PATHOLOGY

CASE PRESENTATION

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 TEXTURE OF MUCOSA N TONGUE SPEECH DIFFICULTY INFILTRATIVE

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

On opening n closing

Degenerative joint d/s Lack of lubrication

Limited mouth opening

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 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 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 Dont 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