Case Report

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Case Report

Intern H 組

謝鎧蔚楊舜捷

張克喬吳學榮 101/4/24

指導醫師: 陳玉昆主任暨口腔病理科全體醫師

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General Data

 Patient name: 江XX

 Chart number: 2XXXXX5

 Gender: Female

 Age: 30

 Native origin: 台灣

 Martial status: 未婚

 Attending doctor: 許瀚仁

 First visit: 101/4/6

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Chief Complaint

 Pain over right anterior region of the mandible for 3 days

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Present Illness

 This 30 y/o female patient suffered from pain and discomfort over her right mandible (tooth 43-45 region) for 3 days, and so came to our OPD seeking help.

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Intraoral Findings

 2cmx2cm lesion buccal of tooth 43.44

 Dome shape

 Hard

 Normal mucosa color

 Fixed

 Pain (+)

 Tenderness (-)

 Suspect bone expansion

101.04.06

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Medical and Dental History



Medical history:



Systematic: Denied



Hospitalization: Denied



Allergies: Denied



Dental history:



General routine dental treatments

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Medical and Dental History

 Oral Risk Factors:



Alcohol consumption: Denied



Betel-quid chewing: Denied



Cigarette Smoking: Denied

 Oral habits: Denied any special oral habits

 Attitude toward dental treatments: cooperative

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Dental Examination

 Missing: Tooth 21, 45

 Crown and bridge: Tooth 11x 22 PFM bridge

 Caries: Tooth11M, 14M, 35M

 Calculus: Tooth 11D, 12M, 14D, 34D, 44M

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Radiographic Examination

 There is a well-defined ovoid shaped unilocular radiolucent lesion mixed with radio- opacities located at lower right premolar area. The lesion extends from the root apex of tooth 41 to distal of root of tooth 44, and extends from middle third of roots of 43, 44 down to the lower border of mandible, measuring about 2 x 2.7 cm in diameter.

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Radiographic Examination

• Root resorption (-)

• Loss of lamina dura: Tooth 44

• Tooth displacement : Tooth

44

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Radiographic Examination

• There is a well- defined unilocular lesion mixed with radiolucency and radiopacity,

measured 3cm x 2.5cm in maximal diameter extending from mesial of tooth 42 to mesial of tooth 46.

• Buccal and lingual bone expansion is present with

thinning of cortical

margins.

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Working Diagnoses

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Inflammation, cyst or neoplasm?

Our case Inflammation Cyst Neoplasm

Color Pink to normal Red Normal Variable

Fever - + - -

Consistency hard Rubbery Soft Variable

Discharge - + - +/-

Pain + + - +/-

Ulceration - - - +

Mobility Fixed Fixed Fixed Fixed

Duration Unknown Days Years Months

Bony destruction or expansion

+ - + +

Cyst or neoplasm

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Benign or malignant?

Our case Benign Malignant

Surface Smooth Smooth Rough

Ulceration - - +

X-ray margin Well-defined Well-defined Poor-defined

Mobility Fixed Movable Fixed

LAP - - +

Duration Unknown Years Months

Benign

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Peripheral or intrabony?

Our case Peripheral Intrabony

Consistency Firm to hard Rubbery Firm

Ulceration - +/- +

X-ray margin Well-defined Poor-defined Well-defined

Induration - + -

Mobility Fixed Fixed Fixed

Bony destruction or expansion

+ - +

Intrabony

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Working diagnosis

Intrabony benign tumor or cyst

Benign Tumor

 Odontogenic

•

Cemento-ossifying fibroma

•

Ameloblastoma (Desmoplastic)

•

Calcifying epithelial odontogenic tumor(CEOT), Pindborg tumor

 Non-odontogenic

•

Osteoblastoma

 Cyst

• Calcifying odontogenic cyst (Gorlin Cyst)

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Working diagnosis

•

The List (more possible → less)

1. Cemento-ossifying fibroma

2. Calcifying epithelial odontogenic tumor (CEOT), Pindborg tumor

3. Osteoblastoma

4. Ameloblastoma (Desmoplastic type)

5. Calcifying odontogenic cyst (Gorlin Cyst)

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Cemento-ossifying fibroma

• Etiology

– A benign neoplasm of odontogenic bone &

cementum (fibro-osseous lesion)

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Our Case Cemento-ossifying fibroma

