What is the gold standard of the dental anxiety scale?

It is important to understand patients' anxiety and fear about dental treatment. A patient's anxiety can be quantified through a self-report questionnaire, and many related scales have been developed. In this review, I tried to find out which scale is most suitable for the patient's dental anxiety and fear evaluation by examining the contents of previously developed scales and comparing the strengths and weaknesses of each scale.

Analysis of the annual changes in dental institutions that claimed dental sedatives in Korea and the types of sedatives using health care big data

Background@#Dentists make various efforts to reduce patients' anxiety and fear associated with dental treatment. Dental sedation is an advanced method that dentists can perform to reduce patients' anxiety and fear and provide effective dental treatment. However, dental sedation is different from general dental treatment and requires separate learning, and if done incorrectly, can lead to serious complications. Therefore, sedation is performed by a limited number of dentists who have received specific training. This study aimed to investigate the proportion of dentists who practice sedation and the main sedatives they use in the context of the Republic of Korea. @*Methods@#We used the customized health information data provided by the Korean National Health Insurance. We investigated the number of dental hospitals or clinics that claimed insurance for eight main sedatives commonly used in dental sedation from January, 2007 to September, 2019 at the Health Insurance Review and Assessment Service. We also identified the changes in the number of dental medical institutions by region and year and analyzed the number and proportion of dental medical institutions prescribing each sedative. @*Results@#In 2007, 302 dental hospitals prescribed sedatives, and the number increased to 613 in 2019. In 2007, approximately 2.18% of the total 13,796 dental institutions prescribed sedatives, increasing to 3.31% in 2019. In 2007, 168 institutions (55.6%) prescribed N2O alone, and in 2019, 510 institutions (83.1%) made claims for it. In 2007, 76 (25.1%) hospitals made claims for chloral hydrate, but the number gradually decreased, with only 29 hospitals (4.7%) prescribing it in 2019. Hospitals that prescribed a combination of N2O, chloral hydrate, and hydroxyzine increased from 27 (8.9%) in 2007 to 51 (9%) in 2017 but decreased to 38 (6.1%) in 2019. The use of a combination of N2O and midazolam increased from 20 hospitals (6.6%) in 2007 to 51 hospitals (8.3%) in 2019. @*Conclusion@#While there is a critical limitation to the investigation of dental hospitals performing sedation using insurance claims data, namely exclusion of dental clinics providing non-insured treatments, we found that in 2019, approximately 3.31% of the dental clinics were practicing sedation and that N2O was the most commonly prescribed sedative.

Analysis of behavioral management for dental treatment in patients with dementia using the Korean National Health Insurance data

Background@#The global population is aging rapidly, and accordingly, the number of patients with dementia is increasing every year. Although the need for dental treatment increases for various reasons in patients with dementia, they cannot cooperate during dental treatment. Therefore, behavioral management, including sedation (SED) or general anesthesia (GA), is required for patients with dementia. Thus, this study aimed to investigate the trends and effects of SED or GA in patients with dementia undergoing dental treatment in South Korea based on the Korean National Health Insurance claims data. @*Methods@#This study utilized customized health information data provided by the Health Insurance Review and Assessment Service. Among patients with records of using sedative drugs during dental treatment from January 2007 to September 2019, patients with the International Classification of Diseases-10 code for dementia (F00, F01, F02, F03, and G30) were selected. We then analyzed the full insurance claims data for dental care.Age, sex, sedative use, and dental treatment of patients were analyzed yearly. In addition, the number of cases of GA or SED per year was analyzed, and changes in behavioral management methods with increasing age were investigated. @*Results@#Between January 2007 and September 2019, a total of 4,383 (male, 1,454; female, 2,929) patients with dementia received dental treatment under SED or GA. The total number of SED and GA cases were 1,515 (male, 528 ; female, 987 ) and 3,396 (male, 1,119 ; female, 2,277) cases, respectively. The total number of cases of dental treatment for 4,383 patients with dementia was 153,051 cases, of which 2.22% were under GA and 0.98% were under SED. Midazolam was the most commonly used drug for SED. @*Conclusion@#Although gingivitis and pulpitis were the most common reasons for patients with dementia to visit the dentist, GA or SED for patients with dementia was frequently used in oral and maxillofacial or periodontal surgery.

