The behavioral characteristics in each dental scene of children with autistic spectrum disorder （ASD） who can remove and put on their clothes independently have not been clarified. Therefore, we examined behavioral characteristics and their factors.

Dental treatment was divided into 12 scenes for 16 ASD children and 40 regular developmental children, and decision tree analysis was used to examine the behavior of 12 scenes：“Adaptation：Cooperative from beginning to end”, “somewhat incompatible”. The subjects were evaluated as “persons who moved or talked but did not disturb the medical treatment” and “non-adaptation：There was rejection behavior and the medical treatment was hindered”.

“Indications” were significantly lower at 87.5% and 6.2% for children with typical development （p＜0.01）, and 87.5% of children with ASD were able to perform dental treatment under infiltration anesthesia. In all the scenes, the ASD children in the scene adaptation group were significantly less in number than those with regular development （p＜0.01）, and the three scene adaptations of “sit on the clinic table”, “opening instruction”, and “intraoral examination”. It is suggested that the factor may be adaptive if the developmental age of movement is 4 years and 6 months or more. The characteristic of ASD is related to adaptability：“it is supine,” （visual aid）, “surface anesthesia application”, “waiting time for surface anesthesia”, “infiltration anesthesia”, “waiting time for infiltration anesthesia”, “dental treatment”, and “return to sitting position”. Although it was found that a characteristic of ASD children is the presence of maladaptive behavior, it was suggested that dental treatment in the area is possible because it does not lead to the hindrance of medical treatment.

Introduction：Infiltration anesthesia is necessary for painless dental treatment, but causing pain during infiltration anesthesia is stressful, making patients with intellectual disabilities panic and making it difficult to perform dental treatment after infiltration anesthesia. For infiltration anesthesia without pain, it is desirable to use a topical anesthetic in combination, and it is reported that painless infiltration anesthesia is possible with lidocaine tape. In this study, adaptability was evaluated from the change of external behavior during infiltration anesthesia using lidocaine tape.

Subjects and Methods：Pain during infiltration anesthesia was evaluated from the external behavior of the patient during infiltration anesthesia after applying lidocaine tape to the patients with intellectual disabilities and ethyl benzoate as a control group. Each topical anesthetic was allowed to act for 5 minutes at the site of infiltration anesthesia. Thereafter, a needle was inserted shallowly in the horizontal direction, and 1.8 ml of a chemical liquid was injected during 2 minutes. The 30G injection shortened needle was selected, and the anesthetic solution was a 2% xylocaine cartridge for dental use. The state of infiltration anesthesia was video-recorded, and the patient’s body movement, utterances, crying, changes in facial expression and adaptive behavior were evaluated by two assistants from the video recording.

Results and Discussion：Compared to the ethyl benzoate group, no significant difference was observed in the lidocaine tape group in terms of body movement, utterances, crying and changes in facial expression. However, significant differences were noted in adaptive behaviors. It is suggested that the use of lidocaine tape did not cause pain without inducing maladaptive behavior of people with intellectual disabilities during infiltration anesthesia.

Introduction：Videofluoroscopic examination of swallowing （VF） has been considered the “gold standard” in dysphagia assessment. However, it does not provide external images such as facial expression, posture, and physique, which are crucial in dysphagia management. In this study, we investigated the effects of adding the patient’s real images during VF to the VF images in dysphagia evaluation on the diagnosis of dysphagia and assessment of body posture.

Materials & Methods：Thirty-two clinicians were enrolled in this study as participants. They were divided into two groups：12 clinicians engaged in dysphagia treatment （DT） and 20 clinicians not engaged in dysphagia treatment （NDT）. We selected six cases in which postural control techniques were applied during VF. Two kinds of sample image （VFI：VF image alone；VF＋R：VF image＋patient’s real image）of the six cases were presented to clinicians random order. The participants were asked to judge the sample images in terms of diagnosis of dysphagia using the penetration aspiration scale （PAS） and assessment of the patient’s posture. To assess the patient’s posture, the positions of chin down or cervical flexion, cervical rotation （right/left bending） and lateral incline （right/left bending） of the upper body were used. The rates of agreement and accuracy of evaluations between two images in the same patients were analyzed.

