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口腔診斷學
陳玉昆副教授 : 高雄醫學大學 口腔病理科 07-3121101~2755 yukkwa@kmu.edu.tw
Oral Red Lesions
口腔紅色病變
學 習 目 標學 習 目 標
1. 明白病歷書寫的方式2. 瞭解病歷書寫的原理3. 知道其中的應用
1. Kaohsiung Medical University, Oral Pathology Department
2. 自購網路資源: super_toolcool
References:References:
參考資料
Chief Complaint
General Data
Present Illness
Extraoral Examination
臨床檢查及病歷書寫應包括
Intraoral Examination
Past Medical History
Past Dental History
Personal Habits
臨床檢查及病歷書寫應包括
Biopsy
Radiographic & imaging examinations
Radiographic & imaging examinations
Laboratory testsLaboratory tests
視個別病例可能還包括
General Data
姓名
性別 籍貫
職業
病歷號碼 首次就診日期
病人的基本資料
年齡
Chief Complaint
病人自己所描述的主訴
可以是以完整的句子寫下來
e.g. a reddish ulceration over theright soft palate
也可以是以鑰詞的方式記錄
Chief complaint 可視為一篇敘述文的題目
e.g. a reddish ulceration
Ref. 1Ref. 1
全部有關病人主訴的病史
Present Illness
按照發生的順序詳細紀載Intraoral examination Extraoral examination
否則會文不對題
Ref. 2Ref. 2
Past Medical History
Past Dental History
所有有關病人過去的醫療病史如 DM, HT, AIDS, Hepatitis… etc.
有關病人過去的牙科醫療病史如 OD, Endo, extraction… etc.
Personal Habits
有關病人的不良習慣如 抽煙 , 咀嚼檳榔 , 喝酒…… etc.
How many packagesper day?
How many grainsper day?
How many bottlesper day?
Refs. 1, 2Refs. 1, 2
有關病人的影像攝影如 Pano, CT, MRI, US, PET,.. etc.
Radiographic & imaging examinations
Radiographic & imaging examinations
Positron emission tomography
Ref. 1Ref. 1
Biopsy
Laboratory testsLaboratory tests
有關病人的實驗室檢查如 blood routine, AKP, Ca2+ … etc.
有關病人的組織學檢查如 incisional/excisional/cytology … etc.
General Data
Name: Name: 蔡蔡 xxxx
Chart no.: xxxxxxxxChart no.: xxxxxxxx
Sex: Sex: 女女Age: 38 y/oAge: 38 y/o
Native: Native: 台灣屏東台灣屏東Occupation: Occupation: 家管家管First visit: 92.7.29First visit: 92.7.29
Ref. 1Ref. 1
Chief Complaint Delayed healing of extraction wound Delayed healing of extraction wound
of tooth 37 for about 3 weeksof tooth 37 for about 3 weeks
Ref. 1Ref. 1
Present Illness (1)The 38 y/o female suffered from 37 The 38 y/o female suffered from 37
toothache since toothache since the end of June, 2003TheThe LDC dentist diagnosed her symptoms LDC dentist diagnosed her symptoms
as periodontitis and no other abnormal as periodontitis and no other abnormal mucosal lesion was noted mucosal lesion was noted
Subsequently, prosthetic crown of 37 was Subsequently, prosthetic crown of 37 was removed to perform endodontic tx. removed to perform endodontic tx. Unfortunately the symptoms/signs were Unfortunately the symptoms/signs were still persistedstill persisted
Present Illness (2)92.7.10, tooth 37 was extracted at , tooth 37 was extracted at
another LDC due to severe painanother LDC due to severe pain
Till Till 92.7.28, the post extraction wound the post extraction wound remained unhealedremained unhealed
Her dentist referred her to visit our OPD Her dentist referred her to visit our OPD for further examinationfor further examination
Extraoral Examination A firm swelling mass A firm swelling mass
over L’t face about over L’t face about 4x4 cm in diameter4x4 cm in diameter
Numbness of left Numbness of left lower liplower lip
A palpable fixed, firm A palpable fixed, firm lymph node in L’t lymph node in L’t
submandibular submandibular regionregion
No fever or local No fever or local hyperemia is notedhyperemia is noted
Ref. 1Ref. 1
Intraoral Examination (1)Tooth 37 extraction wound Tooth 37 extraction wound
Ulcerative unhealed Ulcerative unhealed extraction wound with extraction wound with
