Perioperative arrhythmias may be induced by an imbalance between sympathetic and parasympathetic activities owing to excessive mental and physical stress. To date, no studies have been conducted on intravenous sedation (IVS) during dental procedures in a serious dental anxiety patient with atrioventricular junctional rhythm (AVJR). We describe herein the management of IVS in an outpatient with dental phobia who experienced the AVJR followed by vasovagal reflex (VVR) during dental care. A 26-year-old woman with serious dental anxiety was scheduled for dental extraction under intravenous conscious sedation. A II-lead electrocardiogram revealed AVJR following sinus rhythm. Immediately afterwards, she experienced VVR with dimmed vision, cold sweat, hypotension, and bradycardia. She was made to relax in the supine position, which restored hemodynamics to normal, and sinus rhythm followed. She was optimally sedated with midazolam 4 mg and uneventfully treated under a preparation of intravenous atropine, and hemodynamic and respiratory statuses were closely monitored to ensure spontaneous breathing without any signs of AVJR or cardiorespiratory disorders. Finally, flumazenil 0.5 mg was administered, and she recovered without re-sedation or prolonged sedation. The autonomic nervous system and endocrine system are closely related in order to control the stress responses. The present case suggests that an electrocardiographic change such as AVJR is induced by an imbalance of autonomic activity owing to excessive psychosomatic stress and is considered as a possible prodromal sign of VVR as the dental procedures are likely to be stressful for some patients.

The perioperative cardiac events may be brought about by a relative imbalance of autonomic activities due to excessive psychological and physical stress. The present case study focuses on the asystole that can occur as a serious cardiac adverse event associated with vasovagal reflex likely to be triggered by venipuncture for securing an intravenous line during dental care. In addition, we describe and discuss herein the management of intravenous sedation for a dental phobic patient who experienced the vasovagal reflex involved in an unexpected transient asystole. The patient with vasovagal reflex episodes in daily life, who had no past medical history relevant to cardiovascular disorders, was scheduled for dental extraction under intravenous sedation. Immediately after peripheral intravenous catheterization, she complained of discomfort and nausea, and a II-lead electrocardiogram revealed asystole following bradycardia associated with vasovagal reflex. Oxygenation and intravenous fluid loading in the supine position with elevation of the lower extremities restored sinus rhythm and normal hemodynamics without the intervention of cardiopulmonary resuscitation. With administration of intravenous atropine and betamethasone as premedication, she was uneventfully treated in stress-free psychosomatic conditions under optimal sedation with midazolam without any signs of cardiovascular disorders. After administration of flumazenil, the patient satisfactorily recovered from sedation without re-sedation. The present case suggests that an asystole associated with vasovagal reflex can be triggered by venipuncture for intravenous catheterization during dental anxiety likely to affect the imbalance between sympathetic and parasympathetic activities.

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Introduction Centronuclear myopathy is a hereditary congenital muscle disease. It is characterized by generalized muscle hypotonia from early childhood, elongated cacial appearance, mandibular undergroth, and dental malposition. In this report, we discuss the clinical course and management of a patient with centronuclearmyopathy, who developed a giant dental calculus in the floor of the mouth and underwent surgical excision. Case Report A 37‐year‐old Japanese man was referred to our hospital, and reported a swelling in the floor of the mouth. The patient affects centronuclear myopathy and has generalized muscle weakness. CT images showed a high‐density area in the floor of the mouth measuring 35 × 28 × 20 mm. The lesion was clinically diagnosed as giant dental calculus, and surgically removed. Conclusion We have experienced a case of giant dental calculus in a patient with centronuclear myopathy. In dental treatment, we must consider generalized muscle weakness.

Psoriatic arthritis (PsA) is a common relapsing inflammatory skin disease associated with joint symptoms in patients with psoriasis. Temporomandibular joint (TMJ) disorders are found in 68.8% of affected patients, however most cases of PsA associated with TMJ ankylosis are not reported. We experienced a case of TMJ ankylosis suspected to be caused by PsA. The patient was a 45-year-old male who had developed erythema of the skin and was diagnosed with psoriasis vulgaris at approximately 27 years of age. He was referred to us due to limited range of mouth opening as well as pain in the bilateral TMJ. Panoramic radiography revealed narrowing of the bilateral TMJ space, while computed tomography imaging showed prominent destructive and sclerosing changes in the bilateral mandibular condyle and glenoid fossa. Blood test results indicated a mildly decreased ferritin level and were negative for rheumatoid factor. The patient initially refused surgery and was given mouth opening exercises, though he stopped going to follow-up examinations. A few years later, he returned to our department with the same complaints, and a gap arthroplasty with a temporalis myofascial flap was performed. At a follow-up examination two years later, his maximal mouth opening had been maintained at 34 mm.