Bisphosphonates (BPs) have been widely, efficiently and safely used for the treatment of osteoporosis, malignant hypercalcemia, bone metastasis of solid cancers and multiple myeloma bone diseases. Accumulating recent reports describe that surgical dental treatments in patients with cancer or osteoporosis who have been receiving intravenous or oral BPs are associated with osteonecrosis of the jaw (BRONJ). The accurate incidence, clinical backgrounds and pathogenesis of BRONJ have been unclear and appropriate approaches for prevention and treatment have not been established to date. To address the current situation of BRONJ in Japan, the “Allied Task Force Committee of Bisphosphonate-Related Osteonecrosis of the Jaw” consisting of physicians specializing in bone biology, orthopedic surgery, rheumatology, obstetrics/gynecology and medical oncology and dentists specializing in oral surgery, periodontology, dental radiology and oral pathology was organized. The committee attempted to propose standard position paper for the treatment of BRONJ. The committee expects that this proposal will provide objective and correct scientific information on BRONJ and will serve as a reference for conducting dental procedures for patients receiving BPs and designing prevention and treatment of BRONJ. However, since this position paper is not based on direct clinical evidence, it should be used as a reference and a decision on treatment in each case should be made after an extensive discussion among physicians, dentists/oral surgeons and the patients.

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Bisphosphonates (BPs) have clinically been used as a highly effective drug in the treatment of hypercalcemia of malignancy, skeletal events associated with multiple myeloma, metastatic breast cancer and prostate cancer, and osteoporosis. Despite these benefits, however, the emergence of BP-related osteonecrosis of the jaws (BRONJ) becomes a growing and significant problem in a subset of patients receiving these drugs, especially intravenous preparations. It has also been reported in the patients receiving oral BPs, although the incidence is extremely low. Most of BRONJ cases occur after dental treatments such as tooth extraction, periodontal surgery, and dental implants, and are refractory to conventional treatment modalities such as debridement, antibiotics and hyperbaric oxygen therapy. As compared to USA and EU, the number of BRONJ cases is still small in Japan, but it is exactly increasing year by year. The ratio of the number of BRONJ in patients receiving oral BPs to that in patients receiving intravenous BPs is higher in Japan than in USA and EU, speculating due to the difference of time of approval and oral hygienic condition of the Japanese elderly. In this issue, the present condition of occurrence of BRONJ in USA, EU and Japan and the practical guidelines for diagnosis and treatment proposed in USA and EU are described. Although no effective therapy for BRONJ is established yet, the importance of oral hygiene, patient education and treatments suitable for clinical stage is emphasized. In addition, it is considered that the survey of incidence of BRONJ in Japan and the preparation of Japanese guideline are urgent need.

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Purpose: Recent biochemical studies of synovial fluids indicate that temporomandibular joint (TMJ) symptoms are caused by intra-articular inflammation. There are various ways to manage such disorders.Arthrocentesis is one effective treatment for closed lock. The aim of this study was to evaluate the efficacy of arthrocentesis (steroid injection) followed by mouth opening exercises during non-steroidal anti-inflammatory drug (NSAID) theraphy as a primary treatment for closed lock. The ultimate goal was to increase the improvement rate and the number of patients with no TMJ dysfunction.
Subjects and Methods: Subjects were selected from a series of patients with newly diagnosed closed lock who presented at Aichi-Gakuin University Hospital between January 2003 and December 2004. Sixty-two patients were confirmed to have closed lock with MRI. The patients underwent two consecutive sessions of arthrocentesis at a 2-week interval and were followed up every 2 weeks for 12 weeks. NSAID administration and mouth opening exercises were performed daily until the patient' s symptoms improved. The improvement rate was calculated as the percentage of improved cases among the total number of cases in each group.
Results: The improvement rates were 27 %, 43 %, 56 %, 62 %, 65 %, and 71 % after 2, 4, 6, 8, 10, and 12 weeks, respectively. Improvement to a TMJ classification of no dysfunction was achieved in 11 % of the patients.
Conclusion: This combination therapy (steroid injection) is an effective primary treatment because the improvement rate was as higher as 71 %, and 11 % of all patients had improved to a TMJ classification of no dysfunction.

