중증 지적 장애인을 위한 효과적인 치과치료

장주혜(Juhea Chang) 대한치과의사협회 2011 대한치과의사협회지 Vol.49 No.12

Patients with severe mental challenges are often subjected to extensive dental problems. Their impaired communication and lack of cooperation unable to receive timely dental treatments, which deteriorates their adverse oral conditions. In spite of a limited time frame, well-planned comprehensive treatments can be delivered in an one-day operation setting under general anesthesia. This ultidisciplinary treatment regimen primarily comprises of single-visit endodontics, direct bonded restoration, periodontal treatment, and surgical extraction. Further, one or two additional visits for prosthetic procedures are able to accomplish functional reestablishment and esthetic enhancement. This article discusses on clinical managements for severely mentally challenged patients under a single-day operation.

전신 마취 하 장애인 치과치료에 대한 임상적 고찰

장주혜(Juhea Chang) Asia association of Disability and Oral health 2014 International Journal of Disability and Oral Healt Vol.10 No.2

The aim of this study was to analyze the clinical characteristics of patients with cognitive and behavioral impairments receiving dental treatment under general anesthesia (GA-dental treatment). From August 2007 to April 2014, information was collected from 475 patients who received GA-dental treatment at the Clinic for Persons with Disabilities, Seoul National University Dental Hospital. The demographic factors (gender, age, disability, medication, GA history, residency type, caregiver, meal type, oral hygiene maintenance, and cooperation level) and dental status (operating duration, DMFT, malocclusion, periodontal disease, tooth defect, and treatment protocol) of the patients were evaluated. DMFT and malocclusion levels were compared among the patients with ANOVA and Sheffe’s post-hoc test, and chi-square test, respectively. The correlation between the demographic characteristics and dental status of the patients were analyzed with the Pearson’s correction test. The mean age of the patients was 27.1 (7 - 83) years and they had intellectual disabilities (55.4%), developmental disorders (17.9%), brain disorders (16.6%), neurocognitive disorders (4.6%), or others (5.5%). The mean DMFT (DT) was 8.6 (5.2) with a significant difference among the disability types (p<0.05). The incidence of malocclusion was higher in patients with intellectual disabilities and brain disorders than in the other types (p<0.05). The operation time (191.4 ± 91.2 min) was correlated with decayed or endodontically-treated teeth (p<0.05). Special needs patients requiring GA-dental treatment showed unfavorable oral conditions. Dental practitioners experience time restrictions and additional costs under a GA setting. Treatment planning and decision-making can be efficiently facilitated by evaluating the clinical characteristics of the patients.

치과적 중증 장애인 환자를 위한 치료 계획 수립

장주혜(Juhea Chang) 대한치과의사협회 2015 대한치과의사협회지 Vol.53 No.11

This article discusses how to conduct treatment planning and decision making in special needs dentistry. Special needs patients often lack cooperative ability during dental treatment and have a deteriorated oral health status. To overcome the limitation in communication with special needs patients and solve their complicated dental problems, dentists need to have extensive preoperative information about the patients and their caregivers. Treatment procedures should be organized in a patient-centered and cost-effective manner. Additionally, clinical outcomes need to be predicted taking into consideration of the patients" condition. The clinical experience of committed dentists is another factor that enhances the benefits of extensive treatment in special needs patients with many limitations. The insightful treatment decision-making of dentists will contribute to improving the oral health of special needs patients despite the various obstacles.

장애인 구강진료 접근성 제약 - Part 2. 장애인 환자 보호자 측면에서의 고찰

장주혜(Juhea Chang) Asia association of Disability and Oral health 2019 International Journal of Disability and Oral Healt Vol.15 No.1

The aim of this study was to determine the factors contributing to the barrier of dental treatment for special needs patients perceived by the main caregivers of the patients. A questionnaire was developed with three parts: patient-related factors, caregiver-related factors, and factors for treatment barriers. Patient- and caregiver-related factors were analyzed for correlations with the barrier factors. Fisher’s exact test and Chi-square test were used at the level of 0.05. A total of 52 caregivers (mean age [SD]=50.2 [11.5] years) for the patients with intellectual and cognitive disabilities (mean age [SD]=38.9 [21.3]) responded to the questionnaires. Oral hygiene status, need for assistance in tooth brushing, and cooperation for tooth brushing were correlated with the level of treatment cooperation of the patients (p<0.05). The above three factors were also correlated with the treatment barrier despite patients presenting oral symptoms (p<0.05). Two thirds of the caregivers felt the treatment cost as severe or a considerable financial burden. For patients, insurance types and need for assistance in tooth brushing, and for caregivers, education levels and financial status were significant factors contributing to financial burden (p<0.05). There were background factors of the patients and their caregivers associated with access to dental treatment for special needs patients. Deficient cooperative skills and financial burdens were the main obstacles to treatment access. Tooth brushing skills and oral hygiene status can be proxy measures to cooperative ability for dental treatment.

