OM case report
Reporter：Intern G 組 中山正雄
林哲生 張綺真 楊理涵
Instructor：口病科全體醫師 Date：102.3.26
General Data
Name : 李XX
Sex : 女
Age : 55 y/o
Native : 高雄
Marital status : married
Attending V.S. : XXX 醫師
First visit : 102/01/02
102/02/22
Chief Complaint
Mass over right upper posterior area for 5 years and referred from dental department of KMTTH for surgical intervention
102/02/22
Present Illness
This 56 y/o female patient suffered from a
swelling mass over upper right posterior hard palate for more than 5 years. She felt the mass was slowly growing recently so she went to 第一 門診 for help, then the doctor suggested her to the dental department of KMTTH further
treatment .
But the dental department of KMTTH referred
her to our hospital (KMUH) for further treatment.
So, she comes to our OPD on 102/02/22.
Past History
Past Medical History
- Hospitalization : (+) Hysterectomy，
Appendectomy
- Surgery under GA : (+) Hysterectomy，
Appendectomy
- Systemic diseases : Denied
- Drug or food allergy : Penicillin, tetracycline
Past Dental History
- General routine dental treatment
Attitude to dental treatment: Co-operation
Personal History
Risk factors related to malignancy
• Alcohol: (-)
• Betel quid: (-)
• Cigarette: (-)
Other specific oral habits : Denied
Irritation : Denied
Intraoral Examination-1
Torus was noted
→Site : Upper middle hard palatal area → Color : Pinkish
→Mobility : Fixed →Shape : Dome →Size : 2X2cm →Surface : Smooth →Consistency : Hard →Pain : (-)
→Tenderness : (-) →Induration : (-)
102.01.02
Intraoral Examination-2
A large mass was noted
→Site : Right upper posterior hard palate area and adjucent to right side of torus
(from tooth 24 mesial side to 27 distal side) → Color : Pinkish with areas of bluish color
→Mobility : Fixed →Shape : Dome →Size : 4X3cm →Surface : Smooth →Consistency : Firm →Pain : (-) →Tenderness : (-) →Induration : (-)
02/07/2013
102.01.02
Panorex view (102.01.02)
There is a well-defined oval shaped radiolucency with corticated margin over right palatal molar region,
extending from tooth 16 mesial side to 17 distal side, and from 17 occlusal side to 17 apical side,
measured approximately 2x1.5 cm in diameter.
Panorex view (102.01.02)
Dental findings
Missing tooth : 18,28,32,33,34,35,36,37,38,47,48
Prosthesis : 1) Crown : 14
2)Crown and bridge : 31-x-x-x-x
OD : 24(O),35(D)
Periodontal condition : Horizontal bony resorption
Image Finding-Panorex(102.01.02)
TMJ: N/P bilateral
Idiopathic osteosclerosis was noted over 42,44,45(root apex area) and left posterior mandibular body
Differential Diagnoses
Classification of the lesion
Inflammation, neoplasm or cyst
Benign or malignant
Intrabony or peripheral
Classification of the lesion
Our case features :
– Site : Hard palate – Gender : Female – Age : 55
– Consistency : Firm – Progressive : Slow
Our case Inflammation Neoplasm Cyst
Color
Pinkish Red Variable Yellow or
white
Fever or local heat
(-) (+) (-) (-)
Consistency Firm Rubbery Variable Rubbery
Ulceration (-) (-) (-)/(+) (-)
Duration More than 5 years
Days to Months
Months to years Years
Mobility Fixed
(in palate)
Fixed
(in palate)
Fixed (in palate)
Fixed
(in palate)
Pain (-) (+) (-)/(+) (-)
Inflammation ? Neoplasm ? Cyst ?
Neoplasm!
Our case Benign Malignancy
Surface Smooth Smooth Rough
X-ray margin Well-defined Well-defined Poor-defined
Progressive Slow-
progressing
Slow Variable
Pain - +/- +/-
Induration (in palate)
- Hard to define Hard to defined
Mobility (in palate)
Fixed Fixed Fixed
Benign or Malignancy ?
