Dental treatment under sedation or general anesthesia (GA) is often performed for patients with dental fear ; however, the demand for sedation or GA in dentistry in Japan remains unclear. The aim of this study was to reveal the prevalence of severe dental fear, the degree of recognition, and the demand for dental anesthesiology among the general population in Japan. A total of 400 Internet-monitors were included in this study. Dental fear was measured using the Modified Dental Anxiety Scale (MDAS). In addition, data collection included questions regarding the recognition of technical terms, the demand for dental treatment under general anesthesia or sedation, other factors related to dental fear, and socioeconomic status. The statistical analysis was performed using descriptive statistics and inference testing using the χ² test (with Yate’s continuity correction), the Mann-Whitney U test, the Kruskal-Wallis test, and logistic regression. The estimated proportion of participants with severe dental fear (MDAS≧19) was 11.3%. Over 40% of the participants did not recognize the terms “dental anesthesiologist”, “inhalation sedation,” or “intravenous sedation” ; however, 14.3% and 44.0% of the participants were interested in dental treatment under general anesthesia and sedation, respectively. A statistically significant relationship between the demand for dental treatment under GA and sedation was observed when the analysis was controlled for socioeconomic status. This internet-survey showed that dental fear was common in Japan, as it is in other countries, and that the degree of recognition of dental anesthesiology was relatively low. To inform potential patients with severe dental fear of the possibility of dental treatment under sedation or GA, educational campaigns for dental anesthesiology are needed.

  We report a case of extensive cardiogenic cerebral infarction resulting in permanent disability arising from an interruption in oral anticoagulants before dental surgery. A 71-year-old woman with a history of atrial fibrillation and hypertension was scheduled to undergo an implant placement in the maxillary molar area. She had been taking warfarin (2 mg/day) to prevent thromboembolic events, and the dosage had been titrated to maintain an international normalized ratio of prothrombin time (PT-INR) of 1.7-2.1 for the last nine months. The patient was instructed not to take warfarin for four days before or on the day of surgery by her cardiologist, and warfarin was resumed on the day after surgery. On postoperative day three, she suffered a stroke and was admitted emergently. She presented with right hemiplegia and aphasia, and her Glasgow Coma Scale (GCS) score was 8 (E3V1M4). The PT-INR was 1.17 on admission, and brain magnetic resonance imaging showed an extensive hemorrhagic infarction in the territory of the left anterior and middle cerebral artery. Despite conservative treatment, the brain edema progressed and resulted in impending brain herniation requiring an emergent decompressive craniotomy, which was performed on the sixth day after admission. She was discharged to a nursing home with an improved GCS score of 11 (E4V2M6) but with residual dysphasia 50 days after admission. Recent professional guidelines recommend that anticoagulants not be discontinued in the most patients requiring dental extraction. Following such recommendations is crucial to prevent fatal thromboembolic events in patients receiving anticoagulants who require dental implants.

  Congenital indolent anhidrosis is an autosomal recessive disorder categorized as a hereditary sensory and autonomic neuropathy (HSAN), the symptoms of which include a loss of thermal and pain perception throughout the body, sweating disorders, decreased autonomic function, and mental retardation. We report a patient requiring intensive dental treatment under general anesthesia. The patient was a 20-year-old male (height, 163.8 cm ; weight, 41.7 kg ; BMI, 15.5). General anesthesia was required for the treatment of multiple dental caries and wisdom teeth removal because of coexisting mental retardation. Anesthesia was induced with remifentanil (0.2 μg/kg/min), propofol (4 μg/ml, estimated target concentration), and rocuronium (30 mg). The remifentanil and propofol doses were titrated to within 0.05-0.2 μg/kg/min and 2.0-2.5 μg/ml, respectively, so as to maintain a BIS value of 35-45. The intraoperative body temperature was maintained at 36.6°C-36.9°C using a warming device. The dental treatment required 3 hours to complete, and the patient recovered smoothly after the cessation of the anesthesia. This case required a relatively low dose of remifentanil, as shown by the BIS-guided titration. Previous reports have described the use of minimum doses of narcotics and sedatives during general anesthesia for patients with congenital painless anhidrosis. To avoid awareness and profound circulatory suppression, BIS monitoring was considered to be useful for titrating the anesthesia. In conclusion, our experience performing general anesthesia in a patient with congenital anhidrosis and pain insensitivity suggested that BIS-guided titration of the anesthesia dose was useful.

