PATHOLOGYCASEPRESENTATION : PATHOLOGYCASEPRESENTATION THE CASE : 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 : HISTORY TAKING ANY SPECIFIC HISTORY OF-
Iatrogenic injury EXAMINATION : EXAMINATION Inspection of Oral Cavity
Inspection of TMJ
Auscultation INSPECTION OF ORAL CAVITY : INSPECTION OF ORAL CAVITY INSPECTION OF T.M.J : INSPECTION OF T.M.J Measure Range Of Jaw Movement: : 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 : Measure degree of pain 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 : Lateral movement of jaw Normal - >8 mm
Moderate deformity – 4 to 8 mm
Severe deformity - <4 mm PALPATION : PALPATION AUSCULTATION : AUSCULTATION AN INSIGHT INTO VARIOUS CAUSES OF JAW IMMOBILITY. : AN INSIGHT INTO VARIOUS CAUSES OF JAW IMMOBILITY. Limitations caused by factors external to the joint.
Limitations caused by factors internal to the joint.
Iatrogenic causes. Limitations by factors external to the joint : Limitations by factors external to the joint Neoplasms
Trauma to musculature surrounding joint
Precancerous lesions as leukoplakia,erythroplakia,submucosal fibrosis Limitations by factors internal to joint : Limitations by factors internal to joint Bony ankylosis
Microtrauma as bruxism CNS disorders : CNS disorders Tetanus
Lesions affecting trigeminal nerve
Drug toxicity Iatrogenic causes : 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 : 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. ORALSUBMUCOUSFIBROSIS : ORALSUBMUCOUSFIBROSIS INTRODUCTION : INTRODUCTION Whitish-yellow lesion that has a chronic insidious biologic course;
result of frequent chewing of the areca or betel nut.
Premalignant lesion. EPIDEMIOLOGY : 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 : ETIOPATHOGENESIS ETIOPATHOGENESIS: contd : 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 : 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 : MICROSCOPIC FEATURES Severe epithelial atrophy
Underlying dense collagenous tissue
Coarse fibre formation
Hyperkeratosis n epithelial dysplasia can also be seen CLINICAL FEATURES : 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 : ASSOCIATED FEATURES Pigmentation changes
Depapillation of tongue with fibrosis
Coexistent leucoplakia n oral cancer
Submucous fibrosis is a pre-malignant lesion. INVESTIGATIONS : INVESTIGATIONS HISTOPATHOLOGY : HISTOPATHOLOGY IMMEDIATE INSTRUCTIONS TO THE PATIENT : IMMEDIATE INSTRUCTIONS TO THE 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 : TREATMENT No specific treatment
Intralesional injections of corticosteroids
IFN –gamma anti fibrotic cytokine SURGICAL TREATMENT : 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 : 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 : BIBLIOGRAPHY ROBBINS
CURRENT DIAGNOSIS & TREATMENT-H&N
ORAL MEDICINE-S.R.PRABHU SPECIAL THANKS : SPECIAL THANKS