Методичні розробки 3 модуль

F.has no capsule;

G.atypical cells;

D.does not give metastasises;

E.breaks the general condition. (Right answer: D).

2. Specify the characteristic not peculiar to a benign tumour?

A.Has well expressed capsule;

B.Does not give metastasises;

C.Propensity to disintegration of a tumour;

H.Does not break the general condition;

I.Has no atypical cells.

(Right answer: C).

D. Educational task of the third level:

1.The patient of, 41 years,came to the surgeon-stomatologist with complaints to swelling existence in the right paraparotide area which appeared more than 10 years ago, slowly grew. At objective research the new growth to 3 cm in diameter, soft elastic consistences, painless is revealed, to subject tissues isn't soldered, mobile.

What should be tactics of the doctor? What additional methods of inspection should be carried

out?

(Answer: the doctor should take a material for cytological research. Additional methods of inspection: laboratory (the general and biochemical analysis of blood), if necessary radiological (sialogrames, considering a new growth arrangement)

2.The doctor surgeon-stomatologist directed a material taken from an ulcer in the left submandibular area on cytologic research. By results of cytological research atypical cages are found.

What further actions of the doctor?

(Answer: to send the patient to an oncological clinic)

3.Patient And., 42 years, addressed to the surgeon-stomatologist because it had a dryness in a mouth. At objective research it is established: asymmetry of the face at the expense of a swelling in the right parotid and chewing area, ptosis the right eye and omission of the right corner of a mouth. Integuments in color aren't changed. The right sudmandibular lymph nodes are increased, soldered among themselves, motionless. Mouth opening the free. The mucous membrane of the right shchechny area without visible pathology, dry, a saliva from the mouth of a channel of parotid salivary gland isn't allocated.

Make the preliminary diagnosis. What should be tactics of the doctor?

(Answer: malignant new growth of the right parotid salivary gland. Cytologic and radiological research. Consultation and the subsequent treatment at the oncologist)

7.Literature fundamental (basic):

1.Дунаевский В.А., Шеломенцев Ю.А. Предопухолевые заболевания и злокачественные

опухоли слизистых оболочек полости рта. – Москва:Медицина, 1986. – 184с.

2.Колесов А.А., Воробьев Ю.И., Каспарова Н.Н. Новообразования мягких тканей и костей лица у детей и подростков. – Москва: Медицина, 1989. – 304с.

3.Машкилейсон А.Л. Предрак красной каймы губ и слизистой оболочки полости рта.- Москва: Медицина,1970. – 109с.

4.Пачес А.Г. Опухоли головы и шеи.- Москва: Медицина, 1983. – 416с.

5.Heatley M K 1996 Cytokeratins and cytokeratin staining in diagnostic histopathology. Histopathology 28:479^83

6.Layton S, Korsen J 1994 Informed consent in oral and maxillofacial surgery: a study of the value of written warning. Sr J Oral Maxillofac Surg 32:34-66

7.Minden N J, Fast T B 1994 Evaluation of health history forms used in U.S. dental schools. Oral Surg Oral Med Oral Pathol 77:105-109

8.9.O‘Conner N 1995 Laboratory diagnosis in haematology. Medicine UK 23:489-494 Stanley M W 1995 False-positive diagnoses in exfoliative cytology (editorial). Am J CLin Pathol 104:I17-119

9.11.Whaites E 1996 Essentials of dental radiography and radiology.

Additional (supplementary) literature:

1.Солнцев А.М., Колесов В.С., Доброкачественные опухоли лица, челюстей и органов полости рта.- Киев.: Здоровье,1985.-150 с.

2.Соловьев М.М. Онкологические аспекты в стоматологии. –Москва .: Медицина, 1983. –

150 с.

3.Шувалов С.М. Злокачественные опухоли ротоглотки. Винница, 1996. - 231 с.

Ministry of health Ukraine

Higher state educational establishment of Ukraine

«Ukrainian medical stomatological academy»

It is «ratified» at meeting of chair of surgical stomatology and maxillofacial surgery with plastic and reconstructive surgery of the head and neck

The Head of the chair

doctor of medicine Aveticov D. S.

METHODICAL INSTRUCTION

FOR INDEPENDENT WORK OF STUDENTS DURING PREPARATION FOR PRACTICAL

(SEMINAR) LESSON

Poltava – 2012

1. SUBJECT URGENCY.

Public awareness of head and neck cancer is low.

A randomised controlled trial found that patients attending primary care who had read an information leaflet about head and neck cancer had increased awareness of risk compared to patients who had not seen the leaflet. A questionnaire of awareness of signs and symptoms and risks of oral cancer showed that all those who received the leaflet (smokers, non-smokers and past smokers) reported greater knowledge (p< 0.001) with smokers 16 times more likely to perceive that they were at greater risk.

