The State of UK Dental Anaesthesia: Results From The NAP5 Activity Survey. A national survey by the 5th National Audit Project of the Royal College of Anaesthetists and the Association of Anaesthetists of Great Britain and Ireland.

The National Health Service anaesthesia annual activity (2013) was recently reported by the Fifth National Audit Program of the Royal College of Anaesthetists and the Association of Anaesthetists of Great Britain and Ireland. Within a large dataset were 620 dental cases. Here, we describe this data subset. The estimated annual dental caseload was 111,600:60% were children (< 16 y), 38.5% adults (16 - 65y) and 1.5% the elderly (> 65y). Almost all were elective day procedures (97%) and ASA 1 or 2 patients (95%).The most senior anaesthetist present was a Consultant in 82% and a non-career grade doctor in 14%.Virtually all (98%) cases were conducted during GA. Propofol was used to induce anaesthesia in almost all adults compared with 60% of children. Propofol maintenance was used in 5% of both children and adults. Almost all adults received an opioid (including remifentanil) compared with only 40% of children. Thirty one per cent of children had a GA for a dental procedure without either opioid or LA supplementation. Approximately 50% of adults and 16% of children received a tracheal tube: 20% of children needed only anaesthesia by face mask. These data show that anaesthetists almost always use general anaesthesia for dental procedures and this exposes difficulties in training of anaesthetists in sedation techniques. Dentists, however, are well known to use sedation when operating alone and our report provides encouragement for a comprehensive survey of dental sedation and anaesthesia practice in both NHS and non-NHS hospitals and clinics in the UK.

Prospective study on dental extractions carried out for paediatric patients under general anaesthetic in a district general hospital.

BACKGROUND: The first line approach to managing healthy anxious children requiring dental extractions should include behavioural management and treatment under local anaesthetic. This can be coupled with conscious sedation. AIM: To evaluate alternative methods attempted prior to treatment under general anaesthesia (GA), to establish the incidence of repeat GA procedures. METHOD: Paediatric cases requiring dental extractions under GA were audited from October 2014 - December 2014 in the Oral and Maxillofacial Department, Great Western Hospital, Swindon. RESULTS: 78 paediatric cases requiring dental extractions were carried out during the study period. 91% of referrals came from local general dental practitioners (GDPs). The indication for the GA was included in 59% of the referral letters. The number of teeth extracted per case ranged from 1 - 14. In 18% of cases treatment under local anaesthetic had been attempted previously. Conscious sedation had not been attempted in any of the cases. There were 5 cases (6.4%) of repeat general anaesthetic procedures. CONCLUSION: Local guidance regarding appropriate paediatric referrals should be distributed to primary care referrers. Treatment under conscious sedation should be considered for paediatric cases and an improved referral pathway to the community dental service should be developed. Preventative advice should be reinforced to the referrer and to the patient.

[Relations between extraction of wisdom teeth and temporomandibular disorders: a case/control study]. / Relations entre les extractions de dents de sagesse et les dysfonctionnements de l'appareil manducateur : étude cas / témoins.

The aim of this study was to assess the impact of extraction of third molars on the occurrence of temporo-mandibular disorders (TMD). A review of the literature and a case-control study have been conducted. The case-control study compares the frequency of extraction of third molars between the sample with TMD (case) and the sample without TMD (control). The proportion of patients who had undergone extractions of wisdom teeth was higher in the case group than in the control group. The difference was statistically significant when patients had undergone extraction of all four wisdom teeth or when the extraction of four wisdom teeth underwent in one sitting or under general anesthesia. The study of patients in case sample shows that all signs of TMD were more common in patients who had undergone extractions in several sessions and under local anesthesia. The temporomandibular joint sounds are significantly more frequent with local anesthesia. In the case group, 85 to 92% of patients have parafunctions and 5 to 11% have malocclusion. This demonstrates the multifactorial etiology of temporomandibular disorders.

Analysis of dental care of children receiving comprehensive care under general anaesthesia at a teaching hospital in England.

