Dental anesthesiologists have the following roles in oral and maxillofacial surgery: providing patients with high-quality anesthesia during operations, providing the best conditions for surgeons in an operating room, having to ensure patients have no complications, and relieving pain and anxiety of patients after operations. To achieve these, close cooperation with oral and maxillofacial surgeons is essential, and the general preoperative management of patients, especially preoperative evaluation, is very important. So, in the present review I focused on the following topics that should be considered on preoperative evaluation:
1） Preoperative image inspection of oral and maxillofacial regions, including Cephalo X-ray, C-T, and MR imaging of the head and neck region, is clinically useful to predict the airway condition of patients during and after operations under general anesthesia.
2） Preoperative respiratory conditions and lung diseases of patients undergoing operations under general anesthesia should be carefully evaluated because general anesthesia generally inhibits the respiratory function. So, the operation should be delayed until the respiratory condition improves if possible.
3） Preoperative cardiovascular conditions of patients undergoing operations should be evaluated according to evidence-based guidelines incorporating stepwise assessments, such as “Active Cardiac Condition” or not, physical ability, and other complications. In the case of patients with poor conditions, consultation with specialists of cardiovascular diseases is necessary. The goal is to minimize the incidence of cardiovascular complications in patients during and after operations.
4）The blood pressure and pulse rate (ECG if necessary) should be monitored in patients with cardiovascular disease such as hypertension during operations, even during tooth extraction under local anesthesia.
With the revision in fiscal year 2012 of the healthcare insurance, “the perioperative oral management fee” has been newly established, which is expected to reduce the complications after cancer, cardiac and other surgeries. Possible oral-related complications during perioperative period include 1) damage to teeth during endotracheal intubation, 2) pressure ulcer due to compression of orally-intubated endotracheal tube, 3) postoperative pneumonia, 4) surgical site infection of oropharynx, and others. Also, there is a potential risk of developing foreign material infections due to bacteremia from the oral cavity as the periodontitis remains there. Such risks are found in surgeries where the materials such as prosthetic valves and artificial joints are installed inside the body.
The term “perioperative oral care” is often heard. In order to prevent the above-mentioned complications, however, the author suggests dentists be expected to “not only provide oral care but also put the oralmanagement (OM) into practice”. In addition to the oral Cleaning which is narrowly defined as oral care, it is important for OM here to include the total 5 elements, which are Rehabilitation for mastication and swallowing, Education of patients and medical staff, accurate oral Assessment, and dental Treatment which includes tooth extractions and adjusting dentures. The concept of OM is that fully achieving above 5 elements enables one to Eat or Enjoy food. The 6 initials starting from Cleaning and Rehabilitation to Eat or Enjoy read CREATE in the order described, and the goal of OM is to “CREATE oral cavity that can eat well”.
Therefore, the oral-related perioperative complications can be prevented by “improving one’s oral environment in good condition”, while considering priority of above 5 elements based on a concept of OM in a limited short perioperative period.
Arsenic trioxide used to be used as an effective endodontic treatment. However, domestic production of arsenic trioxide for mortal pulpectomy was discontinued in 2005, because it is a toxic agent that has the risk of injuring periodontal tissues. We report a case of mandibular osteonecrosis caused by leakage of arsenic trioxide in a child after 2005. The patient was a 6-year-old boy who presented with swelling of the right buccal region, after arsenic trioxide had been used for mortal pulpectomy in the mandibular right second primary molar. The condition was diagnosed as mandibular osteonecrosis. The mandibular right first primary molar and mandibular right second permanent premolar were extracted, and a sequestrectomy was performed with the patient under local anesthesia. We still should consider that leakage of pulp devitalizing agents can cause osteonecrosis.
Chondrolipoma is a rare benign tumor composed of mature adipocytes, metaplastic chondro-matrix and c artilaginous t issue with chondrocytes. A 45-year-old woman was referred to our clinic because of a mass in the left side of the tongue. The lesion was painless and the size of a soybean. It was located in the submucosa and well demarcated from the surrounding tissue. The lesion was diagnosed as a benign tumor clinically and was resected with the patient under local anesthesia. The lesion was a solid mass measuring 10 × 9 × 5 mm in diameter. The sectioned surface of the lesion was white-yellowish. Histologically, the lesion was composed of a mixture of mature adipocytes, chodro-matrix with lacunae possessing chondrocytes, and myxoid tissue. There were no atypical cells or atypical mitosis in the specimen. Histopathologically, the lesion was diagnosed as a chondrolipoma of the tongue. There has been no sign of recurrence in the 4 years after the operation.
