Vous êtes sur la page 1sur 59

PATHOLOGY

CASE
CASE
PRESENTATION
PRESENTATION
THE CASE 25 year old boy bought  to OPD for loss of weight.  Detailed
THE CASE
25 year old boy bought
to OPD for loss of
weight.
Detailed history taking
reveals that his food
intake is restricted to
semisolid food (khichdi
or roti dissolved in
vegetables) due to
inability to open his
mouth.
Discuss clinical
approach.
NORMAL TEMPOROMANDIBULAR JOINT
NORMAL TEMPOROMANDIBULAR JOINT
HISTORY TAKING ANY SPECIFIC HISTORY OF- Habits (supari,katha,gutkha,tobbaco)  Infections  Iatrogenic injury 
HISTORY TAKING
ANY SPECIFIC HISTORY OF-
Habits (supari,katha,gutkha,tobbaco)
Infections
Iatrogenic injury
EXAMINATION Inspection of Oral Cavity  Inspection of TMJ  Palpation  Auscultation 
EXAMINATION
Inspection of Oral Cavity
Inspection of TMJ
Palpation
Auscultation
INSPECTION OF ORAL CAVITY INSPECTION EXOPHYTIC BLANCHING CANCEROUS GROWTH FLAT TEXTURE OF MUCOSA N TONGUE SPEECH
INSPECTION OF ORAL CAVITY
INSPECTION
EXOPHYTIC
BLANCHING
CANCEROUS GROWTH
FLAT
TEXTURE OF MUCOSA N TONGUE
SPEECH DIFFICULTY
INFILTRATIVE
pliable. may obscure underlying surface changes.
pliable.
may obscure underlying surface changes.

The vermilion borders of the lips should be smooth and

Ask female patients to remove any lipstick, which

The labial mucosa should be smooth and glistening. If the mucosa is wiped dry, pinpoint mucosal

The labial mucosa should be smooth and glistening. If the mucosa is wiped dry, pinpoint mucosal secretions from the minor salivary glands may become apparent.

The labial mucosa should be smooth and glistening. If the mucosa is wiped dry, pinpoint mucosal
Leukoedema of the buccal mucosa is most commonly noted in persons of color. The milky-white appearance

Leukoedema of the buccal mucosa is most commonly noted in

persons of color. The milky-white appearance of the mucosa

represents tissue hydration and disappears when the cheek is stretched.

The linea alba is a horizontal ridge (often hyperkeratinized) that is located bilaterally on the buccal

The linea alba is a horizontal ridge (often hyperkeratinized) that is located bilaterally on the buccal mucosa at the level of the interdigitation of the teeth. The orifice of the Stensen duct is superior to the linea alba, adjacent to the maxillary 6-year molars. Gentle palpation of the parotid gland results in the expression of serous saliva from the duct.

The dorsal surface of the tongue is an admixture of thin, keratinized, filiform papillae interspersed with

The dorsal surface of the tongue is an admixture of thin, keratinized, filiform papillae interspersed with pink mushroom-shaped fungiform papillae.

associated with several taste buds.
associated with several taste buds.

Each of the pink mushroom-shaped fungiform papillae is

The lateral border of the tongue occasionally has some associated vertical corrugations, but it may appear

The lateral border of the tongue occasionally has some associated vertical corrugations, but it may appear smooth and glistening. Lingual tonsils at the posterior-lateral base of the tongue represent the anterior extension of the Waldeyer ring. These tissues may become enlarged secondary to inflammation, infection, or neoplasia.

The lingual frenum is the primary soft tissue attachment of the tongue to the floor of
The lingual frenum is the primary soft tissue
attachment of the tongue to the floor of the mouth.

Overattachment of the frenum may result in speech impediments ("tongue tied").

The ostia of the Wharton ducts, which are located at the base of the lingual frenum,

The ostia of the Wharton ducts, which are located at the base

of the lingual frenum, appear as 2 bilateral punctate structures.

Mucous saliva can be expressed from the ducts with bimanual palpation of the submandibular glands.

