坐姿時(shí)口腔黏膜檢查順序

1、口腔癌篩檢(口腔黏膜健康檢查、口腔黏膜病變篩檢)—基本觀念與現(xiàn)場(chǎng)實(shí)技—,韓良俊行政院衛(wèi)生署癌癥防治政策委員會(huì)委員臺(tái)灣檳榔防制暨口腔癌防治聯(lián)盟主席行政院衛(wèi)生署口腔醫(yī)學(xué)委員會(huì)主任委員,疾病預(yù)防之分類,初段預(yù)防二段預(yù)防三段預(yù)防,1.初段預(yù)防,重點(diǎn)放在從社區(qū)去除致病危險(xiǎn)因子目的在減少社區(qū)中的疾病個(gè)案(即降低發(fā)生率)如所花成本合理，則在公共衛(wèi)生及個(gè)別方面，皆屬最佳策略預(yù)防口腔癌主要在防制檳榔、菸、酒,2.二段預(yù)防,在早期階段

2、發(fā)現(xiàn)所要注意(已經(jīng)存在)之疾病可供介入以治癒或降低該病傷害，最後可減少死亡率（找出口腔癌前病變尚可降低口腔癌發(fā)生率）篩檢屬此，其利、弊皆須仔細(xì)評(píng)估、處理,3.三段預(yù)防,介入是為降低疾病在治療後之復(fù)發(fā)或?yàn)闇p輕治療後引起之病痛(morbidity),10大癌癥防治策略（衛(wèi)生署國(guó)民健康局）,―98年癌癥防治工作重點(diǎn),口腔癌篩檢的合理性,篩檢要找的相關(guān)病變?cè)诳谇话┑淖匀皇分?，是無(wú)癥狀且又是侷限的(故值得努力去早期發(fā)現(xiàn))開(kāi)始時(shí)常為PMD

3、(potentially malignant disorders)，如白斑（含紅白斑）、紅斑、黏膜下纖維化、疣狀增生等這些病變可經(jīng)由簡(jiǎn)單、一定步驟的口腔黏膜檢查法找出找出後經(jīng)由習(xí)慣介入、飲食介入以及必要時(shí)的外科性處置，可使其消退或清除。,篩檢之分類,ㄧ般民眾型篩檢(population screening)標(biāo)靶型篩檢(targeting screening)隨機(jī)型篩檢(opportunistic screening),1.ㄧ般民

4、眾型篩檢(population screening),不宜以此作口腔癌篩檢(cost-effectiveness不明)在南亞，可疑病變(suspicious lesions)之發(fā)現(xiàn)率雖達(dá)2-16%，但接受轉(zhuǎn)介、追蹤率偏低,2.標(biāo)靶型篩檢(targeting screening),以高危險(xiǎn)族群為標(biāo)的，如（30歲以上之）檳榔、菸使用者及酗酒者有人不出來(lái)接受篩檢—困難點(diǎn)配合其他健康問(wèn)題篩檢則參加率較佳（整合型篩檢）,3.隨機(jī)型篩檢

5、(opportunistic screening),在診所或醫(yī)院看診時(shí)，對(duì)未懷疑之病變做篩檢合理且符合成本效益值得在每一牙科診所或其他科診所進(jìn)行(對(duì)口腔軟組織；亦可做標(biāo)靶型及隨機(jī)型之混合運(yùn)用)僅需多花很短時(shí)間(約3-4分鐘)可達(dá)到早期發(fā)現(xiàn)並達(dá)成“downstaging”效果,Lim, Moles, et al:Opportunistic Screening for Oral Cancer andPrecancer in Ge

6、neral Dental Practice,Opportunistic screening in a general dental practice setting may be a realistic alternative to population screening.General dental practice is ideal for the evaluation of such systems prior to exte

7、nding these studies to other healthcare setting.,Br Dent J 2003;194:497-502.,,篩檢基本原則,要篩檢的對(duì)象(情況)係屬重要的健康問(wèn)題，其自然歷程是已知的已有可行的、實(shí)證的介入方法有適當(dāng)、可行的診斷方法(或test)該篩檢所需的經(jīng)費(fèi)，與其他保健費(fèi)用可達(dá)成平衡，或費(fèi)用合理,口腔癌篩檢潛在的好處,減低死亡率減少侵犯性(已成形)癌瘤之發(fā)生改善個(gè)別患者之預(yù)後接

