【要旨】 日本歯科麻酔学会の会員として40年以上が経過し，理事としても17年間にわたって活動してきて，本学会のプレゼンスを上げ，学会の活動を通じて歯科界や国民に貢献するためには，日常の教育・研究・診療活動だけでなく，日本歯科医学会や行政など，学会の外での活動もまた重要であると実感していたなかで，厚生労働省のいくつかの役職を経験したことから，私なりに厚生労働省関連のいくつかの課題を推進することに取り組んだ．すなわち，「学会活動の成果によって歯科医学・医療の進歩に貢献する」ことから，さらに進んで「学会活動の成果によってわが国の歯科医療に価値ある変化をもたらす」ことを自身の目標に据えることとした．これらのすべての業務において，著者がこれまで本学会で得た知識や経験が大きな役割を果たし，本学会の見解や活動成果を多少なりとも反映させることができたのではないかと考えている．このような経験を踏まえ，現理事や委員会の委員長・委員の皆様だけでなく，これからの本学会のなかで中心的なメンバーとして活躍される若い先生方に，学会活動を背景とした社会貢献に興味をもって積極的かつ戦略的に取り組んでいただき，本学会のプレゼンスを一層高める努力をお願いしたいと考えている．

  Older patients with dementia often exhibit poor cooperation during dental treatment, necessitating intravenous sedation or general anesthesia. Evaluating sedation depth in patients with dementia is challenging, and deep sedation is often required to suppress body movement, posing a risk of oversedation. This report provides details of intravenous propofol sedation in a patient with Lewy body dementia.

  A 105-year-old woman (weight : 48 kg) required tooth extraction and oral cleaning owing to apical periodontitis. Considering her poor cooperation and communication difficulties, intravenous propofol sedation was selected. As the sedation effect was difficult to predict because of her advanced age, careful titration of propofol in small increments based on body movement was proposed. Sedation depth was assessed using the Modified Observer’s Assessment of Alertness/Sedation (MOAA/S) and electroencephalogram monitoring via SedLine^®.

  Sedation was initiated with 7 mg of propofol, followed by additional single-bolus doses based on the Patient State Index and MOAA/S scores (total propofol : 18 mg). The procedure was completed without complications, and the patient recovered from sedation to 60 min after the final dose.

  In this extremely older patient, propofol sedation was selected because of its rapid onset and recovery characteristics. SedLine^® allowed for continuous monitoring of brain activity, facilitating the prevention of oversedation. Despite using low-dose propofol, delayed recovery was observed, likely due to age-related changes in drug metabolism.

  Although only a minimal amount of propofol was used, sufficient sedation and prolonged effects were observed. Further research is warranted to optimize sedation management in this growing population of older patients with dementia.

  Hypertensive encephalopathy is a life-threatening condition caused by a sudden rise in blood pressure, leading to the failure of cerebral autoregulation and vasogenic edema. Proper preoperative blood pressure management is essential for the prevention of perioperative complications, yet the inadequate control of hypertension remains a major cause of surgery cancellations. We report a 63-year-old man with a history of hypertension and poor medication adherence who was scheduled to undergo an elective tumor resection under general anesthesia. Despite presenting with severe hypertension (203/106 mmHg) on the day before surgery, a decision to proceed with the surgery was made under the assumption that intraoperative blood pressure control would be sufficient. Upon entering the operating room, however, the patient developed dizziness, tremors, and impaired consciousness, and a hypertensive crisis (277/131 mmHg) occurred. The surgery was canceled, and he was transferred to the ICU for blood pressure stabilization. A neurological evaluation confirmed hypertensive encephalopathy, and MRI findings suggested a high risk of cerebral hemorrhage. After aggressive antihypertensive therapy, his condition stabilized ; he was scheduled to undergo surgery three months later. This case underscores the importance of early therapeutic intervention in hypertensive patients undergoing elective surgery. An over-reliance on intraoperative blood pressure control can lead to severe complications. Strict adherence to antihypertensive therapy, a comprehensive preoperative evaluation, and interdisciplinary communication are crucial for preventing similar incidents and for ensuring patient safety.

  Examining the anesthesia machine prior to administering general anesthesia is an essential procedure. Newer electronic machines have a computerized safety check that allows for the detection of most defects prior to use. However, breaks in the breathing circuit that go undetected during a leak test can lead to unexpected ventilation failures. In cases of ventilation failure during anesthesia, the respiratory circuit is usually replaced. Such requirements can expose the patient to life-threatening hypoxemia during the exchange of the circuit system. This report presents a case in which a leak test did not detect a defect in the breathing circuit, highlighting the need for vigilance and for additional safety measures in anesthesia practice.

