The purpose of this study was to investigate problems related to eating problems of schoolchildren and to establish appropriate support methods for teachers at special needs intellectual disabilities education schools （including elementary, junior high and high schools）.

We conducted a questionnaire survey of 56 teachers and asked them about the eating problems of their special needs students. The teachers’ observations were classified into 24 items, and the results were as follows.

1）It was found that 96％ of elementary school, 85％ of junior high school and 80％ of high school teachers felt that their students have many problems with eating. There were no significant differences between departments.

2）The most common complaints that elementary school teachers pointed out were “keep food in the mouth” and “not chewing”；those pointed out by junior high school teachers were “swallowing food whole” and “not chewing”, and those pointed out by high school teachers were “swallowing food whole” and “eating quickly”.

3）The percentage of subjects “not chewing” was significantly higher in elementary school than in high school（p＜0.05）.

There are many problems among elementary school children, but we think that such problems often improve during school life or by educational guidance or group life. On the other hand, there were many poor eating manners including “swallowing food whole” and “eating quickly” among junior high school students and high school students.

We conclude that students need support from an early stage to learn how to eat according to their developmental level.

Tooth brushing by caregivers is important for the management of dental hygiene in infants and young children, as well as individuals with a disability or who require nursing care. However, methods used for brushing vary among caregivers depending on such factors as subject disability or developmental stage, physique, and age, as well as environment. We examined the relationship between caregiver posture and motions for tooth brushing effects including plaque removal using 20 female dental hygienists who perform caregiver brushing on a daily basis. A dental mannequin equipped with permanent dentition was placed in both the supine and face-to-face positions. The oral cavity was divided into 12 sections for each position, i.e., buccal and lingual, upper and lower, and anterior and posterior on both sides. A three-dimensional accelerometer and strain tension gauge were attached to the test toothbrush, then brushing motions and force in each position block were measured for 10 seconds. Furthermore, artificial dental plaque was applied to the artificial teeth of the mannequin prior to brushing and the area remaining after brushing was analyzed. Our results showed that brushing was performed with a vertical motion on the lingual side of the incisors and as a scrubbing method in the other regions with both postures. In the incisor regions, there was no significant difference in cycle duration between the postures, whereas three-dimensional displacement on the palatal side of the maxillary incisors was lower in the face-to-face position than in the supine position. In the molar regions, cycle duration was longer and three-dimensional displacement was lower in the face-to-face position than in the supine position, suggesting that the tooth brushing motion used in the face-to-face position had a slower rhythm. In addition, dental plaque was more likely to remain on the upper incisor palatal surfaces following brushing in the face-to-face position. Consistent caregiver posture when performing tooth brushing is difficult because of various factors, such as the body and oral condition of the subject and the brushing environment. It is important to understand the influence of posture in order to develop methods for more efficient tooth brushing by caregivers.

In this study, we evaluated the impact of the Great East Japan Earthquake on regular dental check-ups among disabled individuals. The subjects consisted of 841 disabled persons who were undergoing regular dental check-ups at Tohoku University Hospital before the disaster. The age, type of disorder, place of residence, and the dates of visiting the hospital before and after the disaster were investigated based on their medical records. We compared the re-visit rates at 3, 6, 12, 24, 36, 48, and 60 months after the disaster for each survey item.

Sixty-eight percent of the subjects came back for dental check-ups within 3 months after the disaster, and 83.6％ came back within 6 months. The re-visit rate recovered up to near the usual level 12 months after the disaster. About 80％ of the subjects continued undergoing regular dental check-ups at the same rate as before the disaster. Subjects who lived in the area affected by the tsunami and/or the evacuation zone of the nuclear plant accident（n＝107）had a significantly lower re-visit rate than those who lived in other areas（n＝734）throughout the study period. Subjects who needed other medical treatment had a significantly higher re-visit rate until 6 months after the disaster. There was no significant difference in re-visit rate within 12 months after the disaster among the age groups or the types of disorder.

We carried out a questionnaire survey of parents who have children with autism spectrum disorder（ASD）to identify challenges, difficulties and requests related to eating problems, and to provide appropriate support. Of a total of 248 members of the Parents Association of Children with Disabilities, 120 persons were included in this survey. The questionnaire consisted of 45 questions regarding basic information on parents and children, meals currently provided to children, experience of receiving eating instructions, and dental problems. Among the data collected, those pertaining to eating problems were analyzed. For statistical analysis, Pearson’s chi-square test and Fisher’s exact test were used with a significance level of 0.05.