8、受早期治療者，其病痛可減少篩選高危險(xiǎn)群並獲得介入機(jī)會(huì)對(duì)陰性個(gè)案有安慰作用節(jié)省醫(yī)療資源／社會(huì)成本,口腔癌篩檢可能的缺失,使偽陰性個(gè)案造成錯(cuò)誤的安全感及延誤治療時(shí)機(jī)有些無(wú)進(jìn)展，可予觀察即可之癌前病變，反而可能造成不必要之治療對(duì)偽陽(yáng)性個(gè)案造成心理傷害對(duì)某些陰性個(gè)案反而加強(qiáng)其不良生活習(xí)慣須考慮所需費(fèi)用找出末期已無(wú)法治癒個(gè)案，對(duì)部分病人可能反增其受苦程度,手術(shù)的基本要件(Basic necessities，可應(yīng)用於口腔癌篩檢現(xiàn)場(chǎng)

9、),適當(dāng)?shù)目梢曅?adequate visibility)有3要素:(1)適當(dāng)?shù)目山?adequate access) —如自然開(kāi)口、開(kāi)口度夠大、排開(kāi)身體組織(2　mirror technique)(2)適當(dāng)?shù)恼彰?adequate light)—隨時(shí)調(diào)整光源，以免光線被遮??；亦可使用頭燈 (3)術(shù)野無(wú)多餘的血液或其他液體—可用棉花棒代替抽吸器助手:需受過(guò)適當(dāng)訓(xùn)練，可操作燈光，並協(xié)助記錄檢查單及問(wèn)卷,檢查者/受檢者姿勢(shì),

10、傳統(tǒng)「相親式 (坐姿) 」篩檢新的「水平(躺臥)式」篩檢(2005年起在臺(tái)西全面採(cǎi)用),NOTE : This is a bad example !,NOTE : This is a bad example !,,NOTE : This is a bad example !,,NOTE : This is a bad example !,A PRACTICAL TECHNIQUE OF SCREENING FOR ORAL C

11、ANCER（SUMMARY）,reported at 41st APACPH(Asia Pacific Academic Consortium for Public Health) Conference, 5th Dec. 2009L.J. Hahn, DDS, DDSc, FICDOral and Maxillofacial Surgeon,National Taiwan University Hospital,Curren

12、t and conventional method of screening for oral cancer in Taiwan,The examiner and the examinee sit face to face on 2 chairs.The examiner use only 1-2 disposable tongue depressors without using mouth mirrors, to perform

13、the so-called “oral cancer screening”.,26,Disadvantages of such conventional methods,Against human engineeringNo mouth mirror → no complete screening (there are dead corners on examination)Prone to result in FALSE NEGA

14、TIVE finding.,27,Correct and practical method of screening for oral cancer,The examinee takes supine positionThe examiner sits at 7-11 o’clock position of the head of an examineeUse 2 mouth mirrors( 2-mirror technique

15、)Examine 50 sites of the full mouth mucosa, in definite order without missing any site.,28,4 Functions of the mouth mirror,As a mirrorTo reflex light to the site where close examination is needed.As a retractorFor p

16、rimary “palpation”So, using mouth mirrors is mandatory to perform correct screening for oral cancer.,“Palpation” with a mouth mirror,Whilst digital palpation of the mucosa would be ideal, for practical reasons MOUTH MIR

17、RORS may be used to gain an idea of the texture of the tissues.Digital palpation using any necessary precautions, may then be reserved for the examination of particular lesions. ─ WHO : Guide to epidemiology and di

18、agnosis of oral mucosal diseases and conditions, 1980As suggested in the WHO guide, 2 mouth mirrors are recommended with digital palpation for particular lesions ─Zain et al : Clinical criteria for diag

19、nosis of oral mucosal lesions, 2002,Advantages of 2-mirror technique of screening for oral cancer by supine position,Good accessibility to the oral cavityFit human engineering － for adequate inspect

20、ion and palpationUsing 2 mouth mirrors－much better than just using tongue depressors onlyNatural posture, less fatigabilityCan detect more precancers and early cancers(may achieve “downstaging”)■ ■ Less possibility