red & white appearance,red & white appearance, sessile, firm, fixed and sessile, firm, fixed and painfulpainfulThe adjacent mucosaThe adjacent mucosa seemed to be normal.seemed to be normal.Dimension : 1 cm x 1cmDimension : 1 cm x 1cm Induration (Induration ( -- )) Ref. 1Ref. 1
Intraoral Examination (2)
Dental findings:Dental findings:
Missing teeth : 28Missing teeth : 28 、、 3636 、、 3737 、、 3838 、、 4646 、、48 48
C&B : 11C&B : 11 、、 1212 、、 2121 、、 2222 、、 2323
45x4745x47
3333
Past Medical History
Denied OP/hospitalization historyDenied OP/hospitalization historyDenied any allergiesDenied any allergiesDenied any systemic diseasesDenied any systemic diseases
Past Dental History
OD Extraction RCT Prosthesis
Personal Habits
Alcohol drinking (Alcohol drinking ( -- )) Betel-quid chewing (Betel-quid chewing ( -- )) Cigarette smoking (Cigarette smoking ( -- )) Denied other specific oral habitsDenied other specific oral habits
Radiographic Examinations (1)
Radiographic Examinations (1)
Panorex Occlusal view
Rationale for X-ray taking
臨床檢查顯然存在一個 underlying intrabony lesion
(mesial-disal dimension)
(buccal-lingual dimension)
Panorex showed an ill-defined radiolucency with Panorex showed an ill-defined radiolucency with ragged, irregular border, approximately 3.0x2.5cm ragged, irregular border, approximately 3.0x2.5cm in diameter over the left mandible body areain diameter over the left mandible body area
Panoramic Film (1)
Ref. 1Ref. 1
Extending from Extending from
L’t superior L’t superior alveolar ridge alveolar ridge down to the down to the inferior border of inferior border of mandible, & from mandible, & from edentulous 37 edentulous 37 area posterior to area posterior to ramus & angleramus & angle
The loss of The loss of cortical outline of cortical outline of ID canal is notedID canal is noted
Panoramic Film (2)
Ref. 1Ref. 1
It showed It showed destruction of destruction of lingual and lingual and buccal cortical buccal cortical plates without plates without bony bony expansionexpansion
Occlusal Film
Ref. 1Ref. 1
Radiographic Examinations (2)
Radiographic Examinations (2)
Necessary for CT taking
臨床檢查除了存在一個 underlying intrabony lesion, 還有 submandibulararea 的 soft tissue involvement
Axial CT Scan (1)
CT scan showed destruction of lingual & CT scan showed destruction of lingual & buccal cortical plates buccal cortical plates
Ref. 1Ref. 1
Axial CT Scan (2)
An enlarged lymph An enlarged lymph node is noted in the node is noted in the L’t submandibular L’t submandibular areaarea
Ref. 1Ref. 1
Differential Diagnosis
思考方向
臨床檢查發現
病人過去病史 影像檢查發現
Ref. 2Ref. 2
Inflammation or Neoplasm?
Fever or local heat (Fever or local heat ( -- ) ) No purulent drainage was presentedNo purulent drainage was presented Destruction of lingual and buccal Destruction of lingual and buccal
cortical plates without expansioncortical plates without expansion
Neoplasm
Benign or Malignant? Pain (Pain ( ++ ) ) Tenderness (Tenderness ( ++ )) Lymphadenopathy (Lymphadenopathy ( ++ )) Numbness of left lower lipNumbness of left lower lip Ill-defined radiolucency with ragged, Ill-defined radiolucency with ragged,
irregular borderirregular border Destruction of lingual and buccal cortical Destruction of lingual and buccal cortical
plates without expansionplates without expansion
Malignant
Peripheral or Intrabony origin?
