Case Report
Intern F組: 柯映辰 林威宇 柯紹凱 陳威仁 報告日期: 104/01/27
指導老師：陳玉昆 主任 林立民 教授
暨口病科全體醫師
General Data
• Name: 張XX
• Sex: Female
• Age: 60 y/o
• Native: 屏東
• Marital status: 已婚
• Attending Staff: OOO 醫師
• First visit: 103/12/31
Chief Complaint
• Referred from LDC for upper left (26 palatal) gingiva examination
103/12/31
Present Illness
• This 60 y/o female patient suffered from pain over upper right posterior area; however, the dentist of LDC found another lesion over the upper left palatal gingiva of tooth 26 during oral examination. Then, she was referred to our OPD for further evaluation and treatment.
Past History
• Past Medical History
– Systemic disease (+) HTN Hospitalization (+)
– Surgery under GA (+) Endometriosis – Drug and food allergy: Denied
• Past Dental History
– General routine dental treatment
• Attitude to dental treatment: Co-operative
Personal History
• Risk factors related to malignancy
– Alcohol (-) – Betel quid (-) – Cigarette (-)
– Denied any other oral habits
OMF Examination
• Location: Tooth 26 palatal gingiva
• Color: yellowish red
• Size: 0.3 x 0.4 cm
• Shape: Granular/Papillomatous
• Surface: Rough
• Mobility: Fixed
• Pain (-)
• Tenderness (-)
• Consistency soft
• Induration (-) 103/12/31
Image Finding – Pano(103/12/31)
No bony involvement corresponding to tooth 26 palatal lesion
-impaction: nil
-Endo: 17,27 -C&B: nil -OD: 26,27,46,47 -Missing: nil
-Periodontal condition: WNL -Residual root: 35
Working diagnosis
• Intrabony or peripheral?
• Inflammation, cyst, or neoplasm?
• Benign or malignant?
9
Intrabony or peripheral
Our case Intrabony Peripheral
Mucosal lesion + - +
Bone expansion - +/- -
Cortical bone
destruction - +/- -
Consistency Soft Hard Soft, firm, rubbery
→Our case is a peripheral lesion
Inflammation or neoplasm
Our case Inflammation Neoplasm Regress or
progress Unknown Regress Progress
Symptoms - + +/-
Growth rate Unknown Hours,days,weeks Weeks,months, years
Lymph node
enlarge - + +/-
Tenderness - + -
Fluctuation - + -
11
→Our case is an neoplasm
Benign or malignant
Our case Benign Malignant
Border Well
defined
Well defined
Poor defined
Destruction of cortical margin - - +
Pain - - +
Induration - - +
Swelling with intact epithelium + + -
Progress Unknown Slow Fast
Metastasis Unknown - +
Lymphadenopathy - - +
→Our case is a benign tumor
D ifferential Diagnosis
• Verruciform Xanthoma
• Verrucous Hyperplasia
• Verruca Vulgaris
• Squamous Papilloma
• Condyloma Acuminatum
Verruciform Xanthoma
Our case Verruciform Xanthoma
Age 60 y/o 40-70 y/o V
Gender F none
Site Upper left gingiva
Gingiva, alveolar mucosa
V
Size 0.3x0.4cm <2 cm V
Surface Rough Rough V
Shape Papillomatous Papillomatous V
Symptom Painless Painless V
consistency Soft Soft V