  Femoral Hypoplasia-Unusual Facies Syndrome (FH-UFS) is a rare congenital condition. We treated a 17-year-old woman with FH-UFS and hypoplasia in both legs and arms, micrognathia, and extreme trismus. The excision of the coronoid process under general anesthesia was planned to improve the extreme trismus. She had undergone general anesthesia on several occasions for the treatment of cleft palate, plastic surgery for her hands and legs, and scoliosis surgery.

  For the induction of general anesthesia, tracheal intubation was smoothly performed using a microscope inserted through the nasal cavity under sedation with the continuous injection of propofol smoothly. General anesthesia was maintained with air-oxygen-sevoflurane and the continuous injection of remifentanil without any remarkable episodes. We tried in vain to obtain an arterial line during the operation. After completing the operation, the patient was transferred to the intensive care unit (ICU) and the tracheal tube was removed on the following morning. No remarkable episodes occurred while the patient was in the ICU. FH-UFS is reportedly associated with a high maternal blood glucose level during gestation. However, only 38.2% of patients with FH-UFS are born from pregnant woman with high blood glucose levels, and other pathological background factors remain unknown. Our case was a typical case of FH-UFS, and no particular difficulties occurred except for the extreme trismus and the difficulty in obtaining an arterial line.

  Noonan syndrome is characterized by distinctive clinical features, including cardiovascular anomalies, mental delay and skeletal abnormalities. Orofacially, patients with Noonan syndrome have distinctive facial features that include ptosis of the eyelids, hypertelorism, and a low junction of the ears. Epilepsy is an occasional complication of Noonan syndrome. We describe the anesthetic management of a 15-year-old girl with Noonan syndrome. She had hypertrophic obstructive cardiomyopathy (HCM), mental delay, epilepsy and severe scoliosis ; she was scheduled to undergo dental treatment under general anesthesia. She had experienced daily hypoxia symptoms because of HCM as well as severe scoliosis. Our anesthetic goal was to provide an adequate preload and afterload. Anesthesia was induced with midazolam, propofol, fentanyl and rocuronium and was maintained with isoflurane and remifentanil. Intraoperative monitoring included noninvasive hemodynamic monitoring and direct monitoring of the arterial pressure. During surgery, we observed a unique tongue movement. The operation was completed uneventfully. After extubation, the stable spontaneous respiration of room air was achieved. However, she experienced epileptic symptoms during which her eyes were open and rolled back into her head, she gradually fell asleep, and her breathing was shallow and slow. She became hypoxic, but she recovered with the administration of positive-pressure ventilation. However, her Spo₂ decreased to 84%-88% upon spontaneous breathing only. To prevent hypoxia, respiratory support with non-invasive positive-pressure ventilation was provided for 40 minutes. Her spontaneous respiration recovered after she awakened from the epileptic symptoms. This case suggests that considerable attention is needed not just for the distinctive complications of Noonan syndrome, but for other possible complications such as epilepsy.

  We report a case of wide QRS tachycardia after the local administration of adrenaline to reduce bleeding in a patient under general anesthesia. A 77-year-old woman with suspected angina but no symptoms, such as chest pain, was scheduled to undergo a partial maxillectomy for a malignant tumor in the gingiva. The preoperative laboratory findings were normal, and an electrocardiogram (ECG) revealed a sinus rhythm. Anesthesia was administered with propofol and rocuronium and was maintained with air/oxygen sevoflurane (1.2%) and remifentanil. Before the start of surgery, the patient’s nasal mucosa was soaked with 1 : 100,000 adrenaline using a tampon to prevent bleeding, and 1% lidocaine containing 1 : 100,000 adrenaline was injected into the gingival mucosa for the surgery. About 10 min after soaking the mucosa with adrenaline and 5 min after the local injection, the patient’s blood pressure (BP) and heart rate (HR) suddenly increased and wide QRS tachycardia was observed on an ECG. The wide QRS tachycardia lasted intermittently for 22s, and the patient’s hemodynamic state then stabilized and spontaneously recovered to a sinus rhythm with a gradual decrease in BP and HR.

  In this case, the light anesthesia could have caused wide QRS tachycardia ; however, the surgery was at the stage of the gingival incision, so the depth of anesthesia was unlikely to have been the only problem. Sevoflurane has a lower risk of adrenaline-induced arrhythmia than other inhalation anesthetics, but some studies have shown the occurrence of arrhythmia caused by adrenaline administration in the head and neck region in patients under general anesthesia with sevoflurane. Therefore, the careful use of adrenaline in small amounts is required, and adrenaline-induced arrhythmias must be appropriately managed.

