Submission Policy on Excised Tissue
All tissue removed from the oral and maxillofacial region should be submitted to a pathology laboratory for examination. Histopathologic examination of such tissues should be performed by an oral and maxillofacial pathologist. Tissues possibly exempt from the requirement of submission to a laboratory include:
- extracted teeth lacking attached soft tissue;
- extirpated dental pulp tissue;
- clinically normal tissue;
- excess donor tissue resulting from grafting procedures.
Gross description of all removed tissues should be entered into the patient's dental/medical record by the attending dentist/physician.
The pathology laboratory must prepare and transmit to the attending doctor a written report of the diagnosis. The diagnosis should be discussed with the patient by the attending doctor in a timely manner, and the report should be filed with the patient's dental/medical record.
Submission of removed tissues to a pathology laboratory offers the opportunity to:
- establish a definitive diagnosis;
- confirm a provisional clinical diagnosis;
- provide additional information in instances where there is no clinically evident cause for a lesion, or when there is no resolution after appropriate, conservative treatment;
- establish the adequacy of surgical margins;
- provide diagnostic information to the clinician for management of disease.
Knowledge gained through histopathologic examination is useful in estimating clinical behavior and prognosis of disease, and in assessing the need for any additional therapy and follow-up evaluation. Submission of removed tissues to a pathology laboratory for diagnostic examination constitutes a generally accepted standard of patient care. Documentation of tissue examination and diagnosis enhances the validity of patient management decisions, increases the likelihood of positive clinical outcomes, and substantiates the patient record in the medicolegal context.