The hard palate is keratinized and covered by a series of fibrous ridges or rugae. The

The hard palate is keratinized and covered by a series of fibrous ridges or rugae. The mucosa overlays a number of minor salivary glands.

hard palate, creating the darker red color.
hard palate, creating the darker red color.

The soft palate is not usually keratinized and is more vascular than the

The attached gingiva adjacent to the teeth is keratinized and tightly bound to bone. Healthy noninflamed

The attached gingiva adjacent to the teeth is keratinized and tightly bound to bone. Healthy noninflamed gingiva is stippled and resembles citrus rind (peau d' orange).

INSPECTION OF T.M.J INSPECTION EMACIATION HYPO OR HYPERMOBILITY FACIAL ASYMMETRY PHYSICAL TRAUMA HEAD POSTURE INSPECTION OF
INSPECTION OF T.M.J
INSPECTION
EMACIATION
HYPO OR HYPERMOBILITY
FACIAL ASYMMETRY
PHYSICAL TRAUMA
HEAD POSTURE
INSPECTION OF LYMPH NODES
Measure Range Of Jaw Movement: by mm metal ruler  normal – 40 mm  moderate
Measure Range Of Jaw Movement:
by mm metal ruler
normal – 40 mm
moderate disease – 30 – 39 mm
severe disease - <30 mm

Measure degree of pain

Presence shows TMJ inflammation  Degrees of pain:  Degree 0 - no pain  Degree
Presence shows TMJ inflammation
Degrees of pain:
Degree
0 - no pain
Degree
1 – slight pain
Degree 2 – moderate pain
Degree 3 – severe pain
Lateral movement of jaw Normal - >8 mm  Moderate deformity – 4 to 8 mm
Lateral movement of jaw
Normal - >8 mm
Moderate deformity – 4 to 8 mm
Severe deformity - <4 mm
PALPATION PALPATE TMJ Muscles of mastication Intraoral palpation Palpation of lymph nodes presence of fibrous bands
PALPATION
PALPATE
TMJ
Muscles of mastication
Intraoral palpation
Palpation of lymph nodes
presence of fibrous bands
The anterior changes are
The anterior
changes are

cervical chain of lymph nodes is frequently involved in

both inflammatory oral conditions and metastatic disease. Nodal

palpable all along the sternocleidomastoid muscle.

Parotid masses (especially in superficial lobe) are easily detected by digital palpation.

Parotid masses (especially in superficial lobe) are easily detected by digital palpation.

AUSCULTATION
AUSCULTATION
AUSCULTATION clicks pops crepitus On opening n closing Degenerative joint d/s Lack of lubrication Limited mouth
AUSCULTATION
clicks
pops
crepitus
On opening n closing
Degenerative joint d/s
Lack of lubrication
Limited mouth opening
Disc displacement with reduction

No click

Disc displacement without reduction

Crepitation, clicking,
Crepitation, clicking,

and popping of the temporomandibular joints are most

easily detected by placing the tips of the little fingers in the external auditory canals and having the patient perform a series of excursive mandibular movements. A stethoscope placed anterior to the pinna of the ear can achieve the same result.

