General data
• Name: 陳XX
• Chart no.: 1xxxxxx4
• Gender: Female
• Age: 58 y/o
• Native origin: 屏東
• Martial status: 已婚
• Attending doctor: 吳崇維
• First visit: 101.04.11
Chief complaint
• A swelling over L’t posterior mandible for 1 week
Present illness
• This 58 y/o female accepted periodontal tx at 署屏Hospital for several months. Last week, the dentist found out that there is a swelling mass over L’t posterior mandible, and
suggested her to come to our OPD for further examination. On 101.04.11, she came to our OPD for examination and tx
Medical and dental history
Past Medical History
– Hospitalization: (-) – Surgery under GA: (-) – Hypertension(+)
• Not under medical control
• 140-150mmHg on 101.04.11
– Denied any food or drug allergies
Past Dental History
– General routine dental treatment
Attitude towards dental treatment: co-operative
Medical and dental history
• Risk factor related to malignancy – Alcohol：(-)
– Betel quid: (-) – Cigarette: (-)
• Special oral habits : Denied
• Bite irritation : Denied
Dental examination
• Missing: Tooth 16, 18, 26, 27, 28, 36, 37, 46
• Crown and bridge: 15x17, 25, 34, 35xx38, 45x47
• Caries: Nil
• Calculus: Generalized deposition
Intraoral findings
• Size: 0.7 x 0.5 cm
• Color: pink
• Surface: smooth
• Base: sessile
• Shape: dome
• Consistency: rubbery
• Fluctuation: (-)
• Mobility: fixed
• Pain: (-)
• Tenderness: (-)
• Paresthesia: (-, lip tongue)
101.05.02
Radiographic Examination
There is a well-defined multilocular irregular shaped radiolucence with corticated margin, contains fine radiopaque except superior border over left posterior
mandibular area . The lesion extends from the distal root of tooth 38 up to half of left ramus area, and from left retromolar area down to mandibular body, measuring about 3.0 x 2.0 cm in diameter. The lesion suspect involved to mandibular canal.
101/04/11
Radiographic Examination
There is a well-defined multilocular irregular shaped radiolucence with corticated margin, contains fine radiopaque except superior border over left posterior
mandibular area . The lesion extends from the distal root of tooth 38 up to half of left ramus area, and from left retromolar area down to mandibular body, measuring about 3.0 x 2.0 cm in diameter. The lesion suspect involved to mandibular canal.
101/05/23
CT report
• Image finding:
– There is a marked artifact from dental prosthesis.
– The oral cavity cannot be well evaluated in this study.
– There is a suspicious soft tissue nodule at the left retromolar area.
– An indentation at adjacent mandible is present.
• Impression:
– Suspect a soft tissue nodule at the left retromolar
area with bony indentation.
Inflammation, cyst or neoplasm?
Our case Inflammation Cyst Neoplasm
Color Pink Red Normal Variable
Fever - + - -
Consistency Rubbery Rubbery Soft Variable
Discharge - + - +/-
Pain + + - +/-
Duration weeks Days Years Months
Cyst or neoplasm
Benign or malignant?
Our case Benign Malignant
Surface Smooth Smooth Rough
Ulceration - - +
X-ray margin Well-defined Well-defined Poor-defined
LAP - - +
Duration week Years Months
Benign
Peripheral or intrabony?