Adjacent mucosa Adjacent mucosa seems seems normal appearance
Induration ( - )
,,,,, IntrabonyRef. 1Ref. 1
Working Diagnosis
Intrabony malignant tumor
Epithelial originCentral SCC Fibrous originFibrosarcoma Bone originOsteosarcoma Lymphatic origin Central lymphoma Metastatic tumors in jawbone
由最有可能開始 由最不可能開始
Central SCCHigher compatible ~ Md/30~80 y/o /molars region Surface epithelium appeared normal in
appearance (before tooth extraction) Most often irregular ill-defined
radiolucency Border shows osseous destruction and
varying degree of extension
Less compatible ~ Male
FibrosarcomaHigher compatible ~
Male : Female = 1:1 Mean age 4th decade MandiblePremolar and molars area Painful enlarging mass Overlying mucosa : normal
FibrosarcomaHigher compatible ~ Ragged, noncorticated, ill-defined,
entirely radiolucency, with little internal
structure Destruction of inferior border of the jaw
and cortices of the neurovascular canal
are lost Paresthesia Periosteal reaction is uncommon
Less compatible ~ Usually entirely radiolucency
OsteosarcomaHigher compatible ~ Typically occur in 4th decade Mandible, tooth-bearing area Swelling, pain, tenderness, ulceration Ill-defined radiolucency with little internal structure Destruction of the neurovascular canal and inferior border of the mandible
Less compatible ~ Male :Female 2:1 Lymph node involvement is rare
Central lymphomaCentral lymphomaHigher compatible ~ Occur in all age groups but is rare in the 1st
decade Md (posterior area) Pain, lymphadenopathy, sensorineural
deficits Radiolucency with ill-defined border Destruction of cortex of the neurovascular
canal Less compatible ~ The lesion occurring outside lymph node in The lesion occurring outside lymph node in
head & neck are present in head & neck are present in as much as 1/5as much as 1/5
Metastatic tumor in jawHigher compatible ~ Usually situated deep in the bone 70% in mandible--Premolar and molars
area Slight predilection for female (3:1) Solitary, poorly defined radiolucency Usually erodes rather than expands the
adjacent cortical platesLess compatible ~ There was no systemic symptom to suggest a primary tumor elsewhere
(although there could been occult primary tumor)
Clinical Impression
Intrabony malignant tumor
over left mandible body, ramus and angle areas
Biopsy 92 / 7 / 29 * Refer to O.S. Dept. for incisional biopsy
* Submitted superficial & deep specimens
for H-P exam 92 / 8 / 5 * Recall for H-P report
H-P Report
低倍
高倍
Ref. 1Ref. 1
Final DiagnosisFinal DiagnosisCentral Squamous Cell Carcinoma,Central Squamous Cell Carcinoma,Left mandibleLeft mandible
Treatment Plan
Refer to oncology dept.Refer to oncology dept. for chemotherapy for chemotherapy ( I.A.) then come back for OP( I.A.) then come back for OP
If lesion enlarged OP immediatelyIf lesion enlarged OP immediately
Treatment Course (1) 92 / 08 / 12 ~ Admission
92 / 08 / 14 ~ Arterial system with port implantation
92 / 08 / 15 ~ Started one course chemotherapy with MTX
Treatment Course (2) 92 / 08 / 23 ~ Discharge with stable condition ~ Continue chemotherapy at home with MTX
92 / 09 / 19 ~ Lab. data WBC : 6.9 × 103 / L Hb : 12.1 g / dl PLT : 2.68 × 105 / ul
Discussion
Central SCCDefinition Arising from intraosseous remnants of
odontogenic epithelium
Ariji et al. ,1994 malignant transformation of the epithelial component of an existing odontogenic tumor the epithelial lining of an odontogenic cyst residues of epithelium after tooth development
Central SCC WHO classified into two groups:
those arising in the intrabony cysts
primary carcinoma, presumably started
from the residues of the dental organ
Clinical criteria of central carcinoma
the tumor is not metastatic in origin and is
covered with normal mucosa
Central SCC
Clinical features These neoplasa are rare. Commonly occurred in men, mandible,
and age from 30-80y/o Pain, pathologic fracture, sensory
nerve abnormalibilities, lymphadenopathy
Central SCCRadiographic features Molar region, tooth-bearing area Radiolucency with no evidence of bone
production, irregular in shape, with ill-defined border.
Destruction of buccal or lingual plate and cortical outline of the mandibular neurovascular canal
Central SCC
Differential diagnosis Not aggressive Periapical cyst or
granuloma Extensive bone destruction
metastatic lesion, multiple myeloma, fibrosarcoma
Central SCC
Management En bloc resection Adjunctive therapies of radiation and
chemotherapy
SummariesSummaries 以紅色口腔病變為例,
說明病歷書寫的方式,瞭解病歷書寫的原理,並且知道其中的應用。
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