In selecting antimicrobial agents for oral infections, antimicrobial agents are determined taking into account presumed pathogenic bacteria, inflammation severity, and backgrounds of patients such as underlying disease. When the infections are treated, effectiveness of the treatment is increased by examining pharmacokinetics (PK) and pharmacodynamics (PD) such as in vivo absorption, distribution, metabolism and excretion of the antimicrobial agents, and by giving antimicrobial chemotherapy based on the PK-PD theory. The oral infections are polymicrobial infections with anaerobes and aerobes. The most common species isolated are Prevotella, Peptostreptococcus and Streptococcus. In severe oral infections, beta-lactamase producing bacteria are often involved, and the frequency to detect anaerobes increases with severity of the cases. Beta-lactamase in Prevotella degrades penicillin derivatives and cephem derivatives including the third generation. Anti-inflammatory treatment to decrease the number of pathogenic bacteria in infection foci and appropriate antimicrobial chemotherapy based on the PK-PD theory improve therapeutic efficacy and inhibit emergence of drug resistant bacteria.
We reviewed recent reports related to trigeminal neuralgia. Radiological examination was not required, however, patient interview and physical examination were necessary for diagnosis alone. Considering that many patients were referred by oral-dental surgeons, trigeminal neuralgia is likely to be a disorder commonly encountered by these specialists. They play an important role in the diagnosis of it. The differential diagnosis of trigeminal neuralgia is important in order to initiate appropriate treatment. The patients with trigeminal neuralgia are usually treated with Tegretol at first. When Tegretol Ⓡ therapy is not applicable or proved to be less effective, the patients undergo other therapy, that are surgical therapy, gamma knife radiosurgery, and trigeminal nerve block. In the treatment of the patients with trigeminal neuralgia, the medical cooperation within neurosurgeons, oral-dentist surgeons, neurologists, and pain clinicians should be required.
Reported rates of oral cancer recurrence range from 25 % to 48 %. Improving the treatment outcomes of these cases would lead to a better prognosis of oral cancer. The aim of this study was to evaluate prognostic factors and the outcomes after salvage surgery in patients with squamous cell carcinoma of the tongue. We analyzed 110 patients who underwent primary radical surgery (primary cases) and 77 previously treated patients who underwent salvage surgery (secondary cases) between March 1985 and March 2000. A 5-year survival curve was constructed using the Kaplan-Meier method. Statistical significance was evaluated with the logrank test. A Cox proportional-hazards regression analysis was used to identify prognostic factors. Recurrence rates in primary/secondary cases were 17.3 %/9.1 % for delayed neck metastasis, 10.0 %/15.6 %for local recurrences, 5.5 %/10.4 % for regional recurrences, and 3.6 %/2.6 % for locoregional recurrences.Overall 5-year survival rates were 78.9 % for primary cases and 67.5 % for secondary cases. Survival rates differed significantly between rN − (82.9 %) and rN + (54.8 %) secondary cases treated by salvage surgery. Significant prognostic factors on multivariate analysis were the extracapsular spread of cervical lymph node metastasis in both primary and secondary cases and the pN category in secondary cases. In conclusion, extracapsular spread was a significant predictor of survival. Salvage surgery cases with neck recurrence had poor outcomes.
