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the bone can still be present long after patients have stopped taking the medication. Patients are often able to report accurately what disorder(s) they have and certain disorders should cause dentists to be alert. Patients who can be defined as the Big Five users of bone-modulating medicaments are: 1. patients with osteoporosis, 2. patients who have been long-term users of glucocorticoids, 3. patients with solid tumours, 4. patients with multiple myeloma and 5. patients with congenital or hereditary bone disorders. These patient groups have an indication for bone-modulating medicaments. These are anti-resorptive medications (such as bisphosphonates and denosumab) or anti-angiogenic medications. By recognising the correct patient group, dentists can ask appropriate questions about the use of medicaments in the present or in the past. A dentist can recognise patients with a risk of medication-related osteonecrosis by using this method.

A 48-year-old man was referred for an evaluation of deviations in the pigmentation of the lower lip, intra-oral swelling and persistent numbness of the sensory area of the left mental nerve. In 2011, the diagnosis lentigo maligna of the lower lip was missed by histopathology of a biopsy performed elsewhere. In 2016, the numbness of the lower lip and chin was diagnosed by a neurologist as numb chin of unknown cause. A biopsy in 2017 showed lentigo maligna of the lower lip alongside a primary mucosal melanoma with significant local invasion. Treatment consisted of a hemimandibulectomy with a supraomohyoid neck dissection of the left side. This case shows the importance of the alarm symptom 'a numb lip' and the corresponding necessity of additional investigation. This article shows avoidable pitfalls that general practitioners, dentists and medical specialists need to be vigilant about.

3D technology is increasingly being applied in dentistry and in oral and maxillofacial surgery. An important field of application is reconstructive surgery, especially in the reconstruction of large defects ofthe jaw. In such cases of reconstruction, the goal is the restoration of both the continuity of the defective area and its function. For the functional restoration implant supported dental structures are often employed. In such cases, CAD/CAM superstructures, 3D printed drill and saw templates, anatomical models, wafers and surgical outcome models are used. The combination of the digital planning and the digital fabrication ofsuperstructures and surgical aids offers many preoperative advantages. The use of saw, drill and positioning templates provides for accurate segmentation and implant positioning, by means of which the reconstruction can be carried out in a predictable way.

A 21-year-old woman was referred by the dental practitioner to an oral surgeon concerning a hard elastic swelling of the left cheek in combination with local paresthesia. Histopathologic and radiographic examination revealed an osteosarcoma in the left segment of the maxilla. Subsequently, the patient was referred to a medical centre for head and neck oncology. The treatment consisted of 3 courses neoadjuvant chemotherapy, followed by radical surgical resection of the tumor, and 3 courses adjuvant chemotherapy. One year after treatment, there was no sign of local tumor recurrence or metastases. An osteosarcoma is a malignant tumor of bone forming cells. About 10% of osteosarcomas are appearing in the head and neck region, primarily in the mandible and the maxilla. The treatment of choice is adequate surgical removal. Treatment with (neo)adjuvant chemotherapy seems to have additional benefit, but this needs further research.

A 39-year-old Antillean woman was referred by her family doctor to an oral and maxillofacial surgeon because of an unusual and painful ulcer in the buccal region of the first left mandibular molar. Earlier that day, she was diagnosed as HIV-positive. The ulcer was diagnosed as an atypical necrotising ulcerating periodontitis. Antibiotics were subscribed and after removal of the first left mandibular molar, the ulcer healed. After several weeks, the patient was referred by her internist because of another ulcer at the lateral border of the tongue. This ulcer was diagnosed as an eosinophilic ulcer and was healing slowly. Both ulcer types are seen rarely and are strongly related to immunodeficiency diseases.

The cases presented show that bisphosphonate-induced osteonecrosis of the jaw is difficult to treat. Recently, a classification of bisphosphonate-induced osteonecrosis of the jaw based on clinical appearance was published. On the basis of this classification the seriousness of the osteonecrosis can be evaluated and a method of treatment determined. The common opinion is that treatment should be as conservative as possible. This means that treatment should have as its objective the prevention of the spread of the disease by means of antibiotics and disinfectant mouthwash. Sharp bony edges may be trimmed. Extensive surgical treatment should be reserved for those rare cases in which the osteonecrosis is progressive.

A young African male was referred after the spontaneous loss of sensibility to the left of the lower lip. Anaesthesia of the left lower alveolar nerve could be confirmed. X-rays did not reveal any signs of pathology in the left mandible while clinically the gingival was tender on palpation. He was known to have sickle cell anemia. Differential diagnosis included a sickle cell mediated osteomyelitis due to infarction of the microvasculature. The diagnostic work up included additional PET scans to confirm the clinical diagnosis. The pathogenesis of sickle cell anemia and its importance to the dentist is discussed.

A young woman presented a severe gingivitis that wouldn't respond to antibiotics prescribed by her general practitioner. Thorough clinical examination showed atypical gingival inflammation. In such unusual cases a careful anamnesis is essential in determining appropriate continued diagnostic procedures. Eventually, acute myeloid leukaemia was diagnosed. Since the diagnosis of gingival disease primarily lies with the dentist, it is important to be able to consider any unusual aspects of gingivitis within a dental office.

Since the 1970's lasers are used in oral and maxillofacial surgery. The effect of a laser on tissue is determined by the wavelength of the laserlight and the tissue specific absorbtion. Lasers are used for evaporation, excision and coagulation of tissue. The CO2-laser, the Nd:YAG-laser and the Argonlaser are used for these purposes. Light and laserlight are used for the diagnosis of mucosal lesions. By using different excitation wavelength autofluorescence of lesions can be detected and analysed. An artificial neural network can be used to analyse these data. Photodynamic Therapy (PDT) is a cancer therapy based on the more or less specific absorption of a drug in tumour, that can be activated with light of a specific wavelength. Activation of this drug causes tumour destruction due to the formation of oxyginradicals. PDT is limited by the penetration of the activating light and is therefore only suitable for the treatment of superficial tumours.