Analysis of the effect of oral midazolam and triazolam premedication before general anesthesia in patients with disabilities with difficulty in cooperation

BACKGROUND: When performing dental treatment under general anesthesia in adult patients who have difficulty cooperating due to intellectual disabilities, anesthesia induction may be difficult as well. In particular, patients who refuse to come into the dental office or sit in the dental chair may have to be forced to do so. However, for adult patients with a large physique, physical restraint may be difficult, while oral sedatives as premedication may be helpful. Here, a retrospective analysis was performed to investigate the effect of oral sedatives. METHODS: A hospital-based medical information database was searched for patients who were prescribed oral midazolam or triazolam between January 2009 and December 2017. Pre-anesthesia evaluation, anesthesia, and anesthesia recovery records of all patients were analyzed, and information on disability type, reason for prescribing oral sedatives, prescribed medication and dose, cooperation level during anesthesia induction, anesthesia duration, length of recovery room stay, and complications was retrieved. RESULTS: A total of 97 patients were identified, of whom 50 and 47 received midazolam and triazolam, respectively. The major types of disability were intellectual disabilities, autism, Down syndrome, blindness, cerebral palsy, and epilepsy. Analyses of changes in cooperation levels after drug administration showed that anesthesia induction without physical restraint was possible in 56.0% of patients in the midazolam group and in 46.8% of patients in the triazolam group (P = 0.312). CONCLUSIONS: With administration of oral midazolam or triazolam, general anesthesia induction without any physical restraint was possible in approximately 50% of patients, with no difference between the drugs.

Bonding of the silane containing multi-mode universal adhesive for lithium disilicate ceramics

OBJECTIVES: This study evaluated the influence of a multi-mode universal adhesive (MUA) containing silane (Single Bond Universal, 3M EPSE) on the bonding of resin cement to lithium disilicate. MATERIALS AND METHODS: Thirty IPS e.max CAD specimens (Ivoclar Vivadent) were fabricated. The surfaces were treated as follows: Group A, adhesive that did not contain silane (ANS, Porcelain Bonding Resin, Bisco); Group B, silane (S) and ANS; Group C, hydrofluoric acid (HF), S, and ANS; Group D, MUA; Group E, HF and MUA. Dual-cure resin cement (NX3, Kerr) was applied and composite resin cylinders of 0.8 mm in diameter were placed on it before light polymerization. Bonded specimens were stored in water for 24 hours or underwent a 10,000 thermocycling process prior to microshear bond strength testing. The data were analyzed using multivariate analysis of variance (p < 0.05). RESULTS: Bond strength varied significantly among the groups (p < 0.05), except for Groups A and D. Group C showed the highest initial bond strength (27.1 ± 6.9 MPa), followed by Group E, Group B, Group D, and Group A. Thermocycling significantly reduced bond strength in Groups B, C, and E (p < 0.05). Bond strength in Group C was the highest regardless of the storage conditions (p < 0.05). CONCLUSIONS: Surface treatment of lithium disilicate using HF and silane increased the bond strength of resin cement. However, after thermocycling, the silane in MUA did not help achieve durable bond strength between lithium disilicate and resin cement, even when HF was applied.

A retrospective analysis of outpatient anesthesia management for dental treatment of patients with severe Alzheimer's disease

BACKGROUND: The number of patients with Alzheimer's disease is growing worldwide, and the proportion of patients requiring dental treatment under general anesthesia increases with increasing severity of the disease. However, outpatient anesthesia management for these patients involves great risks, as most patients with Alzheimer's disease are old and may show reduced cardiopulmonary functions and have cognitive disorders. METHODS: This study retrospectively investigated 43 patients with Alzheimer's disease who received outpatient anesthesia for dental treatment between 2012–2017. Pre-anesthesia patient evaluation, dental treatment details, anesthetics dose, blood pressure, duration and procedure of anesthesia, and post-recovery management were analyzed and compared between patients who underwent general anesthesia or intravenous sedation. RESULTS: Mean age of patients was about 70 years; mean duration of Alzheimer's disease since diagnosis was 6.3 years. Severity was assessed using the global deterioration scale; 62.8% of patients were in level ≥ 6. Mean duration of anesthesia was 178 minutes for general anesthesia and 85 minutes for intravenous sedation. Mean recovery time was 65 minutes. Eleven patients underwent intravenous sedation using propofol, and 22/32 cases involved total intravenous anesthesia using propofol and remifentanil. Anesthesia was maintained with desflurane for other patients. While maintaining anesthesia, inotropic and atropine were used for eight and four patients, respectively. No patient developed postoperative delirium. All patients were discharged without complications. CONCLUSION: With appropriate anesthetic management, outpatient anesthesia was successfully performed without complications for dental treatment for patients with severe Alzheimer's disease.