Our case Peripheral Intrabony
Consistency Rubbery Rubbery Firm
X-ray margin Well-defined Poor-defined Well-defined Bony destruction or
expansion
+ - +
Intrabony
Working diagnosis
Intrabony benign tumor or cyst
Benign Tumor
Odontogenic
• Calcifying Epithelial Odontogenic Tumor(CEOT), Pindborg Tumor
• Adenomatoid Odontogenic Tumor
• Ameloblastic Fibroodontonma
• Ameloblastoma (Desmoplastic)
Cyst
• Calcifying Odontogenic Cyst (Gorlin Cyst)
Working diagnosis
• The List(more possible → less)
1. Calcifying Epithelial Odontogenic Tumor (CEOT), Pindborg Tumor
2. Calcifying Odontogenic Cyst (Gorlin Cyst) 3. Adenomatoid Odontogenic Tumor
4. Ameloblastic Fibroodontonma
5. Ameloblastoma
Calcifying Epithelial Odontogenic Tumor(CEOT), Pindborg Tumor
• Etiology
– A tumor of odontogenic origin – Arises possibly from
• Dental lamina remnants
• Statum intermedium of enamel organ
Calcifying Epithelial Odontogenic Tumor(CEOT), Pindborg Tumor
Our case CEOT
Gender Female Both
Age 50 y/o 30-50 y/o
Site Right retromolar area Most on posterior mandible(57%) Symptom/Sign Swelling and pain Slow-growing swelling
Painless
Calcifying Epithelial Odontogenic Tumor(CEOT), Pindborg Tumor
Radiographic features Our case CEOT
Density R/O + R/L R/O + R/L
Border Well-defined with
corticated margin
Well-defined
20% corticated margin (20% Ill-defined)
Scalloped
Ameloblastic Fibroodontonma
• Etiology
– Mixed odontogenic tumor
• Epithelial (enamel) and Mesenchymal tissue (dentin , pulp) inductive
– Arises possibly from
• Dental papilla , immature fibrous tissue
Ameloblastic Fibroodontonma
Our case Ameloblastic
Fibroodontonma
Gender Female none
Age 50 y/o 10 y/o
Site Right retromolar area Mandible posterior (54%) Symptom/Sign Swelling and pain Asymptomatic and painless
swelling of the affected bone in large lesion
Effect Bony destruction and
expansion
Ameloblastic Fibroodontonma
Radiographic features Our case Ameloblastic
Fibroodontonma
Density R/O + R/L R/O + R/L
Border Well-defined with
corticated margin
Well-defined circumscribed RL
Ameloblastoma
• Etiology
– A tumor of odontogenic epithelium
• Ameloblastoma (Desmoplastic type)
– Dense fibrous stroma
– Radiographic features : R/L+R/O
Our case Ameloblastoma (Desmoplastic type)
Gender Female Both
Age 50 y/o 20~70 y/o
Site Right retromolar area Anterior maxilla Symptom/Sign Swelling and pain Rare pain or parethesia
Ameloblastoma
Ameloblastoma
Radiographic features Our case Ameloblastoma (Desmoplastic type)
Density R/L+R/O R/L+R/O
(Dense fibrous septa) Border Well-defined with
corticated margin
Scalloped, well-defined, well-corticated
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
Calcifying Odontogenic Cyst (Gorlin Cyst)
Our case Calcifying Odontogenic Cyst (Gorlin Cyst)
Gender Female No predominant
Age 50 y/o Diagnosed between 20-
30y/o, average 33 y/o Site Right retromolar area Most on Incisors and
Canine areas (65%)
Symptom/Sign Swelling and pain Unspecific
Radiographic Features Our case Calcifying Odontogenic Cyst(Gorlin Cyst)
Density R/L + R/O R/L + R/O
Border Well-defined with corticated margin
Well-defined
Calcifying Odontogenic Cyst
(Gorlin Cyst)
Adenomatoid Odontogenic Tumor
• Etiology
– Uncommon lesion among odontogenic cysts
• Clinical behavior
– Variable, some were regarded as neoplasms (infiltrative or malignant)
– May be associated with AOT or ameloblastoma
Adenomatoid Odontogenic Tumor
Our case AOT
Gender Female Both , male : female 2:1
Age 50 y/o 10~20 y/o
Site Right retromolar area Most on lower Incisors and upper Canine
areas(53%)
Symptom/Sign Swelling and pain Asymtomatic swelling
Radiographic Features Our case AOT
Density R/L + R/O R/L + R/O
Border Well-defined with corticated margin
Well-defined
Adenomatoid Odontogenic Tumor
Clinical Impression
• Calcifying Epithelial Odontogenic Tumor (CEOT), Left mandible
Histological Pathologic Report
• Pathological diagnosis:
– Bone, mandible, left, retromolar,incision, calcifying epithelial odontogenic tumor, clear type
• Gross Examination :
– The specimen submitted consisted of 2 soft tissue fragments in 1 bottle, measuring up to 0.7 x 0.4 x 0.2 cm, fixed in formalin. Grossly, they are brown in color and rubbery in consistency
送檢時間：101/05/03 報告時間：101/05/09 送檢醫師：吳崇維醫師
• Microscopic Examination :
– Microscopically, it is characterized by clusters of
round ,clear or faintly eosinophilic cell together with sheets, or strands of pleomorphic, slightly eosinophilic epithelial cells within a connective tissue stroma. Also homogeneous hyaline areas suggestive of amyloid-like materials are seen.
