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1 口診 SEMINAR 第二組指導老師 : 陳玉昆醫師王文岑醫師陳靜怡醫師陳詠真鄭皓天譚翔之黃于芳羅英睿賴彥成何承樺宋佳芝任心如詹宜錡

2 GENERAL DATA Name: XXX Charting no: xxxxx Gender: male Age: 82 y/o Native: Taiwan Occupation: 退休 Marital status: yes First visit: xxxxxx

3 CHIEF COMPLAINT Unhealed extraction wound and ulceration, sore throat for 2-3 months.

4 PRESENT ILLNESS This 82 y/o male had tooth 22 extraction 2-3 months ago. The extraction ti wound did not heal and ulcerative lesion started to appear. His son give him 蜂膠 (propolis) to use but no improvement was noted. Recently he felt severe pain when swallowing and could not eat. He comes to visit 心血管內科 due to deep vein thrombosis and was referred to our OPD for the oral lesions.

5 PAST HISTORY Past medical history Hypertension (+) Hospitalization (+): Vein thrombosis Drug: anticoagulant for 1 week Denied any drug or food allergy Past dental history Extraction ti of tooth th 22

6 PERSONAL HABIT Smoking: quit for a long time Alcohol: quit for a long time Betel quid:none

7 EXTRAORAL EXAMINATION Unknown

8 INTRAORAL EXAMINATION Upper ant. region (incisive papilla and 14~25) 1. Size:2cmX4cm 2. Surface:ulcerative 3. Base:sessile 4. Shape:polypoid 5. Color: white and red 6. Consistency:soft 7. Mobility: fixed 8. Fluctuation:(-) 9. Induration:(-) 10. Pain:(+)dull 11. Tenderness:(-)

9 INTRAORAL EXAMINATION Soft palate region 1. 3cmx4cm 2. Surface:ulcerative 3. Base:sessile 4. Shape:polypoid 5. Color: white and red 6. Consistency:soft soft 7. Mobility: fixed 8. Fluctuation:(-) 9. Induration:(-) 10. Pain:(+)dull 11. Tenderness:(-)

10 INTRAORAL EXAMINATION Tooth 22 extraction wound Surface: ulcerative Color: yellow Buccal side of tooth Surface: ulcerative ( 病歷記載但無照片 )

11 INTRAORAL EXAMINATION Tongue region Multiple removable white patches

12 INTRAORAL R EXAMINATION Dental findings: 1. Caries: Missing: Residual root:

13 WORKING DIAGNOSIS 1. Upper ant. region (incisive papilla and 14~25) Soft palate region 2. Tongue region

14 Upper ant. region (incisive papilla and 14~25) & Soft palate

15 WORKING DIAGNOSIS Inflammation / Cyst / Neoplasm Redness:(+) Swelling:(+) Pain:(+) inflammation Multifocal ulcerative lesions infection Epithelial-lined cavity:(-) & Fluctuation:(-) R/O cyst Unhealing extraction wound for 2~3 month Polypoid shape Sessile base fixed Neoplasm Infection / Neoplasm

16 WORKING DIAGNOSIS Benign 1. Movable (except palate) 2. Unattached to skin or mucosa (except palate) 3. No ulceration of skin or mucosa 4. Slow growth, Long duration 5. No pain 6. No facial nerve palsy 7. No bony invasion i Features 8. Well-defined radiolucency with corticated margin Malignant 1. Induration 2. Fixed to overlying skin or mucosa 3. Ulceration of skin or mucosa 4. Rapid growth; growth spurt, Short duration 5. Pain, often severe 6. Facial nerve palsy (little numbness over lingual l ) 7. Bony invasion 8. Ill-defined radiolucency without corticated margin

17 WORKING DIAGNOSIS Benign/Malignant Duration:2-3 months Fixed ulcerative surface Ulcerative polypoid lesion Malignant

18 WORKING DIAGNOSIS Central or peripheral origin No X-ray information Lesion appear on soft tissue surface Peripheral origin

19 DIFFERENTIAL DIAGNOSIS- Neoplasm p Origin i Epithelial Metastasis Disease Squamous cell carcinoma Spindle cell carcinoma Adenosquamous carcinoma Metastases to the oral soft tissue

