In patients receiving warfarin potassium anticoagulant therapy, alteration of warfarin potassium administration prior to and following dental extractions increases the risk of thromboembolisms. We investigated if there exist the risk of thromboembolisms due to alteration of warfarin administration by evaluating the changes of PT-INR (prothrombin time international normalized ratio) prior to and following dental extractions.
Subjects enrolled in this study were 83 warfarinised patients that required dental extractions from January 1, 1996 to December 31, 2004 (Maintained group: 25, Reduced group: 11, Reduced and interrupted group: 4, Interrupted group: 35, Heparinized group: 8).
Our study findings suggested that the four groups with the exception of the Maintained group have a risk of thromboembolisms for 7.5 days. In the Maintained group, on case was difficult to attain hemostasis after dental extraction. Therefore, our study findings are suggestive that dental extractions under maintenance doses are possible for cases requiring non-complicated dental extractions if the PT-INR is 3.0 or less.

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Dental treatment for medically compromised patients had often been performed by oral surgeons or oral anesthesiologists for minimization or decrease in incidence of medically oriented accidents. If dental treatment is required for these patients in the setting of general or private practice, they may be recommended to a hospital with a dental department with a utilizing departmental cooperation system. The open system which belongs to a cooperative network system in a general hospital was introduced to improve the quality of treatment. We herein report 2 cases of medically compromised patients whom were treated and managed by dentists in private practice utilizing an open system between private practice and the general hospital.
Case1: A 54-year-old male patient with a history of anaphylactic shock from adverse effects of local anesthesia during dental treatment consulted a dentist in private practice for dental problems. He required dental treatment under local anesthesia for treatment of dental pulpitis and cavity. Therefore, I selected a multidisciplinary joint treatment and management with an anesthesiologist using the open system. Under proper medical management, I was able to accomplish the required pulpectomy and extraction without encountering any anaphylactic shock associated with anesthesia in the operating room.
Case 2: A 43-year-old male patient with a history of atrial fibrillation and transitory focal cerebral ischemia complained of teeth movement in upper and lower dentition. I considered the incidence or risk of general complications such as thromboembolism resulting from the stimulation caused during teeth extraction. Therefore, I selected a multidisciplinary joint team treatment with the general hospital utilizing the open system since the patient required intravenous sedation and rapid thrombolytic therapy for treatment. The extraction was performed by the dentist in private practice without any complications or problems under the sedation and monitoring by the oral anesthesiologist.
It was difficult to use the open system for treatment of minor dental problems due to the tight schedule of the anesthesiologist, operation room and inadequate fee. In addition to the above described difficulties, the clinical indications whether to select the open system or not have not been clarified. However, with the use of the open system, I was able to treat minor dental problems without encountering any accidents utilizing the open system.

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Background: Although intravenous sedation is known for numerous benefits, thorough consideration and management are required for adverse effects and complications that may occur during the perioperative period. We herein report our experiences with patients who underwent intravenous sedation in our department, in addition to frequency and evaluation of adverse effects and complications in these patients.
Methods: From March 1997 to May 2004, intravenous sedation was used in 1938 patients in our department, with midazolam in 804 patients (group M) and propofol in 1134 patients (group P). By examining anesthesia and medical records for these patients, the nature and frequency of any adverse effects or complications during the perioperative period was investigated, and the 2 groups were comparatively evalauted.
Results: Patients with adverse effects or complications in each group are as follows. Blood pressure increased by 30% for 22 patients in group M and 18 patients in group P, and decreased by 30% for 19 patients in group M and 115 patients in group P. Heart rates increased by 30% for 26 patients in group M and 75 patients in group P, and decreased by 30% for 5 patients in group M and 16 patients in group P, while arrhythmia was noted in 8 patients of group M and 2 patients in group P. Respiratory depression was identified in 23 patients of group M and 49 patients in group P, and SpO₂ was identified to be 93% for 30 patients in group M and 32 patients in group P. Nausea and vomiting was present in 12 patients of group M and 4 patients in group P, while discomfort was reported by 2 patients in group M and 1 patient in group P. Allergy-like reactions developed in 4 patients of group M and 2 patients in group P, while vaso-vagal reflex or neurogenic shock was noted in 2 patients of group M and 3 patients in group P. Shivering and tremor occurred in 1 patient of group M and 2 patients in group P, and symptoms of hyperventilation were observed in 1 patient from each group. Choking occurred in 9 patients, vascular pain developed in 217 patients and postoperative angina was identified in 1 patient from group P, but none of these conditions were noted in the patients in group M.
Discussion: Although adequate and favorable sedation was achieved with reduced frequency of nausea or vomiting in group P compared to group M, frequency of hypotension, tachycardia, vascular pain, respiratory depression and choking was identified to occur at higher frequencies and these adverse effects need to be thoroughly considered.