OBJECTIVES: This study aimed to analyse the characteristics of comprehensive dental care provided under general anaesthesia (CDGA) and to review the additional treatment required by children over the 6 years subsequent to CDGA. METHOD: Information collected from hospital records for the 6-year period following the first CDGA included the types of dental treatment performed at CDGA, the return rates for follow-up appointments, further treatment required subsequent to CDGA and the types of dental treatment performed at repeat DGA. RESULTS: The study population consisted of 263 children, of whom 129 had a significant medical history, with mean age of 6.7 years. The results revealed that the waiting time for CDGA was significantly shorter in children who had a significant medical history, with 49% being admitted for CDGA within 3 months of pre-GA assessment, as compared to 29% of healthy children. 67% of children had follow-up care recorded, with a slightly higher proportion of children with significant medical history returning for follow-up [70% (90/129)] compared with 65% (87/134) of healthy children. Re-treatment rates were 34% (88/263), the majority of cases being treated under local analgesia (42/88). 34 of 263 children had repeat DGA (12.9%). Of these 71% (24/34) were children with significant medical history. The mean age at repeat DGA was 9 years. In 25 of 34 children (74%), repeat DGA was due to trauma, oral pathology, supernumerary removal, hypomineralized teeth or new caries of previously sound or un-erupted teeth at CDGA. The ratio of extraction over restoration (excluding fissure sealants) performed at repeat DGA was 2.8, compared with the ratio of 1.3 in the initial CDGA. CONCLUSIONS: There was a higher ratio of extraction over restorations at the repeat DGA. This suggests that the prescribed treatments at repeat DGA were more aggressive as compared to the initial CDGA in 1997. The majority of the treatment required at repeat DGA was to treat new disease.

Dental management of children with special healthcare needs.

INTRODUCTION: Dental caries is a common condition amongst young children that negatively impacts on their quality of life, It is an added burden on children with special healthcare needs (CSHCN) who have an increased risk of developing caries due to the high sugar contents in their medications, regular consumption of cariogenic foods and a poor salivary flow. AIMS AND OBJECTIVES: to analyse the management of dental caries in CSHCN at a tertiary public hospital in South Africa. METHODS: A retrospective analysis was conducted of the dental and medical records of 374 medically compromised children presenting with dental caries. Dental treatment and anaesthetic techniques used were reviewed. RESULTS: Results indicated that the majority of CSHCN presenting with caries were managed by extractions (96.5%) under either local anaesthesia (73.3%) or general anaesthesia (26.7%). There was a lack of restorative care provided to these compromised children, CONCLUSIONS: Treatment by extractions may relieve discomfort and pain; however, early loss of teeth leads to functional, psychological, aesthetic and orthodontic problems, which can result in a further decline in the quality of life of these already compromised patients, Restorative treatment and prevention strategies are critical in managing caries in CSHCN in order to improve their quality of life,

Estimating the need for dental sedation: evaluating the threshold of the IOSN tool in an adult population.

AIM: The aim of this study was, through a service evaluation, to assess the use of the IOSN tool in determining whether threshold values were appropriate for identification of IV sedation and general anaesthetic (GA) cases from a referral population. METHODS: A total of 105 patients were taken from a dental minor oral surgery referral service within a north west primary care trust over the course of six months. The IOSN tool was completed to assess: treatment complexity, medical and behavioural factors and patient anxiety levels. Each patient was then followed through to treatment. The type of sedation modality they received was compared to their IOSN score previously calculated and these results evaluated. RESULTS: The findings suggest that 94% of patients were treated within primary care by the MOS service, of which 58% received local anaesthetic (LA) alone and 42% were treated by LA with IV sedation. There was a general marked trend as the IOSN score increased so did the treatment modality from LA, through sedation to GA. Logistic regression using the components of the IOSN tool to predict sedation use indicated the IOSN predictors distinguished between those who required sedation and those who didn't (chi-square = 56.411, p <0.0001, df = 3) with treatment complexity (Exp B = 10.836, p <0.0001) and anxiety (Exp B = 4.319, p <0.0001) shown to be significant factors in determining sedation need. CONCLUSIONS: The data collected have shown that there is a positive relationship between the IOSN score and the type of treatment modality the patient received, suggesting that the threshold values are correctly set. It is concluded that IOSN tool is a useful means of aiding the clinician in both assessing and referring patients for that sedation need.