Yellow-white
Verrucous Hyperplasia
15
Our case Verrucous Hyperplasia
Age 60 y/o >60 y/o V
Gender F M
Site Upper left gingiva
Gingiva, alveolar mucosa
V
Size 0.3x0.4cm <5cm V
Surface Rough Rough V
Shape Papillomatous Papillary –
verruciform V
Symptom Painless painless V
consistency Soft Soft V
Color Yellowish-red Reddish-white V
Verruca Vulgaris
Our case Verruca Vulgaris
Age 60 y/o Children
Gender F None
Site Upper left gingiva
Vermilion border, labial
mucosa
Size 0.3x0.4cm <5mm V
Surface Rough Rough V
Shape Papillomatous Papular,
cauliflower-like V
Symptom Painless Painless V
consistency Soft Soft V
Squamous Papilloma
Our case Squamous Papilloma
Age 60 y/o 30-50 y/o
Gender F None
Site Upper left gingiva
Hard, Soft palate
Size 0.3x0.4cm <1cm V
Surface Rough Rough V
Shape Papillomatous Papillomatous V
Symptom Painless Painless V
Tenderness Soft Soft V
Color Yellowish-red White
17
Condyloma Acuminatum
Our case Condyloma Acuminatum
Age 60 y/o Yong adult
Gender F None
Site Upper left gingiva
Labial mucosa, soft palate Size 0.3x0.4cm 1-1.5cm
Surface Rough Rough V
Shape Papillomatous Papillary V
Symptom Painless Painless V
consistency Soft Soft V
Color Yellowish-red pink V
Impression
• Verruciform Xanthoma, tooth 26 palatal gingiva
Treatment Course
103/12/31
• Referred from LDC for upper left (26 palatal)gingiva examination.
• Red lesion over 26 palatal was noted
• Excisional biopsy H-P: verruciform xanthoma
103/01/07
• OPD f/u
• Wound treated with H2O2.GI
103/12/31
Discussion
Verruciform Xanthoma
• Uncommon, benign oral mucosal lesion
• Cause is unknown -- however…
It is reported that Missense mutations in exon 6 of the 3 beta-hydroxysteroid dehydrogense (NSDHL) gene in solitary verruciform xanthoma
Verruciform Xanthoma
• Clinical features
-- No gender predilection
--Average age is 45 y/o , few with in 10 to 20 y/o
Verruciform Xanthoma
• Clinical Features
-- Well circumscribed ,with a granular to papillary surface
-- Size ranges from 2mm to more than 2cm -- Exophytic or depressed surface is present -- Occasionally ulcerated
--Cranges from white to red due to keratinization level (most in white)
Verruciform Xanthoma
• Histopathology features -- Flat or slightly raised
-- With a papillomatous or verrucous surface
Verruciform Xanthoma
• Histopathology features
-- Parakeratinized epithelial cell
-- Epithelial component is normal, no evidence of dysplasia or atypia
-- Xanthoma cell could be found in lamina propria or connective tissue papilla
Verruciform Xanthoma
About the xanthoma cell…
(1) Granular to flocculent cytoplasm (2) The cytoplasm may contains:
-- Periodic acid-Schiff (PAS)-positive
-- Diastase-resistent granules or lipid droplets (3) Ultrastructurally, the foam cells are best
