The authors evaluated the medical emergencies accepted at the ambulatory section of Hokkaido University Dental Hospital (presently Hokkaido University Hospital Center for Dental Practice) which required urgent medical attention of the Department of Dental Anesthesiology during the period from January 1998 to September 2003, a period of five years and nine months.
The number of cases evaluated during this period was 22 cases and the incidence of the medical emergencies among the outpatients was 0.003%. As for the site of occurrence of medical emergency, 4 cases occurred before dental treatment in the waiting rooms, 4 case during transportation from the medical school hospital, 16 cases occurred in the treatment rooms and 1 case after dental treatment at the entrance of the hospital. Among the cases that occurred in the treatment room, local anesthesia was administered in 11 cases and local anesthesia was not administered in 5 cases. As for the causes of medical emergencies: vasovagal reflex (6 cases), epileptic attack (4 cases), and anginal attack (3 cases) were commonly observed. Among the 22 cases, 17 cases were medically compromised.
Before the arrival of dental anesthesiologists, treatments of some sort were performed in 12 cases but no treatments were performed in 10 cases. The treatments performed by dental anesthesiologists were as follows: pharmacological agents were administered in 9 cases by dental anesthesiologists, only venipuncture and/or oxygen therapy was performed in 8 cases, only observation in 3 cases, and foreign body removal was attempted in 2 cases. Improvements in symptoms were comfirmed in all cases and there were no patients that deteriorated into a critical state.
It was clarified in this study that medical emergencies occurred not only in the treatment room but also in the waiting room and in the entrance of the hospital. It is important that all hospital personnel must always be observant with the patient's general condition. Since medical emergencies tend to occur in slightly invasive dental treatment settings without local anesthesia, it is important to prepare preventive measures for medical emergencies for all dental treatments. At the time of occurrence of medical emergency, before the arrival of dental anesthesiologists, no treatments were performed in many cases. It is necessary to educate all hospital personnel that vital signs should be checked during medical emergency no matter where it occurs. In addition, since there were many cases related to anxiety or stress concerned with the dental treatment, more dental treatments should be performed under sedation.

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We herein present our experience with tooth extraction performed in conjunction with intravenous sedation using midazolam while monitoring the patients' physical condition as general management for patients in the 1^st and 3^rd month after percutaneous coronary intervation (PCI) for myocardial infarction.
Concerned with the commencement of dental treatment for postmyocardial infarction patients, it is generally postulated in clinical practice that within 6 months from onset of myocardial infraction symptoms, invasive procedures are contraindicated or only symptomatic treatments are permissible. In the two cases that we describe herein, treatments were performed since the Division of Cardiovascular Disease evaluated that the patients' cardiac function was stable after receiving PCI, the dental treatment was postponed for six months after the onset of myocardial infraction symptoms or it would have interfered with the patients' daily life. PCI is possible under local anesthesia and its surgical stress is relatively small, so as to the result, early recovery can be expected. Furthermore, with the use of stents, reduction (decrease) in risk of reinfarction can be speculated. In both cases, there were no deterioration in cardiac function, difficulty in maintaining hemostasis and postoperative hemorrhage (bleeding) observed during and after the operation, and satisfactory results were obtained.
It is of major importance that the medical planning for patients with myocardial infarction, whose number is speculated to increase in the future, be taken into account during consultation by the presiding doctors for the improvement of the patients' quality of life and their general condition.

