ORAL PATHOLOGY

From the Clinic Manual

Associated Forms

Oral Pathology Requisition Form

Introduction

A. Definition: Oral pathology is the specialty of dentistry and pathology which deals with nature, identification, and management of diseases affecting the oral and maxillofacial regions. It is a science that investigates the causes, processes, and effects of these diseases. The practice of oral pathology includes research, diagnosis of diseases using clinical, radiographic, microscopic, biochemical, or other examinations and management of patients.

B. Scope of Care: The practice of pathology is essential to patient care. The oral pathologist provides services including, but not limited to, the examination of patient related oral and maxillofacial hard and soft tissue specimens, clinical interpretation and consultation, scientific investigation, and education to be effective in prevention, recognition, diagnosis, management, and prognosis of diseases affecting the oral and maxillofacial regions.

Biopsy Specimen

A. Procedures:

SDM policy requires that all abnormal tissue removed is to be submitted for histopathologic examination. This policy does not apply to clinically normal soft or hard tissues removed to facilitate closure of a surgical site, normal tissue removed in preparation for a prosthesis, or extracted teeth. When obtaining a biopsy specimen, the clinician must:

• Take care to evaluate the site for potential complications.
• Ensure representative sampling of the lesion if it is not totally excised.
• Submit the specimen the same day it was taken. If the specimen was taken after 4:00 p.m., it must be submitted to the Oral Pathology lab no later than 10:00 a.m. on the next business day.

Good surgical technique, sharp instruments, proper placement of anesthetic solution, and careful delivery of the tissue sample are essential to avoid mutilation of the specimen. Once obtained, the specimen must be placed immediately into an appropriate fixative, usually 10 percent neutral buffered formalin.

The specimen container must be properly identified and delivered to the oral pathology service together with a tissue examination form that contains all necessary information. This includes, but is not limited to the following:

• Specimen container labels must be completely filled in.
• The appropriate fee must be charged in SOE.

Radiographs should be included whenever the specimen is taken from an intrabony lesion.

B. Criteria:

1. Specimen container is properly identified.
2. Specimen container has sufficient quantity of approved fixative.
3. Tissue examination form is included and contains all necessary information.
4. Radiographs accompany intrabony lesion.
5. Specimen is free of obvious mutilation.
6. Surgical margins, if requested for adequacy of surgical removal, are identified and properly labeled.

Microscopic Slide With Sections from Patient’s Specimen

A. Procedures: Upon delivery of a tissue specimen to the oral pathology service, the specimen must be carefully handled to ensure accurate identification during receipt, accessioning, and all other laboratory processes. Prepared microscopic slides must be diagnostic in quality.

B. Criteria:

1. Accurate identification of specimens and their accompanying examination forms is maintained throughout all laboratory processes.
2. Microscopic slides are diagnostic in quality.
3. Microscopic slides are accurately labeled.
4. Diagnoses of a serious nature are reported to the contributor in the most expeditious manner.

Tissue Examination Report

A. Procedures: Prepared tissue sections from patient’s specimen will be examined microscopically by the oral pathologist who renders a written and signed report of findings. A cop of the report is maintained in the laboratory’s records. Diagnoses of a serious nature are reported in the most expeditious manner, usually by telephone, with a written and signed report to follow by fax and/or mail. When appropriate, microscopic slides are submitted for review by peers or by consultants. When differences of interpretation occur, a method of resolving differences has been established and is effectively used.

B. Criteria:

1. Microscopic findings are clearly and concisely rendered in a written and signed report.
2. A copy of each report is maintained in the laboratory’s records.
3. Peer review or consultant opinions are obtained when necessary.
4. A method of resolving differences of opinion has been established and is effectively used.
5. Diagnoses of a serious nature are reported to the contributor in the most expeditious manner.