Medication-related osteonecrosis of the jaw (MRONJ) is caused by local infection and inflammation in association with suppression of bone remodeling by anti-resorptive agents (ARA) such as bisphosphonates and denosumab. Because invasive dental procedures such as tooth extractions are among major risk factors of MRONJ, there has been a long debate about discontinuation of anti-osteoporotic medication before and during such procedures. In the MRONJ Position Paper 2023, continuation of osteoporosis treatment during such procedures is (weakly) recommended: a systematic review has clearly demonstrated that there is little evidence supporting the advantage of discontinuation. However, due to the diversity of the route and frequency of drug administration, as well as various mechanisms of action, physicians often need to make flexible decisions regarding osteoporosis management in real-world clinical scenarios. Both the physicians who prescribe anti-osteoporotic medications and the dentists involved need to fully understand characteristics and mechanism of action of anti-osteoporotic drugs, particularly ARA. By sharing information about the patients’ bone status and oral health, these professionals should collaborate to formulate the optimal strategy to minimize the risk of fragility fracture and MRONJ.

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　Position Paper on Medication-Related Osteonecrosis of the Jaw 2023 has been revised based on the latest findings seven years after the position paper was revised in 2016. The main points of this revision will be focused on seven key points. The first point is that the designation has been changed from ARONJ to MRONJ. The second point is a slight change in diagnostics and staging, with the removal of position 0 from staging. The third point is the incidence of MRONJ at low doses may be higher in Japan than in Europe and the U.S. The fourth point emphasizes odontogenic infection requiring extraction rather than tooth extraction as a risk factor. The fifth point is no evidence for the usefulness of antiresorptive agent (ARA) withdrawal in preventing MRONJ, and it was suggested that, in principle, ARA withdrawal should not be used prior to tooth extraction. The sixth point is that surgical treatment has become a higher priority. The seventh point is importance of medical-dental-pharmaceutical collaboration was emphasized.

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　Oblique facial cleft is quite a rare disease. It is extremely rare for two types of oblique facial clefts to occur simultaneously on the same side, and there are few reports detailing surgical treatments for such cases. Here, we report a case in which we performed one-stage facial repair on a patient with Treacher Collins syndrome (TCS), who had two left-sided oblique facial clefts. A female child born at another hospital was diagnosed with TCS based on her characteristic facial features and choanal atresia. After performing a tracheotomy for persistent respiratory distress, she was transferred to our center at six months of age. She had Tessier No. 3 and No. 5 facial clefts on the left side, and we conducted simultaneous surgery at nine months of age. A combination of midfacial advancement technique and straight line technique was applied for the No. 3 cleft, then we repaired the No. 5 cleft using the Matsuya method involving a Z-plasty. Favorable lip and nose shape was achieved six years after the surgery.

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　Pencil-core granuloma is a reactive granulomatous lesion which occurs due to retained fragments of pencil lead. The disease produces black masses, so it must be differentiated from malignant melanoma, hemangioma, and osteosarcoma. It can occur in various parts of the body, especially in areas that are not covered by clothing, such as the limbs. To date, a small number of cases have been reported in the oral cavity in English literature, however, there are no reports from Japan.
　The patient was a 56-year-old woman who visited a local hospital with the chief complaint of swelling of the right tongue. She had a history of tongue injury caused by a pencil when she was 3 years old, however, she left the injury because the wound healed without any problems. Intraoral findings revealed a dark purple mass with a slightly unclear border in the right dorsal of the tongue. MRI revealed a low intensity mass in T2 weighted imaging.
　The mass was enucleated under general anesthesia, with a clinical diagnosis of benign tongue tumor. Pencil lead was observed inside the mass. Histopathological examination confirmed the diagnosis of pencil-core granuloma. There are no signs of recurrence 2 years and 6 months after the operation. In the case of granulomatous lesions in the oral cavity, it is necessary to conduct a detailed medical interview, taking into consideration the possibility that foreign objects, including pencil lead, may have been impacted, and to confirm the progression of symptoms in detail before making a diagnosis.

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