This survey investigated the availability of nerve block using mepivacaine hydrochloride solution for dental treatment. One hundred and eight consenting patients aged between 16 and 80 years who required a nerve block for dental treatment participated in this survey at one of five hospitals accredited by the Japanese Dental Society of Anesthesiology. The patients included 45 males and 63 females. Eighty-seven patients underwent tooth extraction. The nerve block included the inferior alveolar nerve block (n=106), the posterior superior alveolar nerve block (n=1), and the nasopalatine nerve block (n=1). For the inferior alveolar nerve block, 1.8 ml of mepivacaine hydrochloride solution was administered to 82 patients. The onset time was 4.5±2.0 min, and the duration was 166.3±75.4 min. Sixty-eight patients felt no pain, and 23 patients felt negligible pain. A nerve block using mepivacaine hydrochloride solution was evaluated as being effective in 100 patients and somewhat effective in 5 patients. No adverse events, including hemorrhage, were reported. Nerve block using mepivacaine hydrochloride solution was evaluated as being available for 105 patients. As a result, nerve block using mepivacaine hydrochloride solution was evaluated as being both effective and available in 100 patients. Nerve block using mepivacaine hydrochloride solution for dental treatment should be considered, since many dental patients have cardiovascular comorbidities in Japan's superaged society and this trend is likely to continue.

  Purpose : Articaine hydrochloride is commonly used as a local anesthetic for dentistry in many countries. However, this compound has not been approved for use in Japan. To support the approval of articaine hydrochloride and adrenaline bitartrate (OKAD01) in Japan, we performed a phase Ⅰ clinical trial to clarify the pharmacokinetics and safety of injecting OKAD01 into the oral mucosae of healthy Japanese adults.

  Methods : The subjects were healthy Japanese male adults. One (1.7 ml) or 3 cartridges (5.1 ml) of OKAD01 were injected into the oral mucosae of 6 subjects each. The blood concentration of articaine was measured before the injection and at 15 min, 30 min, 60 min, 2 h, 4 h, 12 h, and 24 h after the injection. Clinical laboratory tests and vital sign measurements were also performed, and adverse events were evaluated during this clinical trial.

  Results : In the 1-cartridge trial, the maximum blood concentration (Cmax) and the time taken to reach it (Tmax) were 374.35±97.65 (252.7-514.5) ng/ml and 0.25±0.00 (0.25-0.25) h, respectively (mean±SD (minimum-maximum)). In the 3-cartridge trial, the Cmax and Tmax were 694.00±175.23 (517.9-970.4) ng/ml and 0.42±0.13 (0.25-0.5) h, respectively. Regarding adverse events, we encountered 1 case of headache in the 1-cartridge trial ; however, this event was not thought to be associated with the OKAD01 injection.

  Conclusion : Injecting OKAD01 into the oral mucosae of healthy Japanese adults resulted in a Cmax of <5.0 μg/ml and did not cause any adverse events. This study demonstrated the safety and tolerability of OKAD01 in the Japanese population.

  We treated 10 cases requiring tooth extraction prior to undergoing cardiac surgery at a cardiovascular hospital during a 17-month period from January 2018 to May 2019.

  We visited the patients in the hospital to extract teeth with advanced marginal periodontitis (defined as the presence of pocket depth ≥6 mm and bleeding), teeth with acute periodontitis based on the patient's history, residual teeth with significant damage, and teeth with impending infection. The cardiovascular functions of the patients with cardiovascular diseases were assessed using RCRI. Teeth are typically extracted under intravenous sedation at dental hospitals for patients without active cardiac conditions. For patients with active cardiac conditions, however, we visited the cardiovascular hospital and performed the extractions on site.

  We retrospectively assessed 10 cases according to the National Surgical Quality Improvement Program (NSQIP) and Gupta Perioperative Cardiac Risk (GUPTA). We assumed that a risk of ≥3.0% as per the NSQIP and GUPTA was a criterion for alternate strategies for noninvasive treatment or the extraction of teeth at a cardiovascular hospital. Although intravenous sedation was valuable in stabilizing the hemodynamics of the patients with heart disease, monitoring them for at least 1 hour after tooth extraction was necessary. Visiting patients at a cardiovascular hospital for tooth extraction is the safest way of managing cardiovascular conditions during perioperative management. However, it is critical to consider the difficulty in performing dental treatments at bedside in cardiovascular hospitals. Discussions regarding the site of tooth extraction, the number of tooth extractions, the prescription of medicine, and necessary changes because of dental phobia should be conducted with the cooperation of both the cardiovascular hospital and the dental clinic. It is important to perform tooth extractions cautiously, considering the physical conditions of the patients. Moreover, dental anesthesiologists should manage the perioperative tooth extraction.

