Appropriate preoperative assessment of dental patients should always include analysis of their medications. Cardiovascular diseases are the most common group of medical disorders that dentists encounter, and the number of drugs prescribed for managing these conditions is staggering. This justifiably raises concern and probable confusion regarding side effects and possible drug interactions with medications the dentist may deem necessary for dental care. This continuing education article is the first in a series that will address essential pharmacology of medications commonly prescribed for chronic medical care. A reasonable understanding of these agents will allow the dentist to better appreciate the medical status of their patients and avoid adverse interactions with drugs they might administer or prescribe.
Preoperative assessment; Drug interactions; Drug side effects; Drug toxicity
We assessed the safety of general anesthesia for dental treatment of special needs patients as it related to American Society of Anesthesiology Physical Status (ASAPS) classification, procedure, and other factors. After Institutional Review Board review and approval, special needs patients who were admitted to the outpatient surgical operating room for comprehensive dental rehabilitation (CDR) under general anesthesia within a period of 5 years had their medical records evaluated retrospectively for intraoperative and postoperative complications both related to anesthesia and surgery. All records were evaluated by an independent evaluator who tabulated the patients' age, gender, ASAPS, and duration of procedure. N = 363, age mean = 46.93 ± 16.835 years, age median = 48 years, male patients = 180, female patients = 183, ASAPS I = 183, ASAPS II = 127, ASAPS III = 53, duration of surgery mean = 140.631 ± 23.104 minutes, duration of surgery median time = 142.000 minutes, and number of complications = 2. One complication resulted in an ASAPS I 16-year-old boy, which was airway related, and a second was an ASAPS III 22-year-old woman, which was surgically related. Both led to unplanned inpatient admissions and were treated successfully with no residual morbidity. Dental rehabilitation of special needs patients under general anesthesia is safe. While morbidity is very low, larger studies are needed to establish risk versus benefit stratification among this patient population.
Special needs; Dental; General; Anesthesia
The authors, using a crossover design, randomly administered, in a single-blind manner, 3 sets of injections: an inferior alveolar nerve block (IANB) plus a mock buccal and a mock lingual infiltration of the mandibular first molar, an IANB plus a buccal infiltration and a mock lingual infiltration of the mandibular first molar, and an IANB plus a mock buccal infiltration and a lingual infiltration of the mandibular first molar in 3 separate appointments spaced at least 1 week apart. An electric pulp tester was used to test for anesthesia of the premolars and molars in 3-minute cycles for 60 minutes. Anesthesia was considered successful when 2 consecutive 80 readings were obtained within 15 minutes following completion of the injection sets, and the 80 reading was continuously sustained for 60 minutes. For the IANB plus mock buccal infiltration and mock lingual infiltration, successful pulpal anesthesia ranged from 53 to 74% from the second molar to second premolar. For the IANB plus buccal infiltration and mock lingual infiltration, successful pulpal anesthesia ranged from 57 to 69% from the second molar to second premolar. For the IANB plus mock buccal infiltration and lingual infiltration, successful pulpal anesthesia ranged from 54 to 76% from the second molar to second premolar. There was no significant difference (P > .05) in anesthetic success between the IANB plus buccal or lingual infiltrations and the IANB plus mock buccal infiltration and mock lingual infiltration. We conclude that adding a buccal or lingual infiltration of 1.8 mL of 2% lidocaine with 1 : 100,000 epinephrine to an IANB did not significantly increase anesthetic success in mandibular posterior teeth.
Buccal infiltration; Inferior alveolar nerve block; Lidocaine; Mandibular posterior teeth
The use of sedatives has established efficacy and safety for managing anxiety regarding dental treatment. This article will provide essential information regarding the pharmacology and therapeutic principles that govern the appropriate use of orally administered sedatives to provide mild sedation (anxiolysis). Dosages and protocols are intended for this purpose, not for providing moderate or deeper sedation levels.
Sedation; Anxiolysis; Oral sedation; Minimal sedation; Hypnotics; Sedatives
Dapsone is a leprostatic agent commonly prescribed for the management of leprosy, malaria, and the immunosuppression-induced infections of Pneumocystis carinii and Toxoplasma gondii. In susceptible patients, methemoglobinemia, a potentially life-threatening event, can occur. We report a case of dapsone-induced methemoglobinemia which was observed during general anesthesia for the management of a fractured mandible. The pathophysiology, diagnosis, and management of dapsone-induced methemoglobinemia will be discussed.