The majority of responders were mothers. The ages of the children ranged from 4 to 17 years, with males accounting for 80％ of all patients. Analysis by children’s age groups revealed a significant correlation between aging and the following problems：1）parents’ problems including “I don’t know how to cook foods properly for my child”, “I don’t have enough time to cook meals” and “My child doesn’t eat enough”, and 2）children’s eating problems including “picky eating”, “spilling food” and “getting distracted”（p＜0.05）. These factors appeared most in the 4-11 age group among all age groups.

These results suggest that eating problems in children with ASD are influenced by aging. Many parents experienced problems like “picky eating”, “spilling food” and “getting distracted” when their children were preschoolers or elementary school students, and these problems then gradually diminished as the children grew older. Eating problems were shown to consist of those requiring：1）observation over time, or psychological considerations and environmental arrangements for the children, and 2）the provision of eating instructions by specialists to the children.

Williams syndrome is a congenital disease accompanied by “elfin-like” facial features, cardiovascular disease with supravalvular aortic stenosis, and delayed development. Because of intellectual disability, it may be difficult for patients with Williams syndrome to adapt to changes in environment such as hospitalization. However, some reports have suggested that ambulatory anesthesia should not be performed for patients with this syndrome because of the possibility of perioperative death caused by their cardiovascular disease. We report herein the perioperative management of a patient with Williams syndrome undergoing extraction of third molar teeth under general anesthesia.

The patient was an 18-year-old woman. She was nervous even during medical interview in the hospital ward. According to her mother, she had an extreme fear of hospitalization and surgery. Therefore, we tried not to frighten her and to make her feel relaxed during hospitalization. We performed only easy medical acts that she had previously been able to accept, such as blood pressure measurement and auscultation. One hour before surgery, we secured vascular access and started intravenous sedation with midazolam in the hospital ward. During intravenous sedation, she was calm and exhibited neither respiratory depression nor glossoptosis, etc. The induction of anesthesia was smooth. As a number of papers have reported, mask ventilation and tracheal intubation were not difficult despite micrognathia. She exhibited no problems during surgery. In order not to make her feel anxiety after awakening, we injected midazolam after extubation. After surgery, she was calm and relaxed with her parents together in the hospital ward. She was in good condition and was discharged from the hospital on the next day. To manage hospitalized patients with Williams syndrome, it is necessary to avoid events and medical actions that may cause the patients to feel stress or anxiety.

Lennox-Gastaut syndrome（LGS）is a disease characterized by refractory epileptic seizures and mental retardation. Anesthetic management problems include prevention of epileptic seizures and attention to the interaction between anesthetics and internal medications. We report the anesthetic management of a patient with LGS with propofol alone.

The patient was a 43-year-old female who had been diagnosed with LGS at 2 years of age. Her concurrent medications included carbamazepine, clobazam, topiramate and rufinamide daily. A dental procedure under intravenous sedation was planned because of difficulty of retaining oral opening.

The patient experienced a small seizure before the first anesthesia, and was feeling sleepy before induction. A 20-mg dose of propofol was administered and sedation maintained at 4 mg/kg/h such that the BIS value was 60-70. Significant hemodynamic changes and respiratory depression were not observed during the operation. She was awake on the second occasion and a 50-mg dose of propofol was administered；sedation was maintained at 2-6 mg/kg/h such that the BIS value was 40-60. Epileptic seizures were not observed on either occasion.

Benzodiazepines（BZ）are effective in preventing epileptic seizures, and this patient was on clobazam therapy. Flumazenil, a BZ antagonist, acts by competitively inhibiting BZ binding to the GABAA receptor. When such patients are sedated with BZ and delay in arousal occurs, administration of flumazenil may decrease the efficacy of clobazam and precipitate a seizure. Therefore, only propofol with a short context-sensitive half-time was used in this case, and the patient was maintained under deep sedation to prevent the occurrence of a seizure. The BIS monitor, which measures sedation degree, is also useful for anesthesia management of epilepsy patients who have difficulty communicating because it continuously monitors brain waves.

