口病 CASE REPORT

組 員 : 蔡 承 翰 張 碩 夫 謝 亞 錚 羅 宏 德 指 導 醫 師 : 口 腔 病 理 科 全 體 醫 師

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口病 CASE REPORT

General Data

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Chief Complaint

 A radiolucency lesion was found at LDC in

8/7/2013, and the patient visited our dental

department for further help.

Present Illness

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This 40 years old woman suffered from a radiolucency lesion over

tooth 31 32 apical area on periapical film 1 years ago. So, doctor of

local dental clinic suggested him come to the dental department of

our institution for further treatment.

Intraoral Examination

 Max dimension : 1.5 x 2 cm

 Location: Tooth 31, 32 buccal gingiva

 Surface: smooth

 Consistency: hard

 Pain (-)

 Non-tender

 Non-ulcerated

Intraoral Examination

 Dentition (tooth 32-33):

1. Tooth vitality : (+)

2. Percussion pain: (+/-)

3. Palpation pain: (-)

Past History

 Past medical history



Underlying disease: (-)



Hospitalization: (-)

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Surgery under GA: (-)

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Allergy: (-)

 Past Dental History

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General routine dental treatment

 Attitude to dental treatment : Co-operative

Personal History

 Risk factors related to malignancy



Alcohol drinking：(-)

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Betel quid chewing：(-)



Cigarette smoking：(-)

 Other special oral habits: Denied

Image finding – Panorex(102/8/7)

There is a well-defined unilocular round shaped radiolucence with a corticated margin over the apex of tooth 32,33, which extending from mesial aspect of tooth 34 root apex to mesial aspect of tooth 32 root apex and from apical third of tooth 33 down to one-third of the mandibular body, measuring approximately 1.5 X 2 cm in diameter.

The lesion caused the tooth 32,33 displacement, tooth 32 distal tilting and tooth 33 mesial tilting. In addition, tooth 32,33 root divergence was noted. There’s no significant influence on left mental foramen, and the inferior border of cortical bone was intact.

Image finding – Panorex(102/8/7)

There is a unilocular round shaped radiopaque lesion over the right retromolar area, which extending from dital root of tooth 47 root apex to the end of the retromolar pad and from the retromolar area down to the superior border of mandibular canal,

measuring approximately 1 X 1.2 cm in diameter.

Image finding-Occlusal film(102/8/8)

There is no cortical bone expansion,and tilting of 32,33 is noted.

Image finding – Cone beam CT(102/8/12)

Image finding – Cone beam CT(102/8/12)

Image finding – Cone beam CT(102/8/12)

Image finding – Cone beam CT(102/8/12)

There is a well-defined unilocular round-shaped radiolucence. Resorption of cortical bone on buccal side is noted .

Image finding – Cone beam CT(102/8/12)

Image finding – Cone beam CT(102/8/12)

Image finding – Cone beam CT(102/8/12)

Image finding – Cone beam CT(102/8/12)

There is a unilocular round-shaped radiopaque lesion.The adjacent bony structures are intact.

Working Diagnosis

Peripheral or Intrabony?

=> Intrabony

Our case Peripheral Intrabony

Mucosal lesion - + -

Induration - + -

Bony expansion - - +/-

Cortical bone destruction + - +/-

Inflammation, Cyst or Neoplasm?

Inflammation

Our case Inflammation

Redness - +

Swelling - +

Local heat Unknown +

Pain - +

Multifocal - -

Skull involvement - -

Cyst or Neoplasm

Cyst or Neoplasm?

Cyst

Our case Cyst

Aspiration Unknown +

Fluctuation - +/-

Well-defined border

+ +

Bone expansion - +/-

Cyst or Neoplasm?

Our case Inflammation

cyst Non-

Inflammation cyst

Pain,

tenderness pain-

tenderness- + -

Local heat Unknown + -

Color Pink to

normal Reddish Pink

Progression Slow Fast Slow

Sclerotic

margin + - +

Cyst or Neoplasm?

Neoplasm

Our

case Benign Malignant

Border Well-defined Well-defined Poorly-defined

Sclerotic margin + + ─

Destruction of cortical margin ─ +/─ +

Pain ─ ─ +

Induration ─ ─ +

Swelling with intact epithelium + + ─

Lymphadenopathy ─ ─ +/-

Progress Slow Slow Fast

Metastasis ─ ─ +/-

Non-inflammation cyst or Benign tumor

Working Diagnosis

 Cemento-osseous dysplasia (early stage)

 Cemento-ossifying fibroma

 Odontogenic fibroma

 Fibrous dysplasia

Differential Diagnosis

Florid cemento-osseous dysplasia(early stage)

Our case Florid cemento-osseous dysplasia (early stage)

Gender female female

Age 40 ＞30歲

Site Left mandibular canine

and lateral incisor Multiple lesions, including anterior mandible

Symptom and

Sign Asymptomatic Asymptomatic

Size 1.5X2.0 cm

Teeth vitality + +

Florid cemento-osseous dysplasia(early stage)

 Radiographic features

Our case Florid cemento-osseous dysplasia(early stage)

