Conscious sedation with diazepam and midazolam for dental patient: priority to diazepam.

AIM: The aim of this paper was to determine whether the use of midazolam is a better technique than the use of diazepam, in relation with the definition of conscious sedation in dentistry. METHODS: Eighty-eight patients undergoing oral surgery were divided into 2 groups in which the sedation was randomly achieved with equipotent cumulative doses of diazepam and midazolam, up to a maximum dose of 8 and 4 mg respectively. Patient's tranquillity was assessed after every dose, using a visual analogue score to ten points and the sedation was evaluated as mild, moderate or deep. Blood pressure, heart rate and SpO2 were also recorded. Psychomotor conditions, by Newman test, and the incidence of amnesia and the patient's satisfaction, by telephone interview, were both evaluated. RESULTS: The number of patients who reached maximum subjective tranquillity was greater already after the third dose of diazepam. The average scores of tranquillity were higher after diazepam. Patients treated with diazepam experienced a higher incidence of mild sedation, patients treated with midazolam a higher incidence of moderate and deep sedation. In patients treated with midazolam blood pressure, heart rate and SpO2 were lower. Postoperative recovery was similar in the 2 groups. After midazolam patients experienced greater amnesia for local anesthesia and drowsiness. Satisfaction was high with both treatments. CONCLUSION: The study shows that sedation with diazepam is more in line with the definition of conscious sedation in dentistry. Diazepam guarantees the persistence of consciousness and maximum subjective tranquillity levels. The recovery and satisfaction were comparable in the 2 groups.

Comparison between two regional anaesthesia techniques performed by inexperienced operators: the Gow-Gates block versus the Kenneth Reed block.

AIM: The aim was to compare the efficacy of Kenneth Reed and Gow-Gates inferior alveolar nerve blocks when performed by an inexperienced operator. METHODS: A group of 60 patients was randomised into two groups. One group had the Kenneth Reed technique used to administer an inferior alveolar nerve block whilst the other received the Gow-Gates technique. The efficacy of nerve block produced was evaluated both clinically and by electric pulp tester. MRI examination was undertaken to determine the spread of local anaesthetic. RESULTS: There were no significant differences in success rate of anaesthesia between groups. The failure rate for the Gow-Gates technique was 16.6%, whilst the failure rate for the Kenneth Reed technique was 23.3%. Time to onset was less with the Kenneth Reed technique. MRI examination showed the solution was more widely distributed after the Kenneth Reed block had been used. CONCLUSIONS: Our research has demonstrated that the Kenneth Reed technique is equally effective at producing anaesthesia of the inferior alveolar nerve. Compared with conventional techniques there is a lower incidence of positive aspiration and potential for lower morbidity as the local anaesthetic is deposited further from the neurovascular bundle than when deposited near the mandibular foramen as in most conventional Inferior Alveolar Nerve Block techniques.

Toward the validation of visual analogue scale for anxiety.

Anxiety is a relevant problem in dental practice. The Visual Analogue Scale for Anxiety (VAS-A), introduced in dentistry in 1988, has not yet been validated in large series. The aim of this study is to check VAS-A effectiveness in more than 1000 patients submitted to implantology. The VAS-A and the Dental Anxiety Scale (DAS) were administered preoperatively to 1114 patients (459 males and 655 females, age 54.7 ± 13.1 years). Statistical analysis was conducted with Pearson correlation coefficient, the receiver operating characteristic (ROC) curve, and McNemar tests. A close correlation between DAS and VAS-A was found (r  =  0.57, P < .0001); the VAS-A thresholds of dental anxiety and phobia were 5.1 and 7.0 cm, respectively. Despite a significant concordance of tests in 800 cases (72%), disagreement was found in the remaining 314 cases (28%), and low DAS was associated with high VAS-A (230 cases) or vice versa (84 cases). Our study confirms that VAS-A is a simple, sensitive, fast, and reliable tool in dental anxiety assessment. The rate of disagreement between VAS-A and DAS is probably due to different test sensitivities to different components of dental anxiety. VAS-A can be used effectively in the assessment of dental patients, using the values of 5.1 cm and 7.0 cm as cutoff values for anxiety and phobia, respectively.

