Assessing the Efficacy of Buffered Versus Nonbuffered Lidocaine in Dental Extractions: A Double-Blinded Randomized Controlled Trial.

BACKGROUND: Injections using buffered lidocaine may decrease discomfort, have a quicker onset, and be a more efficacious local anesthetic. Previous studies have been inconclusive in the oral context. PURPOSE: To address if bicarbonate buffered 2% lidocaine can decrease pain from the use of local anesthesia, has a quicker onset time, and is more efficacious. STUDY DESIGN: The design was a single-center double-blinded randomized control trial, set in an outpatient oral and maxillofacial clinic housed in the University of Cincinnati Medical Center. Inclusion criteria for the study were patients requiring a single tooth extraction due either to caries or periodontal disease. PREDICTOR VARIABLE: The predictor variable was the local anesthetic used either nonbuffered 2% lidocaine with 1:100,000 epinephrine (control) or bicarbonate buffered 2% lidocaine with 1:100,000 epinephrine (study) was randomly assigned. MAIN OUTCOME VARIABLES: Primary outcome variables were injection pain score, and postoperative pain, time to anesthetic onset, and the number of rounds of injections required to achieve adequate anesthesia. COVARIATES: The covariates were jaw involved, age, sex, and race, American Society of Anesthesiologists score, body mass index, current tobacco use, history of psychiatric illness, chronic pain, and preoperative pain score. ANALYSES: Test statistics were calculated using Wilcoxon rank-sum test, Kruskal-Wallis test, Spearman rank correlation test, χ2 test for bivariate analyses, and Fisher's exact test. P values ≤ .05 were considered statistically significant. RESULTS: The final sample was 114 subjects. The mean age of the sample was 42.97 years, standard deviation ±13.43 years. The sample was 39.47% male. The racial demographics were Caucasian (62.28%) and African American (33.33%). Buffered lidocaine did not have a statistically significant relationship with any of the outcomes. The jaw involved had a statistically significant association to the injection pain score (P value = .006), and the number of rounds of anesthetic required (P value = .047). Age showed a statistically significant association to injection pain score (P value = .032), and the number of rounds of anesthetic required (P value = .027). Finally, preoperative pain had a statistically significant relationship with injection pain score (P value = < .001). CONCLUSION AND RELEVANCE: In this study, bicarbonate buffered lidocaine did not exhibit any discernible advantages over nonbuffered lidocaine for any study outcomes.

Immunophenotypic and Gene Expression Analyses of the Inflammatory Microenvironment in High-Grade Oral Epithelial Dysplasia and Oral Lichen Planus.

BACKGROUND: Oral lichen planus (OLP) and oral epithelial dysplasia (OED) present diagnostic challenges due to clinical and histologic overlap. This study explores the immune microenvironment in OED, hypothesizing that immune signatures could aid in diagnostic differentiation and predict malignant transformation. METHODS: Tissue samples from OED and OLP cases were analyzed using immunofluorescence/immunohistochemistry (IF/IHC) for CD4, CD8, CD163/STAT1, and PD-1/PDL-1 expression. RNA-sequencing was performed on the samples, and data was subjected to CIBERSORTx analysis for immune cell composition. Gene Ontology analysis on the immune differentially expressed genes was also conducted. RESULTS: In OED, CD8 + T-cells infiltrated dysplastic epithelium, correlating with dysplasia severity. CD4 + lymphocytes increased in the basal layer. STAT1/CD163 + macrophages correlated with CD4 + intraepithelial distribution. PD-1/PDL-1 expression varied. IF/IHC analysis revealed differential immune cell composition between OED and OLP. RNA-sequencing identified upregulated genes associated with cytotoxic response and immunosurveillance in OED. Downregulated genes were linked to signaling, immune cell recruitment, and tumor suppression. CONCLUSIONS: The immune microenvironment distinguishes OED and OLP, suggesting diagnostic potential. Upregulated genes indicate cytotoxic immune response in OED. Downregulation of TRADD, CX3CL1, and ILI24 implies dysregulation in TNFR1 signaling, immune recruitment, and tumor suppression. This study contributes to the foundation for understanding immune interactions in OED and OLP, offering insights into future objective diagnostic avenues.

Necessity of antibiotics in the management of surgically treated mandibular osteomyelitis: A systematic review.