→ Benign should be considered
Peripheral or intrabony?
Our case Peripheral Intrabony X-ray margin Well-defined - Well-defined
Bony
destruction or
expansion
+ - +
Intrabony
Differential diagnosis
1) Cemento-ossifying fibroma (early stage)
2) Unicystic intraosseous ameloblastoma
3) Central giant cell granuloma (early stage)
4) Fibrous dysplasia (early stage)
1.Cemento-Ossifying fibroma
Our case COF
Gender Female Female
Age 55 20-40
Site Hard palate Posterior mandible
Pain （－） （－）
Ulcer （－） （－）
Consistency Firm Firm
Bone
expansion (+) (+)
Our case COF
2. Unicystic Ameloblastoma
Our case Ameloblastoma
Gender Female none
Age 55 20~70
Site Hard palate Posterior mandible
Pain （－） （－）
Ulcer （－） （－）
Consistency Firm Firm
Bone
expansion (+) (+)
Our case
Ameloblastoma
3. Central giant cell granuloma
Our case Giant cell tumor
Gender Female Female
Age 55 <30(60%)
Site Hard palate Mandible
Pain （－） （－）
Ulcer （－） （－）
Consistency Firm Firm
Bone
expansion (+) (+)
4. Fibrous dysplasia
Our case Fibrous dysplasia
Gender Female none
Age 55 0~20
Site Hard palate Maxilla
Pain （－） （－）
Ulcer （－） （－）
Consistency Firm Firm
Bone
expansion (+) (+)
Our case
Fibrous dysplasia
Clinical impression
Lesion 1:
Torus palatinus
over midline of hard palate
Lesion 2:
Cemento-ossifying fibroma (early
stage) over right posterior palate
Treatment course
102.1.2 First visit -at KMTTH
Arranged OP on 102/03/07
102.3.7 OP: Remove bone tumor and Torus palatinus and 17 ext
102.3.22 f/u
Final Diagnosis
Lesion1:
Torus palatinus
over midline of hard palate
Lesion2:
Osteolipoma
over right hard palate
醫學倫理與病人安全
醫學倫理
一種道德思考、判斷和決策，以倫理學的 觀點出發，以期能做出對病人最有利益、
最能符合道德倫理規範的醫療決策
本案例可能會碰到的問題
病人發現病灶有增大現象 => 第一門診就 診 => 轉診至大同 => 轉診至高醫
是否因為轉診而造成診斷延遲
轉診是否可以讓病人獲得較好的治療
初診日期為2/1，並無先做biopsy，而至 2/22才排3/7 OP處理病人的問題
是否因為間隔時間較長而拖延到治療時間
轉診
病人就診過程之中有轉診至數間醫院
是否因為耗費較多時間在各個醫院轉診過程之 中，而造成病灶較慢被診斷
病人的病灶已經持續很長一段時間，若沒有突然急 遽的變化應該對診斷影響不大
病人由門診轉至地區醫院再轉至教學醫院，是 否可以因此獲得較精確的診斷與較好的治療
病人應該可以藉由轉診獲得專科醫師較專業的建議 與比較完整的治療評估
沒有先biopsy，選擇直接手術
沒有先做切片確定診斷，而是決定直接排 手術治療
如果OP完之後的結果發現並非臨床診斷的良性 病灶，是否有可能因此延遲治療
病灶在臨床表徵上看起來應該是良性的，故選擇直 接手術摘除
手術和就診日期間隔較長
初診日期和實際手術時間相差1個月
間隔時間較長，如果病灶有突然加速加劇的變 化可能影響到病人的治療及預後
病人在就診之前病灶已經持續有5年以上的時間，都 沒有明顯的變化，最近病人覺得有變化也是緩慢的
，故推測為良性的病灶，突然變差的機率較低
