photo on left shows how jaw bone is rebuilding   Another quick trip to Singapore and a 30 min appointment with Dr Ho Kee Hai shows that the bone in my mandible is growing back nicely. To our combined relief there is no indication of a tumour or other growths. The image on the right was taken 6 weeks prior. The conservative treatment appears to be working. I can still walk properly and have avoided the barbed wire scars of a full replacement of the mandible. Next check up is in January 2012.  

This visit has been something of a rollercoaster, but I am feeling very confident about the approach that Dr Ho and I have taken to overcome my case of Ameloblastoma. The sight of the two lumps found by the scan on my jaw on Tuesday had left me directionless; a feeling that I am unfamiliar with and found completely disarming. I focused on going from point to point and accomplishing basic tasks in readiness for the surgery.  I told the anesthetist, a kindly aunt like figure in her late 50's called Monica, that on my way home after the last operation I had vomited blood which wasn't entirely pleasant, and that I had been dizzy - this time she gave me insulin pre-0p.  The Wed surgery was a bit of a blur. The  good news was that I wasn't sick and felt well enough to let Melinda, a colleague at EASTWEST who kindly came to collect me from the hospital, go back to her home without having to nurse me. Post operation I was confronting myself to regain a sense of motivation to beat this thing. It is strange to have a complete lack of vision beyond the immediate daily tasks. One anonymous Amelo blogger I read wrote about 'regaining a sense of direction.' Feeling 'out of control' is very new to me and perhaps one of the least attractive aspects of an illness like this which arrives unexpectedly and changes the course of life. Then on Friday I was given great news by Dr Ho Kee Hai via the histology report sent from the Parkway Laboratory services. James Adrian Jim. parkway The items found in my jaw were 'acute inflammatory granulation tissue with foreign body giant cell response to pigmented non-polarizable foreign bodies. No epithelium is present here. No features to suggest ameloblastoma seen.' According to wikipedia, 'Granulation tissue is the  perfused, fibrous connective tissue that replaces a  fibrin clot in  healing wounds. Granulation tissue typically grows from the base of a wound and is able to fill wounds of almost any size it heals.' In other words my understanding is that these two pieces found are part of the recuperative process that my body is attempting to heal my wound.  Truly we witness a miracle of regeneration when we see our bodies work. I had read that our bones have 3 phases of regeneration, and these tissues are part of that second phase - a kind of scaffolding being built around the newly built facade of bone. It is hard to describe the relief that I felt at these few simple words. It doesn't of course mean that the ameloblastoma is defeated entirely, but our approach is working together with my immune system. I still have the structure of my mandible, and nervous system.  I still stand by the treatment Dr Ho and I have adopted. This latest report and images post operation demonstrate that our faith is being rewarded. As the images show below, the bone structure is recovering well, the bruising is receding, and with a week of stubble covering the area Amity and Halo won't even notice the slight residual swelling. In another 4 weeks (late Oct) I will have another scan here in Singapore - but at least I know more now about what to expect. Next week I will have another course of acupuncture with Alex Tan which I found stabilized the pain in the nerves in my jaw, and proceed with his proscription of balancing the Qi in my system to ensure the bone reconstruction continues apace.

The conservative approach that Dr Ho and I have taken with the Ameloblastoma had a bit of a setback. Returning for a check up after the operation on 23rd August the scan showed two tumour's remaining; or having reformed we are not quite sure which. The larger of the two is some 6.6m across, a bit smaller than a tic tac. As the tumour is not growing in the new bone, the new bone advances pushing out the tumour in its path. Therefore for the path has to be clear to the exit. Ironically as my bone has been growing so quickly we had to take quick action. The bone growth is blocking the exit of these two tumours. I am fortunate that this is a tumour and not a cancer. Tumors and cancers are different. A tumor develops when a lesion or lump is formed in your body due to abnormal cellular growth. In the case of cancer, this cellular growth is uncontrollable and it spreads in the body. According to one site 'All tumors are not life threatening and once a tumor is removed, the condition will not recur. Cancer is a serious condition that requires proper medical attention.'  However, other medical reports suggest recurrence is quite common and patients must continue to check for up to  10 years. If I am fortunate this will be the third and final operation to rid my jaw of this infiltrator. Dr Ho was apologetic that we found another 2 little spots and even offered to waive his fees, which of course I declined. He is so evidently committed to the wellness of his patients that it no wonder all his staff speak of him so highly.                 Erika and the girls are in China, and so I shall have to fend for myself.  I treated myself to some Marks & Spencer Soups and macaroni cheese. What better excuse to eat some British comfort food here in the tropics.  

