A dental appointment at sea often consists of routine cleanings and cavity fillings, but for one newly-commissioned ensign, it led to a complex and life-altering diagnosis, reports dvidshub.
Ens. Ashley Watson, a Sailor assigned to the America-class amphibious assault ship USS Tripoli (LHA 7), presented unusual symptoms to her ship’s dental officer, which ultimately led to her oral cancer diagnosis.
“While underway around South America, [Watson] came into the shipboard dental clinic with a chief complaint of limited jaw opening,” said Lt. Jennifer Kolin, Tripoli’s sole dental officer. “[Her] secondary and tertiary concerns were jaw pain and numbness on the left side of her tongue. It was concerning to me that her jaw opening was so limited. She could only open her mouth 15 millimeters, which is about 35-40 percent of normal opening for a person her age.”
Naval Medical Center San Diego
Kolin identified that her shipmate’s uncommon symptoms required specialist care, and her initiative ultimately led Watson to a highly-specialize team, ready to care for Watson, on board Naval Medical Center San Diego (NMCSD).
“I feel that both my post-graduate dental school and first post-graduate year of training in the Navy prepared me very well to treat common, and some less common, conditions of the oral maxillofacial complex,” said Kolin. “Part of good training and patient care is being able to identify the point at which a case requires advanced diagnostic tools, or is outside the scope of your expertise, both of which applied [to] me in this case.”
When Tripoli successfully executed its homeport change from Pascagoula, Miss., to San Diego, Kolin referred Watson to Capt. Itsvan Hargitai at NMCSD’s Facial Pain Clinic.
Coincidentally, Watson was working on her surface warfare officer qualifications and was training as Tripoli’s conning officer during its arrival into San Diego.
“My hope was that [Hargitai] would utilize advanced imaging techniques such as cone beam computed tomography and/or MRI, both capabilities we don’t have aboard Tripoli, to better diagnose Watson,” said Kolin.
Consult on The Case
Hargitai’s findings were alarming. He called in Lt. Cmdr. Daniel Hammer, a maxillofacial surgical oncologist and reconstructive surgeon assigned to NMCSD, to help consult on the case.
“[Watson] had cancer that started from a saliva gland cell in her lower jaw bone,” said Hammer. “Over time, that cell grew out of control, escaped from the bone and got into muscles around the jaw, tongue and throat. It occurred in an area called the retromolar trigone, which is the small area behind the wisdom teeth. This type of cancer is extremely rare, with less than 200 cases ever reported worldwide.”
Hammer explained that his patient will need a radical resection of not only her bone, but will lose soft tissue, part of her gums, the lateral side of throat and might lose some of her tongue and bottom of her mouth. Additionally, she will need a neck dissection to remove the cancer.
Within NMCSD’s walls lay vast swaths of expertise ready to support the fleet and care for our warfighters and their families. When great minds come together, excellent outcomes are expected. Hammer has enlisted colleagues with arrays of specialties from neighboring departments to form a cohesive, highly trained team to care for Watson. The team has members from 11 departments ranging from Plastic Surgery to Medical and Radiation Oncology with simple goals.
Multi-Disciplinary Team’s Expertise
First, to leverage the multi-disciplinary team’s expertise to stage and remove her cancer. Second, to offer Watson the most cutting-edge reconstruction to optimize her functional and aesthetic outcome. At NMCSD, this can all be completed in one surgical procedure. This minimizes the impact multiple surgeries and hospital admissions can have on the patient and their support system.
During procedures like Watson’s, surgeons remove any cancer from a patient’s head or neck, which often includes a mandibulectomy, the removal of all or a section of the jaw. Then, NMCSD’s Microsurgery team harvests a segment of the fibula, the smaller of the two lower leg bones, and shape it into a jaw using a patient-specific cutting guide. Dental implants are then placed in the newly-formed jaw bone and the new jaw is brought up to the face where, when possible, 3D-printed teeth are screwed in.