Anesthetic efficacy of 1.8 mL versus 3.6 mL of 4% articaine with 1:100,000 epinephrine as a primary buccal infiltration of the mandibular first molar.

INTRODUCTION: No study has compared 1.8 mL and 3.6 mL 4% articaine with 1:100,000 epinephrine in a mandibular buccal infiltration of the first molar. The authors conducted a prospective, randomized, single-blind, crossover study comparing the degree of pulpal anesthesia obtained with 1.8 mL and 3.6 mL 4% articaine with 1:100,000 epinephrine as a primary infiltration in the mandibular first molar. METHODS: Eighty-six asymptomatic adult subjects randomly received a primary mandibular buccal first molar infiltration of 1.8 mL or 3.6 mL 4% articaine with 1:100,000 epinephrine in two separate appointments. The authors used an electric pulp tester to test the first molar for anesthesia in 3-minute cycles for 90 minutes after the injections. RESULTS: Compared with the 1.8-mL volume of 4% articaine with 1:100,000 epinephrine, the 3.6-mL volume showed a statistically higher success rate (70% vs 50%). CONCLUSIONS: The anesthetic efficacy of 3.6 mL 4% articaine with 1:100,000 epinephrine is better than 1.8 mL of the same anesthetic solution in a primary mandibular buccal infiltration of the first molar. However, the success rate of 70% is not high enough to support its use as a primary injection technique in the mandibular first molar.

Dental hygienists' evaluation of local anesthesia education and administration in the United States.

PURPOSE: The goal of this project was to investigate the educational experiences and the use of local anesthesia by dental hygiene providers in the U.S. METHODS: Approved by the Institutional Review Board at the University of Pittsburgh and undertaken from February to May 2009, this study was designed using a questionnaire-based survey. Using a randomized list obtained via the American Dental Hygienists' Association (ADHA), the survey questionnaires were sent via mail to 1,200 dental hygienists in the U.S. Quantitative evaluations were confined to descriptive statistics including standard summation, an estimation of means and a valid percent for identified variables. RESULTS: A total of 432 (n=432) of the 1,200 survey questionnaires were returned, which represents a 36% response rate. The respondents represented a total of 296 dental hygiene educational programs, and included practice sites that span all 50 states. Findings indicate that the majority of responding dental hygienists perceive a need for the use of this pain control modality in their practice and administer local anesthetic injections. Additionally, the majority of respondents that administer local anesthetic injections reported that they perform local anesthetic administration for cases in which the dentist provides total care. Furthermore, the results revealed that the hygienists that received training in the administration of local anesthesia injections reported a higher rate of educational preparedness in 6 of the 7 educational topics listed in this survey: local anesthesia related topics (local anesthesia administration, local anesthetic pharmacology and local anesthetic complications), basic pharmacology, medical emergency management and special needs care. CONCLUSION: This examination parallels the results presented in previous studies, while offering new data relating to local anesthesia administration by dental hygienists. With the majority of dental hygienists reporting a perceived need and the use of this method of pain control, this practice appears to be a significant addition to overall dental care and dental hygiene education.

Repeat general anaesthesia, a 6-year follow up.

