Oxygen saturation during intravenous sedation using midazolam.

Intravenous sedation with midazolam was given to young, fit, adult patients undergoing third molar surgery; oxygen saturation (SpO2) was continuously measured during the surgery and for 30 minutes after the surgery. There were some instances of a brief fall in the oxygen saturation, during the surgery and in the immediate period following surgery. It is suggested that it may be necessary to observe and selectively monitor some patients in the immediate post-surgical period as well as during the period of operation. Although not addressed by this investigation, this would be particularly true of medically compromised patients and the elderly.     

Alterations in monitored vital constants induced by various local anesthetics in combination with different vasoconstrictors in the surgical removal of lower third molars.

The purpose of this study was to observe the hemodynamic changes during surgical extraction of lower third molars induced by three local anesthetics solutions associated with different vasoconstrictors. A double-blind observational and longitudinal study was made of 45 healthy adult volunteers subjected to surgical removal of an impacted lower third molar under local anesthesia. Three groups were established (n = 15) according to the anesthetic solution and associated vasoconstrictor administered (4% articaine + epinephrine 1:200,000; 3% mepivacaine without vasoconstrictor; and 3% prilocaine + felypressin 1:1,850,000). Heart rate, systolic and diastolic pressure, and oxygen saturation were recorded at different times before, during and at the end of surgery, along with the type and amount of anesthetic solution administered. The study variables were found to be more stable with articaine + epinephrine 1:200,000, although the three studied solutions caused no significant hemodynamic changes with respect to the basal values when administered in healthy patients subjected to surgical removal of a lower third molar.     

Effect of conscious sedation with midazolam on oxygen saturation

A randomized cross-over study was done to determine if significant oxygen desaturation occurs during third molar surgery under conscious sedation with midazolam to warrant supplementary oxygen. Thirty-two healthy patients of either sex, between the ages of 18 and 40 years, had bilateral symmetrically impacted lower third molar surgery under local anesthesia in two visits. Randomly at one visit the local anesthesia was supplemented with midazolam sedation. Continuous monitoring of oxygen saturation, blood pressure, and pulse were carried out. At the rate of injection with the dose of midazolam used, no significant desaturation attributable to midazolam sedation was observed. However, short periods of significant desaturation occurred with both procedures. These episodes, though of no consequence to healthy people, may produce problems in compromised patients, and indicate the importance of monitoring of oxygen saturation in all patients during minor oral surgery procedures.     

盐酸咪达唑仑镇静药在阻生智齿拔除术中应用的临床观察

目的观察马来酸咪达唑仑（midazolam HCl）静脉输注提高下颌阻生智齿拔除时患者舒适度的效果。方法50例双侧下颌阻生智齿拔除难度基本相同的患者，采用自身对照设计，一侧采用盐酸咪达唑仑低流量（平均流量0．042±0．010mg·kg^-1）静脉输入，另一侧空白对照。结果试验组焦虑视觉模拟量表（visual analogue scale，VAS）平均得分21．4±12．2mm，疼痛VAS平均得分（6．92±9．50）mm，与对照组（35．9±18．2）mm；（16．4±12．4mm）比较，差异有统计学意义（P=0．000；P=0．000）。结论在拔除阻生智齿时，对轻度恐惧的患者应用盐酸咪达唑仑镇静，可以显著提高患者的舒适度。     

微创拔除压迫下牙槽神经的第三磨牙方法分析

目的: 应用牵引拔牙、截冠和超声骨刀微创拔牙技术拔除压迫下牙槽神经的第三磨牙,观察术后产生下唇麻木等并发症的发生情况。方法: 选择60例全景片和锥形束CT（CBCT）显示下颌第三磨牙牙根压迫下牙槽神经的患者,分别采用3种方法拔牙各20例,术后检查下唇麻木情况。结果: 应用牵引拔牙技术和截冠方法拔除压迫下牙槽神经的第三磨牙,术后无人发生下唇麻木,而应用超声骨刀微创拔牙的患者中有1例出现轻微的下唇麻木症状,经用药1个月后好转。结论: 牵引拔牙技术、截冠和超声骨刀3种方法均可有效避免智牙拔除后下唇麻木的并发症。     

