cone beam international magazine of cone beam dentistry

opinion _ oral surgery I I 07cone beam2_2014 privilege and exert anti-inflammatory abilities like many other mesenchymal stem cells. Introduced in the late 1990s, CBCT is becoming themainimagingarmamentariumoforalsurgeries, as it provides more and comprehensive anatomical information and data that help to improve pre- operativeandperoperativeclinicalimplementation of the extraction of impacted teeth, cystectomies, removal of benign jaw tumours, and placement of dental implants. While oral surgery continues to develop further with new technologies and visions, the assessment and diagnosis of patients will still form the corner- stone of any surgical specialty. Decision-making, a complex cognitive process that involves consid- eration of surgical patients’ complaints and pref- erences, the availability of evidence-based data, as wellaspractitioners’case-specificclinicaljudgement, consequentlyremainsanongoingchallengefororal surgeons and dental general practitioners alike. Inter-clinician variability and disparity in deci- sion-making are very well known in dentistry and medicine.1–5 In oral surgery, treatment recommen- dations, options and decisions can vary widely among practising dentists. In many cases, they are based more on personal values and expertise than on objective, rigorous or evidence-based analysis of treatment alternatives, risks, prognosis and ben- efits. There are treatment guidelines for the man- agement of impacted teeth but none for aggressive and relapsing jaw cysts and odontogenic tumours, for which documented long-term treatment suc- cess has not yet been achieved. Owing to this lack, the treatment planning process in oral surgery remains a dilemma and warrants further interest and research. As a matter of fact, regional differences in training, education, and dental school treatment philosophy, the “schools effect”, may significantly influence decision-making processes.6, 7 It seems likely that specialists are much more confident in their ability to manage surgical cases successfully. A better understanding of interclinician variability in collaborative decision-making will definitely help the oral health community in improving con- sistency and implementation of oral surgical treat- ment recommendations and options. One of the most promising approaches is proba- bly the non-surgical medical treatment of tumours and lesions of the jaws, as reported by Marx and Stern in 2003.8 They found a 65 per cent rate of complete resolution of central giant cell granu- lomas (CGCGs) in the jaws through intra-lesional corticosteroid injections. Dexamethasone and tri- amcinolone are currently the most popular intra- lesional steroids, and weekly injections with these are common practice not only for CGCGs, but also for solitary jawbone lesions of Langerhans cell histiocytosis, a proliferative disease of the macro- phage/dendritic cell lineage. CGCGs, considered troublesome pathologies, are also currently medically managed by calcitonin, a polypeptide hormone produced in humans pri- marily by parafollicular cells of the thyroid gland, C cells. Calcitonin is known to counteract parathy- roid hormone, inhibit osteoclast activity and in- creasecalciuminfluxinbones.Inthisregard,salmon calcitonin, which is used in postmenopausal osteo- porosis, hypercalcaemia, Paget’s disease and bone metastases, is considered to be more active than human calcitonin and to be an important tool in the medical treatment of jaw tumours and lesions. Themainquestioniswhetherintranasalsalmoncalci- tonin is as effective as subcutaneous human calci- tonininthemedicaltreatmentofCGCGsofthejaws. Finallyyetimportantly,manycliniciansandclin- ical investigators believe in the radical treatment of ameloblastomas,odontogenictumourswellknown for their aggressiveness and high recurrence after conservative treatment. For these reasons, en bloc resectionisoftenimplemented,whichincludesare- sectionofatleast1–2cmofnormalsoundjawbone beyond the tumour’s margins. Such a radical sur- gical procedure is unacceptable in children with growing jaws though because segmental resection oftenleadstojawdeformityanddysfunction,which in turn may hamper physical growth and the men- tal wellbeing of the child/adolescent. At the very least, conservative treatment of an ameloblastoma, if indicated, will gain time until growth of the jaw is finally complete.9 Considering that the majority of ameloblastomas in children are unicystic and have a very low rate of recurrence,10 theycanbemanagedbyenucleation,aconservative form of surgical treatment.11–14_ Editorial Note: A complete list of references is available fromthepublisher. Dr Ziad Noujeim is a currently Director of the Oral Pathology Postgraduate Programme at the Lebanese University’s School of Dentistry in Beirut in Lebanon and a Diplomate of the European Board of Oral Surgery. He can be contacted at ziadnari@hotmail.com. cone beam_about the author