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Diclofenac sodium (Voltaren^®) had been frequently administered for menstrual pain, and post tooth extraction pain alleviation by patients even though there are risks of allergic reactions. The patient was a 30 year-old woman with body weight of 45kg and a height of 156cm. Neither the patient's past medical nor family history revealed any relevant information. As to the present illness, the patient sought medical attention at our institution for periodontitis of the right mandibular third molar 19 months ago. Cefuroxime axetil (Oracef^®) and loxoprofen sodium (Loxonin^®) were administered, which did not have any adverse effects to the patient. At the request of the patient, tooth extraction was performed under infiltration anesthesia by administering 2.7ml of 2% dental lidocaine with 1: 80000 epinephrine after induction of topical anesthesia. The tooth extraction was uneventful and took approximately 10 minutes to complete. Fifty minutes after tooth extraction, the patient took 250mg of Oracef^® and 50mg of Voltaren^®, and 45 minutes later the patient visited our institution again due to chill sensation. The patient experienced nausea, facial pallor, lapses in consciousness, acrotism, severe abdominal pain and watery diarrhea. The patient was immediately placed on fluid therapy, and 500mg of hydrocortisone sodium succinate (Solu-Cortef^®) and 20mg of scopolamine butylbromide (Buscopan^®) were administered intravenously. The patient recovered in approximately 25 minutes: blood pressure 112/82mmHg, pulse rate 64 beats/minute, SpO₂ 100% and axillary temperature 37.2°C. Cutaneous symptoms and dyspnea were not confirmed. Lymphocyte stimulation test revealed a positive reaction to Voltaren^®.
Needless to say, it is important to ascertain allergic predisposition, allergy history and medication history to avoid allergic reactions and shock. However, since this patient was taking a separate selfadministered analgesic the allergic reaction could not have been avoided.

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Pyogenic granuloma is a lesion with hyperplasia of granuloma tissue and commonly arises in the skin and the mucosa. In the oral region many causes were reported, but no definite opinion has been described.
We herein report a case of pyogenic granuloma which occurred on the dorsal surface of the tongue in a 65-year-old who has a poor controlled diabetes mellitus. The findings of the tumor was elevated, appeared to be elastic and soft, measuring 15×8×10mm in dimension, had a granular red surface and easily bled. It was excised under general anesthesia and the recurrence has not confirmed (observed/seen). It was suspected that the poor controlled diabetes mellitus had helped the growth of pyogenic granuloma.

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There are various methods of the surgical treatment for recurrent anterior luxation of the temporomandibular joint. The optimal treatment should be selected after a thorough consultation by the patient, the family, and the request of doctor with consideration of the patient's age, the physical state of the patient, etc. We herein describe the surgical treatment for bilateral recurrent anterior luxation of the temporomandibular joint in an elderly patient. A 91-year-old male patient was referred to the Department of Dentistry and Oral Surgery at Toho Hospital, with chief complaint of being unable to close his mouth. The clinical diagnosis of bilateral anterior luxation of the temporomandibular joint was made, and the patient underwent the Hippocrates operation. But luxation remained after surgery therefore surgical intervention with the Buckley-Terry method was performed in order to block condylar translation, under local anesthesia. There were no evidences of recurrent luxation for approximately one month after surgical treatment at which time the patient passed away due to old age.

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When intravenous sedation is administered to patients under continuous administration of benzodiazepine drug, there are some difficulties in determining the quantity and the kind of agents to be used sedation due to the problem of drug resistance. We conducted a comparative study between patients under continuous administration of benzodiazepine (n=8) and patients without drug administration for determining the difference in intravenous sedation administered at an affiliated hospital of Nippon Dental University, Niigata School of Dentistry.
As to the results, among the cases where optimal sedation was obtained with midazolam and where an increase in dosage or where a change to another agent was needed, there were no clear trend in the quantity and in the administration of the kind of oral medication observed. Moreover, considering that there are significant individual differences in the pharmacological clinical effect of benzodiazepine, it was considered to be difficult determine drug resistance of orally administered pharmaceutical drugs. From the above, as recognized previously the determination in establishing the quantity and the type of pharmaceutical agent to be administered, consideration for each case in accordance with the patient's clinical conditions is necessary (and of extreme importance).
In the case where benzodiazepine was not effective, Propofol can be used for substitution. From the fact that there is no specific receptor in the action mechanism of this agent and it has been reported that NMDA receptor is involved. Thus it can be considered to be appropriate as in this case that revealed a resistance to benzodiazepine.

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