The most appropriate primary care setting in which to advise patients seeking help for suspected head and neck cancer has not been identified. Patients have different perceptions of the ability of dentists and doctors to diagnose and treat oral lesions. The signs and symptoms and the location of the lesions all influence a patient‘s choice of health professional for first consultation.

All healthcare practitioners, including dental and medical practitioners, should be aware of the presenting features of head and neck cancer, and the local referral pathways for suspected cancers.

There is no evidence for an effective screening programme for head and neck cancers. In particular, toluidine blue dye does not appear to be a cost-effective method of screening for oral cancers in a primary care (dental) setting.

Dental practitioners should include a full examination of the oral mucosa as part of routine dental check up.

Oral cavity tumours may arise from the anterior two-thirds of tongue (the oral tongue), floor of mouth, buccal mucosa, retromolar trigone, hard palate, or gingiva. Choice of therapeutic option for patients with early cancer of the oral cavity should be determined by the tumour‘s site and extent, the patient‘s general condition and preference and availability of local expertise.

It is important to consider the treatment related morbidity, and likely cosmetic and functional outcome of treatment, as well as tumour control, when making decisions about treatment.

In patients with head and neck cancer, 76% of recurrences occur within the first two years posttreatment, and 11% occur in the third year. In one study, 61% of patients with recurrence reported symptoms but 39% had no symptoms.

2.SPECIFIC GOALS:

2.1.To analyze the reasons of occurrence of tumours and tumours–like formations of

maxillofacial area and a neck.

2.2. To explain pathogenesis of tumours and tumours–like formations of maxillofacial area and a

neck.

2.3.To know definition of concept oncological vigilance.

2.4.To classify tumours and tumours–like formations of maxillofacial area and a neck.

2.5.To know biological bases of clinical oncology.

3. BASIC LEVEL OF PREPARATION.

4. TASKS FOR INDEPENDENT WORK DURING PREPARATION FOR LESSON.

4.1. The list of the main terms, parameters, characteristics which the student should know during preparation for lesson:

4.3. Practical works (tasks) which are carried out on lesson:

1. To make examination of the patient with a tumour in maxillofacial area.

2.To interrogate the patient and to write the document and to make a scheme of examination.

3.To survey the patient with a tumour, to establish the diagnosis and to appoint a treatment.

5.ORGANIZATION OF THE MAINTENANCE OF THE TRAINING MATERIAL. Immunofluorescent and immunohistochemical staining

Immunostaining methods make use of the highly specific binding between antibodies and

antigens to stain specific molecules within the tissues. Fresh (unfixed) tissue is sometimes required. Immunostaimng has revolutionised histological diagnosis and has made some more complex

techniques such as electron microscopy almost redundant. It is time-consuming and must be meticulously carried out with adequate controls to avoid both false -positive and false-negative results.

Antibodies, often monoclonal, can be purchased. They react with the target molecule and the combination is labelled, either by being coupled to a fluorescein or an enzyme such as peroxidase. The antibody is incubated on the section where it binds specifically to the target molecule. Surplus reagent is washed off and any binding (a positive reaction) is visible by its fluorescence in an ultraviolet light microscope or by reacting the enzyme with synthetic substrate to produce a coloured produc.

Molecular biological tests

Molecular biological diagnostic tests have revolutionised diagnosis, particularly in screening for and identification of genetic abnormalities and rapid identification of bacteria and viruses. Some malignant neoplasms have characteristic genetic abnormalities, mostly chromosomal translocations, which can be detected by cytogenetics, polymerase chain reaction (PCR) or fluorescent in situ hybridisation. Molecular techniques are also the method of choice for the diagnosis of some lymphomas which cannot be accurately categorised by routine histological methods.

Identification of many bacteria and viruses is now often undertaken using PCR. In this test the clinical sample is solubilised and the nucleic acids hybridised with complementary probes which are specific for known pathogens. If the pathogen is present in the sample, PCR will copy the nucleic acid repeatedly until enough is synthesised to be seen in an electrophoresis gel .If no pathogen is present no nucleic acid is synthesised. Identification oAnycobacteria is a good example of the value of this type of test. Previously, identification of mycobacterial infection required approximately 6 weeks to culture the sample. PCR can be performed in 48 hours, is more sensitive and differentiates different types of mycobacteria with a high degree of precision. This test is therefore ideal for investigation of enlarged lymph nodes in the neck. A more recent application of PCR to detect micro-metastases of tumours is potentially also of enormous value.

Such methods have yet to become widespread in dentistry, even in hospital specialities. However, when confronted with a difficult diagnosis it is sensible to discuss the case with the pathologist or microbiologist before biopsy, to ensure that appropriate samples are available for these specialised tests.