Results：There was no significant difference in agreement rate of dysphagia diagnosis between VFI and VF＋R in both DT and NDT. VF＋R indicated significantly higher agreement in the rate of patient’s posture （chin down or cervical flexion, cervical rotation and lateral incline of the upper body） in both DT and NDT. Especially, patients in whom both head and body postural control techniques were applied indicated significantly higher agreement in the rate of patient’s posture than VFI in both DT and NDT.

Conclusion：The results of this study suggest that it is difficult to assess the patient’s posture accurately from VF images only. Real images of the patient during VF may help improve the accuracy of assessing the patient’s posture without affecting the dysphagia diagnosis. It is thought that accurate assessment of the patient’s posture is important information to improve the reproducibility of these techniques.

The pharmacological approach is one method of managing behavior in special care dentistry, and is often used in cases where other approaches are difficult to use. In such cases, daily management of oral hygiene is also often difficult and so patients under the pharmacological approach are expected to have a high risk of caries. We report an assessment of caries risk using Caries Management by Risk Assessment （CAMBRA） in patients under the pharmacological approach. We applied CAMBRA to 30 such patients at the Osaka University Dental Hospital and related dental facilities, and classified caries risk as Low, Middle, High, or Extreme （referred to as group L, M, H, and E, respectively）. The average age of patients was 31.7 years （±11.3 years）. There were 2 patients in group L, 5 in group M, 14 in group H, and 9 in group E. Among the patients, 15 received caries treatment （caries treatment group；0 patients in groups L and M, 8 in group H, and 7 in group E）, whereas 15 received periodontal treatment and oral surgery （non-caries treatment group；2 patients in group L, 5 in group M, 6 in group H, and 2 in group E）. Caries risk was approximately two times higher in the caries treatment group （groups H and E） than in the non-caries treatment group. We compared treatment contents at the time of CAMBRA and the initial treatment after CAMBRA, and the results showed that non-caries treatment under the pharmacological approach was the main treatment in groups L and M even after CAMBRA. In groups H and E, 7 patients underwent dental treatment without the pharmacological approach or turned to a dental clinic. This evaluation clearly found a high risk of caries in most of the patients under the pharmacological approach.

Pica is a disorder that causes patients to repeatedly eat non-nutritional, non-food substances for at least one month. Pica is often complicated by intellectual disability, autism spectrum disorder, schizophrenia, and similar diseases. Here, we report a case of suspected esophageal obstruction due to pica found at a regular dental medical checkup. We describe the confirmation of the foreign body by endoscopy and its removal.

The patient was a 38-year-old man with intellectual disability and pica who lives in a support facility for persons with disabilities. During the course of ten days, he repeatedly had fever and was suspected of having an obstructed esophagus caused by foreign matter as he was in a state of oral intake disorder. As a result of an emergency endoscopic examination, foreign bodies were found at the entrance of the esophagus and were subsequently removed with forceps. Immediately after the procedure, the patient showed dish-eating behavior, so we conducted a total inspection and repair of the residential facility. Intellectually disabled people often raise no complaints of obvious subjective symptoms, are uncooperative, and sometimes cannot be examined without applying physical restraint. It can also be difficult to examine the patients for gastrointestinal foreign matter. To prevent serious complications, it is necessary to share information on pica patients with staff.

In recent years, opportunities to treat elderly patients with temporomandibular joint （TMJ） dislocation complicated by systemic diseases or dementia have been increasing. Although manipulative reduction is the primary choice of treatment, patients presenting with recurrent dislocations require surgical methods. We report a case of habitual TMJ dislocation in a patient with cerebrovascular dementia treated surgically by eminectomy. A 74-year-old-male visited our department with a chief complaint of difficulty in closing the mouth. Radiographic examination showed that the head of the condyle was located anterior to the eminence and there was no evidence of morphological malformation. We first attempted manipulative reduction, however, he visited 5 days later with TMJ dislocation, and over the following 5 weeks it dislocated 9 times, each requiring manual reduction. Therefore, a surgical procedure （eminectomy） under general anesthesia was carried out. Anesthesia was induced with intravenous propofol, remifentanil and rocronium and maintained with air, oxygen and sevoflurane. He has been followed for 17 months since surgery and there have been no signs of recurrence of habitual TMJ dislocation.

