Anesthesia Progress Volume 63: Issue 3

Most dental practitioners are aware of the increasing controversy in the United States surrounding the prescribing of opioids for postoperative pain. Fortunately, the use of opioids for surgery with general anesthesia and sedation is not a matter of concern in this controversy.

It is understandable from a US public health standpoint that opioid prescribing should receive increasing scrutiny. In 2012, there were 259 million US opioid prescriptions, more than enough for 1 bottle for every adult in the United States. Since 1999, there have been more than 140,000 opioid overdose deaths. In 2014 alone, there were more than 28,000 overdose

Although several adjuncts to the general anesthetic propofol have been proposed, there is insufficient research identifying the ideal agent, and in what dosage, to combine with propofol in dental outpatient anesthesia. Here we examined the combination of remifentanil or nitrous oxide and propofol in patients with severe dental avoidance undergoing dental treatment in the outpatient setting. Eighty patients were randomized to 4 groups and administered propofol/saline solution (PS; n = 20), propofol/remifentanil 0.25 μg/kg/min (PRe-0.25; n = 20), propofol/remifentanil 0.125 μg/kg/min (PRe-0.125; n = 20), or propofol/66% nitrous oxide (PN; n = 20). During anesthesia, the bispectral index value was kept between 40 and 60. Body movements and hemodynamic changes during anesthesia, emergence, and recovery as well as anesthetic cost were compared between the combinations. Body movements were observed in all patients administered PS but in no patients administered PRe-0.25, PRe-0.125, or PN. Postoperative nausea was observed in 5 patients (25%) administered PRe-0.25 and in 1 patient (5%) administered PN. Although both PRe-0.125 and PN were useful clinically, PRe-0.125 was the least expensive combination.

The purpose of this study was to compare the effectiveness and recovery times of 0.3 and 0.5 mg/kg intranasal midazolam (INM) administered with a mucosal atomizer device (MAD) in a pediatric emergency dental hospital clinic. One hundred eighteen children aged from 4 to 6 years were randomly administered either 0.3 or 0.5 mg/kg INM via an MAD in a triple-blinded randomized controlled trial. Sedation was achieved to some degree in 100% of the sample. The pulse rate and oxygen saturation were within the normal range in 99% of the patients. A burning sensation was reported in 9% of children. The recovery time of the 0.5 mg/kg group was statistically longer than that of the 0.3 mg/kg group (16.5 vs 18.8 minutes) but the difference was not clinically significant. The findings of this study show that 0.3 or 0.5 mg/kg doses of INM resulted in safe and effective sedation. The 0.5 mg/kg dose was more effective than the 0.3 mg/kg dose in reducing anxiety.

To obtain effective infiltration anesthesia in the jawbone, high concentrations of local anesthetic are needed. However, to reduce pain experienced by patients during local anesthetic administration, low-pressure injection is recommended for subperiosteal infiltration anesthesia. Currently, there are no studies regarding the effect of injection pressure on infiltration anesthesia, and a standard injection pressure has not been clearly determined. Hence, the effect of injection pressure of subperiosteal infiltration anesthesia on local anesthetic infiltration to the jawbone was considered by directly measuring lidocaine concentration in the jawbone. Japanese white male rabbits were used as test animals. After inducing general anesthesia with oxygen and sevoflurane, cannulation to the femoral artery was performed and arterial pressure was continuously recorded. Subperiosteal infiltration anesthesia was performed by injecting 0.5 mL of 2% lidocaine containing 1/80,000 adrenaline, and injection pressure was monitored by a pressure transducer for 40 seconds. After specified time intervals (10, 20, 30, 40, 50, and 60 minutes), jawbone and blood samples were collected, and the concentration of lidocaine at each time interval was measured. The mean injection pressure was divided into 4 groups (100 ± 50 mm Hg, 200 ± 50 mm Hg, 300 ± 50 mm Hg, and 400 ± 50 mm Hg), and comparison statistical analysis between these 4 groups was performed. No significant change in blood pressure during infiltration anesthesia was observed in any of the 4 groups. Lidocaine concentration in the blood and jawbone were highest 10 minutes after the infiltration anesthesia in all 4 groups and decreased thereafter. Lidocaine concentration in the jawbone increased as injection pressure increased, while serum lidocaine concentration was significantly lower. This suggests that when injection pressure of subperiosteal infiltration anesthesia is low, infiltration of local anesthetic to the jawbone may be reduced, while transfer to oral mucosa and blood may be increased.

The Opioid Challenge

Remifentanil in Combination With Propofol Is Suitable for Use in the Dental Outpatient Setting

Intranasal Midazolam Sedation in a Pediatric Emergency Dental Clinic

Effect of Injection Pressure of Infiltration Anesthesia to the Jawbone

Effective Dosage of Midazolam to Erase the Memory of Vascular Pain During Propofol Administration

Temporary Diplopia After Gow-Gates Injection: Case Report and Review

Second-Degree Atrioventricular Block Occurring After Tooth Extraction

Benzodiazepine Allergy With Anesthesia Administration: A Review of Current Literature

The Opioid Challenge

Remifentanil in Combination With Propofol Is Suitable for Use in the Dental Outpatient Setting

Intranasal Midazolam Sedation in a Pediatric Emergency Dental Clinic

Effect of Injection Pressure of Infiltration Anesthesia to the Jawbone

Temporary Diplopia After Gow-Gates Injection: Case Report and Review