20 DIFFERENTIAL DIAGNOSIS- Infection Infective Disease Tuberculosis Histoplasmosis Pemphigus vulgaris Major aphthousulcer (immunocompromised) Necrotizing ulcerative mucositis

21 Tongue region

22 WORKING DIAGNOSIS Multiple removable white patches infection DIFFERENTIAL DIAGNOSIS-- 1. Candidiasis 2. Lichen planus

23 DIFFERENTIAL DIAGNOSIS Upper ant. region (incisive papilla and 14~25) & Soft palate Epithelial l Origin i Squamous cell carcinoma Spindle cell carcinoma Adenosquamous carcinoma

24 Squamous cell carcinoma

25 Squamous cell Carcinoma (central type) Our case Gender Male : Female = 3 : 1 Male Age Mostly yrs or older 82 Race Not significant Asian Site On the lip, floor or roof of the mouth, tongue, soft and hard palate,gum Anterior hard palate & Soft palate Size Random 2X4 cm Color Pink, white, red or white & red White & red

26 symptom 1. Painless or pain 1. dull pain 2. Firm 3. Varied clinical i l presentation- 1) Exophytic (massforming; fungating; papillary; verruciform) 2) Endophytic (invasive, burrowing, ulcerated) 3) Leukoplakic (white patch) 4) Erythroplakic (red patch) 5) Erythroleukoplakic (combined red-and-white patch) 2. ulcerative surface 3. sessile base 4. polypoid shape 5. soft consistency 6. fluctuation ti (-) 7. fixed 8. tenderness (-) 9. induration (-) 10. lymphadenopath y (-)

27 DIFFERENTIAL DIAGNOSIS Upper ant. region (incisive papilla and 14~25) & Soft palate Epithelial l Origin i Squamous cell carcinoma Spindle cell carcinoma Adenosquamous carcinoma

28 Spindle cell carcinoma

29 Spindle cell carcinoma Our case Frequency Rare variant of SCC Age 29~93 y/o 82 y/o Sex No sex predilection Male Location Parynx oral cavity Parynx esophagus Lower lip lateral posterior tongue alveolar l ridge alveolar ridge lateral side of tongue Appearance Common:pedunculated or polypoid mass ulceration Polypoid(Paryn x) sessile Occasionally:sessile nodule Red color ulceration Red color Symptom Growing rapidly

30 DIFFERENTIAL DIAGNOSIS Upper ant. region (incisive papilla and 14~25) & Soft palate Epithelial l Origin i Squamous cell carcinoma Spindle cell carcinoma Adenosquamous carcinoma

31 Adenosquamous carcinoma Our case Frequency Rare variant of SCC Age Older adults 82y/o Sex No sex predilection male Location Tongue oral floor other mucosal surface Larynx alveolar ridge lateral side of tongue Appearance Nodule Polypoid(larynx) sessile ulceration Symptom Painless metastatic t ti deposits Dull pain within the neck nodes lymphadenopathy(-)

32 Differentiation Diagnosis Upper ant. region (incisive papilla and 14~25) & Soft palate Metastasis Metastatic t ti tumors to the oral soft tissue

33 Metastatic tumors to the oral soft tissue

34 Metastatic tumors to the oral cavity Our case Gender Male>Female Male Race Not significant Asian Age Middle-aged and older adults 82y/o Site Gingiva-50% Tongue-25% Extraction wound of 22 Hard&soft palate Tongue

35 Symptom Primary lesion.the lesion usually appear.the extraction wound as a nodular mass that often did not heal resembles a hyperplastic or.ulceration over hard reactive growth palate.occasionally,the lesion.pain when swallowing appears as a surface and could not eat ulceration.base:sessile.adjacent teeth may.surface:ulcerative become loosened by an.color:yellow/red underlying destruction of.pain:(+) the alveolar bone.fluctuation:(-) o ( ).Mobility:fixed.Tenderness:(-).Induration:(-) ).Lymphadenopathy (-).Any malignancy from the The patient should receive body site is capable of further systemic metastasis to the oral cavity examnation -Male:lung cancer - Female:breast cancer