Comparison by means of bispectral index score, between anxiolysis induced by diazepam and sedation induced by midazolam.

AIM: Bispectral Index Score (BIS) is an objective tool to assess sedation depth. Benzodiazepines have different pharmacological profiles and diazepam may be safer than midazolam in this setting. The aim of this study was to compare BIS values observed during anxiolysis after diazepam versus sedation after midazolam. METHODS: Thirty-six patients were randomly assigned to 3 groups: group 1 was treated with i.v. diazepam, groups 2 and 3 with iv midazolam 1 and 3 mg, respectively. Sedation was monitored clinically and by means of BIS. BIS values were evaluated as area under the curve (AUC) and compared by variance analysis. The statistical comparison of other data was performed by variance analysis or, alternatively, the χ2 according to Yates. The statistical significance was indicated by P values <0.05. RESULTS: AUC values were significantly lower after midazolam when compared to AUC values registered in diazepam treated patients; 22.6% of the group 3 patients showed BIS values <80, versus 0.4% of group 1 patients. CONCLUSION: Diazepam has a safer profile, with BIS values and clinical conditions according to the definition of minimal and/or moderate sedation. Diazepam represents the safer drug for anxiety management in dentistry, because regularly produces a state of sedation during which verbal contact with the patient is maintained and carry a margin of safety wide enough to render loss of consciousness unlikely.

Patients appreciation for information on anesthesia and anxiolysis in dentistry.

AIM: The research regards information on anesthesia to patients undergoing oral surgery. Every patient evaluated the information received at the end of the preoperative visit and in the postoperative period. METHODS: One hundred-fifty dental patients were asked about the most appreciated information received in the preoperative visit on the anxiolytic technique, local anesthesia and treatment of the perioperative pain. Afterwards the patients had to report on their reaction to the content of the preoperative visit and information quality. On a phone interview they had to evaluate their appreciation of the anxiolytic technique, their perception during loco-regional anesthesia and incidence of pain and edema. RESULTS: The most appreciated details were those on the intervention, pharmacologic treatment, postoperative complicances, postoperative pain and operative competence; less appreciated were those on loco-regional anesthesia, duration of the intervention, anxiolytic techniques, hospital reception and permanence in the hospital. Ninety-eight percent of the patients considered to have been adequately informed on a context judged to be extraordinary (99.3%), 96.6% indicated the information as necessary, 98.6% appreciated the treatment of the intraoperative and postoperative (99.3%) pain and 99.3% the anxiolytic treatment. On the telephone interview, 100% of patients expressed satisfaction for the experienced intraoperative tranquillity, 91.3% complained for not having received in the past a similar preoperative visit, 99.3% wished a diffused application of the information. The loco-regional anesthesia was associated to psychological detachment in 84% of the cases and the incidence of postoperative pain was of 36%. CONCLUSION: The information on the anxiolytic techniques, loco-regional anesthesia, treatment of perioperative pain and postoperative distress was enthusiastically accepted and albeit initially induced feelings of astonishment resulted to be appreciated and preferred in the whole of the patients.

Electronic dental anaesthesia for third inferior molar surgery.

AIM: The aim of this study was to evaluate the efficacy of Electronic Dental Anaesthesia (EDA) for third molar surgery. METHODS: Third molar extraction under regional anaesthesia (inferior alveolar and buccal nerve blocks) was performed in 2 groups of 30 patients each: group 1 = controls, group 2 = EDA treatment. Anxiety and pain level were reported by means of Visual Analogue Scale, postoperative pain description with the McGill Pain Questionnaire. A postoperative phone interview to all patients was made. Computerized randomization was performed; values expressed as mean+/-SD, data comparison evaluated by means of ANOVA and chi squared, statistical significance indicated by P values <0.05. RESULTS: Features of the patients and surgical interventions were similar. EDA has determined lower pain level; moreover, the control patients has shown higher values of blood pressure and heart frequency. Phone interview has reported no amnesia about the perioperative events. A smaller number of EDA treated patients has reported pain during needle prick and/or intraoperatively; 80% of the EDA treated patients has reported a good opinion about the treatment, 93% of the patients would repeat the treatment, if needed. CONCLUSION: EDA is a complementary analgesic technique for dental surgery. Cardiovascular changes, frequently observed during third molar extraction, were not present in the EDA treated patients. These data confirm that EDA is able to modify the physiologic responses to stressful events, blunting the adrenergic upset, maybe by means of an analgesic action on A, fiber and an increase of endorphins' central level. These results underline that the complementary use of EDA in the third molar extraction may be better than regional anaesthesia alone.

