口腔診斷學

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

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

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

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

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

8. 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 Chief Complaint Ref. 1

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

10. 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. Past Medical History Past Dental History

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

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. 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. Laboratory tests Biopsy

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: 92.7.29 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 • TheLDC 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) • 92.7.10, tooth 37 was extracted at another LDC due to severe pain • Till 92.7.28, 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. Denied OP/hospitalization history Denied any allergies Denied any systemic diseases Past Medical History

22. Past Dental History • OD • Extraction • RCT • Prosthesis

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

24. Rationale for X-ray taking 臨床檢查顯然存在一個underlying intrabony lesion Panorex Occlusal view Radiographic Examinations (1) (buccal-lingual dimension) (mesial-disal 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. 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. Occlusal Film It showed destruction of lingual and buccal cortical plates without bony expansion Ref. 1

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

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. 思考方向 病人過去病史 影像檢查發現 臨床檢查發現 Differential Diagnosis 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 seemsnormal appearance • Induration (－) Intrabony ,,,,, Ref. 1

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

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 Lesscompatible ~ • 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 ~ • 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 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 ~ • 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. 高倍 低倍 H-P Report Ref. 1

45. Congratulations, you are correct 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 × 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