Dapsone; Methemoglobinemia; Methemoglobin; Cyanosis; Glucose-6-phosphate dehydrogenase deficiency; Cytochrome b5 reductase; Acquired methemoglobinemia; Congenital methemoglobinemia
Endotracheal intubation has been proposed as a risk factor for temporomandibular joint dysfunction (TMD) in a limited number of published case reports and systematic studies. Symptoms may result from forces applied with the laryngoscope, or manually in an attempt to complete the intubation, and may be related to the duration in which temporomandibular joint (TMJ) structures are stressed. The objective of this study was to examine risk factors for TMD complaints associated with endotracheal intubation. One hundred twenty-two patients who underwent endotracheal intubation for surgery at the University of Washington Medical Center participated. Exclusions included surgery of the head or neck, cognitive deficit, or emergency surgery. Subjects were assessed presurgically, and at 7 and 14 days postoperatively. Gender, interincisal distance, and age were found to be significantly associated with TMD symptoms lasting as long as 14 days following intubation. For both TMD pain and TMD nonpain symptoms, the most reliable predictor of a complaint following intubation was a history of TMD complaints within a year preoperatively. Any association between endotracheal intubation and the development of short-term TMD symptoms is likely to be found in patients with prior report of such conditions, and we therefore recommend a review of TMD complaint history when planning general anesthesia.
Intubation; TMJ; Headache; Facial pain; Mallampati
As increasing attention is paid to disparities in oral health care, cross-cultural means for assessing dental fear, a significant barrier to dental care, are in high demand. There is, however, a surprising shortage of Spanish-language dental fear measures in the literature, despite evidence of dental fear and avoidance in Spanish-speaking populations. The goals of the current series of studies were to develop and validate a Spanish-language version of the Interval Scale of Anxiety Response (ISAR). Magnitude estimation, a technique in which participants are asked to assign a number to indicate the perceived intensity of a stimulus or phrase, was used to compare the Spanish ISAR to the original English ISAR during the development studies. As a result of the 4 initial development studies, modifications were made to both the Spanish and English scales. Once 2 seemingly equivalent scales were established, validation studies were completed with native Spanish- and English-speaking dental patients. The results suggest that both the Spanish and modified English ISAR scales are valid measures of state anxiety associated with dental treatment. Additionally, the results of these studies highlight the importance of thoroughly testing translated measures to ensure they are accurately assessing that which they purport to measure.
Dental anxiety; Psychometrics; Visual analog scale; Translating
The risk for complications while providing moderate and deep sedation is greatest when caring for patients already medically compromised. It is reassuring that significant untoward events can generally be prevented by careful preoperative assessment, along with attentive intraoperative monitoring and support. Nevertheless, we must be prepared to manage untoward events should they arise. This continuing education article will review critical aspects of patient management of respiratory and cardiovascular complications.
Medical emergencies; Sedation; Anesthesia; Complications
This is a 10-year follow-up survey of a 1996 study of all dentists in Illinois holding a permit to administer sedation or general anesthesia. The survey describes the scope of sedation and anesthesia services provided in dental offices in Illinois. A mail survey was sent to 471 dentists who were registered with the department of professional regulation to administer sedation or general anesthesia. Classification by specialty area of practice showed: 63% (84% in 1996) are oral and maxillofacial surgeons, 20% (11% in 1996) general dentists, 6% (5% in 1996) periodontists, 9% (0% in 1996) pediatric dentists, 1% (less than 1% in 1996) dentist anesthesiologists. Advanced cardiovascular life support (ACLS) training was reported by 90% (85% in 1996) of the respondents. The total number of sedations and general anesthetics administered for the year was 115,940. Two mortalities and two cases of long-term morbidity were reported for the 10-year period. Respondents reported that 30 patients required transfer to a hospital but suffered no long-term morbidity. Other practice characteristics were detailed.
Dental sedation; Dental anesthesia; Morbidity and mortality; Practice parameters
Dental trauma during anesthesia is a common occurrence. Many patients have had extensive dental work, which is more fragile than the natural dentition. This work may include crowns, fixed partial dentures (bridges), and porcelain veneers. We report for the first time, a case in which a fixed partial denture became dislodged and was ingested, and was recovered postoperatively with endoscopy.
