Extensive Maxillary Necrosis Following Tooth Extraction

A previously healthy 52-year-old woman presented with painful unhealed extraction sockets in the maxillary right posterior region. No evidence of previous local or total body irradiation, transplantation, iatrogenic immunosuppression, blood transfusion, tuberculosis, or acquired immunodeficiency syndrome was found in the patient’s medical history. She had undergone extraction of her right maxillary premolars and molars at a local dental clinic 1 week before presentation owing to pain and mobility with those teeth. There was no history of noticeable swelling, ulceration, or mucosal changes in relation to the maxillary right posterior teeth or the palate at the time of extractions. She denied any medical ailments and allergies and was not on any medications. She was in extreme pain, which was aggravated upon bending forward, and denied any oral or nasal discharge, dysphagia, neurosensory disturbance, foul odor, persistent cough, night sweats, headache, or recent weight loss. She complained of partial right nasal obstruction. She had an increased body temperature of 100.7°F and appeared cachectic. Blood pressure was 160/90 mm Hg. Pulse rate was 90 beats/min, and respiratory rate was 16 breaths/min. She denied alcohol or tobacco use. Oral examination showed a large necrotic area in the right maxilla extending distally from the right maxillary canine to posteriorly beyond the right maxillary tuberosity, medially to the midline of the palate, and buccally to the depth of the maxillary vestibule (Fig 1). Examination of the adjacent intraoral mucosa and pharynx was unremarkable. The right maxillary sinus was tender to palpation. Examination of the right nasal cavity revealed mucositis and a slight amount of pus but no mass lesion. Right eye movements, visual acuity, and pupillary reaction to light were normal. The neck was without lymphadenopathy. Fasting blood sugar was 90 mg/dL (normal, 60 to 90 mg/dL), and postprandial blood sugar level was 136 mg/dL (normal, 90 to 140 mg/dL). Urine was negative for ketone bodies and glucose. Blood chemistry revealed an increased white blood cell count (14.1 10) and a normal platelet count (395 10). The remain-