36 DIFFERENTIAL DIAGNOSIS Upper ant. region (incisive papilla and 14~25) & Soft palate Infection Tuberculosis Histoplasmosis Pemphigus vulgaris Major aphthous ulcer Necrotizing ulcerative mucositis

37 Tuberculosis

38 Tuberculosis (oral lesion) OUR CASE Gender No specific Male Age Old (reactivation) 82 Frequency more1 billion worldwide; 0.5%~1.5% oral lesion presented symptom Painless lesion, low- Dull pain, unhealing grade fever, malaise wound, swelling Site Gingiva, mucobuccal fold, Anterior hard palate & area adjacent to Soft palate imflammatiom teeth or extraction site, tongue, palate, and lip Size Random 2cmX4cm(Anterior hard palate ) 3cmx4cm(Soft palate)

39 Tuberculosis (oral lesion) OUR CASE Color Red, white White and red Shape Ulcer, nodular, granular, firm leukoplakic area Induration (-) (-) Sessile base, polypoid Surface Ulcerative Ulcerative Duration 2~3 month Tenderness (-) (-) lymphadenopathy (+) (-) Fluctuation (-) (-)

40 DIFFERENTIAL DIAGNOSIS Upper ant. region (incisive papilla and 14~25) & Soft palate Infection Tuberculosis Histoplasmosis Pemphigus vulgaris Major aphthous ulcer Necrotizing ulcerative mucositis

41 Histoplasmosis(disseminated type)

42 Histoplasmosis (disseminated type) Gender No specific Male Age Older patient 82 OUR CASE Frequency symptom Site 2% to 10% with AIDS Firm, painful, ulceration, similar to malignant clinically Lung, tongue, palate, buccal mucosa Dull pain, ulceration, unhealing wound, swelling Anterior hard palate & Soft palate Size Random 2cmX4cm(Anterior hard palate ) 3cmx4cm(Soft palate)

43 Histoplasmosis(dissemin ated type) OUR CASE Color Red, white White and red Shape Rolled margin, solitary Sessile base, polypoid Induration (-) (-) Surface Irragular,ulceration Ulcerative Duration Several weeks 2~3 month Tenderness (-) lymphadenopathy (+) (-) Fluctuation (-) (-)

44 DIFFERENTIAL DIAGNOSIS Upper ant. region (incisive papilla and 14~25) & Soft palate Infection Tuberculosis Histoplasmosis Pemphigus vulgaris Major aphthous ulcer Necrotizing ulcerative mucositis

45 Pemphigus vulgaris

46 Pemphigus vulgaris OUR CASE Gender No sex predilection Male Age 50-average age 82 Frequency symptom One to five cases per million people each year Oral soreness,erosions and ulcerations distributed haphazardly on the oral mucosa,positive Nikolsky sign Dull pain, unhealing wound, swelling Site Any oral mucosal location Soft palate Size Depends on the lesion being 2cmX4cm(anterior gingiva from 14~25) infected 3mm in diameter(ulcer over hard palate) 3cmx4cm(Soft palatetotal ulcerative lesion)

47 Pemphigus vulgaris OUR CASE Color Red Red and yellow Shape Ulcer, irregular Sessile base, polypoid Induration (-) (-) Surface Ulcerative Ulcerative Duration Autoimmune disease,the duration of the disease is related to the treatment taken to treat the disease Tenderness (+) (-) lymphadenopathy (-) (-) Fluctuation (-) (-) 2~3 month

48 DIFFERENTIAL DIAGNOSIS Upper ant. region (incisive papilla and 14~25) & Soft palate Infection Tuberculosis Histoplasmosis Pemphigus vulgaris Major aphthous ulcer Necrotizing ulcerative mucositis

49 Major aphthous ulcer

50 major apthous ulcer OUR CASE Gender Female Male Age The onset of major apthous 82 ulcer is after puberty symptom Site The lesions may be preceded by prodromal symptoms of burning,itching,or stinging,with the development of an erythematous macule Any surface,but the labial mucosa,soft palate, tonsillar fauces are the most commonly affected sites Dull pain, unhealing wound, swelling Soft palate Size 1~3cm in diameter 2cmX4cm(anterior gingiva from 14~25) 3mm in diameter(ulcer over hard palate) 3cmx4cm(Soft palatetotal ulcerative lesion)