Analysis of application of dental sedation in attention deficit hyperactivity disorder (ADHD) patients using the Korean National Health Insurance data

Background@#Attention deficit hyperactivity disorder (ADHD) is characterized by a persistent pattern of inattention and/or hyperactivity-impulsivity that interferes with functioning or development. It has a worldwide pooled prevalence of 5.29%. The characteristics of ADHD can increase the probability of dental treatment, while special behavior management can be required to allow proper treatment. In South Korea, the use of sedation in dental treatment has rapidly increased in recent decades. The present study aimed to investigate the trend and effects of sedation in patients with ADHD undergoing dental treatment in South Korea. @*Methods@#The study used customized health information data provided by the Korean National Health Insurance Service. Among patients with the record of sedative use during the period from January 2007 to September 2019, those with International Classification of Diseases-10 codes for ADHD (F90, F91) were selected; the data of their overall insurance claims for dental treatment were then analyzed. The patients’ age, gender, sedative use, and dental treatment were analyzed per year. The annual number of general anesthesia or sedation cases was also analyzed, and changes in the method of behavior management with increasing age were examined. @*Results@#The study involved 7,654 patients with ADHD (6,270 males; 1,384 females). The total number of dental treatments was 137,778, while the number of sedation cases was 16,109, among which 13,052 involved male patients and 3,057 female patients. The number of general anesthesia cases was 631, among which 538 involved male patients and 93 female patients. The most frequently used sedation method in the dental treatment of patients with ADHD was N2 O inhalation. The percentage of sedation cases was highest in patients aged 4 years, and it decreased with increasing age. @*Conclusion@#In South Korea, both sedation and dental treatments were slightly more common in patients with ADHD than in the general population. With increasing age, the frequency of dental treatments and the percentage of sedation cases decreased.

Analysis of behavioral management for dental treatment in patients with dementia using the Korean National Health Insurance data

Background@#The global population is aging rapidly, and accordingly, the number of patients with dementia is increasing every year. Although the need for dental treatment increases for various reasons in patients with dementia, they cannot cooperate during dental treatment. Therefore, behavioral management, including sedation (SED) or general anesthesia (GA), is required for patients with dementia. Thus, this study aimed to investigate the trends and effects of SED or GA in patients with dementia undergoing dental treatment in South Korea based on the Korean National Health Insurance claims data. @*Methods@#This study utilized customized health information data provided by the Health Insurance Review and Assessment Service. Among patients with records of using sedative drugs during dental treatment from January 2007 to September 2019, patients with the International Classification of Diseases-10 code for dementia (F00, F01, F02, F03, and G30) were selected. We then analyzed the full insurance claims data for dental care.Age, sex, sedative use, and dental treatment of patients were analyzed yearly. In addition, the number of cases of GA or SED per year was analyzed, and changes in behavioral management methods with increasing age were investigated. @*Results@#Between January 2007 and September 2019, a total of 4,383 (male, 1,454; female, 2,929) patients with dementia received dental treatment under SED or GA. The total number of SED and GA cases were 1,515 (male, 528 ; female, 987 ) and 3,396 (male, 1,119 ; female, 2,277) cases, respectively. The total number of cases of dental treatment for 4,383 patients with dementia was 153,051 cases, of which 2.22% were under GA and 0.98% were under SED. Midazolam was the most commonly used drug for SED. @*Conclusion@#Although gingivitis and pulpitis were the most common reasons for patients with dementia to visit the dentist, GA or SED for patients with dementia was frequently used in oral and maxillofacial or periodontal surgery.

Complications caused by nitrous oxide in dental sedation

The first clinical application of nitrous oxide (N₂O) was in 1844, by an American dentist named Horace Wells who used it to control pain during tooth extraction. Since then, N₂O has shared a 170-year history with modern dental anesthesia. N₂O, an odorless and colorless gas, is very appealing as a sedative owing to its anxiolytic, analgesic, and amnestic properties, rapid onset and recovery, and, in particular, needle-free application. Numerous studies have reported that N₂O can be used safely and effectively as a procedural sedation and analgesia (PSA) agent. However, N₂O can lead to the irreversible inactivation of vitamin B12, which is essential for humans; although rare, this can be fatal in some patients.

