It is extremely difficult to evaluate stress reception and reactions by persons and children with severe motor and intellectual disabilities because they may not be able to verbally describe the problem. Therefore, this study attempted to objectively evaluate stress during dental scaling by measuring salivary alpha-amylase activity（sAMY）and taking electromyograms and mechanomyograms to evaluate the relationship between stress and muscle tension. The subjects were 18 patients who were seen at our department and gave their consent to participate in the study. Thirteen persons and children with severe motor and intellectual disabilities were separated depending on the level of their comprehension of simple words into a high-level group（HL group）of six subjects who could comprehend language and a low-level group（LL group）of seven subjects who could not do so. We also set up a control group（C group）of five healthy persons. sAMY levels were measured a total of four times（during rest, after brushing, after completing dental scaling on one side, and after completing the procedure）using a salivary amylase monitor. The results indicated that sAMY levels during rest were significantly lower in the HL group than in the LL and C groups. Levels subsequently increased in the HL group before dropping after the procedure. High levels were observed in the LL group from start to finish. Levels remained continuously low in the C group. Electromyograms taken during dental scaling indicated that root mean square values were highest in the LL group, followed by the HL group and C group. However, no significant difference was observed between the three groups. No significant differences were observed in the mechanomyograms. The above results suggest that the HL group exhibited a marked reaction to dental scaling and gradually reacted to the unpleasant stress experienced, whereas the LL group may have already been experiencing stress due to the external environment. Thus, stress reception may vary in persons and children with severe motor and intellectual disabilities according to the severity of their disability.

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A 58-year-old man with mental retardation and cerebral palsy living in a nursing home accidentally swallowed a 4-unit-bridge #14-17. The bridge was found to be missing by one of the staff while performing oral hygiene care for the patient after lunch. Radiographic examination was immediately performed in order to locate the bridge. The X-ray showed the opacity of the bridge in the stomach. The bridge was immediately removed by endoscopy using a retrieval net and tip hood under intravenous anesthesia. No secondary mucosal damage occurred during removal. The ingested bridge was 35 mm long, weighed 8.3 g, and a 2.5-mm-long post screw for #14 was exposed. The bridge was a part of his 9-unit bridge for #17-#22, and had been cemented 2 years 8 months earlier. When an oral examination was performed in May 2013, the dentist pointed out slackness in the bridge, and the accidental ingestion occurred in July 2013.
It may be difficult to diagnose an ingested foreign body for a patient with severe motor and intellectual disabilities. To prevent accidental ingestion, a team of medical care practitioners plus periodic oral examination and daily oral hygiene care is considered to be important.

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Brugada syndrome shows a right bundle branch block-like waveform and a coved-type or saddle-back-type increase in ST on an electrocardiogram, leading to sudden death due to ventricular fibrillation. We conducted dental treatment for a patient with this syndrome, odontophobia, and an abnormal pharyngeal reflex.
The patient was a 52-year-old female. Concerning her medical history, she had Brugada syndrome, dental phobia, and an abnormal pharyngeal reflex. She consulted our hospital with left upper and lower molar pain. Concerning her family history, her father had died suddenly, and her younger brother had a history of syncope, for which he had undergone ICD implantation. Furthermore, her son also had this syndrome.
At the initial consultation, radiography showed caries reaching the dental pulp in the left upper second molar, caries on the mesial proximal surface of the left lower second molar, and bone resorption at the root apex of the right lower second premolar. Initially, to resolve caries-related pain and reduce stress, which may induce an abnormal pharyngeal reflex and ventricular fibrillation, pulp extirpation and caries treatment were performed under intravenous sedation. In addition, systematic desensitization was applied, and dental treatment was conducted while preparing an external defibrillator for the prompt management of ventricular fibrillation. During treatment, there were no systemic abnormalities such as ventricular fibrillation.
In this patient with dental phobia and Brugada syndrome, dental treatment could be performed through behavioral adjustment using intravenous sedation/systematic desensitization and the preparation of an external defibrillator for the prompt management of ventricular fibrillation. There were no abnormalities, such as ventricular fibrillation, or the appearance of abnormal pharyngeal reflex.

