The dental anesthesia sonophoresis device (DASD) is a novel device that is intended to reduce the discomfort associated with intraoral mucosa needle puncture. The DASD produces ultrasonic energy that provides a sonophoretic effect on the oral mucosa, generating microchannels through the lipids between the keratinized cells that make up the stratum corneum. Once the topical anesthetic has permeated the stratum corneum, it quickly diffuses through the soft tissue, desensitizing the nerve endings and reducing the perception of pain caused by needle penetration. The aim of this study is to evaluate whether topical anesthesia applied using the DASD will reduce the discomfort of the needle puncture when compared to the control device. A split-mouth model, using 50 healthy subjects with puncture site at the maxillary canine vestibule, was used for this study. Subjects received a needle puncture on both sides of the mouth. Prior to the needle puncture, there was randomized application of 5% lidocaine with the DASD and a control device. Subjects rated their discomfort after needle punctures utilizing the visual analog scale pain scoring system. There was no statistically significant difference in the pain perception using the DASD versus the control device.
Dental anesthesia sonophoresis device; Sonophoresis
We compared the buccal infiltration of 4% articaine with 1 : 100,000 or 1 : 200,000 epinephrine without a palatal injection for the extraction of impacted maxillary third molars with chronic pericoronitis. This prospective, double-blind, controlled clinical trial involved 30 patients between the ages of 15 and 46 years who desired extraction of a partially impacted upper third molar with pericoronitis. Group 1 (15 patients) received 4% articaine with 1 : 100,000 epinephrine and group 2 (15 patients) received 4% articaine with 1 : 200,000 epinephrine by buccal infiltration. None of the patients in group 1 reported pain, but 3 patients in group 2 reported pain, which indicated a need for a supplementary palatal injection. The palatal injections were all successful in eliminating the pain. Two additional patients in group 2 experienced pain when the suture needle penetrated their palatal mucosa. Based on these results, 4% articaine with 1 : 100,000 epinephrine was found to be more effective for the removal of upper third molars in the presence of pericoronitis than 4% articaine hydrochloride with 1 : 200,000 epinephrine when only a buccal infiltration was used.
Articaine; Epinephrine; Molar extraction
The aim of this study was to investigate the correlation between dental anxiety, salivary cortisol, and salivary alpha amylase (sAA) levels. Furthermore, the aim was to look into individual differences such as age, race, gender, any existing pain, or traumatic dental experience and their effect on dental anxiety. This study followed a cross-sectional design and included a convenience sample of 46. Every patient was asked to complete the Dental Anxiety Scale (DAS) and a basic demographic/dental history questionnaire. A saliva sample, utilizing the method of passive drooling, was then collected in 2-mL cryovials. Samples were analyzed for salivary cortisol and sAA levels by Salimetrics. Significant associations were observed between DAS scores and presence of pain and history of traumatic dental experience. However, no significant correlations were observed between DAS, cortisol, and sAA levels. Our study reconfirms that dental anxiety is associated with presence of pain and a history of traumatic dental experience. On the other hand, our study was the first to our knowledge to test the correlation between the DAS and sAA; nevertheless, our results failed to show any significant correlation between dental anxiety, cortisol, and sAA levels.
Stress; Dental anxiety; Salivary cortisol; Salivary alpha amylase; Dental Anxiety Scale
Moderate oral sedation is used in pediatric dentistry for safe delivery of dental care to children. However, there is a paucity of data on the effects of pediatric dental sedations after discharge of children from the dental office. The purpose of this study was to evaluate and compare the incidence of adverse events occurring with meperidine and hydroxyzine versus midazolam alone 8 and 24 hours after sedation in pediatric dental patients. In this prospective study, a convenience sample of 46 healthy children presenting to a private pediatric dental practice for dental treatment needs was selected. A telephone survey of the parents of children sedated with either meperidine and hydroxyzine or midazolam alone was conducted 8 and 24 hours after the administration of sedation medications. Data analysis included descriptive statistics, frequency and proportion analysis, and Fisher exact test. Forty children were sedated with meperidine and hydroxyzine, and 6 who were sedated with midazolam. In both groups, 50% of the children slept in the car on the way home. Three children in the meperidine and hydroxyzine group vomited in the car. A significantly larger proportion of children in the meperidine and hydroxyzine group experienced prolonged sleep at home (P = .015). More children in the midazolam group exhibited irritability in the first 8 hours (P = .07). There were no statistical differences between the 2 groups with respect to incidence of pain, fever, vomiting, sleeping in the car, snoring, and difficulty in waking up. The lingering effects of orally administered sedation medications can lead to prolonged sleep, irritability, and vomiting in children after they have been discharged from the dental clinic. Most of these events occurred within the first 8 hours, but in some children the effects were seen up to 24 hours later.
