Cardiovascular considerations for the dental practitioner. 2. Management of cardiac emergencies.

Medical emergencies are not uncommon in dental practices. Syncope has commonly been found to account for the majority of these emergencies in a dental setting, but some studies have reported cardiovascular events as the most common type of emergency. It is critical that every dentist be prepared with the knowledge and equipment necessary to respond in emergency situations. This article aims to provide dentists with essential knowledge about management of cardiovascular emergencies.

Oral adverse events associated with targeted cancer therapies.

Over the past decade, targeted therapies have emerged as promising forms of cancer treatment and are increasingly included in chemotherapeutic regimens for an ever-growing list of human cancers. Targeted therapies are so-named due to their specific targeting of dysregulated signaling pathways in cancer cells. This enhanced discrimination between tumor and normal cells is a more promising and efficacious approach to cancer treatment than conventional cytotoxic chemotherapy. However, targeted therapies still have side effects, and some manifest in the oral cavity. Oral adverse events tend to be mild and thus may be overlooked in the context of a patient's overarching diagnosis and management. These oral lesions are often noted during an intraoral examination and identified in the context of the patient's medical history and medication list. It is imperative that the dentist be informed of the oral sequelae of targeted therapies. Many of these side effects can be successfully managed in a palliative manner with conservative therapy. This article discusses the clinical presentations and treatment of intraoral adverse events attributable to the following classes of targeted therapies: epidermal growth factor receptor inhibitors, mammalian target of rapamycin inhibitors, angiogenesis inhibitors, and selected tyrosine kinase inhibitors.

Cardiovascular considerations for the dental practitioner. 1. Review of cardiac anatomy and preoperative evaluation.

Cardiovascular disease is the most prevalent chronic medical condition in patients treated in a dental setting. Therefore, dental practitioners must have a sound understanding of cardiovascular anatomy and physiology. Dentists also should be equipped to perform an effective preoperative cardiovascular examination and determine when medical consultation is necessary in higher risk patients. This article provides an overview of cardiovascular anatomy and physiology and discusses evaluation of cardiac risk factors with the aim of enabling dentists to effectively assess patients for potential cardiovascular events, thereby avoiding cardiovascular emergencies in the dental setting.

Intraoperative Fluids and Fluid Management for Ambulatory Dental Sedation and General Anesthesia.

Intravenous fluids are administered in virtually every parenteral sedation and general anesthetic. The purpose of this article is to review the physiology of body-water distribution and fluid dynamics at the vascular endothelium, evaluation of fluid status, calculation of fluid requirements, and the clinical rationale for the use of various crystalloid and colloid solutions. In the setting of elective dental outpatient procedures with minor blood loss, isotonic balanced crystalloid solutions are the fluids of choice. Colloids, on the other hand, have no use in outpatient sedation or general anesthesia for dental or minor oral surgery procedures but may have several desirable properties in long and invasive maxillofacial surgical procedures where advanced hemodynamic monitoring may assess the adequacy of intravascular volume.

Local anesthetic calculations: avoiding trouble with pediatric patients.

Local anesthetic systemic toxicity (LAST) is a rare but avoidable consequence of local anesthetic overdose. This article will review the mechanism of action of local anesthetic toxicity and the signs and symptoms of LAST. Due to physiologic and anatomic differences between children and adults, LAST occurs more frequently in children; particularly when 3% mepivacaine is administered. The calculation of the maximum recommended dose based on mg/lb body weight, Clark's rule, and the Rule of 25 in order to prevent LAST will also be reviewed, as well as the appropriate treatment procedures for a local anesthetic overdose.

Three newly approved analgesics: an update.

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.

Severe intraoperative bronchospasm treated with a vibrating-mesh nebulizer.

Bronchospasm and status asthmaticus are two of the most dreaded complications that a pediatric anesthesiologist may face. With the occurrence of severe bronchospasm and the inability to ventilate, children are particularly vulnerable to apnea and ensuing hypoxia because of their smaller airway size, smaller lung functional residual capacity, and higher oxygen consumption rates than adults. Nebulized medication delivery in intubated children is also more difficult because of smaller endotracheal tube internal diameters. This case demonstrates the potentially lifesaving use of a vibrating-mesh membrane nebulizer connected to the anesthesia circuit for treating bronchospasm.