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Nephrotic syndrome is one of the kidney diseases characterized with features like proteinuria, hypoproteinosis, hyperliposis due to the hyperlucency of the glomerulus. It is classified into the primary and secondary types. The minimal change nephrotic syndrome is one of the primary types with no obvious change in microscopic histopathological features. The treatment of choice for these patients is the adrenal cortex hormone therapy however, the relapse of nephrosis is observed at times resulting from stress overload. We herein report a case with minimal change nephrotic syndrome who had a relapse of nephrosis following orthodontic surgery under the general anesthesia, and also discuss the surgical treatment for this patient.

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This report presents a case of the habitual luxation of the temporomandibular joint (TMJ) dislocation surgically treated to limit the movement of the condylar head in a patient with cerebral hemorrhage and chronic renal failure. A 61-year-old woman visited Ehime University Hospital with chief complaint of habitual luxation of the left temporomandibular joint (TMJ) which was not possible for her to control due to right-sided paralysis resulting for a previous cerebral hemorrhage episode. She also suffered from chronic renal failure requiring maintenance hemodialysis three times a week. We first attempted a conservative treatment with a chin cap, however, this was not effective. Therefore, we planned a surgical procedure under general anesthesia. Application of a bent titanium plate on the zygomatic arch to prevent the luxation, the so-called “Buckley-Terry method”, was performed under general anesthesia. Hemodialysis was performed the day prior to and following surgery, and the patient was observed in the Intensive Care Unit on the day of the operation. The postoperative course of this patient was uneventful without any severe complication of renal functions and no clinical evidence of recurrent luxation of TMJ at 8-month postoperative follow up.

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We experienced a case of Eisenmenger's syndrome requiring dental treatment under intravenous anesthesia.
A 35 -year-old male and his parents were referred to our department with chief complaint of severe pain in the left upper first and second molar regions.
The patient's past medical history revealed delay in mental development, and Eisenmenger syndrome. Patient cooperation for routine dental treatment was not obtained and was possible with the use of general anesthesia, intravenous anesthesia, or inhalation sedation with nitrous oxide and oxygen together. There were a few considerations concerned with the patient's cardiac functions and since the depth of anesthesia can be easily adjusted, we extracted the tooth under intravenous anesthesia utilizing Propofol. The circulatory function was controlled with the use of Propofol and a preventative measures for shunt formation, we administered Dopamine continuously.
Please clarify what is meant here: 2-double-diluted = 4 dilutions [double-diluted = 2 dilutions] therefore 2-doubleidiluted = 4 dilutions 2% lidocaine Hydrochloride containing 1 : 80000 Epinephrine with 2% lidocaine Hydrochloride and Propitocaine H ydrochloride containing 0.03IU felypressin 1.8ml. Conclusively, we were able to treat the patient without substantial changes in the hemodynamic state or circulatory conditions. With careful anesthetic management, it was possible to provide and perform dental treatments to these patients with Eisenmenger's syndrome without complications during treatment, such as aggravation of hypoxemia. However, it is necessary that total body management be carefully planned and considerations for an unexpected episode like a tantrum or a fit that may occur during the treatment be speculated and how to manage such episode be planned ahead so that immediate actions can be taken.

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We herein report three patients receiving (on) anticoagulant therapy, who were scheduled for oral and maxillofacial surgery. The three patients receiving Warfarin^® anticoagulant therapy were changed to Heparin^® during the perioperative period. The scheduled surgical procedures were radical surgery of the maxillary sinus, sequestrectomy, and open reduction and internal fixation.
According to our protocol, Warfarin^® was terminated three or four days prior to surgery, and Heparin^® was administered intravenously as a bolus injection at a loading dose of 2, 000 to 3, 000 units; thereafter, Heparin^®, infusion was commenced at a dose of 10, 000 to 15, 000 units per day to maintain the APTT value between 45 and 70 seconds (control, 30-35 seconds). Then, 3-4 hours prior to surgery, Heparin^® infusion was terminated. Postoperatively, Heparin^® infusion was commenced following attainment of hemostasis (restarted after control of any hemorrhage), and the patients were switched back to oral warfarin therapy when oral consumption were authorized to the patients. Heparin^® infusion was terminated when the PT-INR increased beyond (to over) 1.5.
All patients were successfully managed without complications, such as hemorrhage, thrombosis and thrombocytopenia. We revealed (demonstrated) that by switching Wafarin^® to Heparin^® was useful during the perioperative management for patients receiving oral anticoagulant therapy.

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