PATHOLOGYPATHOLOGY

CASECASE

PRESENTATIONPRESENTATIONBY ROLL NOs.BY ROLL NOs.

109 - 116109 - 116

THE CASETHE CASE 25 year old boy bought 25 year old boy bought

to OPD for loss of to OPD for loss of weight.weight.

Detailed history taking Detailed history taking reveals that his food reveals that his food intake is restricted to intake is restricted to semisolid food (khichdi semisolid food (khichdi or roti dissolved in or roti dissolved in vegetables) due to vegetables) due to inability to open his inability to open his mouth.mouth.

Discuss clinical Discuss clinical approachapproach..

NORMAL NORMAL TEMPOROMANDIBULAR TEMPOROMANDIBULAR

JOINTJOINT

HISTORY TAKINGHISTORY TAKING

ANY SPECIFIC HISTORY OF-ANY SPECIFIC HISTORY OF- Habits (supari,katha,gutkha,tobbaco)Habits (supari,katha,gutkha,tobbaco) InfectionsInfections Iatrogenic injuryIatrogenic injury

EXAMINATIONEXAMINATION

Inspection of Oral CavityInspection of Oral Cavity Inspection of TMJInspection of TMJ PalpationPalpation AuscultationAuscultation

INSPECTION OF ORAL INSPECTION OF ORAL CAVITYCAVITY

INSPECTION

BLANCHING

CANCEROUS GROWTH

TEXTURE OF MUCOSA N TONGUE

EXOPHYTIC FLAT INFILTRATIVE

SPEECH DIFFICULTY

The vermilion borders of the lips should be smooth and pliable. Ask female patients to remove any lipstick, which may obscure underlying surface changes.

                              

 

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.

                              

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 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 pink mushroom-shaped fungiform papillae.

                    

Each of the pink mushroom-shaped fungiform papillae is associated with several taste buds.

                              

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 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, 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 mucosa overlays a number of minor salivary glands.

                              

The soft palate is not usually keratinized and is more vascular than the hard palate, creating the darker red color.

                              

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.JINSPECTION OF T.M.J

INSPECTION

EMACIATION

HYPO OR HYPERMOBILITY

FACIAL ASYMMETRY

PHYSICAL TRAUMA

HEAD POSTURE

INSPECTION OF LYMPH NODES

Measure Range Of Jaw Measure Range Of Jaw MovementMovement::

by mm metal ruler by mm metal ruler normal – 40 mmnormal – 40 mm moderate disease – 30 – 39 mmmoderate disease – 30 – 39 mm severe disease - <30 mmsevere disease - <30 mm

Measure degree of painMeasure degree of pain

Presence shows TMJ inflammationPresence shows TMJ inflammation Degrees of pain:Degrees of pain: Degree 0 - no painDegree 0 - no pain Degree 1 – slight painDegree 1 – slight pain Degree 2 – moderate painDegree 2 – moderate pain Degree 3 – severe painDegree 3 – severe pain

Lateral movement of jawLateral movement of jaw

Normal - >8 mmNormal - >8 mm Moderate deformity – 4 to 8 mmModerate deformity – 4 to 8 mm Severe deformity - <4 mmSevere deformity - <4 mm

PALPATIONPALPATION

PALPATEPALPATE

TMJTMJ

Muscles of masticationMuscles of mastication

Intraoral palpationIntraoral palpation

Palpation of lymph nodesPalpation of lymph nodes

presence of fibrous bandspresence of fibrous bands

The anterior cervical chain of lymph nodes is frequently involved in both inflammatory oral conditions and metastatic disease. Nodal changes are palpable all along the sternocleidomastoid muscle.

                              

  

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

                              

    

AUSCULTATIONAUSCULTATION

AUSCULTATION

clicks pops crepitus

On opening n closing

No click

Disc displacement with reduction

Limited mouth opening

Disc displacement without reduction

Degenerative joint d/sLack of lubrication

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 AN INSIGHT INTO VARIOUS CAUSES OF VARIOUS CAUSES OF

JAW IMMOBILITYJAW IMMOBILITY.. Limitations caused by factors Limitations caused by factors

external to the joint.external to the joint. Limitations caused by factors Limitations caused by factors

internal to the joint.internal to the joint. CNS disorders.CNS disorders. Iatrogenic causes.Iatrogenic causes.

