarily infected lesions 1385

E. Presurgical studies for staging purposes: 1386 1. Imaging 1387

a. CT, magnetic resonance imaging, or ultrasonography of primary site for extent of local disease, to 1388 evaluate for regional involvement and to evaluate for the presence of metastatic disease if 1389 appropriate 1390

b. Nuclear medicine scan for evaluation of possible distant metastatic sites (bone scan, PET scan, 1391 PET/CT scan) 1392

c. Conventional films as adjunct, including chest radiograph to complete TNM (Tumor, Node, 1393 Metastasis) staging and skeletal survey for presumptive metastatic lesion 1394

2. Laboratory assessment 1395 a. Culture and sensitivity for secondarily infected lesion 1396 b. Blood tests for presumptive malignant lesions, including complete blood cell count and liver 1397

function tests for tumors that may metastasize to the liver as part of presurgical workup 1398 3. Surgical 1399

a. Evaluation for presence of synchronous tumors that may include evaluation under anesthesia and 1400 panendoscopy, if indicated 1401

4. Clinical staging 1402 II. Specific Therapeutic Goals for Malignant Tumors of Soft Tissue 1403 1404




III. Specific Factors Affecting Risk in the Treatment of Malignant Tumors of Soft Tissue 1411 1412


____________________________________________________________________________________________________ Severity factors that increase risk and the potential for known complications: 1413


and Considerations for Diagnosis and Management of Pathological Conditions 1416 B. Presence of acute and/or preexisting infection 1417 C. Proximity to/invasion of adjacent structures 1418 D. Extent of tumor (eg, limited to primary site, beyond primary site) 1419 E. Presence and extent of regional and/or distant metastasis 1420 F. Degree of mobility of normally mobile organ/structure (eg, tongue, mandible) 1421

IV. Indicated Therapeutic Parameters for Malignant Tumors of Soft Tissue 1422 1423


1426 The following procedures for the management of malignant tumors of soft tissue are not listed in order of 1427 preference: 1428

1429 A. Diagnosis by either aspiration or biopsy 1430 B. Primary treatment 1431

1. Local surgical or chemical excision for malignant tumors deemed to be local 1432 2. Excision of associated structures for invasive tumors as necessary in order to obtain clear anatomic 1433

margins 1434 3. Excision of associated structures in the region, including neck dissection when cervical lymph nodes 1435

are present (N+) or when high risk of occult neck disease exists in patients with malignant disease 1436 4. Adjuvant treatment with radiation therapy and/or chemotherapy when indicated 1437


1440 C. Adjunctive treatment (Also see the Reconstructive Surgery chapter) 1441

1. Adjunctive radiation therapy and/or chemotherapy 1442 2. Primary or secondary reconstruction 1443

a. Vascularized or non-vascularized bone grafts 1444 b. Soft tissue flaps (eg, local, pedicled, free) 1445 c. Skin grafting or acellular dermal matrices 1446 d. Alloplasts (bone plates) 1447

3. Access osteotomies 1448 D. Posttreatment follow-up 1449

1. Baseline plain radiographic imaging in the initial postoperative period when bone evaluation is 1450 needed 1451

2. Plain radiographs of the chest at regularly scheduled intervals 1452 3. Special imaging studies (CT, magnetic resonance imaging, bone scans, PET or PET/CT, according to 1453

tumor type and location and the clinician’s level of suspicion for recurrent and metastatic disease) 1454 4. Clinical and imaging examination for malignant tumors for the patient's lifetime 1455 5. Instructions to return if signs or symptoms recur before regularly scheduled follow-up appointment 1456

E. Instructions for posttreatment care and follow-up 1457 V. Outcome Assessment Indices for Malignant Tumors of Soft Tissue 1458 1459




2. No evidence of disease 1466 B. Known risks and complications associated with therapy 1467



2. Local recurrence of tumor or metastasis 1470 3. Residual functional deformity 1471 4. Residual structural deformity 1472 5. Damage to or loss of adjacent structures 1473 6. Excess morbidity from radiation therapy or chemotherapy 1474 7. Death from tumor metastasis, tumor extension, or as a result of tumor therapy 1475

1476

1477

VASCULAR LESIONS 1478 1479 I. Indications for Therapy for Vascular Lesions 1480 1481


A. Clinical indications 1484 1. Pain 1485 2. Deformity (eg, swelling, expansion) 1486 3. Altered sensation 1487 4. Altered function 1488 5. Induration 1489 6. Thrill 1490 7. Bruit 1491 8. Hemorrhage 1492 9. Elevated temperature 1493 10. Red, white, discolored, or pigmented lesions 1494 11. Secondary infection 1495