The effect of dental scaling noise during intravenous sedation on acoustic respiration rate (RRa™)

BACKGROUND: Respiration monitoring is necessary during sedation for dental treatment. Recently, acoustic respiration rate (RRa™), an acoustics-based respiration monitoring method, has been used in addition to auscultation or capnography. The accuracy of this method may be compromised in an environment with excessive noise. This study evaluated whether noise from the ultrasonic scaler affects the performance of RRa in respiratory rate measurement. METHODS: We analyzed data from 49 volunteers who underwent scaling under intravenous sedation. Clinical tests were divided into preparation, sedation, and scaling periods; respiratory rate was measured at 2-s intervals for 3 min in each period. Missing values ratios of the RRa during each period were measuerd; correlation analysis and Bland-Altman analysis were performed on respiratory rates measured by RRa and capnogram. RESULTS: Respective missing values ratio from RRa were 5.62%, 8.03%, and 23.95% in the preparation, sedation, and scaling periods, indicating an increased missing values ratio in the scaling period (P < 0.001). Correlation coefficients of the respiratory rate, measured with two different methods, were 0.692, 0.677, and 0.562 in each respective period. Mean capnography-RRa biases in Bland-Altman analyses were −0.03, −0.27, and −0.61 in each respective period (P < 0.001); limits of agreement were −4.84–4.45, −4.89–4.15, and −6.18–4.95 (P < 0.001). CONCLUSIONS: The probability of missing respiratory rate values was higher during scaling when RRa was used for measurement. Therefore, the use of RRa alone for respiration monitoring during ultrasonic scaling may not be safe.

Anesthetic management for simultaneous drug-induced sleep endoscopy and maxillomandibular advancement in a patient with obstructive sleep apnea

Drug-induced sleep endoscopy (DISE) is used to identify areas of upper airway obstruction, which occurs when patients with obstructive sleep apnea (OSA) snore. DISE enables effective diagnosis and appropriate treatment of the obstruction site. Among surgical treatment methods for OSA, maxillomandibular advancement surgery (MMA) is performed to move a jaw forward; the surgery has a high success rate for OSA treatment. In DISE, anesthetics such as propofol and midazolam must be administered to induce snoring while the patient is deeply sedated for an accurate diagnosis to be made. When inducing deep sedation in a patient with OSA, airway obstruction may increase, causing oxygen saturation to drop; airway interventions are necessary in such cases. Effective DISE and MMA surgery can be performed by administering propofol through target-controlled infusion while monitoring the bispectral index (BIS).

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..

Effects of airway evaluation parameters on the laryngeal view grade in mandibular prognathism and retrognathism patients

BACKGROUND: Failure to maintain a patent airway can result in brain damage or death. In patients with mandibular prognathism or retrognathism, intubation is generally thought to be difficult. We determined the degree of difficulty of airway management in patients with mandibular deformity using anatomic criteria to define and grade difficulty of endotracheal intubation with direct laryngoscopy. METHODS: Measurements were performed on 133 patients with prognathism and 33 with retrognathism scheduled for corrective esthetic surgery. A case study was performed on 89 patients with a normal mandible as the control group. In all patients, mouth opening distance (MOD), mandibular depth (MD), mandibular length (ML), mouth opening angle (MOA), neck extension angle (EXT), neck flexion angle (FLX), thyromental distance (TMD), inter-notch distance (IND), thyromental area (TMA), Mallampati grade, and Cormack and Lehane grade were measured. RESULTS: Cormack and Lehane grade I was observed in 84.2%, grade II in 15.0%, and grade III in 0.8% of mandibular prognathism cases; among retrognathism cases, 45.4% were grade I, 27.3% grade II, and 27.3% grade III; among controls, 65.2% were grade I, 26.9% were grade II, and 7.9% were grade III. MOD, MOA, ML, TMD, and TMA were greater in the prognathism group than in the control and retrognathism groups (P < 0.05). The measurements of ML were shorter in retrognathism than in the control and prognathism groups (P < 0.05). CONCLUSIONS: Laryngoscopic intubation was easier in patients with prognathism than in those with normal mandibles. However, in retrognathism, the laryngeal view grade was poor and the ML was an important factor.

Dexmedetomidine intravenous sedation using a patient-controlled sedation infusion pump: a case report

Dental treatment under sedation requires various sedation depths depending on the invasiveness of the procedure and patient drug sensitivity. Inappropriate sedation depth may cause patient discomfort or endangerment. For these reasons, patient-controlled sedation (PCS) pumps are commonly used. Patients are able to control the sedation depths themselves by pushing the demand button after the practitioner sets up the bolus dose and lock-out time. Dexmedetomidine is an α-2 adrenoreceptor agonist with sedative, analgesic, and anxiolytic properties. It has been widely used for sedation for its minimal respiratory depression; however, there are few studies on PCS using dexmedetomidine. This study assessed the applicability of dexmedetomidine to PCS.