The mandibular third molars are usually located near the inferior alveolar nerve. Surgical removal of these molars may damage the nerve and cause hypoesthesia of the lower lip. Before surgery, it is important to examine the exact positional relationship between the mandibular third molars and the mandibular canal to prevent such complications. A total of 329 lower third molars from 198 patients were studied on panoramic radiographs and computed tomography (CT). We studied the association of hypoesthesia with the spacial relation between the tooth roots and the mandibular canal. Hypoesthesia occurred in 23 of 329 teeth (7.0 %). Almost all cases of hypoesthesia resolved within 6 months. However, hypoesthesia of 3 teeth (0.9 %) persisted approximately 7 to 12 months after surgery. In 206 of 329 teeth (62.6 %), the assumed location of the mandibular canal differed between panoramic radiography and CT. Furthermore, the prediction rate of the incidence of type 1 hypoesthesia on CT (35.5 %) was higher than that on panoramic radiography (15.9 %). Risk factors related to hypoesthesia included loss of the white line of the root, curve of the mandibular canal, and close proximity of the tooth to the mandibular canal (Type 1) on panoramic radiography. There were also teeth in contact with the canal (0 mm) in all patients in whom hypoesthesia developed. In particular, patients whose mandibular canals were located between the roots of the mandibular third molar or on the lingual side of the mandibular third molar had a high incidence of hypoesthesia (26.0 %). These results suggest that the positional relation between the mandibular third molars and the mandibular canal should be accurately evaluated by CT. Because of its high resolution and ability to examine patients in detail, CT was found to be useful for predicting the risk of inferior alveolar nerve damage before mandibular third molar surgery.
Sudden hemorrhage is a serious complication related to local recurrence of oral cancer and cervical lymph node metastasis. Massive hemorrhage may lead to fatal outcomes. Even when blood loss is small, persistent hemorrhage may reduce the patient's quality of life. In most cases, it is difficult to select a hemostatic procedure after surgery or radiotherapy. On the other hand, recent advances in intravascular treatment have facilitated various minimally invasive therapies. We report a case of subclavian artery hemorrhage caused by invasion of cervical lymph node metastasis in which hemostasis was achieved with a covered stent using Seldinger's method. A 66-year-old woman with mandibular gingival pain was referred to our hospital. After the histopathological diagnosis of squamous cell carcinoma, surgery and radiotherapy were performed. Recurrence in the supraclavicular fossa was detected 7 months after secondary neck dissection. Although sudden hemorrhage from the site was treated by surgical hemostasis under local anesthesia, recurrent hemorrhage occurred repeatedly. Angiography revealed hemorrhage from the subclavian artery. Placement of a covered stent into the artery was intravascularly performed to achieve hemostasis because surgical procedures were of limited value. Angiography after stent placement confirmed the disappearance of irregular contrast medium leakage. This hemostatic procedure with a covered stent was considered useful for the management of hemorrhage from deep vessels.
The patient was a 63-year-old woman with a history of diabetes. At initial diagnosis, blood tests suggested the presence of severe infection because the while cell count was 20800/μland the C-reactive protein level was 35.6 mg/dl, but computed tomographic (CT) imaging showed no gas in the submandibular space. She received anti-inflammatory treatment after hospitalization, but the symptoms did not improve. We therefore repeated CT imaging and discovered gas in the tissue space around the submental region. Based on the diagnosis of cervical necrotizing fasciitis, we performed emergency surgery, curettage of the lesion, and open surgery. The preoperative plain chest X-ray films the showed no abnormal findings. On the following day after surgery, SpO2 fell to the range of 80 %. A plain chest X-ray film showed shadows over the entire right lung field. The left lung showed signs of pneumonia with diffuse shadows. Chest CT images revealed shadows and accumulations of pleural effusion in both lung fields. The patient was given a diagnosis of a lung injury due to acute respiratory distress syndrome (ARDS) complicated by a severe infection. She received an intravenous drip infusion of sivelestat sodium (product name: Elaspol Ⓡ ) at a dose of 200 mg/day for 7 days. Pneumonia started to improve on the day afterstarting treatment. Our findings suggest that patients with severe infection should receive systemic management, bearing in mind potential complications of ARDS.