Elemental analysis of caries-affected root dentin and artificially demineralized dentin

OBJECTIVES: This study aimed to analyze the mineral composition of naturally- and artificially-produced caries-affected root dentin and to determine the elemental incorporation of resin-modified glass ionomer (RMGI) into the demineralized dentin. MATERIALS AND METHODS: Box-formed cavities were prepared on buccal and lingual root surfaces of sound human premolars (n = 15). One cavity was exposed to a microbial caries model using a strain of Streptococcus mutans. The other cavity was subjected to a chemical model under pH cycling. Premolars and molars with root surface caries were used as a natural caries model (n = 15). Outer caries lesion was removed using a carbide bur and a hand excavator under a dyeing technique and restored with RMGI (FujiII LC, GC Corp.). The weight percentages of calcium (Ca), phosphate (P), and strontium (Sr) and the widths of demineralized dentin were determined by electron probe microanalysis and compared among the groups using ANOVA and Tukey test (p < 0.05). RESULTS: There was a pattern of demineralization in all models, as visualized with scanning electron microscopy. Artificial models induced greater losses of Ca and P and larger widths of demineralized dentin than did a natural caries model (p < 0.05). Sr was diffused into the demineralized dentin layer from RMGI. CONCLUSIONS: Both microbial and chemical caries models produced similar patterns of mineral composition on the caries-affected dentin. However, the artificial lesions had a relatively larger extent of demineralization than did the natural lesions. RMGI was incorporated into the superficial layer of the caries-affected dentin.

Use of ADMS™ during sedation for dental treatment of an intellectually disabled patient: a case report

Dental treatment is often performed under general anesthesia or sedation when an intellectually disabled patient has a heightened fear of treatment or has difficulty cooperating. When it is impossible to control the patient due to the severity of intellectual disability, conscious sedation is not a viable option, and only deep sedation should be performed. Deep sedation is usually achieved by propofol infusion using the target controlled infusion (TCI) system, with deep sedation being achieved at a slightly lower concentration of propofol in disabled patients. In such cases, anesthesia depth monitoring using EEG, as with a Bispectral Index (BIS) monitor, can enable dental treatment under appropriate sedation depth. In the present case, we performed deep sedation for dental treatment on a 27-year-old female patient with mental retardation and severe dental phobia. During sedation, we used BIS and a newly developed Anesthetic Depth Monitor for Sedation (ADMS™), in addition to electrocardiography, pulse oximetry, blood pressure monitoring, and capnometry for patient safety. Oxygen was administered via nasal prong to prevent hypoxemia during sedation. The BIS and ADMS™ values were maintained at approximately 70, and dental treatment was successfully performed in approximately 30 min..

Local anesthesia of the temporomandibular joint to reduce pain during mouth opening for dental treatment in a patient with spinal muscular atrophy

Spinal muscular atrophy (SMA) is an autosomal recessive, severe neuromuscular disorder in which degeneration of alpha motor neurons in the spine progressively weakens and ultimately paralyzes the proximal muscles. It occurs in one per 6,000-10,000 infants, and is a genetic disorder with the second-highest mortality rate worldwide. An 18-year-old male patient with SMA was referred for general anesthesia for difficulty in performing dental treatment due to limited mouth opening caused by temporomandibular joint (TMJ) pain. However, the patient had a high risk of general anesthesia complications, so TMJ pain during mouth opening was reduced through local anesthesia of the TMJ. Fortunately, the anesthesia was successful in reducing pain during mouth opening, enabling the patient to receive dental treatment with an adequate mouth opening.