Deep sedation for dental treatment in a Down syndrome patient with Eisenmenger syndrome: A case report

Eisenmenger syndrome (ES) is characterized by pulmonary arterial hypertension and right-to-left shunting. The signs and symptoms of ES include cyanosis, shortness of breath, fatigue, hemoptysis, and sudden death. In patients with ES, it is important that the systemic and pulmonary circulations be properly distributed and maintained. General dental treatment is not known to be particularly dangerous. To control pain and anxiety, local anesthetics without epinephrine are usually recommended. However, in cases of difficulty of cooperation, general anesthesia for dental treatment makes the condition worse. In the present case, intravenous deep sedation with propofol and remifentanil was administered for behavioral management during dental treatment successfully.

Identifying the more suitable nostril for nasotracheal intubation using radiographs

BACKGROUND: One nostril must be selected for nasotracheal intubation. In some cases, structural anomalies within the nasal cavity hinder the insertion of the tube or complications, such as epistaxis, develop. This study examined the possibility of using radiography to select the nostril that would induce fewer complications. METHODS: Four hundred and five patients who underwent nasotracheal intubation under general anesthesia were studied. A 7.0-mm internal diameter nasal right angle endotracheal (RAE) tube and 6.5-mm internal diameter nasal RAE tube were inserted into men and women, respectively. Complications were considered to have developed in cases in which insertion of the tube into the nasal cavity failed or epistaxis occurred. The tube was inserted into the other nostril for insertion failures and hemostasis was performed in cases of epistaxis. The degree of nasal septal deviation was determined from posteroanterior skull radiographs or panoramic radiographs; the incidence of complications was compared depending on the direction of the septal deviation and the intubated nostril. RESULTS: The radiographs of 390 patients were readable; 94 had nasal septum deviation. The incidence of complications for cases without nasal septum deviation was 16.9%, that for cases in which the tube was inserted into the nostril on the opposite side of the deviation was 18.5%, and that for cases in which the tube was inserted into the nostril with the deviation was 35.0%, showing a high incidence of complications when intubation is performed through the nostril with septum deviation (chi-square test, P < 0.05 ). CONCLUSIONS: Although there were no differences in the incidence rates of complications between intubation through the left nostril and that through the right nostril, radiological findings indicated that incidence of complications significantly increased when the tube was inserted into the nostril with the septum deviation.

Identifying the more suitable nostril for nasotracheal intubation using radiographs

BACKGROUND: One nostril must be selected for nasotracheal intubation. In some cases, structural anomalies within the nasal cavity hinder the insertion of the tube or complications, such as epistaxis, develop. This study examined the possibility of using radiography to select the nostril that would induce fewer complications. METHODS: Four hundred and five patients who underwent nasotracheal intubation under general anesthesia were studied. A 7.0-mm internal diameter nasal right angle endotracheal (RAE) tube and 6.5-mm internal diameter nasal RAE tube were inserted into men and women, respectively. Complications were considered to have developed in cases in which insertion of the tube into the nasal cavity failed or epistaxis occurred. The tube was inserted into the other nostril for insertion failures and hemostasis was performed in cases of epistaxis. The degree of nasal septal deviation was determined from posteroanterior skull radiographs or panoramic radiographs; the incidence of complications was compared depending on the direction of the septal deviation and the intubated nostril. RESULTS: The radiographs of 390 patients were readable; 94 had nasal septum deviation. The incidence of complications for cases without nasal septum deviation was 16.9%, that for cases in which the tube was inserted into the nostril on the opposite side of the deviation was 18.5%, and that for cases in which the tube was inserted into the nostril with the deviation was 35.0%, showing a high incidence of complications when intubation is performed through the nostril with septum deviation (chi-square test, P < 0.05 ). CONCLUSIONS: Although there were no differences in the incidence rates of complications between intubation through the left nostril and that through the right nostril, radiological findings indicated that incidence of complications significantly increased when the tube was inserted into the nostril with the septum deviation.

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.

