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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

2 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

3 Chief Complaint Pain over L t lower molar area since February 2007.

4 Present Illness This 22 y/o male suffered from episode for 2~3 days. He said his tooth fractured during chewing. Then teeth over L t lower posterior area became pain.he came to LDC, then the doctor suggested him to our OPD for further exam. OPD had biopsy of L t edentulous ridge showed osteomyelitis( )and inflammatory fibrous hyperplasia( ). Clindamycin was prescribed. However, he felt teeth pain aggravated. Biopsy was performed again over bilateral mandible and maxilla( ).

5 Past History Past Medical History Aspirin allergy Past Dental History 日期 CC Dx Specimen L t Md. pain Osteomyelitis, 35, Extraction of Retained dental root (distal root of 36) Other disturbances of oral epithelium, including tongue Periodontitis Periodontitis H-P: Ulcer with subacute inflammation (edentulous ridge of 36) Inflammatory fibrous hyperplasia (edentuloous ridge of 36)

6 Alcohol :(+) Personal History Betel nut : (+) Cigarette : (+) 1 package / day

7 Intraoral Examination 16 Elongation 16 Root exposure Dehiscence Gingival swelling Gingival inflammation Alveolar bone resorption

8 Intraoral Examination (cont.) 17 un-healing tooth socket located between tooth 16 &18 measuring 1.5X1.5cm Color:pink No pus discharge Tooth 15 lingual tipping

9 Physical Examination Pain (+) Swallowing pain (-) Fever or local heat (-) Indurations (?) Tenderness (?) Lymphadenopathy (?)

10 X-ray finding:panorex Lesion 2 Lesion

11 X-ray finding Panorex (cont.) Lesion 1 is located in the L t mandibular ramus There is an ill-defined and irregular radiolucency without a corticated margin over the left mandibular body extending from 37 distal root mesial aspect to 34 root and extending from alveolar ridge down to mandibular canal measuring 4X2.5 cm No root resorption. Tooth floating in the air over tooth PDL destruction over 34 35

12 X-ray finding Panorex (cont.) Lesion 2 is located over R t maxilla tuberosity There is an ill-defined and irregular radiolucency without a corticated margin over R t maxilla tuberosity extending from tooth 18 distal buccal root to 15 root mesial aspect and extend from hard palate down to 16 furcation, mesauring about 3X1.5 cm No root resorption but 16 elongation PDL destruction over tooth 16

13 Dental X-ray finding Missing tooth: (R.R ) residual root: 46 caries: periodontal condition: poor endodontic condition:37 restoration (e.g. C & B):12XXX2324 filling: resin filling,37 amalgam filling Other dental finding:47 distal root resorption

X-ray finding:periapical film Tooth floating in air over tooth 16 PDL destruction over tooth 16 31 32 PDL widering over tooth 15 There is an ill-defined and irregular radiolucency without a

14 X-ray finding:periapical film Tooth floating in air over tooth 16 PDL destruction over tooth PDL widering over tooth 15 There is an ill-defined and irregular radiolucency without a corticated margin over mandibular symphysis extedning from tooth 31 root mesial aspect to 32 root distal aspect and extending from 31 root apex down to mental spine,measuring about 1X1cm. Internal root resorption of 31 was noted.

X-ray finding Lesion 1 : 34 floating in air Bone remodeling Lesion 2 2007.

15 X-ray finding Lesion 1 : 34 floating in air Bone remodeling Lesion Lesion 1 Lesion Lesion 1 Lesion 1 Lesion 2 : 17 missing

17 X-ray summary RL with ill-defined margin over area Bone remodeling ability over can be seen Incisor lesion PDL remained upon 2/3 root length 24 apex area bone density decreased area bone density decreased -- Multiple area -- Ill-defined margin -- Tooth floating in the air PDL disappear -- Bone remodeling character

18 1. Disease origin : Bony or periodontal origin 2. Infection or neoplasm 3. Benign or malignant

