Pharmacotherapy in Temporomandibular Disorders: A Review.

Temporomandibular disorder (TMD) is a collective term that includes disorders of the temporomandibular joint (TMJ) and of the masticatory muscles and their associated structures. TMDs are characterized by pain, joint sounds and restricted mandibular movement, and drugs are widely used in the management of that pain. Pharmacological agents commonly used for the treatment of TMDs include non-steroidal anti-inflammatory drugs (NSAIDs), opioids, corticosteroids, muscle relaxants, antidepressants, anticonvulsants and benzodiazepines. In this paper, we discuss these agents and the potential adverse drug reactions and interactions associated with their use. Temporomandibular disorder (TMD) is a collective term used for a number of clinical problems that involve the masticatory muscle complex, the temporomandibular joint (TMJ) and associated structures. TMD is one of the most common disorders in the maxillofacial region. Signs and symptoms of TMD may include pain, impaired jaw function, malocclusion, deviation from the midline on opening or closing the jaw, limited range of motion, joint noises and locking.1 Among other signs and symptoms, headaches and sleep disturbances can appear concomitantly.2 This disorder is most prevalent in people aged 20-40 years.3 Approximately 33% of the population have at least 1 TMD symptom, and 3.6-7.0% of the population have TMD with sufficient severity to seek treatment.3 There is some evidence to suggest that anxiety, stress and other emotional disturbances exacerbate TMD.4 As many as 75% of patients with TMD have a significant psychological abnormality.5 Most TMD symptoms resolve over time, but, for a significant number of patients, this may take a year or more.3 Treatment is directed toward reducing pain and improving function. Many non-invasive therapies, such as self-care, physical therapy and appliance therapy, are commonly used for the treatment of TMD.3 Pharmacological intervention has been used for many years, and the most effective pharmacological agents for the treatment of TMD include analgesics, non-steroidal anti-inflammatory drugs (NSAIDs), opioids, corticosteroids, anxiolytics, muscle relaxants, antidepressants, anticonvulsants and benzodiazepines. However, we found only 1 relevant Cochrane study, which included 11 randomized controlled trials of pharmacotherapy for TMD.6 In this article, we review the pharmacology and research supporting the use of a host of pharmacologic agents that have been prescribed for patients who have TMD. The decision to select any of these agents depends on a full understanding of the drug's risks and benefits.

Ontario Dentists' Estimation of Patient Interest in Anesthesia.

Objective: To investigate Ontario dentists' perceptions of patient interest in sedation and general anesthesia (GA) during treatment and patient fear and avoidance of dental treatment. Methods: Using the Royal College of Dental Surgeons of Ontario roster, we randomly selected 3001 practising Ontario dentists, from among those who listed an email address, to complete a 16-question survey by mail or online. Demographic information (e.g., gender, size and type of primary practice, and years of experience) was collected as well as dentist reports of patient interest in sedation/GA and level of fear regarding treatment. Analysis included sample t-tests to compare Ontario dentist responses with patient responses to a 2002 national survey. Results: 1076 dentists participated (37.9% response rate), comprised of 69.7% males, 84.4% general practitioners, 0.5­42 years of practice (mean 20.6 years), and 40.6% from cities with a population larger than 500,000. Dentists underestimated patients' interest in sedation/GA, with dentists and patients reporting patients "Not interested" as 66.8% and 43.9%, respectively, and "Interested depending on cost," 19.8% v. 42.3%. Dentists also underestimated patient interest in sedation/GA for specific dental procedures including scaling, fillings/crowns, root canal therapy and periodontal surgery (p < 0.01). Dentists overestimated patient fear levels ("Somewhat afraid," 19.9% v. 9.8%; "Very afraid," 10.6% v. 2.0%; "Terrified," 6.0% v. 3.5%) and the proportion of patients avoiding dental care (13.3% v. 7.6%). Conclusion: Dentists underestimate patients' preference for sedation/GA and overestimate their fear and avoidance of dental care. The significant disparities between the views of dentists and patients may affect the availability and provision of sedation and general anesthesia in Ontario dental practices.

PHARMACOTHERAPY FOR THE ELDERLY DENTAL PATIENT.