Ingestion; Dental; Denture; Aspiration; General anesthesia
The purpose of the present study is to determine the cardiovascular effects produced by intravascular injection of 2% lidocaine with 20 μg/mL of norepinephrine on systolic, diastolic, and mean arterial pressures and heart rate of rats at the following times: control period, during the injection (first 15 seconds), during the first minute, and at the end of 1, 2, 3, 4, 5, 10, 15, 20, 25, and 30 minutes after drug administration. The study was performed on 13 male Wistar rats with weights between 200 grams and 220 grams that were awake during the recording of these parameters. The dose administered was proportional to 1 cartridge of local anesthetic (1.8 mL) in an average-size human, which is equivalent to 0.51 mg/kg of lidocaine hydrochloride and 0.51 μg/kg of norepinephrine hydrochloride. The average time of injection was 15.7 seconds. The results of this study showed significant increases in systolic, diastolic, and mean arterial pressure and a noticeable decrease in heart rate. The greatest variation occurred in the systolic blood pressure. The greatest alterations occurred during injection and within the first minute following administration of the anesthetic solution. We would anticipate these changes in the parameters analyzed to be clinically significant. Thus, dentists using 2% lidocaine with norepinephrine 20 μg/mL should be very careful to avoid intravascular injection.
Intravascular injection; Lidocaine; Norepinephrine
We describe a case in which reflection of a palatal flap for removal of a mesiodens is presented as the triggering factor for bradycardia caused by stimulation of the trigeminocardiac reflex. The management of the case, as well as the reflex arc, is discussed.
Trigeminocardiac reflex; Bradycardia
Monitoring and assessing of patient respiratory function during conscious sedation are important because many drugs used for conscious sedation produce respiratory depression and subsequent hypoventilation. The purpose of this study is to assess the value of a dynamic air-pressure sensor for respiratory monitoring of clothed patients. Eight clothed adult volunteers were reclined on a dental chair positioned horizontally. The air bag for measuring air-pressure signals corresponding to respiration was placed on the seat back of the dental chair in the central lumbar area of the subject. The subject breathed through a face mask with a respirometer attached for measuring expiratory tidal volume. The air-pressure signals corresponding to respiration were obtained and the time integration values for air pressure during each expiration (∫Pexp) were calculated. The expiratory tidal volume (TVexp) was measured simultaneously by respirometer. The relationship between TVexp and ∫Pexp for each subject was assessed by a Pearson correlation coefficient. A strong correlation between TVexp and ∫Pexp was observed in all subjects. Measuring ∫Pexp by dynamic air-pressure sensor makes it possible to estimate respiratory volume breath by breath, and the respiratory pressure–time integral waveform was useful in visually monitoring the respiration pattern. We believe that in the future this device will be used to monitor respiratory physiology in clothed patients, contributing to safer sedative procedures.
Air-pressure sensor; Respiratory; Monitor; Nonrestrictively
The fundamental principles that govern drug therapy are often overlooked by the busy clinician. This disregard frequently results in the use of particular drugs and regimens that may be less ideal for the clinical situation being managed. By convention, these principles are categorized as pharmacokinetic and pharmacodynamic. Pharmacokinetic processes include drug absorption, distribution, biotransformation (metabolism), and elimination—essentially reflecting the influence of the body on the drug administered. These principles were addressed in the preceding issue of this journal. Pharmacodynamics deals with the actual mechanisms of action and effects a drug produces on the patient and is the topic for this continuing education article.
Drug therapy; Pharmacodynamics; Dental pharmacology
Nitrous oxide (N2O) has been used for well over 150 years in clinical dentistry for its analgesic and anxiolytic properties. This small and simple inorganic chemical molecule has indisputable effects of analgesia, anxiolysis, and anesthesia that are of great clinical interest. Recent studies have helped to clarify the analgesic mechanisms of N2O, but the mechanisms involved in its anxiolytic and anesthetic actions remain less clear. Findings to date indicate that the analgesic effect of N2O is opioid in nature, and, like morphine, may involve a myriad of neuromodulators in the spinal cord. The anxiolytic effect of N2O, on the other hand, resembles that of benzodiazepines and may be initiated at selected subunits of the γ-aminobutyric acid type A (GABAA) receptor. Similarly, the anesthetic effect of N2O may involve actions at GABAA receptors and possibly at N-methyl-D-aspartate receptors as well. This article reviews the latest information on the proposed modes of action for these clinicaleffects of N2O.
Nitrous oxide; Pharmacology; Anesthesia; Analgesia; Anxiolysis