2种不同方法在下颌中位近中水平阻生智牙拔除术的疗效比较

目的:比较“T”形截断法与单纯锤凿劈冠法拔除下颌中位近中水平阻生智牙的疗效。方法:138例需要拔除单侧下颌中位近中水平阻生智牙的患者,随机分为A、B 2组,A组70例,B组68例。 A组采用“T”形截断法,B组采用传统锤凿冠劈法,去除阻力后拔除。对拔牙术中、术后并发症进行观察,采用SPSS13 .0软件包对数据进行统计学分析。结果:A 组术中、术后并发症显著少于B 组(P< 0.05 )。结论:“T”形截断法在下颌中位近中水平阻生智牙拔除术中创伤小、并发症少,值得临床推广。     

Inhaled methoxyflurane (Penthrox) sedation for third molar extraction: a comparison to nitrous oxide sedation

Background: The aim of this study was to evaluate the use of inhaled methoxyflurane (Penthrox^®) in the reduction of dental anxiety in patients undergoing mandibular third molar removal in a specialist surgical suite and compare it to the conventional nitrous oxide sedation. Methods: A prospective randomized, non‐blinded crossover design study of 20 patients receiving two types of sedation for their third molar extraction who participated in 40 treatment sessions. At first appointment, a patient was randomly assigned to receive either nitrous oxide sedation or intermittent Penthrox^® inhaler sedation, with the alternate regimen administered during the second appointment. Peri‐procedural vital signs (heart rate and blood pressure) were recorded and any deviations from 20% from the baseline values, as well as any drop in oxygen saturation below 92% were documented. The Ramsay Sedation Scale (RSS) score was recorded every five minutes. Patient cooperation during the procedure, patients’ general opinion about the sedation technique, surgeon satisfaction and the occurrence of side effects were all recorded. After the second procedure, the patient was also asked if he or she had any preference of one sedation technique over the other. Results: Levels of sedation were comparable in nitrous oxide and Penthrox^® sedation sessions. However, at 15 minutes of sedation it was significantly lighter (p < 0.05) in Penthrox^®. No patient in both regimens reached a RSS deeper than a score of 4. Parameters measured for assessment of sedation (patient cooperation, surgeon satisfaction and patient general opinion about sedation technique) were all similarly comparable for both nitrous oxide and Penthrox^®. In both sedation sessions, the odour of the inhalational agent was accepted by the patients; half of the patients (10 patients) who received methoxyflurane thought its odour was pleasant. Patients preferred methoxyflurane (Penthrox^®) inhalation over nitrous oxide sedation (Fisher’s Exact test, p < 0.05). Adverse events were minimal. No patient was either deeply sedated or agitated. Blood pressure was within ± 20% from the baseline values. No patient had oxygen saturation less than 92%. Dizziness was the most frequently encountered side effect in both regimens (four patients each). Two patients had bradycardia (HR < 60 beats/minute) when nitrous oxide was used in comparison to one patient with Penthrox^® sedation. Paraesthesia of fingers and heaviness of the chest was encountered only with nitrous oxide sedation (four patients). Mild self‐limited shivering occurred in one patient with Penthrox^® sedation. Conclusions: The Penthrox^® Inhaler can produce a comparable sedation to that of nitrous oxide for the surgical extraction of third molars under local anaesthesia.     

鼻腔喷雾右美托咪定在下颌第三磨牙拔除术中的应用

目的:探讨鼻腔喷雾右美托咪定在下颌第三磨牙拔除术中的临床应用价值。方法 :30例需拔除下颌第三磨牙的患者随机分为右美托咪定组(DEX组)和对照组(C组),每组15例。DEX组鼻腔喷雾1.5μg/kg右美托咪定,C组鼻腔喷雾生理盐水,30 min以后实施局部麻醉,拔出下颌第三磨牙。每10 min记录患者的收缩压(SBP)、心率(HR)、血氧饱和度(SpO2),评估患者的改良OAA/S评分,同时记录注射局麻药时的VAS评分。结果:DEX组的SBP和HR在鼻腔喷雾给药后的30⁶0 min出现一定程度下降,与C组比较,差异有统计学意义(P<0.05)。DEX组在给药后2060 min出现一定程度下降,与C组比较,差异有统计学意义(P<0.05)。DEX组在给药后20⁶0 min时出现镇静作用,差异有统计学意义(P<0.05)。注射局麻药时两组患者均感到轻微疼痛,差异无统计学意义(P>0.05)。结论:鼻腔喷雾右美托咪定1.5μg/kg,能够有效、安全且便捷地应用于健康成人下颌第三磨牙拔除术中的镇静,缓解患者的焦虑情绪。     