Current demographic data clearly show that the North American population is aging, and projections suggest that the percentage of older people will increase. The elderly often suffer from multiple chronic conditions that affect their quality of life, use of health services, morbidity and mortality. Also, in those of advanced age, the pharmacokinetics and pharmacodynamics of many drugs are altered. Polypharmacy increases the incidence of adverse drug reactions and drug interactions in this population. Thus, the dentist must be continually aware of the pharmacologic status of each patient and consider the likelihood of interactions between drugs prescribed by the dentist, drugs prescribed by the physician and drugs that are self-administered, including over-the-counter medications and natural supplements. In this article, we discuss pharmacokinetic and pharmacodynamic changes in the elderly patient, polypharmacy and the changes in prescribing for our dental patients. Specific emphasis is placed on the drugs commonly prescribed by dentists: local anesthetics, analgesics and antibiotics.

Postoperative Pain in Children After Dentistry Under General Anesthesia.

The objective of this study was to determine the prevalence, severity, and duration of postoperative pain in children undergoing general anesthesia for dentistry. This prospective cross-sectional study included 33 American Society of Anesthesiology (ASA) Class I and II children 4-6 years old requiring multiple dental procedures, including at least 1 extraction, and/or pulpectomy, and/or pulpotomy of the primary dentition. Exclusion criteria were children who were developmentally delayed, cognitively impaired, born prematurely, taking psychotropic medications, or recorded baseline pain or analgesic use. The primary outcome of pain was measured by parents using the validated Faces Pain Scale-Revised (FPS-R) and Parents' Postoperative Pain Measure (PPPM) during the first 72 hours at home. The results showed that moderate-to-severe postoperative pain, defined as FPS-R ≥ 6, was reported in 48.5% of children. The prevalence of moderate-to-severe pain was 29.0% by FPS-R and 40.0% by PPPM at 2 hours after discharge. Pain subsided over 3 days. Postoperative pain scores increased significantly from baseline (P < .001, Wilcoxon matched pairs signed rank test). Moderately good correlation between the 2 pain measures existed 2 and 12 hours from discharge (Spearman rhos correlation coefficients of 0.604 and 0.603, P < .005). In conclusion, children do experience moderate-to-severe pain postoperatively. Although parents successfully used pain scales, they infrequently administered analgesics.

Survey of local anesthetic use by Ontario dentists.

OBJECTIVE: Local anesthetics are believed to be the most frequently used drugs in clinical dentistry, and although they are generally regarded as safe, some adverse reactions can be expected and do occur. The purpose of this study was to obtain, by means of a mail survey, information on the types and amounts of local anesthetics used by Ontario dentists during 2007. MATERIALS AND METHODS: A survey requesting data on the annual use of injectable local anesthetics was mailed to all 8,058 dentists licensed by the Royal College of Dental Surgeons of Ontario in 2007. RESULTS: The effective response rate to the single mailing was 17.3% (1,395 respondents). By extrapolation, the estimated use of local anesthetics by all Ontario dentists during 2007 was determined to be about 13 million cartridges, which represents an average of 1,613 cartridges per dentist per year. Lidocaine with epinephrine 1:100,000 was the most commonly used formulation with 37.31% of total anesthetic use, followed by articaine with 1:200,000 epinephrine (27.04%) and articaine with 1:100,000 epinephrine (17.16%). Overall, local anesthetics combined with a vasoconstrictor accounted for more than 90% of total anesthetic use. A minority of survey respondents (15.68%) indicated that their pattern of anesthetic use had changed significantly in the past few years. Patterns of use were similar for early and late survey respondents. These data provide a current account of the use of local anesthetics by Ontario dentists.

Retrospective review of voluntary reports of nonsurgical paresthesia in dentistry.

OBJECTIVE: Paresthesia is an adverse event that may be associated with the administration of local anesthetics in dentistry. The purpose of this retrospective study was to analyze cases of paresthesia associated with local anesthetic injection that were voluntarily reported to Ontario"s Professional Liability Program (PLP) from 1999 to 2008 inclusive, to see if the findings were consistent with those from 1973 to 1998 from this same source. MATERIALS AND METHODS: All cases of nonsurgical paresthesia reported from 1999 to 2008 were reviewed; cases involving surgical procedures were excluded. Variables examined included patient age and gender, type and volume of local anesthetic, anatomic site of nerve injury, affected side and pain on injection or any other symptoms. RESULTS: During the study period, 182 PLP reports of paresthesia following nonsurgical procedures were made; all but 2 were associated with mandibular block injection. There was no significant gender predilection, but the lingual nerve was affected more than twice as frequently as the inferior alveolar nerve. During 2006-2008 alone, 64 cases of nonsurgical paresthesia were reported to PLP, a reported incidence of 1 in 609,000 injections. For the 2 local anesthetic drugs available in dental cartridges as 4% solutions, i.e., articaine and prilocaine, the frequencies of reporting of paresthesia were significantly greater than expected (chi2, exact binomial distribution; p < 0.01) based on their level of use by Ontario dentists. These data suggest that local anesthetic neurotoxicity may be at least partly involved in the development of postinjection paresthesia.