A 71-year-old man who had been diagnosed with inoperable stage Ⅳ gastric cancer was scheduled to undergo chemotherapy（S1/CDDI）in the Clinic of General Surgery, Fukuoka Dental College Medical and Dental General Hospital in May 2015. He was introduced to our department for oral management during chemotherapy. On the first day he visited our department, we performed dental checks that included dental X-rays, and found a large periapical lesion over 5 mm in diameter at the root apex of the left mandibular first premolar. Previous reports on oral health care during chemotherapy including hematopoietic cell transplantation typically recommend extraction of teeth with chronic periapical cysts over 5-6 mm in diameter before chemotherapy to prevent blast crisis and bloodborne infection. However, he had never felt any subjective symptoms and strongly hoped for tooth preservation. Therefore, we tried endodontic treatment for the infection after obtaining informed consent. On the first day of dental treatment, he took 1 g of prophylactic amoxicillin 1 hour before the endodontic treatment. We used, in order, iodine glycerin, metronidazole, and calcium hydrate paste for medical application in the root canal. The therapeutic course of the root canal treatment was good and the root canal filling was completed 3 months after the initial dental treatment. Since then, we have continuously monitored his oral health, including the periapical lesion, with X-rays and monthly professional oral health care. At 18 months after the root canal filling, bone formation was seen around the periapical lesion. Eight months after starting S1/CDDI chemotherapy, his gastric cancer, including lymph node metastasis, had been greatly reduced, as confirmed by PET-CT. Thereafter, the chemotherapy regimen was changed to XELOX therapy, and oral mucositis developed because of acute reduction of the white blood cell count. We treated the mucositis using CO₂ laser, topical anesthesia for pain relief and oral health care, while keeping his mouth clean daily to prevent secondary microbial infection until the mucositis disappeared. With the aid of dental treatment, the oral mucositis gradually healed within 2 weeks. The left mandibular first premolar did not show any symptoms of recurrent infection throughout the duration of chemotherapy, despite the reduction of the white blood cell count below the reference value. In conclusion, we suggest that it is possible to preserve an infected tooth with a large periapical cyst during chemotherapy if the tooth is asymptomatic and is treated appropriately.

Everolimus（Afinitor^®）is a mammalian target of rapamycin（mTOR）inhibitor and is effective in the treatment of renal angiomyolipomas associated with tuberous sclerosis. However, it is associated with a high incidence of oral mucositis. Here, we describe the prophylactic oral management of a patient with tuberous sclerosis who was undergoing treatment with oral everolimus.

The patient was a 20-year-old man with a history of tuberous sclerosis, intellectual disability, epilepsy, and renal angiomyolipomas. His primary care physician, an internist, prescribed oral everolimus（10 mg/day）for management of the renal angiomyolipomas and subsequently referred him to our clinic for a dental examination. There were no abnormal findings in the oral mucosa, although the oral hygiene state was not good. Furthermore, the maxillary left second premolar exhibited buccoversion. Considering the risk of oral mucositis caused by the sharp margins of the tooth, we decided to perform prophylactic extraction of the second premolar, followed by regular maintenance and oral hygiene instruction. The tooth was extracted 6 months later. In the meantime, the patient developed several bouts of mild（grade 1）oral mucositis without any appetite loss, and his symptoms did not require dose reductions or discontinuation of everolimus. After extraction, oral management was regularly performed once a month. Severe mucositis never developed, and the everolimus therapy was unaffected.

In the present case, we were able to minimize the patient’s oral mucositis, and he could continue everolimus treatment for the renal angiomyolipomas. Our collaboration with his primary care internist and appropriate maintenance of oral hygiene and oral hygiene instruction are likely responsible for the uneventful course of everolimus treatment in this case.

A questionnaire survey was conducted targeting the parents of physically disabled children of three special-needs schools in two cities to investigate their expectations of home dentists. The questionnaire forms were distributed to 334 families and 229（68.6％）responded. One hundred and sixty-nine（50.6％）respondents answered that their children visit home dentists at least once a year, and the questionnaire forms collected from these respondents were analyzed.

The results showed that 100 respondents considered “high expertise in dentistry for the disabled” as a good point, followed by “doctor’s hospitality”（97 respondents）, “staff’s hospitality”（88 respondents）and “being located in the neighborhood”（64 respondents）. “Facilities for barrier-free environment”, “being adjoined to medical clinics” and “being adjoined to care or rehabilitation facilities” were evaluated as good by 50, 22 and 17 respondents, respectively.

