Outcomes of moderate sedation in paediatric dental patients.

BACKGROUND: The aim of this study was to evaluate the outcomes of moderate sedation with nitrous oxide/oxygen (N(2) O/O(2)) alone or combined with different dosages and administration routes of midazolam in uncooperative paediatric dental patients using the Bispectral Index System (BIS). METHODS: This one-year clinical study examined first-visit moderate sedation performed in 240 healthy children aged 4-6 years. Subjects were randomly divided into four groups according to drug, route and dosage, as follows: Group 1 - 0.20 mg/kg midazolam (40 mg/ml) delivered intranasally; Group 2 - 0.75 mg/kg midazolam (15 mg/3 ml) delivered orally; Group 3 - 0.50 mg/kg midazolam (15 mg/3 ml) delivered orally. All children in these three groups also received inhalation sedation with 50%-50% N(2) O/O(2), whereas children in Group 4 received inhalation sedation with 50%-50% N(2) O/O(2) only. The outcome of sedation was evaluated as either 'successful', 'failed' or 'not accepted'. RESULTS: The highest success rate was found in Group 1 (0.20 mg/kg intranasally, 87%), followed by Group 2 (0.75 mg/kg orally, 79%). The overall mean success rate for all groups was 73%. CONCLUSIONS: Moderate sedation can be successfully used in the clinical management of paediatric dental patients, with both intranasal and oral sedation using midazolam in conjunction with nitrous oxide found to be effective methods.

[Emergencies evolving from local anesthesia].

Local anesthesia is without doubt the most frequently used drug in dentistry and in medicine. In spite of records of safety set by using these drugs, there is evidence to adverse reactions ranging from 2.5%-11%. Most of the reactions originate from the autonomic system. A recent, well-planned study indicates that adverse reactions are highly correlated to the medical status of the patient: the higher the medical risk, the greater the chance to experience an adverse reaction. This study also found that adverse reactions highly correlated to the concentration of adrenalin. Another recent study found a direct relationship between adverse reactions and the level of anxiety experienced by the patient and to the dental procedure. Most of the reactions in this study occurred either immediately at injection time and within 2 hours following the injection. Since the beginning of last century, vasoconstrictors have been added to local anesthesia solutions in order to reduce toxicity and prologue activity of the LA. However, today it is commonly agreed that this addition to local anesthesia should not be administered to cardiac patients especially those suffering from refractory dysrhythmias, angina pectoris, post myocardial infarction (6 months) and uncontrolled hypertension. Other contraindications to vasoconstrictors are endocrine disorders such as hyperthyroidism, hyperfunction of the medullary adrenal (pheochromocytoma) and uncontrolled diabetes mellitus. Cross reactivity of local anesthetic solutions can occur with MAO inhibitors, non specific beta adrenergic blockers, tricyclic antidepressants, phenothiazides and cocaine abusers. Noradrenaline added to local anesthetics as a vasoconstrictor has been described as a trigger to a great increase in blood pressure and therefore has been forbidden for use in many countries. This paper describes 4 cases of severe complications following the injections of local anesthesia of which three ended in fatality.

[Syncope in the dental environment].

Syncope or Fainting is, by far, the most common emergency situation in the dental practice. Syncope is defined as an abrupt, transient, short term loss of consciousness and postural tone, followed by spontaneous and complete recovery. The pathophysiology of syncope consists of a sudden cessation or decrease in cerebral perfusion. Differential diagnosis of these medical conditions is of paramount importance in uncovering unrecognized systemic diseases. The dental team plays an important role in the process of establishing the correct diagnosis by its ability to recognize and document all the clinical symptoms and signs evident at the time of fainting. The dental surgeon is expected to be familiar with the various etiologies of syncope and should be able to differentiate between them. This article provides the essentials of the diagnostic procedure and an approach to the evaluation of the unconscious patient.

[Respiratory distress].