Diagnosis to Remove
Hammer explained that a standard rule in head and neck oncology is that surgeons have six weeks from initial diagnosis to remove the cancer. Any time outside of that window has the potential to change the patient’s long-term survival. At NMCSD, the use of virtual surgical planning and 3D printing expedites any possible delay to our patient’s treatment.
“3D printing is critical because we can have teeth printed 24 hours after the virtual surgical planning is completed,” said Hammer. “I can scan a patient and plan their procedure, then have them in the operating room in two weeks.”
Diagnosis is Daunting
A cancer diagnosis is daunting, even when a patient knows they’ll have the best care available.
“I was in shock,” said Watson. “It wasn’t what I was expecting. I never in a million years thought it was cancer. I had to call all of my family and tell everyone.”
A support network for cancer patients is critical.
“I was initially angry because she had been dealing with her mouth issues for a while, had been seen for it and not diagnosed [until arriving at NMCSD],” said Interior.
Communications Electricians 2nd Class Angela Watson, Ashley’s wife, who is stationed aboard the Blue Ridge-class amphibious command ship USS Mount Whitney (LCC 20) in Italy.
Watson said that her family was in disbelief, and that, ironically, almost everyone in her family uses tobacco except her, yet she had a form of oral cancer.
To ensure optimal patient outcomes, Hammer and his team established the Early Recovery After Surgery (ERAS) protocol for all maxillofacial reconstructive surgeries at NMCSD. The ERAS protocol consists of numerous teams focused on multidisciplinary, patient-centered care. The goal of this dynamic team is to enhance every patient’s recovery and rehabilitation.
NMCSD Team Members
“In addition to the surgeons involved in the planning process and [those] who perform the procedures, we rely on numerous NMCSD team members to care for our patients,” said Hammer. “Intensive care unit (ICU) nursing staff and hospital corpsmen, speech pathologists, occupational therapists, physical therapists, chaplains, mental health counselors and many other services are all brought into the ERAS protocol.”
Hammer explained that there are many advantages to building this practice in the military.
“Collaboration is key,” said Hammer. “The military in general is mission-focused with a strong, collaborative culture. We value teamwork, and take pride in our individual and collective role in every patient’s care. Some of the things that may impede patient care, innovation or collaboration in the private sector don’t exist here. We’re only doing the best thing for the patient. This is what makes me most proud to be part of Navy medicine.”
Surgical Techniques and Technologies
A cancer diagnosis is already an incredibly stressful moment for all patients, and cost may be a prohibitive aspect for some patients in the civilian sector to seek providers with advanced surgical techniques and technologies. However, that doesn’t apply to military members and their families.
“When a patient comes to me, I can treat them to not only the standard of care, but the cutting edge of care,” said Hammer. “I can offer them these amazing techniques, and I know, financially, they’re covered. A service member and their family have made the decision to serve their country, and we are standing by to care for them.”
A patient’s experience often comes down to open communication with their treatment team, and the trust they share with their doctors.
“My experience [at NMCSD] has been great,” said Watson. “[Hammer and his team] are amazing. The plastic surgery team have done a great job in my leg, even down to the way they stitched me up. Everyone has been very open with communication. It was really helpful that Dr. Hammer called both Angela and my mom after the surgery to tell them how everything was going. They gave it to me [and them] straight, and I appreciate that.”
Watson said that she had to put her trust in the team.
“They’re here to steer you in the right direction and won’t put you through any unnecessary pain,” said Watson. “[I believe they’re] here to take care of you. The nurses and hospital corpsmen in the wards are awesome, and you feel like you’re getting the best care.”
Hammer and his team have performed multiple immediate jaw reconstruction procedures which utilized 3D-printed teeth. More information about a previous case can be found at dvidshub.net/news/386246/following-up-with-dods-califs-first-ever-immediate-jaw-reconstruction-with-3d-printed-teeth-patient.
Deploy in Support
NMCSD’s mission is to prepare service members to deploy in support of operational forces, deliver high quality healthcare services and shape the future of military medicine through education, training and research. NMCSD employs more than 6,000 active duty military personnel, civilians and contractors in Southern California to provide patients with world-class care anytime, anywhere.
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