Following the surgery for the ameloblastoma in February this year, I returned to Singapore for another check up with Dr Ho Kee Hai on Tues 14th August. The overall prognosis was good, with solid bone growth across the lower mandible. This is superb news. The nerve pain has subsided to be a nuisance rather than a distraction and I am no longer conscious when speaking of the need to drain the saliva from my mouth to avoid unseemly drooling (some press shots have me looking as though I am about to explode as I was caught sucking my lower cavity dry before answering a journalist.) The not so good news from the cat scan were two circular points in the jaw by the hinge; which prompted Dr Ho to suggest surgery at the earliest time. He isn't sure if these remain from his earlier surgery or are new. Needless to say I hope that it is the former. On Tues 21st I will go back into Mt Elizabeth to have a small operation to remove them, and we shall know after that. It will be tremendous if the Mandible Nerve doesn't get jostled again as I have the launch of the Morgan's in Chengdu on the 31st August, and don't want to unavoidably drool at the press conference; even though the prospect of opening up the west of China for the Morgan brand does make me salivate somewhat.  

The amazing body has started it's work. One month post the Ameloblastoma operation I went back to see Dr Ho Kee Hai in Singapore. On examination it appears that the surgery which I underwent at Mount Elizabeth has been successful in removing the tumour, and that my body has started the healing process. The early weeks post op were not very pleasant, although for 24 hours I thought the process was painless until the morphine wore off. The pain from the swelling and bone was in competition with the mandible nerve which has a way of remaining switched on. Now the sharp pain has subsided leaving only the swollen lip, rather unseemly slurping of drinks, and an itch in my numb chin which feels like scratching a mosquito bite through a  duvet. Dr Ho removed the filling and took another scan. After one month there are signs that the bone is growing back again; evidenced by the opaque areas on the jaw where previously there had been darkness.  The photo on the left shows structure in the top right hand corner which wasn't seen in the post op scan. The puffy textured image is the filling used to pad the cavity in the jaw which extends from the pre molar to the hinge in my lower jaw. There there are signs of recuperation is great news. Apparently there  are three major phases of bone healing, two of which can be further sub-divided to make a total of five phases, although for my purposes these three seem sufficient: 1. Reactive Phase i. Fracture and inflammatory phase ii. Granulation tissue formation 2. Reparative Phase iii. Cartilage Callus formation iv. Lamellar bone deposition 3. Remodeling Phase v. Remodeling to original bone contour Apparently the process of replacement takes 3-5 years, recovering from a condition which was took approximately 3 years to manifest itself in my mandible. I will be returning to Singapore in May for another check up. Dr Ho has been superb, and I have been determined to post these blogs so that others may find him. Indeed within weeks of my first post an Ameloblastoma sufferer from the Philippines found my blog looking for alternatives to extensive surgery.  As I found it so hard to find alternatives to extensive surgery, my goal is to post as much positive news as I can in the hope of sharing information about the alternatives.

