Hyperthyroidism has some general symptoms such as remittent fever with chill, palpitation tachycardia, hyperhidrosis and anxiety neurosis. We herein report a case of a female patient with mental symptoms associated with hyperthyroidism following treatment for subacute thyroiditis where consequent treatment and prognosis of her oral disease was affected. The patient is a 51-year-old female who was treated for subacute thyroiditis with some post-therapeutic subjective symptoms associated with hyperthyroidism. It appeared that these symptoms, especially anxiety about diagnosis and treatment of her oral disease, resulted in her negligence to visit a dental clinic even though the swelling in the right side of the mandible had persisted for the past five years. Since the swelling and pain of the mandible worsened, she sought medical attention at a dental clinic and was referred to our hospital. We diagnosed her to be suffering from osteomyelitis of mandible that extended from the apical lesion of the right mandibular molars confirmed from evaluation of her oral conditions and X-P, CT and MRI images. After administration of antibiotics, the acute inflammatory symptoms subsided. However, surgery was required for tooth extraction and corticotomy of the mandible, informed consent was obtained and she underwent successful extraction of the molars and corticotomy of the mandible. We considered that her delay in seeking medical attention affected her dental treatment. If she had sought medical attention examination earlier, such surgery might have been unnecessary. It is of importance that we clinicians should pay much attention to the mental symptoms associated with hyperthyroidism when we treat a patient with past history of thyroid function disorder.

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In recent years, dental implant treatment has become a well accepted and practiced surgical procedure in dentistry, due to its technological advancements. But we must carefully decide if this treatment is applicable to the patient since implant surgery involves risks for patients with systemic diseases. We herein describe and report two cases where we were faced in making such decisions in their management.
Case 1: A 36-years-old woman scheduled for implant treatment was diagnosed with hypertension, hyperlipidemia, Sturge-Weber syndrome (mental retardation, epilepsy, glaucoma) and severe obesity (height: 155cm, weight: 155kg). Since complications due to the time requirement for surgery was anticipated, the patient underwent implant surgery under general anesthesia.
Case 2: A 57 years-old man diagnosed with unstable angina, old myocardial infarction and diabetes mellitus, with past history of paroxysmal atrial fibrillation and cerebral infarction underwent implant surgery under local anesthesia and intravenous sedation.
The importance in understanding systemic diseases and proper selection of treatment according to the clinical situation of the patient for implant surgery are mandatory and of extreme importance. The 2 cases with serious systemic diseases indicated that successful implant treatment depends largely on establishing a good rapport with the patient, attaining patient cooperation, and practitioner's experience.

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Inflammatory change is known to involve and occur in the masticator space, but due to the complicated anatomical configuration of the space, pathological diagnosis and treatment approach to lesions in this area is very difficult. The patient was a 30-year-old pregnant woman who underwent left lower third molar extraction at a dental clinic under the suspicion of pericoronitis. Six days following extraction of the wisdom tooth, the patient delivered and one months after delivery the patient complained of severe pain in the vicinity of the site of extraction. Swelling of the mandibular angle and trismus were noted and she was referred to our department for evaluation. Her clinical course, physical findings and CT images indicated mandibular inflammation. Oral administration of antibiotics of the penicillin group was selected and commenced. However, long-term antibiotic administration revealed no satisfactory improvement of her condition. Therefore we performed surgical extirpation of the lesion located between the superficial and deep layer of the masticator (muscle) under general anesthesia. The pathological examinations revealed diagnosis for mandibular actinomycosis. Most (Majority) of abscesses located in the masticator space originate from the mandibular molar, while the most impressive clinical finding is identified between the submandibular region and temporal fossa, where acute and chronic symptoms are sometimes encountered. In this case we performed various staining methods to isolate and confirm the pathogenic organism that caused the tissue invasion and to establish the diagnosis for this patient.

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Tracheostomies performed on nineteen patients with terminal stage oral cancer in our department between April, 1996 and March, 2002 were clinically evaluated. The results were as follows:
1. Tracheostomies were performed on 14 (73.7%) males and 5 (26.3%) females. The mean age of the patients was 67.1 years, ranging from 19 to 90 years. Recurrence sites were: the cervical region in 12 cases and oral or oro-cervical regions in seven cases.
2. Tracheostomies were performed on 12 cases (11 cases with local anesthesia and 1 case with combination of local anesthesia and intravenous sedation with a minor tranquilizer) in the ward or the treatment room and 7 cases (3 cases with local anesthesia, 4 cases with general anesthesia) in the central operation room.
3. The criteria for indication of tracheostomy were: difficulty in expectoration of sputum in nine cases, upper airway obstruction in nine cases and one case for management of homeostasis.
4. As for pre-operative cervical findings for all the cases revealed that the trachea was palpable in 18 cases (94.7%) and the cervical extension was possible in 14 cases (73.7%). There was one case of respiratory arrest and one case of acute airway obstruction as an intra-operative incident (episode) encountered, in spite of all the precautions exercised. Conclusively, we postulated that pre-operative findings of the cervical region are important factors in deciding the timing of surgery and for the avoidance of intra- and post-operative complications.