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AIM: The purpose of this study was to evaluate the effectiveness of early alveolar bone grafting in patients younger than 8 years.
MATERIALS AND METHODS: The treated group comprised 15 patients (mean age, 13.2 years; range, 11.4-16.3 years) with cleft lip and alveolus (13 unilateral and 2 bilateral clefts) who underwent alveolar bone grafting at Kitasato University Hospital between July 1999 and January 2004. The mean age at the time of surgery was 6.8 years (range, 5.3 to 7.11) and the mean follow-up period after grafting was 6.6 years (range, 4.8 to 9.1) . We evaluated maxillary growth, bone bridge formation, alveolar bone height and overjet in the cleft area, molar overjet on the cleft side, dental arch width, and basal arch width. The control group comprised 13 patients (mean age, 13.4 years; range, 12.4-14.2) with unilateral cleft lip and alveolus who underwent alveolar bone grafting. The mean age at the time of surgery was 9.2 years (range, 8.0 to 11.4). The Mann-Whitney U-test was used to examine the statistical significance of differences between the two groups in upper jaw growth, dental arch width, and basal arch width.
RESULTS: Maxillary growth was not significantly restricted in any of the patients in the treated group, with a mean SNA angle of 82.4° and 81.6° and a mean ANB angle of 7.3° and 6.1° before and after grafting, respectively. After surgery, the mean dental arch width was 44.8 mm, and the mean basal arch width was 48.8 mm. Bone bridge formation in the cleft area was observed in all patients in the treated group, and the alveolar bone height was similar to that on the non-cleft side. A proper overjet was achieved in 14 of the 15 patients by orthodentic treatment after grafting. In the control group, the mean SNA angle was 80.8°, the mean dental arch width was 44.0 mm, and the mean basal arch width was 48.8 mm after bone grafting. There was no significant difference in SNA angle, dental arch width, and basal arch width between the treated and control groups.
CONCLUSION: The results suggest that early alveolar bone grafting followed by orthodontic treatment at least does not affect the maxillary growth of patients with cleft lip and alveolus who are younger than 8 years.

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Pleomorphic adenoma is the most frequent salivary gland tumor. The most common site of this tumor in the major salivary glands is the parotid gland, while that in the minor salivary glands is the palate. We report a giant pleomorphic adenoma that extended into the parapharyngeal space. The patient was a 55-year-old woman who had been referred to our hospital because of swelling of the left palate region. Magnetic resonance imaging (MRI) revealed a bulky mass extending from the skullbase to the left parapharyngeal space and the submandibular region. Although no malignancy was detected after cytodiagnosis and biopsy had been performed twice, a definitive diagnosis was difficult. Surgery was planned for a diagnosis of a benign tumor arising from the minor salivary glands of the pharynx since preoperative computed tomography and MRI showed interposition of a fat pad between the lesion and the parotid gland. The tumor was removed by an inverted L ramus osteotomy as described by Flood et al. rather than by a midline mandibulotomy to ensure safety because the tumor was large as well as for esthetic reasons. The excised tumor measured 80 × 70 × 50 mm. A postoperative histological examination revealed a pleomorphic adenoma. No recurrence was observed during 1 year of follow-up.

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Patients who have maxillofacial fractures with a traumatic severe craniofacial injury often have disturbed consciousness. Early surgical treatment of such patients remains controversial.
We treated maxillofacial fractures in three patients with a traumatic disturbance of consciousness. These patients underwent open reduction using a mini-plate under general anesthesia. Early surgical fixation was associated with no clinically significant complications. All three patients recovered consciousness completely within 50 days after injury.
Early surgical treatment can reduce occlusal dysfunction and cosmetic damage. A close working relationship with neurosurgeons and anesthesiologists is critical to deciding the optimal timing for surgical treatment in patients who have maxillofacial fractures associated with disturbed consciousness.