Local anesthesia of the temporomandibular joint to reduce pain during mouth opening for dental treatment in a patient with spinal muscular atrophy

Spinal muscular atrophy (SMA) is an autosomal recessive, severe neuromuscular disorder in which degeneration of alpha motor neurons in the spine progressively weakens and ultimately paralyzes the proximal muscles. It occurs in one per 6,000-10,000 infants, and is a genetic disorder with the second-highest mortality rate worldwide. An 18-year-old male patient with SMA was referred for general anesthesia for difficulty in performing dental treatment due to limited mouth opening caused by temporomandibular joint (TMJ) pain. However, the patient had a high risk of general anesthesia complications, so TMJ pain during mouth opening was reduced through local anesthesia of the TMJ. Fortunately, the anesthesia was successful in reducing pain during mouth opening, enabling the patient to receive dental treatment with an adequate mouth opening.

How to design in situ studies: an evaluation of experimental protocols

OBJECTIVES: Designing in situ models for caries research is a demanding procedure, as both clinical and laboratory parameters need to be incorporated in a single study. This study aimed to construct an informative guideline for planning in situ models relevant to preexisting caries studies. MATERIALS AND METHODS: An electronic literature search of the PubMed database was performed. A total 191 of full articles written in English were included and data were extracted from materials and methods. Multiple variables were analyzed in relation to the publication types, participant characteristics, specimen and appliance factors, and other conditions. Frequencies and percentages were displayed to summarize the data and the Pearson's chi-square test was used to assess a statistical significance (p < 0.05). RESULTS: There were many parameters commonly included in the majority of in situ models such as inclusion criteria, sample sizes, sample allocation methods, tooth types, intraoral appliance types, sterilization methods, study periods, outcome measures, experimental interventions, etc. Interrelationships existed between the main research topics and some parameters (outcome measures and sample allocation methods) among the evaluated articles. CONCLUSIONS: It will be possible to establish standardized in situ protocols according to the research topics. Furthermore, data collaboration from comparable studies would be enhanced by homogeneous study designs.

Flexural strength and microstructure of two lithium disilicate glass ceramics for CAD/CAM restoration in the dental clinic

OBJECTIVES: There has been a growing interest in glass ceramic systems with good esthetics, high fracture resistance and bonding durability, and simplified fabrication techniques using CAD/CAM. The aim of this study is to compare flexural strength before and after heat treatment of two lithium disilicate CAD/CAM blocks, IPS e.max CAD (Ivoclar Vivadent) and Rosetta SM (Hass), and to observe their crystalline structures. MATERIALS AND METHODS: Biaxial flexural strength was tested according to ISO 6872 with 20 disc form specimens sliced from each block before and after heat treatment. Also, the crystalline structures were observed using field-emission scanning microscopy (FE-SEM, Hitachi) and x-ray diffraction (XRD, Rigaku) analysis. The mean values of the biaxial flexural strength were analyzed by the Mann-Whitney U test at a significance level of p = 0.05. RESULTS: There were no statistically significant differences in flexural strength between IPS e.max CAD and Rosetta SM either before heat treatment or after heat treatment. For both ceramics, the initial flexural strength greatly increased after heat treatment, with significant differences (p < 0.05). The FE-SEM images presented similar patterns of crystalline structure in the two ceramics. In the XRD analysis, they also had similar patterns, presenting high peak positions corresponding to the standard lithium metasilicate and lithium disilicate at each stage of heat treatment. CONCLUSIONS: IPS e.max CAD and Rosetta SM showed no significant differences in flexural strength. They had a similar crystalline pattern and molecular composition.

Effects of matrix metallproteinases on dentin bonding and strategies to increase durability of dentin adhesion

The limited durability of resin-dentin bonds severely compromises the longevity of composite resin restorations. Resin-dentin bond degradation might occur via degradation of water-rich and resin sparse collagen matrices by host-derived matrix metalloproteinases (MMPs). This review article provides overview of current knowledge of the role of MMPs in dentin matrix degradation and four experimental strategies for extending the longevity of resin-dentin bonds. They include: (1) the use of broad-spectrum inhibitors of MMPs, (2) the use of cross-linking agents for silencing the activities of MMPs, (3) ethanol wet-bonding with hydrophobic resin, (4) biomimetic remineralization of water-filled collagen matrix. A combination of these strategies will be able to overcome the limitations in resin-dentin adhesion.