Limitations by factors external to Limitations by factors external to the joint the joint

NeoplasmsNeoplasms Acute infectionsAcute infections MyositisMyositis PseudoankylosisPseudoankylosis Burn injuriesBurn injuries Trauma to musculature surrounding jointTrauma to musculature surrounding joint Precancerous lesions as Precancerous lesions as

leukoplakia,erythroplakia,submucosal leukoplakia,erythroplakia,submucosal fibrosisfibrosis

Limitations by factors internal to Limitations by factors internal to jointjoint

Bony ankylosisBony ankylosis Fibrous ankylosisFibrous ankylosis ArthritisArthritis InfectionsInfections TraumaTrauma Microtrauma as bruxismMicrotrauma as bruxism

CNS disordersCNS disorders

TetanusTetanus Lesions affecting trigeminal nerveLesions affecting trigeminal nerve Drug toxicityDrug toxicity

Iatrogenic causesIatrogenic causes Third molar extractionThird molar extraction Hematomas secondary to dental Hematomas secondary to dental

injectioninjection Late effects of intermaxillar fixation Late effects of intermaxillar fixation

after mandible fracture or other after mandible fracture or other traumatrauma

WHERE DO YOU GO???WHERE DO YOU GO???

GENERAL APPROACHGENERAL APPROACH

In indian context,and more In indian context,and more particularly in context of bhopal with particularly in context of bhopal with such a large population of guthka such a large population of guthka and supari eaters,the more practical and supari eaters,the more practical approach when a patient with such approach when a patient with such problem comes to the OPD is to problem comes to the OPD is to suspect presence of oral submucosal suspect presence of oral submucosal fibrosis.The element of weight loss fibrosis.The element of weight loss further adds to the suspicion.further adds to the suspicion.

ORALORAL

SUBMUCOUSSUBMUCOUS

FIBROSISFIBROSIS

INTRODUCTIONINTRODUCTION

Whitish-yellow lesion that has a Whitish-yellow lesion that has a chronic insidious biologic course; chronic insidious biologic course;

result of frequent chewing of the result of frequent chewing of the areca or betel nut.areca or betel nut.

Premalignant lesion.Premalignant lesion.

EPIDEMIOLOGYEPIDEMIOLOGY occurs primarily in India, Pakistan occurs primarily in India, Pakistan

and Burma. and Burma. females more often than males.  females more often than males.   Age 20 – 40 yrsAge 20 – 40 yrs Involves buccal mucosa, retromolar Involves buccal mucosa, retromolar

areas, soft palate, uvula, tongue n areas, soft palate, uvula, tongue n labial mucosa.labial mucosa.

ETIOPATHOGENESISETIOPATHOGENESIS

TANNINS FROM ARECA NUT

ACTIVATE FIBROBLASTS

CROSSLINKING OF COLLAGEN PEPTIDE CHAINS

INFLAMMATION

INHIBITS COLLAGEN DEGRADATION

CYTOKINE, GROWTH FACTORS PRODUCTION

FIBROSIS

ETIOPATHOGENESIS: contdETIOPATHOGENESIS: contd

Upregulation of lysyl Upregulation of lysyl oxidase activity: oxidase activity: increased conversion of increased conversion of collagen monomers collagen monomers into insoluble polymersinto insoluble polymers

Raised tissue copper Raised tissue copper levels lead to increased levels lead to increased lysyl oxidase activity.lysyl oxidase activity.

ETIOPATHOGENESIS: contdETIOPATHOGENESIS: contd

Keratinocytes secrete TGF-beta Keratinocytes secrete TGF-beta which may also play a role.which may also play a role.

