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。