19 Neoplasm or Infection? Fever or Local heat: (-) Pus discharge : (-) Duration:14 months Lymphadenopathy: (?) Induration:(?) Neoplasm

20 Benign or malignant? Margin:poor-defined Pain:(+) Ulceration: (+) Duration : 14 months + Malignant

21 Working diagnosis 1. Multiple myeloma 2. Langerhan cell disease 3. Metastatic carcinoma

22 Multiple myeloma Gender Our case Male Multiple myeloma Age y/o (60 y/o average) Frequency Symptom & Sign Contineous pain Dull bone pain Tooth mobility Bone pain, Bone swelling Pain paraesthesia Tooth mobility Location L t ramus, R t tuberosity Jaw bone (30%) Size 4x2.5cm, 3x1.5cm Number 3, Multiple Multiple Margin Ill-defined Well-defined Shape (X-ray) Radioluency Punched out radiolucency Tooth involvement Floating in the air

23 Multiple myeloma Our case

24 Langerhan cell disease Our case Langerhan cell disease Gender Male Male prediction Age 23 < 10 y/o (50%), All aged Frequency Symptom & Sign Contineous pain Dull bone pain Tooth mobility Dull pain Tenderness Location L t ramus, R t tuberosity Mandible posterior Number 3, Multiple Monostotic, polyostotic Osteolytic bone lesion Margin Ill-defined No corticated rim Ill-defined radiolucency Shape (X-ray) Radioluency punched out radiolucency Scoope out Tooth involvement Floating in the air Floating in the air Tooth mobility, loss Severe periodontitis

25 Langerhan cell disease Our case

26 Metastastic tumor Our case Metastastic tumor Gender Male Male inclination Age 23 Middle age to older adult Frequency Contineous Unknown Symptom & Sign Dull bone pain Mucosa ulceration Location L t ramus, R t tuberosity Gingival>50% Tongue 25% Number 3, Multiple Uncertain Shape (X-ray) Radioluency Ill-defined bony destruction Tooth involvement Floating in the air uncertain But p t didn t have medical history of origin primary tumor

27 Langerhan cell disease

28 Other test and examination: 染色體檢查報告 : Date : 2008/4/21 Specimen site: Buccal mucosa Result : No chromosome abnormality was found

29 Biopsy : Date: 2008/3/27 Site: bilateral maxillary & mandibular: A area; B14-16 area Pathologic diagnosis: A &B all showed Langerhan cell disease with feature of lymphoproliferative disorder Date: 2008/4/24 Site: bilateral maxillary & mandibular: A area; B15,16 area Pathologic diagnosis: A &B all showed Langerhan cell disease with feature of lymphoproliferative disorder

30 MRI examination(2008/4/9): Tc -99m MDP whole body bone scan Impression: High probability of local bone invasion from oral cancer to facial bones and distant bone metastasis to spine

31 Chest X ray examination (lung windows) 2008/4/21 Specific findings: Multiple lung cyst (multiple cyst ) Compatable with langher cell hisiocytosis Lung cyst

32 Final diagnosis: Langerhan cell disease

33 References Oral and maxillofacial pathology Second edition Different diagnosis of oral and maxillofacial lesions fifth edition Essentials of ORAL PATHOLOGY AND ORAL MEDICINE ; R.A. CAWSON, E.W. ODELL, CHURCHILL LIVINGSTONE, Sixth edition Langerhan cell granulomatosis with unusual FNAC findings. SenGupta SK, Vince JD, Chakravorty P, Sinha SK. Department of Pathology, Faculty of Medicine, University of Papua New Guinea, Papua New Guinea. Histiocytoses in children: analysis of 120 cases and the bone marrow findings in infection-induced hemophagocytic syndrome vs malignant histiocytosis. Hathirat P, Chuansumrit A, Nitiyanant P, Kraipibool P, Ruangdaraganon N, Mahaphan W, Daengprasert S, Isarangkura P. Department of Pediatrics, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand. Osteomyelitis caused by mycobacterium fortuitum. Ohry A, Brooks M, Steinbach T, Rozin R.

34 Thanks for your attention

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