OBJECTIVE: To investigate the number of children who subsequently required further dental general anaesthesia (DGA) following the baseline DGA for exodontia in 1997 over the next 6 year period, and identify any common factors related to these repeat DGAs. DESIGN: A retrospective longitudinal analysis. MATERIALS AND METHODS: Records from a UK teaching hospital for patients who had extractions under DGA within the calendar year of 1997 were identified and analysed. The individual's demographic details, reasons for the baseline DGA, teeth extracted, number of subsequent DGAs, the reasons for repeat DGA and finally any episodes of pain and/or infection after 1997 were recorded. RESULTS: During 1997, a total of 484 children with mean age of 6.35 (ranged between 1 and 16 years) received a DGA for exodontias. The most common reason for the exodontias carried out at this baseline DGA was dental caries and mean number of exodontias was 4.24. Of the total study population 8.9% subsequently had at least one unplanned repeat DGA, with dental caries being a factor in 84% of the cases. Of the subsequently extracted teeth 71.9% were caries free or unerupted at the time of the initial DGA. Of the children who had a repeat DGA, 61% had experienced at least one episode of pain and/or infection subsequent to the first episode of DGA. The pattern of the child's attendance and the recorded experience of oral pain and infection after the baseline DGA in 1997 were variables proved to be strongly associated with the risk of having an unplanned repeat DGA, with the children who were irregular attenders having a four times increased risk. CONCLUSIONS: Two common factors were identified which might predict the potential for a child requiring a repeat DGA; irregular attendance and oral pain and infection.

Anesthesia morbidity and mortality experience among Massachusetts oral and maxillofacial surgeons.

PURPOSE: To document the incidence of specific complications and the mortality rate for office anesthesia administered by fully qualified oral and maxillofacial surgeons in the state of Massachusetts. MATERIALS AND METHODS: A survey questionnaire was mailed to the 169 active members of the Massachusetts Society of Oral and Maxillofacial Surgeons. Using a specific method for follow-up, a 100% response was obtained. RESULTS: The frequency of office anesthetic complications occurring in 2004 were consistent with our previous studies. There was 1 office death, for a mortality rate of 1/1,733,055. The incidence of other specific anesthetic-related complications is documented. CONCLUSION: From the data presented here, we conclude that outpatient anesthesia in the oral and maxillofacial surgery office continues to be a safe therapeutic modality.

A comparison of dental service use among commercially insured women in Minnesota before, during and after pregnancy.

BACKGROUND: The authors examined and compared dental services used by women before, during and after pregnancy. METHODS: In their study, the authors combined medical and dental claims data for 3,462 pregnant women in Minnesota with commercial dental insurance who had been pregnant between Jan. 1, 2004, and Dec. 31, 2005. The authors used McNemar pairwise comparisons, with each subject serving as her own control and her use of various dental services before pregnancy as her own baseline, to evaluate and compare the dental services used during and after pregnancy. RESULTS: During pregnancy, subjects' use of several dental services-radiographs, restorative services, third-molar extractions and anesthesia-decreased significantly (P < .001) in comparison with their prepregnancy use. After pregnancy, subjects' use of checkups, radiographs and restorative services showed significant increases (P < .001). CONCLUSIONS: The significant decreases in use of these services during pregnancy and significant increases after pregnancy may suggest that these women and their dentists were using these services only conservatively during pregnancy or postponing their use altogether until after delivery. CLINICAL IMPLICATIONS: This study's findings may provide useful background information to medical and dental providers, health care plan administrators and policymakers as they consider recommendations regarding oral health care for women during pregnancy.

The use of general anesthesia in pediatric dental care of children at multi-dental centers in Saudi Arabia.

OBJECTIVE: High caries reports in young Saudi children strongly suggest the need occasionally for general anesthesia to provide quality dental work. The purpose of this study was to investigate the characteristics of patients, dental procedures and hospital protocols for Pediatric Dental General Anesthesia (PDGA) procedure at multi-dental centers in Jeddah, Saudi Arabia. STUDY DESIGN: Study sample included 90 children attending PDGA treatment at three governmental hospitals in Jeddah. Collected data included patient's demographics, medical condition, admission type, intra-operative protocols, and dental procedures. RESULTS: Results showed the mean age of treated children was 5 +/- 2 years and the majority of them (93%) were treated for the first time under general anesthesia (GA). Long waiting duration for PDGA procedure was reported regardless of the patient age and medical status. Being very young with extensive caries was the major indication for GA (58%). Children mean preoperative fasting times were 10 +/- 2 hours. Hospitals were significantly different in some protocols for PDGA procedures. Child behavior during GA induction was significantly related to child's age, premedication use, and hospital admission type. The mean number of treated teeth per child was 14 +/- 3.8 and the treatment mostly included restorations. Age was found to significantly affect the type of dental treatment, while gender and medical status did not. CONCLUSIONS: PDGA procedure is used mostly for young children with extensive dental caries. Children treated under GA received a comprehensive dental care in Saudi hospitals. Efforts should be directed to improve some of the existing hospitals protocols with PDGA procedure. The long waiting period for PDGA operation indicated the need to improve available facilities in the three hospitals.