Bispectral Index in the sedation with intranasal midazolam and intravenous diazepam in dental practice.

AIM: Aim of this study was to assess by clinical evaluation and by Bispectral Index (BIS) the tranquillizing properties of diazepam injected intravenously, and midazolam by intranasal route according to the body weight in dental patients. METHODS: A group of 34 patients undergoing implantology were divided at random into 2 groups of 17. They were evaluated physically, clinically and psychologically. The psychomotor activity was measured by the Newman's test. Preoperative anxiety was treated with chlordemethyldiazepam (CHDDZ) per os, administered before induction of conscious sedation. In the first group, conscious sedation was accomplished by induction with titrated doses of i.v. diazepam, and in the second group with 0.1 mg/kg of intranasal midazolam. BIS values were analysed as Area Under the Curve (AUC). RESULTS: The AUC BIS values after CHDDZ presedation were overlapping in both groups. AUC after midazolam decreased after induction of the conscious sedation (P<0.05), during anesthesia (P<0.01) and during intervention (P<0.01) compared to the diazepam treatment. In the midazolam group the BIS values were on average lower than 90, while in the diazepam group they were on average higher than 95 (P<0.01). The psychomotor recovery was more impaired after midazolam. CONCLUSIONS: The study shows that nasal route ensures the quick absorption of midazolam as revealed during the first 3 min from drug administration. The depressant effect of midazolam increased as a function of time, reaching the highest levels during intervention. The results suggest that midazolam is endowed with sedative effects which may compromise the state of consciousness of the patient and be incompatible with the definition of conscious sedation in dentistry.

Analysis of an anxiolytic technique applied in 1179 patients undergoing oral surgery.

AIM: The aim of this study was to evaluate the effects of sedation with benzodiazepines in a large population of patients undergoing oral surgery and age-related implications. METHODS: A group of 1 179 consecutive patients undergoing oral surgery in the Dental Clinic of the University of Padua between 2001 and 2003 was evaluated by analysing their anaesthesiological records. The patients were divided into 5 age groups. All were pre-sedated with chlordemethyldiazepam per os, while induction of maximum subjective tranquillity was obtained with fractionated doses of intravenous diazepam. Arterial pressure (AP), heart rate (HR), anxiety level, pathologies, drugs taken, types of intervention, techniques of loco-regional anaesthesia, immediately preoperative AP and HR and tranquillity, intraoperative AP and HR, data regarding postoperative psychomotor recovery, complications and drugs used for the treatment of perioperative pain, were evaluated in each group. RESULTS: Most of the patients (679) were in the 45-64 year-old group. Cardiovascular, respiratory and digestive pathologies proved to be age-dependent. Control AP and HR respectively increased and decreased with age. The doses of chlordemethyldiazepam used induced age-dependent preoperative tranquillity levels. The doses of i.v. diazepam necessary to obtain maximal preoperative subjective tranquillity fell as a function of age. The AP and HR values respectively increased during intervention and decreased in the first hour of intervention. Normal psychomotor recovery was less evident in older patients. The most significant corrective intraoperative interventions consisted of the administration of sublingual hypotensive drugs and in the immediate treatment of some cases of orthostatic hypotension and vaso-vagal syncope. CONCLUSIONS: The sedation technique and the antistress procedures employed proved safe and the intra- or postoperative complications almost non-existent. The variations observed in the parameters considered are compatible with the greater age of the treated subjects.

Enzymatic assay of fructose-1,6-diphosphate for the measurement of its utilization by tissues.

The enzymatic analysis of fructose-1,6-diphosphate by a coupled assay utilizing triose-phosphate isomerase, glycerol-3-phosphate dehydrogenase and aldolase was carried out in rat serum and human plasma after fructose-1,6-diphosphate administration. The rate of disappearance of fructose-1,6-diphosphate was determined and compared to the activity of aspecific phosphatase. The uptake of fructose-1,6-diphosphate by rat liver and ileum was also determined with the same method.