Sedation; Children; Adverse events
The magnetic resonance imaging (MRI) room is a special environment. The required intense magnetic fields create unique problems with the use of standard anesthesia machines, syringe pumps, and physiologic monitors. We have recently experienced 2 oral maxillofacial surgery cases requiring MRI: a 15-year-old boy with developmental disability and a healthy 5-year-old boy. The patients required complete immobilization during the scanning for obtaining high-quality images for the best diagnosis. Anesthesia was started in the MRI scanning room. An endotracheal intubation was performed after induction with intravenous administration of muscle relaxant. Total intravenous anesthesia via propofol drip infusion (4–7 mg/kg/h) was used during the scanning. Standard physiologic monitors were used during scan pauses, but special monitors were used during scanning. In MRI scanning for oral maxillofacial surgery, general anesthesia, with the added advantage of having a secured airway, is recommended as a safe alternative to sedation especially in cases of patients with disability and precooperative chidren.
Magnetic resonance imaging (MRI); General anesthesia; Propofol drip infusion; Children; Developmental disability patients
Emergence delirium and agitation (EAD) associated with sevoflurane general anesthesia are very commonly observed in young children. Such events pose a risk for injury as well as decreased parental satisfaction, especially in the ambulatory and office-based setting. This article reviews the different approaches described in the literature to reduce EAD. A novel approach using a Bispectral Index System (BIS)-guided anesthesia with propofol washout technique is proposed as a viable and effective approach to prevent EAD.
Agitation; Delirium; Propofol; Sevoflurane
Appropriate preoperative assessment of the dental patient should always include an analysis of the patient's medications. This article reviews the actions and indications for the various categories of antithrombotic medications and considers actual risks for postoperative bleeding and potential interactions with drugs the dental provider might administer or prescribe.
Drug interactions; Drug side effects; Antiplatelet drugs; Anticoagulants; Postoperative bleeding; Dental treatment
Many patients with disabilities need recurrent dental treatment under general anesthesia because of high caries prevalence and the nature of dental treatment. We evaluated the use of a nasal device as a possible substitute for flexible laryngeal mask airway to reduce the risk of unexpected failure accompanying intubation; we succeeded in ventilating the lungs with a cut nasotracheal tube (CNT) with its tip placed in the pharynx. We hypothesized that this technique would be useful during dental treatment under general anesthesia and investigated its usefulness as part of a minimally invasive technique. A prospective study was designed using general anesthesia in 37 dental patients with disabilities such as intellectual impairment, autism, and cerebral palsy. CNT ventilation was compared with mask ventilation with the patient in 3 positions: the neck in flexion, horizontal position, and in extension. The effect of mouth gags was also recorded during CNT ventilation. The percentages of cases with effective ventilation were similar for the 2 techniques in the neck extension and horizontal positions (89.2–97.3%). However, CNT ventilation was significantly more effective than mask ventilation in the neck flexion position (94.6 vs 45.9%; P < .0001). Mouth gags slightly reduced the rate of effective ventilation in the neck flexion position. Most dental treatments involving minor oral surgeries were performed using mouth gags during CNT ventilation. CNT ventilation was shown to be superior to mask ventilation and is useful during dental treatment under general anesthesia.
General anesthesia; Cut nasotracheal tube.