Color and hardness changes in artificial white spot lesions after resin infiltration

OBJECTIVES: The purpose of this study was to determine the effect of resin infiltration technique on color and surface hardness of white spot lesion (WSL) with various degrees of demineralization. MATERIALS AND METHODS: Ten human upper premolars were cut and divided into quarters with a 3 x 4 mm window on the enamel surface. Each specimens were separated into four groups (n = 10) and immersed in demineralization solution to create WSL: control, no treatment (baseline); 12 h, 12 hr demineralization; 24 h, 24 hr demineralization; 48 h, 48 hr demineralization. Resin infiltration was performed to the specimens using Icon (DMG). CIEL*a*b* color parameters of the enamel-dentin complex were determined using a spectroradiometer at baseline, after caries formation and after resin infiltration. Surface hardness was measured by Vickers Micro Hardness Tester (Shimadzu, HMV-2). The differences in color and hardness among the groups were analyzed with ANOVA followed by Tukey test. RESULTS: Resin infiltration induced color changes and increased the hardness of demineralized enamel. After resin infiltration, there was no difference in color change (DeltaE*) or microhardness among the groups (p < 0.05). CONCLUSION: There was no difference in the effect of resin infiltration on color and hardness among groups with different extents of demineralization.

Theory of X-ray microcomputed tomography in dental research: application for the caries research / 대한치과보존학회지

Caries remains prevalent throughout modern society and is the main disease in the field of dentistry. Although studies of this disease have used diverse methodology, recently, X-ray microtomography has gained popularity as a non-destructive, 3-dimensional (3D) analytical technique, and has several advantages over the conventional methods. According to X-ray source, it is classified as monochromatic or polychromatic with the latter being more widely used due to the high cost of the monochromatic source despite some advantages. The determination of mineral density profiles based on changes in X-ray attenuation is the principle of this method and calibration and image processing procedures are needed for the better image and reproducible measurements. Using this tool, 3D reconstruction is also possible and it enables to visualize the internal structures of dental caries. With the advances in the computer technology, more diverse applications are being studied, such automated caries assessment algorithms.

Elemental analysis of the fluoride varnish effects on root caries initiation / 대한치과보존학회지

OBJECTIVES: The usage of fluoride varnish for a moderate to low caries-risk group has not been well validated. This study aimed to evaluate the preventive and therapeutic efficacies of fluoride varnish on the initiated root caries. MATERIALS AND METHODS: Ten premolars were sectioned into quarters, further divided into two windows, one of which was painted with Fluor Protector (1,000 ppm fluoride, Ivoclar Vivadent). An initial lesion with a well-preserved surface layer was produced by pH cycling. Scanned line analysis using energy dispersive spectrometry determined the weight percentages of Ca and P in the demineralized layer. Scanning Electron microscopy and confocal laser scanning microscopy (CLSM) evaluated the varnish-applied root surfaces. RESULTS: The mean lesion depth (SD) was 12.3 (2.6) microm (single cycling) and 19.6 (3.8) microm (double cycling). Double cycling extended the lesion depth, but induced no more mineral loss than single cycling (p < 0.05). The mean weight percentages of Ca and P between groups with and without varnish were not significantly different (p < 0.05). A CLSM showed varnish remained within 15 microm of the surface layer. CONCLUSIONS: When a mild acid challenge initiated root tissue demineralization, the application of low-concentration fluoride varnish did not influence the lesion depth or the mineral composition of the subsurface lesion.

Rheological characterization of thermoplasticized injectable gutta percha and resilon / 대한치과보존학회지

