Nitrous oxide has been used in anesthetic practice for nearly 170 years, longer than any other anesthetic agent. It has withstood the test of time despite its critics. In the pioneering days of anesthesia, nitrous oxide general anesthesia, using the primary and secondary saturation technique described by Dr Fred Clement, was by far best suited for ambulatory office dental surgery compared to diethyl ether and chloroform. Induction of ether anesthesia was slow and unpleasant, its recovery was prolonged, and it was explosive. Chloroform induction was somewhat more pleasant and faster than ether, but recovery was still slow and sudden cardiac
The purpose of this prospective randomized, single blind study was to determine the anesthetic efficacy of 68.8 mg of lidocaine with 50 μg epinephrine compared to 68.8 mg lidocaine with 50 μg epinephrine plus 0.9 M mannitol in inferior alveolar nerve (IAN) blocks. Forty subjects randomly received 2 IAN blocks consisting of a 1.72-mL formulation of 68.8 mg lidocaine with 50 μg epinephrine and a 5-mL formulation of 68.8 mg lidocaine with 50 μg epinephrine (1.72 mL) plus 0.9 M mannitol (3.28 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. 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), for each tooth, over the 60 minutes. One hundred percent of the subjects had profound lip numbness with both inferior alveolar nerve blocks. The results demonstrated that the 5 mL-formulation of 68.8 mg lidocaine with 50 μg epinephrine plus 0.9 M mannitol was significantly better than the 1.72-mL formulation of 68.8 mg lidocaine with 50 μg epinephrine for all teeth, except the lateral incisor. We concluded that adding 0.9 M mannitol to a lidocaine with epinephrine formulation was significantly more effective in achieving a greater percentage of total pulpal anesthesia (as defined in this study) than a lidocaine formulation without mannitol. However, the 0.9 M mannitol/lidocaine formulation would not provide 100% pulpal anesthesia for all the mandibular teeth.Abstract
The purpose of this study was to identify the risk factors associated with low peripheral oxygen saturation (SpO2) and delayed recovery of dental patients with disabilities after intravenous sedation. A total of 1213 patients with disabilities were retrospectively investigated with respect to demographic parameters and sedation conditions. Multivariate logistic analyses were conducted for patients with an SpO2 <90% and a recovery period of >60 minutes to identify the risk factors for poor sedation conditions. A significant odds ratio related to decreased SpO2 was observed for age, sex, midazolam and propofol levels, concurrent use of nitrous oxide, cerebral palsy, Down syndrome, and mental retardation. The most problematic patients were those diagnosed with Down syndrome (odds ratio, 3.003–7.978; 95% confidence interval; P < .001). Decision tree analysis showed an increased risk of decreased SpO2 in males with Down syndrome or after administration of >0.493 mg/kg propofol in combination with midazolam. An increased risk of delayed awakening was seen in patients aged less than 21 years and in males administered >0.032 mg/kg of midazolam. Intravenous sedation for dental patients with disabilities, particularly those with cerebral palsy, Down syndrome, or mental retardation, increases the risk of decreased SpO2. In addition, delayed recovery is expected after midazolam administration.Abstract
Moderate intravenous (IV) sedation combined with local anesthesia is common for outpatient oral surgery procedures. An ideal sedative agent must be safe and well tolerated by patients and practitioners. This study evaluated fospropofol, a relatively new sedative/hypnotic, in comparison to midazolam, a commonly used benzodiazepine, for IV moderate sedation during oral and maxillofacial surgery. Sixty patients were randomly assigned to either the fospropofol or the midazolam group. Each participant received 1 μg/kg of fentanyl prior to administration of the selected sedative. Those in the fospropofol group received an initial dose of 6.5 mg/kg, with 1.6 mg/kg supplemental doses as needed. Those in the midazolam group received initial doses of 0.05 mg/kg, followed by 0.02 mg/kg supplemental doses. The quality of sedation in each patient was evaluated with regard to (a) onset of sedation, maintenance, and recovery profile; (b) patient and surgeon satisfaction; and (c) hemodynamic stability and adverse effects. The fospropofol group demonstrated shorter physical recovery times than midazolam patients, taking a mean of 11.6 minutes versus 18.4 minutes for physical recovery (P = .007). Cognitive recovery comparison did not find any difference