AN INSIGHT INTO VARIOUS CAUSES OF JAW IMMOBILITY. Limitations caused by factors  external to the
AN INSIGHT INTO VARIOUS CAUSES
OF JAW IMMOBILITY.
Limitations caused by factors
external to the joint.
Limitations caused by factors
internal to the joint.
CNS disorders.
Iatrogenic causes.
Limitations by factors external to the joint Neoplasms  Acute infections  Myositis  Pseudoankylosis 
Limitations by factors external to
the joint
Neoplasms
Acute infections
Myositis
Pseudoankylosis
Burn injuries
Trauma to musculature surrounding joint
Precancerous lesions as
leukoplakia,erythroplakia,submucosal
fibrosis
Limitations by factors internal to joint Bony ankylosis  Fibrous ankylosis  Arthritis  Infections 
Limitations by factors internal to
joint
Bony ankylosis
Fibrous ankylosis
Arthritis
Infections
Trauma
Microtrauma as bruxism
CNS disorders Tetanus  Lesions affecting trigeminal nerve  Drug toxicity 
CNS disorders
Tetanus
Lesions affecting trigeminal nerve
Drug toxicity
Iatrogenic causes Third molar extraction  Hematomas secondary to dental  injection  Late effects of
Iatrogenic causes
Third molar extraction
Hematomas secondary to dental
injection
Late effects of intermaxillar fixation
after mandible fracture or other
trauma
WHERE DO YOU GO???
WHERE DO YOU GO???
GENERAL APPROACH  In indian context,and more particularly a large population of guthka and supari eaters,the
GENERAL APPROACH
 In indian context,and more
particularly a large population of
guthka and supari eaters,the more
practical approach when a patient
with such problem comes to the OPD
is to suspect presence of oral
submucosal fibrosis.The element of
weight loss further adds to the
suspicion.
SUBMUCOUS FIBROSIS
SUBMUCOUS
FIBROSIS
INTRODUCTION Whitish- yellow lesion that has a  chronic insidious biologic course;  result of frequent
INTRODUCTION
Whitish- yellow lesion that has a
chronic insidious biologic course;
result of frequent chewing of the
areca or betel nut.
Premalignant lesion.
EPIDEMIOLOGY  occurs primarily in India, Pakistan and Burma. females more often than males.  Age
EPIDEMIOLOGY
occurs primarily in India, Pakistan
and Burma.
females more often than males.
Age 20 – 40 yrs
Involves buccal mucosa, retromolar
areas, soft palate, uvula, tongue n
labial mucosa.
ETIOPATHOGENESIS TANNINS FROM ARECA NUT ACTIVATE FIBROBLASTS CROSSLINKING OF COLLAGEN PEPTIDE CHAINS INHIBITS COLLAGEN DEGRADATION INFLAMMATION
ETIOPATHOGENESIS
TANNINS FROM ARECA NUT
ACTIVATE FIBROBLASTS
CROSSLINKING OF COLLAGEN PEPTIDE CHAINS
INHIBITS COLLAGEN DEGRADATION
INFLAMMATION
CYTOKINE, GROWTH FACTORS PRODUCTION
FIBROSIS
ETIOPATHOGENESIS: contd Upregulation of lysyl  oxidase activity: increased conversion of collagen monomers into insoluble polymers
ETIOPATHOGENESIS: contd
Upregulation of lysyl
oxidase activity:
increased conversion of
collagen monomers
into insoluble polymers
Raised tissue copper
levels lead to increased
lysyl oxidase activity.
ETIOPATHOGENESIS: contd Keratinocytes secrete TGF-beta  which may also play a role.  Genetic basis has
ETIOPATHOGENESIS: contd
Keratinocytes secrete TGF-beta
which may also play a role.
Genetic basis has also been
suggested
Eating chillies – hypersenstivity
reaction to capsaicin
MICROSCOPIC FEATURES Severe epithelial  atrophy  Underlying dense collagenous tissue Coarse fibre  formation Hyperkeratosis
MICROSCOPIC FEATURES
Severe epithelial
atrophy
Underlying dense
collagenous tissue
Coarse fibre
formation
Hyperkeratosis n
epithelial dysplasia
can also be seen
CLINICAL FEATURES Palpable fibrous bands  Mucosal texture tough n leathery  Blanching of mucosa 
CLINICAL FEATURES
Palpable fibrous bands
Mucosal texture tough n leathery
Blanching of mucosa
Symptoms include burning sensation
of oral mucosa aggravated by spicy
food
Inability to open mouth.
Weight loss
ASSOCIATED FEATURES Pigmentation changes  Vesicles  Ulceration  Petechiae  Fibrous bands  Depapillation of
ASSOCIATED FEATURES
Pigmentation changes
Vesicles
Ulceration
Petechiae
Fibrous bands
Depapillation of tongue with fibrosis
Coexistent leucoplakia n oral cancer
Submucous fibrosis is a pre-malignant
lesion.
INVESTIGATIONS
INVESTIGATIONS
Local infiltration anesthesia for intraoral biopsies generally is easy to administer. Use of topical anesthesia prior

Local infiltration anesthesia for intraoral biopsies generally is easy to administer. Use of topical anesthesia prior to needle insertion has not been shown to provide any significant relief of actual discomfort; however, it does decrease patient anxiety regarding local anesthesia.

