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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 Oral Red Lesions 口腔紅色病變.

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Presentation on theme: "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 Oral Red Lesions 口腔紅色病變."— Presentation transcript:

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

2 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

3 1.Kaohsiung Medical University, Oral Pathology Department 2. 自購網路資源: super_toolcool References: 參考資料

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

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

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

7 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

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 e.g. a reddish ulceration over the right 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. 1

9 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. 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. 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 packages per day? How many grains per day? How many bottles per day? Refs. 1, 2

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

13 Biopsy Laboratory tests 有關病人的實驗室檢查 如 blood routine, AKP, Ca 2+ … 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 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 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  , tooth 37 was extracted at another LDC due to severe pain  Till the post extraction wound remained unhealed  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 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, red & white appearance, sessile, firm, fixed and sessile, firm, fixed and painful painful  The adjacent mucosa seemed to be normal. seemed to be normal.  Dimension : 1 cm x 1cm  Induration ( - ) Ref. 1

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

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) PanorexOcclusal 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)

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

26  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 Panoramic Film (2) Ref. 1

27 It showed destruction of lingual and buccal cortical plates without bony expansion It showed destruction of lingual and buccal cortical plates without bony expansion Occlusal Film 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 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 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  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  4 th decade   Mandible  Premolar and molars area   Painful enlarging mass   Overlying mucosa : normal

38 Fibrosarcoma Higher 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 ~   Typically occur in 4 th 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 ~   Occur in all age groups but is rare in the 1 st 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 Central Squamous Cell Carcinoma, Left mandible

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 × 10 3 / L Hb : 12.1 g / dl PLT : 2.68 × 10 5 / 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 Summarie s 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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