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In patients saved from cardiopulmonary arrest and ventricular fibrillation, the adoption of an implantable cardioverter defibrillator（ICD）is recommended based on the arrhythmic fault medical treatment guidelines in patients in whom recurrence is expected with clear lethal arrhythmia. We experienced a case of a patient who had previously been rescued by cardiopulmonary resuscitation from idiopathic ventricular fibrillation who decided, at the time of dental consultation, to have a cardioverter defibrillator implanted even though she had refused the frequent advice of cardiologists for several years. The patient, a 59-year-old woman, had complications of idiopathic ventricular fibrillation and aortic incompetence（mild）as a medical history. When the cardiac function was evaluated for perioperative general management in the cardiology department during hospitalization, it was recommended that the ICD be implanted before dental treatment. She finally decided to have the surgical procedure because of her strong wish to receive dental treatment. As a result, after full recovery from the ICD surgery she safely underwent the dental procedure under local anesthesia with a vasoconstrictor in the outpatient center. Depression and post-traumatic stress disorder has been reported in patients for whom ICD is indicated, and so the establishment of a psychological support system in patients with ICD is desirable. We should carefully consider the primary cause of avoiding dental treatment and what kind of approach is necessary to manage not only oral health but also the general condition of patients.

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Holoprosencephaly is a group of disorders characterized by failure of differentiation and cleavage of the prosencephalon. Because this shows various clinical symptoms including craniofacial malformation and mental retardation, dental treatment for this disorder needs special care such as intravenous sedation or general anesthesia.
We report a case of holoprosencephaly with severe mental retardation, cleft lip and palate, defects of the nasal septum, and epilepsy, who underwent dental treatment under intravenous sedation.
The patient, a 22-year-old female, was diagnosed as holoprosencephaly at birth. Because she had dental phobia with difficulty in communication, intravenous sedation was necessary for computed tomography scan and dental treatment.
Eventually, we could perform computed tomography scanning of the head, scaling, and tooth extraction during three visits without complications.
Although the nasal cavity and oral cavity were connected in this patient, side effects such as coughing due to water or secretion did not occur during the treatment. Furthermore, this patient could breathe through the nose, and oxygenation through the nose was useful for preventing respiratory depression and airway obstruction during intravenous sedation.

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Noonan syndrome is an autosomal dominant disorder which includes cardinal symptoms such as specific facial features, congenital heart disorder, and skeletal anomaly. Although suckling disorder during the neonatal period and feeding difficulties during infancy have been observed, there have been no reports regarding the development of feeding and swallowing function in Noonan syndrome. Here, we report on a patient with Noonan syndrome who underwent long-term functional therapy for eating.
Case Presentation：At the initial examination（3 years and 2 months old）, the patient could suck the thumb, but refused a spoon and paste food. Therefore, we diagnosed the case as oral intake preparatory dysfunction accompanied by refusal to orally ingest. We performed taste stimulation training by having a researcher wet a finger with dashi stock and then wetting the patient’s lower lip with it to make the patient be stimulated by the taste and swallow the secreted saliva. We used toys and similar items to stimulate the oral cavity tactilely.
Course：As the patient accepted liquids well, liquid paste-based foods were gradually introduced. At 4 years and 5 months old, the patient acquired the ability to capture food and at 5 years and 6 months the patient could chew and grind food. From 6 years old, the patient started to refuse assistance and ate independently, thus losing the ability to eat paste foods. From 8 years and 2 months old, the patient was able to accept assistance and soft solid-shaped foods. At 8 years and 6 months, the patient regained the ability to eat paste foods and at 9 years and 5 months the patient could bite through food using the anterior teeth. Our current aim is to enable the patient to acquire chewing function through masticatory training.
Discussion：In the case of this sensory biased and finicky patient, we had to consider pediatric psychological and social development achieved by rehabilitation and education, so we did not force the patient to accept assistance or engage in direct training when they refused to do so. We also found it necessary to offer continuous feeding support so that we could give functional therapy for eating at the appropriate time.

