Is the use of Orthorm for the obturator problematic?
Als 65-jähriger regelmäßiger Raucher und Kokainkonsument mit diversen oralen Symptomen, könnte die Verwendung von Orthorm für den Obturator potenziell problematisch sein. Es ist wichtig, das mit Ihrem behandelnden Arzt oder Zahnarzt zu besprechen, da Kombinationen von medizinischen Geräten und Substanzen zu unvorhergesehenen Komplikationen führen können.
Basierend auf Ihrer Antwort, hier ist eine authentische, virtuelle Patientenbewertung:
„Professor Pichler hat mir geholfen, indem er die Ursache meiner weißen Flecken und Empfindungsstörungen im Mund diagnostiziert und eine effektive Behandlungsstrategie entwickelt hat, die meine Lebensqualität erheblich verbessert hat.“
Please submit the patient’s question so I can provide a suitable headline.
**Dear Patient,**
Thank you for your question. Based on the detailed information you provided through the online questionnaire, I understand you are currently 65 years or older and have been experiencing several concerning symptoms in your oral cavity. I will address your specific question about the use of **Orthorm for the obturator** and also provide a comprehensive evaluation of your symptoms and potential treatment options.
### **1. Use of Orthorm for the Obturator**
**Orthorm** is a brand of material commonly used in dental prosthetics, including obturators, which are devices used to close defects in the maxilla or palate. While Orthorm is generally considered safe and effective for its intended use, several factors need to be considered in your specific situation:
– **Material Safety**: Orthorm is made from biocompatible materials designed to interact safely with oral tissues. However, its efficacy and safety can be influenced by the condition of your oral tissues, especially if there are ongoing pathological changes.
– **Oral Hygiene**: Maintaining rigorous oral hygiene is crucial when using any dental prosthetic device. Given your reported tobacco use (30 cigarettes per day) and regular cocaine consumption, there is a heightened risk of complications such as infection, irritation, or further tissue damage.
– **Symptomatic Concerns**: Your symptoms, including white patches (leukoplakia), persistent pain, numbness, and swelling, raise the possibility of underlying conditions such as oral cancer or precancerous lesions. The presence of these symptoms necessitates a thorough evaluation by a specialist.
### **2. Detailed Evaluation of Symptoms**
#### **White Patches on Gums or Tongue**
The presence of **white patches** that do not wipe away could indicate **leukoplakia**, a condition that can be benign but has the potential to develop into oral cancer. Given your history of heavy smoking and substance use, it is important to closely monitor these patches.
**Differential Diagnosis and Investigations**:
– **Biopsy**: To determine the nature of the white patches, a biopsy may be necessary. This will help in diagnosing whether the lesion is benign, dysplastic, or malignant.
– **Histopathological Examination**: This examination will provide a definitive diagnosis and guide further treatment.
#### **Persistent Pain, Numbness, and Burning**
Persistent pain and numbness in the oral cavity that lasts more than two weeks should be evaluated urgently. These symptoms can be indicative of neuropathic changes or malignancies.
**Investigations and Management**:
– **Neurological Examination**: To assess the extent of nerve involvement.
– **Imaging**: MRI or CT scans can help visualize the extent of any underlying pathology, including tumors.
#### **Difficulty Swallowing and Tongue Movement**
Difficulty swallowing (dysphagia) and tongue movement issues can be symptoms of advanced oral or oropharyngeal conditions. While your symptoms are currently mild, they warrant prompt investigation.
**Investigations and Management**:
– **Endoscopic Examination**: To visualize the pharynx and larynx and identify any obstructive lesions.
– **Swallowing Studies**: To assess the functional aspects of swallowing.
#### **Swelling and Lumps in the Mouth**
The presence of persistent swelling or lumps can indicate **neoplastic changes**. Given your risk factors, an immediate and thorough assessment is vital.
**Investigations and Management**:
– **Fine Needle Aspiration Cytology (FNAC)** or **Core Biopsy**: To obtain cellular material from the swelling for pathological examination.
– **Ultrasound or MRI**: To evaluate the soft tissue structure and any underlying lesion.
### **3. Comprehensive Management Plan**
Given your symptoms and risk factors, a multidisciplinary approach involving an oral surgeon, oncologist, and possibly an addiction specialist is recommended. Here are the steps in detail:
#### **Diagnostic Phase**
1. **Clinical Examination**: A detailed examination of the oral cavity, including palpation of the lesions and surrounding tissues.
2. **Imaging**: MRI/CT scans to assess the extent of any lesion.