B. Imaging indications 1496 1. Infiltration of adjacent soft tissue and/or bony structures 1497 2. Assess possible source (feeding vessel) 1498

C. Studies may include: 1499 1. Imaging 1500

a. Conventional angiography with possible therapeutic intervention and/or ultrasonographic 1501 examination for presumptive vascular malformation 1502

b. Magnetic resonance imaging or magnetic resonance angiography for presumptive vascular 1503 malformations 1504

c. CT angiography 1505 2. Laboratory assessment when needed 1506

a. Culture and sensitivity for secondarily infected lesion 1507 D. Results of differential diagnosis 1508 E. Results of additional studies, as indicated 1509

1. Fine-needle aspiration 1510 2. Biopsy (incisional or excisional, depending on lesion size, site, extent, character, and differential 1511

diagnosis 1512 II. Specific Therapeutic Goals for Vascular Lesions 1513 1514



Considerations for Diagnosis and Management of Pathological Conditions 1519 B. Eradication of tumor or malformation 1520

III. Specific Factors Affecting Risk in the Treatment of Vascular Lesions 1521


____________________________________________________________________________________________________ 1522



B. Presence of acute and/or preexisting infection 1527 C. Proximity to/invasion of adjacent structures 1528 D. Extent of tumor or malformation (eg, limited to primary site, beyond primary site) 1529 E. Degree of mobility of normally mobile organ/structure (eg, tongue, mandible) 1530 F. Excessive bleeding 1531 G. Pregnancy 1532

IV. Indicated Therapeutic Parameters for Vascular Lesions 1533 1534


1537 The following procedures for the management of vascular lesions are not listed in order of preference: 1538

1539 A. Diagnosis by physical examination, imaging, aspiration, or biopsy 1540 B. Primary treatment 1541

1. Embolization and/or vessel ligation for vascular lesions 1542 2. Excision or resection (possibly postembolization) 1543



1. Laser 1548 2. Sclerotherapy 1549 3. Primary or secondary reconstruction 1550

a. Bone grafts 1551 b. Skin grafting 1552 c. Soft tissue flaps (eg, local, pedicled, free) 1553 d. Alloplasts (bone plates) 1554

4. Access osteotomies 1555 D. Posttreatment follow-up 1556

1. Clinical examination for vascular lesions until form and/or function are restored 1557 2. Instructions to return if signs or symptoms recur before the regularly scheduled follow-up 1558

appointment 1559 3. Repeat imaging study (based on symptoms and clinical findings) 1560

a. Conventional angiogram 1561 b. CT angiogram 1562 c. Magnetic resonance imaging angiogram 1563

E. Instructions for posttreatment care and follow-up 1564 V. Outcome Assessment Indices for Vascular Lesions 1565 1566




2. Disease eliminated 1573 B. Known risks and complications associated with therapy 1574



2. Local recurrence of tumor 1577 3. Cosmetic deformity and functional limitations 1578 4. Death from hemorrhage 1579

1580

1581

MUCOSAL DISEASES 1582 1583 I. Indications for Therapy for Mucosal Diseases 1584 1585


A. Clinical indications 1588 1. Pain 1589 2. Altered function 1590 3. Altered appearance (eg, change in color or character) 1591 4. Altered mucosal integrity (eg, ability to elevate or wipe off lesion by rubbing surface) 1592

B. Results of differential diagnosis 1593 C. Additional studies, as indicated, may include: 1594

1. Exfoliative cytology 1595 2. Microbiologic assessment 1596 3. Diagnosis via biopsy for conventional staining, direct or indirect immunofluorescence 1597 4. Brush biopsy 1598

II. Specific Therapeutic Goals for Mucosal Diseases 1599 1600



Considerations for Diagnosis and Management of Pathological Conditions 1605 B. Elimination or control of disease 1606 C. Elimination of symptoms 1607

III. Specific Factors Affecting Risk in the Treatment of Mucosal Diseases 1608 1609



B. Presence of acute and/or preexisting infection 1614 IV. Indicated Therapeutic Parameters for Mucosal Diseases 1615 1616


1619 The following procedures for the management of mucosal diseases are not listed in order of preference: 1620

1621 A. Diagnosis by physical examination and/or biopsy 1622 B. Primary treatment 1623

1. Observation and periodic follow-up (eg, lichen planus) 1624 2. Elimination of etiologic factor (eg, change medication in cases of lichenoid drug reaction) 1625 3. Medication (eg, antifungal, topical and/or systemic corticosteroid therapy, antineoplastic, other 1626

immune modulation therapy) 1627 4. Surgical removal 1628 5. Ophthalmologic consultation when indicated (eg, pemphigus) 1629