– Immunohistochemical staining of pan-keratin :
• clear cell (+) ,epithelial tumor cells (+) .
• PAS (-) ,PASD (-) , mucicarmine stain (-) .
• Based upon the above finding, it shows calcifying
epithelial odontogenic tumor, clear cell type.
TREATMENT PLAN
Treatment procedure
• 101.04.11
– Pano finding: Mild radiolucent image over 37 distal side, size 1.2x1.8 cm
– Imp: Odontogenic tumor, left mandible – Arrange CT exam and check BUN/Cr
• 101.05.02
– CT Imp(101.04.25):
Suspect a soft tissue nodule over left retromolar area with bony indentation
– Incisional biopsy
Treatment procedure
• 101.05.09
– HP report:
Calcifying epithelial odontogenic tumor (clear cell type), left retromolar region of mandible, bone
Special stain :
• Congo red: (+)
• Mucin stain/ PAS /PASD: (-)
– Arrange OP on 101.06.01
―OP: Excision+ Bone trimming + 37 & 48 extraction
Treatment plan
• It was originally believed that CEOT had about the same biologic behavior as the
ameloblastoma.
– Experience indicated that is tends to be less aggrssive.
• Tx.: concervation local resection to include a narrow rim of surrounding bone appears to be the treatment of choice.
醫學倫理討論
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。
行善原則(Beneficence)
• 手術的介入對於陳女士來說是否是一個較 佳的治療方式?
誠信原則(Veractity)
• 醫師對於陳女士是否有以誠信相對待?
• 病況與治療的急迫性?
• 治療方式(excision. resection )?預後?風險?後 續的治療?
自主原則(Autonomy)
• 在說明清楚病情,各種治療方式及其預後與 風險之後,是否有讓陳女士自主選擇所要的 治療方式?
• 手術同意書與麻醉同意書一式兩份，由醫
療機構人員先行完成「基本資料」之填寫。
不傷害原則(Nonmaleficence)
• 在治療(手術)的過程應與陳女士同意的治療 方式相符合,醫師須盡自己所能減量減少對 於病人的傷害
• 另外在詳細說病情時也不應給予病人過多 的心理壓力
保密原則(Confidentiality)
告知的對象
1. 本人為原則
2. 病人未明示反對時, 亦得告知其配偶與親屬 3. 病人為未成年人時, 亦須告知其法定代理人
4. 若病人意識不清或無決定能力, 應須告知其法定 代理人.配偶.親屬或關係人
5. 病人得以書面敘明僅向特定之人告知或對特定
對象不予告知
公義原則(Justice)
• 合理分配醫療資源 1. 手術的必要性?
2. 藥物的需求是否合理?
3. 住院的時間?
醫學倫理總結
• 在病例方面(病兆描述,治療計畫,病人態度) 應書寫詳盡
• 在進行治療之前,須請病人簽屬同意書
• 應在不違反醫學倫理的原則之下進行治療 的行為