Myasthenia gravis （MG） is an autoimmune disease caused by antibodies that block acetylcholine receptors in the postsynaptic membrane at the neuromuscular junction. We report here on a patient who visited our hospital with complaints of hard to move the mouth smoothly and slurring and who was subsequently diagnosed with MG.

A 23-year-old woman began to experience lip incompetence during eating and dysarthria during long periods of speech in autumn 2017. In May 2018, she was examined at the dysphagia rehabilitation department of a dental hospital. She was lucid and did not demonstrate drooping eyelids. Although she did not complain of general fatigability, her body weight had decreased. Because she was examined in the morning, she demonstrated almost no dysarthria, and she was capable of closing her mouth. Her swallowing function was within normal range （Repetitive Saliva Swallowing Test：3 times, Modified Water Swallow Test score：5）. However, she took one hour to eat a meal, was unable to eat hard foods due to fatigue during eating, and placed her hand over her mouth when drinking soup. Her tongue pressure, which was measured as a test of oral function, was 16.0 kPa, which is well below the mean tongue pressure. On a dysphagia screening questionnaire, three of 15 items applied to the patient, thus indicating dysphagia. Based on this, the patient underwent fiberoptic endoscopic evaluation of swallowing, which revealed velopharyngeal insufficiency and marked pharyngeal residue. Therefore, we suspected MG and requested a neurological examination, which yielded a definitive diagnosis of MG. Although the patient’s MG initially went unnoticed due to characteristic diurnal variation, her complaint of oral dysfunction in the initial examination led to oral function testing, while an assessment of swallowing led to cooperation with a specialist, which resulted in a diagnosis of MG.

The frequency of oral trauma in children with disabilities is higher than that in typically developing children, and tends to increase in children with multiple disabilities.

Here, we describe a case of mandibular fracture in a 14-year-old girl with intellectual disability and epilepsy. The patient presented to our clinic complaining of trismus and swelling of the left cheek. Two days prior, she had fallen and her lower jaw had struck the floor. Panoramic X-ray examination, posterior-anterior X-ray examination, and computerized tomography （CT） showed that the left mandibular condyle and right mandibular body were fractured. We chose conservative treatment for the condyle fracture in accordance with the guideline （“Clinical Practice Guidelines for Oral and Maxillofacial Trauma 2015”）.

Various types of plate fixation or intermaxillary fixation are recommended for the treatment of fracture of the mandibular body, and we too chose conservative treatment for this fracture because we suspected that the patient’s developmental level was insufficient to accept fixation；moreover, fracture of the mandibular body was incomplete. Thus, we monitored the healing process by CT follow-up.

Four months after the injury, the patient could open her mouth 40 mm without pain and/or displacement. Seven months after the injury, we confirmed that the fracture line had disappeared, both at the mandibular condyle and at the mandibular body. The fractures fully recovered and neither facial asymmetry nor malocclusion was observed. The present report indicates that conservative treatment may be appropriate for children with severe intellectual disability with minimal intervention.

To enable pediatric patients with severe physical and psychological disabilities to maintain comfortable lives, it is important to accurately understand their individual needs related to disabilities and to provide appropriate interventions in accordance with their characteristics. In doing so, the concept of the International Classification of Functioning, Disability and Health （ICF） is useful. This paper reports a case of dental intervention through inter-professional collaboration in which an ICF sheet was used and the application of a dental hygiene care process was found to be effective.

Case：The patient was a 52-year-old male suffering from cerebral palsy with a chief complaint of oral function management. The patient had currently been admitted to a ward dedicated to severe psychological disorders in our hospital, and he was usually in a right lateral decubitus position. Right scoliosis, moderate thoracic deformity, myotonia, limb contractures, and labored breathing were observed. Nutrition intake was through gastrogavage. Oral findings were mouth dryness and the adherence of peeled epithelium.

