Techniques to administer oral,inhalational, and IV sedation in dentistry

Background

Sedation in dentistry is a controversial topic given the variety of opinions regarding its safe practice.

Aims

This article evaluates the various techniques used to administer sedation in dentistry and specific methods practiced to form a recommendation for clinicians.

Methods

An extensive literature search was performed using PubMed, Medline, Google Scholar, Google, and local library resources.

Results

Most of the literature revealed a consensus that light sedation on low-risk American Society of Anesthesiologists (ASA) groups, that is ASA I, and possibly II, is the safest method for sedation in a dental outpatient setting.

Conclusion

Formal training is essential to achieve the safe practice of sedation in dentistry or medicine. The appropriate setting for sedation should be determined as there is an increased risk outside the hospital setting. Patients should be adequately assessed and medication titrated appropriately, based on individual requirements.     

全科口腔医学的现状和发展

全科口腔医学是口腔医学领域中一种崭新的发展形式，其起源于全科医学，是全科医学在口腔医学领域的体现。在我国，虽然全科口腔医疗服务的概念存在已久，但直至2009年才明确提出全科口腔医疗的概念，对全科口腔医疗的范围、从业人员的要求等均进行了相应的规范，推动了综合医院口腔科、民营口腔诊所甚至全国范围内全科口腔医疗理念的应用。随着社会进步和口腔医学的发展，患者对全科口腔医疗的需求越来越旺盛，在日益重视以患者为导向的现代临床诊疗模式中，口腔多学科协作诊疗(oral multidisciplinary team，OMDT)应运而生。OMDT可以帮助患者全面综合评估疾病情况，专业化、规范化、个性化地为患者提供最佳综合治疗方案，依托于多学科团队的协作配合，将各专业的技术优势发挥到最佳，以恢复口颌系统功能乃至全身健康为主要目标，为患者提供全面系统的治疗，是我国未来全科口腔医学诊疗的重要开展模式。为了进一步探究全科口腔医学，本文就其历史、目前现状及未来发展进行相应的总结及合理的探讨，并提出目前全科口腔医学发展中存在的问题，从而提出科学合理的建议，促进更符合我国国情的全科口腔医学模式进一步壮大发展。      

笑气联合咪达唑仑在智障儿童口腔治疗中的应用研究

目的 在笑气镇静联合咪达唑仑口服镇静条件下对智障患儿实施口腔治疗,评估镇静的有效性及 安全性。方法 纳入91 例在口腔诊疗中不配合的智障患儿,随机分为笑气镇静组、咪达唑仑口服镇静组、联 合组。笑气镇静组：给予35% ～ 50% 浓度的笑气镇静;咪达唑仑口服镇静组：给予0.50 ～ 0.75 mg/kg 咪达 唑仑口服镇静;联合组：笑气镇静联合咪达唑仑口服镇静。记录治疗中患儿的心率、呼吸、血氧饱和度,以 及治疗内容和持续时间,患儿的治疗完成状况采用Houpt 量表评估,跟踪记录患儿24 h 内的反应。结果 联 合组的成功率（83.9%）高于笑气镇静组（53.3%）和咪达唑仑口服镇静组（56.7%）（P <0.05）。笑气镇静组 不良反应发生率为6.7%,联合组的不良反应发生率为6.5%,均低于咪达唑仑口服镇静组（33.3%）。结论 智 障儿童行口腔治疗时,笑气镇静联合咪达唑仑口服镇静是一种安全有效的镇静方法,其成功率高于单独使用 笑气镇静或咪达唑仑口服镇静,其不良反应发生率低于单独口服咪达唑仑镇静。     

Revision of loop colostomy under regional anaesthesia and sedation

Patients presenting for emergency abdominal procedures often have medical issues that cause both general anaesthesia and central neuraxial blockade to pose significant risks. Regional anaesthetic techniques are often used adjunctively for abdominal procedures under general anaesthesia, but there is limited published data on procedures done under peripheral nerve or plexus blocks. We herein report the case of a patient with recent pulmonary embolism and supraventricular tachycardia who required colostomy refashioning. Ultrasonography-guided regional anaesthesia was administered using a combination of ilioinguinal-iliohypogastric, rectus sheath and transversus abdominis plane blocks. This was supplemented with propofol and dexmedetomidine sedation as well as intermittent fentanyl and ketamine boluses to cover for visceral stimulation. We discuss the anatomical rationale for the choice of blocks and compare the anaesthetic conduct with similar cases that were previously reported.     

Concepts and techniques of conscious sedation.

