Expert: Mark Bornfeld DDS - 3/1/2009

Question
My nine-year-old son was just diagnosed (yesterday) with an ameloblastoma
in the right mandible. This was confirmed by a frozen section biopsy at a
children's hospital in the New York City area. We are also awaiting the results
of  a fresh section. But the oral surgeon who performed the procedure
seemed pretty certain of the diagnosis. The problem was initially found at a
recent check up when a family dentist noticed that my son, about to turn 9,
hadn't yet gotten a 6-year molar in his right mandible. This was a new dentist
for us as we had recently relocated for my husband's work. First question: at
what point should a health care professional become suspicious of a missing
molar? Should our previous dentist and/or pediatrician have acted on this?
Also, the oral surgeon who performed the procedure wants to perform a
more complete excision almost immediately. He is young but confident. How
do I know if he is really qualified? How can I find someone who might be a
specialist in this type of disorder? We live in the New York City area. Any
insight would be appreciated. Thanks very much.

Answer
Dear Camille,

Implicit in your question is the suspicion that your son's previous dentist was careless in not diagnosing the ameloblastoma (or at least having some inkling that something was wrong). Although there is no way to know for sure without more specific knowledge of the chronology of your son's previous dental visits, I would be inclined to give the previous dentist the benefit of the doubt. Even if the previous dentist took x-rays that indicated the congenital absence of the first permanent molar, it might not yet have been evident that an odontogenic lesion was present at the time. Most of these lesions start at a location that is low in the mandible, where they would be out of the range of intra-oral (in-the-mouth) x-rays. Most dentists do not have facilities for panoramic or other extra-oral x-rays, and it would not be routine to refer a young child for one of these x-rays. Ameloblastoma is quite rare in a child so young, and the failure of a permanent tooth to form most commonly has no implications other than the lack of a tooth. I have never personally seen an ameloblastoma in a child in 32 years of practice, and I can easily imagine myself missing an early lesion like this in a child. All disorders ultimately start from zero, and they all must progress to a point where they are detectable before they can be discovered. The important thing here is that the problem has been found, and it will now be managed. It is unlikely that any harm will come as a result of not discovering the problem earlier.

That being said, ameloblastoma is a type of lesion that must be treated properly. Typically, these growths must be aggressively removed along with a relatively wide margin of clinically normal tissue so that risk of recurrence can be kept to a minimum. Although the approach is surgical and would typically be performed by an oral surgeon or a head and neck surgeon, I prefer to have an oral pathologist directing the treatment. Oral pathologists are more conversant with the clinical behavior of these lesions, and have a greater familiarity with the clinical responses that can be expected from the available therapeutic approaches.

To find local oral pathologists, you can consult the web site of the American Academy of Oral and Maxillofacial Pathology:

http://tinyurl.com/c9s467

Of those listed, I have the closest working relationship with Dr. Paul Freedman and his partner, Dr. Stanley Kerpel. If you don't mind going to Columbia University, they are certainly worth the trip. Dr. Fantasia and Dr. Zegarelli are also highly recommended.

Good luck!

Mark Bornfeld DDS
www.dentaltwins.com
Brooklyn, NY