characterized as macrophages
Verruciform Xanthoma
• Differential Diagnosis:
Verruciform xanthoma
Squamous papilloma
Condyloma acuminatum Cause unknown HPV HPV subtype 6
and 11
Site Gingiva and
alveolar mucosa
Hard and soft palate,uvula
Anogenital region
Age Average 45 y/o 30-50y/o Young adult
Size 2mm to more than 2cm
Less than 1cm 1cm to 1.5cm
Color White to red Pink to white Pink
Verruciform Xanthoma
• Treatment:
-- Conservative excision
◆ No recurrences have been reported
醫學倫理討論
1.生命的神聖性 (Sanctity of life)
•Tom Beauchamp &James Childress 六大原則 - 1979
1. 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。
2. 誠信原則 (Veractity):醫師對其病人有「以誠信相對待」的義務 3. 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。
4. 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。
5. 保密原則 (Confidentiality):醫師對病人的病情負有保密的責任。
6. 公義原則(Justice): 醫師在面對有限的醫療資源時，應以社會公 平正義的考量來協助合理分配醫療資源給真正最需要它的人。
七大原則
生命的神聖性
「上帝按他自己的形象造人。」「你將是神聖的,因 為我是神聖的。」「生命神聖」觀即由此衍生而 得。(創世紀1)
• 該觀點主張人的生命是無條件的,有價值及神聖的, 人繼承了上帝的品質,包括一切價值的來源-內具的 善 (intrinsic goodness),因此必須受到尊重。
• 藉此瞭解他個人生命的原真,而認知他個人存活在 世上的主要工作和生活的目的,找到個人存在的意 義、價值、目的與任務。
行善原則
讓我們的善行是生命流露的真善，而非求外表的偽 善。當在暗中求的神滿足，而非求人的稱讚。行 善不要灰心，而且行善是本分，不行就是罪(雅 4:17)。
• 以我們的專業知識和技能，站在患者的角度，訂 定最適合患者的診療計畫？
→有抽菸喝酒吃檳榔的患者，等口腔環境改善後再 進行各項翻瓣手術。
誠信原則
惟用愛心說誠實話，凡事長進，連於元首基督。全 身都靠他聯絡得合式，百節各按各職，照著各體 的功用，彼此相助，便叫身體漸漸增長，在愛中 建立自己。(弗4:15 ~16)
• 對於患者的疾病嚴重程度是否有確實地通知，盡 到告知的義務？ 是否有清楚的向病人說明清楚疾 病病程、治療計畫、預後、風險？
→皆已告知病人後，經同意才進行不可逆治療。
自主原則
耶和華 神將那人安置在伊甸園，使他修理看守。耶 和華 神吩咐他說:“園中各樣樹上的果子，你可 以隨意吃；只是分別善惡樹上的果子，你不可吃
，因為你吃的日子必定死!” (創2:15~17)
• 充分說明病情及治療計畫、風險之後，是否有讓 病人充分自主地選擇治療計畫？
→有讓病人決定治療計畫，醫師只是提供專業建議
，決定權還是在病人自己身上
不傷害原則
要愛你們的仇敵，為那逼迫你們的禱告(太5:44)
前來求助於我們的患者沒有得罪我們，我們更不應 該傷害患者
• 是否有先完整瞭解病人的病史?
→治療前有完整蒐集病史資料，並與病患溝通後擬 定進一步的治療計畫
保密原則
• 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
耶穌正在吃飯的時候，有一個女人帶來一隻玉瓶，
裡面盛滿很珍貴的純哪噠香膏；她打破玉瓶，把 香膏倒在耶穌頭上。有些人看了很不高興。耶穌 卻說那是一件美事！(可14:3~9)
•落實小病小醫院，大病大醫院的公義原則
→診所處理基本牙科問題，需要昂貴的檢驗器具(例 如pano, CT scan, biopsy examination)時，再轉診到大 醫院接受進一步的檢查及治療 。
醫學倫理總結
身為基督徒醫療人員，我們要委身於合乎聖經原則 的醫學倫理，以實踐「愛人如己」的誡命，成為 眾人的祝福。 ---基督徒的醫療倫理與責任 林慶豐
• 在病例撰寫方面應書寫詳盡， 使治療過程有詳實 的記錄及治療順利。
• 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
• 術後照護應盡心，盡力做好，以幫助病人恢復正 常生活
References
• Neville BW. Oral & maxillofacial pathology. 3rd ed. Philadelphia; Toronto:
W.B. Saunders; 2008.
• Dorankula, S. P. R., Ramani, P., Premkumar, P., Anuja, & Sherlyn, H. J.
(2013). Verruciform Xanthoma of the Oral Cavity – A Case Report. Journal of Clinical and Diagnostic Research : JCDR, 7(8), 1799–1801.
doi:10.7860/JCDR/2013/6559.3309
• http://www.clinicaladvisor.com/oral-lesions-caused-by-human- papillomavirus/article/193918/
• http://emedicine.medscape.com/article/1061445-overview
• http://www.maxillofacialcenter.com/BondBook/mucosa/verrxanth.html