An extremely rare case of metachronous multiple primary cancers of the tongue, breast, and gingiva is reported. A 61-year-old man was referred to our hospital because of a tumor of the tongue in June 2005. A clinical diagnosis of tongue cancer (T2N0M0) was made, and the patient underwent a partial glossectomy for the tongue cancer. Histopathological examination revealed a well-differentiated squamous cell carcinoma (SCC). In September 2006, left breast cancer was suspected on FDG PET-CT examination (max SUV=2.5). Physical examination showed an elastic hard mass, measuring 2.4 × 2.0 cm, under the nipple. Mammography and fine needle aspiration cytology revealed a breast cancer. A clinical diagnosis of T4bN0M0 was made, and a left mastectomy and sentinel lymph node biopsy were performed. The histopathological diagnosis was an invasive duct carcinoma (pT4bN0). HER2 was positive (HER2-FISH). Hormone receptor evaluation (Allred score) was estrogen receptor (ER) 8 and progesterone receptor (PgR） 4. Endocrine therapy with anastrozole was indicated and given for 5 years. In June 2014, an ulcerative lesion was seen on the left mandibular gingiva. A clinical diagnosis of gingival cancer (T1N0M0) was made, and marginal resection of the mandible was performed. The histopathological diagnosis was moderately differentiated SCC. The postoperative course was uneventful. There has been no evidence of recurrence, metastasis, or another primary cancer.
Lipomas are benign tumors arising frequently in the trunk and extremities. They are uncommon neoplasms of the oral cavity and account for only 1% to 5% of all neoplasms arising in the oral cavity. Osteolipoma, a subtype of lipoma, is particularly rare among such tumors. Osteolipoma was first described by Plaut et al. in 1958. We report a case of osteolipoma that arose in the buccal region. A 57-year-old man presented to our hospital because of swelling of the buccal region. On palpation of the left buccal mucosa, a hard tumor was felt. Both T1- and T2-weighted magnetic resonance imaging (MRI) showed high signal intensity in most of the tumor. Fat suppression T1-weighted images showed low signal intensity. T1-weighted MRI showed low and high signal intensity inside the tumor. MRI thus revealed the presence of non-adipose tissue in the tumor. A biopsy of the tumor showed that it was a subtype of lipoma, and the preoperative diagnosis was a subtype of lipoma. Surgical excision of the buccal tumor was performed with the patient under general anesthesia. The pathological diagnosis of the resected tumor confirmed that it was an osteolipoma. No signs of recurrence have been noted as of 30 months postoperatively.
Von Recklinghausen’s disease is an autosomal-dominant hereditary disorder that is rarely accompanied by rhabdomyosarcoma of the head and neck in an adult. We report a case of von Recklinghausen’s disease complicated by rhabdomyosarcoma of the tongue and thyroid cancer. A 38-year-old man was referred to our hospital because of spontaneous pain of the left side of the tongue. An intraoral examination revealed a palpable hard tumor measuring 24 × 17 mm. Because we suspected a benign tumor, we performed a partial glossectomy with the patient under local anesthesia. Histological examination showed an embryonal rhabdomyosarcoma. We performed an additional resection with general anesthesia. Three weeks later, the patient underwent a thyroid resection and neck dissection. The histopathological examination revealed a papillary carcinoma. The patient declined to receive adjuvant chemotherapy as well as radiotherapy. He has not had recurrence or metastasis in the 4 years since the resection.
Solitary fibrous tumor (SFT) was first reported in 1931 by Klemperer and Rabin 1). Although this tumor occurs mostly in the pleura, extra-pleural SFT including the head and neck region has also been reported. This paper describes a case of SFT arising in the lower gingiva. A 49-year-old woman visited our clinic because of swelling of the lower gingiva. Intra-oral examination revealed a well-defined elastic hard mass measuring 50 × 33 × 25 mm in the anterior lower gingiva. After several clinical and radiographic examinations, a clinical diagnosis of a benign tumor in the lower gingiva was made. The lesion was surgically excised with the patient under general anesthesia. The histological diagnosis was SFT. Two years and 10 months after surgery, no recurrence was observed. This article includes a review of previously reported cases.
We report a case of synchronous squamous cell carcinoma of the mandibular gingiva and primary malignant lymphoma of the neck. A 51-year-old man was referred to our hospital for further evaluation of an intractable gingival ulcer. Physical examination at initial presentation showed an ulcerative lesion of the left mandibular molar gingiva with an irregular border and induration, which was diagnosed as squamous cell carcinoma on abiopsy. An imaging study showed mandibular invasion of squamous cell carcinoma and metastases to the left cervical lymph nodes. Marginal resection of the mandible and left neck dissection were performed with the patient under general anesthesia. There was no histopathological evidence of cervical lymph node metastasis. However, postoperative physical and radiographic findings at 2 months showed two swollen lymph nodes in the right side of the neck, suggesting early metastases to the contralateral cervical lymph nodes. Right neck dissection was performed with the patient under general anesthesia, and the histopathological diagnosis was malignant lymphoma (marginal zone B-cell lymphoma). The final diagnosis was synchronous squamous cell carcinoma of the mandibular gingiva and primary malignant lymphoma of the neck. The patient was strictly followed up with no additional treatment because of the low malignancy of marginal zone B-cell lymphoma. There has been no evidence of recurrence or metastasis during the 6 years 9 months after the operation.