Evidence-based clinical practice guideline for the pharmacologic management of acute dental pain in adolescents, adults, and older adults: A report from the American Dental Association Science and Research Institute, the University of Pittsburgh, and the University of Pennsylvania.

BACKGROUND: A panel convened by the American Dental Association Science and Research Institute, the University of Pittsburgh, and the University of Pennsylvania conducted systematic reviews and meta-analyses and formulated evidence-based recommendations for the pharmacologic management of acute dental pain after simple and surgical tooth extraction(s) and for the temporary management (ie, definitive dental treatment not immediately available) of toothache associated with pulp and periapical diseases in adolescents, adults, and older adults. TYPES OF STUDIES REVIEWED: The panel conducted 4 systematic reviews to determine the effect of opioid and nonopioid analgesics, local anesthetics, corticosteroids, and topical anesthetics on acute dental pain. The panel used the Grading of Recommendations, Assessment, Development and Evaluation approach to assess the certainty of the evidence and the Grading of Recommendations, Assessment, Development and Evaluation Evidence-to-Decision Framework to formulate recommendations. RESULTS: The panel formulated recommendations and good practice statements using the best available evidence. There is a beneficial net balance favoring the use of nonopioid medications compared with opioid medications. In particular, nonsteroidal anti-inflammatory drugs alone or in combination with acetaminophen likely provide superior pain relief with a more favorable safety profile than opioids. CONCLUSIONS AND PRACTICAL IMPLICATIONS: Nonopioid medications are first-line therapy for managing acute dental pain after tooth extraction(s) and the temporary management of toothache. The use of opioids should be reserved for clinical situations when the first-line therapy is insufficient to reduce pain or there is contraindication of nonsteroidal anti-inflammatory drugs. Clinicians should avoid the routine use of just-in-case prescribing of opioids and should exert extreme caution when prescribing opioids to adolescents and young adults.

Evidence-based clinical practice guideline for the pharmacologic management of acute dental pain in children: A report from the American Dental Association Science and Research Institute, the University of Pittsburgh School of Dental Medicine, and the Center for Integrative Global Oral Health at the University of Pennsylvania.

BACKGROUND: A guideline panel convened by the American Dental Association Council on Scientific Affairs, American Dental Association Science and Research Institute, University of Pittsburgh School of Dental Medicine, and Center for Integrative Global Oral Health at the University of Pennsylvania conducted a systematic review and meta-analyses and formulated evidence-based recommendations for the pharmacologic management of acute dental pain after 1 or more simple and surgical tooth extractions and the temporary management of toothache (that is, when definitive dental treatment not immediately available) associated with pulp and furcation or periapical diseases in children (< 12 years). TYPES OF STUDIES REVIEWED: The authors conducted a systematic review to determine the effect of analgesics and corticosteroids in managing acute dental pain. They used the Grading of Recommendations Assessment, Development and Evaluation approach to assess the certainty of the evidence and the Grading of Recommendations Assessment, Development and Evaluation Evidence to Decision framework to formulate recommendations. RESULTS: The panel formulated 7 recommendations and 5 good practice statements across conditions. There is a small beneficial net balance favoring the use of nonsteroidal anti-inflammatory drugs alone or in combination with acetaminophen compared with not providing analgesic therapy. There is no available evidence regarding the effect of corticosteroids on acute pain after surgical tooth extractions in children. CONCLUSIONS AND PRACTICAL IMPLICATIONS: Nonopioid medications, specifically nonsteroidal anti-inflammatory drugs like ibuprofen and naproxen alone or in combination with acetaminophen, are recommended for managing acute dental pain after 1 or more tooth extractions (that is, simple and surgical) and the temporary management of toothache in children (conditional recommendation, very low certainty). According to the US Food and Drug Administration, the use of codeine and tramadol in children for managing acute pain is contraindicated.

ACE-Inhibitor or ARB-Induced Refractory Hypotension Treated With Vasopressin in Patients Undergoing General Anesthesia for Dentistry: Two Case Reports.

Two case reports present the use of vasopressin for treating refractory hypotension associated with continued angiotensin-converting enzyme inhibitor (ACEI) or angiotensin receptor blocker (ARB) therapy prior to general anesthesia for oral surgery. Both patients were treated in an ambulatory dental surgery clinic and took either their ACEI or ARB medication for hypertension within 24 hours prior to undergoing an intubated general anesthetic. Persistent profound hypotension was encountered intraoperatively that was refractory to treatment with traditional methods. However, the ACEI- or ARB-induced refractory hypotension was successfully managed with the administration of vasopressin.

The Oral and Maxillofacial Surgery Anesthesia Team Model.

Oral and maxillofacial surgeons have been providing safe anesthesia to their patients using the anesthesia team model; this has allowed access to care for patients that have significant anxiety. The AAOMS strives to maintain the excellent safety record of the anesthesia team model by creating simulation programs in anesthesia, regularly updating the office anesthesia evaluation program, convening anesthesia safety conferences and strengthening the standards in our training programs. Through these efforts, our delivery of anesthesia to our patients will remain safe and effective.