Dental treatment is usually conducted in the oral cavity and in very close proximity to the upper respiratory airway. The possibility of unintentionally compromising this airway is high in the dental environment. The accumulation of fluid (water or blood) near to the upper respiratory airway or the loosening of teeth fragmentations and fallen dental instruments can occur. Also, some of the drugs prescribed in the dental practice are central nervous system depressants and some are direct respiratory drive depressors. For this reason, awareness of the respiratory status of the dental patient is of paramount importance. This article focuses on several of the more common causes of respiratory distress, including airway obstruction, hyperventilation, asthma, bronchospasm, pulmonary edema, pulmonary embolism and cardiac insufficiency. The common denominator to all these conditions described here is that in most instances the patient is conscious. Therefore, on the one hand, valuable information can be retrieved from the patient making diagnosis easier than when the patient is unconscious. On the other hand, the conscious patient is under extreme apprehension and stress under such situations. Respiratory depression which occurs during conscious sedation or following narcotic analgesic medication will not be dealt with in this article. Advanced pain and anxiety control techniques such as conscious sedation and general anesthesia should be confined only to operators who undergo special extended training.

[Chest pains in the dental environment].

Chest pain does not necessarily indicate cardiac disease. The most common causes of acute chest pain encountered in dental situations include hyperventilation, pulmonary embolism, angina pectoris and myocardial infarction. Stress and fear often cause rapid breathing or hyperventilation. This usually occurs in young adults and although the hyperventilating patient often complains of chest pain, this is rarely a manifestation of cardiac disease. Pulmonary embolism usually indicates the occlusion of a pulmonary artery causing severe chest pain. The primary clinical manifestation of angina pectoris is chest pain. Although most instances of anginal pain are easily terminated, the dentist must always consider the possibility that the supposed anginal attack is actually a sign of acute myocardial infarction (AMI). AMI is a clinical syndrome caused by a deficient coronary arterial blood supply to a region of myocardium that results in cellular death. There is a high incidence of mortality among AMI with death often occurring within 2 hours of the onset of signs and symptoms. The initial clinical manifestations of all types of chest pain can be similar. Therefore the dentist must develop proficiency in constituting a differential diagnosis and an efficient management protocol. As in most medical situations prevention is the most powerful tool. However, if chest pains do occur, measures such as airway management, oxygen supplementation, coronary artery dilation, analgesis and in extreme cases, cardiopulmonary resuscitation and evacuation to the emergency room, may be necessary.

[Allergy-related emergencies].

Allergic reactions can develop to any of the drugs or materials commonly used in dentistry. They exhibit a broad range of clinical signs and symptoms ranging from mild, delayed reactions to immediate and life-threatening reactions developing within seconds. Allergies usually manifest themselves in reactions that are related to histamine release in one of three ways: skin reactions, respiratory problems and anaphylaxis. Anaphylaxis is the most critical allergic reaction in the dental environment. Measures such as airway management, oxygen supplementation, antihistamine, adrenaline and corticosteroid medication, cardiopulmonary resuscitation and evacuation to the emergency room, may be necessary.

[The potential dangers of endocrinal disorders].

The symptoms of most endocrine system diseases are usually clearly recognizable and most of the times are accompanied by a rich medical history. Many general practitioners are reluctant to treat such cases and prefer to refer these patients to specialists who are trained in management of the medically compromised thus increasing the chances of dental treatment without complications. However, sometimes endocrinal diseases develop slowly and their clinical manifestations are hidden or subclinical in nature. In these cases, neither the patient nor the dentist are aware of the condition and there is the potential of life threatening, emergency situations in what at first seem as simple, straightforward dental procedures. Therefore, the dentist must be able to recognize the clinical problem, differentiate between the different symptoms and initiate the proper management protocol. The most unstable endocrinal disorders that should be treated with great care are diabetes mellitus, mainly hypoglycemia, hyperthyroidism and adrenal insufficiency. The general practitioner dentist can treat patients suffering from these disorders providing the disease is well controlled and balanced and that the dental treatment is not very traumatic.

[Legal and ethical considerations of emergencies in the dental office].

The dentist has the ethical and legal responsibility to anticipate emergency situations in correlation with the patient's medical status. He has the obligation to do all in his power to prevent emergencies from happening and to be prepared to manage any emergency that might occur. This article also discusses the importance of monitoring and documentation.

Articaine hydrochloride: a study of the safety of a new amide local anesthetic.