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Sources and patterns of referrals of oral cancer: role of general practitioners

Referrals of patients with oral squamous cell carcinomas to an oral medicine clinic were assessed with regard to the sources, delays, and pattern of referrals from general medical practitioners and general dental practitioners. Slightly more patients were referred by dental practitioners than by medical practitioners, but general medical practitioners were far more likely to see advanced tumours and to request an urgent second opinion or suggest a diagnosis of malignant disease. The greatest delay overall was caused by the patients in seeking advice from their practitioner, particularly those who attended a general medical practitioner. Both groups of practitioners requested a hospital opinion within roughly a month--a reasonable interval. Subsequent delays were minimal. Delays occur mainly because the patients are slow in seeking professional advice and, in general, do not appear to have been reduced over the decade since a previous British study on referral patterns was carried out. This study emphasises the importance of educating patients about oral cancer since it is they who appear to be mainly responsible for the delays in diagnosis. The results also help to dispel the myth that general medical practitioners might be less competent at diagnosis and referral of patients with oral cancer than are dental practitioners, though we are aware of misdiagnoses from both groups.     

Assuring access to dental care for low-income families in North Carolina. The NC Institute of Medicine Task Force Study

Following publication of the Task Force's recommendations for improving dental care access among low-income populations, North Carolina has taken several steps forward. The Division of Medical Assistance and the NC Dental Society are forming an advisory committee (comprising Medicaid patients, providers, and representatives from all elements of organized dentistry in the state) to review dental coverage and reimbursement rates. Using existing state funds, the NC Office of Research, Demonstrations and Rural Health Development has recruited 15 additional dentists and 1 dental hygienist to practice in community facilities serving low-income and uninsured patients. In 1999, the NC General Assembly revised the NC Dental Practice Act. Now, under the general direction of a licensed public health dentist, specially trained public health dental hygienists can perform oral health screenings and preventive and educational services outside the public school setting. The NC Institute of Medicine has begun exploring how to use dental hygienists to expand preventive dental services to underserved populations in federally-funded community or migrant health centers, state-funded health clinics, and the not-for-profit clinics that serve predominantly Medicaid, low-income or uninsured populations. A report is to be sent to the Governor and the Joint Legislative Commission on Governmental Operations no later than May 1, 2000. In 1999, the General Assembly directed the NC State Board of Dental Examiners to establish a procedure for streamlined licensing of dentists and dental hygienists who have been practicing in other states. This should increase the number of qualified dental practitioners in the state. The proposed rules governing the new licensing pathway are to be prepared by May 15, 2000. The Board of Dental Examiners will determine which new procedures will be needed to allow less burdensome and more timely entry of qualified out-of-state licensed applicants, while still affording the public the same protection as under current law and procedures. The NC Institute of Medicine is organizing a work group to study the feasibility of new residency programs in pediatric dentistry in addition to the current program located in Chapel Hill. The Institute will present a report to the General Assembly, no later than May 1, 2000. On April 1, 1999, the state Medicaid program authorized use of ADA Procedure Code 1203, which allows reimbursement for the application of dental fluoride varnishes without a full prophylaxis. It also authorized pediatricians, nurse practitioners, or physician's assistants to apply these varnishes to the teeth of young children, allowing more rapid dissemination of this proven preventive procedure among the state's low-income children. Implementation began in Carolina Access II and III project sites in the fall, 1999, and should spread statewide in 2000. Furthermore, the General Assembly's 1999 session expanded NC Health Choice to cover dental sealants, fluoride treatment, simple extractions, stainless steel crowns, and pulpotomies. Since publication of the Task Force Report in May 1999, considerable forward movement has taken place. It was apparent that the problems associated with poor dental care were severe, of immediate concern, and needed a broad, nonpolitical analysis followed by action from public and private-sector policy makers and shapers. The key recommendation of the Task Force (to increase the level of payment to dentists for services provided to Medicaid beneficiaries) was not acted on in the 1999 session of the General Assembly, but it was seriously discussed in legislative hearings and will be considered further in the year 2000 legislative session. Given the number of problems surrounding adequate health care for North Carolina's low-income populations, inquiries such as that described here can point the way to the concrete and feasible steps that need to be taken. (ABSTRACT TRUNCATED)     

