chief ncomplaints /endodontic courses

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INDIAN DENTAL ACADEMY
Leader in continuing Dental Education
CHIEF COMPLAINTCHIEF COMPLAINT

CHIEF COMPLAINTCHIEF COMPLAINT
• 17yrs male patient
• C/O of ulcer in the right
posterior part of the mouth
since 8 months.

HISTORY OF PRESENTING ILLNESSHISTORY OF PRESENTING ILLNESS
* Insidious in onset.
* Initially noticed a small peanut sized swelling
which was associated with pain and blood
discharge.
Since past 4 months
* gradually progressed in size & symptoms.
* Pain radiates to lower jaw and ear.
* Associated with pus discharge & bad breath.
* Associated with difficulty in swallowing since
2months.
* Not associated with fever or any other systemic
symptoms. www.indiandentalacademy.com

Indian Dental academy
• www.indiandentalacademy.com
• Leader continuing dental education
• Offer both online and offline dental
courses

MEDICAL HISTORYMEDICAL HISTORY
Non contributory

PERSONAL HISTORYPERSONAL HISTORY
☻Oral hygiene practice
☻Mixed diet
☻No addictive habits
☻Normal bowel and Bladder habits
☻Disturbed sleep

GENERAL PHYSICAL EXAMINATIONGENERAL PHYSICAL EXAMINATION
Conscious and Co-operative
Moderately built and moderately nourished
 Pallor present
No signs of icterus, cyanosis, clubbing,
edema
Vital signs - within normal range

HEAD AND NECK EXAMINATIONHEAD AND NECK EXAMINATION
o Facial asymmetry detected
on right side.
o Eyes, ears, nose - no
clinically detectable
abnormalities
o TMJ – no clinically
detectable abnormalities.
o Mouth opening - restricted

LYMPH NODE EXAMINATIONLYMPH NODE EXAMINATION
• Right submandibular lymph node
palpable - Single, Size- 2cm ,Firm,
Tender, Fixed.
• Right superficial cervical node
palpable - Single, Size-1cm,
Firm, Nontender, Partially Fixed.

INTRAORAL EXAMINATIONINTRAORAL EXAMINATION

INSPECTION
• Single irregular ulcer
noticed involving right
soft palate, faucial pillar,
posterior pharyngeal wall,
retromolar region,
base of the tongue, floor
of the mouth.
• Size:- 4x5cm

EXTENSIONS
• Ant:- right lower first molar
• Post:- soft palate, faucial pillar and
extending posteriorly into oropharynx
• Lingually:- Base of the tongue & Floor
of the mouth
• Borders were ill-defined.
• Surface appeared to be covered with
irregular areas of sloughing and
erythema.
Tongue movements - restricted.
Uvula movements- restricted on right side.

PALPATION
Inspectory findings regarding site, size and number
were confirmed.
Tender
Borders ill-defined and indurated.
Pus discharge noticed.

TO SUMMARIZE…..TO SUMMARIZE…..
• 17yrs male with the C/O ulceration in the right posterior
part of the mouth of 8months duration associated with
pain and difficulty in swallowing.
• Extra oral examination revealed palpable lymphnodes in
submandibular and superficial cervical region, 2 in no.,
firm, tender and fixed.
• Intra orally, a single irregular ulcer noticed on posterior
palatal, oropharyngeal and retromolar region, base of
the tongue, floor of the mouth with indurated ill defined
borders, with the overlying necrotic surface.

PROVISIONAL DIAGNOSISPROVISIONAL DIAGNOSIS
• Carcinoma of soft palate and retromolar
area.