21、of causing FALSE NEGATIVE result.,A simplified method of screening for oral cancer (Hahn’s method),Can be used if the dental, or flexible and portable chair for oral cancer screening is unavailable(Please watch DVD demo

22、nstration, if available),躺臥式口腔癌篩檢的好處,檢查者在被檢查者頭部8-9(7-11)點(diǎn)位置，有利於篩檢時(shí)之視診及觸診之操作。檢查者在此法所採(cǎi)姿勢(shì)，比坐式較符合人體工學(xué)操作的原理。視野較佳，加上使用口鏡，可減少小部位、小角落成為死角檢查不到的缺點(diǎn)（請(qǐng)勿只使用壓舌板）。被檢查者較舒適、輕鬆，頭部固定、不易亂動(dòng)。時(shí)間較久之篩檢亦較不感疲勞，效率較佳。可避免造成偽陰性之結(jié)果。,口腔癌篩檢需準(zhǔn)備器械、物品,折

23、疊式牙科檢查椅，附無(wú)影燈(或頭燈)口鏡(2 mirror technique—每一受檢者使用2枝口鏡)口罩棉花棒(或棉籤)可棄式手套(最好為單包裝者)牙科鑷子(非每一受檢者皆需要)面紙、小紗布篩檢紀(jì)錄單(special sheet)問(wèn)卷,Two Mouth Mirrors在篩檢時(shí)的功能－2 Mirror Technique,鏡子功能：照出視線無(wú)法直接看到的地方，如小部位、小角落或牙齒後方視線死角處（舌側(cè)、腭側(cè)）黏膜。

24、反射功能：可藉反射送更多光線到需細(xì)看的部位。當(dāng)做肌鈎（retractor）:推開(kāi)或拉開(kāi)舌、唇、頰等。用來(lái)觸診：可做經(jīng)常性或初步的觸診，必要時(shí)對(duì)特殊病變(particular lesions)才換用手指觸診即可（WHO Guide to epidemiology and diagnosis of oral mucosal diseases and conditions/Clinical Criteria for Diagnosis

25、of Oral Mucosal Lesions－An aid for dental and medical practitioners in the Asia-Pacific Region）,口腔黏膜檢查紀(jì)錄表/單,檢查日期受檢者基本資料各項(xiàng)危險(xiǎn)因子檢查結(jié)果圖示以項(xiàng)目勾選為原則 轉(zhuǎn)介醫(yī)院檢查者,,,§口腔黏膜細(xì)部區(qū)分 (1) 1.Vermilion border ― upper (1), lower (2

26、) 口唇(唇紅部)－上、下 2.Labial commissures ― right (3), left (4) 唇聯(lián)合－右、左 3.Labial mucosa ― upper (5), lower (6) 唇黏膜－上、下,4. Cheek (buccal muccsa) ― right (7), left (8) 頰黏膜－右、左 5. Labial sulci ― upper (9), low

27、er (10) 唇溝－上、下 6. Buccal sulcus ― right upper (11) lower (12) 頰溝－右上、右下 7. Buccal sulcus ― left upper (13) lower(14) 頰溝－左上、左下,TOPOGRAPHICAL CLASSIFICATION OF ORAL MUCOSA,(HAHN,L.J. modified after WHO monogragh),§

28、;口腔黏膜細(xì)部區(qū)分 (2) 8.Posterior gingiva and alveolar ridge (process) buccally 後牙頰側(cè)牙齦及齒槽堤 Upper gingiva or edentulous alveolar ridge buccally ― right (15), left (16) 上右、上左 Lower gingiva or edentulous alveolar ridge

29、 buccally ― right (17), left (18) 下右、下左 9.Anterior gingiva and alveolar ridge (process) labially: 前牙唇側(cè)牙齦及齒槽堤－上、下Upper (19)Lower (20),TOPOGRAPHICAL CLASSIFICATION OF ORAL MUCOSA,(HAHN,L.J. modified after WHO monogra

30、gh),§口腔黏膜細(xì)部區(qū)分 (3) 10. Posterior gingiva and alveolar ridge (process) palatally and lingually後牙腭側(cè)或舌側(cè)牙齦及齒槽堤－上右、上左、下右、下左Upper ― right (21), left (22)Lower ― right (23), left (24) 11. Anterior gingiva and alveolar