Progress and Discussion：Information was collected through the hospital ICF sheet. A cross-professional discussion discovered that：attention was required for scoliosis, thoracic deformity and breathing；attention was required for the swallowing of secretions；and it was necessary to address dry mouth and the adherence of peeled epithelium and tongue coating. A method of dental hygiene care process was adopted in such a way that the above issues would be addressed. After finalizing the order of priority for intervention based on the collected information, intervention was provided through information sharing via an oral care sheet. While the quality of care varied depending on the skills of nurses, the viscosity of saliva reduced due to the implementation of oral care and moisturization. The adherence of peeled epithelium in the oral cavity was no longer observed, and no post-intervention onset of pneumonia was observed. The respiratory condition stabilized and it became possible for the patient to receive treatment and care outside the hospital.

It was considered that implementing an oral hygiene care process through inter-professional collaboration by using an ICF sheet enabled effective collaboration and information sharing, which benefited the patient.

We conducted a survey to clarify the actual situation of collaboration between dentists and dieticians, the skills and effects of dieticians required by dentists, and the issues of promoting collaboration.

In this survey, we received responses from 95 people who distributed questionnaires to 219 members of the Sunto Dental Association, Mishima City Dental Association, and Numazu City Dental Association in Shizuoka prefecture.

The skills required for a dietician for cooperation were “to evaluate and judge nutritional status corresponding to evaluation of feeding and swallowing function” and “to propose a meal form based on evaluation”. These results were expected to have the effect of “improving patientʼs QOL and nutritional status”. Ten dentists experienced collaboration with dieticians, five dentists wanted to increase collaboration frequency more than once a month, and six dentists wanted to increase more. Types of collaboration （17 cases） were most common in order of “proposal/guidance on meal form of dysphagia diet” and “nutritional guidance for malnutrition”. They evaluated these effects as “very beneficial”. In addition, 79 people （93%） who had no collaborative experience thought “I would like to collaborate if necessary.” The reasons why dentists could not cooperate were “I do not know the method of cooperation and the client”, “Inadequate benefits of cooperation with dentists and collaboration with dieticians” and “I do not know what dieticians can do”.

The results of this survey suggest that, in order to promote collaboration, it is necessary to enhance collaborative systems and to improve the skills of dieticians that are required by dentists, and to deepen the mutual understanding of specialized fields of both dentists and dieticians.

In Okinawa Prefecture, a dental association has been providing oral treatment for handicapped people at the Oral Hygiene Center （present Oral Medical Treatment Center） since 1975, which includes an oral treatment project for physically and mentally handicapped children （people） under general anesthesia, as well as medical workshops for regional cooperative dentists on dental treatment for handicapped people.

The Center was relocated in 2014 and the general anesthesia project was completed in 2016. After the relocation, the number of full-time dentists decreased to three, whereas the number of patients doubled. As a result, there have been changes in the types of problems, response methods, residential areas, etc., and various responses are required. Moreover, dental care for handicapped patients in rural areas such as remote islands is not fully functioning yet and still requires some help from the Center, although it is shifting to a self-complete treatment system within the area.

In future, it is necessary to establish a follow-up support system with regional cooperative dentists and also to cooperate with oral and maxillofacial surgery departments in other medical institutions throughout the prefecture through workshops and practical training.

With the aid of a questionnaire, we confirmed the number of home medical care services for children with severe motor and intellectual disabilities （SMID） in Tokyo that collaborated with home dental care services. A total of 584 visiting nurse services were extracted from the list of the Tokyo Visiting Nurse Service Association. The response rate was 31.5% （184/584）. Only 18 home medical care services （19.1%） were found to collaborate with dental care services；this result was overwhelmingly low in Tokyo. Other dental care demands by parents, hospitals （medical doctors）, and visiting nurses included “oral care,” “eating function therapy,” and “dental treatment.” However, the demands were too high for the number of dentists in collaboration with the home medical care services. The results of this survey confirmed the increasing need for comprehensive dental care from visiting nurse services for children. It is imperative to improve child dental home care services corresponding to the dental care demands of parents, hospitals （medical doctors）, and visiting nurses.