Fatal Bleeding in Conjunction with Mandibular Medication-related Osteonecrosis of the Jaw (MRONJ).

Here, we report a case of fatal bleeding in conjunction with mandibular medicationrelated osteonecrosis of the jaw (MRONJ). A 75-year-old Japanese man was referred to our department with osteonecrosis of the jaw due to bisphosphonate (BP) for multiple bone metastases from prostate cancer. Aggressive surgical intervention was ruled out due to a poor prognosis in terms of life expectancy. Death occurred due to hemorrhagic shock resulting from massive oral bleeding caused by necrosis of the mandible. Numerous reports have suggested that jaw necrosis is induced not only by BP, but also RANKL antibody, steroids, and molecularly-targeted agents. This suggests that the number of cases of MRONJ is likely to increase among elderly patients in whom general health is already poor. The American Association of Oral and Maxillofacial Surgery recommends aggressive treatment only in cases of stage 3 disease. Therefore, such a therapeutic strategy may only be available for cases of jaw necrosis in which the general health status of the patient is otherwise good. To prevent a life-threatening outcome in cases of MRONJ, physicians, who are responsible for determining the drug strategy, should cooperate with oral surgeons in determining the best therapeutic strategy.

Postoperative follow-up strategy in patients with oral squamous cell carcinoma.

PURPOSE: The duration of follow-up after treatment of oral squamous cell carcinoma and the frequency of routine visits are based on common usage rather than evidence-based practice. The purpose of this study was to determine the appropriate postoperative routine follow-up program in patients with oral squamous cell carcinoma. PATIENTS AND METHODS: Three hundred four cases treated curatively mainly by surgery at Tokai University Hospital from 1994 to 2004 were analyzed. A secondary event was defined as a local recurrence, a regional recurrence, a distant metastasis, or a second primary cancer. To evaluate the follow-up program, data on the first tumor recurrence or first second primary tumor in the head and neck region or elsewhere in the body were used. Overall survival rate, disease-specific survival rate, relapse-free rate, and cumulative risk of developing a second primary cancer were estimated by the Kaplan-Meier product limit method. RESULT: All relapse cases were detected within 3 years postoperatively, of which 86.3% were detected within 1 year. Most relapses were in the neck, and regional recurrences had a dismal salvage rate. Second primary cancers were constantly detected 1 to 10 years postoperatively. CONCLUSION: Follow-up should be performed more frequently in the first year, with 2 weekly follow-ups with monthly ultrasound examinations, and should be continued after 3 years to exclude the development of second primary cancers.

Ameloblastic carcinoma, secondary type: a case report.

Malignant variants of ameloblastoma include metastasizing ameloblastoma, which microscopically appears benign but has metastasized and ameloblastic carcinoma that exhibits malignant histopathologic features. Ameloblastic carcinoma is classified into 2 types: a primary odontogenic malignancy and a secondary type resulting from malignant transformation of ameloblastoma. Most secondary ameloblastic carcinomas result from malignant transformation of a primary lesion after repeated postsurgical recurrences. Therefore it is rare to find an untreated secondary type presenting with histologic features of malignant transformation from an earlier benign lesion. We experienced a rare case of ameloblastic carcinoma, secondary type which might arise in an untreated ameloblastoma. The mechanism by which a preexisting benign ameloblastoma goes through a malignant transformation is also described.

Analysis of risk factors for surgical-site infections in 276 oral cancer surgeries with microvascular free-flap reconstructions at a single university hospital.

The purpose of this study was to elucidate the risk factors for surgical-site infection (SSI) in oral cancer surgery with microvascular free-flap reconstructions and to propose appropriate SSI prevention. There were 276 patients who underwent oral cancer surgery with microvascular free-flap reconstructions at the Department of Oral and Maxillo-facial Surgery of Tokai University Hospital. The following variables were assessed as risk factors for SSIs: preoperative variables, including age, sex, body mass index, American Society of Anesthesiologist's (ASA) score, debilitating comorbidities, smoking, alcohol consumption, and Union Internationale Contre le Cancer Tumor Node Metastasis (UICC-TNM) classification; and operative variables, including duration of surgery, amount of blood loss, quantity of blood transfusion, tracheostomy, area of neck dissection, and previous chemotherapy. Statistical analysis was conducted to determine whether these factors constitute risks for SSI. Total overall SSI rate was 40.6% (112/276). When the occurrence of SSI was compared with the variables, ASA score (P=0.036), T stage (P=0.013), duration of surgery (P<0.001), blood loss (P=0.001), blood transfusion (P=0.01), and area of neck dissection (P=0.009) showed statistical significance. Analysis of these variables with a logistic regression model yielded ASA score and duration of surgery as significant factors. There was a tendency for blood loss and duration of surgery to increase in patients with a high T stage. A high T stage not only broadens the resection area and increases surgical invasiveness, it also increases susceptibility to dead space after microvascular reconstruction for oral cancer. Particular care in treating the wound should be taken in surgical patients with high T-stage scores. The occurrence of SSI is of particular concern in oral cancer surgery in patients with high ASA scores.

A case of brain abscess extended from deep fascial space infection.

A case of brain abscess in the temporal lobe caused by direct intracranial extension of deep neck abscess is described. The abscess also spread to the orbital cavity through infraorbital fissure. The possible etiology of this case might be dental surgery. The diagnostic imaging clearly showed the routes of intracranial and -orbital extension of parapharyngeal and masticator space abscesses. From the abscess specimens, oral streptococci, anaerobic streptococci, and anaerobic gram-negative bacilli were isolated. Antimicrobial susceptibility testing of isolates showed that some Prevotella and Fusobacterium strains had decreased susceptibility to penicillin, and these bacteria produced beta-lactamase. The bacteria from the deep neck abscess were consistent with those detected from the brain abscess. Proper diagnosis, aggressive surgical intervention, and antibiotics chemotherapy saved the patient from this life-threatening condition.