  The patient was a 45-year-old male with right-side tongue cancer (T4aN2b) ; general anesthesia had been planned for a tracheostomy, bilateral radical neck dissection and reconstruction with a rectus abdominis muscle flap. Three days before the scheduled operation, the tumor started bleeding and a tracheotomy was performed under intravenous sedation to prevent airway obstruction resulting from blood clotting. The day before the scheduled surgery, extensive pneumomediastinum and subcutaneous emphysema were identified on a chest computed tomography (CT) image, and the planned operations were deferred. One week later, the size of the pneumomediastinum had clearly decreased, and the operations were performed as previously planned. During the operations, the internal airway pressure was kept lower to prevent tension pneumomediastinum, and after the operations, the patient was sedated with the continuous injection of dexmedetomidine. The operations were performed without any further events, and the postoperative course was also uneventful. In this case, one of the causes of the pneumomediastinum and subcutaneous emphysema was considered to be air leakage or air aspiration into the soft tissues of the neck and the mediastinal space through the tracheostomy wound as a result of events related to a higher airway pressure, such as cuffing. The frequency of pneumomediastinum and subcutaneous emphysema after tracheostomy is relatively rare. However, these complications after a tracheostomy require careful attention.

  Oral and maxillofacial surgery is rarely performed with the patient in a prone position, since the risk of serious complications is increased for patients receiving general anesthesia in this position. Here, we report a case of safe general anesthesia management for an obese patient who was atypically treated in a prone position.

  A 53-year-old man with a body mass index of 33 kg/m² had undergone a mandibular resection for the treatment of oral cancer 2 years previously. To improve postoperative oral dysfunction, iliac bone harvesting and bone grafting surgery were planned with the patient in a prone position under general anesthesia. The case was reviewed by the attending dentists, nurses, and medical appliance vendors. The procedure was carefully simulated using a simulated patient in a prone position on the day before the actual surgery. Anesthesia was induced rapidly, and nasotracheal intubation was performed. The patient was placed in the prone position smoothly and was repositioned in the supine position after bone harvesting without any difficulties. While the patient was in the prone position, the cardiac output and stroke volume decreased, but the respiratory and circulatory dynamics were stable throughout the time spent with the patient in a supine position, even during the changing of positions. The patient was extubated once fully awake, and no postoperative complications were reported. Performing surgery with the patient in a prone position often increases the risk of serious complications because of risk factors for complications, limited surgical experience, and unfamiliarity with appliances. In this study, the preoperative simulation was thought to have helped to prevent complications. During respiratory care, low tidal volume ventilation with PEEP is recommended, and it is important to understand the hemodynamics of patients in a prone position. These considerations enable a safer and smoother general anesthesia management.

  Cryopyrin-associated periodic syndrome (CAPS) is an autosomal dominant inherited disorder characterized by repetitive systemic inflammation. The representative symptoms include fever, fatigue, rashes, headaches and arthralgia, which appear as familial cold auto-inflammatory syndrome (FCAS). FCAS symptoms are triggered by cold stimulation and continue for a few hours or several days. We experienced a surgical case of a 13-year-old female with FCAS. The patient had been treated with canakinumab (IL-1 inhibitor) every two months in the winter, and her symptoms were under control. Since a reduction in body temperature was a concern, we planned to monitor the patient's temperature intraoperatively at the axilla, superficial temporal artery, and rectum. We started by prewarming the patient using a forced-air warming system before the anesthesia induction. General anesthesia was maintained with air-oxygen-sevoflurane and intravenous remifentanil. The initial axillary temperature was 36.0℃, but her temperature rose to 37.6℃ at 45 minutes after the anesthesia induction. The superficial temporal artery temperature rose gradually from 36.6℃ to 37.1℃. The rectal temperature was stable at between 37.4℃ and 37.5℃ throughout. The temperature at these three locations differed by as much as 2℃ at the start of surgery, but the use of forced air warming decreased this difference to 0.4℃ at 60 minutes after the anesthesia induction. The durations of the surgery and anesthesia were 37 minutes and 1 hour, 17 minutes, respectively, and a low body temperature was successfully avoided. The patient was discharged from hospital on the following day without any symptoms of FCAS.