報告組別:Intern K 組 報告日期 : 101.07.24
指導醫師:林立民醫師、陳玉昆醫師、
王文岑醫師、陳靜怡醫師
組員:李懿修、廖力行、劉裕誠、林洋均
General Data
Name: 方OO
Sex: Male
Age: 40 y/o
Native: 台灣
Marital status: 已婚
Attending V.S.:吳崇維醫師
First visit: 100.11.8
Chief Complaint
Gingiva swelling over right lower lingual area for two days
Present Illness
This 40y/o male patient found that there is a painful, tender and numbness swelling over the lower right lingual area from central incisor to premolar area for two. So, he came to KMU dental department for
further examination and treatment.
94. 2.15
Toothache over tooth 42, 43 area and found
fistula on tooth 42 lingual. He went to many LDC and accepted RCT but the lesion became larger.
Therefore, the dentist referred him to 輔英hospital and subsequently, referred to KMU dental
department.
94.03.22 OD/Endo dept
Accepted flap op, bone window, root tip amputation in OD/Endo dept (tooth 42,43) plus medications
Past History
Past Medical History
• Denied any underlying diseases
• Denied any food or drug allergies
• Hospitalization: (-)
• Surgery under GA: (-)
Past Dental History
General routine dental treatment
Root tip amputation and flap op of 42 43
Attitude to dental treatment: co-operative
Personal History
Risk factor related to malignancy
• Alcohol:(+), sometimes 1-2 bottles
• Betel quid: (-)
• Cigarette: (-)
Special oral habits : Denied
Bite irritation : Denied
Dental Examination
Missing: Tooth18, 28, 37, 38
C&B: Tooth14
Restorations: Tooth15, 36, 46
General plaque and calculus deposition
Food impaction
Intraoral Findings
Max. Dimension: 2.5x1.5 cm
Color: Red
Surface: Smooth
Base: Sessile
Shape: Dome
Consistency: Soft
Fluctuation (+)
Mobility: Fixed
Pain (+)
Tenderness (+)
Induration (-)
Panoramic Radiography
100.11.08
There was a well-defined multilocular round-shaped radiolucence with
corticated margin over the apex of tooth 32 to 46, extending from 32 root apex to mesial root apex of tooth 46 and from mandible alveolar ridge of 41 to 45 down to the inferior border of right mandible, measured 4.0x2.5cm in diameter. Right mandibular canal may have been involved. Ambiguous external root resorption of tooth 42 43 are found. Tooth 42, 43 with RCT can also be noted.
Periapical Radiography
100.11.8
1. Well-defined multilocular RL over root apex of tooth 43, 44, 45
2. Restoration: Tooth 46
3. Previously RCT: Tooth 43
Peripheral or intrabony ?
42~43 lingual side:
2.5X 1.5 cm, dome shape, sessile base, soft consistency with fluctuation, red
color
Tenderness (+)
Pain (+)
Peripheral or intrabony ?
Multilocular radiolucence with bony destruction
Intrabony lesion
Inflammation,cyst,neoplasm?
Due to panorex finding: Large multilocular RL destruction lesion cyst or neoplasm
Cyst or neoplasm?
Our case cyst
Fluctuation + +-
Well + defined border + +
Bone expansion - +-
Our case Inflammation cyst <Non-inflammation cyst>
Pain,
tenderness
+ + -
Local heat Unknown + -
Color Pink Reddish Pink
Progression Slow Fast Slow
Sclerotic margin
+ - +
Cyst or neoplasm?
Our case <benign> <Malignance>
Border Well-defined Well-defined Ill-defined
Margin Smooth Smooth Irregular
Sclerotic margin + + -
Destruction of cortical margin
+ -+ +
progressive Slow Slow fast
Swelling with intact epi.
