We carried out a clinically-based statistical observation of patients referred to our Department of Oral and Maxillofacial Surgery, Tokyo Women's Medical College from November 1993 to October 1994. The following results were obtained:
1) The number of people referred to our department was 1, 323. among whom 885 were ill, i. e., they were patients.
2) Of these patients. 461 were men and 424 were women. Patients in their sixties accounted for the largest number, 206 (23.3%), followed by those in their fifties and then in their forties. The mean age was 48.7 years.
3) Among the patients coming from other hospitals, 57 were referred by dentists or dental departments, 36 by physicians or medical departments. Patients referred by other departments in our hospital totaled 792, among whom 597 were inpatients and 195 were outpatients.
4) Most patients were referred by other hospitals from management of oral and dental complications of systemic diseases while many in-hospital patients were referred because they requested dental care.
5) Among diseases not within our area of specialization, circulatory diseases accounted for the largest fraction, affecting 383 patients (33.7%), followed by neoplasms, endocrine or metabolic diseases and urologic diseases.
6) Among diseases within our area of expertise, the majority were dental diseases, seen in 656 patients (74.1%). followed by inflammation, temporomandibular arthrosis, and injuries.
7) The most frequent treatment provided was filling or prosthesis, followed by tooth extraction and specified duration of observation.

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Patients with ischemic heart disease account for about 50 per cent of all patients with cardiac disease in our clinic.
We have recently used our own evaluating method for patients who have ischemic heart disease before oral surgery. In our evaluation method, we use the Master's test and risk factors, and combine the results. The incidence of complications during and after oral surgery was 5 cases among the patients with ischemic heart disease treated from 1983 to 1995. In 4 out of these 5 cases, Master's test were positive and 1-3 risk factors were added by our method.

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Dental treatment of medically compromised patients has become routinized in the current society with a large aged population. Among 13, 455 patients undergoing first examinaion at the Department of Oral Surgery, Machida City Hospital during the 6-year period, from January 1988 to December 1993, 2, 209 patients had underlying disease and were treated at other department, such as internal medicine. We statistically analyzed these so-called compromised patients, The results of the analysis are herein reported.
They consisted of 1, 025 male and 1, 184. female. The largest number of patients (521 cases; 23.6%) were the sixties, the second largest number (499 cases; 22.6%) was found in patients aged 50-59; 351 patients (15.9%) were aged 70-70. Regarding the underlying diseases, cardiovascular diseases were predominantly often observed (1, 469 cases; 58.0%), and the majority of these patients (862 cases; 58.7%) had hypertension. Metabolic disorders, gastrointestinal diseases, and respiratory diseases were then observed in 393 (15.5%), 324 (12.8%), and 103 patients (4.1%), respectively. More than a half of these patients (1, 245 cases; 53.6%) received surgical treatment, the majority of which (947 cases; 76.1%) were tooth extraction. Hundred and fifty seven patients (14.6%) received conservative or/and prosthetic treatment. Seven hundreds and thirty eight patients (31.8%) of the surgical cases required some anesthetic management, including nitrous oxide inhalation sedation in more than a half (388 cases; 52.6%).
Compared with other reports, the percentage of compromised patients was low in the present servey. The reason for this was thought to be that the compromised patients were limited to those having underlying diseases being treated at the time of dental treatment, and the patients with past history were excluded.

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Three cases of temporomandibular joint luxation in patients with complications are reported.
Case 1: A 68-year-old woman suffering from myocardial infarction and complaining of habitual luxation of the left temporomandibular joint was introduced to our clinic. She has not worn dentures since she had heart attack. Conservative treatment was done by remodeling and by fitting her dentures. With wearing well fitting dentures, habitual luxation was terminated.
Case 2: An 86-year-old woman who had an apoplectic stroke and was suffering from hemiparalysis and hypertension was proved to have long-standing bilateral forward dislocation of the temporomandibular joint. Open reduction was performed under general anesthesia.
Case 3: A 68-year-old woman suffering from atrophy of the cerebellum and Parkinsonism complained of recurrent forward dislocation of her bilateral temporomandibular joints.
Open reduction according to the Myrhaug's eminectomy was performed under general anesthesia. The postoperative course was satisfactory.
A way to treat temporomandibular joint luxation in a patient with complications must be chosen under careful considerations. There are many ways, either conservative or operative, to treat temporomandibular luxation. Though the conservative treatments are preferable, operative treatments must be chosen in some cases.