선천성 갑상선기능저하증과 가성부갑상선기능저하증을 동반한 환자의 전신마취 하 치과치료

서광석,신터전,김현정,장주혜,Seo, Kwang-Suk,Shin, Teo-Jeon,Kim, Hyun-Jeong,Chang, Juhea 대한치과마취과학회 2013 Journal of Dental Anesthesia and Pain Medicine Vol.13 No.3

The patient who has congenital hypothyroidism and pseudohypoparathyroidism could have mental retardation even though adequate hormone treatment and cannot endure conventional dental treatment. In this case, general anesthesia is selected to administer effective dental treatment. But, there could be symptoms such as anemia, neuropathy, associated pituitary or adrenal hypofunction, cardiac failure even in euthyroid state. And, bradycardia, mental dullness, hypothermia, slow reflexes can appear in case of inadequate thyroid hormone replacement. Especially, macroglosssia, slow drug metabolism, exaggerated responses to anesthetic agents and decreased ventilatory responses could be problem during general anesthesia. The presentation of hypoparathyroidism also varies depending on the chronicity of the result of hypocalcemia. Muscle spasms/tetany, paresthesias, and seizures may occur in an acute onset. Chronic hypocalcaemia causes fatigue, muscle cramps, lethargy, personality changes, and cerebration defects.

선천성 심장질환을 가진 다운증후군환자에서 치과치료를 위한 전신마취 시 산소포화도 하강

서광석(Kwang-Suk Seo),장주혜(Juhea Chang),신터전(Teo-Jeon Shin),김현정(Hyun-Jeong Kim) Asia association of Disability and Oral health 2009 International Journal of Disability and Oral Healt Vol.5 No.1

A 26-year-old female patient with Down syndrome visited to recieve dental treatment under gnenral anesthesia 6 years ago. The patient had difficulties in oral examination, radiograph taking and laboratory test. The patient had congenital heart disease and medical consultation based on the echocardiography was provided by a cardiologist indicating that the patient could tolearte general anesthesia during dental treatment. And two times of general anesthesia were administered during a dental treament with the interval of 3 years and no postoperpative complicaton was reported. At the third dental operation, the patient had a relatively good condition and her prescreening test revealed no abnormalities. Without further consultation with a cardiologist, general anesthesia was administered to the patient. Anaesthesia was based on thiopental and ventilation of desflurane and N2O in oxygen via an endotracheal tube with an appropriate monitoring. During the maintenance of anesthesia, the blood pressure of the patient started to drop and the oxygen saturation also began to decrease. Consequently, the proceding operation was discontinued and also inhalation anesthesia was ceased. As the patient was recovered from anesthesia, her systemic conditions were alleviated. After the complete recovery of the patient, she visited the cardiologist, and the cardiologic test revealed her severe right ventricular dilatation. In the anesthesia of patients with congenital heart disease, information on their systemic conditions needs to be undated from the medical consultation, which assures the safety of treatment.

심한 구역반사를 가진 성인환자에서 프로포폴 목표농도 주입법으로 시행한 깊은 진정

신순영,차민주,서광석,김현정,이정만,장주혜,Shin, Soonyoung,Cha, Min-Joo,Seo, Kwang-Suk,Kim, Hyun-Jeong,Lee, Jung-Man,Chang, Juhea 대한치과마취과학회 2012 Journal of Dental Anesthesia and Pain Medicine Vol.12 No.2

The gag reflex is a physiological reaction, but, an exaggerated gag reflex can be a severe limitation not only to treat dental caries but also to do oral exam. Procedures such as surface anesthesia of the palate and pharyngeral area, sedation, or general anesthesia can be options as behavioral management. But, there are no golden rule for the sever gag reflex patients. We present a case report of propofol intravenous sedation using TCI pump for simple dental treatment. A 44-year-old man, who had past history of general anesthesia for dental treatment because of severe gag reflex, was scheduled intravenous sedation for simple dental treatment. After 8 hour fasting he entered the clinic for persons with disabilities. We explained about intravenous deep sedation and got informed consent. First, we kept intravenous catheter (22G) in the arm and started monitoring ECG, non-invasive blood pressure, pulse oximetry and end-tidal $CO_2$ through nasal cannula. We started propofol infusion with TCI pump at the target concentration of 3 mcg/ml. The patient became sedated, but he showed involuntary movement during dental treatment, so we increased the target concentration to 4 mcg/ml. We finished the dental treatment without complications during 30 min. And after 40 min recovery room stay he was discharged without any complications.