BACKGROUND: Articaine is an amide local anesthetic introduced clinically in Germany in 1976 and subsequently throughout Europe, Canada and, in 2000, the United States. METHODS: The authors report on three identical single-dose, randomized, double-blind, parallel-group, active-controlled multicenter studies that were conducted to compare the safety and efficacy of articaine (4 percent with epinephrine 1:100,000) with that of lidocaine (2 percent with epinephrine 1:100,000). RESULTS: A total of 1,325 subjects participated in these studies, 882 of whom received articaine 4 percent with epinephrine 1:100,000 and 443 of whom received lidocaine 2 percent with epinephrine 1:100,000. The overall incidence of adverse events in the combined studies was 22 percent for the articaine group and 20 percent for the lidocaine group. The most frequently reported adverse events in the articaine group, excluding postprocedural dental pain, were headache (4 percent), facial edema, infection, gingivitis and paresthesia (1 percent each). The incidence of these events was similar to that reported for subjects who received lidocaine. The adverse events most frequently reported as related to articaine use were paresthesia (0.9 percent), hypesthesia (0.7 percent), headache (0.55 percent), infection (0.45 percent), and rash and pain (0.3 percent each). CONCLUSIONS: Articaine is a well-tolerated, safe and effective local anesthetic for use in clinical dentistry.

[New anesthetics]. / Nouveaux anesthésiques.

Since the introduction of cocaine local analgesia in 1886, and the subsequent development of procaine (1904) and other closely related ester-type compounds, dentistry has prided itself on being as close to 'painless' as possible. In the late 1940s the newest group of the local anesthetic compounds, the amides, was introduced. The initial amide local analgesic, lignocaine (Xylocaine), revolutionised pain control in dentistry worldwide. In succeeding years other amide-type local anesthetics, mepivacaine, prilocaine, bupivacaine and etidocaine, were introduced. They gave the dental practitioner a local anesthetic armamentarium which provided pulpal analgesia for periods of from 20 minutes (mepivacaine) to as long as three hours (bupivacaine and etidocaine with adrenaline). In addition these popular drugs proved to be more rapid-acting than the older ester-type drug and, at least from the perspective of allergenicity, more safe. In 1976, in Germany, the newest amide local analgesic, carticaine HCl was introduced into dentistry. Articaine (the generic name was changed) possesses properties similar to lignocaine but has additional properties which made the drug quite attractive to the general dental practitioner. In 1986 articaine was introduced in North America (Canada) where it has become the most used local anesthetic, supplanting lignocaine. Articaine has been approved for use in the United Kingdom. In this introductory discussion we review the development of articaine and discuss its place in the dental local analgesic armamentarium.

[The possible secondary effects in cases of local anesthesia]. / Effets secondaires possibles en cas d'anesthésie locale.

Local anesthetics are the safest and most effective drugs for pain control. Over 300 million local anesthetic cartridges are administered by dentists in the United States of America annually, yet serious complications reported number but a handful. Complications are categorised as localised or systemic. Localised complications arise at the site of needle penetration or anesthetic administration while systemic complications involve the entire organism. Localised complications include needle breakage, paresthesia, trismus, haematoma and facial nerve paralysis, while systemic complications are psychogenic to the act of receiving an injection, allergy and drug overdose (toxic reaction). These potential complications are briefly described in the following paper.

A comparison between articaine HCl and lidocaine HCl in pediatric dental patients.