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It is reported that treatment of oral disease before bone marrow transplantation (BMT) decreases the incidence of infectious complications during BMT. However, we often hesitate to treat postendodontic periapical lesion without a sign of inflammation.
In this study. we examined 24 patients with asymptomatic post-endodontic periapical radiolucencies of 78 patients for pre-BMT dental assessment between October 1987 and December 1993 at Department of Oral and Maxillofacial Surgery, Nagoya Daini Red Cross Hospital.
The purpose of this study was to compare the effect of dental treated group (extraction or root canal retreatment) with non-treated group of periapical lesion on the frequency of infectious oral complications during BMT.
We examined (1) the number of days when the patients temperature was greater than 38.0°C (2) the number of days when the absolute neutrophil count was less than 500/μl and (3) local signs and symptoms associated with odontogenic infection, such as swelling, pain and sensitivity.
There was no significant difference in both systemic and local infectious complications between treated group and non-treated group.
These results suggested that asymptomatic post-endodontic periapical radiolucencies might not always increase of infectious complications during BMT.

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We report a case of the infection around a subperiosteal implant with intraoral autogenous hemorrhage in a patient recieving maintenance hemodialysis. The patient was recieving hemodialysis for diabetic nephropathy and had other complications such as myocardial infarction. And then the removal of a subperiosteal implant under general anesthesia was associated with extremely high risk, and perioperative management was very difficult.
Progressive anemia attributed to continuous autogenous bleeding around the implant was managed by blood transfusion. Preoperative hemodialysis for the control of serum potassium, BUN, serum creatinine etc was performed until the day before the operation. Postoperatively, intravenous hyperalimentation was given to provide a high calorie intake, to simplify the control of water balance and blood sugar, and maintain good oral hygiene. The operation required 3 hours 8 minutes and the total intraoperative blood loss was 831g. However, blood transfusion was not necessary because the management for the blood loss was successfuly controlled by infusion during the opration. Postoperative hemodialysis could be started on the day after the operation, without bleeding or other problems. The patient gradually recovered and now uses normal upper and lower full dentures without any problem.
This case emphasizes that implantologists have to evaluate not only the oral condition but also the systematic condition and long-term prognosis of patients, particularly when they are medically compromised. It is therefore indispensable to educate physicians about dental implant treatment and to establish a cooperative system for patients who require both dental and medical management.

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A 53-year old male, 151cm tall and 52kg, was referred to the Tsurumi University Dental Hospital for severe dental pain of the left upper jaw (Photo. 1, 2). At 41 years old he had visited a physician for hematuria and short breath, and was diagnosed as suffering from Eisenmenger's syndrome owing to a ventricular septal defect and subsequent pulmonary hypertension. The lesion was considered inoperable and he received pharmacotherapy during his forty days' admission. During the admission echocardiogram and cardiac scintigram were carried out and they revealed the enlargement of left and right ventricles, and mean pulmonary artery pressure was more than 38mmHg. Two years ago, the patient was readmitted to the hospital for forty days with cardiac failure. Since then he had been taking cardiac drugs, furosemide (Lasix(R)), spironolactone (Aldactone(R)) and diltiazem (Herbesser(R)), and he was assessed as NYHA II-III. His blood pressure was 115-140/65-70 mmHg, and pulse rate was 68-89bpm, but percutaneous O2 saturation was 88-93%. Laboratory data showed slight hemoconcentration (Table 1). ECG indicates atrial fibrillation and complete right bundle branch block (Fig. 1). X-ray film of the chest revealed cardiomegaly with cardiothoracic ratio 66% (Photo 3).
Periodontitis was diagnosed and scaling and extractions of the left upper second and third molar teeth and right lower second molar tooth were scheduled for four separate occasions.
Close consultation was conducted with the patient's physician who was aware of the necessity of treatment but also of the potent risk of sudden death. The risk was explained to his family and himself, and informed consent was obtained. He was admitted the hospital the day before the procedure, and a prophylactic antibiotic was administered intravenously from the day before the treatment. Before the treatment, cardiovascular and antishock agents (Table 2), and equipment for resuscitation, all of which were screened from the patient, had been set up. On arrival at the operating theater, ECG, blood pressure and percutaneous O2 saturation were monitored. An intravenous needle was placed on the dorsum manus and 5% sugar solution was dripped. 20% benzocaine (Hurricaine Gel(R)) was applied for the surface anesthesia, and 3% propitocaine with felypressin 0.03U/ml was used for infiltration anesthesia. The record and ECG during the first procedure were shown in Fig. 2 and 3. The procedures on the four occasions were uneventful. After the procedures he had been observed carefully with pulseoxymeter for 30 min, and an antibiotic was administered postoperatively for three days. He also had an uneventful postoperative course.
Patients with Eisenmenger's syndrome usually die at 30-50 years old. Since such patients are thought to be at risk from the aggravation of cardiac problems, complications induced by dental treatment should be avoided as much as possible.