牙科畏惧症患儿清醒镇静下牙病治疗的效果观察

目的：观察牙科畏惧症患儿清醒镇静下进行牙病治疗的安全性及镇静效果.方法：选择儿童牙病科门诊60例患有牙科畏惧症的患儿,年龄3～10岁,采用静脉注射咪达唑仑和靶控输注舒芬太尼,使患儿处于清醒镇静下接受牙病治疗.记录HR、SpO2、RR、镇静和行为分级,治疗结束后随访不良反应及家属满意度.结果：60例患儿中,55例镇静效果满意,Ramsay分级为Ⅱ～Ⅲ级,Frankl评分和Houpt评分分别为（3.6±0.5）分与（4.6±1.2）分,顺利完成预期治疗;5例镇静效果不理想,改为深度镇静后完成治疗.所有患儿治疗中生命体征平稳,未见严重不良反应,95.0％的家属愿意患儿下次牙病治疗时选择清醒镇静.结论：儿童牙科畏惧症患儿在清醒镇静下进行牙病治疗,安全性高,镇静效果好,值得推广.     

加强口腔治疗整体设计意识实现口腔进修教学重点转移

口腔综合教学是我国口腔医学继续教育中非常重要的组成部分.加强口腔综合教学能够提高基层医院口腔医师的整体治疗水平,为我国口腔治疗的整体进步提供必要的基础.北京大学口腔医院综合科不断探索和创新继续教育项目,于2011年进行了进修教学模式和教学大纲的修订,改单专业教学模式为综合教学模式并应用于进修教学中.实践证明,口腔综合教学能够为进修医师提供更多的学习内容,更好地发挥继续教育项目的作用.     

笑气/氧气吸入镇静在儿童牙科畏惧症患者中的应用

目的 :探讨笑气镇静麻醉在儿童牙科畏惧症(DF)患者中的应用效果。方法:选择DF患儿231例,随机分为实验组(116例)和对照组(115例)。实验组在使用笑气/氧气吸入镇静技术下进行治疗,对照组按常规程序进行治疗。比较治疗前后DF发生率、CFSS-DS评分变化等。结果:术后实验组DF发生率为31.03%,对照组DF发生率为85.21%,两组差异有统计学意义(x2=69.601,P=0.000);实验组治疗后CFSS-DS评分明显下降(P<0.05)。结论:使用笑气/氧气吸入镇静技术,可缓解患儿的紧张、恐惧心理,降低DF发生率,对儿童心理的健康成长有良好的保护作用。     

静脉给药镇静技术在2 582例口腔外科门诊手术中的临床应用

目的:分析镇静给药镇静技术用于口腔外科门诊手术患者基本资料,了解其流行病学特点,评价该技术用于口腔外科手术的效果及安全性,并总结相关经验。方法:统计北京大学口腔医院口腔颌面外科2010年1月至2018年12月间行静脉镇静下口腔颌面外科手术患者的病例资料,对其性别、年龄、疾病种类、围手术期的生命体征监测数值、镇静、镇痛用药情况、手术和镇静时长、术中镇静效果及术后顺行性遗忘情况进行总结分析。结果:9年间进行静脉镇静下口腔外科手术共2 582人次,患者年龄段集中于3.5岁至10岁及21~40岁。疾病种类最多的为多生牙,占38%(981/2 582), 阻生智牙占30%(775/2 582),其他疾病共占32%。围手术期患者心率(heart rate,HR)、平均动脉压(mean arterial pressure,MAP)、呼吸频率(respiratory rate,RR)、脑电双频指数(bispectral index,BIS)的数值在患者入室、局部麻醉、手术切开、手术开始10 min及术毕的差异有统计学意义。单独使用咪达唑仑静脉镇静占69%(1 781/2 582);单独使用丙泊酚占7%(181/2 582);咪达唑仑联合丙泊酚复合镇静占24%(620/2 582)。使用的静脉麻醉性镇痛药物主要为芬太尼、氟比洛芬酯、酮咯酸氨丁三醇,分别占33%(852/2 582)、 23%(594/2 582)、 6%(157/2 582), 未使用静脉镇痛药患者占35%(907/2 582)。手术总时长平均(31.2±20.8) min,镇静给药总时长平均(38.4±19.2) min;术中总体镇静效果较好,Ramsay镇静评分多为2~4分;术后患者对局部麻醉注射、手术切开、牙钻声音的顺行性遗忘率分别为94%(2 431/2 582)、 92%(2 375/2 582)、 75%(1 452/1 936)。结论:静脉镇静下口腔颌面外科门诊手术治疗安全有效,提高了手术的舒适性,应进一步推广应用。     