OBJECTIVES: Mandibular osteomyelitis remains an incompletely understood entity, and treatment of its various presentations remains diverse. The purpose of this study was to review the necessity of antibiotic therapy after surgical treatment of mandibular osteomyelitis. STUDY DESIGN: A systematic review of published articles on surgical management of mandibular osteomyelitis with or without postoperative antibiotic therapy was performed to answer the question, "Does the use of postoperative antibiotics compared with surgery alone alter the success rate in treating mandibular osteomyelitis?" The most recent evidence was sought by searching PubMed, Embase, and Scopus databases. Article appraisal was performed by 2 reviewers. RESULTS: Forty-five articles were found that met the inclusion criteria, with all studies being retrospective cohort or case series designs. Only 13 articles used Zurich classification designations of acute osteomyelitis, secondary chronic osteomyelitis, or primary chronic osteomyelitis, and the general heterogeneity of these articles made comparison difficult. No study made an intentional statistical assessment of various antibiotic protocols. CONCLUSIONS: Limited evidence suggested that resection may have better success rates than other forms of surgical intervention, regardless of antibiotic therapy. This systematic review questions the perceived necessity of intermediate- or long-term antibiotic therapy in the management of mandibular osteomyelitis after surgical resection.

What Happens to Full Mouth Extraction Patients? A Retrospective Review of Patient Mortality at an Academic Medical Center.

PURPOSE: When providers are forced to address the growing oral healthcare needs of an aging and sick population, full mouth extractions (FMEs) are often sought as a solution. The purpose of this observational study was to evaluate mortality rates, mortality timeline, and to identify associated risk factors. METHODS: A single-center retrospective cohort study was conducted at the University of Cincinnati Medical Center. All patients who underwent FMEs at the Oral and Maxillofacial Surgery clinic from July 1, 2012 to December 31, 2019 due to caries or periodontal disease were included. Predictor variables recorded included a medical history, social history, and patient demographics. The main outcome variable was post-FME death, including the elapsed time from procedure to death. Deaths were identified using the National Death Index. Data were analyzed using simple descriptive statistics and Cox proportional hazard models. Deceased FME patients were compared to living FME patients to identify potential risk factors. Mortality risk index was derived from multivariable logistic regression. RESULTS: One thousand eight hundred twenty nine patients were included in the study. Nine hundred seventy six were female with a median age of 49 years (interquartile range 38-58). One thousand seven hundred nine were diagnosed with more than 1 comorbidity and 89% were on medicaid or medicare insurance. One hundred seventy patients (9.3%) were identified as deceased as of December 31, 2019. Of those who died, 87 patients were deceased within 2 years of the procedure and 147 within 5 years of the procedure. Statistically significant factors associated with mortality (P value < .01) included age (hazards ratio [HR] 1.01, 95% confidence interval [CI] 1.01-1.03), ASA score >3 (HR 3.12, 95% CI 2.2-4.42), nursing home residence (HR 2.66, 95% 1.67-4.28), hepatic disease (HR 1.81, 95% CI 1.18-2.78), and oncologic disease (HR 1.91, 95% 1.32-2.77). CONCLUSIONS: Approximately 1 in 10 patients died within 5 years of FME at our center. These patients may be medically and socially compromised. More research is needed to develop FME-specific mortality indices, which may serve useful for clinical decision-making and surgical palliative care.

Buffered 1% Lidocaine With Epinephrine Can Be as Effective as Nonbuffered 2% Lidocaine With Epinephrine for Maxillary Field Block.

PURPOSE: Buffering local anesthetics with epinephrine (Epi) offers clinicians options not often considered. This study assessed outcomes for pulpal anesthesia, pain on injection, and time to midface numbness for buffered 1% lidocaine with 1:100,000 Epi versus nonbuffered 2% lidocaine with 1:100,000 Epi. MATERIALS AND METHODS: In this trial with a randomized, crossover design, buffered 1% lidocaine was compared with nonbuffered 2% lidocaine. Subjects were adult volunteers who served as their own controls. The predictor variables were alternate drug formulations. The outcome variables were subjects' responses to cold and electric pulp testing (EPT) stimulation of the maxillary first molar and canine, pain levels during the injection, and time to midface numbness. After maxillary field blocks with 40 mg of buffered lidocaine or 80 mg of nonbuffered lidocaine, subjects reported pain on injection and responses of the maxillary first molar and canine after cold and EPT stimulation. Teeth were tested before field block and at 30-minute intervals until a positive response was detected. Two weeks later, subjects were tested with the alternate drug combinations. For all outcome variables, assessment of treatment difference, calculated as 1% buffered minus 2% nonbuffered, was performed with the Wilcoxon rank sum test with significance at P < .05. RESULTS: More of the 24 subjects were women and Caucasian. The median age was 23.5 years (interquartile range, 21, 25 years), and the median body weight was 155 lb (interquartile range, 128.5, 176.5 lb). Pain levels during the injection were significantly lower for 1% buffered lidocaine, with P = .04. Times to response after injection were not significantly different between the 2 drug formulations for the cold test on a molar, with P = .08, or the cold test on a canine, with P = .22. However, times to response were significantly longer for nonbuffered drugs for EPT on the molar and canine, both with P = .01. CONCLUSIONS: Buffering 1% lidocaine with 1:100,000 Epi reduces the pain on injection with a maxillary field block and results in similar lengths of pulpal anesthesia tested with a cold stimulus as compared with nonbuffered 2% lidocaine with 1:100,000 Epi.