  Intravenous indwelling needles are widely used in intravenous sedation and perioperative management for general anesthesia. We report two cases in which cracks were observed near the hub of indwelling needles. The first patient was a 47-year-old woman with dental phobia who was scheduled to receive dental treatment under intravenous sedation. Peripheral intravenous access was secured using the BD Insyte^TM Autoguard^TM BC Pro 24G, manufactured by Becton, Dickinson and Company. Immediately after initiating the infusion, fluid leakage was observed near the connection between the intravenous needle and the IV circuit. The intravenous needle was removed, and another intravenous needle was used to resecure the venous access. The second patient was a 39-year-old woman who was scheduled to undergo an intramaxillary foreign body removal after sagittal splitting of the mandibular ramus under intravenous sedation. An intravenous line was established using the above-mentioned product from the same company and an infusion was initiated ; immediately afterwards, however, the infusion began to leak from the indwelling needle. In both cases, the intravenous access was resecured, and intravenous sedation was performed without any subsequent problems. When the removed indwelling needles were examined, cracks were found near the hub of the indwelling needles in both cases. Safety inspections are necessary before using medical devices, but unexpected problems can occur. In such cases, both early problem recognition and appropriate responses are necessary.

  Head and neck photoimmunotherapy is a novel treatment for the local control of head and neck carcinoma that utilizes cetuximab sarotalocan-sodium (Akalux^®) and a laser system to target tumor cells selectively. Photoimmunotherapy has been associated with severe pain during laser irradiation and during the postoperative period, along with tongue swelling and laryngeal edema following surgery. We attempted to manage postoperative pain and airway complications in a patient who underwent photoimmunotherapy for recurrent maxillary gingival cancer. Akalux^® was administered intravenously on the day before the surgery. Anesthesia was maintained with sevoflurane, intravenous remifentanil, and fentanyl. Following a tracheostomy, intravenous patient-controlled analgesia (IV-PCA) with fentanyl (20 μg/h, bolus dose of 10 μg, lockout time of 20 minutes) was initiated. Infiltration anesthesia with 1.5 mL of 2% lidocaine was applied, followed by a needle puncture for irradiation. During the surgery, the patient received 1,000 mg of acetaminophen and 50 mg of flurbiprofen axetil intravenously, followed by infiltration anesthesia with 4 mL of 0.75% ropivacaine. The NRS score upon ICU admission was 5, but the score decreased to 1 after six hours of IV-PCA. IV-PCA was discontinued on POD 1, and pain management was switched to flurbiprofen axetil and acetaminophen. Since the NRS score remained below 2, we considered this multimodal approach to analgesia to have been effective. Additionally, Akalux^® has been reported to cause significant tongue swelling and laryngeal edema postoperatively. In the presently reported case, a prophylactic tracheotomy successfully prevented airway complications after surgery. Multimodal pain management was effective for managing postoperative pain in a patient with oral cancer who underwent photoimmunotherapy.

  Microvascular angina (MVA) is caused by structural and functional abnormalities in microvascular coronary arteries smaller than 100 μm ; it is also known as coronary microvascular dysfunction (CMD). These abnormalities are difficult to visualize using coronary angiography, making the diagnosis of MVA challenging. We report a case of MVA that was diagnosed after the occurrence of chest pains during dental treatment under intravenous sedation. The patient was a 58-year-old man (height : 165 cm, weight : 60 kg, BMI : 22.0) with a history of a hyperactive gag reflex requiring intravenous sedation for dental treatment. Three years earlier, he had experienced chest pain during dental treatment, but a coronary spasm provocation test was negative and CMD was not evaluated. On the day of the presently reported treatment, the patient had stable vital signs. Propofol sedation and local anesthesia were administered. Shortly thereafter, he experienced nausea, convulsions, dizziness, and chest pain. The sedation was stopped, and the administration of sublingual nitroglycerin resolved his symptoms. He was transferred to the emergency room. A coronary angiography revealed no significant stenosis, and a coronary spasm was ruled out. An evaluation of coronary microvascular function showed a coronary flow reserve (CFR) of 2.3, an index of microvascular resistance (IMR) of 28, and a fractional flow reserve (FFR) of 0.91/0.91, leading to a diagnosis of MVA. This case highlights the need to consider MVA in patients with unexplained chest pain. Assessing coronary microvascular function is crucial for avoiding missed diagnoses and ensuring appropriate management.

  Multiple system atrophy (MSA) is a neural degenerative disease, mainly of the cerebellar-extrapyramidal tract-autonomic nervous system. Complications of perioperative management include cyclical fluctuations due to autonomic dysfunction, upper airway obstruction due to vocal cord paralysis, and prolonged effects of muscle relaxants. We encountered two cases of general anesthesia in patients with MSA with different clinical findings. Case 1 involved a 79-year-old man scheduled for implant removal. He had been diagnosed with MSA 6 years previously and had recurrent fainting spells due to orthostatic hypotension. During anesthesia induction, transient hypotension was observed ; however, no excessive hypotension due to the vasopressor was observed intraoperatively. After surgery, sugammadex was administered, and the patient was extubated.

  Case 2 involved a 65-year-old man who was scheduled for epulis resection and extraction. Preoperative otolaryngological examination revealed asymmetry in vocal fold movement. After the surgery, sugammadex was administered and sufficient spontaneous respiration was confirmed. The patient was extubated and it was confirmed that there was no limitation of vocal cord movement. Both two patients were discharged with no problems.

  It is estimated that approximately 12,000 individuals in Japan are affected by MSA, and it is anticipated that the disease will emerge as a clinical concern in the future.