先天性心脏病患儿术后镇静护理的实践调查

目的探讨儿童心脏外科重症监护室（CICU）护士在先天性心脏病（先心病）患儿术后机械通气期间的镇静护理实践现况,并了解与镇静实践相关的因素。方法采取横断面调查研究方法,通过方便抽样,对275名在上海、北京、武汉三地的6所儿童CICU工作的临床护士使用护士镇静实践量表（中文版）开展调查。结果接受调查的6所CICU中仅2所CICU（33.3%）使用镇静评估工具评估患儿镇静水平。217名护士中,59.4%-81.6%的护士认为患儿的行为状态（如有无咳嗽反应、躯体运动等）反映了不同的镇静深度。98.2%的护士认为镇静治疗是促进先心病患儿术后机械通气舒适感的重要方法。仅48.8%的护士愿意对所有机械通气的患儿使用镇静剂。62.1%-68.8%的护士认为身边护理同行的镇静药物知识和观点影响其镇静用药实践,并且87.1%的护士认为自身所提供的看法会影响医师镇静用药的决策。分别有62.9%、60.2%和50.7%的护士认为护患沟通障碍、护患比及工作量会影响他们是否对患儿使用镇静剂。镇静态度、主观规范和知觉行为控制与镇静意向及镇静实践行为间呈显著正相关（P〈0.01）。结论儿科CICU护士对先心病术后机械通气时期的患儿给予镇静治疗的态度积极。护士的镇静实践与多种因素有关,如护士对镇静的态度、身边同伴对镇静的看法和护士的人口学特征等。一些非患者因素,如临床工作量,可能影响护士的镇静实践行为。医护人员间对于镇静治疗的看法会相互影响各自的镇静用药决策。     

小波指数与丙泊酚镇静深度的相关性

目的 观察小波指数(WAV)、脑电双频指数(BIS)、频谱熵指数[反应熵(RE)和状态熵(SE)]与丙泊酚静脉麻醉时镇静深度的关系.方法 随机选择美国麻醉医师学会(ASA)分级Ⅰ～Ⅱ级拟在全身麻醉下行择期手术的患者22例,年龄18～65岁.丙泊酚靶控输注(TCI)起始血浆浓度为1μg/mL,以后每4 min增加1μg/mL,直至觉醒/镇静评分(OAA/S评分)为1分时停止给药.记录每一级OAA/S评分和复苏期间患者呼之睁眼及能握手时的心率(HR)、血压(BP)、WAV、BIS、RE和SE值.结果 WAV(r=0.945)、BIS(r=0.940)、RE(r=0.911)和SE(r=0.896)与OAA/S评分均呈正相关(P值均<0.05),WAV与OAA/s评分的r值与BIS、RE相似,但显著高于SE(P<0.05).WAV对患者意识消失有较好的预测性,其预知概率(Pk)值与BIS、RE和SE相近,分别为0.73、0.76、0.71、0.79.停止输注丙泊酚后,WAV降至最低值的时间较RE迟(14.3±8.4)s,但较BIS早(8.7±8.6)S.WAV对患者意识恢复亦有较好的预测性,其Pk值(0.77)与RE(0.76)和SE(0.74)相近,优于BIS(0.69).患者意识恢复时RE较BIS和WAV高,但均未恢复至基础值.结论 WAV、BIS和频谱熵指数均与丙泊酚麻醉中镇静深度呈正相关.WAV对单纯丙泊酚麻醉时意识消失和恢复均有良好的预测性,且可能优于BIS.     

Local infiltration and spermatic cord block for inguinal, scrotal and testicular surgery

This was a prospective study involving 372 male patients. Surgical procedures including simple inguinal hernia repair, inguinal lymph node biopsy, hydrocelectomy, testicular biopsy, testicular fixation, orchidectomy and scrotal exploration were performed under local anaesthesia using various quantities of 0.5% xylocaine with adrenaline depending on the procedure, in the form of spermatic cord block and local infiltration nerve blocks. No premedication was given to any patient and only five patients (1.34%) were given intraoperative sedation due to anxiety. No complication directly attributed to the anaesthetic agent used or the technique of spermatic cord and nerve blocks were reported during the study. Three hundred and sixty patients (96.77%) were operated on as outpatients and were happy and satisfied to return home on the same day. This experience confirms that spermatic cord block accompanied by local infiltration with 0.5% xylocaine with adrenaline is simple, safe and effective technique that should be used more widely in outpatient urological and general surgical settings in this locality. It provides excellent intra-scrotal and inguinal anaesthesia. Furthermore, the technique is cost effective, and personnel effective since no anaesthetist is required for the procedure which is usually carried out by the surgeon. This would enable many more people to afford the surgical procedures.     