We report a case of pathological mandible fracture associated with a bisphosphonate preparation that was treated by low-intensity pulsed ultrasound. A 58-year-old woman was referred to our hospital because of right submandibular swelling. She had received methotrexate, mizoribine, prednisolone, and tacrolimus hydrate for articular rheumatism for 8 years, and arendronate sodium hydrate for osteoporosis for 6 years. After extraction of the right mandibular wisdom tooth associated with submandibular cellulitis, a pathological mandible fracture occurred. Conservative treatment for 4 months did not improve the lesion. Low-intensity pulsed ultrasound 20 min/day was then started. After ultrasound treatment for 3 months, radiography and computed tomography showed fracture healing and the exposure of necrotic bone. We could perform sequestrectomy after 5 months of ultrasound treatment. Healing of fractured mandible was satisfactory, and the ultrasound treatment for the pathological mandible fracture was considered useful.
We report on a 65-year-old woman with primary squamous cell carcinoma of the sublingual gland. She consulted our department because of a painless mass of the left side of the oral floor. The results of a biopsy were squamous cell carcinoma or mucoepidermoid carcinoma. The tentative diagnosis was a malignant tumor of the left sublingual gland. Radical neck dissection, tumorectomy, and reconstruction were performed. Histopathological examination suggested squamous cell carcinoma. Systemic investigation revealed no tumors of other organs; the possibility of a metastatic tumor was ruled out.Because the tumor was localized in the sublingual gland, the diagnosis was primary squamous cell carcinoma of the sublingual gland. This type of carcinoma is rare. To date, the course has been favorable. However, squamous cell carcinoma of the salivary gland has a poor prognosis; follow-up should be continued in the future.
Although surgery for upper spinal tumors is usually performed via a posterior approach, a transoral approach from the anterior direction is necessary if the tumor is too big to extirpate via the posterior approach alone. To obtain a good anterior view of the surgical field, the mandible, tongue, and soft palate have to be split in some patients. Oral and maxillofacial surgeons thus play an important role in such procedures. We report the case of a 66-year-old woman who presented with neck pain. The diagnosis was chordoma of the second centrum, and the patient was referred to the Department of Orthopedics of our hospital by an orthopedic clinic. Computed tomography and magnetic resonance imaging indicated that the tumor was located at the level of C2 and spread to the lower part of C3, destroying the bone. The orthopedic surgical team decided to employ both posterior and anterior approaches and invited our department to assist in the transoral anterior approach. Vertical splitting of the mandible, incising the skin of the mental region and splitting the middle of the tongue were extremely effective as supportive procedures for an anterior approach to the spinal tumor.
Arteriovenous malformation (AVM) of the oral and maxillofacial region is considered a rare disease. We report a case of AVM extending from the upper third molar region to the left maxillary sinus, diagnosed on hemorrhage after tooth extraction. The patient was a 27-year-old man referred to our hospital to undergo extraction of the left upper third molar.We performed an emergency operation to achieve hemostasis of abnormal bleeding after tooth extraction. After hemostasis we examined the left maxillary region by computed tomographic (CT) -angiography and magnetic resonance imaging (MRI). An AVM extending from the upper third molar region to the left maxillary sinus was found on CT-angiography anf MRI. We could not perform embolization because the patient was allergic to contrast media. We performed surgical resection using Seiffert's method. No recurrence developed during 8 years of follow-up. Care should be exercised during daily minor surgery such as tooth extraction because serious and abnormal bleeding similar to that in the present case may occur.
Lemierre syndrome is a potentially life-threatening disease caused by an acute oropharyngeal infection with secondary septic thrombophlebitis of the internal jugular vein, frequently associated with abscess formation in distant organs. We report the case of a 78-year-old woman who received surgical therapy, chemotherapy, and radiation therapy for malignant lymphoma in 2001. She visited our hospital because of a swelling and pain of the left submandibular region in August 2009. The patient was immediately hospitalized to control the pain and infection. PET images showed tracer uptake in the lung. Bilateral multiple septic emboli of the thorax were detected on CT. On the basis of these findings, Lemierre syndrome was diagnosed. The patient was treated with antibiotics intravenously, and surgical drainage was performed. All symptoms improved, and she was discharged after 32 days.