The use of compound topical anesthetics: a review.

BACKGROUND: The author reviewed the history of, federal regulations regarding, risks of and adverse drug reactions of five compound topical anesthetics: tetracaine, adrenaline/epinephrine and cocaine (TAC); lidocaine, adrenaline/epinephrine and tetracaine (LET); lidocaine, tetracaine and phenylephrine (TAC 20 percent Alternate); lidocaine, prilocaine and tetracaine (Profound); and lidocaine, prilocaine, tetracaine and phenylephrine with thickeners (Profound PET). TYPES OF STUDIES REVIEWED: The author reviewed clinical trials, case reports, descriptive articles, and U.S. Food and Drug Administration (FDA) regulations and recent public advisory warnings regarding the federal approval of and risks associated with the use of compound topical anesthetics. RESULTS: Compound topical anesthetics are neither FDA-regulated nor -unregulated. Some compounding pharmacies bypass the new FDA drug approval process, which is based on reliable scientific data and ensures that a marketed drug is safe, effective, properly manufactured and accurately labeled. Two deaths have been attributed to the lay use of compound topical anesthetics. In response, the FDA has announced the strengthening of its efforts against unapproved drug products. CLINICAL IMPLICATIONS: Compound topical anesthetics may be an effective alternative to local infiltration for some minimally invasive dental procedures; however, legitimate concerns exist in regard to their safety. Until they become federally regulated, compound topical anesthetics remain unapproved drug products whose benefits may not outweigh their risks for dental patients.

Use of local anesthesia in restorative treatment for adults in Finland.

OBJECTIVE: In this survey we investigated the frequency of use of local anesthesia (LA) in restorative treatment for vital teeth in adults in Finland. MATERIAL AND METHODS: A postal questionnaire was mailed to 592 dentists selected by systematic sampling from the membership list of the Finnish Dental Association; 57% responded. The questionnaire inquired "How often do you use local anesthesia when restoring vital teeth in adults?" for three types of primary restorations: class III for incisors, class II for premolars or molars, and class V on gingival margin for premolars or molars. Statistical evaluation included chi-square and logistic regression modeling. RESULTS: For restorative treatment of class III primary restoration for incisors, 21% of the dentists used LA always or almost always, 47% fairly often, 30% occasionally, and 2% rarely or never. For class II restoration for premolars or molars, 25% of dentists used LA always or almost always, 58% used LA fairly often, 16% occasionally, and 1% rarely or never. Controlling for gender and time elapsed since graduation, public dentists were more likely to use LA always or almost always for Class II (OR=2.0) and Class III (OR=1.8) restorations. No such difference appeared for Class V restorations. CONCLUSION: The majority of dentists have accepted LA as part of their everyday practice, with more widespread use among public dentists. Still, to prevent future dental fear among patients, dentists should emphasize pain-free treatment.

Palatal anaesthesia for the removal of maxillary third molars as practised by oral and maxillofacial surgeons in Australia and New Zealand.

BACKGROUND: Injections of local anaesthetic to the palate are well known to be poorly tolerated. The absolute requirement of a palatal injection for the removal of maxillary third molars has never been investigated. The aim of this study was to document the current practice of palatal anaesthesia for extraction of these teeth with local anaesthesia as practised by oral and maxillofacial surgeons. METHODS: A postal survey was sent via the ANZAOMS office to all oral and maxillofacial surgeons who were members of the Australian and New Zealand Association, a total of 131. A response rate of 64 per cent (n = 84) was achieved. The frequency of administration and the factors that determined the decision to administer a palatal injection were assessed, as well as the methods employed for reducing the injection discomfort. RESULTS: The majority (77 of the 84) "always" gave a palatal injection for the removal of maxillary third molars, four respondents administered an injection "most of the time", and two respondents "occasionally". Significantly, one respondent "never" gave a palatal injection. The majority (76 per cent) utilized at least one adjunct in order to reduce the discomfort of the injection. CONCLUSIONS: The results of this survey suggest that for removal of maxillary third molars the requirement of the poorly tolerated palatal injection may not be absolute as conventionally taught and demonstrates the need for further investigation.