OBJECTIVES: The purpose of this study was to observe the change in the viscoelastic properties of thermoplasticized injectable root canal filling materials as a function of temperature and to compare the handling characteristics of these materials. MATERIALS AND METHODS: Three commercial gutta perchas and Resilon (Pentron Clinical Technologies) in a pellet form were heated in the Obtura-II system (Obtura Spartan) at 140degrees C and 200degrees C, and the extrusion temperature of the thermoplasticized materials was measured. The viscoelastic properties of the materials as a function of temperature were evaluated using a rheometer. The elastic modulus G', viscous modulus G", loss tangent tandelta, and complex viscosity eta* were determined. The phase transition temperature was determined by both the rheometer and a differential scanning calorimeter (DSC). The consistency of the materials was compared under compacting pressure at 60degrees C and 40degrees C by a squeeze test. RESULTS: The three gutta perchas had dissimilar profiles in viscoelastic properties with varying temperature. The phase transition of softened materials into solidification occurred at 40degrees C to 50degrees C, and the onset temperatures obtained by a rheometer and a DSC were similar to each other. The onset temperature of phase transition and the consistency upon compaction pressure were different among the materials (p < 0.05). Resilon had a rheologically similar pattern to the gutta perchas, and was featured between high and low-flow gutta perchas. CONCLUSIONS: The rheological characteristics of the thermoplasticized root canal filling materials changed under a cooling process. The dissimilar viscoelastic properties among the materials require different handling characteristics during an injecting and compacting procedure.

Comparison of operative techniques between female and male dentists in class 2 and class 5 resin composite restorations / 대한치과보존학회지

This study aimed to assess whether the gender of the dental practitioner affects operative techniques in class 2 and class 5 resin composite restorations. In 2008, a nationwide survey was given to Korean dentists. Total 12,193 e-mails were distributed, 2,632 were opened by recipients, and 840 responses were collected. Of the respondents, 78.9% were male and 21.1% were female. The gender distribution in the age groups between respondents and the total population did not differ (p > 0.05). A chi-square test was used to compare technical differences between female and male dentists. A multiple logistic regression analysis was performed to assess the association between gender and operative techniques in resin composite restoration. For class 2 resin composite restoration, female dentists were 1.87 times more likely than male dentists to do multiple incremental fillings (four layers or more) and 2.72 times more likely than males to spend 30 minutes or more for the treatment (p < 0.05). For class 5 resin composite restoration, female dentists were 2.69 times more likely than their male counterparts to use a cavity base or liner, 1.83 times more likely to do multiple incremental fillings (four layers or more) and 1.63 times more likely to spend 20 minutes or more for the procedure (p < 0.05). The gender factor was influential to individual operative techniques in restorative treatment.

Quantitative comparison of permeability in the adhesive interface of four adhesive systems / 대한치과보존학회지

The purpose of this study was to perform quantitative comparisons of water permeable zones in both the adhesive and the hybrid layer before and after thermocycling in order to assess the integrity of the bonding interface. Twenty eight flat dentin surfaces were bonded with a light-cured composite resin using one of four commercial adhesives [OptiBond FL (OP), AdheSE (AD), Clearfil SE Bond (CL), and Xeno III (XE)]. These were sectioned into halves and subsequently cut to yield 2-mm thick specimens; one specimen for control and the other subjected to thermocycling for 10,000 cycles. After specimens were immersed in ammoniacal silver nitrate for 24 h and exposed to a photo developing solution for 8 h, the bonded interface was analyzed by scanning electron microscopy (SEM) and wavelength dispersive spectrometry (WDS) at five locations per specimen. Immediately after bonding, the adhesive layer of OP showed the lowest silver uptake, followed by CL, AD, and XE in ascending order (p < 0.0001); the hybrid layer of CL had the lowest silver content among the groups (p = 0.0039). After thermocycling, none of the adhesives manifested a significant increase of silver in either the adhesive or the hybrid layer. SEM demonstrated the characteristic silver penetrated patterns within the interface. It was observed that integrity of bonding was well maintained in OP and CL throughout the thermocycling process. Adhesive-tooth interfaces are vulnerable to hydrolytic degradation and its permeability varies in different adhesive systems, which may be clinically related to the restoration longevity.

A survey on the use of composite resin in Class II restoration in Korea / 대한치과보존학회지