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Case and management：A 20-year-old, 27.3-kg man with cerebral palsy was scheduled for dental treatment under general anesthesia. Although the patient had had a swallowing disorder since infancy, he was given food orally; however, each meal required at least 2 hours and he often choked on his food. Secretions always pooled in his pharynx. Therefore, careful perioperative management was required in order to prevent aspiration pneumonia. The treatment was postponed five times because of the generally unsatisfactory status of the patient, and one year passed without treatment since his first dental consultation. On the day of treatment, his pharyngeal condition was good and his lungs were clear. Propofol was administered after suctioning of the pharynx. Mask ventilation and endotracheal intubation were performed uneventfully. Anesthesia was maintained using propofol and remifentanil, and intraoperative vital signs remained stable. Upon emergence from anesthesia, extubation was performed under adequate respiratory status. After full recovery from anesthesia, the large volume of secretions required frequent suctioning, and although breath sounds were bilaterally equal, rhonchi were audible. Thus, he was given nutrition intravenously for one night and was allowed to commence oral intake the next morning. After oral ingestion, the patient developed sudden fever and oxygen desaturation. Blood tests indicated signs of inflammation, in the form of an increased white blood cell count. Moist rales were heard over some areas of the lung. Since this was believed to be due to aspiration, antimicrobial therapy was started. Since continuing nutrition as he usually did at home was considered a priority, we continued oral intake. His general medical condition improved and the patient was discharged 4 days after treatment.
Discussion：Although we postponed anesthesia and dental treatment until the patient seemed to be in his best possible condition, aspiration pneumonia developed after anesthesia. In this case, significant symptoms were avoided by cooperation with pediatricians. Nutritional management in the perioperative period is an indispensable component of perioperative care. In cases such as this, it is necessary to choose an appropriate nutrition strategy after careful consideration of the level of dysfunction.

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The use of the indwelling gastric tube（GT）has become common. However, if placed for long periods of time, dental crowding has been observed. The patient in this study had undergone a tracheotomy and had used a GT for the past five years. The patient does not utilize his mouth for eating or breathing. Due to lack of use, skeletal narrowing and severe crowding have resulted, causing buccal mucosal stomatitis. A clear acrylic appliance was placed to align his misplaced premolars and to help protect his buccal mucosa. One-year post treatment, no further mucosal stomatitis was observed. The aligner was used as a retainer. Preemptive fabrication of a retainer for patients who are not expected to utilize their oral function for long periods of time is highly recommended to counter these changes.

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The purpose of this study was to investigate differences in ambulatory anesthesia between healthy persons and disabled persons in our hospital. During the 5-year period between 2008 and 2012, general anesthesia was administered to 2,300 persons in our hospital. Of this total, ambulatory anesthesia accounted for 242 persons （10.5％）, of whom 136 were disabled （92 males and 44 females） and 106 were healthy （72 males and 34 females） ranging in age from 24.1±11.4 years for disabled persons and 8.7±5.4 years for healthy persons.
The most common disability was mental retardation, followed by autism, then epilepsy. Ambulatory anesthesia was commonly administered as part of dental and surgical procedures in the case of disabled persons and commonly administered for surgical procedures in the case of healthy persons.
Normally, no premedication was administered to either disabled persons or healthy persons. After slow induction with sevoflurane, tracheal intubation was done. General anesthesia was generally maintained with nitrous oxide, oxygen, and sevoflurane.
Operative times were 105±54 （mean±standard deviation） minutes for disabled persons and 48±47 minutes for healthy persons. Anesthetic times were 152±55 minutes for disabled persons and 93±49 minutes for healthy persons. All persons were treated safely, with no serious perioperative complications.

