{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,2,15]],"date-time":"2026-02-15T02:49:49Z","timestamp":1771123789757,"version":"3.50.1"},"reference-count":32,"publisher":"American Dental Society of Anesthesiology (ADSA)","issue":"1","content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":[],"published-print":{"date-parts":[[2020]]},"abstract":"<jats:p>Systemic sclerosis (SSc) is an autoimmune disease that can cause fibrosis in vital organs, often resulting in damage to the skin, blood vessels, gastrointestinal system, lungs, heart, and\/or kidneys. Patients with SSc are also likely to develop microstomia, which can render dental treatment difficult and painful, thereby necessitating advanced anesthetic management. This is a case report of a 61-year-old woman with a history of SSc with microstomia, interstitial pneumonia, and gastroesophageal reflux disease in whom intravenous moderate sedation was performed using a combination of dexmedetomidine and ketamine for dental extractions. Both anesthetic agents are known to have analgesic effects while minimizing respiratory depression. Consequently, the increased discomfort caused by opening the patient's mouth and stretching the buccal mucosa was sufficiently managed, permitting an increase in maximum interincisal opening and completion of treatment without complications. Patients with SSc present with serious comorbidities that can negatively impact anesthetic management, so the implementation of an anesthetic plan that takes such risks into account is required. Furthermore, emergency airway management is likely to be difficult in patients with microstomia. For intravenous moderate sedation, combined use of dexmedetomidine and ketamine, which have analgesic effects while minimizing respiratory depression, may be particularly effective in patients with SSc and microstomia.<\/jats:p>","DOI":"10.2344\/anpr-66-03-07","type":"journal-article","created":{"date-parts":[[2020,3,19]],"date-time":"2020-03-19T18:40:56Z","timestamp":1584643256000},"page":"28-34","source":"Crossref","is-referenced-by-count":6,"title":["Anesthetic Management of a Patient With Systemic Sclerosis and Microstomia"],"prefix":"10.2344","volume":"67","author":[{"given":"Yoshiki","family":"Shionoya","sequence":"first","affiliation":[{"name":"Department of Dental Anesthesia, Nippon Dental University Hospital, Tokyo, Japan"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Hatsuko","family":"Kamiga","sequence":"additional","affiliation":[{"name":"Department of Dental Anesthesia, Nippon Dental University Hospital, Tokyo, Japan"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Gentarou","family":"Tsujimoto","sequence":"additional","affiliation":[{"name":"Department of Dental Anesthesia, Nippon Dental University Hospital, Tokyo, Japan"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Eishi","family":"Nakamura","sequence":"additional","affiliation":[{"name":"Department of Dental Anesthesia, Nippon Dental University Hospital, Tokyo, Japan"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Kiminari","family":"Nakamura","sequence":"additional","affiliation":[{"name":"Department of Dental Anesthesia, Nippon Dental University Hospital, Tokyo, Japan"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Katsuhisa","family":"Sunada","sequence":"additional","affiliation":[{"name":"Department of Dental Anesthesiology, Nippon Dental University School of Life Dentistry, Tokyo, Japan"}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"1191","reference":[{"key":"i0003-3006-67-1-28-b01","series-title":"J Clin Anesth","first-page":"474","article-title":"Progressive systemic sclerosis: clinical manifestations and anesthetic considerations","volume":"14","author":"Roberts \n              JG,","year":"2002","unstructured":"Roberts \n              JG, \n            \n            \n              Sabar \n              R, \n            \n            \n              Gianoli \n              JA, \n            \n            \n              Kaye \n              AD. \n            \n          \n          Progressive systemic sclerosis: clinical manifestations and anesthetic considerations. J Clin Anesth. 2002;14:474\u2013477."},{"key":"i0003-3006-67-1-28-b02","series-title":"Curr Opin Rheumatol","first-page":"508","article-title":"Assessment and management of scleroderma lung disease","volume":"11","author":"Bolster \n              MB,","year":"1999","unstructured":"Bolster \n              MB, \n            \n            \n              Silver \n              RM. \n            \n          \n          Assessment and management of scleroderma lung disease. Curr Opin Rheumatol. 1999;11:508\u2013513."