It is my distinct honor and privilege to assume the reins as editor of Anesthesia Progress from my dear friend and mentor, Dr Steven Ganzberg. This is a challenge that I approach with the utmost reverence. I will pause to reflect upon the journal's storied history, replete with a long line of previous editors who have each left their own indelible marks of progressive change, before moving onward to discuss my own goals and vision. The official journal of the American Dental Society of Anesthesiology (ADSA), which originated as a monthly newsletter produced by Dr Harcourt Stebbins back
The aim of this study was to compare the efficacy of articaine versus lidocaine, both containing epinephrine, using a single buccal infiltration for extraction of primary molars.A total of 100 children requiring primary molar extraction received buccal infiltration using either 4% articaine or 2% lidocaine, both with epinephrine, with 50 children in each group. The Wong-Baker Facial Pain Scale (FPS) was used to evaluate pain perception subjectively. The heart rate and the blood pressure values were assessed objectively as an indirect measure of physiological pain perception. The Wilcoxon-Mann-Whitney test was used for comparing mean pain scores, heart rate, and blood pressure in both the groups. Single buccal infiltration with articaine was sufficient for achieving palatal or lingual anesthesia in all the children receiving it while all children in the lidocaine group required supplemental anesthesia. The mean FPS value was found to be higher in lidocaine group and was statistically significant. The mean heart rate recorded during the intervention was less than the mean baseline values in the articaine group, which was found to be statistically significant. For pediatric patients age 7 to 12 years, single buccal infiltration with 4% articaine with 1:100,000 epinephrine is more effective compared to 2% lidocaine with 1:80,000 epinephrine for primarly molar extraction.
An estimation of the appropriate tubing depth for fixation is helpful to prevent inadvertent endobronchial intubation and prolapse of cuff from the vocal cord. A feasible estimation formula should be established. We measured the anatomical length of the upper-airway tract through the oral and nasal pathways on cephalometric radiographs and tried to establish the estimation formula from the height of the patient. The oral upper-airway tract was measured from the tip of the incisor to the vocal cord. The nasal upper-airway tract was measured from the tip of the nostril to the vocal cord. The tracts were smoothly traced by using software. The length of the oral upper-airway tract was 13.2 ± 0.8 cm, and the nasal upper-airway tract was 16.1 ± 0.9 cm. We found no gender difference (p > .05). The correlations between the patients' height and the length of the oral and nasal upper-airway tracts were 0.692 and 0.760, respectively. We found that the formulas (height/10) − 3 (in cm) for oral upper-airway and (height/10) + 1 (in cm) for nasal upper-airway tract are the simple fit estimation formulas. The average error and standard deviation of the estimated values from the measured values were 0.50 ± 0.66 cm for the oral tract and 0.39 ± 0.63 cm for the nasal tract. Thus, considering the length of the intubation marker of each product (DM), we would like to propose the length of tube fixation as (height/10) + 1 + DM for nasal intubation and (height/10) − 3 + DM for oral intubation. In conclusion, the estimation formulas of (height/10) − 3 + DM and (height/10) + 1 + DM for oral and nasal intubation, respectively, are within almost 1 cm error in most cases.
The location of the mandibular foramen (MF) on digital panoramic radiographs can be an important guide for clinicians when administering the inferior alveolar nerve block (IANB) for dental anesthesia of the mandible. This study, aimed to assess the location of the MF relative to the anterior border (AB) of the ramus and the occlusal plane (OP) from digital panoramic radiographs. An observational case series study was conducted on digital panoramic radiographs from the oral and maxillofacial radiology department archives of patients at least 18 years of age with a 1:1 scale (100%). The samples had to have at least 2 lower molar teeth on both sides without any blurring, previous fracture of the ramus or other artifacts. The distance of the MF to the OP and the AB of the ramus was measured using a caliper. The role of age and gender were also analyzed statistically using the 2-way analysis of variance test. One hundred ninety-four digital panoramic radiographs were included in the analysis. The findings showed that the vertical distance of the MF to the OP was a maximum of 14.52 mm and a minimum of −3.0 mm (mean 4.32 ± 2.34 mm). The distance of the MF to the AB of the ramus was a maximum of 25.52 and a minimum 9.68 mm (mean 16.48 ± 3.28 mm). Based on these findings, the IANB target site for injection should be approximately 5 mm above the OP and approximately 16.5 mm beyond the AB of the ramus to achieve successful anesthesia of the mandible via standard IANB in an Iranian population.
This study aims to compare the effect of topical anesthesia against the use of no topical agent on pain of needle penetration and local anesthesia deposition during buccal infiltration in anterior maxilla. In a randomized controlled trial, 100 adult participants were randomly allocated to the benzocaine group (received 20% benzocaine gel) and no benzocaine group (received no topical agent) prior to buccal infiltration in maxillary anterior teeth. A 27-gauge needle was used to deposit 2% lidocaine with 1:100,000 epinephrine. Pain of needle penetration and local anesthesia deposition was recorded separately using an 11-point Numeric Pain Rating Scale. Results showed that although 20% benzocaine significantly reduced pain on needle penetration during buccal infiltration in maxillary anterior teeth, the difference was small and the clinical significance is not clear. Topical anesthetic did not affect pain of local anesthetic deposition.
