In advancing the clinic/hospital referrals, questionnaires were administered to private clinicians and hospital dentists, to grasp their level of awareness, and the reality faced by them.
As a result, the following points came to light;
1: For both private clinicians and hospital dentists, their level of acceptance and understanding of the medical legislation and the District Health and Medical Services Scheme (hereafter referred to as DHMSS) were not necessarily high, and their level of understanding varied. This may later hamper the advancement of the DHMSS; thus a higher understanding of the scheme is desirable.
2: The questionnaire has shown that a rise in the understanding of the DHMSS would make the clinic/hospital referrals more effective in providing dental services in the district.
3: There is a need to advance not individual referrals, but systematic clinic/hospital referrals.

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In this article a case of temporomandibular joint luxation observed in a schizophrenic patient under the treatment with antipsychotic drugs is reported.
A schizophrenic female 53-year-old patient visited our branch complaining of difficulty of mastication and swallowing refered by her psychiatrist. She had been under treatment with antipsychotic drug namely fluphenazine. Her symptom had been continued for more than 1 year. There had not been any action or involuntary movement namely oral dyskinesiaor tremor which brought her TMJ luxation. She was diagnosed as bilateral chronic TMJ subluxation based on clinical findings and X-ray phtograms (Photo. 1 & 2).
The author suspected that the luxation was caused by extrapyramidal symptom, one of the side effects of fluphenazine. However, considering the necessity of treatment for mental symptoms, the prescription was continued. The condition of TMJ was notimproved but did not become so severe (Fig. 2). However after five months, she suffered from complete TMJ luxation. She could not eat and swallow anything for a week but she did not ask us any help. She was brought to our hospital. Treatment with manual repositioning of TMJ was done almost succsessfuly. Then fluphenazine was exchanged for chrolpromazine.
Her TMJ condition continued to be almost good for about one year. But again hermental state become worse gradually. The psychiatrist began to prescribe haloperidol, one of antipsychotic drugs, because of exacerbation ofauditory hallucination. After seven months, she suffered from recurrence of complete TMJ luxation and again came to our hospital. Manual repositioning was done. Haloperidol was exchanged for chrolpromazineand levomepromazine.
After then she has not suffered from any trouble of TMJ and her occlusion has been kept to be completely normal (Photo. 3). The author suspect that tardive dystonia, which is one of the extrapyramidal symptoms induced with fluphenazine and haloperidol, brought her the TMJ troubles. Dentist should detect TMJ trouble in schizophrenic patients under the treatment with antipsychotic drugs through careful inspection of theirocclusion and inform it to the psychiatrist to check his prescription.

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Clinico-Statistical analysis of patients with suspected hemorrhagic tendency who had needed dental and oral surgical manegement has been reported. There were 261 patients who suspected hemorrhagic tendency among 7988 outpatients visited at our hospital in the period from July, 1986 to June, 1990, with an incidence of 3.3%. The mean age of the patients was 37.5 years. The hematological disease was the most common disease (63.2%), followed by disease of cardiovascular disease (24.9%), hepatic disease (5.4%), renal disease (3.8%) and cerebral vascular disease (2.7%). Of 261 patients with suspected hemorrhagic tendency, 147 patients (56.3%) recieved on blood managements. Of these 147 patients, 56 patients (38.1%) recieved total special concideration for hemorrhagic tendency. There are six patients with after-bleeding.

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We should be aware of lithium poisoning and side effects when we perform general anesthesia for patients taking this drug. Perioperatively it is important to take much care concerning interactions with anesthetics, abnormal ECG, renal dysfunction, and electrolyte unbalance. Therefore it is necessary to measure the perioperative serum lithium level and to consider whether lithium treatment should be discontinued. Operatively we should evaluate the effects of muscle relaxants by monitoring the degree of neuromuscular blockade, manage appropriate infusion by measuring electrolyte, especially serum sodium levels, and be careful not to give overdosages of anesthetics.
We managed successful general anesthesia for tumor extirpation in a patient taking lithium by measuring the perioperative serum lithium level and paying attention to interactions between lithium and the drugs administered. Moreover, we managed infusion carefully to avoid electrolyte unbalance and monitored neuromuscular function in addition to routine monitoring.