},{"key":"i0003-3006-67-1-28-b03","series-title":"Ann Rheum Dis","first-page":"940","article-title":"Changes in causes of death in systemic sclerosis, 1972\u20132002","volume":"66","author":"Steen \n              VD,","year":"2007","unstructured":"Steen \n              VD, \n            \n            \n              Medsger \n              TA. \n            \n          \n          Changes in causes of death in systemic sclerosis, 1972\u20132002. Ann Rheum Dis. 2007;66:940\u2013944."},{"key":"i0003-3006-67-1-28-b04","series-title":"Oral and Maxillofacial Pathology. 2nd ed","first-page":"137","author":"Neville \n              BW,","year":"2002","unstructured":"Neville \n              BW, \n            \n            \n              Damm \n              DD, \n            \n            \n              Allen \n              CM, \n            \n            \n              Bouquot \n              JE. \n            \n          \n          Oral and Maxillofacial Pathology. 2nd ed. Philadelphia, Pa: WB Saunders Co;2002:137."},{"key":"i0003-3006-67-1-28-b05","series-title":"J Can Dent Assoc","first-page":"831","article-title":"Small mouths ... big problems? A review of scleroderma and its oral health implications","volume":"73","author":"Albilia \n              JB,","year":"2007","unstructured":"Albilia \n              JB, \n            \n            \n              Lam \n              DK, \n            \n            \n              Blanas \n              N, \n            \n            \n              Clokie \n              CM, \n            \n            \n              S\u00e1ndor \n              GK. \n            \n          \n          Small mouths ... big problems? A review of scleroderma and its oral health implications. J Can Dent Assoc. 2007;73:831\u2013836."},{"key":"i0003-3006-67-1-28-b06","series-title":"Drugs","first-page":"263","article-title":"Dexmedetomidine","volume":"59","author":"Bhana \n              N,","year":"2000","unstructured":"Bhana \n              N, \n            \n            \n              Goa \n              KL, \n            \n            \n              McClellan \n              KJ. \n            \n          \n          Dexmedetomidine. Drugs. 2000;59:263\u2013268."},{"key":"i0003-3006-67-1-28-b07","series-title":"J Oral Maxillofac Surg","first-page":"1353","article-title":"Dexmedetomidine vs. midazolam in outpatient third molar surgery","volume":"64","author":"Ustun \n              Y,","year":"2006","unstructured":"Ustun \n              Y, \n            \n            \n              Gunduz \n              M, \n            \n            \n              Erdogan \n              O, \n            \n            \n              Benlidayi \n              ME. \n            \n          \n          Dexmedetomidine vs. midazolam in outpatient third molar surgery. J Oral Maxillofac Surg. 2006;64:1353\u20131358."},{"key":"i0003-3006-67-1-28-b08","series-title":"Anesthesiology","first-page":"269","article-title":"Sole use of dexmedetomidine has limited utility for conscious sedation during outpatient colonoscopy","volume":"103","author":"Jalowiecki \n              P,","year":"2005","unstructured":"Jalowiecki \n              P, \n            \n            \n              Runder \n              R, \n            \n            \n              Gonciarz \n              M, \n            \n            \n              Kawecki \n              P, \n            \n            \n              Petelenz \n              M, \n            \n            \n              Dziurdzik \n              P. \n            \n          \n          Sole use of dexmedetomidine has limited utility for conscious sedation during outpatient colonoscopy. Anesthesiology. 2005;103:269\u2013273."},{"key":"i0003-3006-67-1-28-b09","series-title":"Br J Anaesth","first-page":"171","article-title":"Dexmedetomidine: review, update, and future considerations of paediatric perioperative and periprocedural applications and limitations","volume":"115","author":"Mahmoud \n              M,","year":"2015","unstructured":"Mahmoud \n              M, \n            \n            \n              Mason \n              KP. \n            \n          \n          Dexmedetomidine: review, update, and future considerations of paediatric perioperative and periprocedural applications and limitations. Br J Anaesth. 2015;115:171\u2013182."},{"key":"i0003-3006-67-1-28-b10","series-title":"Minerva Anestesiol","first-page":"812","article-title":"Continuous intravenous infusion of ketamine for maintenance sedation","volume":"77","author":"Miller \n              AC,","year":"2011","unstructured":"Miller \n              AC, \n            \n            \n              Jamin \n              CT, \n            \n            \n              Elamin \n              EM. \n            \n          \n          Continuous intravenous infusion of ketamine for maintenance sedation. Minerva Anestesiol. 2011;77:812\u2013820."