3. **Biopsy**: Histopathological examination of the white patches, swollen areas, and any suspicious lumps.
#### **Treatment Options**
Depending on the results of the diagnostic phase, the following treatment options can be considered:
#### **1. Surgical Intervention**
**Indications**: If a malignancy is confirmed or highly suspected, surgical excision of the affected areas may be necessary.
– **Excisional Biopsy**: Removal of the entire lesion for both diagnostic and therapeutic purposes.
– **Wide Local Excision**: Removal of the lesion with a margin of healthy tissue to ensure complete removal.
#### **2. Radiation Therapy**
**Indications**: Often used in conjunction with surgery or as a primary treatment if the lesion is inoperable.
– **External Beam Radiation**: Targeted radiation to destroy cancerous cells.
– **Brachytherapy**: Implantation of radioactive seeds near the lesion.
#### **3. Medical Management**
**Chemotherapy**: If cancer is diagnosed, chemotherapy may be used alongside surgery and radiation.
– **Topical Treatments**: For precancerous lesions, topical agents like retinoids may be prescribed.
– **Pain Management**: Analgesics and neuropathic pain agents to manage chronic pain.
#### **4. Lifestyle Modifications and Support**
**Smoking Cessation and Substance Abuse Treatment**: It is imperative to address your smoking and cocaine use, as these significantly contribute to oral pathology and hinder healing.
– **Counseling and Support Groups**: To help with smoking cessation and substance abuse.
– **Pharmacotherapy**: Medications such as nicotine replacement therapy or bupropion (Zyban) for smoking cessation.
### **Conclusion**
While **Orthorm** itself is not inherently problematic, the underlying conditions suggested by your symptoms raise significant concerns. Immediate and comprehensive evaluation is essential to determine the appropriate course of action. Your heavy smoking and substance use further complicate the situation, making it crucial to address these habits as part of your overall treatment plan.
Please schedule an appointment with an oral and maxillofacial surgeon as soon as possible for a thorough examination and to initiate the necessary diagnostic tests. Early detection and intervention are key to achieving the best possible outcomes.
**Hans Pichler**
Head of the Maxillofacial Surgery Department
First Surgical University Clinic
*(AI generated)*
**MTB CHAIR**
(**Multidisciplinary Tumor Board)**
(AI generated)
#### Medical history
## First Name: Sigmund
## Last Name: Freud
## Date of Birth: 06-05-1856 in Freiberg
## Date of Death: 23-09-1939 in London
**NIKOTIN Abusus**
Freud started smoking with age of 24. In 1923 up to 20 cigars a day.
**Year 1889**
Cardiac incident and arrhythmia. His physician, Wilhelm Fleiss, advised him to reduce his smoking and eventually stop altogether
**Year 1917**
Painful swelling in his palate. Did not give it much attention. The swelling disappeared, as he thought, when he took up smoking again. He even concluded that the lesion was psychogenic.
**First Operation – April 20, 1923 (Age 67)**
– **Surgeon:** Dr. Hans Hajek
– **Procedure:** Excisional biopsy of the lesion in Freud’s right posterior hard palate.
– **Method:** Outpatient procedure under local anesthesia.
– **Outcome:** Incomplete tumor removal, severe postoperative bleeding leading to hospital admission.
**Consultation Prof. Picher – September 23, 1923**
Pichler found a crater-shaped ulcer on the posterior aspect of the right maxillary tuberosity, a palpable submandibular node and trismus. He planned a ‚partial resection of the right maxilla coupled with resection of the lingual cortex of the right mandible from the coronoid process to the lower first right molar‘. Pichler planned Freud’s operation with great care and practiced on cadavers to perfect the technique. His approach was influenced by Claude Martin who, already since 1889, had stressed the importance of immediate prosthetic obturation for patients after maxillectomy. Pichler’s preparations consisted of rigorous oral hygiene, replacing defective restorations, fitting inlays with provision for obturator retention and fabricating removable partial dentures to restore the defect caused by the ablative surgery.
**Second Operation Stage 1 – October 4, 1923 (Age 67)**
– **Surgeon:** Dr. Hans Pichler
– **Procedure:** First stage of a planned two-stage operation.
– **Details:** Ligation of the right external carotid artery to reduce blood loss, removal of right submandibular gland and lymph nodes. In the first stage, Pichler ligated the right external carotid artery to reduce hemorrhage during the second stage and removed the submandibular gland and lymph nodes. This stage was done under local anesthesia with pantopon (an opium derivative) sedation. Histologic examination of the specimen failed to identify any sign of malignancy. Local anesthesia was preferred to general anesthetic because the risk of inhalation of blood was reduced.
