Purpose：To clarify the effectiveness of wiping during oral care by guardians at home, and factors associated with salivary bacterial count.

Method：The participants were 20 children with severe motor and intellectual disabilities （SMID） （mean age 5.5±3.8 years old） requiring both mechanical ventilator and tube-feeding. The survey was conducted during home-visit dental treatment. Guardians were instructed to do oral care （brushing their children’s teeth for 2 minutes and wiping the inside of the oral cavity with gauze）. They were taught how to wipe before oral care. Suction during brushing was carried out in case guardians performed brushing on a daily basis. The saliva was taken from the floor of the mouth, and the number of bacteria in saliva was measured by a bacteria detection apparatus （Panasonic Healthcare Co., Ltd.）. Collection and measurement were conducted before brushing, after brushing, and after wiping. The correlations between the number of bacteria taken before brushing and information regarding patient characteristics such as method of feeding, use of mechanical ventilator, existence of tracheostomy, existence of continuous suction, and existence of swallowing were examined statistically.

Results：The number of bacteria in saliva decreased significantly from before and after brushing to after wiping. There was no significant correlation between the existence of suction during brushing and variation of salivary bacterial count before and after brushing. The independent variables shown by univariate analysis to have a significant relationship with salivary bacterial count before brushing were use of mechanical ventilator, existence of tracheostomy, and existence of swallowing. Multiple regression analysis identified existence of swallowing as an independent associated factor for salivary bacterial count.

Conclusion：Wiping was an effective method to decrease bacteria after brushing. Children who do not swallow had larger numbers of bacteria in saliva before brushing. These findings indicated that it is important for children who do not swallow to have their oral cavity wiped after tooth-brushing.

It is important to help intellectually disabled persons understand behavior management in their dental treatment so that they may be involved in the decision-making process.

Legally, patients themselves are allowed to choose their medical treatment. Decision-making by a patient is important in dental treatment for people with intellectual disabilities, but they need to be supported in the decision-making process；the decision-making process is the patient’s right. Currently, intellectually disabled persons have not been supported in choosing the method of behavior management in their dental treatment；rather, the parents have decided the method. The intellectual level at which people with intellectual disabilities can understand behavior management techniques during dental treatment is unclear. Videos, illustrations and photos are used to help patients understand behavior management. If patients are able to understand the options, there is a possibility that decision-making support at the time of dental treatment of persons with intellectual disabilities will be provided.

The purpose of this study was to investigate the ability of patients to understand and select the type of behavior management. The methods were general anesthesia and physical restraint. These methods were explained to the patient using videos, illustrations and photos.

Ninety people with intellectual disabilities were studied （24 intellectually disabled patients, 54 autistic patients and 12 Down syndrome patients）. General anesthesia and physical restraint were explained to 90 subjects using videos, illustrations or photos. After the explanation, they were asked five questions：1） “Which method uses medicine?”, 2） “Which is the method where I sleep during treatment?”, 3） “Which is the method where I am physically controlled during treatment?”, 4） “Which do you like?”, 5） “Which do you dislike?” The first group answered all three questions correctly （question 1） to 3））, the second group mistook at least one question. It is suggested that patients with intellectual disabilities equivalent to a developmental age of 4 years and 6 months in basic life and understanding of language are able to understand general anesthesia and physical restraint using videos, illustrations or photos. There was no significant difference in ease of understanding among using videos, illustrations and photos. The proportion of those who agreed with the answers twice was 90.9％ for videos；92.3％ for illustrations；and 100％ for photos. 88.6％ of the subjects of the first group answered that they preferred general anesthesia rather than physical restraint.

2q-syndrome is a rare disease；there have been reports of a high palate as a dental feature, but no reports on the dental findings of cases with deletion of 2q23q24.2. We experienced a case with deletion of 2q23q24.2 requiring dental treatment, and report the dental findings.

A 21-year-old male visited our clinic for treatment of dental caries. He had intellectual disability, epilepsy, syndactyly of fingers, sensory deafness and cryptorchidism. His craniofacial features included microcephaly, squint, cafe au lait patches, entropion, concave nasal ridge, asymmetry of ala nasi, anteverted nares, smooth philtrum and downturned corners of the mouth. The dental features included congenital lack of the right mandibular central incisor, tubercle of the upper lateral incisor, and paramolar cusp of the mandibular first premolar. His small mandibular anterior teeth had a prominent notch of the incisal edge, appearance of labioclination and widely-spaced teeth. Dental treatment and maintenance have been performed under intravenous anesthesia due to his severe intellectual disability and gag reflex, as well as his guardians’ request.

The congenital lack of the right mandibular central incisor and paramolar cusp of the mandibular first premolar found in this patient are extremely rare expressions compared with past reports. Although it is unknown whether these are features of this syndrome at this stage, it is necessary to compare with the dental characteristics of 2q23 and 2q24 partial deletion syndrome reported in the future.

The present patient with deletion of 2q23q24.2 showed these dental findings such as congenital lack of the mandibular central incisor, and paramolar cusp of the mandibular first premolar. We need to perform dental hygiene management continually because he has severe intellectual disability.

