A Case of Systemic Management for an Autism Spectrum Disorder and Dental Phobia Patient with Fontan Circulation

• Published in: Journal of the Japanese Society for Disability and Oral Health Vol. 45; no. 2; pp. 104 - 111
• Main Authors: MIYAZAKI, Hironori, ODA, Yuki, ODA, Aya, TAKAHASHI, Tamayo, SHIMIZU, Yoshitaka, YOSHIDA, Mitsuhiro, IMADO, Eiji, YOSHIDA, Yuriko, OKADA, Yoshiyuki, OUE, Kana, HANAMOTO, Hiroshi
• Format: Journal Article
• Language: Japanese
• Published: The Japanese Society for Disability and Oral Health 30.06.2024; 一般社団法人 日本障害者歯科学会
• Subjects: Congenital heart disease; Dental treatment; Fontan circulation; Intravenous sedation; Tooth extraction
• ISSN: 0913-1663; 2188-9708
• DOI: 10.14958/jjsdh.45.104

Introduction：The Fontan procedure is surgical palliation used for a range of congenital heart defects with a single functional ventricle or in conditions for which biventricular repair is impossible or unfavorable. We experienced perioperative management of a patient with Fontan circulation undergoing dental treatment.Patient：A 22-year-old female. Chief complaint：Dental problems. Past medical history：The patient underwent Damus-Kaye-Stansel anastomosis and Fontan surgery （epicardial conduit type） in childhood due to double outlet right ventricle, hypoplastic mitral valve, and aortic stenosis. History of current illness：The patient had been undergoing dental treatment under intravenous sedation at a dental clinic because of dental phobia and intellectual disorder. She was referred to our hospital due to her markedly low blood pressure during intravenous sedation. Current symptoms：Height 166 cm, weight 70kg. Three teeth required extraction and 13 teeth received caries treatment.Treatment and Course：The first treatment （extraction of three wisdom teeth and caries treatment of six teeth） was performed in the operating room under inpatient management. Propofol and midazolam were used for intravenous sedation. Intraoperative SpO2 was 90-95％, and 85-87％ after the treatment under 3L/min of oxygen via a nasal cannula, without dyspnea or cyanosis. One of the possible reasons for the decrease of SpO2 was considered to be an increase in intrathoracic pressure caused by choking. The patient was admitted to the ward with stable vital signs and was discharged from the hospital without any complications on the next day. The second and third treatments （caries treatment of four and three teeth, respectively） were performed in the outpatient ward. At the time of the second treatment, the patient was crying due to anxiety, so before the third treatment, oral administration of midazolam was performed, leading to smooth induction of intravenous sedation. Preoperative SpO2 was around 93％, and intraoperative SpO2 was 95-99％ under 3L/min of oxygen via a nasal cannula. Perioperative heart rate and blood pressure were stable. The patient was allowed to go home after recovering consciousness and confirmation of motor function. The amnesic effect caused by midazolam satisfied the patient.Discussion and Conclusion：It is very important to assess heart and pulmonary function and other complications before performing dental treatment for patients with congenital heart disease like Fontan circulation. As in this case, patients who are uncooperative with dental treatment because of dental phobia or intellectual disorder undergo pharmacological behavioral adjustment like intravenous sedation, and need consideration to reduce stress using premedication or topical anesthesia.