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Discuss clinical approach. NORMAL TEMPOROMANDIBULAR JOINT : NORMAL TEMPOROMANDIBULAR JOINT HISTORY TAKING : HISTORY TAKING ANY SPECIFIC HISTORY OF- Habits (supari,katha,gutkha,tobbaco) Infections Iatrogenic injury EXAMINATION : EXAMINATION Inspection of Oral Cavity Inspection of TMJ Palpation 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. CNS disorders. Iatrogenic causes. Limitations by factors external to the joint : 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 : Limitations by factors internal to joint Bony ankylosis Fibrous ankylosis Arthritis Infections Trauma 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 Vesicles Ulceration Petechiae Fibrous bands 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 Plastic surgery Use hyaluronidase 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 E-MEDICINE CURRENT DIAGNOSIS & TREATMENT-H&N ORAL MEDICINE-S.R.PRABHU SPECIAL THANKS : SPECIAL THANKS You do not have the permission to view this presentation. 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