Effect of time on clinical efficacy of topical anesthesia.

The objective of this study was to determine the effect of time on the clinical efficacy of topical anesthetic in reducing pain from needle insertion alone as well as injection of anesthetic. This was a randomized, double-blind, placebo-controlled, split-mouth, clinical trial which enrolled 90 subjects, equally divided into 3 groups based upon time (2, 5, or 10 minutes) of topical anesthetic (5% lidocaine) application. Each group was further subdivided into 2: needle insertion only in the palate or needle insertion with deposition of anesthetic (0.5 mL 3% mepivacaine plain). Each subject received drug on one side and placebo on the other. Subjects recorded pain on a 100-mm visual analog scale (VAS). The results showed that for needle insertion only, 5% lidocaine reduced pain as determined by a significant difference in mean VAS after 2 minutes (20.1 mm, P < .002), 5 minutes (15.7 mm, P < .022), and 10 minutes (13.7 mm, P < .04), as analyzed by paired t tests. For needle insertion plus injection of local anesthetic, a significant difference in mean VAS was noted only after 10 minutes (14.9 mm, P < .031), yet pain scores for both topical anesthetic and placebo were elevated at this time point resulting in no reduction in actual pain. Time of application did not result in a significant difference in effect for either needle insertion only or needle insertion plus injection of local anesthetic, as analyzed by 1-way analysis of variance (ANOVA). In conclusion, topical anesthetic reduces pain of needle insertion if left on palatal mucosa for 2, 5, or 10 minutes, but has no clinical pain relief for anesthetic injection.

Mortality and Morbidity in Office-Based General Anesthesia for Dentistry in Ontario.

Our objective was to estimate the prevalence of mortality and serious morbidity for office-based deep sedation and general anesthesia (DS/GA) for dentistry in Ontario from 1996 to 2015. Data were collected retrospectively in 2 phases. Phase I involved the review of incidents, and phase II involved a survey of DS/GA providers. In phase I, cases involving serious injury or death for dentistry under DS/GA, sourced from the Office of the Chief Coroner of Ontario and from the Royal College of Dental Surgeons of Ontario (RCDSO), were reviewed. Phase II involved a survey of all RCDSO-registered providers of DS/GA in which they were asked to estimate the number of DS/GAs administered in 2015 and the number of years in practice since 1996. Clinician data were pooled to establish an overall number of DS/GAs administered in dental offices in Ontario from 1996 to 2015. Prevalence was calculated using phase I (numerator) and phase II (denominator) findings. The estimated prevalence of mortality in the 20-year period from 1996 to 2015 was 3 deaths in 3,742,068 cases, with an adjusted mortality rate of 0.8 deaths per 1 million cases. The estimated prevalence of serious morbidity was 1 injury in 3,742,068 cases, which adjusts to a serious morbidity rate of 0.25 per 1 million cases. The mortality rate found in this study was slightly lower than those published by earlier studies conducted in Ontario. The risk of serious morbidity was found to be low and similar to other studies investigating morbidity in office-based dental anesthesia.

Balancing efficacy and safety in the use of oral sedation in dental outpatients.

BACKGROUND: Concerns about the safety of pediatric oral sedation and the incremental use of triazolam in adults prompted a workshop cosponsored by several professional organizations. OVERVIEW: There is a strong need and demand for adult and pediatric sedation services. Using oral medication to achieve anxiolysis in adults appears to have a wide margin of safety. Mortality and serious morbidity, however, have been reported with oral conscious sedation, especially in young children. Most serious adverse events are related to potentially avoidable respiratory complications. CONCLUSIONS: Clinical trials are needed to evaluate oral sedative drugs and combinations, as well as to develop discharge criteria with objective quantifiable measures of home readiness. Courses devoted to airway management should be developed for dentists who provide conscious sedation services. State regulation of enteral administration of sedatives to achieve conscious sedation is needed to ensure safety. PRACTICE IMPLICATIONS: Safety in outpatient sedation is of paramount concern, with enteral administration of benzodiazepines appearing safe but poorly documented in the office setting. Conscious sedation by the enteral route, including incremental triazolam, necessitates careful patient evaluation, monitoring, documentation, facilities, equipment and personnel as described in American Dental Association and American Academy of Pediatric Dentistry guidelines.