Hereditary angioedema (HAE) is a rare genetic disease that results from deficiency or dysfunction of C1 inhibitor (C1-INH). This disease is characterized by sudden attacks of angioedema. When edema occurs in the pharynx or larynx, it can lead to serious airway compromise, including death. Physical and/or psychological stress can trigger an attack. Dental treatment, including tooth extraction, is also a recognized trigger. We report a case of a 20-year-old male with HAE who required impacted third molar extractions. C1-INH concentrate was administered 1 hour before surgery, which was completed under deep intravenous sedation. This report describes the anesthetic management of a patient with HAE and reviews treatment options and concerns.
A 26-year-old woman with a history of feeling nauseated during dental local anesthesia presented to our clinic for tooth extraction under intravenous sedation. Although she had experienced episodes of neurally-mediated syncope, her symptoms were controlled well with drug therapy, stopped 3 years earlier. No syncope episodes developed over the previous 2 years. Tooth extraction was performed under intravenous sedation without incident. When she was returned to a sitting position after being roused, convulsion, loss of consciousness, and cardiac arrest developed. One week later, similar symptoms occurred immediately after suture removal. We suspect that the change in body position triggered these episodes. It is important to avoid abrupt changes in body position and any other triggers and to administer preventive drugs in patients at high risk of syncope.
Type II Arnold-Chiari malformation (ACM) is an abnormality in which the cerebellum, pons, and medulla oblongata are displaced downward into the spinal cord. Type II ACM is often complicated by respiratory depression, sleep-disordered breathing, and deglutition disorder as a result of medullary dysfunction and impairment of the lower cranial nerves. Bending and stretching of the neck is restricted, and anesthetic management is problematic in patients with the disorder. We performed dental treatment twice under intravenous sedation in a patient with intellectual disability with type II ACM complicated by hypercapnic respiratory failure. Propofol was used for the first sedation procedure. Repeated bouts of respiratory depression occurred on that occasion, so the airway was managed manually by lifting the jaw. However, aspiration pneumonitis occurred postoperatively. A combination of dexmedetomidine and midazolam was used for sedation on the second occasion, and the intervention was completed uneventfully without any respiratory depression. Our experience with this patient highlights the need for selection of an agent for intravenous sedation that does not require neck extension and has minimal effect on respiration in patients with type II ACM, who are at high risk of respiratory depression and pulmonary aspiration.
We report a case of difficult endotracheal intubation in a patient with Treacher Collins syndrome. A sixteen-year-old female patient scheduled for general anesthesia had a displaced palatal tooth that interfered with laryngoscope insertion into the pharyngeal space. To address this problem, we successfully performed endotracheal intubation using a fiberscope while elevating the epiglottic vallecula using a King Vision™ video laryngoscope. A later operation was performed after tooth extraction without difficult laryngoscopy. Our experience stresses the importance of removing obstructions to laryngoscopic inspection prior to general anesthesia.
The safe treatment of patients with chronic obstructive pulmonary disease (COPD) in dental office office-based settings can be quite complex without a current understanding of the etiology, course, severity, and current treatment modalities of the disease. The additional concerns of providing sedation and/or general anesthesia to patients with COPD in settings outside of a hospital demand thorough investigation of individual patient presentation and realistic development of planned treatment that patients suffering from this respiratory condition can tolerate. Along with other co-morbidities, such as advanced age and potential significant cardiovascular compromise, the dental practitioner providing sedation or general anesthesia must tailor any treatment plan to address multiple organ systems and mitigate risks of precipitating acute respiratory failure from inadequate pain and/or anxiety control. Part I of this article covered the epidemiology, etiology, and pathophysiology of COPD. Patient considerations in the preoperative period were also reviewed. Part II will cover which patients are acceptable for sedation/general anesthesia in the dental office-based setting as well as sedation/general anesthesia techniques that may be considered. Postoperative care will also be reviewed.
Dantrolene is an effective treatment for malignant hyperthermia (MH). Succinylcholine and volatile anesthetic agents are potential triggers for inducing MH; however, discrepant recommendations for emergency preparedness exist regarding the availability of dantrolene during general anesthesia. The Malignant Hyperthermia Association of the United States (MHAUS) guidelines state dantrolene must be available within 10 minutes of the decision to treat MH whenever volatile agents or succinylcholine are administered.1 InSuccinylcholine Use and Dantrolene Availability for Malignant Hyperthermia Treatment. Larach MG, Klumpner TT, Brandon BW, Vaughn MT, et al. on behalf of the Multicenter Perioperative Outcomes Group. Anesthesiol. 2019;130:41–54.