Efficacy and complications associated with a modified inferior alveolar nerve block technique. A randomized,triple-blind clinical trial

Objectives: To compare the efficacy and complication rates of two different techniques for inferior alveolar nerve blocks (IANB). Study Design: A randomized, triple-blind clinical trial comprising 109 patients who required lower third molar removal was performed. In the control group, all patients received an IANB using the conventional Halsted technique, whereas in the experimental group, a modified technique using a more inferior injection point was performed. Results: A total of 100 patients were randomized. The modified technique group showed a significantly higher onset time in the lower lip and chin area, and was frequently associated to a lingual electric discharge sensation. Three failures were recorded, 2 of them in the experimental group. No relevant local or systemic complications were registered. Conclusions: Both IANB techniques used in this trial are suitable for lower third molar removal. However, performing an inferior alveolar nerve block in a more inferior position (modified technique) extends the onset time, does not seem to reduce the risk of intravascular injections and might increase the risk of lingual nerve injuries. Key words:Dental anesthesia, inferior alveolar nerve block, lidocaine, third molar, intravascular injection.     

Respiratory effects of fentanyl, diazepam, and methohexital sedation.

The respiratory depressant effects of fentanyl, diazepam, and methohexital were studied in 18 patients who were breathing room air. Two patients had 70% oxygen supplementation administered by a nasal inhaler. Varying degrees of hypoxia occurred when the narcotic was given but hypoxia was not seen in patients who received diazepam alone. The hypoxic changes may be attributed to various physiological responses and can probably be prevented with administration of adequate oxygen.     

Postoperative swelling and trismus after mandibular third molar removal with the lingual split bone technique.

Several factors have been suggested as possible causes for the development of the swelling and trismus which occur after the surgical removal of impacted third molar teeth. In this investigation, measurements of swelling and trismus were made before and after lower third molar removal by the lingual split technique, in a series of 53 patients. No single cause of these surgical sequelae was identified and the duration and pattern of both swelling and trismus were recorded.     

Tramadol premedication in operative extraction of the mandibular third molar: a placebo-controlled crossover study

Anxiolytic drugs are widely used for premedication in oral surgery. Since anxiety is usually associated with the fear of pain, we tested the effects of the analgesic tramadol in premedication before operative extraction of the mandibular third molar under local anesthesia. In a double-blind crossover study, 20 patients were randomized to receive 100 mg oral tramadol or placebo 1 h before operation. Anxiety, nausea, dryness of the mouth, pain and discomfort were recorded before administration of the drug, immediately before and after operation, and 0.5, 1, and 2 h postoperatively using ungraded 0-100 mm VAS scales. Blood pressure and heart rate were measured at the same times; vigilance was tested using the Maddox Wing Test and sensorimotor performance using the Trieger Dot Test; hemoglobin oxygen saturation (SpO2) was measured using a pulse oximeter. In addition, SpO2 and heart rate were recorded continuously in nine patients using a pulse oximeter connected to a computer. The surgeon assessed the quality of operating conditions on the VAS scale. Tramadol delayed and decreased the need of analgesics on the day of operation (p < 0.05). The operating conditions were better in patients on tramadol premedication than in those on placebo during the first operation (p < 0.05), but no differences were seen in patient well-being between treatments. The second operation was less stressful than the first. Tramadol is recommended only with special indications for premedication of patients undergoing third molar extraction under local anesthesia.     