Can the season of birth risk factor for schizophrenia be prevented by bright light treatment for the second trimester mother around the winter solstice?

The season of birth risk factor for schizophrenia exerts a pervasive effect on the global population, particularly at northerly latitudes. The winter infection hypothesis and the low vitamin D hypothesis are both compelling but lack conclusive clinical data. The present work develops a maternal-fetal chronobiological hypothesis for this season of birth risk factor and its prevention by maternal bright light treatment. Around the winter solstice, due to decreased sunlight, the chronobiological apparatus of the at-risk second trimester mother is characterized by a reduced amplitude circadian pacemaker, and a reduced maximum of her nocturnal plasma melatonin concentrations (MTmax) and an increased minimum of her nocturnal core body temperatures (Tmin)--both of which exert adverse effects on the fetal hippocampus and dorsal striatum. The consequences for the fetus include reduced volume and increased excitability of the hippocampus, ventral striatal dysfunction, increased presynaptic nigrostriatal dopamine transmission, and increased propensity for pathological nigrostriatal neuronal phasic firing. Thus, the maternal-fetal chronobiological hypothesis fully accounts for the fetal precursors of the major pathognomonic abnormalities in adults with schizophrenia. Bright light treatment for the second trimester mother around the winter solstice, by increasing maternal circadian amplitude, could possibly prevent the fetal hippocampal and striatal abnormalities and eliminate the season of birth risk factor for schizophrenia.

Season of birth in schizophrenia: a maternal-fetal chronobiological hypothesis.

Being born in the winter and spring significantly increases one's risk for developing schizophrenia. This birth seasonality may account for as many as 10% of all cases of schizophrenia. Maternal third trimester infections or vitamin D deficiencies are hypothesized to be the most likely cause and can account for many of the important features of schizophrenia, although each hypothesis has limitations. Alternatively, around the winter solstice, reduced maternal sunlight exposure during the second trimester of pregnancy may result in a reduced amplitude maternal circadian pacemaker, reduced maternal nocturnal plasma melatonin concentrations, elevated maternal nocturnal core body and incubator temperatures, and elevated fetal core body and brain temperatures. Indeed, studies in humans have shown that the core body temperatures of human fetuses near birth may vary by >2.5°C. Reduced melatonin concentrations and elevated temperatures have been shown to have detrimental effects on immature hippocampal neurons in animals. In addition, plasma melatonin concentrations and core body temperatures are critical determinants of the dopaminergic programming of the striatal component of the human central thermostat, which appears to be functioning by the second trimester of gestation and responsive to whatever chronobiological signals its mother correctly or incorrectly transduces from the prevailing meteorological conditions. Both hippocampal and striatal thermostat dysfunction may result in reduced striatal extracellular dopamine concentrations and a tendency towards increased phasic dopamine release-the characteristic biochemical lesion in schizophrenia. Thus, the maternal-fetal chronobiological dysfunction hypothesis could account for the birth seasonality in schizophrenia and warrants further investigation.

A biochemical assay for acetylcholinesterase activity in PC12 cells.

This lab describes two biochemical assays: One for measuring acetylcholinesterase activity and one for measuring protein concentration. Students learn how to manipulate small-volume samples, use a standard spectrophotometer or a microplate reader spectrophotometer, construct a standard curve, and normalize data. The lab is intended to be used in conjunction with a cell culture lab in which PC12 cells are exposed to various agents that influence their phenotypic state.

Teaching resources. The Sherlock Holmes lab: investigations in neurophysiology.

This Teaching Resource describes a research project that can be used in an advanced undergraduate course in neurobiology that covers basic electrophysiology and synaptic transmission. A thought experiment is provided that can be used to assess student understanding of (i) the scientific method, (ii) the process whereby nerve stimulation leads to muscle contraction, and (iii) the use of pharmacological agents to analyze a physiological system.

Regulation of central dopamine-2 receptor sensitivity by a proportional control thermostat in humans.

Central dopamine-2 (D2) receptors are importantly involved in the pathogenesis and treatment of schizophrenia. Central D2 receptors are also involved in thermoregulation. Recently, a type of central nervous system proportional control thermostat was described that governs the magnitude of several serotonin receptor-mediated core body thermoregulatory responses in proportion to both the amount of nocturnal melatonin secreted and the minimum level of nocturnal core body temperature (Tmin). The present study investigated whether the magnitude of D2 receptor-mediated hypothermia--a putative index of central D2 receptor sensitivity--is also regulated by this proportional control thermostat in humans. Twenty healthy subjects had their 02:00 h melatonin concentrations (MT2am) and Tmin measured during consecutive sleep episodes and their core body temperature responses (TAUC) measured the next two mornings after oral ingestion of either the D2 receptor agonist bromocriptine 3.125 mg or placebo. We found that the bromocriptine-induced TAUC was significantly and independently correlated with both Tmin and MT2am. In conclusion, D2 receptor-mediated hypothermia, an index of central D2 receptor sensitivity, is regulated by a proportional control thermostat in humans. The abnormal D2 receptor function in schizophrenia could be related to dysfunction of this thermostat.