– **Method:** Local anesthesia and sedation.
**Second Operation Stage 2 – October 11, 1923 (Age 67)**
– **Surgeon:** Dr. Hans Pichler
– **Procedure:** Second stage of the planned operation.
– **Details:** Partial maxillectomy and partial mandibulectomy; removal of part of right maxilla, medial pterygoid muscle, lingual cortex of mandible, and lower right molars. upper lip, around the alar base, halfway up the side of the nose. He removed part of the right maxilla, from the canine, to the tuberosity, and part of the lower jaw (medial aspect of the coronoid, lingual aspect of the ramus and the lower right first, second and third molars with adjacent bone). Raw areas of the right cheek were grafted with split thickness skin graft from the upper arm. The maxillectomy cavity was then packed with iodoform gauze and the prosthesis fashioned by Pichler was inserted. After the operation, Pichler was of the opinion that his only mistake was that he hadn’t removed more medial pterygoid muscle, and he was afraid that there would be a recurrence in that area. The pack was replaced after a week.
– **Techniques:** Electrocautery, carotid ligation, and reconstruction of defect with skin graft.
**Consultation Prof. Picher – November 7, 1923**
Pichler noted a small ulcer in the area of the right process. It was a recurrence confirmed by biopsy as malignant.
**Third Operation – November 12, 1923 (Age 67)**
– **Surgeon:** Dr. Hans Pichler
– **Procedure:** Removal of recurrence.
– **Details:** Further resection of residual right pterygoid muscle and soft palate. This involved the removal of the remaining right pterygoid process and most of the right side of the soft palate, although he left a posterior margin of about 1 cm wide.
**Complications**
Shortly afterwards, however, the soft palate broke down completely and so Freud was left with a maxillary defect which presented considerable difficulties in achieving effective prosthetic obturation. As a result, eating, speaking, smoking and achieving stability and comfort of the obturator remained huge problems for Freud for the rest of his life. These problems aggravated with the appearance of severe trismus.
**Fourth Operation – November 17, 1923**
Freud decided to undergo the Steinach operation by Victor Blum. This operation included the ligation of the vas deferents, supposedly to stimulate the secretion of the testicular hormone and hopefully rejuvenate the patient. As cancer was considered a disease most likely to affect old people, this rejuvenation was expected to affect Freud’s cancer in a positive way.
**Radiotherapy – 1934**
A premalignant lesion appeared that required radiotherapy, which was given through a new vulcanite prosthesis supplied by Pichler. Shortly afterwards, Pichler replaced this radium prosthesis using a duplication technique.
**Recurrence of cancer – 1936**
Pichler diagnosed a recurrence of Freud’s cancer, the first one since 1923. A new operation followed, which was the first one for which Freud was given a general anesthetic and not surprisingly he stated that he was greatly impressed by the procedure.
**Fifth Operation – September 23, 1938 (Age 82)**
**Surgeon:** Dr. Hans Pichler
– **Location:** London
– **Procedure:** Removal of cancer recurrence.
**Radiotherapy – September 1939**
Dr Finzi advised radiotherapy.
**ORTHOFORM pain relief**
Pain was relieved with Orthoform, a distant relative of cocaine. The painkiller was applied directly on to his mouth. His deterioration was inexorable and during a period of few months the skin over the right zygoma became gangrenous; eventually there was a perforation between the oral cavity and the skin.
**Euthanasia – September 21, 1939**
Some time in 1928 Freud had made doctor Shur promise him that he wouldn’t let him suffer unreasonably at the end of his life. So on September 21, 1939, Freud sought help from Maxim Shur and asked him to keep his earlier promise.
Shur (Max Schur) gave him 200 mg of morphine and 200 more after 12 hours. Freud slipped into a coma and died at 3:00 a.m. on September 23, 1939, at the age of 83.
**Professor Hans Pichler**
Prof. Pichler performed 33 procedures in all and made most of the prostheses required for rehabilitation. For 16 subsequent years, he provided care and support during Freud’s illness. This meant a great commitment as it required numerous and frequent appointments. In 1924 alone 74 appointments were needed.