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Yokohama City Center for Oral Health was established in 1982, and developed functions as a secondary dental care center, especially for the disabled. The clinic was reconstructed to be barrier-free, and a system of anesthetic management for dental procedures was set up in 2009. This study reviewed the background of patients who visited the center, and analyzed how the center should function in the integrated community healthcare system for people with disabilities.
The subjects were 1,703 patients who visited our clinic between April 2009 and March 2014, and 145 patients who were treated by the home-visit dental treatment team between April 2013 and March 2014.
We obtained the following results from clinical records. Most of the patients were the young with developmental disabilities who were able to come to our center with their families by public transportation. This suggested that our center, as a secondary dental care center, adequately provides oral healthcare to patients with developmental disabilities, and so we built closer communication with special-needs schools and facilities for the mentally challenged. On the other hand, we received fewer middle-aged, severely mentally and physically disabled, and elderly patients than those with developmental disabilities, suggesting a problem of less collaboration with welfare professionals, and we had little information on the latent patients who needed dental treatment.
In order to perform adequate dental treatment for disabled people who need dental care, it is important to gather the necessary information on patients from their hospitals or rehabilitation facilities, and to keep in touch with welfare professionals. Therefore, our center needs to build closer collaboration with the team of home-visit dental treatment in order to fulfill its role as a beneficial societal resource in the integrated community healthcare system.

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Our center was established in 1982 as a dental clinic for disabled patients at the same time as the Okayama University School of Dentistry was established. It serves as the third medical facility for disabled individuals for dental treatment in Okayama Prefecture. In recent years, the form of medical care has changed from being completed at a medical facility to being completed at a regional facility. Along with this trend, we are also conducting research on regional cooperative clinical path through which we hope to improve oral QOL in the lives of disabled people in the region. In this study, we report on the results of dental examinations of first-visit regional disabled patients for the years 2006 to 2013.
The total number of patients surveyed was 697. The majority of the patients suffered autism disabilities. By residential area, the largest number（295, 42.3％）lived in Okayama city. However, compared to our previous studies（1989 to 2006）, the ratio of residents of Okayama city decreased and that of patients visiting from outside the city increased. Regarding the route to examination at our facility, 79.9％ of patients were referred, an increase from the previous survey. The most common purpose of visit among referred patients was dental treatment（70.4％）, while examination and maintenance was the most common purpose among those who were not referred（27.1％）. Treatment under sedation was performed in 67.3％ of patients with referrals, which was significantly higher than the 39.0％ of patients without referrals.
Both the majority of patients with autism and the purpose of the visit being for dental treatment suggest that they had sought treatment at a dental office in the community but were referred to this center due to non-cooperation with treatment or other reasons.
The increase of patients from outside Okayama city as well as the increase in referrals is due to the establishment of a smooth referral system with regional dentists and the fact that this center is recognized regionally as the third medical facility.
We intend to continue monitoring the ratio of requests at this center, cooperating with the regions, and distributing information for medical facilities and patients.