The purpose of this trial was to assess the effect of soft tissue massage on the efficacy of the mental and incisive nerve block (MINB). Thirty-eight volunteers received MINB of 2.2 mL of 2% lidocaine with 1 : 80,000 epinephrine on 2 occasions. At one visit the soft tissue overlying the injection site was massaged for 60 seconds (active treatment). At the other visit the crowns of the mandibular premolar teeth were massaged (control treatment). Order of treatments was randomized. An electronic pulp tester was used to measure pulpal anesthesia in the ipsilateral mandibular first molar, a premolar, and lateral incisor teeth up to 45 minutes following the injection. The efficacy of pulp anesthesia was determined by 2 methods: (a) by quantifying the number of episodes with no response to maximal electronic pulp stimulation after each treatment, and (b) by quantifying the number of volunteers with no response to maximal pulp stimulation (80 reading) on 2 or more consecutive tests, termed anesthetic success. Data were analyzed by McNemar, Mann-Whitney, and paired-samples t tests. Anesthetic success was 52.6% for active and 42.1% for control treatment for lateral incisors, 89.5 and 86.8% respectively for premolars, and 50.0 and 42.1% respectively for first molars (P = .344, 1.0, and .508 respectively). There were no significant differences in the number of episodes of negative response to maximum pulp tester stimulation between active and control massage. A total of 131 episodes were recorded after both active and control massage in lateral incisors (McNemar test, P = 1.0), 329 (active) versus 316 (control) episodes in the premolars (McNemar test, P = .344), and 119 (active) versus 109 (control) episodes respectively for first molars (McNemar test, P = .444). Speed of anesthetic onset and discomfort did not differ between treatments. We concluded that soft tissue massage after MINB does not influence anesthetic efficacy.
Dental pulp anesthesia; Lidocaine; Mental and incisive nerve block
We present 2 cases of fulminant malignant hyperthermia (MH), complicated with massive rhabdomyolysis. The patients were successfully treated in the intensive care unit of our university teaching hospital, despite the lack of availability of dantrolene in our country, by early application of continuous veno-venous hemofiltration (CVVH). Both male patients developed fulminant malignant hyperthermia during anesthesia for oromaxillofacial surgery. CVVH was employed when the values of creatine phosphokinase (CPK), myoglobin (Mb), and lactate dehydrogenase (LDH) increased significantly. After emergency treatment and CVVH therapy, the values of CPK, Mb, and LDH in the blood plasma of the patients decreased significantly. The complications, including acute renal failure, disseminated intravascular coagulation, and acute respiratory distress syndrome were also treated without any obvious organ damage. Early detection and management are the keys to treat MH successfully. CVVH is a valuable therapeutic application in the initial/critical management of severe rhabdomyolysis. If these complications occur even with initial treatment with dantrolene, our experiences may be useful adjunctive treatments to consider.
Malignant hyperthermia; Continuous veno-venous hemofiltration.
Glucocorticosteroids are a product of the adrenal cortex and perform a staggering number of physiological effects essential for life. Their clinical use is largely predicated on their anti-inflammatory and immunosuppressive properties, but they also have notable efficacy in the prophylaxis of postoperative nausea and vomiting. This article reviews the basic functions of glucocorticoids and their clinical use in dental practice.
Glucocorticosteroid; Trauma; Postoperative swelling; PONV; Dentistry; Mucosal lesions
The purpose of this prospective, randomized, single-blind study was to determine the anesthetic efficacy of 127.2 mg lidocaine with 50 μg epinephrine compared to 127.2 mg lidocaine with 50 μg epinephrine plus 0.5 M mannitol in inferior alveolar nerve (IAN) blocks. Forty subjects randomly received 2 IAN blocks consisting of a 3.18 mL formulation of 127.2 mg lidocaine with 50 μg epinephrine and a 5 mL formulation of 127.2 mg lidocaine with 50 μg epinephrine (3.18 mL) plus 0.5 M mannitol (1.82 mL) in 2 separate appointments spaced at least 1 week apart. Mandibular anterior and posterior teeth were blindly electric pulp tested at 4-minute cycles for 60 minutes postinjection. Pain of solution deposition and postoperative pain were also measured. No response from the subject to the maximum output (80 reading) of the pulp tester was used as the criterion for pulpal anesthesia. Total percent pulpal anesthesia was defined as the total of all the times of pulpal anesthesia (80 readings) over the 60 minutes. One hundred percent of the subjects had profound lip numbness with both inferior alveolar nerve blocks. The results demonstrated that a 5 mL formulation of 127.2 mg lidocaine with 50 μg epinephrine plus 0.5 M mannitol was significantly better than the 3.18 mL formulation of 127.2 mg lidocaine with 50 μg epinephrine for all teeth. Solution deposition pain and postoperative pain were not statistically different between the lidocaine/mannitol formulation and the lidocaine formulation without mannitol. We concluded that adding 0.5 M mannitol to a lidocaine with epinephrine formulation was significantly more effective in achieving a greater percentage of total pulpal anesthesia than a lidocaine formulation without mannitol.
