Th 331135

Don't lose sight of the big picture

Jan. 1, 2010
Do you drill, fill, and bill, or do you practice oral medicine?

For more on this topic, go to and search using the following key words: oral medicine, recare visit, mobility, adenocarcinoma, lesion, Dr. Brian Nylaan.

Do you drill, fill, and bill, or do you practice oral medicine?

Does your career path involve just fixing teeth or do you actively involve yourself in your patients' total health? Have you fallen prey to the numbers game, pricing your work like a store–bought commodity while losing sight of the big picture? My patient, Jim — a healthy 60–year–old — was glad I didn't.

Jim came to see me on a busy day, his chief complaint being he talked funny and his tongue felt weird. Knowing him for my entire career, we sat down and talked about some unique complaints. Posing the necessary questions to him, my first conclusion was his speech seemed normal but he deserved a thorough oral examination.

Click here to enlarge image

Visually, I saw nothing out of the ordinary. No discolorations, no swelling, and no open lesions were apparent. My schedule was tightening as my frustration increased. Should I have just dismissed him with a tongue brush until his next recare visit?

Before that, we took a look at mobility. Hundreds of times I had asked patients to fully extend their tongues to the left and right, making sure the range of motion was symmetrical. Jim was the first to fail that test.

My next step was to explain that there could be a problem, which a specialist could diagnose. With my urging, he went to an oral surgeon, then to an otolaryngologist, followed by a neurologist, and ending with an oncologist.

It was adenocarcinoma, a three–cm lesion bilaterally set in the anterior portion of his tongue. Two teams of surgeons, following a submandibular track, took 12 hours to remove the lesion by resecting the entire anterior tongue, then grafting a portion of his thigh to replace it. Intense radiation and chemotherapy followed. This shrank the new tongue to nothing, precipitated osteoradionecrosis, but gave him life.

Every time we meet, this man gives me chills when he thanks me for saving his life. To think I could have dismissed his complaint as nonsense is scary, considering the impact of a treatment delay on his prognosis. I am glad I listened that day and didn't let the schedule control my judgment. The smile on Jim's face is worth much more than money.

Dr. Brian Nylaan has practiced in Grand Rapids, Mich., for the last 24 years. He and his team enjoy exploring new technologies to improve the quality of care for their patients. He can be reached at [email protected].

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