1630


____________________________________________________________________________________________________ All specimens must be submitted for pathologic assessment. 1631


1. Ensuring oral hygiene 1634 2. Evaluation of medications 1635 3. Nutritional support 1636

D. Posttreatment follow-up (dependent on nature of disease) 1637 1. Consider repeat biopsy if change occurs in the clinical appearance of the lesion 1638

E. Instructions to return if signs or symptoms recur before the regularly scheduled follow-up appointment 1639 F. Instructions for posttreatment care and follow-up 1640

V. Outcome Assessment Indices for Mucosal Diseases 1641 1642




2. Elimination or amelioration of symptoms (pain) 1649 3. Elimination or control of disease 1650


Criteria, Parameters, and Considerations for Diagnosis and Management of Pathological Conditions 1653 2. Recurrence of symptoms 1654 3. Recurrence of disease 1655 4. Functional disability 1656 5. Chronic pain 1657

1658

1659

SALIVARY GLAND DISEASES: BENIGN AND MALIGNANT TUMORS AND 1660

MISCELLANEOUS LESIONS 1661 1662 I. Indications for Therapy for Salivary Gland Diseases: Benign and Malignant Tumors and Miscellaneous 1663

Lesions 1664 1665


A. Clinical indications 1668 1. Pain 1669 2. Mass effect (eg, swelling, expansion) 1670 3. Ulceration 1671 4. Altered neurologic function dependant on anatomic location of gland 1672 5. Reduced or absent salivary flow 1673 6. Alteration in color of overlying tissue 1674 7. Fluctuance 1675 8. Secondary infection 1676 9. Altered speech or masticatory function 1677 10. Evidence of regional or distant metastasis 1678 11. Auditory changes 1679

B. Imaging indications 1680 1. Displacement of adjacent anatomical structures 1681 2. Proximity to/invasion of adjacent structures (eg, deep lobe of parotid gland, palatal bone) 1682



1. Fine-needle aspiration 1685 2. Incisional or excisional biopsy, depending on lesion location, extent, and character 1686 3. Core needle biopsy with or without imaging guidance. 1687

E. Additional presurgical studies may include: 1688 1. Magnetic resonance imaging, CT or PET, PET/CT scanning, as indicated, for evaluation of primary 1689

site, neural involvement, and metastases 1690 2. Plain radiographs, including panoramic radiograph, for intraosseous salivary gland tumors or other 1691

tumors with suspected bone involvement 1692 3. Chest radiographs in cases of malignant lesions 1693 4. Laboratory tests, including complete blood cell count and liver function tests in cases of malignant 1694

disease 1695 5. Contrast-enhanced sialography 1696 6. Quantitative and qualitative salivary flow studies 1697

II. Specific Therapeutic Goals for Salivary Gland Diseases: Benign and Malignant Tumors and 1698 Miscellaneous Lesions 1699

1700 The goal of therapy is to restore form and/or function. However, risk factors and potential complications may 1701 preclude complete restoration of form and/or function. 1702


Considerations for Diagnosis and Management of Pathological Conditions 1705 B. Eradication of cyst or tumor 1706

III. Specific Factors Affecting Risk in the Treatment of Salivary Gland Diseases: Benign and Malignant 1707 Tumors and Miscellaneous Lesions 1708

1709 Severity factors that increase risk and the potential for known complications: 1710


and Considerations for Diagnosis and Management of Pathological Conditions 1713 B. Presence of acute and/or preexisting infection 1714 C. Proximity to/invasion of adjacent structures 1715 D. Extent of cyst or primary tumor 1716 E. Presence and extent of regional and/or distant metastases 1717

IV. Indicated Therapeutic Parameters for Salivary Gland Diseases: Benign and Malignant Tumors and 1718 Miscellaneous Lesions 1719

1720 The presurgical assessment includes, at a minimum, a comprehensive history and a physical examination. An 1721 imaging evaluation may be indicated depending on the salivary lesion being evaluated. Also see the Patient 1722 Assessment chapter. 1723