31、 ridge (process) palatally and lingually, palatally (25) and lingually (26)前牙腭側(cè)或舌側(cè)牙齦及齒槽堤－腭側(cè)、舌側(cè) 12. Dorsum (dorsal surface)of the tongue ― right (27), left (28)舌背－右、左,TOPOGRAPHICAL CLASSIFICATION OF ORAL MUCOSA,(HAHN,L

32、.J. modified after WHO monogragh),§口腔黏膜細(xì)部區(qū)分 (4) 13. Base of the tongue ― right (29), left (30)舌根－右、左 14. Tip of the tongue (31)舌尖 15. Margin (lateral border) of the tongue ― right (32), left (33)舌側(cè)緣－右、左 16

33、. Ventral(inferior) surface of the tongue ― right (34), left (35)舌腹面－右、左,TOPOGRAPHICAL CLASSIFICATION OF ORAL MUCOSA,(HAHN,L.J. modified after WHO monogragh),§口腔黏膜細(xì)部區(qū)分 (5) 17. Floor of the mouth Frontal (36)口底－中

34、央Floor of the mouth Lateral ― right (37), left (38)口底－右邊、左邊 18. Hard palate ― right (39), left (40)硬腭－右、左 19. Soft palate ― right (41), left (42)軟腭－右、左,TOPOGRAPHICAL CLASSIFICATION OF ORAL MUCOSA,(HAHN,L.J. modif

35、ied after WHO monogragh),§口腔黏膜細(xì)部區(qū)分 (6) 20. Anterior tonsillar pillar ― right (43), left (44)扁桃前柱－右、左 21. Uvula (45)懸雍垂 22. Retromolar region (trigone) － right (46), left (47)臼齒後(三角)區(qū)－右、左 23. Oropharynx an

36、d tonsils (48)口咽 24. Tonsils-right (49), left (50)扁桃腺－右、左,TOPOGRAPHICAL CLASSIFICATION OF ORAL MUCOSA,(HAHN,L.J. modified after WHO monogragh),A. 口唇(唇黏膜)B. 頰黏膜C. 口腔前庭黏膜D. 臼齒後三角區(qū)E. 硬腭黏膜F. 軟腭黏膜G. 舌H. 牙齦I. 口底黏膜

37、J. 懸壅垂K. 口咽黏膜L. 齒槽黏膜,,全口需檢查部位示意圖:,口腔黏膜健檢口訣：,由外向內(nèi)先觀察顏面、頸部、口腔前庭 外：顏面、頸部；口腔前庭（含臼齒後三角區(qū)及上下顎唇 頰側(cè)牙齦） 內(nèi)：固有口腔由上中而下（「內(nèi)」之固有口腔） 上：上顎舌側(cè)牙齦、硬腭、軟腭、懸壅垂、口咽、扁桃腺 中：舌背面、左右舌側(cè)緣 下：舌腹面、口底、下顎舌側(cè)牙齦及齒槽黏膜,全口部位篩檢操作實(shí)技/步驟,簡(jiǎn)要地進(jìn)行問(wèn)診(有無(wú)不

38、舒服/疼痛部位及ABC使用情形等等)及視診(顏面/頸部之腫塊，必要時(shí)加上觸診，觸診也可包括頰黏膜、舌、口底、腭等部位)引導(dǎo)受檢者躺好，並調(diào)好照明。接著，依如下順序進(jìn)行檢查:右側(cè)頰黏膜，加上、下後牙頰側(cè)牙齦/口腔前庭黏膜及臼齒後三角區(qū)(頭輕微向右)上唇黏膜，加上顎前齒唇側(cè)牙齦/口腔前庭黏膜(頭回正前方)下唇黏膜，加下顎前齒唇側(cè)牙齦/口腔前庭黏膜左側(cè)頰黏膜，加上、下後牙頰側(cè)牙齦/口腔前庭黏膜及臼齒後三角區(qū)(頭輕微向左),全口部位篩