Sensibility and taste alterations after impacted lower third molar extractions. A prospective cohort study

Objectives: To determine the incidence, severity and duration of lingual tactile and gustatory function impairments after lower third molar removal. Study Design: Prospective cohort study with intra-subject measures of 16 patients undergoing lower third molar extractions. Sensibility and gustatory functions were evaluated in each subject preoperatively, one week and one month after the extraction, using Semmes-Weinstein monofilaments and 5 different concentrations of NaCl, respectively. Additionally, all patients filled a questionnaire to assess subjective perceptions. Results: Although patients did not perceive any sensibility impairments, a statistically significant decrease was detected when Semmes-Weinstein monofilaments. This alteration was present at one week after the surgical procedure and fully recovered one month after the extraction. There were no variations regarding the gustatory function. Conclusions: Lower third molar removal under local anesthesia may cause light lingual sensibility impairment. Most of these alterations remain undetected to patients. These lingual nerve injuries are present one week after the extraction and recover one month after surgery. The taste seems to remain unaffected after these procedures. Key words:Lingual nerve, third molar, nerve injury, paresthesia, surgical extraction     

Comparison of oral versus sublingual piroxicam during postoperative pain management after lower third molar extraction

In this study, 53 patients received piroxicam, administered orally or sublingually, after undergoing removal of symmetrically positioned lower third molars, during two separate appointments. This study used a randomized, blind, cross-over protocol. Objective and subjective parameters were recorded for comparison of postoperative results for 7 days after surgery. Patients treated with oral or sublingual piroxicam reported low postoperative pain scores. The patients who received piroxicam orally took a similar average amount of analgesic rescue medication compared with patients who received piroxicam sublingually (p > 0.05). Patients exhibited similar values for mouth opening measured just before surgery and immediately following suture removal 7 days later (p > 0.05), and showed no significant differences between routes of piroxicam administration for swelling control during the second or seventh postoperative days (p > 0.05). In summary, pain, trismus and swelling after lower third molar extraction, independent of surgical difficulty, could be controlled by piroxicam 20 mg administered orally or sublingually and no significant differences were observed between the route of delivery used in this study.     

Tramadol premedication in operative extraction of the mandibular third molar: a placebo-controlled crossover study

Anxiolytic drugs are widely used for premedication in oral surgery. Since anxiety is usually associated with the fear of pain, we tested the effects of the analgesic tramadol in premedication before operative extraction of the mandibular third molar under local anesthesia. In a double-blind crossover study, 20 patients were randomized to receive 100?mg oral tramadol or placebo 1?h before operation. Anxiety, nausea, dryness of the mouth, pain and discomfort were recorded before administration of the drug, immediately before and after operation, and 0.5, 1, and 2?h postoperatively using ungraded 0–100?mm VAS scales. Blood pressure and heart rate were measured at the same times; vigilance was tested using the Maddox Wing Test and sensorimotor performance using the Trieger Dot Test; hemoglobin oxygen saturation (SpO₂) was measured using a pulse oximeter. In addition, SpO₂ and heart rate were recorded continuously in nine patients using a pulse oximeter connected to a computer. The surgeon assessed the quality of operating conditions on the VAS scale. Tramadol delayed and decreased the need of analgesics on the day of operation (p<0.05). The operating conditions were better in patients on tramadol premedication than in those on placebo during the first operation (p<0.05), but no differences were seen in patient well-being between treatments. The second operation was less stressful than the first. Tramadol is recommended only with special indications for premedication of patients undergoing third molar extraction under local anesthesia.     

Incidence of hypoxemia in the postanesthetic recovery room in patients having undergone intravenous sedation for outpatient oral surgery

This study prospectively quantitated the incidence of hypoxia in outpatients in a postanesthetic recovery unit following intravenous (IV) sedation. After identifying the high incidence of hypoxia by the use of pulse oximetry, supplemental oxygen was given to another group of patients and the incidence of the hypoxia was again monitored. Twenty of 100 patients experienced hypoxic episodes in the postanesthetic recovery unit when no supplemental oxygen was administered; only 3 of an additional 100 patients who received supplemental oxygen had episodes of hypoxia. The difference between the groups receiving and not receiving supplemental oxygen was both clinically and statistically significant. As result of this study, the use of supplemental oxygen is recommended for all patients undergoing IV sedation for outpatient oral surgery.     

Pulse oximetry during minor oral surgery with and without intravenous sedation.