},{"key":"i0003-3006-67-1-28-b11","series-title":"Anesthesiology","first-page":"613","article-title":"Circulatory responses to ketamine anesthesia","volume":"37","author":"Tweed \n              WA,","year":"1972","unstructured":"Tweed \n              WA, \n            \n            \n              Minuck \n              M, \n            \n            \n              Mymin \n              D. \n            \n          \n          Circulatory responses to ketamine anesthesia. Anesthesiology. 1972;37:613\u2013619."},{"key":"i0003-3006-67-1-28-b12","series-title":"Anesthesiology","first-page":"153","article-title":"Respiratory interactions of ketamine and morphine","volume":"66","author":"Bourke \n              DL,","year":"1987","unstructured":"Bourke \n              DL, \n            \n            \n              Malit \n              LA, \n            \n            \n              Smith \n              TC. \n            \n          \n          Respiratory interactions of ketamine and morphine. Anesthesiology. 1987;66:153\u2013156."},{"key":"i0003-3006-67-1-28-b13","series-title":"Anesth Prog","first-page":"61","article-title":"Ketamine: a review of its pharmacologic properties and use in ambulatory anesthesia","volume":"39","author":"Haas \n              DA,","year":"1992","unstructured":"Haas \n              DA, \n            \n            \n              Harper \n              DG. \n            \n          \n          Ketamine: a review of its pharmacologic properties and use in ambulatory anesthesia. Anesth Prog. 1992;39:61\u201368."},{"key":"i0003-3006-67-1-28-b14","series-title":"Pediatr Crit Care Med","first-page":"423","article-title":"Dexmedetomidine and ketamine: an effective alternative for procedural sedation?","volume":"13","author":"Tobias \n              JD.","year":"2012","unstructured":"Tobias \n              JD. \n            \n          \n          Dexmedetomidine and ketamine: an effective alternative for procedural sedation?\n          Pediatr Crit Care Med. 2012;13:423\u2013427."},{"key":"i0003-3006-67-1-28-b15","series-title":"J Oral Maxillofac Surg","first-page":"1920.e1","article-title":"and ketamine sedation for dental extraction in children with cyanotic heart disease","volume":"72","author":"Hasan \n              MS,","year":"2014","unstructured":"Hasan \n              MS, \n            \n            \n              Chan L. \n              Dexmedetomidine \n            \n          \n          and ketamine sedation for dental extraction in children with cyanotic heart disease. J Oral Maxillofac Surg. 2014;72:1920.e1\u2013e4."},{"key":"i0003-3006-67-1-28-b16","series-title":"Oral Maxillofac Surg Clin North Am","first-page":"439","article-title":"Pharmacology of intravenous sedative\/anesthetic medications used in oral surgery","volume":"25","author":"Giovannitti \n              JA\n              Jr.","year":"2013","unstructured":"Giovannitti \n              JA\n              Jr. \n            \n          \n          Pharmacology of intravenous sedative\/anesthetic medications used in oral surgery. Oral Maxillofac Surg Clin North Am. 2013;25:439\u2013451."},{"key":"i0003-3006-67-1-28-b17","series-title":"Anesthesiology","first-page":"787","article-title":"Dexmedetomidine as a total intravenous anesthetic agent","volume":"101","author":"Ramsay \n              MA,","year":"2004","unstructured":"Ramsay \n              MA, \n            \n            \n              Luterman \n              DL. \n            \n          \n          Dexmedetomidine as a total intravenous anesthetic agent. Anesthesiology. 2004;101:787\u2013790."},{"key":"i0003-3006-67-1-28-b18","series-title":"Br J Clin Pharmacol","first-page":"357","article-title":"Ketamine for chronic pain: risks and benefits","volume":"77","author":"Niesters \n              M,","year":"2014","unstructured":"Niesters \n              M, \n            \n            \n              Martini \n              C, \n            \n            \n              Dahan \n              A. \n            \n          \n          Ketamine for chronic pain: risks and benefits. Br J Clin Pharmacol. 2014;77:357\u2013367."},{"key":"i0003-3006-67-1-28-b19","series-title":"Anesth Essays Res","first-page":"87","article-title":"Dexmedetomidine premedication in relevance to ketamine anesthesia: a prospective study","volume":"5","author":"Gupta \n              K,","year":"2011","unstructured":"Gupta \n              K, \n            \n            \n              Gupta \n              A, \n            \n            \n              Gupta \n              PK, \n            \n            \n              Rastogi \n              B, \n            \n            \n              Agarwal \n              S, \n            \n            \n              Lakhanpal \n              M. \n            \n          \n          Dexmedetomidine premedication in relevance to ketamine anesthesia: a prospective study. Anesth Essays Res. 2011;5:87\u201391."