Good news to report post surgery on Sat 25th Feb under the care of Dr Ho Kee Hai. The procedure took 4 hours at the Mt Elizabeth Hospital, under general anesthetic, with Erika patiently waiting for me. As Dr Ho had extracted a wisdom tooth on the Monday, there appeared to be less work to do in the theatre. Certainly I was surprised by the lack of swelling post operation. One week after arriving in Singapore I was flying out having completed the procedure to remove the ameloblastoma.   Dr Ho has removed the tumor. Apparently it was expansive and also within an almost self contained lining. This meant that the extraction was clean and the chances of the tumor remaining in the bone are minimal. Instead he has packed the area with Avolgyl dressing, antiseptic medicant which releases a medicated taste. The wound is left unsealed so that the bone can expand and force the tissue out of the cavity. I was given a syringe with which to wash the cavity, and after dinner several pieces of tissue came out into my mouth. I am sure that I will get used to this. There is some discomfort as one would imagine, but I am still counting my blessings that this treatment has left my mandible intact. The healing process will take about 24 months, with a monthly visit to Dr Ho for the next 3 months.     The overall process would have been worth planning for financially. I realized any insurance company would have considered this a pre-existing condition, but only because we elected 4 years ago let the expensive premiums lapse. Either way, unless I had managed to get back to the UK there were going to be bills to pay. On arrival at Mount Elizabeth the cheery cashier took my credit card and pre -billed S$10,500 (GBP5,250) for the operation and one night stay. The final bill was closer to S$15,000 and I am awaiting the calculation to determine how much will be covered by my Singapore  Medisave, Singapore's national insurance. This came on top of the flights and S$2,953 bill from Dr Ho's clinic on the 20th for the wisdom tooth removal and biopsy. This ameloblastoma has taken a significant bite out of the family finances and spurs me to get the family insurance reinstated. Now to follow the process of natural healing, enjoy the family, and find soft food to bite on.  

On Monday 13th Feb I bit my sandwich and felt as though the waiter had whacked me in the side of the jaw with the sharp end of a skillet. I couldn’t open my eyes for the pain, but when I did I was alone except for the searing jabbing sensation that persisted in my left side. I thought it was a bad wisdom tooth, little did I know that I had a dental condition which afflicts 1 in 5 million people. Within a few days I had an appointment Chung Ming Tse, Dentist and Prosthodontist at Beijing United Family Hospital. Dr Tse was comforting but his manner betrayed an underlying concern. To my untrained eye the x-ray appeared to show the source of the pain to be a sunken wisdom tooth. Dr Tse gently suggested a CT scan after pointing out the lack of structure around the left jaw from the molars to the hinge. The 3-D images of the skull led to Dr Tse asking the nurses to leave the room and for the first time in my life I felt that sense of fear of the medical unknown. He pointed out the lack of extensive lack bone structure on the left side of  my lower jaw, the mandible, and in a very caring manner gave me the sense that this condition needed urgent attention as the bone had become very thin and would eventually fracture. The following 24 hours were spent in a state of denial, shock and a sense of purpose.  The near constant aching pain which I had tolerated in my lower jaw for several years was caused by an ameloblastoma; a rare, highly destructive, benign, rapidly growing tumor of the jaw.   ‘ameloblastoma /am·e·lo·blas·to·ma/ (-blas-to´mah) a usually benign but locally invasive neoplasm of tissue of the type characteristic of the enamel organ, but which does not differentiate to the point of enamel formation.’ The importance of the correct classification via histopathologic exam became clear to me later as I searched for a solution. Ameloblastomas are classified as solid/multicystic, classical intraosseous; peripheral; or unicystic sybtypes. The prevalent treatment on the internet is that of replacement of the mandible to a margin wide enough to ensure that the surrounding areas will not allow recurrence. Recurrence is common, upto 70%, and in some cases fatal.   On the Sat 18 ^th Feb I visited Dr Tse at BJU to view the CT scans.  