치과장애인 환자의 외래마취 하 치과치료 귀가 후 전화추후 관리 분석

김미선,서광석,이정만,김혜정,한진희,한희정,이은희,신순영,신터전,김현정,장주혜,Kim, Mi-Seon,Seo, Kwang-Suk,Lee, Jung-Man,Kim, Hye-Jung,Han, Jin-Hee,Han, Hee-Jeong,Lee, Eun-Hee,Shin, Soonyoung,Shin, Teo-Jeon,Kim, Hyun-Jeong,Chang, Juhea 대한치과마취과학회 2012 Journal of Dental Anesthesia and Pain Medicine Vol.12 No.2

Background: Some disabled patients show insufficient cooperation during dental treatment, and general anesthesia in an outpatient setting can be successfully administered. To minimize post-anesthetic complications is an essential issue, and strict discharge protocols are required for the safety of the patients. Post-anesthetic follow-ups using telephone calls can be applied to improve the quality of the outpatient care system. The authors evaluated the post-operative condition of patients after dental treatment under general anesthesia. Methods: Total 143 patients and their caregivers included in this study. The patients received general anesthesia for dental treatment in Seoul National University Dental Hospital, Clinic for Persons with Disabilities from July, 2011 to April, 2012. Telephone calls were given to the patients or their caregivers to collect information about the patients' systemic condition and anesthesia-related complications. Results: Among 131 patients with responses of telephone calls, 87 patients (66.4%) reported no discomfort, while 44 patients (33.6%) presented post-anesthetic complications. A total of 20 patients reported mild fever, 10 patients had vomiting, and 7 patients had sore throat. Other complications included nausea, fatigue, nasal bleeding, skin sore, and body rash. Among the patients with the history of epilepsy, 63.6% showed post-anesthetic discomfort or complication (P = 0.027, ${\chi}^2$ test). Conclusions: One third of dental patients who received general anesthesia due to insufficientcooperation complained discomfort after discharged from outpatient anesthetic care.

설암 수술 후 구강 내 기능장애 및 치과공포증이 생긴 환자의 외래 마취관리

이수언(Soo Eon Lee),서광석(Kwang-Suk Seo),최윤지(Yoon-Ji Choi),김현정(Hyun-Jeong Kim),장주혜(Juhea Chang) Asia association of Disability and Oral health 2014 International Journal of Disability and Oral Healt Vol.10 No.2

We experienced a case of dental treatment under general anesthesia in a 22-year-old female patient with dysphagia and dental phobia following partial glossectomy. She was diagnosed of squamous cell carcinoma of tongue and received surgical, radiation treatment two years ago. We report the experiences of anesthetic management for dental treatment in a patient with dysphagia and dental phobia following partial glossectomy.

치과 진료실에 들어오지 않으려는 자폐환자에서 미다졸람 경구투여

이정후(Jung-Hoo Lee),서광석(Kwang-Suk Seo),신터전(Teo-Jeon Shin),김현정(Hyun-Jeong Kim),장주혜(Juhea Chang) Asia association of Disability and Oral health 2009 International Journal of Disability and Oral Healt Vol.5 No.2

Dental treatment of mentally challenged patients under general anesthesia is a series of challenging procedures not only for dental operators but also for dental anesthesiologists. Patients presenting with uncooperative behavior often resist the perioperative management for adesthestic administration. This case report suggests oral premedication as a conjuctive method for anestheitic induction. A 26-year-old male dental patient with autism was referred to dental treatment under general anesthesia. The patient refused to enter dental clinic office and was not able to receive preoperative assessment. In the day of operation, 15 mg of midazolam was given to the patient for oral premedication prior to anesthetic induction. Ater 20 minutes, the patient presented with drowziness and was transferred to the office. Anesthestic staff were able to achieve appropriate intravenous access and mask inhalation. The patient recieved 8 hrs long dental treatment and recovered in a noncomplicated way. Oral midazolam is commonly used to reduce anxiety for combative and irritated pateints. In this case, oral midazolam sedation was used as a preanesthetic management of a highly uncoopearive patient.