Inferior alveolar nerve block; Lidocaine; Mannitol; Epinephrine
The purpose of this study was to test the null hypothesis that children with environmental tobacco smoke (ETS) exposure (also known as passive smoke exposure) do not demonstrate an increased likelihood of adverse respiratory events during or while recovering from general anesthesia administered for treatment of early childhood caries. Parents of children (ages 19 months–12 years) preparing to receive general anesthesia for the purpose of dental restorative procedures were interviewed regarding the child's risk for ETS. Children were observed during and after the procedure by a standardized dentist anesthesiologist and postanesthesia care unit nurse who independently recorded severity of 6 types of adverse respiratory events—coughing, laryngospasm, bronchospasm, breath holding, hypersecretion, and airway obstruction. Data from 99 children were analyzed. The children for whom ETS was reported were significantly older than their ETS-free counterparts (P = .03). If the primary caregiver smoked, there was a significantly higher incidence of smoking by other members of the family (P < .0001) as well as smoking in the house (P < .0005). There were no significant differences between the adverse respiratory outcomes of the ETS (+) and ETS (−) groups. The ETS (+) children did have significantly longer recovery times (P < .0001) despite not having significantly more dental caries (P = .38) or longer procedure times. ETS is a poor indicator of post–general anesthesia respiratory morbidity in children being treated for early childhood caries.
Passive smoke exposure; Dental caries
Pediatric dental patients who cannot receive dental care in the clinic due to uncooperative behavior are often referred to receive dental care under general anesthesia (GA). At Stony Brook Medicine, dental patients requiring treatment with GA receive dental care in our outpatient facility at the Stony Brook School of Dental Medicine (SDM) or in the Stony Brook University Hospital ambulatory setting (SBUH). This study investigates the time and cost for ambulatory American Society of Anesthesiologists (ASA) Class I pediatric patients receiving full-mouth dental rehabilitation using GA in these 2 locations, along with a descriptive analysis of the patients and dental services provided. In this institutional review board–approved cross-sectional retrospective study, ICD-9 codes for dental caries (521.00) were used to collect patient records between July 2009 and May 2011. Participants were limited to ASA I patients aged 36–60 months. Complete records from 96 patients were reviewed. There were significant differences in cost, total anesthesia time, and recovery room time (P < .001). The average total time (anesthesia end time minus anesthesia start time) to treat a child at SBUH under GA was 222 ± 62.7 minutes, and recovery time (time of discharge minus anesthesia end time) was 157 ± 97.2 minutes; the average total cost was $7,303. At the SDM, the average total time was 175 ± 36.8 minutes, and recovery time was 25 ± 12.7 minutes; the average total cost was $414. After controlling for anesthesia time and procedures, we found that SBUH cost 13.2 times more than SDM. This study provides evidence that ASA I pediatric patients can receive full-mouth dental rehabilitation utilizing GA under the direction of dentist anesthesiologists in an office-based dental setting more quickly and at a lower cost. This is very promising for patients with the least access to care, including patients with special needs and lack of insurance.
Pediatric dentistry; Dental anesthesia; Cost analysis; Operating room; Office-based anesthesia; Health economics
For several decades, anesthetic gases have greatly enhanced the comfort and outcome for patients during surgery. The benefits of these agents have heavily outweighed the risks. In recent years, the attention towards their overall contribution to global climate change and the environment has increased. Anesthesia providers have a responsibility to minimize unnecessary atmospheric pollution by utilizing techniques that can lessen any adverse effects of these gases on the environment. Moreover, health care facilities that use anesthetic gases are accountable for ensuring that all anesthesia equipment, including the scavenging system, is effective and routinely maintained. Implementing preventive practices and simple strategies can promote the safest and most healthy environment.
Volatile anesthetics; Environmental pollution; Greenhouse warming potential; Ozone depletion potential
Autonomic drugs are used clinically to either imitate or inhibit the normal functions of the sympathetic and parasympathetic nervous systems. A large number of additional drug classes also interact with these systems to produce a stunning number of possible side effects. This article reviews the basic function of the autonomic nervous system and the various drug classes that act within these neural synapses.
Autonomic drugs; Sympathomimetics; Adrenergic agonists; Adrenergic antagonists; Cholinergic drugs; Anticholinergic drugs