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Summary: We herein report our experience in treatment for carcinoma of the tongue in an advanced age pregnant woman expecting her first child birth (delivery).
The patient is a 38-year-old female who was referred to our hospital with an ulcer locate on the right lateral margin of her tongue on October 5, 1998.
Since there were many matters that had to be considered in establishing a protocol for surgery and since this was her first child birth at an advanced age, we cooperated with her obstetrician with the initiative based on giving birth safely. Thus, informations were constantly exchanged between her obstetrician and the dental team.
The patient's course of pregnancy was stable (24^th week of gestation) which was determined by her obstetrician, we decided to commence treatment.
The results of scrutinization, since the stage of her illness was in the initial stage (T1N0M0), she was admitted to our hospital on October 19, 1998, and underwent partial resent of the tongue under local anesthesia. Through the advice of her obstetrician, postoperative medication was administered only when required. β2-stimulant (UTEMERIN) was administered through the directions of her obstetrician for prevention of threatened abortion. Postoperative progress observation was favorable and she gave birth to the boy safely in March, 1990.
After the delivery, we consulted with her husband and obstetrician and notified her on the true nature of her disease. Since it was after delivery and she was mentally stable, she was not greatly disturbed.
There is no sign of recurrence or transition and her progress is good after 5 years and 7 months from surgery.

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A 46-year-old woman was referred to our hospital on September 19, 2001, with a chief complaint of swelling of the left parotid gland. She first noticed the lesion 3 years prior to this visit. She had a medical history of hyperthyroidism. Laboratory examination data revealed that her TSH was 0.05μU/ml; 1.3ng/ml for T3; 4.30pg/ml for FT3; 10.5μg/dl for T4 and 2.11ng/dl for FT4, indicating that her thyroid function is well controlled with propylthiouracil (Thiuragyl^®).
Clinical examination revealed a 40×45mm painless swelling in the left parotid gland. Magnetic resonance imaging (MRI) revealed that the tumor was of low intensity in the T1-weighted image, and of high intensity in the T2-weighted image. Clinical diagnosis of parotid tumor was established. On October 18, 2001, superficial parotidectomy was performed under general anesthesia, in order to resect the tumor with an adequate surgical margin and to manage the patient under a stress free-condition. Her blood pressure was controlled at 85-95/45-55mmHg, with a heart rate of 60-80/min during the operation. Methimazole (Mercazole^®) (30mg) was infused intravenously. The post-operative course was uneventful without any symptom of thyrotoxic storm. There was no evidence of recurrence at 2 years and 10 months postoperatively. Histopathologically, the tumor demonstrated a reticular growth pattern; and the tumor cells were polygonal to relatively short spindle-like in shape with uniform appearing oval to round nuclei. Diagnosis of ‘myoepithelioma reticular variant’ was established pathologically.

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We herein report a case requiring dentaltherapy where the patient was diagnosed with borderline personality disorder. Dental work ups were performed under intravenous sedation. Managements of such patients with an immature mental state are often challenging.
The patient was a seventeen years old female, with a height and weight of 161cm and 42kg, respectively. She had refused intake of food from the age of thirteen and had been under medical care of the pediatric department, after repeated episodes of self-mutilation, she was placed under psychiatric care. The psychological diagnosis made was borderline personality disorder. At present she is taking five types of minor tranqulizers and drugs that promote nutritional intake.
The surgical plan that we selected was to extract her wisdom tooth separately from the surgery for pericoronitis. The first surgery was for the extraction of her right superior and inferior wisdom teeth. Midazolam and ketamine were used as medicaments for sedation. Sedation was induced successfully however when the local anesthesia was administered onset of personality disorder manifested and propofol was administered to complete the surgery. On her way back to the ward, breath-holding spells appeared and SpO₂ fell to 74%. Artificial respiration (Mechanical ventilation) was promptly commenced. The state of apnea persisted and spontaneous respiration did not return for an hour.
From our experience with her first surgery, propofol was selected for the second sergery. As with the first surgery, on her way back to the ward, breath-holding spells appeared and SpO₂ dropped to 56% and her consciousness became delirious with signs of cyanosis. Artificial respiration (Mechanical ventilation) was commenced since the state of apnea persisted and spontaneous respiration did not return for an hour.
On both occasions surgery and dental treatments were successfully completed and she was discharged. We are still corresponding with the patient regarding her ongoing treatment at the hospital.
Dental anesthesiologists must offer a safe environment involving various methods of dental treatment in patients with psychiatric disorders. We also recognize the importance of establishing a good rapport with the patient and assisting and supporting the patient in stabilizing the mental state of these patients.

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Cases with problems associated with intravenous sedation administered at the Nippon University School of Dentistry Hospital in Niigata from 1998 to 2002 were selected in order to examine and to evaluate how to cope with these problems.
1. The number of cases where intravenous sedation was administered in 1998 was 228 and has continued to increase thereafter.
2. The number of cases that required intravenous sedation for more than two hours accounted for 3.2% of all cases evaluated. Our findings revealed that the cases requiring more than two hours of intravenous sedation were associated with a higher incidences of systemic complications than the cases that required less than two hours of intravenous sedation.
3. The problems revealed for the cases that required intravenous sedation for more than two hours were due to the stress of lying still in the same position for many hours, wearing off of or withdrawal from local anesthetic effect, and dehydration due to insufficient fluid hydration.
From the above results, it is important to establish a patient management system that is based on the fundamental concepts and basis to offer safe and comfortable dental care to the patients where surgical time is to be considered in the management system. It is also important to create an environment where patients can express their views openly where the attending doctors should respond to them promptly and adequately.

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