Assessment of stress during periodontal surgery with intravenous sedation and with local anesthesia only

Ten patients with moderate to advanced periodontal disease were subjected to two similar periodontal surgical procedures. Each patient received either intravenous conscious sedation with local anesthesia or local anesthesia only. The stress-reducing effects of a conscious sedation regimen consisting of pentobarbital, meperidine, and diazepam were evaluated in these patients. Stress was evaluated by monitoring changes in serum cortisol, human growth hormone, and vital signs. Blood samples were obtained at 15- to 30-minute intervals throughout each procedure and were evaluated for serum cortisol and growth hormone. The conscious sedation group had significantly lower serum cortisol levels and lower systolic blood pressure, indicating that the patients having periodontal surgery with conscious sedation experienced reduced stress. Physiologic stability was maintained for each patient, indicating that this conscious sedation regimen can be used to reduce measurable parameters of stress that patients develop during periodontal surgery.     

Guidelines for intraoperative monitoring of dental patients undergoing conscious sedation, deep sedation, and general anesthesia

The promulgation and adoption of intraoperative monitoring standards in medicine for anesthesia has resulted in early detection of untoward events during sedation and anesthesia, lowering of malpractice premiums, and an improvement in the quality of care. The American Dental Society of Anesthesiology has devised specific, detailed monitoring standards with universal applicability in the dental setting.     

Prevention of complications associated with intravenous sedation and general anesthesia

An analysis of three time phases--induction, maintenance, and recovery from anesthesia--is presented to clarify specific risk situations and the treatment necessary to decrease morbidity and mortality in the dental office.     

Recent developments in local anesthesia and oral sedation

This article reviews 3 recent developments in anxiety and pain control with significant potential for altering dental practice. First is the introduction of articaine hydrochloride as an injectable local anesthetic. Although articaine is an amide, its unique structure allows the drug to be quickly metabolized, reducing toxicity associated with repeated injections over time. The second development is the formulation of a lidocaine and prilocaine dental gel for topical anesthesia of the periodontal pocket. This product may significantly reduce the need for anesthetic injections during scaling and root planing. Finally, the use of triazolam as an oral sedative/anxiolytic is reviewed. The recent administration of triazolam in multiple doses has extended the availability of anxiety control to many dental patients, but unknowns about the safety of the technique as practiced by some dentists remains a concern.     

Cardiovascular response to epinephrine-containing local anesthesia in patients with cardiovascular disease

OBJECTIVE: The purpose of the present study was to examine the safety of epinephrine-containing local anesthesia for use on patients with cardiovascular disease. STUDY DESIGN: Twenty-seven patients with cardiovascular disease were studied. The cardiac functional capacity of 9 patients was New York Heart Association class I; 11, class II; and 7, class III. Hemodynamic responses to intraoral injection of 1.8 mL of 2% lidocaine with 1:80,000 epinephrine were measured with impedance cardiography. RESULTS: Systolic blood pressure and heart rate increased by 4.1% and 5.1%, respectively, immediately after the lidocaine-epinephrine injection. Consequently, rate pressure product increased by 10.0%. Cardiac index increased by 14.2%, and total peripheral resistance decreased by approximately 10%. No patient complained of cardiac symptoms. There were no significant differences in hemodynamic responses related to the extent of the cardiac functional capacity. CONCLUSION: We concluded that lidocaine-epinephrine was safe and had few, if any, hemodynamic consequences in patients with cardiovascular disease.     

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.     

Propofol based total intravenous anesthesia versus sevoflurane based inhalation anesthesia: The postoperative characteristics in oral and maxillofacial surgery

ObjectiveTotal intravenous anesthesia and inhalation/volatile anesthesia are the main general anesthesia procedures used in all surgical applications. The aim of this study was to compare sevoflurane anesthesia and total intravenous anesthesia with propofol in terms of postoperative complications, especially after oral and maxillofacial surgeries.Material and methodsEach patient was taken to the recovery room following extubation, and the pulse rate, non-invasive blood pressure (NIBP) and oxygen saturation were monitored. Presence of hypoxia, tachycardia, bradycardia, hypertension and hypotension were determined as vital sign complications.ResultsThe risk of complications related to vital functions were low for both anesthesia methods, and no statistically significant difference between the groups. The incidence of nausea and vomiting was found to be significantly higher in the patients undergoing both major (p = 0.011) and minor (p = 0.021) surgeries in the IA-S group. The recovery time was found to be significantly longer in the TIVA-P group compared to the IA-S group in the patients undergoing both major (p = 0.026) and minor surgery (p = 0.018).ConclusionTIVA and IA methods, which are considered safe in terms of vital signs, should be preferred according to patient characteristics. Despite the fact that inhaled anesthetics require PONV premedication for long term interventions, we believe that they could be preferred due to shorter recovery time compared to intravenous anesthetics.     