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The initial symptoms of leukemia include oral manifestations such as gingival hemorrhage and swelling. In patients with these symptoms, attention should be paid to the early diagnosis of acute leukemia. This report describes three cases of acute myelogenous leukemia (AML) with initial manifestations in the oral cavity.
Patient 1: A 32-year-old woman. Ulcer lesions of the oral mucosa were diagnosed as decubital ulcers, and symptoms did not respond to the application of steroid ointment. She also had appetite loss, general malaise, and bloody stools. Blood examination showed a low white-cell count (1,600/μl).
Patient 2: A 52-year-old man. He received anti-inflammatory treatment and had pain at the mandibular third molar region and gingival swelling, but the symptoms did not improve. At the initial visit, pericoronitis of the mandibular third molar with fever and general malaise were observed. Blood examination showed a low white-cell count (2,300/μl) and remarkably increased myeloblasts (20 %) .
Patient 3: A 54-year-old woman. She received medication to treat full-mouth gingival swelling. However, fever and general malaise persisted. Blood examination showed a high white-cell count (47,000/μl).
All three patients were given a diagnosis of AML on bone marrow biopsy.
When the patients present with oral symptoms such as gingival swelling and ulcers accompanied by fever and general malaise, blood examinations should be promptly performed for the differential diagnosis of acute leukemia.

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We describe orthognathic surgery in a patient with mandibular prognathism who was receiving anticoagulant therapy with warfarin.
A 29-year-old woman was referred to our hospital because of malocclusion. She had been receiving warfarin for5 years after mitral valve replacement surgery. Preoperatively, we switched to heparin from warfarin as anticoagulant, and we performed sagittal splitting ramus osteotomy. During the operation, abnormal bleeding did not occur,and the blood loss was 90 ml. She was switched back to warfarin therapy 3 days after the operation. Postoperative swelling of the cheek region was remarkable, but her condition was successfully managed without any complications, such as hemorrhage, thrombosis, and dyspnea.

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Paraquat-diquat products are used as herbicicides, but are toxic to humans, even in small amounts.These products mainly damage the lungs, liver, and kidneys. To treat intoxication resulting from ingestion of paraquat-diquat products, gastric lavage, intestinal lavage, forced diuresis, and blood purification are generally performed, or a laxative or an adsorbent may be used. However the associated mortality rate is approximately 70 %. A 51-year-old woman put a paraquat-diquat product accidentally into her mouth, but immediately spit it out. Spontaneous pain developed in the oral cavity after 2 days, and she visited our hospital 4 days later with this pain as the chief complaint. Erosive lesions had developed from the oral cavity to the pharynx, and the patient had severe haphalgesia and odynophagia. The patient was given a diagnosis of oral chemical injury and was immediately hospitalized to control the pain and monitor general condition. Blood examinations revealed acute renal failure. Four sessions of hemodialysis were performed. The patient's general health status improved, and the pain in the oral cavity subsided. She was discharged after 17 days.

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We retrospectively studied of 20 patients who were admitted to the department of cardiovascular internal medicine of our hospital between January 2001 and March 2007 for a diagnosis of infective endocarditis. On blood cultures, oral bacteria were detected in 9 patients. Furthermore, 10 of the 20 patients visited our department. We examined the correlation of dental treatments and oral diseases with infective endocarditis in the 10 patients. The results of the blood cultures suggested correlations of dental treatments or oral diseases with infective endocarditis in 4 patients. Two patients had oral infections, while the other 2 had undergone dental treatment within 2 weeks before the onset of infective endocarditis. Currently, there are two different guidelines (AHA2007 and JCS2008) for the prevention of infective endocarditis. As stated in the JCS2008 guidelines, we believe that, it is necessary to carefully administer prophylactic antibacterial drugs to patients undergoing dental treatments. In addition, we also believe that it is necessary to improve oral hygiene conditions to prevent infective endocarditis associated with dental treatments or oral diseases.

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