Gender Female Female

Age 30 y/o 20~40 y/o

Site Right mandibular premolar and incisors region

Mandibular premolar or molar region

Symptom/Sign Swelling and pain Painless swelling Effects Bony destruction and

expansion

Teeth displacement

Bony destruction and expansion

Roots of related teeth can be displaced

Cemento-ossifying fibroma

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Cemento-ossifying fibroma

Radiographic features Our case Cemento-ossifying fibroma

Density RL+R/O RL+RO

Border Well-defined with corticated margin

Well-defined, with thin R/L rim surrounded by a

narrow zone of cortication

Shape Unilocular Unilocular

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Calcifying epithelial odontogenic tumor (CEOT), Pindborg tumor

• Etiology

– A tumor of odontogenic origin – Arises possibly from

•

Dental lamina remnants

•

Statum intermedium of enamel organ

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Calcifying epithelial odontogenic tumor (CEOT), Pindborg tumor

Our case CEOT

Gender Female Both

Age 30 y/o 30-50 y/o

Most on posterior mandible(57%) Symptom/Sign Swelling and pain Slow-growing swelling

Painless Effect Bony destruction and

expansion

Teeth displacement

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Calcifying epithelial odontogenic tumor (CEOT), Pindborg tumor

Radiographic features Our case CEOT

Density RO + RL RO + RL

Well-defined

20% corticated margin (20% Ill-defined)

Scalloped

Multilocular (honeycomb)

Often with impacted 3^rd molar

Driven snow appearance

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Osteoblastoma

• Etiology

– A benign tumor arises from osteoblast

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Osteoblastoma

Our case Osteoblastoma

Gender Female Female≧Male

Age 31 y/o < 30 y/o

Normal: Vertebral column Sacrum

calvarium

Jaw: posterior teeth area of jaw bone

Symptom/Sign Swelling and pain pain

Not relieved by aspirin Effect Bony destruction and

expansion

Teeth displacement

Bony destruction

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Osteoblastoma

Radiographic Features Our case Osteoblastoma

Density RL + RO RL + RO

Well-defined/ill-defined Corticated margin

Shape unilocular Unilocular or Multilocular

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Ameloblastoma

•

Etiology

– A tumor of odontogenic epithelium

•

Ameloblastoma (Desmoplastic type)

– Dense fibrous stroma

– Radiographic features : R/L+R/O

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Our Case Ameloblastoma (Desmoplastic type)

Gender Female Both

Age 30 y/o 20~70 y/o

Anterior maxilla

Symptom/Sign Swelling and pain Rare pain or parethesia Effects Bony destruction and

expansion

Teeth displacement

Adjacent teeth displaced, loosened, often resorbed, extensive expansion in all

directions

Ameloblastoma

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Ameloblastoma

Radiographic features Our case Ameloblastoma (Desmoplastic type)

Density RL+RO RL+RO

(Dense fibrous septa) Border Well-defined with

corticated margin

Scalloped, well-defined, well-corticated

Shape Unilocular Multilocular (soap-

bubble or honeycombed)

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Calcifying odontogenic cyst (Gorlin Cyst)

• Etiology

– Uncommon lesion among odontogenic cysts

• Clinical behavior

– Variable, some were regarded as

neoplasms(infiltrative or malignant) – May be associated with AOT or

ameloblastoma

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Calcifying odontogenic cyst (Gorlin Cyst)

Our case Calcifying odontogenic cyst (Gorlin Cyst)

Gender Female No predominant

Age 30 y/o Diagnosed between 20-

30y/o, average 33 y/o Site Left mandibular body Most on Incisors and

Canine areas(65%)

Symptom/Sign Swelling and pain Unspecific

Effect Bony destruction and expansion

Teeth displacement and root resorption

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Radiographic Features Our case Calcifying odontogenic cyst (Gorlin Cyst)

Density RL + RO RL + RO

Well-defined

Occasionally Multilocular

Calcifying odontogenic cyst

(Gorlin Cyst)

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Clinical impression

• Cemento-ossifying fibroma over tooth 43, 44, 45

area

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Histological Pathologic Report

Pathological diagnosis:

Bone, mandible, tooth 43&44 apical area, incision, cemento-ossifying fibroma

Gross Examination :

The specimen submitted consists of more than 10 soft tissue fragments in 1 bottle, measuring up to 0.3 x 0.2 x 0.2 cm in size, fixed in formalin. Grossly, they are white in color and elastic in consistency.