  Patients with MSA have various symptoms that differ with individuals ; therefore, it is necessary to accurately assess a patient’s general condition through detailed interviews and anesthesia planning.

  Spinal muscular atrophy (SMA) is a progressive motor neuron disease characterized by the degeneration of anterior horn cells in the spinal cord. Anesthetic management in patients with SMA presents challenges such as respiratory muscle weakness and heightened sensitivity to muscle relaxants. This study reports a case of general anesthesia management in a patient with type Ⅱ SMA.

  A 22-year-old woman underwent wisdom tooth extraction under general anesthesia. Neuromuscular monitoring was performed at two sites : the ulnar nerve-abductor digiti minimi and the facial nerve-corrugator supercilii. Following administration of 10 mg rocuronium bromide, the train-of-four count (TOFc) was 0 at the abductor digiti minimi, while the corrugator supercilii maintained a TOFc of 4. However, sufficient muscle relaxation was achieved to allow successful nasal intubation. Postoperatively, the neuromuscular blockade was reversed with sugammadex sodium, and the patient recovered and was extubated without complications.

  In general anesthesia for SMA patients, the ulnar nerve-abductor digiti minimi demonstrates higher sensitivity to muscle relaxants compared to the facial nerve-corrugator supercilii. Monitoring the ulnar nerve-abductor digiti minimi may offer a more reliable assessment of the optimal timing for intubation. The reversal of neuromuscular blockade with sugammadex sodium is effective ; however, extubation should be carefully assessed using both neuromuscular monitoring and clinical indicators, such as adequate ventilation volume, to ensure a comprehensive evaluation.

 【要旨】 神経ブロックとは末梢神経の近傍または神経束に針を刺入して，局所麻酔薬，神経破壊薬，高周波熱凝固法などによって神経機能を一時的，または長期的に遮断する方法である．九州歯科大学附属病院歯科麻酔・ペインクリニック科でよく行われる神経ブロック療法である星状神経節ブロック，三叉神経ブロック，トリガーポイント注射について解説する．

 星状神経節ブロック：頸部交感神経周囲に局所麻酔薬を注入するコンパートメントブロックである．交感神経活動亢進が関与する疼痛性疾患のみでなく麻痺性疾患にも使用される．痛覚変調性疼痛への治療効果の可能性もある．合併症を避けるために，超音波ガイド下に行う．

 三叉神経ブロック：カルバマゼピンによる薬物療法が奏功しない症例に対して行われる．当科では微小血管減圧術，ガンマナイフ治療を受けても疼痛コントロールができない症例に用いられることが多い．神経幹にブロック針を刺入し，神経破壊剤，高周波熱凝固で神経を破壊する．超音波ガイド，エックス線透視下に神経孔を明示して行われる．

 トリガーポイント注射：筋・筋膜性疼痛の治療法である．筋硬結内にあるトリガーポイントに局所麻酔薬を注入して痛みの悪循環を断つことで痛みを軽減する．筋・筋膜性疼痛への筋膜の関与が明らかとなっており，筋膜リリースを併用する．筋膜リリースは筋体周囲の筋膜の重積を生理食塩水，局所麻酔薬で剝離する．いずれも超音波ガイド下に行う．

 【要旨】 口腔・顎顔面領域手術は一般的に強い術後痛と高い術後合併症リスクを伴う．高侵襲手術に対して術後鎮痛はオピオイド持続静注が一般的だが，投与量が多くなると致命的合併症のリスクを高めるため，オピオイド投与量を抑えた鎮痛法の確立が求められている．安全で有効な術後鎮痛を実現するためにはマルチモーダル（多様式の）鎮痛が推奨され，その一環として，超音波ガイド神経ブロックが注目されている．本手技は術後の疼痛スコアやオピオイド消費量を低下させるというエビデンスが複数報告されている．筆者自身でも献体を用いた超音波ガイド下歯槽神経ブロックの効果範囲を検証する研究を行っており，より安全かつ効果的な方法を探求している．本稿では超音波ガイド神経ブロックの手技解説とともに，マルチモーダル鎮痛の柱としての可能性について論じる．

 【要旨】 「歯科口腔保健の推進に関する法律」（2011年施行）は，国民の口腔の健康保持や歯科疾患の予防を推進し，国民保健の向上を目的とするもので，これを受け全国で歯科保健関連の条例制定が進んだ．さいたま市もその流れに沿い，2012年12月に条例を制定し，口腔保健施策を強化している．

 同法および条例では，障害者が歯科医療を受けやすい環境を整えるよう，地方自治体に対策が求められている．このため，さいたま市では「（仮称）さいたま市口腔保健センター」を整備することとなった．また，妊娠中の歯科疾患予防や高齢者の口腔機能の維持・向上に関する施策が法・条例に規定され，妊婦や71歳以上の高齢者を対象とした新たな歯科健診も開始されている．

 このように，従来のライフステージに応じた歯科健診事業の延長上にありつつ，国会や地方議会の議論を経て制定された基本法や条例は，住民に身近な地方公共団体の歯科保健施策をさらに充実させる役割を果たしている．