Open Access
Table II
“Check-list” request form for submitting jaw lesions on histological examination.
| Clinical data | Radiological data |
|---|---|
| Identity of the patient/medical records | Radiodensity |
| • Patient's name:.......... | • Radiolucent lesion |
| • Radiolucent lesion | |
| • Patient's age ………………… | • Mixed density |
| • Patient's gender: ……………….. | |
| • Patient's ethnicity:…………………. | Radiological locularity |
| • Unilocular | |
| • Pertinent medical history/medical records:………………. | • Multilocular |
| ‘Moth-eaten’ appearance | |
| Dimensions of the lesion | |
| Historic data concerning the lesion | |
| • Duration of the lesion.………………… | • Size ………………… |
| • Well defined margins (with or without corticated border) | |
| • Previous recurrence:………………… | • Ill-defined margins |
| • Familial history of jaw lesion? ……………… | Site of the lesion |
| • Intra-osseous, specify: | |
| Maxillar ? Mandibular ? | |
| Symptomatology | |
| • Swelling: Yes/No …… | Quadrant concerned :…… |
| • Nervous manifestations, pain, paresthesia: Yes/No …………… | |
| Tooth number concerned :……… | |
| • Adenopathy ? ……………… | • Extra-osseous, specify. ……………… |
| • Vitality of concerned teeth …………… | |
| • Impacted tooth concerned ?…………… | Anatomical relationships |
| • Inflamed tooth concerned ?:…………… | • Cortical perforation or defect |
| • Resorption of concerned teeth:…………… | • Involvement of inferior alveolar nerve |
| • Displacement of concerned teeth …………… | • Involvement of sinus floor |
| • Involvement of nasal floor | |
| Specimen submitted | • Other anatomical involvement, specify. |
| • Curettage/enucleation | |
| • Incisional biopsy | ……………… |
| • Excisional biopsy | |
| • Surgical resection. | |
| • Needle biopsy/fine-needle biopsy | Schema of the lesion: |
| • Other, specify …………… | |
| CLINICAL DIAGNOSES | |
| 1 …………… | |
| 2 …………… | |
| 3 …………… | |
| 4 …………… |
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