Microscopic Examination :

The slide contains two identical groups of irregular- shaped soft tissue specimens. Microscopically, it shows cemento-ossifying fibroma .

送檢時間：101/04/09 報告時間：101/04/11 送檢醫師：許瀚仁醫師

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Treatment Plan

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Treatment procedure

• First visit at OS(101/04/06)

Radiographic exam : PE, panoramic and occlusal film

Clinical exam

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First visit at OS (101/04/06)

Incisional biopsy under local anesthesia Specimen sent for H-P report

Rx: Amoxicillin 500mg, 1# , QID x III days Strocain , 1# , QID x III days Panadol 500mg, 10# , sig. 1# , p.r.n.

Treatment procedure

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Treatment procedure

OS (101/04/13)

Appointment for H-P report Wound condition: OK

Symptoms and signs stationary

H-P report : Cemento-ossifying fibroma Suture removal

Arrange CT scan on 101/04/27

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Treatment Plan

Cemento-ossifying fibromas can usually be

readily enucleated, separating from bone in the plane of their capsule.

Occasionally, large tumors that have distorted the jaw require local resection and bone grafting, but recurrence is rare.

Cawson’s essentials of oral pathology and oral medicine (8^th edition)

◎ R. A. Cawson, E. W. Odell

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醫學倫理討論

以 Jonsen架構檢視這次病例的治療模式

是否符合醫學倫理

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Tom Beauchamp &James Childress 六大原則- 1979

 1. 行善原則(Beneficence)，亦即醫師要盡其所能延長病人之生命且減輕病人之痛苦。

 2. 誠信原則(Veractity)，亦即醫師對其病人有「以誠信相對待」

的義務。

 3. 自主原則(Autonomy)，亦即病患對其己身之診療決定的自主權必須得到醫師的尊重。

 4. 不傷害原則(Nonmaleficence)，亦即醫師要盡其所能避免病人承受不必要的身心傷害。

 5. 保密原則(Confidentiality)，亦即醫師對病人的病情負有保密的責任。

 6. 公義原則(Justice)，亦即醫師在面對有限的醫療資源時，應以社會公平、正義的考量來協助合理分配此醫療資源給真正最需要它的人。

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Jonsen架構

 Jonsen, Siegler and Winslade; Clinical Ethics: A Practical Approach to Ethical Decisions in Clinical Medicine (3rd edition McGraw-Hill 1992 )

 1. 醫療現況

 2. 病人抉擇

 3. 生命品質

 4. 社會脈絡

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Medical indication for intervention

 江小姐因切片診斷出其右下顎骨有

Cemental-ossefying fibroma, 因此要考慮

治療的選擇。考慮接受腫瘤切除術與否，

需考慮若切除與否預後各是如何？

 是否有其他替代治療以維護病人自主選擇的權益？

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Patient’s Preference

 江小姐並無心智失能且在法律上有能力，

理應選擇對她最有利的治療方式，並需被告之治療可獲得的利益及其風險，且病歷記載中並無記錄病人於術前表示其喜好，並於之後排定治療流程中皆相當配合，於此方面應無違反醫療倫理。

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Quality of life

 若施行腫瘤切除術合併移除因病灶而影響到的牙齒42, 43, 44，病人即使治療成功，病人需面對該處咬合重建的問題，

醫療提供者是否將此考慮進去並告知病患，是否會影響病人對此病灶處理方式的態度？

 在腫瘤邊緣的牙齒41, 42是否先以保留為目標?

 若不治療，則病患是否能行使正常生活不受病灶影響？

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Contextual issues

 江小姐目前未婚，無丈夫子女等家庭因素影響治療，但病歷上並未詳載病人使否有經濟、宗教、文化上之因素會影響病人選擇治療。其餘法律因素、社會資源應對此病例無影響，且無利益衝突者介入醫療過程。

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醫學倫理總結

 應多注意病歷記載，特別對於病灶之治療計畫及病人態度，以了解此案例在醫療現況及病人抉擇上是否合乎醫學倫理原則。

 此病人需手術介入，並需長期配合及考慮家庭支持之因素，應更詳盡詢問病人社會脈絡部分。

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Reference

 Oral & Maxillofacial pathology 3rd ed.

 Cawson’s essentials of oral pathology and oral medicine (8th ed.)

◎ R. A. Cawson, E. W. Odell

 台灣臨床倫理網絡

http://www.tcen.org.tw/index.asp

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