DIFFERENTIAL DIAGNOSIS
• Carcinoma of minor salivary gland
• Deep fungal infection
• Lymphoma
• Necrotizing sialometaplasia

INVESTIGATIONSINVESTIGATIONS
☺Chair side investigations – Exfoliative
cytology
☺Routine Blood Investigations
☺Radiographic Investigations
☺CT Imaging
☺Ultrasonography
☺Incisional biopsy
☺Microbial culture

PANORAMIC VIEWPANORAMIC VIEW

ROUTINE BLOOD INVESTIGATIONSROUTINE BLOOD INVESTIGATIONS
• Hemoglobin- 12.6g/dl
• TLC – 7800/cumm
• DLC – Neutrophils- 65%
• Lymphocytes- 22%
• Eosinophils- 13%
• Monocytes – 5%
• Basophils- 0%
• ESR – 30mm/hr
• Platelet count – 3.62 lakhs/cumm
• RBC count – 4.44 millions/dl
Special investigations – ELISA Negativewww.indiandentalacademy.com

CT SCANCT SCAN
Soft tissue growth involving the Rt lateral oropharyngeal
extending inferiorly upto C4 level with no bony involvementwww.indiandentalacademy.com

ULTRASONOGRAPHYULTRASONOGRAPHY
• Revealed multiple
enlarged lymph nodes in
right submandibular
region and bilateral deep
cervical lymph node
involvement.
• Major Salivary glands
appeared to be normal.

INCISIONAL BIOPSY REPORTINCISIONAL BIOPSY REPORT
• Islands of large to polygonal
pleomorphic cells with
vesiculated nuclei and
prominent nucleolus
• Interspersed lymphocytic
infiltration.
Original magnification x 10X
Original magnification x 40X

IMMUNOHISTOCHEMISTRYIMMUNOHISTOCHEMISTRY was advised
to rule out undifferentiated carcinoma,
lymphoma, and other round cell lesions.

IMMUNOHISTOCHEMISTRYIMMUNOHISTOCHEMISTRY
•Pan cytokeratin AE1/ AE3:
Negative
•CD 45/ LCA: Intensely positive
•CD 20: Intensely positive on tumor
cell membranes

OTHER INVESTIGATIONSOTHER INVESTIGATIONS
• Chest x-ray
• USG abdomen
• Bone marrow aspiration
Showed no abnormality

FINAL DIAGNOSISFINAL DIAGNOSIS
Extranodal Non Hodgkin Large B-cell Lymphoma
STAGE –II E (Ann-Arbor)

TREATMENT ADMINISTERED
Referred to a Medical Oncologist
• CHOP THERAPY ADMINISTERED
Cyclophosphamide-750mg/m2
IV
Oncovin-1.4mg/m2
IV
Adrimycin-50 mg/m2
IV
Prednisone -100mg
– ONCE IN 21 DAYSONCE IN 21 DAYS
– 6 CYCLES FOLLOWED BY6 CYCLES FOLLOWED BY
RADIOTHERAPYRADIOTHERAPY

POSTPOST 11STST
CYCLE OFCYCLE OF CHEMOTHERAPYCHEMOTHERAPY
BEFORE AFTER

REVIEW OF LITERATUREREVIEW OF LITERATURE

REVIEW OF LITERATUREREVIEW OF LITERATURE
DEFINITION: Lymphomas are heterogenous group of
neoplastic disorders originating from the
Lymphoreticular system
Lymphomas account for 4-5% of all neoplasms.
Non-Hodgkin's lymphomas account for 65%
Incidence is low in Asia
Williams et al, Hematology 4th
edition 1991

ETIOLOGY;
Unknown
PREDISPOSING FACTORS;
Exposure to drugs or infectious agent
History of Sjogrens syndrome
Immunosuppression
Previous irradiation
edition 1991
Stenson et al,Am J Of Otolar
1996;17(4);276-280.www.indiandentalacademy.com

PATHOGENESIS
Brayn et al, The Lancet 2004:5:341-53...