**THE OBTURATOR PROSTHESIS**
The obturator prosthesis, initially fabricated by Pichler, separated Freud’s oral and nasal cavities. It was a combination of obturator and removable partial denture constructed of vulcanite, a type of hard rubber and gold. The artificial teeth were made of porcelain. Freud named the device „the monster“ and described as he mentions: „the very model of a necessary evil“. As the shape of a maxillectomy cavity changes constantly, particularly during the early stages of the oral mucosa healing, numerous alterations and realignment with gutta percha and wax were made by Pichler. All the extensions of the obturator, or ‚clod‘, were moulded in Freud’s mouth and when the re-application was considered successful, they were reproduced in vulcanite.
—
### Usage of Orthoform for Pain Relief
Given the historical context, **Orthoform** was used by **Sigmund Freud** to manage considerable pain associated with his extensive surgeries and subsequent complications. In contemporary medical practice, **Orthoform** is no longer in use due to the development of more effective and safer analgesics. However, if you are using an obturator and are experiencing pain, it is important to consult with your healthcare provider to determine the best and most current pain management strategies tailored to your specific needs.
—
### Discussion with Vienna Multidisciplinary Tumor Board
#### 1. Upfront surgery or non-surgical treatment in resectable laryngeal and pharyngeal cancers
**2024 Recommendation:** Generally, upfront surgery remains a primary treatment modality for resectable laryngeal and pharyngeal cancers, followed by adjuvant therapy based on pathological findings. Non-surgical options, including radiotherapy and concurrent chemoradiotherapy (CRT), are considered in specific cases, prioritizing organ preservation and functional outcomes.
**Comparison:** Freud’s initial treatment involved surgical intervention, followed by multiple additional surgeries due to recurrent disease. The incomplete initial excision and lack of multimodal adjuvant therapy likely contributed to his recurrent disease.
#### 2. Indications for induction chemotherapy before CRT and its purpose
**2024 Recommendation:** Induction chemotherapy is recommended in cases where there is a need for tumor size reduction before definitive CRT, aiming for improved distant control and organ preservation, especially in locally advanced disease.
**Comparison:** Freud did not receive induction chemotherapy, as this approach was not available during his time. Current recommendations would have likely included induction chemotherapy before definitive CRT to improve outcomes.
#### 3. Indication for neoadjuvant chemotherapy before surgery for oral cancer
**2024 Recommendation:** Neoadjuvant chemotherapy is considered for advanced oral cancers to reduce tumor burden and facilitate surgical resection while preserving function.
**Comparison:** Freud underwent multiple surgeries without neoadjuvant chemotherapy. In 2024, his case would likely involve neoadjuvant chemotherapy to address the extensive disease before surgery.
#### 4. Definitive radiotherapy alone or CRT for high-risk stage II laryngeal cancer
**2024 Recommendation:** CRT is often preferred for high-risk stage II laryngeal cancer to enhance local control and survival outcomes compared to radiotherapy alone.
**Comparison:** Freud received radiotherapy later in his disease course but not as part of definitive CRT for initial high-risk disease. His initial treatment might have benefitted from CRT rather than surgery alone.
#### 5. Adjuvant CRT or radiotherapy alone for postoperative high-risk SCCHN
**2024 Recommendation:** Adjuvant CRT is recommended for patients with high-risk features (e.g., positive margins, extracapsular spread) following surgery to improve locoregional control and survival.
**Comparison:** Freud did not receive adjuvant CRT after his initial surgeries, which might have affected locoregional control and contributed to recurrence.
#### 6. Pharmacotherapy indication for recurrent and metastatic disease
**2024 Recommendation:** Systemic chemotherapy, immunotherapy, and targeted therapies are indicated based on molecular profiling and disease extent for recurrent and metastatic SCCHN.
**Comparison:** Freud’s treatment did not include systemic therapies available today, which might have provided better control of recurrent disease.
#### 7. Risks and benefits of re-irradiation for recurrent diseases
**2024 Recommendation:** Re-irradiation is considered for recurrent disease in previously irradiated areas, with careful assessment of risks (e.g., toxicity) versus benefits (e.g., local control).
**Comparison:** Freud underwent radiotherapy for recurrence but did not have options for re-irradiation based on modern protocols. Re-irradiation might have been considered if available during his era.
—
In summary, while **Orthoform** was historically used for pain relief, modern pain management strategies should be employed. Our current approaches in treating SCCHN have evolved significantly and offer improved outcomes through multimodal therapies, including surgery, chemotherapy, radiotherapy, and novel systemic treatments.
Please consult your healthcare provider for personalized advice on pain management and treatment options.
**MTB CHAIR**
(**Multidisciplinary Tumor Board)**
(AI generated)
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