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When general anesthesia is administered for the dental treatment of patients with severe mental and physical disabilities, it is important to pay attention to the postoperative course as well as to the anesthesia period in this patient group because of the high risk of complications such as epilepsy, gastrointestinal dysfunction, or chronic bronchitis.
We researched the postoperative course of 38 patients with severe mental and physical disabilities who had received dental treatment under general anesthesia. The patients were classified according to Yokochi’s Classification （Table 1；A1-4 and B1-4）. Data was collected with the help of a questionnaire （Table 2） about the first post-operative night, including：1） Recovery of consciousness, 2） Postoperative vomiting, 3） Recovery of nutrient intake, 4） Recovery of swallowing, and 5） Airway condition. In addition, there was a sixth question about the general condition of the patient during the first week after anesthesia. For the purpose of recognizing the specific care and attention to the postoperative course of this patient group, the frequency of problems between bedridden patients who could not roll over （BR group, n=22） and those who were not bedridden and were able to roll over （NBR group, n=16）, were compared. Anthropometric characteristics and treatment status of the patients are shown in Table 3, while Table 4 details the underlying illnesses of the subjects.
Anesthesia was induced in all cases with nitrous oxide/oxygen/3％ sevoflurane and was maintained with nitrous oxide （or air）/oxygen/0.4-0.8％ sevoflurane （or 1.0-2.0％）/2-4 mg/kg/hr propofol.
Results：Regarding the total frequency of problems, recovery of consciousness was the most frequently encountered （Fig. 1） on the operative night （Questions 1-5）. Two of the BR group patients who were complicated with delayed recovery of consciousness also had difficulty in consuming nutrients, and the problem persisted for two days after operation. Other postoperative problems （Question 6） included persistent fever, agitation, decrease in appetite, and diarrhea. There was no statistically significant difference in the incidence of postoperative problems between the two groups, except in terms of their poor general condition, which was encountered more frequently in the NBR group （p＜0.05, Table 5）. Though the causes of problems in Question 6 in the NBR group are unclear, we consider that postoperative pain, uncomfortable sense, difficulty in swallowing or extreme anxiety may induce those problems.

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This study aims to clarify the provision of feeding services at welfare facilities and rehabilitation centers for the disabled in the Tohoku area. We surveyed a total of 120 welfare facilities and rehabilitation centers in the area.
We collected the questionnaires, and examined the 75 facilities with valid responses. The questionnaire asked about the type of facility where the staff were working, the status of users’ disabilities, the status of feeding services, the number of food types available, establishments where food is provided, study sessions related to ingestion, and cooperation with other facilities.
The most common type of facility was residential care facility for the disabled （39 facilities）. Main users were physically disabled persons and the intellectually disabled. Feeding services had been installed at 54 facilities. Three food types were the most common. Regarding ingestion, 70.7％ of facilities were concerned about this matter. We found that staff members at the facilities felt anxiety and doubt when providing feeding services and carrying out daily operations. In addition, 76.0％ of facilities had conducted studies on ingestion, and 18.9％ had cooperated with external studies.
Efforts have been made to enhance feeding service initiatives in each facility. Nevertheless, because we only conducted our study inside the facilities, a future challenge is to cooperate with multidisciplinary and other facilities.

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As the nature of dental diseases in disabled people has changed, it has become necessary for us to consider continuous health management as well as to deal with the diseases. Therefore, we devised a plan for allowing disabled people to use dental care services, by incorporating the method of service management planning for the welfare of disabled people into the dental hygiene process. We report the development of the plan chiefly through case examples.
Regarding the study method, we adopted the method based on the principle of the service use plan for the welfare of disabled people, in addition to the oral management plan in accordance with the dental hygiene process. Regarding collecting information about patients, we organized the following：（1）the patient’s desired goal in dental health,（2）a holistic view and a profile of the patient,（3）the current condition of the oral cavity,（4）the current issues found in the dental health and life of the patient,（5）strong points of the patient, and（6）social resources available to the patient. On the basis of this information and evaluating the patients, we developed a plan for allowing disabled people to use necessary dental care services.
Results：By establishing both the short-term goal of “Let’s restore your mouth to feel comfortable through accepting teeth and oral cleaning because you have not been managed by a dentist for a long time,” and the long-term goal of “Let’s learn how to brush your teeth and practice it three times a day by yourself while allowing your regular dentist to clean the parts that you cannot clean by yourself,” we performed interventions such as removal of plaque, removal of tartar, and periodontal treatment at a specialized dental care institution, and we also became in charge of the short-term management at a medical institution providing rehabilitation services.
We conclude that the evidence-based continuous management of disabled people in accordance with a plan such as ours, which must be established on patients’ independence, provides a warning for treatment-centered consultations.

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