The frequency of repeat general anaesthesia for teeth extractions in children.

AIM: The purpose of this study was to determine the frequency of repeat extractions under general anaesthesia (GA) in children. METHODS: The dental hospital records of patients attending for outpatient GA extractions at Liverpool University Dental Hospital, Liverpool, UK, between January and March 2003 were examined retrospectively. A data collection form was used to record the relevant information. RESULTS: A total of 278 patients with a mean age of 6.5 years (SD = 2.2 years) were seen for GA extractions. Of those, 33 patients (11.9%) with a mean age of 4.9 years (SD = 2 years) at the time of their initial GA had had a previous or would undergo a subsequent episode of GA extraction. The mean interval between repeat GA was 2.3 years (SD = 1.6 years). Fifteen cases (45.5%) had the repeat GA within 2 years. Radiographs were available as part of the assessment process for 84 (34.3%) of the 245 patients who had had a single episode of GA. However, of the 33 patients who had had a repeat GA, only seven (21.2%) had radiographs available at the time of the initial GA. Regarding the number of teeth extracted, a significant difference (P < 0.01) was found between the number of teeth extracted in patients who had had a single GA (mean = 4.6, SD = 2.5), compared with those extracted at the initial GA for the repeat GA group (mean = 3.2, SD = 2). CONCLUSION: The frequency of repeat GA is relatively low, but there is a need for appropriate treatment planning incorporating the use of radiographs to reduce this even further.

Effect of clinical guidelines on practice for extraction of lower third molars: study of referrals in 1997 and 2000.

We made a retrospective study of patient records for 3-month periods during 1997 and 2000 to assess changes in referral patterns and decision-making for extraction of lower third molars after publication of national guidelines. A total of 277 patients were referred to the department for extraction of lower third molars in 1997 and 234 in 2000 while overall referrals increased from 884 to 979. The number having extractions dropped from 243/277 (88%) to 190/234 (81%) of those referred (P=0.05) and of those operated on, bilateral removal dropped from 120/243 (49%) to 65/190 (34%) (P=0.002). The number of patients operated on under general anaesthesia reduced from 161/243 (66%) to 103/190 (54%) (P=0.01). However, women remained more likely to get treatment under general anaesthesia than men. In conclusion, there was a reduction in referrals for extraction of third molars, the proportion of referred patients having extractions, the number of bilateral operations, and changes in the choice of anaesthesia over the period of introduction of national guidelines on operations for third molars.

Restorative treatment and use of local anesthesia in free and subsidized public dental services in Helsinki, Finland.

Our aim was to evaluate restorative treatment and the use of local anesthetics in free and subsidized public dental care in Helsinki, Finland. Public dental clinics are open to all patients under the age of 36, and to some specific groups above that age. Patients up to age 19 receive all treatment free of charge and others at highly subsidized rates. Data were collected in May 2001 during a maximum 2-week period covering all public dental clinics in Helsinki. A one-page questionnaire was sent to all dentists (n = 140) in clinical fields. The data requested included the patient's gender and year of birth, and details on restorations: which tooth and which surfaces were filled, the reason for placement or replacement, the material used, and use of local anesthetic. The response rate was 96%. Of all restorations (n = 3057) placed, 14% were in primary teeth and in permanent teeth: 17% in premolars, 17% in incisors, and 52% in molars; the restorative material most often used was composite resin (69%). Glass-ionomer/compomers dominated in the primary teeth. Local anesthetic was used least (35%) in patients under 13 years of age. Replacements of restorations accounted for 10% of all in the free service (under 20 years of age) and 46% in subsidized dental care (20 and older). The major reasons for replacement were secondary caries (41%) and fractured or lost restoration (40%).