Density RL RL

Border Well-defined with

corticated margin Well-defined with corticated margin

shape Unilocular Unilocular

Cemento-ossifying fibroma

Our case Cemento-ossifying fibroma

Gender female female

Age 40 20~40

Site Left mandibular canine

and lateral incisor Mandibular premolar-molar region Symptom and

Sign Asymptomatic Painless swelling

Jaw expansion - +

Teeth

displacement + +

Cemento-ossifying fibroma

 Radiographic features

Our case Cemento-ossifying fibroma

Density RL Mixed lesion(RL+RO)

Border Well-defined with

corticated margin Well-defined with corticated margin R/L rim is uncommon

shape Unilocular Unilocular

Root divergence

or resorption + +

Odontogenic fibroma

Our case Odontogenic fibroma

Gender Female Female

Age 40 4~80(mean=40)

Site Left mandibular canine

and lateral incisor mandible Symptom and

Sign Asymptomatic Asymptomatic

Teeth vitality + +

Root divergence

or resorption + +

Odontogenic fibroma

 Radiographic features

Our case Odontogenic fibroma

Density RL RL

Border Well-defined with

corticated margin Well-defined with corticated margin shape Unilocular Unilocular or multilocular

Fibrous dysplasia(monostotic)

Our case F.D.

Gender female both

Age 40 10~20

Site Left mandibular canine

and lateral incisor Maxilla

Symptom and

Sign Asymptomatic Painless swelling

Displacement of

mandibular canal - Superior displacement

Hormone related unknown +

(do not progress beyond puberty)

Fibrous dysplasia

 Radiographic features

Our case F.D.

Density RL Ground glass

Border Well-defined with

corticated margin Poorly-defined

shape Unilocular

Clinical impression

 Cemento-osseous dysplasia (early stage) over

tooth 32

Treatment course

 102.08.07

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Referred from for a lesion found in routine X-ray exam one year ago

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Arrange to biopsy in OS

Treatment course

 102.08.08

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occlusal film and cone beam CT taking

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Arrange surgery under general anesthesia

 102.08.09

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Pre-OP full mouth scaling

 102.08.12

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Admission for operation

Treatment course

 102.08.14

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OP day

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Bone tumor excision

Treatment course

 102.08.19

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Pathologic diagnosis:

Bone,mandible,left,enucleation,cemento-osseous dysplasia

 102.09.22

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Suture removal and topical application of BI

Florid cemento-osseous

dysplasia

INTRODUCTION

 Fibro-osseous lesion

 Site: jaw bone

 Age:mid-aged

 Radiographic:multi-quadrant radiopaque cementum-like masses

 Usually asymptomatic

 Biopsy is usually not recommended

CASE REPORT

P.I.

A 45-year-old female patient presented to our

department with a chief complaint of pain in the left

molar region of the mandible for 1 month. The patient

was otherwise healthy, and her physical examination

showed no significant abnormality.

Intraoral examination

 Caries: Tooth 36

 Missing: Tooth 18,28,37,38,48

 Previous endo. tx: Tooth 36

X-ray finding

Discussion

 Pathogenesis  obscure

 Theories:

1. Proliferation of the fibroblastic mesenchymal stem cells

2. Reactive or dysplastic changes in PDL

3. Trauma from occlusion

Discussion

D.D.

1.FGC(familial gigantiform cementoma )

 Autosomal trait genetic disease

 Affect mostly children

 Often crosses the midline

 Without gender predilection

 Need surgery

Discussion

D.D.

2. Gardener's syndrome

 Skeletal changes

 Skin tumors

 Dental anomalies

Discussion

D.D.

3. Paget's disease

 Affect mostly white males

 More of polyostotic with pathognomonic increase in

serum alkaline phosphatase level

Discussion

D.D.

4. Cemento-ossifying fibroma

 More buccolingual expansion

Discussion

D.D.

5. Chronic diffuse sclerosing osteomyelitis

 Unilateral

 Soft-tissue swelling,

 Fever

 Lymphadenopathy affecting primarily mandible

Conclusion

 FCOD is diagnosed principally by its clinico- radiological features

 If asymptomaticno surgical treatment is required

 Long term follow-up

醫學倫理討論

六大原則

Tom Beauchamp &James Childress

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行善原則(Beneficence)：

醫師要盡其所能延長病人之生命且減輕病人之痛苦。



誠信原則(Veractity)：

醫師對其病人有「以誠信相對待」的義務。

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自主原則(Autonomy)：

病患對其己身之診療決定的自主權必須得到醫師的尊重。



不傷害原則(Nonmaleficence)：

醫師要盡其所能避免病人承受不必要的身心傷害。

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保密原則(Confidentiality)：

醫師對病人的病情負有保密的責任。

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公義原則(Justice)：

醫師在面對有限的醫療資源時，應以社會公平、正義的考量

協助合理分配此醫療資源給真正最需要它的人。

 行善原則(Beneficence)



考慮到持續破壞骨頭可能性甚至惡性的變化

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病患能夠較免於提心吊膽

 誠信原則(Veractity)

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清楚詳細地並且以病人能理解的語言，告知病人手術中可能遭 遇的風險和術後會有的疼痛及不方便



估計所需要費用和住院時間的說明

 自主原則(Autonomy)



告知病情狀況後，尊重病人及家屬的決定，決定是否開刀移除 病兆



手術同意書、全身麻醉同意書等等

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

病兆以外的正常組織

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無菌控制

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病情以對本人說明為原則，尊重病的隱私權

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考慮病人年紀或病情嚴重度等等

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是否有手術的必要

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醫療資源的分配

THANKS FOR

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