[Proposed method for double-blind study of reflexotherapy phenomena]. / Proposta di un metodo per lo studio dei fenomeni riflessoterapici in "doppio cieco".

The Authors report their experience with the placebo, an essential step in the clinical study of reflexotherapy. They assert that also in this branch of medicine it is possible to carry out a "double blind" clinical experimentation by means of placebo, that is, an essential condition in order to develop a scientific assessment of both the limits and the potentialities of reflexotherapy.

Comparison study between acupuncture and pentazocine analgesic and respiratory post-operative effects.

The authors studied the effects of acupuncture and pentazocine on post-operative respiratory function and pain management on patients hysterectomized by means of a subumbilical midline incision. The acupunctural technique consisted of GB-26, St-36, Sp-6 and auricular Shen-Men bilateral electrostimulation for 40 minutes. The analgesic effect of acupuncture was equivalent to that of 30 mg pentazocine, yet the most important effect of acupuncture consisted in a net increase of vital capacity during the period of acupuncture analgesia that lasted for 3-4 hr after stimulation; contrariwise, pentazocine did not cause any vital capacity increment and vital capacity remained at the levels observed prior to narcotic administration.

Fatal air embolism after subclavian vein catheterization. Case report.

The authors describe a case of fatal air embolism in a patient with an endovenous catheter introduced into the subclavian vein through a supraclavicular way. The opening of pleura caused by the needle during the thrusting of the needle caused a subcutaneous supraclavicular and laterocervical emphysema during ventilation with intermittent positive pressure (IPPV). The authors suggest that IPPV, in the postoperative period following kidney removal, was the main ancillary reason of the air embolism since opening of pleura, in a patient who breathes spontaneously, only induces pneumothorax according to the majority of the authors.

Sciatic nerve block by the anterior and posterior approach for operations on the lower extremity. A comparative study.

The results of the analgesic block of the lower extremity by means of an anterior (150 patients) or a posterior (114 patients) approach to the sciatic nerve, associated to a "3 in 1 block" were compared. The anterior approach technique was associated with a higher incidence of failures, insufficient analgesia and hence a higher demand for intraoperative analgesic and sedative drugs. Also tolerance to a pneumatic tourniquet over the proximal thigh was less than with the posterior approach. However, the sciatic nerve block by anterior approach granted a more prolonged analgesia. This technique was suitable for trauma patients immobilized in the supine position, for patients with skeletal traction on Zupinger frame, both for surgery and for closed reduction of lower extremity fractures.

Pancuronium bromide precurarisation. II An evaluation of clinical aspects in patients of female sex.

The authors have studied the effects of precurarisation by means of pancuronium on 120 female patients by using three multiple doses of pancuronium bromide. The authors have demonstrated that the dose of pancuronium, capable of abolishing almost completely fasciculations and postoperative succinylcholine myalgias, corresponds to 0.009 mg/kg. This dose has proved to be most efficient in causing a considerable increase in subjective precurarisation symptoms (Heavy eye-lids, blurred vision etc.). Such symptoms have never caused even the least discomfort to the patients. The authors have finally demonstrated that the doses of pancuronium employed cause a decrease in V.C. within limits that do not, however, compromise ventilation.

Influence of acupuncture on the postoperative complications following ketamine anesthesia. The importance of manual stimulation of point R and shen menn.

The Authors have investigated the antihallucinogenic and sedative effects of auricular points R and shen menn during surgery under ketamine anesthesia. The results demonstrate that the insertion of the needle in point R is very efficient in reducing hallucinations of ketamine emergence, while the insertion of needle in auricular point shen menn causes only a brief period of sedation in the beginning of the emergence period. The acupunctural technique employed by the Authors has been shown to increase considerably approbation of ketamine anesthesia.

[Double-blind analysis of the possibilities of the use of trazodone in sedation of ambulatory dental patients]. / Analisi in doppio cieco delle possibilità di impiego del trazodone nella sedazione del paziente odontoiatrico ambulatoriale.

