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patient was a 23-year-old female (height 135 cm; weight 24 kg; body mass index 13.2 kg/m 2 ) who required general anesthesia for treatment of dental caries due to her intellectual disability, as she was generally unable to tolerate dental care otherwise. She was diagnosed with RTT at 2 years of age and had a history of pneumonia requiring hospitalization more than 10 years earlier. The patient also had epilepsy, which was difficult to control despite being maintained on antiepileptic medications. Her seizures, presenting as twitching or jerking limb movements and upward

arrhythmias associated with myocardial fibrosis. 1 Interstitial pneumonia due to pulmonary fibrosis develops in approximately 80% of patients with SSc, 2 so restrictive lung disease is commonly found in these patients. Currently, the most common cause of death in patients with SSc is pulmonary fibrosis. 3 Seventy percent of patients with SSc also develop microstomia secondary to fibrosis of the facial skin and oral mucosa. These patients can have increased discomfort during dental treatment because of the microstomia, which can necessitate excessive stretching of the

did not require any food modification. However, he needed total assistance in eating because of involuntary movements of the upper limbs. He was not able to take tablets, but was able to take powdered medicine. Physical examination revealed nystagmus; ataxia with spasticity, especially in the lower limbs; and frequent movements of the upper limbs and upper body. He could not stand straight and walk, but he could operate a wheelchair by himself. As he had no past history of epilepsy, aspiration pneumonia, or swallowing difficulties, it was decided to perform general