Haematology, clinical chemistry and serology

Blood investigations are clearly essential for the diagnosis of diseases such as leukaemias, myelomas, or leukopenias which have oral manifestations, or for defects of haemostasis which can greatly affect management. Blood investigations are also helpful in the diagnosis of other conditions such as some infections, and sore tongues or recurrent aphthae which are sometimes associated with anaemia.There are many different types of haematological examinations but despite the frequent use of the term 'routine blood test`, no test should ever be requested as a routine, only to answer a specific question (Table 1).The request form should always be completed with sufficient clinical detail to allow the haematologist or clinical chemist to check that the appropriate tests have been ordered and to allow the interpretation of the results. It is important to include details of any drug treatment on blood test request forms. Always put the blood into the appropriate tube because some anticoagulants are incompatible with certain tests.A haematologist will not be impressed with a request for assessment of clotting function on a specimen of coagulated blood.

Table 1. Types of blood test useful in oral diagnosis

Microbiology. Despite the fact that the most common oral diseases are infective, microbiology is surprisingly rarely of practical diagnostic value in dentistry (Table 2). Direct Gram-stained smears will quickly confirm the diagnosis of thrush or acute ulcerative gingivitis, and H & E-stained smears can show the distorted, virally infected epithelial cells in herpetic infections more easily than microbiological tests for the organisms themselves. A key microbiological investigation is culture and sensitivity of pus organisms. Whenever pus is obtained from a soft tissue or bone infection it should be sent for culture and determination of antibiotic sensitivity of the causative microbes. Those of osteomyelitis, cellulitis, acute parotitis, systemic mycoses (frequently mistaken for tumours), or other severe infections need to be identified if appropriate antimicrobial treatment is to be given. However, such treatment has usually to be started empirically without this information but the sensitivity test may dictate a change.

Viral identification is rarely required for oral diseases as many oral viral infections are clinically typical and indicate the causative virus. A smear alone may show the nuclear changes of herpetic infection in epithelial cells from the margins of mucosal ulcers. A more sensitive and almost as rapid result may be obtained by sending a swab for virus detection using ELISA (enzyme-linked immunosorbent assay.

Table 2. Microbiological tests useful in oral diagnosis

Practical point Always take a sample of pus for culture and antibiotic sensitivity from bone and soft tissue infections before giving an antibiotic.

Practical point Always take the temperature of any patient with a swollen face, enlarged lymph nodes, malaise or other symptom or sign which might indicate infection.

Other clinical tests. Several simple clinical tests may be valuable in diagnosis of oral disease. Urine tests are valuable for the diagnosis of diabetes (suggested by repeated candidal or periodontal infection), autoimmune conditions which damage the kidneys, for instance Wegener's granulomatosis, and for the detection of Bence -Jones protein in myeloma.

Taking the patient's temperature is an easily forgotten investigation.The temperature should be noted whenever bone or soft tissue infections are suspected. It helps distinguish facial inflammatory oedema from cellulitis and indicates systemic effects of infections and the need for more aggressive therapy.

Interpreting special investigations and making a diagnosis and treatment plan

The history, examination and results of special investigations should provide the material for a diagnosis and treatment plan. Check that the results of each investigation are compatible with the preliminary diagnosis and do not indicate any need to avoid a particular treatment.

If a result appears at odds with other information take into account the normal variation, perhaps with age or diurnal variation, and consider the possibility of false-positive and false-negative results. A common cause of unusual blood test results is a delay in taking blood samples to the laboratory.

Further advice and specialised tests may be appropriate. General medical, ear, nose and throat, neurological and psychiatric referral are among the specialities to whom patients may be referred. In referrals, it is important to state whether the dentist is requesting the medical specialist to exclude a condition and refer the patient back, or to take over investigation. If the latter, it is essential that dental causes have been completely eliminated as the cause of the problem.

Practical point Good clinical record keeping is essential for good patient management as well as for medicolegal reasons

Finally, ensure that the patient's notes include a complete record of the consultation and investigation results. This must be correctly dated, legible, limited to relevant facts and include a clear complaint history, list of clinical findings, test results and plan of treatment organised in a suitable form for quick reappraisal.It must be signed by the clinician and in addition, the name should be printed below if the signature is anything less than perfectly legible. It should be possible for another person to continue to investigate or treat the patient without difficulty on the basis of the clinical record.

Photograhy or computerised video imaging is a very valuable adjunct to the clinical record. Pictures are especially useful in monitoring lesions which may vary in the course of a long follow-up, for instance white patches. It is useful to include teeth or a scale in the frame to allow accurate assessment of small changes in size. Photographs may also be helpful in explaining to patients about their condition and to show the effects of treatment.