PURPOSE: Three identical single-dose, randomized, double-blind, parallel-group, active-controlled multicenter studies were conducted to compare the safety and efficacy of articaine HCl (4% with epinephrine 1:100,000) to that of lidocaine HCl (2% with epinephrine 1:100,000) in patients aged 4 years to 79 years, with subgroup analysis on subjects 4 to < 13 years. METHODS: Fifty subjects under the age of 13 years were treated in the articaine group and 20 subjects under the age of 13 were treated with lidocaine. Subjects were randomized in a 2:1 ratio to receive articaine or lidocaine. Efficacy was determined on a gross scale immediately following the procedure by having both the subject and investigator rate the pain experienced by the subject during the procedure using a visual analog scale (VAS). Safety was evaluated by measuring vital signs before and after administration of anesthetic (1 and 5 minutes post-medication and at the end of the procedure) and by assessing adverse events throughout the study. Adverse events were elicited during telephone follow-up at 24 hours and 7 days after the procedure. RESULTS: Pediatric patients received equal volumes, but higher mg/kg doses, of articaine than lidocaine during both simple and complex dental procedures. Pain ratings: Articaine: VAS (Visual Analogue Scale) scores (from 0 to 10 cm) by patients 4 to < 13 years of age were 0.5 for simple procedures and 1.1 for complex procedures, and average investigator scores were 0.4 and 0.6 for simple and complex procedures, respectively. Lidocaine: patients 0.7 (simple) and 2.3 (complex); investigators 0.3 (simple) and 2.8 (complex). Adverse events: No serious adverse events related to the articaine occurred. The only adverse event considered related to articaine was accidental lip injury in one patient. CONCLUSIONS: VAS scores indicate that articaine is an effective local anesthetic in children and that articaine is as effective as lidocaine when measured on this gross scale. Articaine 4% with epinephrine 1:100,000 is a safe and effective local anesthetic for use in pediatric dentistry. Time to onset and duration of anesthesia are appropriate for clinical use and are comparable to those observed for other commercially available local anesthetics.

Efficacy of articaine: a new amide local anesthetic.

BACKGROUND: The authors compared the safety and efficacy of 4 percent articaine with epinephrine 1:100,000 with 2 percent lidocaine with epinephrine 1:100,000. METHODS: In three identical randomized, double-blind, multicenter trials, subjects 4 to 80 years of age received either 4 percent articaine with epinephrine 1:100,000 or 2 percent lidocaine with epinephrine 1:100,000 for simple or complex dental procedures. In each trial, the authors randomized the subjects in a 2:1 ratio to receive articaine or lidocaine. Efficacy was determined by both subject and investigator using a visual analog scale, or VAS. The authors used the Kruskal-Wallis test to analyze the data. RESULTS: A total of 882 subjects received articaine, and 443 received lidocaine. The authors found no statistical differences between the groups (P = .05). They also compared drug volumes for both articaine and lidocaine groups (2.5 milliliters +/- 0.07 standard error of mean, or SEM, vs. 2.6 mL +/- 0.09 SEM for simple procedures and 4.2 mL +/- 0.15 SEM vs. 4.5 mL +/- 0.21 SEM for complex procedures). The procedures' durations were comparable for both the articaine and lidocaine groups. The authors found no statistical difference between the two treatment groups (P = .05) with respect to subject or investigator pain ratings using the VAS; the mean pain scores determined by both patients and investigators for all groups tested were less than 1.0. CONCLUSIONS: The authors found that 4 percent articaine with epinephrine 1:100,000 was well-tolerated in 882 subjects. It also provided clinically effective pain relief during most dental procedures and had a time to onset and duration of anesthesia appropriate for clinical use and comparable to those observed for other commercially available local anesthetics. CLINICAL IMPLICATIONS: Pain control is a major component of patient comfort and safety. Local anesthetics form the backbone of pain control techniques in dentistry. Four percent articaine with epinephrine is an amide local anesthetic that will meet the clinical requirements for pain control of most dental procedures in most patients.

Pediatric oral conscious sedation: changes to come.

Recent media attention has focused the public's attention on issues surrounding pediatric oral conscious sedation. Under a law passed in 1998 and taking affect on Jan. 1, 2000, California dentists will be subject to certification and procedural provisions designed to ensure the educational qualification of the provider and the standards under which the procedure is performed. This article discusses the history of concern and regulation regarding sedation of children in the dental office.

Morbidity, mortality and local anaesthesia.

Two cases of local anaesthetic overdose and death are described. The patients, a four-year-old child and a 68-year old female, received local anaesthetic doses greatly in excess of those recommended. Their overdose reactions are described as well as subsequent management. The paper reviews the causes of local anaesthetic overdose, its signs and symptoms, and the recommended management of these reactions. Specific discussion as to the cause of death of these two patients and of the means to prevent such occurrences in the future concludes the paper.

Emergency medicine: beyond the basics.

Medical emergencies can arise in the dental office. Preparedness for these emergencies is predicated on an ability to rapidly recognize a problem and to effectively institute prompt and proper management. In all emergency situations, management is based on implementation of basic life support, as needed. The author describes the appropriate management of two common emergency situations: allergy and chest pain.