The sedative properties of trazodone were the object of a double blind study in dental out-patients, comparison being made with diazepam. It was observed that oral trazodone possesses considerable tranquillizing activity. It has no side-effects either after intake or during return home. The use of capsules containing 50 mg of trazodone is recommended. At this dose, sympathetic hyperactivity is also inhibited. Diazepam doses of 15 mg lead to mental sedation and inhibition of symptoms due to sympathetic hyperactivity but, unlike trazodone, diazepam possesses hypnotic acitivity and side-effects that make its use dangerous in patients who cannot be taken home by somebody else, or who have to drive a car.

Combined sedation with oral chlordemethyldiazepam and midazolam by nasal route in third molar surgery.

AIM: This study was performed to evaluate the effects on the cardiocirculatory system, on perioperative anxiety and compliance of sedation with 2 benzodiazepines, chlordemethyldiazepam (CDDZ) a long acting oral drug for presedation and midazolam, a short acting drug, administered by nasal route to induce intraoperative sedation. METHODS: Fifty randomized patients undergoing third molar extraction at the Dental Clinic, University of Padua, were preoperatively evaluated. Anxiety was evaluated through a visual, analogue, scale (VAS) of 10 cm, a questionnaire of adjectives called interval scale of anxiety response (ISAR) and the Newman test was applied to evaluate the changes in psychomotor functions. All patients were treated with 1 ml of oral CDDZ for presedation and midazolam by the nasal route for intraoperative sedation at doses of 1 mg in Group 1 (25 patients) and 2 mg in Group 2 (25 patients). In all patients preoperative cardiocirculatory parameters were evaluated and in the first 20 min after the beginning of intervention. At the end of intervention the Newman test was reapplied, anxiety and postoperative cardiocirculatory data were reevaluated and the quality of the intervention judged in an interview made 1 week after the intervention (quality of the sedation technique, perioperative pain intensity, assumption of analgesic drugs, swelling, amnesia etc. after intervention). RESULTS: The treatment with 1 mg CDDZ + 2 mg midazolam by nasal route is the best association to slightly attenuate intra- and postoperative cardiocirculatory response, anxiety and to improve the quality of the treatment without interfering on the psychomotor response of patients at the time of the discharge. CONCLUSION: To conclude, the sedative technique employed is easily applied by the dentist, and is safe, efficacious and well tolerated by patients.

[Devices for the reduction of N2O pollution during conscious sedation in dentistry]. / Dispositivi per la riduzione dell'inquinamento da N2O durante la sedazione cosciente in odontoiatria.

We considered data of environmental monitoring during three working days in a dentist's office who habitually employs nitrous oxide (N2O): conscious sedation is used to alleviate anxiety and to diminish or eliminate dental pain. Three different nose masks were tested to determine influence on environmental pollution by N2O. The study shows that the levels of N2O always remains low with the use of proper dental procedures, although the chose of the type of nose mask can further diminish air pollution and the exposure of dental personnel.

[Cardiocirculatory responses to tracheal intubation in the heart patient]. / Réactions cardio-circulatoires à l'intubation trachéale chez le cardiaque.

Laryngo-tracheal nebulization with 10% lidocaine was performed in 10 patients undergoing cardiosurgery for substitution of mitral valve, five min. before induction of anesthesia with 0.007 mg . kg-1 of Fentanyl. Hemodynamic studies of these cases were compared to similar observations without nebulization. It appears tha laryngotracheal lidocaine nebulization reduces circulatory disturbances and attenuates the adrenosympathetic response to intubation.

[Anesthesia and nanism. Apropos of 2 cases]. / Anesthésie et nanisme. A propos de deux observations.

The authors describe the favourable outcome of general anaesthesias in a female patient with achondroplastic dwarfism and in another patient with dystrophic dwarfism. In the first patient the gall-bladder was removed and a plastic reconstruction of the diaphragm was carried out. In the second patient a Girdlestone's operation was performed. The difficulty of intubation of the dystrophic dwarf due to stiffness of the cervical spine suggested a procedure of intubation under fibroscopy. The doses of agents and the size of the tracheal tubes were calculated on the basis of the patients weight and the controlled ventilation was carried out after determining the current volume and the respiratory frequency in the awaken patient.