In recent years persons with severe motor and intellectual disabilities （SMID） who have lived in institutions for persons with SMID have reached advanced ages, and so diseases caused by aging are increasing. Here we report a case of a white lesion of the tongue detected by the staff of the ward, which was diagnosed by excisional biopsy as early tongue cancer.

The patient was a 63-year-old female who had lived in our institution for persons with SMID due to sequela of meningitis. During oral care on the ward, a white lesion was found on the left lower tongue surface. Half a year later, I was consulted about gingival pain and the white lesion on the left lower tongue surface.

A white lesion of 12×10mm was found on the left lower tongue surface, and leukoplakia was suspected. Because it was difficult to perform a biopsy subconsciously, an excisional biopsy was performed under general anesthesia. The pathological diagnosis was carcinoma in situ of the tongue. The postoperative course was good, and 2.5 years have passed with no recurrence seen.

In institutions for persons with SMID, due to aging, the proportion of malignant tumors as a cause of death is increasing. Persons with SMID cannot express subjective symptoms verbally, so it is difficult to find cancer at an early stage. Especially if cancer in the oral cavity progresses, it can deprive them of their greatest enjoyment of eating. The importance of observation based on expertise in SMID care was once again recognized because observation during oral care by the ward staff led to the early detection of cancer.

18p-syndrome is a chromosomal abnormality syndrome caused by deletion of the short arm of chromosome 18, and mental retardation and delayed development of language have been reported in this syndrome. In addition, evaluation of cardiovascular disease is recommended for general anesthesia. Here, we report on the extraction of mandibular impacted wisdom teeth under general anesthesia of 18p-syndrome patient with mental retardation and pulmonary hypertension.

The patient was a 22-year-old man who was diagnosed with pericoronitis of mandibular impacted bilateral wisdom teeth by the primary care dentist. It was difficult for the clinic to control the patient’s behavior, therefore he was referred to the department of oral surgery in our hospital and was scheduled for extraction of his bilateral wisdom teeth under general anesthesia for the purpose of behavior management.

This case was a 18p-syndrome patient with mental retardation and pulmonary hypertension. Therefore, we commissioned cardiologists to evaluate preoperative circulatory dynamics, and carefully examined the management of circulatory dynamics during anesthesia before oral surgery. In addition, in order to prevent deterioration in circulatory dynamics caused by the patient’s excitement due to mental retardation, we fully discussed with pediatricians about the method of behavior management before and after anesthesia.

In order to avoid the patient’s excitement when entering the operating room and to avoid deterioration of pulmonary hypertension due to increased pulmonary vascular resistance, he entered the operating room under sedation. Under anesthesia management pursuant to the management of pulmonary hypertension, mandibular impacted wisdom teeth were extracted.

This case shows that in order to treat a 18p-syndrome patient with mental retardation and pulmonary hypertension under safe general anesthesia, it is important to avoid deterioration in the circulatory dynamics in consideration of mental protection of the patient. We consider that preoperative consultation with each professional medical doctor is indispensable for management planning during the perioperative period.

Because intellectual disability appears during the development of intellectual function and disturbs daily life, it is a situation requiring special support. Persons with intellectual disability not only have delayed intellectual growth, but also their daily life capacities are limited, resulting in troubles in the lives of individuals and groups. For adults, problems with self-management ability may arise, as well as with communication skills in society.

In the present case, two elderly persons with intellectual disability staying in a mental hospital fought over a sweet bun. The aggressor punched his right fist into the oral cavity of the other patient, resulting in laceration at the bilateral corners of the mouth. A few hours later, the victim was referred by the hospital to our department. At the first visit, the patient was in a state of control and there were no abnormal findings other than the laceration at the corners of the mouth. The course after suturing the laceration was good and at day 15 after the injury, treatment in our department ended.

Problem behaviors in persons with intellectual disability include difficulties in interpersonal relationships, self-injury, harm to others, sudden behavior, etc. It is speculated that these actions occur on a daily basis and that oral traumas may arise. However, because there is less chance of visiting medical institutions, there are few similar reports. By collecting reports similar to the present case, it may be possible to gain an overview of oral traumas associated with problem behaviors in persons with intellectual disability. In addition, to prevent such trauma, it is important to understand the current status of problem behaviors and oral traumas in persons with intellectual disability and to provide information, advice, and support from the dental care side.

Smith-Magenis syndrome （SMS） is caused by a deletion in region 17p11.2, which includes the RAI1 gene, or by point mutation in the RAI1 gene. SMS is characterized by craniofacial anomalies, as well as neurological, behavioral and sleep disorders. Reported oral characteristics are congenital missing teeth, taurodontism and dilacerations, however, in Japan there are few reports of orofacial manifestations. We aimed to survey general and oral characteristics from nine cases of SMS between age 5 and 18 years old.

Results：1） All cases had moderate mental retardation. 2） Behavioral problems were sleep disorder （9/9）, panic attack （9/9） and self-injurious behavior （8/9）. 3） All cases had synophrys, upslanting palpebral fissures and everted upper lip as craniofacial manifestations. 4） Most common oral findings were taurodontism （9/9）, congenital missing teeth （2/9）, and dilacerations of the tooth root （2/9）.

Conclusions：Behavioral problems such as mental retardation, sleep disorders and panic attack require special consideration in dental examination and oral hygiene management.