51 major apthous ulcer OUR CASE Color Red, yellow Red,yellow Shape Ulcer, irregular Sessile base, polypoid Induration (-) (-) Surface Ulcerative Ulcerative Duration Taking from 2~6 weeks to heal,but the recurrent episodes may continue to develop for up to 20 years or more Tenderness (+) (-) lymphadenopath (-) (-) y Fluctuation (-) (-) 2~3 month

52 DIFFERENTIAL DIAGNOSIS Upper ant. region (incisive papilla and 14~25) & Soft palate Infection Tuberculosis Histoplasmosis Pemphigus vulgaris Major aphthousulcer Necrotizing ulcerative mucositis

53 Necrotizing ulcerative mucositis

54 Necrotizing ulcerative mucositis OUR CASE Gender Not specific Male Age Young (1~10 y/o) 82 Frequency symptom Site 140,000 worldwide per year Significant pain, fever, malaise, and regional lymphadenopathy p y Gingiva and the ajjacent soft tissue Dull pain, unhealing wound, swelling Anterior hard palate & Soft palate Size Random 2cmX4cm(Anterior hard palate ) 3cmx4cm(Soft palate)

55 Color Shape Necrotizing ulcerative mucositis White, yellowish, bluish- black Ulcerative or necrosis endophytic lesion Indurations (-) OUR CASE White and red Polypoid Surface Ulcerative, necrosis Ulcerative Duration 2~3 month Tenderness (+) (-) lymphadenopathy (+) (-) Fluctuation (-) (-)

56 Rank The Differentiation Diagnosis Tuberculosis Histoplasmosis Squamous cell carcinoma Spindle cell carcinoma Adenosquamous carcinoma Pemphigus vulgaris Major aphthousulcer (immunocompromised) Necrotizing i ulcerative mucositis Metastatic tumor to the oral soft tissue

57 Clinical Impression Tuberculosis

58 DIFFERENTIAL DIAGNOSIS OF TONGUE REGION Candidiasis Lichen planus

59 Candidiasis

60 Candidiasis Our case Gender X Male Race Not significant Asian Age Elderly and children (immuno-compromised) 82 Size Random 2 4 cm Site Buccal mucosa, tongue, palate, angles of month, denture-bearing area Anterior hard palate & soft palate Color White, red White & red

61 candidiasis Our case Symptom 1. White plaque 1. dull pain (removable or not removable) 2. Red macules, burning sensation 3. Atrophic mucosa 4. Foul taste 5. Asymptomic 6. Systemic compromised 2. ulcerative surface 3. sessile base 4. polypoid shape 5. soft consistency 6. fluctuation (-) 7. fixed 8. tenderness (-) 9. induration (-) 10. lymphadenopathy (-) 11. multiple removable white patch at tongue region

62 DIFFERENTIAL DIAGNOSIS OF TONGUE REGION Candidiasis Lichen planus

63 Lichen planus

64 Lichen planus (oral lesion) Gender Female Male Age Middle-aged 82 Frequency symptom 1%of population; 0.1%~2.2% oral lesion presented Painless lesion, lowgrade fever, malaise OUR CASE Dull pain, unhealing wound, swelling Site Lateral &dorsal tongue Anterior hard palate & Gingiva, palate,vermillon border mucobuccal fold, Soft palate for Size Random 2cmX4cm(Anterior hard palate ) 3cmx4cm(Soft palate)

65 Lichen planus (oral lesion) OUR CASE Color Red, white White and red Shape Atrophic, erythematous area with central ulceration of varying degress,bordered by fine,white radiating striae Induration (-) (-) Sessile base, polypoid Surface Ulcerative Ulcerative Duration 2~3 month Tenderness (-) (-) lymphadenopathy (-) (-) Fluctuation (-) (-)

66 Clinical Impression Of Tongue Region Candidiasis

投影片 1

投影片 1 指導老師 : 林立民陳玉昆王文岑陳靜怡醫師報告者 :Intern G 組張啟源鄧聖霖戴宇昀何盈興 General Data Name : 蔡昇峰 Gender : male Age : 23 Native : Taiwan Occupation : 勞工 Attending V.S. : 王文岑醫師 First visit :2007/02/14 Chief Complaint Pain