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A 52-year-old woman with idiopathic interstitial pneumonia was scheduled for a dental teratment in Osaka University Dental Hospital the last year.
At age 44 she complained of dyspnea and palpitation. She was diagnosed to have idiopathic interstitial pneumonia with heart failure and experienced 90-day hospitalization in a general hospital. At age 50 oxygen inhalation therapy for 24 hours a day was initiated. She had ever become powerless and transferred to the hospital four times for two years.
A chest X ray showed cardiac enlargement (CTR 70%) (Fig. 2). An electrocardiogram showed frequent ventricular premature beats and load of the right ventricle (Fig. 1). Fine crackles were heard over the both lower lung field. Physical activity was evaluated to be class III of New York Heart Association classification and class IV of Hugh Jones classification.
Heart rate, blood pressure, electrocardiogram and oxygen saturation were monitored throughout the dental treatment. We prepared to administer antiarrhythmic agents. Although the electrocardiogram revealed frequent ventricular premature beats and paroxysmal supraventricular tachycardias (Fig. 3), we did not use any drugs because she did not complained of unpleasantness. A resin filling was performed in safety. Ten days later she died of respiratory disjunction.
We recognized the risk about dental treatments of medically compromised patients again.

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Managements of the general condition for dental treatment of three patients with dilated cardiomyopathy were performed.
Case 1: A l6-year old male was diagnosed as having dilated cardiomyopathy and slitht mental retardation due to glycogen storage disease. He was assessed as NYHA physical status 2, and ECG indicated atrial fibrillation and occasional tachycardia. The result of an echocardiogram revealed the EF (ejection fraction of left ventricles) was 30-34% and an x-ray film of the chest revealed cardiomegaly with CTR (cardiothoracic ratio) 63%. Resin restorations of four molars were performed without local anesthesia. During the procedure, nasal oxygen was administered and general conditions were monitored. They passed uneventfully.
Case 2: A 47-year old female was the mother of case 1. At 43-years old she noticed palpitation and edema of the lower extremities and dilated cardiomyopathy was diagnosed. After then, she had repeated admissions for cardiac failure. She was assessed as NYHA 3. ECG indicated atrial fibrillation and bradycardia, and Holter ECG showed PVC 17000pre day. CTR was 57% and EF 50%. Treatments were performed 13 times over nine months. On addition to the management performed on case 1, prophylactic antibiotic coverage before and after procedure was done. No cardiovascular agents were needed through treatments.
Case 3: A 41-year old female had been diagnosed as having dilated cardiomyopathy after the delivery of her first child at 22-year old. Her condition was assessed as NYHA 2. ECG indicated tachycardia of 100bpm, occacsional PVC, slight ST depression at V 4-6. CTR was 54% and EF was only 18%. Our examination revealed that five months before she had _??_8_??_8 were extracted at the department of oral surgery without the use of prophylactic antibiotic. In addition, 5.4ml of local anesthetic of 2% lidocaine containing 1/80000 epinephrine had been used. Fortunately the course had been uneventful. This time, we managed general condition and enough attention was paid. At the second treatment of infected root canal treatment, the prophylactic penicillin was administered from before the treatment. During the procedure PVC became frequent, and lidocaine was administered successfully. The third treatment was cancelled due to the aggravation of cardiac failure.
Close consultations were conducted with physician and general conditions were estimated. The plan of dental treatment should be discussied with dentist. During the treatment, monitoring of cardiovariables such as ECG, blood pressure, and Spo₂ were performed. A root for intravenous injection was obtained and cardiovascular agents including lidocaine were set up. Coverage of prophylactic antibiotic was done as needed. These measures were thought to contribute to uneventful results. Careful attention should be paid for dental treatments on patients with dilated cardiomyopathy.

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This case report describes chronic ischemic heart disease developed another myocardiac infarction onset after the tooth extraction. The patient was a 59-year-old male with chronic ischemic heart disease and diabetes mellitus. He has been taking both anti-platelet and anti-coagulant drugs. Tooth extraction had been carries out with 4-time. When the fourth tooth extraction, the physician discontinued anti-platelet drug and anti-coagulant drug for 10 days. When the tooth extraction or minor surgical procedure, anti-platelet drug and anti-coagulant drug might be better to be discontinued, because these drugs were very important medicine to prevent a relapse of basic disease. From the experienece of this event, the definitive criteria to manage these drugs in oral surgery will be required.

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