1. 口腔紅色病變 口腔診斷學 Oral Red Lesions 陳玉昆副教授: 高雄醫學大學 口腔病理科 07-3121101~2755

2. 學 習 目 標
明白病歷書寫的方式
瞭解病歷書寫的原理
知道其中的應用

3. 參考資料
References:
Kaohsiung Medical University, Oral Pathology Department
自購網路資源：super_toolcool

4. Extraoral Examination
臨床檢查及病歷書寫應包括
General Data
Chief Complaint
Present Illness
Extraoral Examination

5. Intraoral Examination
臨床檢查及病歷書寫應包括
Intraoral Examination
Past Medical History
Past Dental History
Personal Habits

6. Radiographic & imaging examinations
視個別病例可能還包括
Radiographic & imaging examinations
Laboratory tests
Biopsy

7. General Data 年齡 籍貫 性別 職業 姓名
病人的基本資料
病歷號碼
首次就診日期

8. Chief Complaint 病人自己所描述的主訴 可以是以完整的句子寫下來 也可以是以鑰詞的方式記錄
e.g. a reddish ulceration over the
right soft palate
e.g. a reddish ulceration
Chief complaint可視為
一篇敘述文的題目
Ref. 1

9. Present Illness 全部有關病人主訴的病史 按照發生的順序詳細紀載 否則會文不對題 Intraoral examination
Extraoral examination
Ref. 2

10. 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.
Past Dental History
有關病人過去的牙科醫療病史
如 OD, Endo, extraction… etc.

11. Personal Habits 有關病人的不良習慣 如 抽煙, 咀嚼檳榔, 喝酒…… etc. How many bottles
per day?
Refs. 1, 2
How many grains
per day?
How many packages
per day?

12. Radiographic & imaging examinations
有關病人的影像攝影
如 Pano, CT, MRI, US, PET,.. etc.
Positron emission
tomography
Ref. 1

13. Laboratory tests Biopsy 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.

14. General Data Name: 蔡xx Chart no.: xxxxxxxx Sex: 女 Age: 38 y/o
Native: 台灣屏東
Occupation: 家管
First visit:
Ref. 1

15. Chief Complaint
Delayed healing of extraction wound of tooth 37 for about 3 weeks
Ref. 1

16. Present Illness (1)
The 38 y/o female suffered from 37 toothache since the end of June, 2003
The LDC dentist diagnosed her symptoms as periodontitis and no other abnormal mucosal lesion was noted
Subsequently, prosthetic crown of 37 was removed to perform endodontic tx. Unfortunately the symptoms/signs were still persisted

17. Present Illness (2)
, tooth 37 was extracted at another LDC due to severe pain
Till , the post extraction wound remained unhealed
Her dentist referred her to visit our OPD for further examination

18. Extraoral Examination
A firm swelling mass over L’t face about 4x4 cm in diameter
Numbness of left lower lip
A palpable fixed, firm lymph node in L’t
submandibular region
No fever or local hyperemia is noted
Ref. 1

19. Intraoral Examination (1)
Tooth 37 extraction wound
Ulcerative unhealed extraction wound with
red & white appearance,
sessile, firm, fixed and
painful
The adjacent mucosa
seemed to be normal.
Dimension : 1 cm x 1cm
Induration (－)
Ref. 1

20. Intraoral Examination (2)
Dental findings:
Missing teeth : 28、36、37、38、46、48
C&B : 11、12、21、22、23
45x47 33

21. Past Medical History Denied OP/hospitalization history
Denied any allergies
Denied any systemic diseases

22. Past Dental History OD
Extraction
RCT
Prosthesis

23. Personal Habits Alcohol drinking (－) Betel-quid chewing (－)
Cigarette smoking (－)
Denied other specific oral habits

24. Radiographic Examinations (1)
Rationale for X-ray taking
臨床檢查顯然存在一個underlying
intrabony lesion
Panorex
Occlusal view
(mesial-disal
dimension)
(buccal-lingual
dimension)

25. Panoramic Film (1)
Panorex showed an ill-defined radiolucency with ragged, irregular border, approximately 3.0x2.5cm in diameter over the left mandible body area
Ref. 1

26. Panoramic Film (2)
Extending from L’t superior alveolar ridge down to the inferior border of mandible, & from edentulous 37 area posterior to ramus & angle
The loss of cortical outline of ID canal is noted
Ref. 1

27. Occlusal Film
It showed destruction of lingual and buccal cortical plates without bony expansion
Ref. 1

28. Radiographic Examinations (2)
Necessary for CT taking
臨床檢查除了存在一個underlying
intrabony lesion, 還有submandibular
area的soft tissue involvement

29. Axial CT Scan (1)
CT scan showed destruction of lingual & buccal cortical plates
Ref. 1

30. Axial CT Scan (2)
An enlarged lymph node is noted in the L’t submandibular area
Ref. 1

31. 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. 2

32. Inflammation or Neoplasm?
Fever or local heat (－)
No purulent drainage was presented
Destruction of lingual and buccal cortical plates without expansion
Neoplasm

33. Malignant Benign or Malignant? Pain (＋) Tenderness (＋)
Lymphadenopathy (＋)
Numbness of left lower lip
Ill-defined radiolucency with ragged, irregular border
Destruction of lingual and buccal cortical plates without expansion
Malignant

34. Peripheral or Intrabony origin?
Adjacent mucosa seems normal appearance
Induration (－)
Intrabony
,,,,,
Ref. 1

35. Working Diagnosis Intrabony malignant tumor
Epithelial originCentral SCC
Fibrous originFibrosarcoma
Bone originOsteosarcoma
Lymphatic origin Central lymphoma
Metastatic tumors in jawbone
由最有可能開始
由最不可能開始

36. Central SCC Higher 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

37. Fibrosarcoma Higher compatible ~ Male : Female = 1:1
Mean age 4th decade
MandiblePremolar and molars area
Painful enlarging mass
Overlying mucosa : normal

38. Fibrosarcoma Higher compatible ~ Less 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

39. Osteosarcoma Higher compatible ~ Less 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

40. Central lymphoma Higher compatible ~ Less 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 head & neck are present in as much as 1/5

41. Metastatic tumor in jaw
Higher 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 plates
Less compatible ~
There was no systemic symptom to
suggest a primary tumor elsewhere (although there could been occult primary tumor)

42. Clinical Impression Intrabony malignant tumor
over left mandible body, ramus and angle areas

43. 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

44. H-P Report 低倍 高倍
Ref. 1

45. Final Diagnosis Congratulations, you are correct
Central Squamous Cell Carcinoma,
Left mandible
Congratulations,
you are correct

46. Treatment Plan
Refer to oncology dept. for chemotherapy ( I.A.) then come back for OP
If lesion enlarged OP immediately

47. Treatment Course (1) 92 / 08 / 12 ~ Admission 92 / 08 / 14
~ Arterial system with port implantation
92 / 08 / 15
~ Started one course chemotherapy with
MTX

48. 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

49. Discussion

50. Central SCC Definition
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

51. 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

52. 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

53. Central SCC Radiographic 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

54. Central SCC Differential diagnosis
Not aggressive  Periapical cyst or granuloma
Extensive bone destruction metastatic lesion, multiple myeloma, fibrosarcoma

55. Central SCC Management En bloc resection
Adjunctive therapies of radiation and chemotherapy

56. Summaries
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。