  Familial Mediterranean fever (FMF) is recognized as an autoinflammatory disease with repeated serositis as the main symptom. FMF is a genetic disease that is known to occur in the Arab world, Turkey, and Armenia, all of which are located in the Mediterranean coastal region. FMF is rare in Japan, and the estimated total number of patients is about 300 cases. We report a pediatric patient who developed a fever of more than 38 degrees Celsius after undergoing dental treatment with physical restraint and who received dental treatment under anesthetic management at our university hospital. The pediatric patient (5 years old) had been diagnosed as a typical case of FMF based on a genetic examination. Oral colchicine was administered to prevent fever. Dental treatment under monitored anesthesia care was requested by our pediatric dentist to prevent postoperative complications. The patient had no medical history other than FMF and was classified as ASA-PS 1. Intensive dental treatment was performed under the continuous infusion of propofol (10 mg/kg/h) and the intravenous injection of acetaminophen (255 mg) to prevent fever at the end of the anesthesia. The patient was observed by the pediatrician during the postoperative period, and no post-operative complications, such as fever, occurred.

  In pregnant women, non-obstetric surgery should be performed during an appropriate period to prevent congenital anomaly and to avoid miscarriage or premature labor. The second trimester of pregnancy is better for surgery because the risk of maternal, anatomical and physiological changes is lower. Neurotoxicity and the teratogenicity of anesthetic agents should be considered. In addition, blood flow to the placenta must be maintained during the surgery.

  We performed anesthesia for an 18-week pregnant woman who required a radical neck dissection because of the metastasis of tongue cancer. She was 29 years old, 160 cm tall, and weighed 46.1 kg. Before the induction of anesthesia, the patient was placed in a left half-lateral position by placing towels under the right lower back to avoid supine hypotension syndrome, as the patient complained of a sense of abdomen distension while in a supine position. Her face was twisted to the right to secure a surgical field. General anesthesia was induced with intravenous propofol, atropine, fentanyl and remifentanil. Two milliliters of 4% lidocaine was sprayed on the subglottic area and the glottis for topical anesthesia. A tracheal tube (ID, 6.0 mm) was intubated orally using McGRATH. The anesthesia was maintained with the inhalation of 1.5%-1.7% sevoflurane in oxygen (Fio₂, 0.4), as sevoflurane may be less neurotoxic to a fetus than isoflurane or desflurane. Ephedrine was administered intravenously to maintain blood flow to the placenta when the blood pressure decreased. The operation and anesthesia were completed uneventfully.

  After the operation, the obstetrician performed an ultrasonography examination to confirm that the fetus had good fetal movement and a normal pulse.

  Supernumerary teeth usually occur in the gingiva or jawbones and rarely in the nasal cavity. Computed tomography (CT) can be used for identification and diagnosis. Endotracheal intubation can introduce foreign bodies into the trachea, if such bodies are not detected before the induction of anesthesia. Herein, we report the case of a supernumerary tooth that fell into the pharynx during tracheal intubation. A 19-year-old woman was scheduled for a double jaw surgery. An oral surgeon scheduled the extraction of a supernumerary tooth in the maxilla after the double jaw surgery. The radiologist also pointed out the presence of a supernumerary tooth in the right nasal cavity on a preoperative CT image. However, the presence of the supernumerary tooth was not confirmed.

  Using a 7.0-mm diameter tracheal tube, we performed nasotracheal intubation via the right nasal cavity because of a narrow left nasal cavity. When the oral surgeon tried to remove the supernumerary tooth after the double jaw surgery, the tooth could not be found. A postoperative radiograph revealed the presence of the supernumerary tooth in the pharynx. After consulting an otolaryngologist, the patient was managed until the next morning with intubation under sedation with propofol and dexmedetomidine hydrochloride. The next day, the tooth was removed from the pharynx without complications. This case illustrates the importance of preoperative examinations, including CT imaging, before tracheal intubation.

  We treated a case of prolonged unconsciousness after general anesthesia. The patient was a 26-year-old woman who had epilepsy and a mild intellectual disability and who had been receiving ongoing treatment with a psychotropic drug and an antiepilepsy drug. General anesthesia was scheduled for the extraction of an impacted wisdom tooth during hospitalization. Intravenous midazolam was administered as a premedication, and general anesthesia was induced using remifentanil, propofol, and rocuronium. Cefmetazole, hydroxyzine, and pentazocine were infused during general anesthesia maintenance with remifentanil and propofol. The duration of operation was 80 minutes, and the duration of the general anesthesia was 160 minutes ; after the operation, she was returned to her room. Her level of consciousness was very clear at 60 minutes after the procedure, but she suddenly lost consciousness while in the lavatory. The unconsciousness persisted for 4 days after the general anesthesia without any abnormalities in her vital signs or neurological findings. Her attending psychiatrist diagnosed the prolonged unconsciousness as postoperative hypoactive delirium. Delirium is very rarely seen in young patient. However, if various combinations of triggers are present, such as the use of opioids and psychotropic drugs, postoperative delirium can occur even in young patients. When postoperative unconsciousness persists without any abnormalities in vital signs or neurological findings, postoperative hypoactive delirium should be suspected after a consideration of the possible triggers.