Articaine and paresthesia: epidemiological studies.

Permanent paresthesia following a local anesthetic injection is a possible adverse event. Epidemiological studies have suggested that the 4% solutions used in dentistry, namely prilocaine and articaine, are more highly associated with this occurrence. This article reviews the epidemiological evidence regarding articaine and paresthesia.

Injection pain: comparison of three mandibular block techniques and modulation by nitrous oxide:oxygen.

BACKGROUND: The authors conducted this study to compare the pain on injection of the three mandibular block techniques and to determine the effect that the delivery of nitrous oxide:oxygen, or N2O:O2, had on this pain. METHODS: Based on sample size calculation, the authors randomly assigned 60 subjects to receive either local anesthetic alone or local anesthetic with N2O:O2 titrated to effect. Each subject received two mandibular block injections bilaterally from three possible pairings: Gow-Gates/standard block, standard block/Vazirani-Akinosi or Gow-Gates/ Vazirani-Akinosi. Subjects scored their pain using a 100-millimeter visual analog scale immediately after each injection. The authors analyzed data using analysis of variance, Student t tests and multiple regression analyses. RESULTS: There were no significant differences in pain on injection among the three injection techniques. The subjects in the group that received N2O:O2 and the local anesthetic demonstrated a statistically significant reduction in pain on injection compared with subjects in the group that received the local anesthetic only (P < .05). When N2O:O2 was used, there was a statistically significant decrease in pain with the first injection (P < .0005), an effect not seen with the second injection. CONCLUSIONS: There was no significant difference in pain among the three mandibular block techniques. N2O:O2 can reduce pain on the first injection given, but this effect is not seen subsequently. CLINICAL IMPLICATIONS: The decision to select one of the three mandibular block techniques should be based on factors other than pain on injection. N2O:O2 reduces pain on the first injection only.

Emergency drugs.

There is universal agreement that dentists require emergency drugs to be readily available. Opinions differ as to the specific drugs that should comprise an emergency kit. This article has provided one opinion. Oxygen, epinephrine, nitroglycerin, injectable diphenhydramine or chlorpheniramine, albuterol, and aspirin should be readily available in a dental office. Other drugs such as glucagon, atropine, ephedrine, hydrocortisone, morphine or nitrous oxide, naloxone, midazolam or lorazepam, and flumazenil should also be considered. There are differences in the level of training of dentists in the management of medical emergencies [25]. Therefore the final decision should be made by the individual dentist who is in the best position to determine the appropriateness of these agents for the particular practice. Despite the best efforts at prevention, emergencies may still arise. Plans to manage these events are needed and there is the possibility that the drugs discussed above may be required. Their presence may save a life.

An update on local anesthetics in dentistry.

Local anesthetics are the most commonly used drugs in dentistry. This article provides a brief update on the pharmacology, adverse effects and clinical applications of these drugs, as well as the role of vasoconstrictors.

An update on analgesics for the management of acute postoperative dental pain.

Acetaminophen, nonsteroidal anti-inflammatory drugs (NSAIDs) and opioids are available as analgesics in dentistry. They each have specific advantages, disadvantages, indications and contraindications. This article provides a brief review of their role in the management of acute postoperative pain.

Local anesthetic cartridges and latex allergy: a literature review.

PURPOSE: To assess the validity of recommendations to avoid using cartridges for dental local anesthetic in patients with latex allergies. METHODS: A MEDLINE search was conducted for the period 1966 to 2001, and relevant publications were reviewed for evidence of allergic reactions precipitated by latex in medication vials or cartridges for dental local anesthetic. RESULTS: Twelve publications met the selection criteria and are summarized here: 4 case reports, 5 experimental studies, 1 clinical update and 2 letters to the editor. CONCLUSION: The medical literature provides some evidence that latex allergen can be released into pharmaceutical solutions contained within vials, by either penetration through or direct contact with natural latex stoppers. However, there are no reports of studies or cases in which a documented allergy was due to the latex component of cartridges for dental local anesthetic.

Capsaicin-induced joint inflammation is not blocked by local anesthesia.