Combitube insertion in the situation of acute airway obstruction after extubation in patients underwent two-jaw surgery

The Combitube is an emergency airway-maintaining device, which can supply oxygen to dyspneic patients in emergency situations following two-jaw surgery. These patients experience difficulty in opening the mouth or have a partially obstructed airway caused by edema or hematoma in the oral cavity. As such, they cannot maintain the normal airway. The use of a Combitube may be favorable compared to the laryngeal mask airway because it is a thin and relatively resilient tube. A healthy 24-year-old man was dyspneic after extubation. Oxygen saturation fell below 90% despite untying the bimaxillary fixation and ambubagging. The opening of the mouth was narrow; thus, emergency airway maintenance was gained by insertion of a Combitube. The following day, a facial computer tomography revealed that the airway space narrowing was severe compared to its pre-operational state. After the swelling subsided, the patient was successfully extubated without complications.

Clinical considerations in the use of forced-air warming blankets during orthognathic surgery to avoid postanesthetic shivering

BACKGROUND: During head and neck surgery including orthognathic surgery, mild intraoperative hypothermia occurs frequently. Hypothermia is associated with postanesthetic shivering, which may increase the risk of other postoperative complications. To improve intraoperative thermoregulation, devices such as forced-air warming blankets can be applied. This study aimed to evaluate the effect of supplemental forced-air warming blankets in preventing postanesthetic shivering. METHODS: This retrospective study included 113 patients who underwent orthognathic surgery between March and September 2015. According to the active warming method utilized during surgery, patients were divided into two groups: Group W (n = 55), circulating-water mattress; and Group F (n = 58), circulating-water mattress and forced-air warming blanket. Surgical notes and anesthesia and recovery room records were evaluated. RESULTS: Initial axillary temperatures did not significantly differ between groups (Group W = 35.9 ± 0.7℃, Group F = 35.8 ± 0.6℃). However, at the end of surgery, the temperatures in Group W were significantly lower than those in Group F (35.2 ± 0.5℃ and 36.2 ± 0.5℃, respectively, P = 0.04). The average body temperatures in Groups W and F were, respectively, 35.9 ± 0.5℃ and 36.2 ± 0.5℃ (P = 0.0001). In Group W, 24 patients (43.6%) experienced postanesthetic shivering, while in Group F, only 12 (20.7%) patients required treatment for postanesthetic shivering (P = 0.009, odds ratio = 0.333, 95% confidence interval: 0.147-0.772). CONCLUSIONS: Additional use of forced-air warming blankets in orthognathic surgery was superior in maintaining normothermia and reduced the incidence of postanesthetic shivering.

Circadian variation of IV PCA use in patients after orthognathic surgery: a retrospective comparative study

BACKGROUND: An understanding of the features of postoperative pain is essential for optimal analgesic dosing strategies. Using a visual analogue scale (VAS) score and patient controlled analgesia (PCA) infusion pattern analysis, an anesthesiologist can estimate when and how severely patients suffer from pain. Several reports have been published about circadian changes in the pain threshold. Postoperative pain was analyzed retrospectively in 250 patients who underwent orthognathic surgery. METHODS: A total of 250 patients were allocated into two groups according to the time of recovery from anesthesia. Patients in the early group (group E) recovered from anesthesia before 06:00 p.m. Patients in the late group (group L) recovered from anesthesia after 06:00 p.m. All patients received intravenous patient controlled analgesia (IV PCA) at the end of the operation. The VAS score of pain intensity was measured. Self-administration of bolus analgesic from the IV PCA device was also analyzed according to actual time and elapsed time. RESULTS: VAS scores showed no difference between the two groups except 36 hours after recovery from anesthesia. On POD1, there were two peaks for self-administration of bolus analgesics in group L and one peak in the morning for group E. Two peaks each in the morning and in the afternoon were shown in both groups on POD2. CONCLUSIONS: Diurnal variance in pain should be considered for effective dosing strategies.

Immediate implant placement for schizophrenic patient with outpatient general anesthesia

The difficult oral healthcare in intellectually disabled patients with poor behavioral control has led to debate over the cost-effectiveness and validity of implant treatment in these patients. The patient in the present report had schizophrenia that had led to poor oral care and severe dental caries in the full mouth. Tooth extraction and a removable prosthesis were planned, but the guardian wanted an implant procedure. Since the guardian showed strong will and cooperation with regard to the patient's oral healthcare, extraction followed by immediate implant placement was performed across two rounds of general anesthesia. Since the outcome appears successful, we present this case report. Immediate implant placement after tooth extraction requires fewer surgeries and rounds of general anesthesia, reduces horizontal bone resorption, and can achieve better esthetic results. Therefore, as long as a certain degree of oral care is possible, this can be a positive option for restoration of a partially edentulous mouth, even in intellectually disabled patients.