+ + -
Pain + - +
Induration - - +
Non-Inflammation cyst or Benign tumor
Working Diagnosis
(1) Keratocystic odontogenic tumor (2) Ameloblastoma
(3) Odontogenic myxoma
(4) Central giant cell granuloma (5) Aneurysmal bone cyst
Keratocystic odontogenic tumor
Our case KCOT (larger)
Gender Male Slight male
Age 40 10~40
Site 32~46 Mandible (posterior body and
ascending ramus)
Paresthesia Pain Ppain
Swelling + +
Drainage + (Fluctuation) +
Shape
Well-defined, smooth, scalloped, multilocular,
corticated margin
Well-defined, smooth, multilocular, corticated margin
Bony expansion - -
Teeth displacement
/root resorption + +
Duration Suspected 7 years Slow
Ameloblastoma
Our case Ameloblastoma
Gender Male Equal
Age 40 30~70
Site 32~46 Mandible (molar ascending
ramus)
Paresthesia Pain Uncommon
Swelling + +
Drainage + (Fluctuation) +
Shape
Well-defined, smooth, scalloped, multilocular,
corticated margin
Well-defined, smooth, multilocular, corticated margin
Bony expansion - +
Teeth
displacement /root resorption
+ +
Duration Suspected 7 years slow
Odontogenic myxoma
Our case Odontogenic myxoma
Gender Male Slight female
Age 40 10~50 (mean25~30)
Site Tooth 32~46 Max.:Mand.=3:4 or 3:7 (tooth-bearing areas)
Paresthesia Pain -
Swelling + -
Drainage + (Fluctuation) -
Shape
Well-defined, smooth, scalloped, multilocular,
corticated margin
Often well-defined, unilocular or multilocular, may with corticated
margin
Bony expansion - +
Teeth
displacement /root resorption
+ +
Duration Suspected 7 years Slow
Central giant cell granuloma
Our case Nonaggresive(
most) Aggressive
Gender Male Female
Age 40 <30
Site Tooth 32~46 Mandible (anterior region) frequently cross the midline
Paresthesia Pain - Pain
Swelling + - +
Drainage + (Fluctuation) - -
Shape
Well-defined, smooth, scalloped, multilocular,
corticated margin
Well-defined, unilocular or multilocular, non-corticated
margin
Bony expansion - - +
Teeth
displacement /root resorption
+ - +
Duration Suspected 7 years Slow Rapid
Aneurysmal bone cyst
Our case Aneurysmal bone cyst
Gender Male Equal
Age 40 <30
Site 32~46 Posterior of jaw
Paresthesia Pain Often
Swelling + +
Drainage + (Fluctuation) +
Shape
Well-defined, smooth, scalloped, multilocular,
corticated margin
Well- defined or diffuse, unilocularor multilocular, often with marked cortical expansion
and thinning
Bony expansion - +
Teeth
displacement /root resorption
+ +
Duration Suspected 7 years Rapid
Clinical Impression
Keratocystic odontogenic tumor, over tooth 32~46
Treatment course
100. 11. 08
1. Return to OS and the lesion was found expanded from tooth 41 to 46
2. Incisional biopsy was immediately taken and visit in next week
100.11.15
1. Pathology finding: Keratocystic odontogenic tumor
2. Suture removal of biopsy
100.11.22
1. Decompression and extraction of tooth 42
2. Bone trimming and flap reflection over 42 labial side for enlargement of socket wall near gingiva .Soft tissue sent to HP for examination
100.11.29~5.15
Wound irrigation and instruction Follow up every 6weeks
Treatment Course
101.4.24
CT was arranged and pano was taken
101.6.27
Pre-operative examination
101.7.6
Op : bone tumor excision + bone graft repair + complicated extraction of 43 44
101.7.6~7.18
Suture removal + wound check
Treatment Course
Radiographic Examination
101.2.14
1. Multilocular RL turns into bilocular RL with more RO in the lesion indicated new bone formation
2. Tooth42 extracted in 100/11/22 3. Size of lesion decreased
Radiographic Examination
101.4.24
A well-defined unilocular round-shaped radiolucence between tooth 31 and 43,from 2/3 portion of root to root apex of 43, measuring about 1x 0.5cm lesion remain. Tooth43 has been displaced into tooth 42 and
continuous bone formation can been noted between tooth apex 32 to 46
Suspect of bony perforates so CT was arranged
Image Finding – CT
An unilocular cystic
lesion (2.6x0.9x1.0 cm) with cortical
breakthrough at right mandibular body. DDx:
radicular cyst,
odontogenic keratocyst Recommend clinical correlation.
Retention cysts in the left maxillary sinus
101.5.16
Radiographic Examination
101.6.27
1. An unremarkable poorly defined radiolucence between apex of tooth 31 and 43
2. Multilocular radiolucence disappears
3. Shrinkage of cyst but suspect of cortical plate perforate
Skull AP and lateral views
Image findings:
There was solitary,
unilocular cystic lesion with cortical breakthrough at right mandibular body.The orbits appeared unremarkable.
