Does Including Dexmedetomidine Improve Outcomes After Intravenous Sedation for Outpatient Dentoalveolar Surgery?

PURPOSE: Dexmedetomidine represents an intriguing adjunct to outpatient intravenous (IV) sedation owing to its decreased risk of respiratory depression. The purpose of the present study was to measure the incremental effect of incorporating dexmedetomidine (DXM) into an established IV sedation regimen compared with control IV sedation without the DXM infusion. MATERIALS AND METHODS: We designed a prospective, controlled trial in which American Society of Anesthesiologists Class 1 and 2 patients requiring both maxillary and mandibular dentoalveolar surgery would undergo 2 sedation appointments: 1 arch treated with surgery with control sedation (DXM-) using midazolam, fentanyl, and propofol as needed, and a second surgery on the opposite arch using the experimental sedation regimen (DXM+) of midazolam, fentanyl, and propofol, as needed, and a DXM infusion at 4 µg/kg/hr. The surgeon was the same for every appointment, and the patients were kept unaware regarding which sedation had included the experimental regimen. Whether the experimental sedation was used at the first or second surgery was randomized. The primary measured outcomes were efficiency in terms of anesthesia time for each sedation, the physiologic response in terms of vital signs, and the subjective patient experience. RESULTS: A total of 12 patients completed the trial. With DXM-, the patients had significantly shorter total (∼15 minutes) and adjusted anesthesia (∼10 minutes) times. With DXM+, the patients had significantly lower average systolic blood pressure (SBP), SBP low values, diastolic blood pressure (DBP) low values, average heart rate (HR), and HR low values. None of the other continuous patient outcomes differed significantly between the 2 groups. Of the 12 patients, 10 (83.3%) reported that they preferred the experimental sedation experience with DXM (95% confidence interval, 0.52 to 0.98). CONCLUSIONS: Using a DXM infusion with outpatient dentoalveolar surgery allowed for acceptable levels of sedation, greater patient satisfaction, and longer anesthesia and appointment times and often resulted in lower BP and heart rate.

Posttraumatic arteriovenous malformation of the face: a case report.

BACKGROUND: Head and neck arteriovenous malformations (AVMs) are reported to occur in 0.1% of the population. Extracranial AVMs account for only 8.1% of head and neck AVMs. Of these, traumatically acquired AVMs of the face are generally reported as quite rare. When secondary to trauma, the lesion is usually supplied by a single vessel, as compared to the multiple vessels often seen with congenital etiology. OBJECTIVES: Understanding of regional anatomy is paramount when assessing and managing facial injuries. As an integral health care provider for the facial trauma patient, it is the responsibility of the emergency physician to recognize this rare pathologic lesion necessary to coordinate surgical management of the traumatic AVM. CASE REPORT: We present a case report of a patient who sustained a facial laceration complicated by the development of a vascular malformation. The facial laceration in this case report highlights the complexity of wound evaluation and management when treating patients in the emergency department. CONCLUSION: Traumatic AVMs are quite rare in the head and neck and are mostly seen in the extremities. Although rare, they have been reported after typical facial trauma as well as elective surgical procedures. The management of such lesions may include selective embolization or surgical exploration with ligation. Emergency physicians and facial trauma surgeons are challenged with recognizing and treating these rare but very real vascular lesions. It is our hope that this case report provides an overview of posttraumatic AVMs in the head and neck.

Dental care for patients with heart failure: an update.

BACKGROUND: Heart failure (HF) is a common clinical syndrome that affects an estimated 5.7 million Americans. It is a growing health problem, particularly in people 65 years or older. Therefore, the probability that dental practitioners will have patients who have HF is increasing. METHODS: The authors reviewed medical literature from 2000 through 2009 to determine the incidence, classifications, pathophysiology and advances in the medical diagnosis and treatment of HF. They also reviewed available dental literature during the same period to formulate treatment recommendations for dental care of people who have HF. RESULTS: Medicine has made advances in understanding and treating HF. These advances have resulted in the development of revised classification systems, a more structured approach to patient assessment and improved therapeutic options. CONCLUSIONS: Dentists need to be aware of advances in the diagnosis and treatment of HF. Keeping in mind the potential for morbidity in patients who have HF, identifying and accurately assessing these patients is imperative for clinical management. CLINICAL IMPLICATIONS: Often it is necessary for dentists to consult with patients' physicians to coordinate care and determine whether treatment can be rendered appropriately in a routine dental setting or whether advanced support, monitoring or both are necessary.

Advances in head and neck radiotherapy to the mandible.

Management of radiation-exposed bone in the mandible is a dilemma many oral and maxillofacial surgeons must confront and manage. Current advances in radiotherapy techniques using pin-point computerized accuracy in combination with other advances, such as morphed imaging, fractionalization protocols, minimization of scatter, and pretreatment dental examinations, have greatly decreased the late effects of radiation and osteoradionecrosis. The intent of this article is to provide a brief overview of the following topics: radiotherapy physics and radiobiology, effects of radiotherapy on normal tissues, including the pathogenesis of osteoradionecrosis, and advances in contemporary radiotherapy treatment.

Distraction osteogenesis in irradiated rabbit mandibles with adjunctive hyperbaric oxygen therapy.

PURPOSE: The purpose of this study was to evaluate the effect of hyperbaric oxygen therapy on bone regeneration during distraction of irradiated rabbit mandibles. MATERIALS AND METHODS: Twenty New Zealand white rabbits were randomly sub-divided into 4 groups. Group 1 served as control, group 2 received preoperative radiation therapy, group 3 received pre- and postoperative hyperbaric oxygen (HBO) therapy, and group 4 received preoperative radiation therapy and pre- and postoperative HBO therapy. All rabbits underwent a corticotomy of the left body of the mandible after placement of a distraction device. Distraction, at a rate of 1 mm/day and a rhythm of 1 turn/day, began after a 3-day latency period for 14 days. Thirty days after completion of the distraction protocol, the animals were euthanized, and histomorphometric and radiographic data of the distraction segments were obtained. RESULTS: Histomorphometric analysis of new bone fill was greatest in the non-irradiated groups compared to groups receiving radiation therapy, regardless of HBO therapy (P = .03). Pre-corticotomy bone density measurements showed a significant increase in bone density over time (P = .0007). This resulted in a significant relationship between HBO therapy, radiation therapy, and time (P = .0050). CONCLUSIONS: The results of the study support the use of HBO therapy during distraction osteogenesis. Any additional therapeutic benefit of HBO therapy in irradiated bone would require additional investigation.

AAOMP case challenge: "The case of a subtle expansion of the mandible".

A healthy 25-year old Caucasian man presented for a routine dental examination. He was unaware of a subtle expansion involving the right posterior mandible, which was bony hard and nontender. Radiographic findings prompted an immediate referral of the patient to an oral and maxillofacial surgeon for diagnosis and management of the jaw lesion. What is your diagnosis?