  Stellate ganglion block (SGB) is expected to be effective in treating various diseases including headaches. However, several reports have described the occurrence of headaches after SGB. We experienced a suspected case of a vertebral artery dissecting aneurysm triggered by an SGB.

  A 55-year-old woman had been treated with SGB and pharmacotherapy for left mandibular neuropathic pain after tooth extraction. SGB was performed using a paratracheal approach with palpation of the sixth cervical vertebra in a supine and cervical lordosis position. After 35 minutes of SGB, the patient changed from a supine to a sitting position and suddenly complained of severe headache. We suspected an intracranial hemorrhage, but no evidence of hemorrhage was observed using computed tomography imaging. Four days after the onset of the headache, a magnetic resonance angiography suggested a dissecting cerebral aneurysm with a length of 7.7 mm and a width of 5.1 mm in the right vertebral arteries. In cases of dissecting cerebral aneurysm rupture, the majority of cases report rupture within 3 days of the appearance of headache. However, no change in the size of the dissecting cerebral aneurysm or the exacerbation of the headache occurred in the presently reported patient.

  Dissecting cerebral aneurysms frequently occur in the vertebral arteries. Reportedly, the internal elastic membrane of vertebral arteries can easily be subjected to a load through slight extensions with daily cervical rotation, potentially resulting in the formation of dissecting cerebral aneurysms. In the presently reported patient, the dissecting cerebral aneurysm might have been caused by the load to the neck because of the cervical lordosis position and the change in position during SGB.

  Factors resulting in difficult ventilation during general anesthesia induction include bronchospasm, laryngeal spasm, lead pipe phenomenon, and anaphylaxis. Here, we report a case of difficult ventilation caused by an asthmatic attack during the induction of anesthesia.

  The patient was an 8-year-old girl with a previous history of bronchial asthma. Nine months earlier, the patient had undergone general anesthesia for the extraction of an excess medial impacted tooth, but the operation was discontinued because of a ventilation impairment immediately after tracheal intubation. We planned to perform general anesthesia once again for the extraction of the same tooth.

  A slow induction with sevoflurane at a higher concentration than that used previously was performed, but prior to intubation we had difficulty with the mask ventilation and intubation and requested support from medical anesthesiologists. Intubation was successfully performed and the difficult airway was improved by tracheal aspiration and the administration of adrenaline and β₂-agonist, but the operation was postponed. The patient was brought to the SICU under intubation, extubated after confirming that her respiratory condition was stable, and then returned to the general ward on the following day. She was discharged on the second day after anesthesia.

  This ventilation disorder may have been caused by an asthmatic attack brought on by residual airway hyper-responsiveness caused by a history of asthma. Another possible cause was anaphylaxis. Based on the previous anesthesia experience, we may have been able to prevent difficulties by administering corticosteroids and β₂ agonists before induction.

  Parotid gland swelling that occurs during general anesthesia is called anesthesia mumps. Although most cases of anesthesia mumps reportedly occur during general anesthesia, there are some cases of anesthesia mumps occurring during intravenous sedation. The mechanism for anesthesia mumps has not yet been elucidated. However, according to previous reports, anesthesia mumps are caused by various factors such as the effects of anticholinergic drugs on the autonomic nervous system, mechanical pressure on the parotid gland, and intubation damage. We treated a case with bilateral parotid gland swelling after dental treatment under intravenous sedation with propofol.

  The patient was a 39-year-old man (height, 180 cm ; weight, 75 kg) who was scheduled to undergo dental treatment under intravenous sedation because of a severe gag reflex. Intravenous sedation was performed using propofol. During the treatment, a large amount of saliva was secreted from the parotid papillae. However, no other problems occurred. After the completion of the dental treatment, the swelling of bilateral parotid glands was observed. We then consulted an oral surgeon, and he widened the bilateral orifice of the parotid papillae. A large amount of saliva was drained, and the swelling of the parotid gland was reduced somewhat. Axial magnetic resonance imaging performed on the first postoperative day (POD) showed bilateral parotid gland swelling and duct enlargement. However, no organic disorder in the parotid gland was observed. The parotid gland swelling disappeared on the twelfth POD.

  The enhancement of salivary secretion in response to propofol may cause swelling of the parotid gland.