1724 The following procedures for the management of salivary gland diseases are not listed in order of preference: 1725


1. Marsupialization (eg, ranula) 1729 2. Local excision of lesion (eg, canalicular adenoma) 1730 3. Local excision of lesion with adjacent tissue (eg, mucous retention phenomenon, pleomorphic 1731

adenoma) 1732 4. Sialadenectomy (eg, sublingual gland for ranula, pleomorphic adenoma of major gland) 1733 5. Sialadenectomy with excision of associated adjacent tissues (eg, malignant tumor of major gland) 1734 6. Simultaneous or delayed prophylactic or therapeutic lymph node dissection (eg, specific malignant 1735

tumors) 1736 7. Radiation therapy and/or chemotherapy for malignant tumors 1737 8. Sialoendoscopy for benign duct blockage 1738 9. Sialography for benign duct blockage and stenosis 1739


____________________________________________________________________________________________________ 1740

All specimens must be submitted for pathologic assessment. 1741 1742

C. Adjunctive treatment 1743 1. Radiation therapy and/or chemotherapy for malignant tumors, when indicated 1744 2. Reconstructive procedures (Also see the Reconstructive Surgery chapter) 1745

a. Bone, nerve, and soft tissue grafts, including local pedicled and microvascular free grafts 1746 3. Nutritional support 1747

D. Posttreatment follow-up 1748 1. Clinical follow-up of cyst or benign tumors until form and/or function are restored 1749 2. Annual clinical follow-up of recurrence-prone tumor (eg, pleomorphic adenoma), with special 1750

reference to primary site 1751 3. Continual clinical examination for malignant tumors for the patient’s lifetime, with type of 1752

examination and imaging depending on tumor type, likely site of metastasis, and likely length of time 1753 to appearance of recurrence or metastasis 1754

4. Instructions to return if signs or symptoms recur before the regularly scheduled follow-up 1755 appointment 1756

E. Instructions for posttreatment care and follow-up 1757 V. Outcome Assessment Indices for Salivary Gland Diseases: Benign and Malignant Tumors and 1758

Miscellaneous Lesions 1759 1760




2. Patient free of cyst or tumor at primary, regional, or distant site 1767 B. Known risks and complications associated with therapy 1768


2. Local recurrence of cyst or tumor 1771 3. Metastasis 1772 4. Death from tumor metastasis, extension, or therapy 1773

1774

1775

SALIVARY GLAND INFECTIONS 1776 1777 I. Indications for Therapy for Salivary Gland Infections 1778 1779


A. Clinical indications 1782 1. Pain 1783 2. Swelling 1784 3. Erythema 1785 4. Altered neurologic function 1786 5. Drainage of pus or mucus 1787 6. Reduced salivary flow 1788 7. Sinus tracts (fistula) 1789 8. Fluctuance 1790 9. Induration 1791 10. Fever 1792 11. Dehydration 1793


12. Leukocytosis 1794 13. Elevation of sedimentation rate 1795 14. Evidence from culture 1796

B. Results of differential diagnosis 1797 C. Results of additional studies, as indicated 1798

1. Culture and sensitivity 1799 2. Gram stain 1800 3. Aspiration 1801

D. Additional studies, as indicated, may include: 1802 1. Radiographs for sialolith (occlusal films) 1803 2. Office-based scans (panoramic and/or cone beam computed tomography) 1804 3. CT 1805 4. Magnetic resonance imaging 1806 5. Sialography 1807 6. Complete blood cell count with differential count 1808 7. Sedimentation rate 1809 8. Evaluation for underlying disease process (eg, alcohol, starvation, diabetes, immunosuppression, 1810

collagen vascular disease, etc) 1811 9. Microbiologic assessment 1812

II. Specific Therapeutic Goals for Salivary Gland Infections 1813 1814



Considerations for Diagnosis and Management of Pathological Conditions 1819 B. Eradication of infection 1820

III. Specific Factors Affecting Risk in the Treatment of Salivary Gland Infections 1821 1822



B. Presence of acute infection 1827 C. Extent of infection (eg, localized, diffuse) 1828 D. Identification of organism (eg, known, classified) 1829 E. Virulence of organism and/or responsiveness to antibiotics 1830 F. Potential for injury to adjacent structures 1831 G. Degree of vascularity in region (eg, after radiation therapy, multiple operations) 1832 H. Postsurgical state with intensive care unit admission 1833 I. Presence of chronic infection 1834 J. Presence of sialoliths 1835

IV. Indicated Therapeutic Parameters for Salivary Gland Infections 1836 1837


1840 The following procedures for the management of salivary gland infections are not listed in order of 1841 preference: 1842

1843 A. Appropriate antibiotic therapy 1844 B. Incision and drainage (if indicated) 1845 C. Control of pain 1846 D. Management of underlying medical condition when present 1847 E. Maintenance of hydration and nutrition 1848


