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Dental Alumni Association Mysteries Presents­
The Case of the Swollen Lip

by Phil Cornell

In the mid-1980s, a Hazlet policeman named Robert Mulligan walked into the Holmdel office of Dr. Frank A. Miele, Jr. ('66), with a big mystery on his hands. Or rather on his upper lip, which had inexplicably ballooned two to three times its normal size while he had been on vacation. Could Dr. Miele help him?

Thus began a quest that would absorb the dentist for the next five years ­ even as a series of specialists struck out ­ and lead him to lecture about his findings at Walter Reed Army Medical Center in Washington, D.C. The case also tested a caregiver's obligation to a patient in need.

Dr. Miele's patient had assumed, not unreasonably, that the lip condition had originated in his mouth, an infection perhaps, a theory that led him to the dentist's door for an examination. "There was nothing that was obvious," Dr. Miele recalls of that initial visit. "I gave him an antibiotic. He took it for a week, and nothing happened. I was in kind of a quandary. I was saying to myself, 'What is this? Is it a bee sting? A disease process?'"

He sent Mr. Mulligan to see an oral surgeon, who took an X-ray of the man's skull."He couldn't find anything," Dr. Miele continues. "Nothing. Zero."

Dr. Miele wondered if an allergy was to blame, perhaps to a filling he had used. He referred him to an allergist, who detected no ill reaction to the filling material, or anything else for that matter. He sent him to an ear, nose and throat doctor, who came to the same head-scratching conclusion.

Mr. Mulligan's family physician tried the anti-inflammatory prednisolone, but that wasn't the answer. A dermatologist was of no help.

Meanwhile, Mr. Mulligan grew a mustache to hide the deformity and otherwise tried to cope with a condition that seemed to defy analysis. The lip would enlarge for a couple of days to three weeks and be at its most distended size for no more than three or four days. "It would swell up so much it would actually break the skin," the patient recounts. "It would almost feel like it was going to burst."

Then the swelling would subside and raise the false hope that the ailment was finally behind him.

The policeman, a captain on the Hazlet force, ruefully describes a visit to a New York allergist who conducted a 10-minute interview, then matter-of-factly declared there was nothing that he could do that hadn't already been done: "Sorry, can't help you. By the way, that will be $200."

Now, if it seemed that fate had cruelly conspired to make this man's life miserable, it did provide him one staunch ally. Frank Miele wasn't going to give up.

It was in his makeup not to. As the son of a physician, he had developed a keen appreciation for the diagnostic gifts of a general practitioner. And he saw firsthand the value of resourceful health care while in the Army Dental Corps at Fort Gordon, Ga., during the Vietnam War. "Wartime is very good for medicine and dentistry," he observes. "Lots of things happen that are different Surgeons have to improvise."

In the final analysis, though, Dr. Miele just could not throw up his hands while a patient of his was suffering. "I refused to let go," he says. "How could you not try? He was left out there, and the medical community at large didn't have an answer."

"Dr. Miele was super-positive," confirms Mr. Mulligan about the personable dentist. "He made me feel like he was really trying."

Then came a break. While at Atlanta's Emory University, attending a course in head and neck pathology, Dr. Miele heard an instructor discuss a syndrome that sounded like the condition bedeviling his patient. He began to read research papers on the topic and came across Melkersson-Rosenthal syndrome, describing a facial palsy, plicated tongue, and lip or other facial swelling. He learned that treatments had ranged from antibiotics to radiation to plastic surgery. When the lip size was surgically reduced, the swelling sometimes returned.

Dr. Miele came up with his own idea: He would inject the corticosteroid triamcinolone into the patient's lip. Since Mr. Mulligan was a big man ­ just under 6 feet tall and about 260 pounds ­ he would use more of the medication than usual, 40 milligrams instead of 5-10, and not just in one dose. He injected the triamcinolone once a month for four months, working from the top of the lip down in a stepping procedure.

"It worked," Dr. Miele reports. "I think I was more surprised than anybody, truthfully."

The dentist said he also was taken aback by admonishments that he was getting in over his head and exposing himself to a potentially devastating legal liability. "I was floored by some of the remarks that were made to me," Dr. Miele recalls. "One colleague told me I was nuts, that the malpractice case that could come out of this could destroy me."

A far more encouraging reaction came from Dr. Christopher Papa, a patient of Dr. Miele's and at the time director of dermatology at Robert Wood Johnson Medical School. Dr. Papa knew his dentist to have an expansive concern for his patients, asking for literature about melanoma detection, for example, so as to be better able to spot such abnormalities in those he treated. "He's doing more than just filling teeth," observes Dr. Papa. "He's taking care of the patient's health."

One day, while treating the dermatologist, Dr. Miele spoke of Mr. Mulligan's odd ailment. "I pulled the suction device out of my mouth and said, 'You mean Melkersson-Rosenthal syndrome?' " Dr. Papa relates. "He [Dr. Miele] said: 'You mean you've heard of it?'"

Dr. Papa invited the dentist to address a dermatology conference at his school and urged him to write up his findings.

The resulting article appeared in the May-June 1994 issue of the journal General Dentistry. Subsequent articles in dermatology magazines have borne out Dr. Miele's approach, Dr. Papa says.

Two years ago, Dr. Miele was invited to Walter Reed Army Medical Center to address dermatologists at the military facility. Packing up his slide projector following the lecture there, he was asked to demonstrate his technique on a patient. Soon, the dentist was administering his remedy, assisted by an Army major/dermatologist.

The cause of the policeman's swollen lip never was discovered, Dr. Miele said, even if the treatment proved successful. But his years of investigation have convinced him that there is no such thing as Melkersson-Rosenthal syndrome: The facial palsy and grooved tongue are unrelated to the lip swelling, he believes.

Still, this 58-year-old father of five (his youngest graduated college in May) is not about to fancy himself a researcher now. "No, I'm a plain old country bumpkin," he counters. "I just happened to be in the right place at the right time. And I'm very hard-headed. I refused to give up."

 

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