The purpose of this study was to assess the current materials, methods and difficulties according to the year of licence and educational background of Korean dentists in Class II direct composite resin restorations. Total 17 questions were included in the questionnaire. Questions were broadly divided into two parts; first, operator's information, and second, the materials and methods used in Class II posterior composite restoration. The questionnaire was sent to dentists enrolled in Korean Dental Association via e-mail. Total 12,193 e-mails were distributed to dentists, 2,612 e-mails were opened, and 840 mails (32.2%) were received from respondents. The data was statically analyzed by chi-square test using SPSS(v. 12.0.1, SPSS Inc, Chicago, IL, USA). Male dentists among respondents was 79%. 60.3% of the respondents acquired their licences recently (1998-2007), and 77% practiced in private offices. 83.4% have acquired their knowledge through school lectures, conferences and seminars. For the Class II restorations, gold inlays were preferred by 65.7% of respondents, while direct composite resin restorations were used by 12.1% amalgam users were only 4.4% of respondents. For the restorative technique, 74.4% of respondents didn't use rubber dam as needed. For the matrix, mylar strip (53.4%), metal matrix (33.8%) and Palodent system (6.5%) were used. 99.6% of respondents restored the Class II cavity by incremental layering. Obtaining of the tight interproximal contact was considered as the most difficult procedure (57.2%) followed by field isolation (21%). Among various bonding systems, 22.6% of respondents preferred SE Bond and 20.2% used Single Bond. Z-250 was used most frequently among a variety of composite resins.

Comparison of the elastic modulus among three dentin adhesives before and after thermocycling / 대한치과보존학회지

The purpose of this study was to determine the effects on the elastic moduli of the adhesive and the hybrid layer from thermocycling. Twenty one human molars were used to create flat dentin surfaces. Each specimen was bonded with a light-cured composite using one of three commercial adhesives (OptiBond FL [OP], Clearfil SE Bond [CL], and Xeno III [XE]). These were sectioned into two halves and subsequently cut to yield 2-mm thickness specimens; one specimen for immediate bonding test without thermocycling and the other subjected to 10,000 times of thermocycling. Nanoindentation test was performed to measure the modulus of elasticity of the adhesive and the hybrid layer, respectively, using an atomic force microscope. After thermocycling, XE showed a significant decrease of the modulus in the adhesive layer (p < 0.05). Adhesives containing hydrophilic monomers are prone to hydrolytic degradation. It may result in the reduced modulus of elasticity, which leads to the mechanically weakened bonding interface.

Development of nano-fluid movement measuring device and its application to hydrodynamic analysis of dentinal fluid / 대한치과보존학회지

This study was aimed to develop an instrument for real-time measurement of fluid conductance and to investigate the hydrodynamics of dentinal fluid. The instrument consisted of three parts; (1) a glass capillary and a photo sensor for detection of fluid movement, (2) a servo-motor, a lead screw and a ball nut for tracking of fluid movement, (3) a rotary encoder and software for data processing. To observe the blocking effect of dentinal fluid movement, oxalate gel and self-etch adhesive agent were used. BisBlock (Bisco) and Clearfil SE Bond (Kuraray) were applied to the occlusal dentin surface of extracted human teeth. Using this new device, the fluid movement was measured and compared between before and after each agent was applied. The instrument was able to measure dentinal fluid movement with a high resolution (0.196 nL) and the flow occurred with a rate of 0.84 to 15.2 nL/s before treatment. After BisBlock or Clearfil SE Bond was used, the fluid movement was decreased by 39.8 to 89.6%.

Effect of anticurvature filing method on preparation of the curved root canal using ProFile / 대한치과보존학회지

This study investigated the effect of anticurvature filing method on preparation of the curved root canal using ProFile. Thirty six resin blocks were divided equally into three groups by instrumentation motions: anticurvature filing motion, circumferential filing motion and straight up-and-down motion. Each resin block was sectioned at 8 mm level from the apex and at the greatest curvature of the canal and reassembled in metal mold by a modified Bramante technique. All groups were instrumented with the ProFile system. At each levels, image of sectioned surface were taken using CCD camera under a stereomicroscope at x40 magnification and stored. Distances of transportation at the inner and outer area of curvature and the centering ratio were determined and compared by statistical analysis, along with the assessment of the increase of root canal cross-sectional area. The results were as follows; 1. In all groups, there was no statistical difference in the mean increase of root canal cross-sectional area, the centering ratio, and the mean distances of transportation at the inner area of curvature at each level. 2. At 8 mm level from the apex, the mean distances of transportation at the outer area of curvature decreases in following order anticurvature filing motion, circumferential filing motion, straight up-and-down motion but, no significant difference at the greatest curvature of the canal among three groups. Effect of anticurvature filing motion using ProFile does not seem to be different from other instrumentation motions at the inner area of curvature in curved root canal.