Alfentanil for general anesthesia in oral and maxillofacial surgery

This study evaluated alfentanil (Alfenta, Janssen Pharmaceutica, Piscataway, NJ) as an analgesic supplement to oxygen/nitrous oxide anesthesia for outpatient oral and maxillofacial surgical procedures. Fifty American Society of Anesthesiology (ASA) class I and II patients were induced and maintained with an established regimen. Parameters measured included anesthetic properties, orientation time, recovery time, and presence of side effects. The results indicated that alfentanil provides acceptable anesthesia with minimal recovery time, but occasional side effects such as nausea and vomiting occurred postoperatively. This drug, when properly used, is a welcome addition to other established general anesthetic agents in oral and maxillofacial surgery.     

两种全凭静脉麻醉维持方法在老年口腔颌面部手术中的比较

目的比较异丙酚麻醉镇静下,瑞芬太尼复合顺式阿曲库铵和芬太尼复合维库溴铵两种麻醉维持方法在老年口腔颌面手术麻醉时临床效果。方法 50例老年口腔颌面部择期手术患者,手术时间在1h～3h,随机分成R和F两组（N=25）,两组术中异丙酚持续输入4mg/kg/h,R组持续泵入瑞芬太尼4ug/kg/h～12ug/kg/h＋顺式阿曲库铵1ug/kg/min～2ug/kg/min;F组持续泵入芬太尼1.5ug/kg/h～2ug/kg/h＋维库溴铵1ug/kg/min～2ug/kg/min,估计在手术结束前10分钟停药。监测指标包括手术开始时,开始后10分钟,开始后30分钟开始后1h,停药时和拔管时的平均动脉压（MAP）,心率（HR）和心输出量（CO）。记录停药后唤名睁眼时间,拔管时间,PACU滞留时间。结果两组患者手术开始时,开始后10分钟的MAP,HR和CO无显著差异;R组手术开始后30分钟HR低于F组（P〈0.05）。R组唤名睁眼时间,拔管时间,PACU滞留时间短于F组（P〈0.05）,R组的苏醒快于F组。结论老年口腔颌面部手术异丙酚全凭静脉麻醉时,瑞芬太尼复合顺式阿曲库铵与芬太尼复合维库溴铵两种维持方法术中均适合,瑞芬太尼复合顺式阿曲库铵维持组意识恢复好,效果优于芬太尼复合维库溴铵组。     

Complications of local anesthesia used in oral and maxillofacial surgery

Local anesthetics are used routinely in oral and maxillofacial surgery. Local anesthetics are safe and effective drugs but do have risks that practitioners need to be aware of. This article reviews the complications of local anesthesia. A brief history is provided and the regional and systemic complications that can arise from using local anesthesia are discussed. These complications include paresthesia, ocular complications, allergies, toxicity, and methemoglobinemia. Understanding the risks involved with local anesthesia decreases the chances of adverse events occurring and ultimately leads to improved patient care.     

Cost of a genioplasty under deep intravenous sedation in a private office versus general anesthesia in an outpatient surgical center.

The cases of twenty-four patients who underwent genioplasties either under deep intravenous (IV) sedation in a dental office or under general anesthesia in a surgical center were reviewed. A cost comparison of this operation in these two environments showed that it was twice as expensive to have the same procedure done in an outpatient surgical suite under general anesthesia as it was in a private office under IV sedation.     

Fifty years of general anesthesia in California oral and maxillofacial surgery

In summary, the advances of the last half of the 20th century in general anesthesia delivery by oral and maxillofacial surgeons are the following: 1. Oral and maxillofacial surgeons in training are exposed to significantly more hospital general anesthesia training and in addition spent much of their residency training performing general anesthesia on outpatient dental patients undergoing dentoalveolar surgery. Training programs increased from one year to three years, then to four years and finally, many six-year programs were developed that award the MD degree during or following completion of the residency program. 2. Self-evaluation programs were initiated in the late 1960s and evolved into mandatory in-office evaluation by peer practitioners and later into state-regulated evaluation. These programs began in Southern California and spread to encompass the entire United States. 3. Intravenous ultra-fast acting barbiturate office anesthesia became very refined and several combination drug "balanced" techniques developed. 4. Benzodiazepines, first diazepam then midazolam were introduced and gained wide acceptance by the dental profession. 5. New synthetic narcotic agents were introduced, which give the oral surgeon another pain control and anesthesia supplement. The new agents were short acting but very effective for the period necessary to complete most office surgical procedures. Fentanyl is the prototype for these agents. 6. Monitoring devices were incorporated into practice, and currently all oral surgeons use the pulse oximeter, the electrocardiograph, and blood pressure monitoring devices. All of these monitors are required by the California general anesthesia regulations. 7. Propofol, an entirely new type of intravenous agent, was introduced and is used by more than half of oral surgeons reporting in a survey of drugs used in 2003. Propofol may be used by incremental injection or by continuous infusion incorporating an automatic infusion pump. 8. Sevoflurane, a potent inhalation anesthetic that has many properties of an ideal agent - rapid onset, potent, easily delivered by calibrated vaporizers, rapid emergence, infrequent postoperative nausea, and favorable acceptance by almost all patients about to undergo general anesthesia - is gaining acceptance and use by oral and maxillofacial surgeons.