Buffered Versus Non-Buffered Lidocaine With Epinephrine for Mandibular Nerve Block: Clinical Outcomes.

PURPOSE: Outcomes for peak blood levels were assessed for buffered 2% lidocaine with 1:100,000 epinephrine compared with non-buffered 2% lidocaine with 1:100,000 epinephrine. PATIENTS AND METHODS: In this institutional review board-approved prospective, randomized, double-blinded, crossover trial, the clinical impact of buffered 2% lidocaine with 1:100,000 epinephrine (Anutra Medical, Research Triangle Park, Cary, NC) was compared with the non-buffered drug. Venous blood samples for lidocaine were obtained 30 minutes after a mandibular nerve block with 80 mg of the buffered or unbuffered drug. Two weeks later, the same subjects were tested with the alternate drug combinations. Subjects also reported on pain on injection with a 10-point Likert-type scale and time to lower lip numbness. The explanatory variable was the drug formulation. Outcome variables were subjects' peak blood lidocaine levels, subjective responses to pain on injection, and time to lower lip numbness. Serum lidocaine levels were analyzed with liquid chromatography-mass spectrometry. Statistical analyses were performed using Proc TTEST (SAS 9.3; SAS Institute, Cary, NC), with the crossover option for a 2-period crossover design, to analyze the normally distributed outcome for pain. For non-normally distributed outcomes of blood lidocaine levels and time to lower lip numbness, an assessment of treatment difference was performed using Wilcoxon rank-sum tests with Proc NPAR1WAY (SAS 9.3). Statistical significance was set at a P value less than .05 for all outcomes. RESULTS: Forty-eight percent of subjects were women, half were Caucasian, 22% were African American, and 13% were Asian. Median age was 21 years (interquartile range [IQR], 20-22 yr), and median body weight was 147 lb (IQR, 130-170 lb). Median blood levels (44 blood samples) at 30 minutes were 1.19 µg/L per kilogram of body weight. Mean blood level differences of lidocaine for each patient were significantly lower after nerve block with the buffered drug compared with the non-buffered agent (P < .01). Mean score for pain on injection for nerve block (n = 46 scores) was 3.3 (standard deviation, 0.9). Seventy-eight percent of subjects reported lower or the same pain scores with the buffered drug; 61% of subjects reported a shorter time to lower lip numbness with the buffered drug. CONCLUSIONS: Buffering 2% lidocaine with epinephrine can produce clinical outcomes favorable for subjects and clinicians without clinically detrimental peak blood lidocaine levels.

Intraoperative seizure and cerebrospinal fluid leak during adult cochlear implant surgery.

OBJECTIVE AND IMPORTANCE: To report a rare case of cerebrospinal fluid gusher and subsequent seizure immediately after cochlear implant electrode insertion. CLINICAL PRESENTATION: After the cochlear implant electrode was inserted, brisk flow of 10 mL of cerebrospinal fluid was seen. The electrode was promptly inserted and the leak was additionally sealed with fascia. Seconds later, the patient had a tonic-clonic seizure lasting 30 seconds. Two additional episodes occurred during the case. Her postoperative course was uneventful with no subsequent seizures. The device has been successfully activated. Intervention & Technique: Postoperative imaging showed correct intracochlear placement of the electrode as well as an incidental enlarged vestibular aqueduct. Neurology consultation including electroencephalogram was unremarkable. CONCLUSION: To our knowledge, this is the first report of a seizure temporally associated with cochlear implant electrode insertion. The significance and possible casual relationship between these two events is discussed.

Special Contribution: Third Molar Clinical Trials Annotated Bibliography.

PURPOSE: To provide clinicians with an annotated bibliography of published articles from research funded externally by the Oral and Maxillofacial Surgery Foundation, spanning 1996 to 2015, addressing the topic of third molar management. MATERIALS AND METHODS: A brief summary for each article was generated by the respective authors. RESULTS: The complete annotated bibliography generated by the authors is included in the Appendix. CONCLUSION: The annotated bibliography provides clinicians and other interested individuals with a summary of current literature emanating from clinical studies on third molar topics.

Essentials of Airway Management, Oxygenation, and Ventilation: Basic Equipment and Devices.