NORMAL HAEMATOLOGICAL VALUES

The factors causing occurrence of a tumour.

From the earliest times, physicians have puzzled over the causes of cancer. Ancient Egyptians blamed cancers on the gods.

Humoral theory. Hippocrates believed that the body had 4 humors (body fluids): blood, phlegm, yellow bile, and black bile. When the humors were balanced, a person was healthy. Too much or too little of any of the humors caused disease. An excess of black bile in various body sites was thought to cause cancer. This theory of cancer was passed on by the Romans and was embraced by the influential doctor Galen‘s medical teaching, which remained the unchallenged standard through the Middle Ages for over 1,300 years. During this period, the study of the body, including autopsies, was prohibited for religious reasons, which limited progress of medical knowledge. Lymph theory. Among theories that replaced the humoral theory of cancer, was the formation of cancer by another body fluid, lymph. Life was believed to consist of continuous and appropriate movement of the fluid parts of the body through the solid parts. Of all the fluids, the most important were blood and lymph. Stahl and Hoffman theorized that cancer was composed of fermenting and degenerating lymph varying in density, acidity, and alkalinity. The lymph theory gained rapid support. The eminent Scottish surgeon John Hunter (1728−1793) agreed that tumors grow from lymph constantly thrown out by the blood. Blastema theory. In 1838, German pathologist Johannes Muller demonstrated that cancer is made up of cells and not lymph, but he believed that cancer cells did not come from normal cells. Muller proposed that cancer cells developed from budding elements

(blastema) between normal tissues. His student, Rudolph Virchow (1821−1902), the famous German pathologist, determined that all cells, including cancer cells, are derived from other cells. Chronic irritation theory. Virchow proposed that chronic irritation was the cause of cancer, but he falsely believed that cancers ―spread like a liquid.‖ In the 1860s, German surgeon, Karl Thiersch, showed that cancers metastasize through the spread of malignant cells and not through some unidentified fluid. Trauma theory. Despite advances in the understanding of cancer, from the late 1800s until the 1920s, trauma was thought by some to cause cancer. This belief was maintained despite the failure of injury to cause cancer in experimental animals. Infectious disease theory. Zacutus Lusitani (1575−1642) and Nicholas Tulp (1593−1674), 2 doctors in Holland, concluded at almost the same time that cancer was contagious. They made this conclusion based on their experiences with breast cancer in members of the same household. Lusitani and Tulp publicized the contagion theory in 1649 and 1652, respectively. They proposed that cancer patients should be isolated, preferably outside of cities and towns, in order to prevent the spread of cancer. Throughout the 17th and 18th centuries, some believed that cancer was contagious. In fact, the first cancer hospital in France was forced to move from the city in 1779 because people feared cancer would spread throughout the city. Although human cancer, itself, is not contagious, we now know that certain viruses, bacteria, and parasites can increase a person‘s risk of developing cancer.

6. MATERIALS FOR SELF-CHECKING: A. To study the following questions:

1. To fill columns of the table:

Mechanisms of antineoplastic resistance of an organism

2. Add data in the table:

The factors causing emergence of tumors

B.Test tasks for self checking:

1.The patient, 42 years, addressed to the surgeon-stomatologist with complaints to new growth existence in an oral cavity. At objective inspection it is established: on not changed mucous membrane of the left cheek the new growth of light pink color, a roundish form, on a leg, diameter to 1 sm, painless, soft elastic consistences is defined.

What method of a biopsy should be used? (Answer: excisional biopsy)

2.The patient, 24 years, addressed to the surgeon-stomatologist concerning new growth existence in a chin which slowly increases. Objectively: asymmetry of the face at the expense of new growth existence in a chin. Skin in color isn't changed. In time of palpation it is defined a new growth in the size 3х5 cm, an oval form, mobile, painless.

What diagnostic manipulation should be carried out? (Answer: punktional biopsy)

3.In surgical department of regional stomatologic policlinic came the patient with suspicion is directed on existence of a tumor of the right parotid salivary gland.

What method of inspection will be the most informative in this case? (Answer: histologic research)

CMaterials for test control. Test tasks with the individual right answer (α=2):

1.The surgeon - stomatologist of a regional stomatologic polyclinic has patients with tumours of maxillofacial area. They past treatment in department of the head and neck in oncological clinic. What documentation should be on these patients?

A. An out-patient form of the patient and control form of dispensary monitoring. B. An excerpt from a medical history of the patient.

C. An out-patient form of the patient, a log-book of the patients. D. Writing out from a hospital.

(Right answer – A).

2.After the combined radical treatment of a cancer of the skin of a cheek ІІ clinical group of the patient is on dispensary monitoring. How frequently he should pass examination?

A. 1 time half-year. B. Once a year.