CLINICAL PRESENTATION
Males
5th
-7th
decades
Tonsil- Waldeyers ring (34%)followed by salivary glands (15%)
Swelling or Mass (59%)
Pain and dysphagia ( 7%)
Primary osseous lymphoma accounts for 4% of all ENH
Mandible is most common site presenting as osteolytic lesion.
Hart et al. .Clinical Oncology 2004;16;186-192.
Bryan et al. The Lancet 2004:5:341-53.
Gusenbauer et al, J O M S 1990;46;409-415.

STAGING
ANN-ARBOR STAGING
STAGE I ; Involvement of a single lymph node region or of a single
extranodal organ or site (IE)
STAGE II; Involvement of two or more lymph node regions on the
same side of the diaphragm, or localized involvement of
an extranodal site or organ (IIE) and one or more lymph
node regions on the same side of the diaphragm
STAGEIII; Involvement of lymph node regions on both sides of the
diaphragm, which may also be accompanied by localized
involvement of an extranodal organ or site (IIIE) or
spleen (IIIS) or both (IIISE)
STAGEIV; Diffuse or disseminated involvement of one or more distant
extranodal organs with or without associated
lymph node involvement
SYSTEMIC SYMPTOMS
A-NO SYMPTOMS
B-WEIGHT LOSS>10% IN 6 MONs,FEVER, NIGHT SWEATS
Carbone et al. Cancer Res 1971;31;1860

SPREAD OF ORAL LYMPHOMA
• Lymphatic spread via cervical lymph nodes to extra
nodal organs.
• Contiguous spread to adjacent organs.
• Blood-borne distant metastases
Takahashi et al. J Oral Max Surge 1990;46;409-415

TREATMENT OPTIONS
• RADIOTHERAPY
2000-2500cGy - palliative therapy
4500-5000cGy –curative therapy
• CHEMOTHERAPY
CHOP- Cyclophosphamide-750mg/m2
IV
Oncovin-1.4mg/m2
IV
Adrimycin-50 mg/m2
IV
Prednisone -100mg
MOPP- Nitrogen mustard-6mg/m2
IV
Oncovin-1.4mg/m2
IV
Prednisone-40mg/m2
Procarbazine-100mg/m2
edition 1991

• MONOCLONAL
ANTIBODIES - Brayn et al
Rituximab-anti CD-20 antibody
Tositumomab-anti CD-20 antibody
Alemtuzumab-anti CD-52 antibody.
• RADIOIMMUNOTHERAPY
• STEM CELL
TRANSPLANTATION
• COMBINATION www.indiandentalacademy.com

PROGNOSIS
Age
Site of primary
Histology
Stage
Overall 5-Year Survival for patients with head
and neck lymphoma(50-60%)
Brayn et al, The Lancet 2004:5:341-53.

This case of extra oral NHL is a rarity and
illustrates the wide variation in presentation.
Highlights the importance of early biopsy and
immuno histochemical assay for early
diagnosis, staging and appropriate treatment.
Oral and maxillofacial diagnostician should
be familiar with its presentation in head and
neck region.
CONCLUSION

REFERENCES
1. Brayn et al, Non-Hodgkin's lymphoma; an update. The Lancet
2004:5:341-53.
2. Hart et al, Localized extra nodal lymphoma of the head and neck;
The Sheffield lymphoma group experience(1971-2000) .Clinical
Oncology 2004;16;186-192.
3. Richards et al, Oral mucosal non Hodgkin's lymphoma-a dangerous
mimic. Oral Onc 2000;36;556-558.
4. Minor salivary gland carcinoma involving the oral cavity or
oropharynx. Australian Dental Journal 2004;49:(1):16-19
5. Nonsquamous Cell Malignant Tumours of the Oral Cavity: An
Overview. J Can Dent Assoc 2003; 69(9):577–82

REFERENCES
6. Maxymiw et al, B-Cell lymphoma presenting as a
midfacial necrotizing lesion Oral Surg Oral Path Oral
Med 1992;74;343-347
7. Williams et al, Hematology 4th
edition 1991.
8. Oropharyngeal cancer: Treatment - Health
Professional Information [NCI PDQ]

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