39、檢操作實(shí)技/步驟(續(xù)),7. 上顎齒列腭側(cè)牙齦，加硬腭/軟腭粘膜 (頭回到正前方) 8. 懸壅垂/口咽後壁/扁桃腺(令發(fā)「啊」聲)9. 舌背面(舌伸出、並做上下左右運(yùn)動(dòng))10.舌右側(cè)緣(舌尖舔左嘴角)11.舌左側(cè)緣(舌尖舔右嘴角)12.口底（舌縮入口腔內(nèi)），加下顎齒列舌側(cè)牙齦/齒槽黏膜，及舌腹面(舌尖舔腭部後方)‘09.6.30.修訂,口腔癌篩檢重點(diǎn)(1),口腔癌在臺(tái)灣(尤其是嚼檳榔族群)好發(fā)部位是頰黏膜、舌、後牙齒齦（尤

40、其是下顎）、臼齒後區(qū)、口底等部位，故應(yīng)仔細(xì)檢查此等部位。主要注意黏膜之顏色或表面結(jié)構(gòu)異常、腫塊(tumor mass)或腫脹(swelling)之有無(wú)，必要時(shí)要加以觸診，以注意是否其表面為粗糙、不平滑，或周邊有硬結(jié)(marginal induration，尤其是在舌側(cè)緣之病變)。發(fā)現(xiàn)白斑時(shí)，可先區(qū)分究係均勻性或非均勻性者；而對(duì)均勻性白斑，需再辨別其屬於薄型或厚型者，以決定是否確須轉(zhuǎn)介。,口腔癌篩檢重點(diǎn)(2),如在臨床(醫(yī)院或診所)作

41、隨機(jī)篩檢時(shí)發(fā)現(xiàn)異常，可先探究其是否為口腔癌或/及癌前病變，以及可能原因，並將此原因予以去除後，評(píng)估病變處是否改善或消失。去除原因後經(jīng)過(guò)兩週仍無(wú)改善，則儘快轉(zhuǎn)介適當(dāng)處所；但在診斷未明前，切勿輕易處方類固醇口內(nèi)膏予受檢者長(zhǎng)期使用。篩檢時(shí)，對(duì)篩檢之意義、口腔癌或癌前病變之癥狀、徵兆以及預(yù)防之知識(shí)，可同時(shí)作適當(dāng)之說(shuō)明/宣導(dǎo)。,篩檢後流程表,★個(gè)案層次:?需轉(zhuǎn)介個(gè)案?已轉(zhuǎn)介個(gè)案?疑似陽(yáng)性個(gè)案?陽(yáng)性個(gè)案?陰性個(gè)案資料來(lái)源:韓良俊,白

42、斑惡性轉(zhuǎn)變率,薄白斑—近0%厚白斑—1-7%粒狀或結(jié)節(jié)狀白斑—4-15%紅白斑—28%(18-47%)中度上皮變異—4-11%重度上皮變異—20-35% —臺(tái)大江俊斌教授,口腔癌篩檢的效果研究,篩檢之六個(gè)月後再訪問(wèn)時(shí)—減量或停止 71%之「陽(yáng)性個(gè)案」 57%之「陰性個(gè)案」 —臺(tái)大陳秀熙教授,§ 坐姿時(shí)口腔黏膜

43、檢查順序: (ㄧ) 看上、下唇紅部及翻開(kāi)上唇 (1-2-5-9-19) (二) 翻開(kāi)下唇 (6-10-20) (三) 翻看右頰內(nèi)側(cè) (3-7-11-15-12-17-43-46) (四) 翻看左頰內(nèi)側(cè) (4-8-13-16-14-18-44-47) (五) 請(qǐng)其開(kāi)口，看上顎及腭部 (21-25-22-39-40-41-42-45-48-49-50) (六) 請(qǐng)其伸舌或輕拉舌 (31-27-28-29-

44、30) (七) 請(qǐng)其舌尖舔左嘴角 (32，由前方到後方葉狀乳頭部位) (八) 請(qǐng)其舌尖舔右嘴角 (33，由前方到後方葉狀乳頭部位) (九) 請(qǐng)其舌尖舔腭部後方 (31-34-35-23-26-24-36-37-38),TOPOGRAPHICAL CLASSIFICATION OF ORAL MUCOSA,(HAHN,L.J. modified after WHO monogragh),臺(tái)灣嚼檳榔盛行率較高職場(chǎng),客運(yùn)公司