Ninety-two respondents wrote their opinions on the question “What do you expect from a dental clinic?” Key words were then picked up from the sentences and classified. The key words frequently found in the sentences were those related to “special-needs dentistry”（25 respondents）, “barrier-free（including rest rooms）”（24 respondents）, “hospitality for the patients”（20 respondents）, “comfort of dental chairs（including posture during dental care）”（19 respondents）and “considerations in dental treatment”（19 respondents）.

These results indicate that the parents of physically disabled children were concerned about the specialty and hospitality of dental clinics, while they were not particularly satisfied with the barrier-free level.

Erosive tooth wear is often observed in patients with severe disabilities, and detachment of filling material, hypersensitivity to dentin and dental caries may occur. The purpose of this study was to investigate, by questionnaire and intraoral findings, patients diagnosed with erosive tooth wear among those visiting our dental clinic.

Twenty-one patients（18 males, 3 females, average age 37.9±5.9 years）were diagnosed as having erosive tooth wear, 4.6％ of the total. By disability, 13（61.9％；10.8％ of the total）were autistic and 8（38.1％；3.3％ of the total）had intellectual disabilities. Most of them were severely disabled. Detachment of filling material was observed in 7 patients（33.3％）and dental caries in 6 patients（28.6％）. Regarding preference for drinks, many patients liked cola, coffee, and juice, and 17 patients（81.0％）had behavioral problems such as self-injury and other forms of harm.

In this study, erosive tooth wear was observed in the patients with autism and intellectual disabilities. These patients had ruminant habits and behavioral behaviors, and preferred acidic drinks such as cola and juice, so the endogenous and extrinsic causes were considered.

It is difficult for intellectually handicapped children to brush their teeth by themselves, so they need tooth brushing by caregivers. Touch care, which involves touching the body of a child with the hands, has the effect of reducing the tension and anxiety of children. Therefore, in this study, instruction on tooth brushing while using touch care for caregivers of intellectually handicapped children was given, and the improvement effects of giving oral health instruction on tooth brushing and changes in the oral environment were examined.

The study participants were 19 intellectually handicapped children and their caregivers who used an institution for disabled children in Aichi prefecture. At the start of the study, the children were orally examined and a saliva test was conducted. We conducted a questionnaire survey on the implementation of tooth brushing and oral health instruction including tooth brushing to caregivers. Six months after the baseline examination, the same examinations ware conducted for the children, and caregivers were asked about changes in implementing their tooth brushing.

As a condition of the tooth brushing by caregivers at the time of the re-evaluation, the number of persons conducting it every day and doing it in the lying-down state increased, and the time taken for tooth brushing tended to be longer. Also, improvements were observed in crying, rampaging, and dislike during the tooth brushing. More than 80％ of caregivers showed satisfaction with participating in this study. There was no significant change in the results of the saliva test.

This study suggests that instruction of tooth brushing while using touch care is effective for managing the oral health of intellectually handicapped children.

Aichi Children’s Health and Medical Center（ACHMC）, opened in 2001, has been dedicated to providing specific subspecialty care for children. The Department of Dentistry and Oral Surgery provides dental procedures and surgical treatment of diseased tissue and developmental malformations of the mouth and jaws.

General anesthesia is commonly used to facilitate dental treatment in uncooperative younger child patients with or without medical complications. The purpose of this study was to investigate the outline of children who received dental treatment under general anesthesia by our team in ACHMC from 2003 to 2017.

Dental treatment under general anesthesia was performed 199 times for 183 children（113 boys and 70 girls）. The median age was 6 years with over 88 percent having a medical complication. The most common comorbidity was autism spectrum disorder（n＝61）, followed by intellectual disability（n＝28）and congenital heart disease（n＝11）. The average number of treated teeth per child was 9.6, and the average operation time was 2 hours 11 minutes.

Children who undergo dental treatment under general anesthesia should be followed up by a general practitioner in their community, but 50％ remained in our department. The lack of a general practitioner for these children is considered a serious issue. The establishment of an effective medical cooperation system and provision of reliable medical support information for these children are necessary.