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PATHOLOGY

CASE

PRESENTATION
BY ROLL NOs.
109 - 116
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
HISTORY TAKING
ANY SPECIFIC HISTORY OF-
 Habits (supari,katha,gutkha,tobbaco)

 Infections

 Iatrogenic injury
EXAMINATION
 Inspection of Oral Cavity
 Inspection of TMJ

 Palpation

 Auscultation
INSPECTION OF ORAL
CAVITY

INSPECTION

BLANCHING

CANCEROUS GROWTH

EXOPHYTIC FLAT INFILTRATIVE

TEXTURE OF MUCOSA N TONGUE

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.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 disease – 30 – 39 mm

 severe disease - <30 mm


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
 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


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.
AUSCULTATION

AUSCULTATION

clicks pops crepitus No click

Degenerative joint d/s


On opening n closing Limited mouth opening
Lack of lubrication

Disc displacement with reduction Disc displacement without reduction


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 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
 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

 Trauma

 Microtrauma as bruxism
CNS disorders
 Tetanus
 Lesions affecting trigeminal nerve

 Drug toxicity
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???
GENERAL APPROACH
 In indian context,and more
particularly in context of bhopal with
such 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
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 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

CYTOKINE, GROWTH FACTORS PRODUCTION

FIBROSIS
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 also been

suggested
 Eating chillies – hypersenstivity

reaction to capsaicin
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

 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 tongue with fibrosis
 Coexistent leucoplakia n oral cancer
 Submucous fibrosis is a pre-malignant
lesion.
INVESTIGATIONS
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.
HISTOPATHOLOGY
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
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
 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 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
of eustachian tube
 Difficulty in
tracheal intubation
n bronchoscopy
BIBLIOGRAPHY
 ROBBINS
 E-MEDICINE

 CURRENT DIAGNOSIS &

TREATMENT-H&N
 ORAL MEDICINE-S.R.PRABHU
SPECIAL THANKS
 Dr.Chandrashekhar,Deptt.pathology
 Dr.Chitij Arora,ENT