____________________________________________________________________________________________________ F. Sialolithotomy 1849 G. Sialodochotomy 1850 H. Sialodochoplasty 1851 I. Sialadenectomy 1852 J. Instructions for posttreatment care and follow-up 1853

1854 All specimens must be submitted for microbiologic assessment. 1855

1856 V. Outcome Assessment Indices for Salivary Gland Infections 1857 1858




2. Absence of infection 1865 B. Known risks and complications associated with therapy 1866


2. Persistent infection 1869 3. Systemic sequelae of the infection 1870

1871

1872

SALIVARY GLAND DISEASES: OTHER LOCAL OR SYSTEMIC 1873 1874 This section includes but is not limited to Sjögren syndrome, sarcoidosis, and necrotizing sialometaplasia. 1875 1876 I. Indications for Therapy for Salivary Gland Diseases: Other Local or Systemic 1877 1878


A. Clinical indications 1881 1. Xerostomia 1882 2. Salivary gland enlargement 1883 3. Ulceration 1884 4. Hypersalivation 1885

B. Results of differential diagnosis 1886 C. Results of additional studies, as indicated 1887

1. Clinical 1888 a. Keratoconjunctivitis sicca 1889 b. Rheumatoid or other immune mediated arthritis 1890 c. Lacrimal gland enlargement 1891 d. Signs and symptoms of sarcoidosis (eg, hilar lymphadenopathy, Heerfordt syndrome, 1892

hypercalcemia, Löfgren syndrome) 1893 2. Imaging 1894

a. Sialography 1895 b. Nuclear medicine scan (bone scan) 1896 c. CT 1897 d. Magnetic resonance imaging 1898 e. Chest radiograph for sarcoidosis 1899

3. Laboratory 1900 a. Evidence of Sjögren syndrome (eg, SSA, SSB, antinuclear antibody, latex fixation test) 1901 b. Elevated sedimentation rate 1902


c. Serum angiotensin-converting enzyme (eg, sarcoidosis) 1903 4. Surgical 1904

a. Fine-needle aspiration 1905 b. Biopsy (lip vs parotid) 1906 c. Core needle biopsy 1907

D. Additional presurgical studies may include: 1908 1. Magnetic resonance imaging or CT 1909

II. Specific Therapeutic Goals for Salivary Gland Diseases: Other Local or Systemic 1910 1911



Considerations for Diagnosis and Management of Pathological Conditions 1916 B. Elimination or control of disease 1917

III. Specific Factors Affecting Risk in the Treatment of Salivary Gland Diseases: Other Local or Systemic 1918 1919



B. Presence of acute and/or preexisting infection 1924 C. Potential for injury to adjacent structures 1925

IV. Indicated Therapeutic Parameters for Salivary Gland Diseases: Other Local or Systemic 1926 1927


1930 The following procedures for the management of salivary gland diseases are not listed in order of preference: 1931

1932 A. Diagnosis by aspiration or biopsy 1933 B. Medical treatment of underlying disorders 1934 C. Palliative treatment of pain, dehydration, malnutrition 1935 D. Sialadenectomy in chronic and persistent disease 1936 E. Instructions for posttreatment care and follow-up 1937

V. Outcome Assessment Indices for Salivary Gland Diseases: Other Local or Systemic 1938 1939




2. Patient free of disease 1946 3. Reduction in number and severity of symptoms 1947 4. Reversal of damage to structures 1948 5. Controlled progression of disease 1949 6. Improved clinical status 1950


Criteria, Parameters, and Considerations for Diagnosis and Management of Pathological Conditions 1953 2. Deterioration of clinical status or progression of disease 1954 3. Malignant transformation 1955 4. Injury (temporary or permanent) to sensory or motor nerves 1956

1957


____________________________________________________________________________________________________

1958

SELECTED REFERENCES - DIAGNOSIS AND MANAGEMENT OF 1959

PATHOLOGICAL CONDITIONS 1960 1961 This list of selected references is intended only to acknowledge some of the sources of information drawn on in 1962 the preparation of this document. Citation of the reference material is not meant to imply endorsement of any 1963 statement contained in the reference material. The list is not an exhaustive compilation of information on the 1964 topic. Readers should consult other sources to obtain a complete bibliography. 1965 1966 1967

SPECIAL CONSIDERATIONS FOR PEDIATRIC DIAGNOSIS AND MANAGEMENT OF 1968 PATHOLOGICAL CONDITIONS 1969

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1992 1983 1984 1985

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