Local infiltration anesthesia for intraoral biopsies generally is easy to administer. Use of topical anesthesia prior
Biopsy punches come in a variety of sizes and in both reusable and disposable forms. Disposable

Biopsy punches come in a variety of sizes and in both reusable and disposable forms. Disposable biopsy punches are lighter and more easily manipulated than their metal counterparts. Most incisional intraoral biopsies can be performed with a 3- or 4-mm punch without suturing. Larger punches can be used for small excisional biopsies but usually require suturing for hemostasis.

Biopsy punches come in a variety of sizes and in both reusable and disposable forms. Disposable
material are procedures. suture material for submucosal closure.
material are
procedures.
suture material for submucosal closure.

A No. 15 Bard-Parker blade, atraumatic forceps, and suture

used for many oral biopsies and other soft tissue

Take care to avoid the use of nonresorbable

material are procedures. suture material for submucosal closure. A No. 15 Bard-Parker blade, atraumatic forceps, and
ensure that the tissue is handled properly.
ensure that the tissue is handled properly.

Tissue removed from the mouth must be placed in a fixative solution (except for the submission of material for frozen section in the hospital). For routine biopsies, 10% neutral buffered formalin is the fixative of choice. For direct immunofluorescence, Michel solution is an excellent transport medium.

Consult the pathology laboratory for any anticipated special procedures to

HISTOPATHOLOGY
HISTOPATHOLOGY
The brush biopsy is an excellent procedure to screen benign-appearing oral mucosal leukoplakias to determine the

The brush biopsy is an excellent procedure to screen benign-appearing oral mucosal leukoplakias to determine the need for subsequent scalpel biopsy. The procedure can be performed without anesthesia.

The brush biopsy is an excellent procedure to screen benign-appearing oral mucosal leukoplakias to determine the
Latex agglutination – based diagnostic tests for Candida albicans have been available for use in gynecology

Latex agglutinationbased diagnostic tests for Candida albicans have been available for use in gynecology for several years. While not specifically marketed for use in the diagnosis of oral candidiasis, such tests have proven to be very accurate, easy to use, and cost effective.

IMMEDIATE INSTRUCTIONS TO THE

PATIENT  Most important of all – DISCONTINUE ARECA NUT N TOBACCO USE Don’t eat hard
PATIENT
Most important of all –
DISCONTINUE ARECA NUT N
TOBACCO USE
Don’t eat hard n spicy foods
Prevent opening jaw wider than the
thickness of thumb
Avoid protrusion of jaw
Muscle stretching exercises
(physiotherapy)
TREATMENT No specific treatment  Intralesional injections of  corticosteroids Plastic surgery  Use hyaluronidase 
TREATMENT
No specific treatment
Intralesional injections of
corticosteroids
Plastic surgery
Use hyaluronidase

TREATMENT No specific treatment  Intralesional injections of  corticosteroids Plastic surgery  Use hyaluronidase 

IFN gamma anti fibrotic cytokine

SURGICAL TREATMENT Excision of fibrous band  Nasolabial flaps n lingual pedicle  flaps: in patients
SURGICAL TREATMENT
Excision of fibrous band
Nasolabial flaps n lingual pedicle
flaps: in patients where tongue is not
involved
Use of lasers to cut the bands
COMPLICATIONS ORAL CARCINOMA:  risk 7.6% over a 10 years period Conductive hearing  loss: involvement
COMPLICATIONS
ORAL CARCINOMA:
risk 7.6% over a
10 years period
Conductive hearing
loss: involvement
of eustachian tube
Difficulty in
tracheal intubation
n bronchoscopy
BIBLIOGRAPHY ROBBINS  E-MEDICINE  CURRENT DIAGNOSIS &  TREATMENT-H&N ORAL MEDICINE-S.R.PRABHU 
BIBLIOGRAPHY
ROBBINS
E-MEDICINE
CURRENT DIAGNOSIS &
TREATMENT-H&N
ORAL MEDICINE-S.R.PRABHU
SPECIAL THANKS
SPECIAL THANKS