Impressions:
An unilocular cystic lesion with cortical breakthrough at right mandibular body.
Recommend clinical correlation.
PA View of the Chest
The heart size is not enlarged.
The aorta and great
vessels are unremarkable.
No active lung
consolidation is noted.
The hila and mediastinum are unremarkable.
The costophrenic sulci are clear.
The thoracic cage is intact.
Impression:
No imaging evidence of active cardiopulmonary disease.
Operation method
Bone tumor excision + bone graft 2.5cc + tooth 43 44 extraction
Radiographic Examination
101.7.7
1. Lesion disappeared after excision and tooth extraction of 43 44 2. Right mandibular canal can be seen
Pathologic diagnosis --101/7/9--
Bone, mandible, tooth 32-46 apical area, excision, keratocystic odontogenic tumor
Gross Examination:
The specimen submitted consists of 1 soft tissue fragment in 1 bag, measuring up to 1.8 x 1.5 x 0.7 cm in size, in fresh state. Grossly, it is gray in color and firm in consistency.
Microscopic Examination:
The slide contains two identical groups of irregular-shaped soft tissue specimens.Microscopically, it shows
keratocystic odontogenic tumor.
Prognosis
Thin, friable cyst wall – difficult complete removal
Often tend to recur after treatment
Due to
- remain of fragments of the original cyst
- “new” cyst developed from dental lamina
Recurrence rate: approximately 30%
Treatment
Excision + bone trimming + tooth 43.44 extraction + FDBA graft
- Marginal or partial resection - Chemical cauterization
Treatment
Marginal or partial resection
Chemical cauterization
Marginal or partial resection
Marginal or partial resection
Indication
Lesion is known to be aggressive
When total removal by enucleation, curettage, or both would be difficult
Technique
Lesion and 1-cm bony margins
Full thickness mucoperiosteal flap
Section the bone and remove segment
If tumor perforated the cortical plate
- sacrifice soft tissue to eradicate tumor
Chemical cauterization
Carnoy’s solution is composed of - 60% ethanol
- 30% chloroform
- 10% glacial acetic acid
Applied directly following enucleation for the treatment of keratocystic
odontogenic tumors
Nevoid basal cell carcinoma syndrome
Also called Gorlin syndrome
Major clinical features
- Multiple basal cell carcinomas - Odontongenic keratocysts
- Palmar/plantar pits - Calcified flax cerebri - Rib anomalies
- Mild ocular hypertelorism
Nevoid basal cell carcinoma
syndrome
Nevoid basal cell carcinoma