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A statistical study was made for the understand of the actual states in the management for the medically compromised patients at the clinic of dental anesthesia. The subjects were the patients who visited to our out-patient clinic as the request from the other clinics in the hospital for the evaluation of the present states or general care for the safety in the dental procedure, for the last 9 years (from April '85 to march '94).
Results were as follows:
1) The medically compromised patients were 44.8% (425 cases) among the total 1055 cases who were treated as the out-patients.
2) The ratio of male to female was 50.6% (215 cases) /49.4% (210 cases) which was appeared in no significantly deference. But the average of age was 56.4±15.3 year-old which was significantly higher than 27.3±17.2 year-old of those normal heaethy patients.
3) Among systemic diseases, both hypertension and cardiovascular diseases reached to 74.4%. And hypertensive patients were frequent complicated with multiple systemic diseases.
4) As the dental treatment, oral surgery including teeth extraction amounted to 78.7%.
5) The general management were made under N₂0 inhalation sedation or intravenous sedation with minor tranquilizers, monitoring cardiac and respiratory function, and SpO₂.
6) In 121cases among patients with hypertension and cardiovascular diseases, positive treatment for hypertensive crisis was done during the operation using vasodilators such as diltiazem, nifedipine and nitroglycerine.

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Glanzmann's thrombasthenia is a rare congenital platelet disorder characterized by prolonged bleeding time, qualitative platelet defect, and severe hemorrhagic episodes. Patients with this disorder have been managed by transfusion of whole blood and blood components (most recently, Platelet-rich plsma and platelet concentrates) to control hemorrhage resulting from trauma or surgical procedures.
In this paper, we reported the experience of tooth extraction of patient with thrombasthenia. A 31-year-old woman visited our department on May, 1992, complaining of tooth pain. The gingival bleeding was seen from the upper and lower left molars. Three tooth were extracted as atraumatically as possible under general anesthesia. Before and after operation, ten units of platelet concentrates were transfused. Then, we used leucocyte-removal filters on platelet transfusion. As local hemostatic treatment, we used Oxycel(R) and a resin sprint. No postoperative hemorrhage was observed, and the surgical site healed normaly.

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A case of tuberculous cervical lymphadenitis in patient with dialysis is reported.
A 50-year-old woman who was seen with the chief complaint of rapidly swelling around the left submandibular region. A CT scan showed tumorous mass ranging from submandibular gland to the hyoid bone. Although tuberculin skin test was positive, a chest X-ray finding showed no pulmonary tuberculosis and tubercle bacilli was not detected from sputa. The clinical findings suspected a tuberculous cervical lymphadenitis or a malignant Tumor arising in the submandibular region. Under general anesthesia, upper neck dissection was performed. The resected material was histopathologically interpreted as tuberculous lesions. Thus a diagnosis of tuberculous lymphadenitis was made on the basis of these findings.
Dialysis patients are known to be immunodeficient. Percentages of lymphnode tuberculosis among all tuberculosis are higher in dialysis patient than in the general population. It is important that timely proper dosage of anti-tuberculous drugs must be administered with care to side effects.

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