激光取代高速手机在口腔科应用的SWOT分析调查研究

目的：了解激光在口腔科应用的优势、劣势、机会、威胁,探讨激光能否替代高速手机在口腔领域的应用及其发展前景。方法基于当前激光发展的最前沿资料,以相关群体为调查对象,运用SWOT分析法制作调查问卷。针对口腔科医生、口腔疾病患者及口腔医学专业在校学生三个人群进行调查,将搜集到的数据进行统计、整理、分析、研究。结果经SWOT分析,医生与患者认为激光能减少感染机会、保证术中良好止血为主要优势因素,而激光的临床应用存在盲目性和探索性为主要劣势因素,获得牙科恐惧患者支持为主要机会因素,治疗效果无法保证是主要威胁因素。结论激光可以安全、精确切割牙体硬组织,减少震动、噪音,并降低患者恐惧心理,但激光在具有显著优势的同时还可能带来热损伤和微裂纹会对粘接修复带来影响,且临床应用上尚存在盲目性和探索性,应用效果尚待进一步研究。与此同时,口腔医生应开拓思维,主动学习相关知识,了解激光发展动态。医生及患者应积极配合并尝试激光的临床应用与调查研究工作,推动激光技术的发展。并争取政府及相关单位的政策支持,让医患双方获益,使激光有望在口腔科得到广泛应用。     

Local anaesthesia for major general surgical procedures. A review of 116 cases over 12 years.

Between 1980 and 1992, 116 patients had either a simple mastectomy (32) or intra-abdominal procedures (84) under local anaesthesia (0.5-1% lignocaine with 1:200 000 adrenaline). A wide variety of general surgical procedures were feasible using only supplementary intravenous sedation (54%). Complications were uncommon and related to surgical procedure (three incorrect diagnoses, three procedures impossible) rather than the anaesthetic technique. There were no anaesthetic toxicity or postoperative problems. Local anaesthesia is extremely safe and facilitates larger surgical procedures than is generally appreciated.     

癌症晚期/生命有限患者的姑息性镇静治疗（一）

姑息性镇静治疗是姑息关怀整体的一部分.镇静治疗是一种常规的临床治疗方法,包含深度持续和浅度间隙镇静,即在生命末期有意降低意识水平,目的是缓解不能忍受的痛苦.预期患者将会濒死,降低生命末期的意识以缓解痛苦是恰当的.姑息性镇静治疗就是应对顽固性症状和由此而引起的无法忍受的痛苦;深度持续镇静应具有适应证和预期死亡将在1～2周的条件.     

激光在牙体疾病诊治中的研究进展

在医学领域内,激光技术已广泛应用于诊断、治疗及基础理论研究。龋病、牙本质过敏是口腔医学中的常见疾病,激光技术在此领域的应用,为该疾病的诊断和治疗提供了新的前景,同时在牙齿美容方面也有其他方法不可替代的治疗效果。随着科技的不断发展,激光技术会在牙体疾病中的应用更加广泛,治疗效果会更加明显,以便更好地服务于广大患者。     

Can bispectral index or auditory evoked potential index predict implicit memory during propofol-induced sedation?

Background Some patients still suffer from implicit memory of intraoperative events under adequate depth of anaesthesia. The elimination of implicit memory should be a necessary aim of clinical general anaesthesia. However, implicit memory cannot be tested during anaesthesia yet. We propose bispectral index （BIS） and auditory evoked potential index （AEPI）, as predictors of implicit memory during anaesthesia. Methods Thirty-six patients were equally divided into 3 groups according to the Observer＇s Assessment of Alertness/Sedation Score： A, level 3; B, level 2 ;and C, level 1. Every patient was given the first auditory stimulus before sedation. Then every patient received the second auditory stimulus after the target level of sedation had been reached. BIS and AEPI were monitored before and after the second auditory stimulus presentation. Four hours later, the inclusion test and exclusion test were performed on the ward using process dissociation procedure and the scores of implicit memory estimated. Results In groups A and B but not C, implicit memory estimates were statistically greater than zero （P〈0.05）. The implicit memory scores in group A did not differ significantly from those in group B （P〉0.05）. Implicit memory scores correlated with BIS and AEPI （P〈0.01）. The area under ROC curve is BIS〉 AEPI. The 95% cutoff points of BIS and AEPI for predicting implicit memory are 47 and 28, respectively. Conclusions Implicit memory does not disappear until the depth of sedation increases to level 1 of OAA/S score. Implicit memory scores correlate well with BIS and AEPI during sedation. BIS is a better index for predicting implicit memory than AEPI during propofol induced sedation.