Dr Tse and Dr Zhang, his colleage told me that the treatment is one of a segmental resection of the mandible , taking bone from the tibia. An operation which could be conducted by a University of Peking Maxillofacial surgeon the following week. This 8 hour operation would require a week in hospital and several months recuperation. My face, and leg, would not be the same again. Dr Tse patiently talked me through the options and benefits of being closer to home in Beijing, but also shared that the technical skills in China were hard to compare with this in Singapore. At this stage my lack of medical insurance preyed on my mind, but was a secondary consideration with the Peking University Hospital option costing approximately RMB60,000. The 3D Image gave me a new look at my dental condition. The Ameloblastoma has expanded along the lower jaw exposing that painful molar, and upto toward the hinge. The slight tingling sensation in my cheek, and feeling that I was drooling from the left corner of my mouth was explained as the pressure and potential disruption to the nerve. I would apparently not lose control, but potentially the sensation from parts of my left cheek. Any questions about timing of my treatment were answered in the picture.   I have always had great faith in Singapore and the quality of the medical expertise. Statistically the Republic with a population of 4.5m may not even have cases of Ameloblastoma which affects 0.18 males in 1 million. By a miracle of the advanced search function on google, before going to the BJU on the Saturday morning I had found Professor Ho Kee Hai, Oral and Maxillofacial Surgeon. I had used my iphone to take screen shots of the CT scans and emailed them to Professor Ho. Within an hour he took the time to talk with Dr Tse. He then told me that he has an alternative, “conservative method,” to tackling the tumor. It was all conditional upon which type of Ameloblastoma which required a biopsy. I booked a Singapore Airlines flight and was in his office at 0900 on Monday 20th. Professor Ho operates an eponymous clinic,  Ho Kee Hai and Partners Dental Implant Maxillofacial Aesthetic Centre at the Paragon Medical Centre, and but few a couple of obscure references within user groups and specialist medical papers, one would never know that he has been operating on Ameloblastoma’s for over 30 years. A patrician gentlemen who immediately made me feel comfortable, Professor Ho showed me cases from a 157 slide power point presentation made to The 9th Asian Congress on Oral & Maxillfacial Surgery ( ACOMS) held in Malaysia in 2011. Essentially the “conservative approach” is to extract the tumor and to leave the wound dressed, but open. The wound dressing allows nature to take its course. They pack the cavity with an equivalent of WhiteHead Varnish; gum benzoin, 4 parts; styrax, 3 parts ; balsam tolu, 1 part; ether, 40 parts ; with the addition of 10 per cent iodoform. All five constituent drugs are antiseptic when used. Apparently the British WhiteHead Varnish was excellent and it's disappearance confounded Professor Ho who had to replace it with a French equivalent. The bone repairs and expurgates the tumor. This is possible with certain types of Ameloblastoma. Professor Ho was hopeful having seen the nature of the cavity from his own 3-D X-ray, but performed a biopsy on Monday 20 ^th. Today the results came back from Quest Laboratories. I went in to see Professor Ho. This would decide the likely success of the conservative approach, or being forced into taking the more conventional resection. The report reads, ‘fragments of lamellar bone and fibrous tissue, covered in …stratified squamous epithelium featuring peripheral palisading of elongated columnar cells, with a suggestion of reversed polarity…Features are suggestive of a cystic ameloblastoma.’ Professor Ho kindly shared the report with me, but for my part it could have been Mandarin, but his reassuring smile was all the answer that I needed. We could proceed with the “conservative approach.” The reason that the majority of procedures are ‘replacement of mandible’ is because the belief is that the tumor behaves like a cancer and must be eradicated by a wide margin. Apparently some strains of tumor penetrate into the bone, but I am fortunate in that my ameloblastoma has been “expansionary” in nature; it has grown along the jaw cavity rather than into the bone matter. I have been cautioned that I may lose some nerve sensation in the left cheek and left side of the tongue; but this still seems a great deal better than mandible replacement and bone graft. I have faith that my body will heal the cavity created by the surgery on Saturday.       Years ago I read a book by Dr Andrew Weil a practitioner and teacher of integrative medicine for the last thirty years, entitled "Spontaneous Healing." The book talks to the bodies natural desire to heal given our support with the proper nutrition, exercise and spiritual care. I believe in his philosophy, and found in Professor Ho a practitioner who does too.  All I can do now is to entrust myself to Professor Ho, the nurses at Mount Elizabeth Hospital, and the healing processes of nature.