The purpose of this study was to evaluate the effect of local anesthetic blockade of afferent innervation on the development of capsaicin-induced edema in the rat temporomandibular joint (TMJ) region and on reflex jaw muscle activity. Under halothane anesthesia, 64 male Sprague-Dawley rats were prepared for monitoring of edema development by lateral movement of a needle overlying the left TMJ region and for acute recording of electromyographic activity in ipsilateral digastric and masseter muscles. A double-barrel catheter was inserted into the TMJ region for delivery of saline or 0.5% bupivacaine from 1 needle, followed with the injection of 1% capsaicin, 0.1% capsaicin, or vehicle control from the other needle 5 minutes later. Application of capsaicin into the saline pretreated TMJ region led to dose-dependent edema development and reflex jaw muscle activity; however, only 1% capsaicin solution resulted in significant tissue expansion and muscle activity when compared with the vehicle control. Pretreatment of the rat TMJ region with bupivacaine failed to inhibit capsaicin-induced edema development, although successful blockade of nerve conduction was confirmed with the absence of reflex jaw muscle activity. Capsaicin-induced edema of the rat TMJ region developed independent of axonal conduction, suggesting neurogenic inflammation may arise regardless of functional nerve conduction.

The effect of smoking on the bioavailability of metronidazole in plasma and saliva.

BACKGROUND: Cigarette smoking is considered to be a major risk factor for periodontal disease, and the antimicrobial agent metronidazole is commonly used for treatment of periodontitis. The authors evaluated the effect of cigarette smoking on the bioavailability of metronidazole in plasma and saliva. METHODS: Thirteen smokers and 13 nonsmokers received a single oral dose of 750 milligrams of metronidazole. Study personnel collected blood and saliva samples at baseline and at 0.5, 1, 1.5, 2, 4, 6, 8, 12, 24 and 48 hours after metronidazole administration. The authors quantified plasmatic and salivary metronidazole concentrations by means of high-performance liquid chromatography, and they determined the pharmacokinetic parameters and analyzed them statistically by using the Mann-Whitney test and nonpaired t test (α = 5 percent). RESULTS: The authors detected a significant reduction in plasmatic metronidazole concentrations in smokers at 1 hour, 1.5 hours and 2 hours compared with nonsmokers (P < .05). They also found a significant reduction in the maximum concentration in plasma in smokers as compared with that of nonsmokers (P < .05). The authors observed no statistically significant differences in the salivary concentration or pharmacokinetics between the two groups, however (P > .05). CONCLUSION: Cigarette smoking interfered with the bioavailability of metronidazole in plasma but not in saliva. Practice Implications. The clinical significance of these findings needs to be investigated further to verify the effectiveness of metronidazole in smokers.

Alternative mandibular nerve block techniques: a review of the Gow-Gates and Akinosi-Vazirani closed-mouth mandibular nerve block techniques.

BACKGROUND: and Overview. The limited success rate of the standard inferior alveolar nerve block (IANB) has led to the development of alternative approaches for providing mandibular anesthesia. Two techniques, the Gow-Gates mandibular nerve block and the Akinosi-Vazirani closed-mouth mandibular nerve block, are reliable alternatives to the traditional IANB. The Gow-Gates technique requires the patient's mouth to be open wide, and the dentist aims to administer local anesthetic just anterior to the neck of the condyle in proximity to the mandibular branch of the trigeminal nerve after its exit from the foramen ovale. The Akinosi-Vazirani technique requires the patient's mouth to be closed, and the dentist aims to fill the pterygomandibular space with local anesthetic. CONCLUSION: Both techniques are indicated for any type of dentistry performed in the mandibular arch, but they are particularly advantageous when the patient has a history of standard IANB failure owing to anatomical variability or accessory innervation. CLINICAL IMPLICATIONS: Having the skill to perform these alternative anesthetic techniques increases dentists' ability to provide successful local anesthesia consistently for all procedures in mandibular teeth.

Preparing dental office staff members for emergencies: developing a basic action plan.

BACKGROUND AND OVERVIEW: A medical emergency can occur in any dental office, and managing it successfully requires preparation. The dentist should develop a basic action plan that is understood by all staff members. The goal is to manage the patient's care until he or she recovers fully or until help arrives. The most important aspect of almost all medical emergencies in dentistry is to prevent or correct insufficient oxygenation of the brain or heart. The dentist or a staff member needs to position (P) the patient appropriately. He or she then needs to assess and, if needed, manage the airway (A), breathing (B) and circulation (C). The dentist and staff members then can consider 'D,' which stands for definitive treatment, differential diagnosis, drugs or defibrillation. A team approach should be used, with each staff member trained in basic life support and understanding the role expected of him or her ahead of time. Clear and effective communication is essential during any emergency. CONCLUSIONS: All staff members should understand the basic action plan so that they can put it into effect should any emergency arise in the dental office. CLINICAL IMPLICATIONS: Preparing staff members is integral to the successful management of a medical emergency in the dental office.