Treatment Planning Presentaion

8/13/2019 Treatment Planning Presentaion

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Ahmed Hussain Al- Ghdban 200910244

Saif Haider Al- Kaisi 200911232


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Case scenario:-43 year old lady to restore a decayed tooth. Theexamination revealed a restricted mouth opening.

With thickness and hardness of both cheeks. her

past medical history elicited ingestion of ahousehold bleach during childhood results insignificant burning of her mouth then gradually shenoted the progressive reduction of the mouth

opening. The condition was stable over the last 15years.


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Key words:-house hold bleach ingestionburning sensationLimited mouth opening

Thickening and hardening of both cheeks


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Differential Diagnosis :--Oral Cancer-TMJ problems-Scleroderma

-Radiation fibrosis-Chronic infection (actinomycosis)-Tissue contracture due to scarring-Oral submucous fibrosis


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Oral cancer :-Malignant tumors inside the oral cavity mightcause the same symptoms the patient is having

which is the limitation of mouth opening and

thickening and hardening of the buccal soft tissueBut the cancer is a progressive disease so weexclude it because the in this case the condition

was stable over the past 15 years.


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TMJ problems :-TMJ related problems will cause limitation in mouthopening with pain but It will not cause thickeningand hardening of the cheeks and we exclude it cause

there is no history of trauma of inflammation In thecase scenario


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Scleroderma:-Is a progressive auto-immune disease affecting the skin and

connective tissue. In this condition there is anoverproduction of abnormal collagen. This collagenaccumulates throughout the body, causing hardening(sclerosis), scarring (fibrosis), and other damage.

*it affects about four females for every male. And Mostpatients with systemic sclerosis are diagnosed between ages30 and 50.This disease has many systemic manifestations notmentioned in the case scenario like (Raynaud's phenomenon,mouth and nose may become smaller, trouble in swallowingfood ( stiff and scarred esophagus) , Swelling followed bythickening and tightening of the skin, which becomes tautand shiny, flexed fingers,..)


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Radiation fibrosis:-The presentation of restricted jaw opening issuggestive of radiation fibrosis if there is a historyof radiotherapy of over 5000 cGy. we exclude it

because it is not mentioned in the history.

Actinomycosis:-Is a chronic infection that is well-known to induce

fibrosis and may also present with a limited jawopening with a firm and inelastic quality butusually this infection will happen following anapical abcess or recent extraction of a tooth (not

mentioned in history)


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Oral sub mucous fibrosis:-Oral submucous fibrosis is a chronic precancerous diseaseof the oral cavity characterized by inflammation andprogressive fibrosis of the submucosal tissues (laminapropria and deeper connective tissues). Oral submucousfibrosis results in marked rigidity and an eventual inability

to open the mouth.The buccal mucosa is the mostcommonly involved site, but any part of the oral cavity canbe involved, even the pharynx.

*more common in female than In males.More common in ages between 45 and 55 yearsCommon in Indian subcontinent and asiansMainly it is associated with tobacco chewing


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Symptoms:-Progressive inability to open the mouth (trismus)due to oral fibrosis and scarring.Burning sensation.

Dryness of the mouth.Impaired mouth movements (eg, eating, whistling,blowing, sucking).


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DiagnosisFibrosis and scaring of buccal soft tissue dueTo chemical burn caused by the ingestion of thehousehold bleach.


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DiagnosisNo specific tests will confirm the diagnosis , thediagnosis is made from a history of exposure tochemical substance , the clinical appearance , and

the texture of the tissue.An incisional biopsy will revealed a thinnedepithelial and the excessive deposition ofotherwise normal collagen in the mucosa

Also the biopsy is needed to rule out any chance oforal cancer like the squamous cell carcinoma


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How can household bleach cause fibrosis ?

Chlorine is an alkaline solution that inducesliquifective necrosis by absorbing water from thetissues resulting in deeper tissue penetration

.injuries lead to nausea ,vomiting ,diarrhea ,andburning of the tissues which will cause on the longterm fibrosis due to increase collagen deposit anddecrease in tissue elasticity which will result in

trismus and thickness and hardness of tissues onlong term.


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Treatment :-

The treatment will depend on the degree of clinicalinvovlement and the stage of the fibrosis.

Most patients with fibrosis will present with

moderate to severe fibrosis which is irreversible.

The treatment of the fibrosis will be symptomaticand predominantly aimed at improving mouthmovements.The treatment strategy will depend on the stage ofthe disease and will include non-surgical therapy and

surgical therapy.


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Non-surgical treatment:-1- steroids:-

In patients with moderate fibrosis, weekly submucosalintralesional injections or topical application of steroids mayhelp prevent further damage.Dexamethasone (Decadron)4mg/ml twice a week for 6-8 weeksSteroids will have an anti-inflammatory action and willincrease the apoptosis (cell death) of the inflammatory cells.2-Placental extracts:-The rationale for using placental extract in patients with

fibrosis derives from its proposed anti-inflammatory effect,hence, preventing or inhibiting mucosal damage submucosaladministration of aqueous extract of healthy human placentalextract (Placentrex) has shown marked improvement of the

condition.
http://reference.medscape.com/drug/decadron-dexamethasone-intensol-dexamethasone-342741http://reference.medscape.com/drug/decadron-dexamethasone-intensol-dexamethasone-342741http://reference.medscape.com/drug/decadron-dexamethasone-intensol-dexamethasone-342741http://reference.medscape.com/drug/decadron-dexamethasone-intensol-dexamethasone-342741http://reference.medscape.com/drug/decadron-dexamethasone-intensol-dexamethasone-342741http://reference.medscape.com/drug/decadron-dexamethasone-intensol-dexamethasone-342741


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3-Hyaluronidase:-an enzyme that depolymerize hyaluronic acid and increases

the permeability of the connective tissue and will decreasethe collagen formation.Dose: hyalase 1500 I.U. dissolved in 2% lignocaineThe combination of steroids and topical hyaluronidase shows

better long-term results than either agent used alone.4- IFN-Gamma:-This plays a role in the treatment of patients

with fibrosis because of its immunoregulatory effect. IFN-gamma is a known antifibrotic cytokine. IFN-gamma,through its effect of altering collagen synthesis, appears to bea key factor to the treatment of patients with fibrosis, andintralesional injections of the cytokine may have a significanttherapeutic effect on patients with fibrosis.Dose: 0.01-10 U/ml intralesionally twice a week for 8 weeks .


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5-Lycopene:-Is an anti-oxidant that will cause inhibition of abnormalfibroblasts and will have an anti-inflammatory effect

Also it will act chemopreventive agent for oral premalignantlesions.Dose:- lycored 10 mg twice daily for 2 months

It is very effective treatment especially when combined withsteroids.

6-Pentoxifylline:-is a cardiovascular drug that has avasodilation activity this drug has fibronlytic and anti-

plasmin activity, anti-inflammatory action and immunemodulating action.Dose : Trental 400 mg tablet 3 times daily for 8 weeks.


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Surgical treatment :-Surgical treatment is indicated in patients with severe trismusand/or biopsy results revealing dysplastic or neoplasticchanges. Surgical modalities that have been used include thefollowing:-

1-Simple excision of the fibrous bands : not recommended asit may cause contracture of the tissue and exaggerate thecondition2-Split-thickness skin grafting following bilateral temporalismyotomy or coronoidectomy3-Nasolabial flaps and lingual pedicle flaps gives good resultsbecause tongue flap is highly vascular and resist furtherfibrosis4- The use of laser was found to have promising results for the

cases of fibrosis


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THANKYOU

Treatment Planning Presentaion

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