Offices and outpatient dental facilities must be properly equipped with devices for airway management, oxygenation, and ventilation. Optimizing patient safety using crisis resource management involves the entire dental office team being familiar with airway rescue equipment. Basic equipment for oxygenation, ventilation, and airway management is mandated in the majority of U.S. dental offices, per state regulations. The immediate availability of this equipment is especially important during the administration of sedation and anesthesia, as well as the treatment of medical urgencies/emergencies. This article reviews basic equipment and devices essential in any dental practice, whether providing local anesthesia alone or in combination with procedural sedation.

Airway Assessment for Office Sedation/Anesthesia.

Whenever a patient is about to receive sedation or general anesthesia, no matter what the technique, the preoperative assessment of the airway is one of the most important steps in ensuring patient safety and positive outcomes. This article, Part III in the series on airway management, is directed at the ambulatory office practice and focuses on predicting the success of advanced airway rescue techniques.

A novel index of hypoxemia for assessment of risk during procedural sedation.

BACKGROUND: Procedural sedation is essential for many procedures. Sedation has an excellent safety profile; however, it is not without risks. Assessment of risk using clinical outcomes in clinical studies is difficult due to their rare occurrence. Therefore, surrogate end points are frequently used in a clinical study in lieu of clinical outcomes. As a clinician integrates multiple aspects of a physiological variable to determine potential risk, a surrogate end point should consider a similar approach. In this study, we identified and tested the appropriateness of a new surrogate end point that may be used in clinical studies, area under the curve of oxygen desaturation (AUCDesat). A review of patient sedation records by anesthesiologists was conducted to assess its relationship to the anesthesia professional perception of risk. METHODS: This study was a post hoc analysis and assessment of perceived risk by anesthesiologists. It consisted of 13 U.S.-trained board-certified anesthesiologists ranking physiological variables as indicators of risk and then reviewing 204 records from 3 completed sedation studies involving the SEDASYS System. After review, each anesthesiologist assigned a Likert score based on his or her perception of risk for oversedation-related sequelae in each record. These scores were analyzed to determine their relationship to desaturation presence/absence, duration, depth, number of events, and AUCDesat that incorporates each component. RESULTS: Anesthesiologists ranked arterial oxygenation to be the most important factor in assessing risk post hoc (mean rank of 4.69 of 5, P = 0.0007 compared with next highest ranked factor-respiratory rate, N = 13). AUCDesat was better correlated to the Likert scores (rs = 0.85) when compared with the individual elements of AUCDesat, binary assessment of desaturation (rs = 0.73), desaturation depth (rs = -0.70), desaturation duration (rs = 0.70), and incidence of desaturations (rs = 0.55) (all 4 comparisons versus rs = 0.85, P < 0.0001). CONCLUSIONS: Anesthesiologists determined arterial oxygenation to be the most important physiological variable in assessing sedation risk and the potential for adverse clinical outcomes. AUCDesat, a composite index that incorporates duration, incidence, and depth of oxygen desaturation, was better correlated to the Likert scores. AUCDesat, given that it is a single numerical variable, is an ideal end point for assessment of risk of adverse clinical outcomes in clinical sedation studies. Future studies using AUCDesat and actual physiological outcomes may be useful in further defining this end point.

Essentials of airway management, oxygenation, and ventilation: part 1: basic equipment and devices.

Offices and outpatient dental facilities must be properly equipped with devices for airway management, oxygenation, and ventilation. Optimizing patient safety using crisis resource management (CRM) involves the entire dental office team being familiar with airway rescue equipment. Basic equipment for oxygenation, ventilation, and airway management is mandated in the majority of US dental offices per state regulations. The immediate availability of this equipment is especially important during the administration of sedation and anesthesia as well as the treatment of medical urgencies/emergencies. This article reviews basic equipment and devices essential in any dental practice whether providing local anesthesia alone or in combination with procedural sedation. Part 2 of this series will address advanced airway devices, including supraglottic airways and armamentarium for tracheal intubation and invasive airway procedures.

Adult airway evaluation in oral surgery.

Patients with a history of difficult intubation or with conditions associated with difficult airway should be approached with organized primary and secondary plans for airway management. When these potential problems are detected, patient safety may be improved with use of advanced airway management techniques and equipment. Additionally, patient referral for consultation and/or management at facilities where advanced airway management practitioners and equipment are available may be beneficial in some cases.

Management of allergy and anaphylaxis during oral surgery.

Minor and major allergic reactions occur during oral and maxillofacial treatment. Immediate diagnosis and pharmacologic intervention are imperative. Signs and symptoms may be variable. The early administration of epinephrine is critical.