This study investigated the levels of oxygen saturation and pulse rates of patients undergoing minor oral surgery under local analgesia, with (20 patients) or without (20 patients) intravenous sedation with midazolam. The results indicated that a statistically significant fall in arterial blood oxygenation of 1% to 2%, as measured by pulse oximetry, followed midazolam administration; however, this was physiologically insignificant. Both groups showed a similar postoperative small fall in oxygen saturation. Transient episodes (24 to 36 seconds) of physiologically significant mild hypoxia occurred during breath holding, but this condition was readily corrected by encouraging patients to breathe deeply. Midazolam had a small but significant calming effect on the higher preoperative pulse rates exhibited by anxious patients, but this effect was not sustained during the operating period. Both sedated and unsedated patients showed episodes of tachycardia that could have significance for patients with cardiac disease.     

Sensibility and taste alterations after impacted lower third molar extractions. A prospective cohort study

Objectives: To determine the incidence, severity and duration of lingual tactile and gustatory function impairments after lower third molar removal. Study Design: Prospective cohort study with intra-subject measures of 16 patients undergoing lower third molar extractions. Sensibility and gustatory functions were evaluated in each subject preoperatively, one week and one month after the extraction, using Semmes-Weinstein monofilaments and 5 different concentrations of NaCl, respectively. Additionally, all patients filled a questionnaire to assess subjective perceptions. Results: Although patients did not perceive any sensibility impairments, a statistically significant decrease was detected when Semmes-Weinstein monofilaments. This alteration was present at one week after the surgical procedure and fully recovered one month after the extraction. There were no variations regarding the gustatory function. Conclusions: Lower third molar removal under local anesthesia may cause light lingual sensibility impairment. Most of these alterations remain undetected to patients. These lingual nerve injuries are present one week after the extraction and recover one month after surgery. The taste seems to remain unaffected after these procedures.     

A comparison of midazolam and midazolam with remifentanil for patient-controlled sedation during operations on third molars

Our aim was to compare patients' satisfaction and cooperation, and clinical efficacy, of midazolam alone, and midazolam and remifentanil for patient-controlled sedation during removal of third molars. Forty patients, American Society of Anesthesiologists grades I and II, admitted for extraction of impacted mandibular third molars were included in this randomised, prospective study. They were given an intravenous bolus of midazolam 0.03 mg/kg and then allowed to use patient-controlled sedation. In the midazolam group, 2 ml of 0.5 mg/ml midazolam was given automatically. In the midazolam-remifentanil group, 2 ml of 0.5 mg/ml midazolam and 12.5 microg/ml remifentanil were given in the same manner. The lockout period was 5 min. Vital signs and oxygen saturation were recorded. Patients' and surgeons' satisfaction, and the patients' degree of amnesia about the local anaesthetic, drilling, removal of the tooth, and pain during extraction were also assessed. There were no significant differences between systolic and diastolic blood pressures during sedation, but heart rate after 30 min in the combined group was significantly lower than in the midazolam group (p<0.05). Surgeons described the midazolam group as excellent in 9 and good in 11. In the combined group, satisfaction was excellent in 11, good in 7, and satisfactory or unacceptable in 1 of each. Immediately postoperatively, 19 patients in each group ranked their satisfaction as excellent and 1 as good. Twenty-four hours later it was unchanged in the midazolam group, while 15 patients in the other group thought it was excellent, 3 good, and 2 poor. Patient-controlled analgesia with midazolam or midazolam and remifentanil is safe and reliable during extraction of third molars.     

Temporomandibular joint disorders in patients referred for third molar extraction

Background: Third molar removal has been implicated as a precipitating event for temporomandibular joint disorders. The aim of this study was to determine what proportion of patients had pre‐existing pain and dysfunction that could be attributed to the temporomandibular joints. Methods: Sixty patients referred for third molar removal were clinically examined and a history of their presenting complaint recorded at the initial consultation visit. Patients were then diagnosed and categorized. Results: Of the total number of patients examined, 13.3 per cent showed signs and symptoms of temporomandibular joint pain and dysfunction while a further 23.3 per cent also had symptomatic third molar teeth. Conclusions: The results of this study suggest that the signs of temporomandibular joint disorders are common in patients referred for third molar extractions.