},{"key":"i0003-3006-67-1-28-b20","series-title":"Anesthesiology","first-page":"1117","article-title":"Dexmedetomidine premedication attenuates ketamine-induced cardiostimulatory effects and postanesthetic delirium","volume":"82","author":"Lev\u00e4nen \n              J,","year":"1995","unstructured":"Lev\u00e4nen \n              J, \n            \n            \n              M\u00e4kel\u00e4 \n              ML, \n            \n            \n              Scheinin \n              H. \n            \n          \n          Dexmedetomidine premedication attenuates ketamine-induced cardiostimulatory effects and postanesthetic delirium. Anesthesiology. 1995;82:1117\u20131125."},{"key":"i0003-3006-67-1-28-b21","series-title":"Anesthesiology","first-page":"382","article-title":"The effects of increasing plasma concentrations of dexmedetomidine in humans","volume":"93","author":"Ebert \n              TJ,","year":"2000","unstructured":"Ebert \n              TJ, \n            \n            \n              Hall \n              JE, \n            \n            \n              Barney \n              JA, \n            \n            \n              Uhrich \n              TD, \n            \n            \n              Colinco \n              MD. \n            \n          \n          The effects of increasing plasma concentrations of dexmedetomidine in humans. Anesthesiology. 2000;93:382\u2013394."},{"key":"i0003-3006-67-1-28-b22","series-title":"Arthritis Rheum","first-page":"3043","article-title":"Clinical differences between idiopathic and scleroderma-related pulmonary hypertension","volume":"54","author":"Fisher \n              MR,","year":"2006","unstructured":"Fisher \n              MR, \n            \n            \n              Mathai \n              SC, \n            \n            \n              Champion \n              HC, \n            \n            et al. \n          Clinical differences between idiopathic and scleroderma-related pulmonary hypertension. Arthritis Rheum. 2006;54:3043\u20133050."},{"key":"i0003-3006-67-1-28-b23","series-title":"Anesth Analg","first-page":"1578","article-title":"Ketamine does not increase pulmonary vascular resistance in children with pulmonary hypertension undergoing sevoflurane anesthesia and spontaneous ventilation","volume":"105","author":"Williams \n              GD,","year":"2007","unstructured":"Williams \n              GD, \n            \n            \n              Philip \n              BM, \n            \n            \n              Chu \n              LF, \n            \n            et al. \n          Ketamine does not increase pulmonary vascular resistance in children with pulmonary hypertension undergoing sevoflurane anesthesia and spontaneous ventilation. Anesth Analg. 2007;105:1578\u20131584."},{"key":"i0003-3006-67-1-28-b24","series-title":"J Cardiothorac Vasc Anesth","first-page":"e24","article-title":"Role of ketamine in the management of pulmonary hypertension and right ventricular failure","volume":"26","author":"Maxwell \n              BG,","year":"2012","unstructured":"Maxwell \n              BG, \n            \n            \n              Jackson \n              E. \n            \n          \n          Role of ketamine in the management of pulmonary hypertension and right ventricular failure. J Cardiothorac Vasc Anesth. 2012;26:e24\u2013e25."},{"key":"i0003-3006-67-1-28-b25","series-title":"Pediatr Crit Care Med","first-page":"207","article-title":"Dexmedetomidine sedation for pediatric post-Fontan procedure patients","volume":"10","author":"Tokuhira \n              N,","year":"2009","unstructured":"Tokuhira \n              N, \n            \n            \n              Atagi \n              K, \n            \n            \n              Shimaoka \n              H, \n            \n            \n              Ujiro \n              A, \n            \n            \n              Otsuka \n              Y, \n            \n            \n              Ramsay \n              M. \n            \n          \n          Dexmedetomidine sedation for pediatric post-Fontan procedure patients. Pediatr Crit Care Med. 2009;10:207\u2013212."},{"key":"i0003-3006-67-1-28-b26","series-title":"Br J Anaesth","first-page":"76","article-title":"The effect of thiopentone and suxamethonium on gastrooesophageal pressure gradients","volume":"50","author":"Smith \n              G,","year":"1978","unstructured":"Smith \n              G, \n            \n            \n              Dalling \n              R, \n            \n            \n              Dougan \n              LR, \n            \n            \n              Williams \n              TI. \n            \n          \n          The effect of thiopentone and suxamethonium on gastrooesophageal pressure gradients. Br J Anaesth. 1978;50:76\u201327."