Burning mouth syndrome （BMS） is classified into chronic primary orofacial pain. Chronic primary pain syndrome is characterized by nociplastic pain in which pain arises from altered nociception despite no clear evidence of actual or threatened tissue damage causing the activation of peripheral nociceptors or evidence for disease or lesion of the somatosensory system causing the pain. Historically, these types of pain have been regarded as psychogenic pain. Recent studies have revealed that chronic primary pain syndrome including BMS shows dysfunction of the pain modulatory system, especially descending pain inhibition. This altered brain function can be monitored by neurophysiologic tests including quantitative sensory testing and conditioned pain modulation （CPM） in combination with imaging modalities. These research modalities have revealed that the brain in BMS patients shows temporal summation of activity in areas associated with pain modulation during tonic noxious hot stimulation of the lower lip and temporal suppression of activity in these areas by repeated noxious stimuli without perceptional pain habituation. Further, there are reports in the literature of facilitated pain response to heat and our experimental data have revealed the lack of CPM in BMS patients. The results of previous studies have suggested that dysfunction in the dopaminergic neural system is involved in altered pain modulating function.

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We described our experience with a case of necrotizing fasciitis accompanied with broad necrosis of cervical skin caused by acute osteoradiomyelitis.
　A 60-year-old man was referred to our hospital because of swelling and pain of the submandibular region. He had undergone radical surgery for maxillary gingival squamous cell carcinoma and radiation therapy a year before. On the basis of imaging findings and clinical course, osteoradiomyelitis and necrotizing fasciitis were diagnosed, and surgical and chemical debridement was performed. After chemical debridement was performed on strongly attached black scar tissue in the neck, reconstruction of the skin defect was performed by pectoralis major myocutaneous flap and split-thickness skin grafting. Moreover, because of DIC and internal jugular vein thrombosis with distant infection comorbidity and clinical findings revealed Lemierre’s syndrome, we performed anticoagulant therapy additionally. Our experience shows that time to reconstruction and treatment of scar tissue in the neck are controversial.

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A granular cell tumor is a relatively rare benign tumor arising in various soft tissues of the body. In the oral region, it commonly occurs in the tongue. We report three cases of granular cell tumor arising in the tongue and the floor of the mouth.
　Case 1: A 33-year-old woman had an elastic-hard mass of 18×13mm in the left lateral border of the tongue. The tumor was excised with a 3-mm margin under general anesthesia.
　Case 2: A 35-year-old man complained of a small mass at the left lateral border of the tongue. The tumor was excised with a 3-mm margin under local anesthesia.
　Case 3: A 62-year-old woman had a small submucosal mass of 7×7mm at the left sublingual caruncle. The tumor was excised with a 3-mm margin under local anesthesia. In all cases, histopathologic examinations revealed granular cell tumor. There was no distinct capsule around the tumor. Tumor cells had intracytoplasmic granules immunostained with S-100 protein, NSE, CD68, Vimentin, and Galectin3. In cases 2 and 3, tumor cells were positive for Calretinin, suggesting neurogenic origin. We searched and discuss 130 cases of granular cell tumor reported in Japan.

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We report the extraction of a mandibular third molar with six roots.
　The patient was a woman in her twenties. She was referred to our hospital with the chief complaint of gingival swelling of the right mandibular third molar region. Impacted teeth with many roots were found by dental X-ray imaging.
　We diagnosed pericoronitis and extraction was performed under local anesthesia. Extraction was easy, and no fracture was observed in any of the roots. There were no postoperative complications. As seen by CT, the extracted teeth revealed 7 cusps and 6 roots with 5 root canals.

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We report the case of a lateral dermoid cyst on the floor of the mouth of a 14-year-old boy. T2-weighted magnetic resonance imaging revealed a high signal and homogeneous density, a finding consistent with that of a ranula. However, atypical findings, such as the appearance of expanded displacement, were also observed. Since the lesion was benign based on the clinical course and biopsy involved a risk of causing a secondary infection, we decided to examine the lesion based on the intraoperative findings. On the basis of the intraoperative findings, we diagnosed the cyst as an epidermoid/dermoid cyst; therefore, total enucleation was performed. A postoperative histopathological diagnosis suggested a dermoid cyst. The postoperative course was good, with no dysfunction observed.

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Superficial mucocele is a variant of common mucocele. A few cases of superficial mucocele have been reported. In this study, a woman in her 50s presented with multiple vesicles on the floor of her mouth, retromolar region, lower labial and buccal mucosa. Some vesicles had ruptured, and the patient felt mild pain and discomfort. A biopsy was taken from the vesicles. Histopathologically, intraepithelial mucocele was observed. On the basis of the clinical findings, superficial mucocele was diagnosed. After discontinuing a cysteine-based preparation thought to be a contributing factor, the symptoms improved.

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The patient was a man in his thirties. During extraction of the left mandibular third molar, the distal root of the tooth was accidentally inserted into the oral floor. As the inserted tooth root could not be returned to the extraction socket, it was decided to remove the root by approaching from a marginal incision on the lingual side at a later date. A gingival marginal incision was made from the distal aspect on the lingual side of the left mandibular second molar to the mesial angle on the lingual side of the left mandibular first molar, and a full-thickness flap was elevated to confirm the inserted tooth root. The root was grasped with cupped forceps and removed, and hemostasis was achieved with sutures. The sutures were removed one week later and progress was satisfactory. We discuss the importance of determining the difficulty of an extraction along with the possibility of procedural accidents and measures to address them prior to the procedure, in order to avoid accidental insertion into the oral floor. We also consider the importance of using computed tomography imaging in the event of accidental insertion into the oral floor for selecting an appropriate method of removal.

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Currently, Japan is becoming a super-aged society with the proportion of elderly people exceeding 25%. In the field of dentistry, the opportunities for treating oral cancer in elderly patients have also shown a tendency to increase. We encountered a case of gingival carcinoma in an elderly person and herein report an outline of the case, together with a literature review of the choice of and issues in the treatment of oral cancers in elderly patients.
　The patient was a 96-year-old woman who was referred to our hospital and presented with an ulcer and pain from the premolar to the molar area in the left lower jaw. She had noticed maladaptation of the upper and lower dentures and visited a nearby dentist. As adjustment of the upper and lower dentures due to intrusion of the dentures into the alveolus in the molar region in the right upper jaw and from the premolar to the molar area in the left lower jaw and ulcer formation found in the same areas failed to improve her symptoms, she was referred to our hospital. Ulcers with pain were found in the molar area in the right upper jaw and from the premolar to the molar area in the left lower jaw. The imaging findings revealed marked bone destruction and infiltration of tumor lesions. The results of the biopsy performed at the time of the first visit indicated squamous cell carcinoma. Follow-up of the patient was decided in consideration of her age, body condition, and consultation with her family members.
　Cancer treatment in elderly patients is not intended to cure the disease, and advanced treatments should be determined in consideration of life expectancy, physical fitness, family environment, and financial status. As oral cancers, particularly in elderly patients, require whole-body control in addition to control in the head and neck, the number of items to be considered increases and treatments become complicated. On the basis of the current situation, we suggest that the focal points should be thoroughly acquiring informed consent to encourage self-determination in patients, establishing a comprehensive treatment guideline, and introducing the concept of frailty.

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