with a mean of 7.5 minutes versus 8.8 minutes between the 2 drug groups (P = .123). The fospropofol group had a higher rate of local anesthetic injection recall (90.5 vs 44.4%, P = .004). Other parameters of recall were comparable. Two adverse effects demonstrated significance, with more patients in the midazolam group experiencing tachycardia (48.2 vs 9.4%, P = .001), and more patients in the fospropofol group experiencing perineal discomfort (40.6 vs 0, P < .001). No significant difference was found in any other measures of sedation safety, maintenance, or satisfaction. Fospropofol, when administered intravenously by a dentist anesthesiologist at the indicated dose in this study, appears to be a safe, well-tolerated alternative to midazolam for intravenous moderate sedation during minor oral surgery procedures.Abstract
Since 2008, three new analgesic entities, tapentadol immediate release (Nucynta) diclofenac potassium soft gelatin capsules (Zipsor), and bupivacaine liposome injectable suspension (EXPAREL) were granted US Food and Drug Administration (FDA) approval to treat acute pain. Tapentadol immediate-release is a both a mu-opioid agonist and a norepinephrine reuptake inhibitor, and is indicated for the treatment of moderate to severe pain. Diclofenac potassium soft gelatin capsules are a novel formulation of diclofenac potassium, which is a nonsteroidal anti-inflammatory drug (NSAID), and its putative mechanism of action is through inhibition of cyclooxygenase enzymes. This novel formulation of diclofenac allows for improved absorption at lower doses. Liposomal bupivacaine is a new formulation of bupivacaine intended for single-dose infiltration at the surgical site for postoperative analgesia. Bupivacaine is slowly released from this liposomal vehicle and can provide prolonged analgesia at the surgical site. By utilizing NSAIDs and local anesthetics to decrease the transmission of afferent pain signals, less opioid analgesics are needed to achieve analgesia. Since drug-related adverse events are frequently dose related, lower doses from different drug classes may be employed to reduce the incidence of adverse effects, while producing synergistic analgesia as part of a multimodal analgesic approach to acute pain.Abstract
Adverse reactions to medications prescribed or administered in dental practice can be worrying. Most of these reactions are somewhat predictable based on the pharmacodynamic properties of the drug. Others, such as allergic and pseudoallergic reactions, are generally unpredictable and unrelated to normal drug action. This article will review immune and nonimmune-mediated mechanisms that account for allergic and related reactions to the particular drug classes commonly used in dentistry. The appropriate management of these reactions will also be addressed.Abstract
Please see the pdf version for the Continuing Education Program Answer Sheet.
At dental hospitals, dental anesthesiologists often treat medical emergencies of outpatients and inpatients. In the Nihon University School of Dentistry Dental Hospital, when a medical emergency occurs, dental anesthesiologists are called to give treatment with the attending dentist. To review the recent emergency management systemMedical Emergencies Experienced in the Nihon University School of Dentistry Dental Hospital
J Jpn Dent Soc Anesthesiol 2013;41:153–159
Adachi S, see Asahi Y, 11 Al-Baqshi B, see Jaber A, 15 Asahi Y, Ventilation via Cut Nasotracheal Tube During General Anesthesia (scientific report), 11 Beck M, see Cohen H, 145 Beck M, see Smith S, 3 Becker DE, Antimicrobial Drugs (continuing education), 111 Becker DE, Antithrombotic Drugs: Pharmacology and Implications for Dental Practice (continuing education), 72 Becker DE, Basic and Clinical Pharmacology of Glucocorticosteroids (continuing education), 25 Cao LT, see Ritwik P, 54 Chen J-W, see Gutenberg LL, 99 Cohen H, Anesthetic Efficacy of a Combination of
Adverse events, 54 Agitation, 67 Analgesics, 178 Antibiotic prophylaxis, 111 Antibiotics, 111 Anticoagulants, 72 Antifungals, 111 Antiplatelet drugs, 72 Articaine, 42 Benzodiazepine, 162 Children, 54, 60 Continuous veno-venous hemofiltration, 21 Cut nasotracheal tube, 11 Delayed recovery, 153 Delirium, 67 Dental anesthesia sonophoresis device, 37 Dental anxiety, 46 Dental Anxiety Scale, 46 Dental infections, 111 Dental pulp anesthesia, 15 Dental sedation, 153 Dental treatment, 72 Dentistry, 25, 188 Developmental disability patients, 60 Diclofenac potassium soft gelatin capsules, 178 Drug allergy, 188 Drug interactions, 72 Drug side effects, 72, 188 Epinephrine, 3, 42 Fospropofol, 162 General anesthesia, 11, 60 Glucocorticosteroid, 25 Inferior