},{"key":"i0003-3006-67-1-28-b27","series-title":"Anesth Analg","first-page":"839","article-title":"Pregnancy complicated by severe preeclampsia and thrombocytopenia in a patient with scleroderma","volume":"85","author":"D'Angelo \n              R,","year":"1997","unstructured":"D'Angelo \n              R, \n            \n            \n              Miller \n              R. \n            \n          \n          Pregnancy complicated by severe preeclampsia and thrombocytopenia in a patient with scleroderma. Anesth Analg. 1997;85:839\u2013841."},{"key":"i0003-3006-67-1-28-b28","series-title":"Anesthesiology","first-page":"19","article-title":"Effects of dexmedetomidine and propofol on lower esophageal sphincter and gastroesophageal pressure gradient in healthy volunteers","volume":"112","author":"Turan \n              A,","year":"2010","unstructured":"Turan \n              A, \n            \n            \n              Wo \n              J, \n            \n            \n              Kasuya \n              Y, \n            \n            et al. \n          Effects of dexmedetomidine and propofol on lower esophageal sphincter and gastroesophageal pressure gradient in healthy volunteers. Anesthesiology. 2010;112:19\u201324."},{"key":"i0003-3006-67-1-28-b29","series-title":"Rheum Dis Clin North Am","first-page":"193","article-title":"Scleroderma","volume":"15","author":"Black \n              CM,","year":"1989","unstructured":"Black \n              CM, \n            \n            \n              Stevens \n              WM. \n            \n          \n          Scleroderma. Rheum Dis Clin North Am. 1989;15:193\u2013212."},{"key":"i0003-3006-67-1-28-b30","series-title":"Anesthesiology","first-page":"69","article-title":"Anesthetic management of a patient with scleroderma","volume":"59","author":"Thompson \n              J,","year":"1983","unstructured":"Thompson \n              J, \n            \n            \n              Conklin \n              KA. \n            \n          \n          Anesthetic management of a patient with scleroderma. Anesthesiology. 1983;59:69\u201371."},{"key":"i0003-3006-67-1-28-b31","series-title":"Anesthesiology","first-page":"836","article-title":"Bispectral analysis measures sedation and memory effects of propofol, midazolam, isoflurane, and alfentanil in healthy volunteers","volume":"86","author":"Glass \n              PS,","year":"1997","unstructured":"Glass \n              PS, \n            \n            \n              Bloom \n              M, \n            \n            \n              Kearse \n              L, \n            \n            \n              Rosow \n              C, \n            \n            \n              Sebel \n              P, \n            \n            \n              Manberg \n              P. \n            \n          \n          Bispectral analysis measures sedation and memory effects of propofol, midazolam, isoflurane, and alfentanil in healthy volunteers. Anesthesiology. 1997;86:836\u2013847."},{"key":"i0003-3006-67-1-28-b32","series-title":"Br J Anaesth","first-page":"336","article-title":"Comparative effects of ketamine on bispectral index and spectral entropy of the electroencephalogram under sevoflurane anaesthesia","volume":"94","author":"Hans \n              P,","year":"2005","unstructured":"Hans \n              P, \n            \n            \n              Dewandre \n              PY, \n            \n            \n              Brichant \n              JF, \n            \n            \n              Bonhommonee \n              V. \n            \n          \n          Comparative effects of ketamine on bispectral index and spectral entropy of the electroencephalogram under sevoflurane anaesthesia. Br J Anaesth. 2005;94:336\u2013340."}],"container-title":["Anesthesia Progress"],"original-title":[],"link":[{"URL":"https:\/\/anesthesiaprogress.kglmeridian.com\/view\/journals\/anpr\/67\/1\/article-p28.xml","content-type":"text\/html","content-version":"vor","intended-application":"text-mining"},{"URL":"http:\/\/meridian.allenpress.com\/anesthesia-progress\/article-pdf\/67\/1\/28\/2436494\/anpr-66-03-07.pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"syndication"},{"URL":"https:\/\/anesthesiaprogress.kglmeridian.com\/downloadpdf\/journals\/anpr\/67\/1\/article-p28.xml","content-type":"text\/html","content-version":"vor","intended-application":"syndication"},{"URL":"https:\/\/anesthesiaprogress.kglmeridian.com\/downloadpdf\/journals\/anpr\/67\/1\/article-p28.xml","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2024,10,7]],"date-time":"2024-10-07T12:45:03Z","timestamp":1728305103000},"score":1,"resource":{"primary":{"URL":"https:\/\/anesthesiaprogress.kglmeridian.com\/view\/journals\/anpr\/67\/1\/article-p28.xml"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2020]]},"references-count":32,"journal-issue":{"issue":"1"},"URL":"https:\/\/doi.org\/10.2344\/anpr-66-03-07","relation":{},"ISSN":["0003-3006","1878-7177"],"issn-type":[{"value":"0003-3006","type":"print"},{"value":"1878-7177","type":"electronic"}],"subject":[],"published":{"date-parts":[[2020]]}}}