syndrome
Treatment and prognosis
Most anomalies are minor, not life threating
Prognosis depends on the behavior of skin tumors
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
• 醫病關係的轉變:醫師中心模式轉變為病人 中心模式 (physician-centered model →
patientcentered model
醫學倫理原則
由Tom Beauchamp & James Childress在1979提 出
自主原則(Autonomy)
不傷害原則(Non-maleficence)
行善原則(Beneficence)
公義原則(Justice)
自主原則(Autonomy)
• 原則:一位具理性思考能力的病人,在完全瞭 解醫療處置方針的利弊得失下,有權決定自己 的行為,包括決定及選擇醫療專業人員和治療 方式
• 臨床意義
(1) 病人之自主行為不應遭受他人之操控或干預 (2)指醫療人員應提供充分且適當之資訊,以促 成病人針對診療方式主動作一抉擇
不傷害原則(Non-maleficence)
• 源自希波克拉底之醫師誓約,即醫師之職責:
「最首要的是不傷害」
• 原則:不殺害病人、不能侵害病人權益和福祉以 及平衡利害得失,使痛苦減到最低
• 臨床意義
(1)醫療上是必須的,或是屬於醫療適應症範圍,
因所施行的各種檢查或治療而帶來的傷害應符 合不傷害原則
(2)權衡利害原則 → 兩害相權取其輕 (3)保護病人的生命安全
行善原則(Beneficence)
• 原則:行善原則包括不傷害原則的反面義務(不
應該做的事)和確有助益的正面義務(應該做的
事),包括維護和促進病人的健康、利益和福祉,
為基本倫理原則,也是醫護人員的基本義務
• 臨床意義
(1) 勿施傷害:不得故意對他人施予傷害或惡行 (2) 預防傷害:應該預防傷害或惡行
(3) 移除傷害:應該移除傷害或惡行
(4) 維持善行:應該致力於行事或維持善行
公義原則(Justice)
• 原則:強調資源合理分配、賞罰分明以及合 乎正義之事。醫療上公平原則指基於正義與 公道,以公平合理的態度來對待病人、病人 家屬和受影響的社會大眾
• 臨床意義
(1) 公平地分配不足的資源 (2) 尊重病人的基本權利
(3) 尊重道德允許的法律,法律之前人人平 等 (4) 先來先服務與急重症優先
臨床案例討論
X光照射量在醫療上對病人的影響
47歲陳先生於今年5月時前往小港醫院接
受全口14張X-ray拍攝,由一名clerk為其 拍攝,由於該生未熟悉拍攝方法與技巧導 致多張拍攝失敗,且當時報章雜誌報導牙 科X-ray對腦部有不好影響,故陳先生放 棄重新拍攝並離開診間
輻射劑量對一般民眾的影響
• 一次牙科單齒X光攝影劑量:0.005毫西弗
• 一次頭部X光攝影劑量:0.01毫西弗
• 台北搭飛機往返美國西岸一趟劑量:0.09毫 西弗
• 台灣地區民眾每年接受天然背景輻射劑量:
1.6 毫西弗
• 一次胸部電腦斷層掃描劑量:7毫西弗
(註:1西弗=1000毫西弗 1毫西弗=1000微 西弗)
報章雜誌對牙科X光的說法
•
牙科X光易致腦膜瘤
(天下雜誌 2012.04)耶魯大學Elizabeth Claus的研究顯示,你可能是對的。富有國家裡,每20萬個男人就有5 人患有腦膜瘤,女性患病率則是男性的2倍;只有2%的腦膜瘤是惡性腫瘤,但良性腦膜瘤 還是會致命,約30%的人會在診斷出良性腦膜瘤後5年內死亡。
由過去的研究來看,腦膜瘤最重要的成因是游離輻射,而在今日,游離輻射最重要的來源 既非核戰、也不是放射線治療,而是牙科的X光。令人意外的是,這方面的研究並不多,
Claus博士和她的同事試圖填補這個缺口,他們研究了1433名患有腦膜瘤的美國人,並與 1350名年齡、性別、居住地組成相似、但沒有腦膜瘤的人進行比較。
結果發現,腦膜瘤患者曾接受過至少一次牙科X光照射的機會,是非腦膜瘤患者的2倍。
更讓人擔心的是,曾在十歲以下接受過環口放射線影像檢查(panorex)的人,出現腦膜 瘤的機率是正常風險的4.9倍。
Claus博士指出,過去30多年,牙科X光的輻射劑量已經減少約一半;少部分牙醫改用輻 射量更低的數位式檢查,但其他牙醫則使用錐束電腦斷層等輻射水準較高的新技術。
此外,美國牙醫協會的指導方針指出,健康成人每二或三年最多只能接受一次牙科咬翼片 X光檢查,沒有相關症狀的病人也不該接受X光檢查。但如果Claus博士的研究對象沒有說 謊,那就表示部分牙醫並未遵照此指導方針;大多數研究對象表示自己每年至少接受一次 X光檢查。X光有其危險性,牙醫應該只在必要時使用,擔心健康的病人也不見得是在胡 思亂想
醫源性傷害
由資料顯示,全口14張X-ray總照射劑量
約0.07毫西弗,而台灣民眾每年接受的天 然背景輻射約為1.6毫西弗,換算起來每 天接受的輻射量約為0.044毫西弗。至於 目前尚無更多證據顯示出腦膜瘤確實和頭 頸部X-ray照射有關
此案例違背了哪些原則?
自主原則(Autonomy):該生並未告知病人自 己為實習醫學生,所以使病人無法選擇是否 要讓clerk為其拍攝X-ray
不傷害原則(Non-maleficence):由於不純熟 的技巧導致多張拍攝失敗而需要重照,會使 病人暴露於比原先預期更多的輻射量中,違 反ALARA原則
總述
在這一年的intern生涯中要學習的不只是
臨床技術與學識,更重要的還有對病人的 安全與醫學倫理方面的學問,空有良好的 技能與知識卻無法合乎倫理的對待病人,
充其量只能算是一台醫療機器而非醫師,
期許未來的這一年我們能做得更好