Genetic basis has also been Genetic basis has also been suggestedsuggested

Eating chillies – hypersenstivity Eating chillies – hypersenstivity reaction to capsaicinreaction to capsaicin

MICROSCOPIC FEATURESMICROSCOPIC FEATURES

Severe epithelial Severe epithelial atrophyatrophy

Underlying dense Underlying dense collagenous tissue collagenous tissue

Coarse fibre Coarse fibre formationformation

Hyperkeratosis n Hyperkeratosis n epithelial dysplasia epithelial dysplasia can also be seencan also be seen

CLINICAL FEATURESCLINICAL FEATURES

Palpable fibrous bandsPalpable fibrous bands Mucosal texture tough n leatheryMucosal texture tough n leathery Blanching of mucosaBlanching of mucosa Symptoms include burning sensation Symptoms include burning sensation

of oral mucosa aggravated by spicy of oral mucosa aggravated by spicy foodfood

Inability to open mouth.Inability to open mouth. Weight lossWeight loss

ASSOCIATED FEATURESASSOCIATED FEATURES Pigmentation changesPigmentation changes VesiclesVesicles Ulceration Ulceration PetechiaePetechiae Fibrous bandsFibrous bands Depapillation of tongue with fibrosisDepapillation of tongue with fibrosis Coexistent leucoplakia n oral cancerCoexistent leucoplakia n oral cancer Submucous fibrosis is a pre-malignant Submucous fibrosis is a pre-malignant

lesion.lesion.

INVESTIGATIONSINVESTIGATIONS

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.

                              

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.

                              

A No. 15 Bard-Parker blade, atraumatic forceps, and suture material are used for many oral biopsies and other soft tissue procedures. Take care to avoid the use of nonresorbable suture material for submucosal closure.

                              

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 ensure that the tissue is handled properly.

                              

HISTOPATHOLOGYHISTOPATHOLOGY

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.

                              

Latex agglutination–based 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 IMMEDIATE INSTRUCTIONS TO THE PATIENTTO THE PATIENT

Most important of all – DISCONTINUE Most important of all – DISCONTINUE ARECA NUT N TOBACCO USEARECA NUT N TOBACCO USE

Don’t eat hard n spicy foodsDon’t eat hard n spicy foods Prevent opening jaw wider than the Prevent opening jaw wider than the

thickness of thumbthickness of thumb Avoid protrusion of jawAvoid protrusion of jaw Muscle stretching exercises Muscle stretching exercises

(physiotherapy)(physiotherapy)

TREATMENTTREATMENT

No specific treatmentNo specific treatment Intralesional injections of Intralesional injections of

corticosteroidscorticosteroids Plastic surgeryPlastic surgery Use Use hyaluronidasehyaluronidase IFN –gamma anti fibrotic cytokine

SURGICAL TREATMENTSURGICAL TREATMENT

Excision of fibrous bandExcision of fibrous band Nasolabial flaps n lingual pedicle Nasolabial flaps n lingual pedicle

flaps: in patients where tongue is not flaps: in patients where tongue is not involvedinvolved

Use of lasers to cut the bandsUse of lasers to cut the bands

COMPLICATIONSCOMPLICATIONS

ORAL CARCINOMA: ORAL CARCINOMA: risk 7.6% over a 10 risk 7.6% over a 10 years periodyears period

Conductive hearing Conductive hearing loss: involvement loss: involvement of eustachian tubeof eustachian tube

Difficulty in Difficulty in tracheal intubation tracheal intubation n bronchoscopyn bronchoscopy

BIBLIOGRAPHYBIBLIOGRAPHY

ROBBINSROBBINS E-MEDICINEE-MEDICINE CURRENT DIAGNOSIS & TREATMENT-CURRENT DIAGNOSIS & TREATMENT-

H&NH&N ORAL MEDICINE-S.R.PRABHUORAL MEDICINE-S.R.PRABHU

SPECIAL THANKSSPECIAL THANKS

Dr.Chandrashekhar,Deptt.pathologyDr.Chandrashekhar,Deptt.pathology Dr.Chitij Arora,ENTDr.Chitij Arora,ENT