Regimens for pediatric sedation.

Pediatric sedation is one of the most challenging areas of clinical practice. The goal of pediatric management is to accomplish treatment on a comfortable and cooperative child. While comfort may be achieved with or without drugs, cooperation may occasionally be achieved only when levels of sedation deepen to the point of obtunding the child. Anatomic and physiologic differences in the pediatric patient give high priority to airway management, oxygenation, and ventilation. Techniques for pediatric sedation and anesthesia are reviewed and recommendations are made for the rational selection of an appropriate pharmacological management technique.

Midazolam: review of a versatile agent for use in dentistry.

Midazolam is a relatively new benzodiazepine that is widely used in both medicine and dentistry. Its multiplicity of uses makes it unique among the benzodiazepines, and its water solubility and lack of active metabolites give it distinct advantages over diazepam. This paper reviews the clinical pharmacology of midazolam, provides comparison with diazepam and presents current information regarding its indications, limitations, advantages, disadvantages, methods of administration and precautions for use.

Faint in the supine position. Selective review of the literature and a case report.

A case of faint occurred in a patient undergoing periodontal surgery with intravenous conscious-sedation in the horizontal position. The faint occurred 3 hours and 40 minutes into the procedure, immediately following the extraction of a maxillary molar that could not be salvaged due to excessive bone loss. Since the patient was judged to be adequately sedated by both the operator and the anesthetist, the faint could not be attributed to anxiety. Recent evidence suggests that somatosensory stimulation of the trigeminal nerve may produce a reflex parasympathetic discharge that could account for some syncopal episodes observed during dental procedures.

Digitalis toxicity. A case report.

Digitalis has a clinically useful therapeutic ratio (LD50/ED50), but doses must be carefully adjusted for each patient to avoid manifestations of toxicity. This paper reviews the pharmacology and toxicology of digitalis and reports an occurrence in which life-threatening cardiac dysrhythmias occurred as a result of digitalis toxicity in a patient undergoing full mouth gingival curettage. In addition, some recommendations for prevention and management of this problem are discussed.

Local anesthetics in dental practice.

Local anesthetics are the most widely used drugs in dentistry today. Knowledge of the pharmacology and toxicology of these agents will result in their intelligent and judicious use. The choice of local anesthetic should be individualized for each patient. The duration of the dental procedure should be weighed against the duration of action of the local anesthetic; a decision should be made as to whether a vasoconstrictor is needed to prolong its action. However, if the duration of numbness is too long, the possibility of self-mutilation must be considered in certain patients (for example, children and the mentally retarded). In other patients with whom postoperative pain is expected, it may be beneficial to administer a long-acting local anesthetic such as bupivacaine for control of postoperative pain. The total dose of local anesthetic and vasoconstrictor must be determined for each patient based upon body weight; the maximal dosages for each agent should be known. Small children or frail individuals will require below average dosages. The use of a vasoconstrictor may constitute the limiting factor to the total number of local anesthetic cartridges that can be administered safely over a given period of time. Certain medical problems, such as cardiovascular system impairments or hyperthyroidism, may influence the choice of anesthetic and the quantity of vasoconstrictor. An understanding of the physicochemical properties of local anesthetics is also important to a rational process of selection. There are several causes for failure to achieve profound regional anesthesia. These include inflammation and/or infection, anatomic variation, intravascular injection, accessory innervation, and deflection of the needle. Inflammation and infection reduce the efficacy of a local anesthetic by reducing its bioavailability. Local anesthetics with low pKa values (for instance, mepivacaine) are the most effective in this clinical situation. Other causes of inadequate regional anesthesia are primarily related to technique of administration and can be circumvented by the use of the periodontal ligament injection. A comprehensive review of this technique and its application has been presented by the Council on Dental Materials and Equipment of the American Dental Association. Occasionally, a clinician may be unsuccessful at achieving regional anesthesia despite these additional measures. Highly anxious dental patients or patients with a genuine tolerance to local anesthetics normally pose the most problems. Transitional block or threshold block phenomena should also be suspected in these situations.(ABSTRACT TRUNCATED AT 400 WORDS)

Nitrous oxide and oral premedication.

Patients frequently require conscious-sedation to achieve anxiety relief in the dental office. There are specific indications, contraindications, advantages, and disadvantages to each sedation modality. Selection of the appropriate anesthetic technique should be individualized for each patient. This paper reviews two important conscious-sedation modalities: oral premedication and nitrous oxide/oxygen inhalation sedation.Pertinent drugs are reviewed and recommendations are made for their use; current researches are presented and new areas for investigation are suggested.

Hypersensitivity to amide local anesthetics? Report of a case.

The majority of adverse reactions to local anesthetics are either the direct result of pharmacologic properties of the local anesthetics and/or vasoconstrictors or the result of excessive anxiety. However, because of the insidious nature of the symptoms, many adverse reactions are mistakenly identified as allergic. The following case illustrates how knowledge of the above and persistence in evaluation can lead to proper classification of adverse reactions to amino-amide local anesthetics.

Stress-induced urticaria associated with local anesthetic administration.

A case is reported in which chronic urticaria developed following local anesthetic administration in a 21-year old Chinese-American male who had presented for routine dental care. An in-depth medical history and intradermal skin-testing failed to disclose a reason for this reaction. Referral to an allergist revealed a previously unknown underlying emotional tension which contributed to the development of chronic urticaria. A brief trial of hydroxyzine (Vistaril), an antihistaminic and anxiolytic medication, was successful in controlling this condition. This case illustrates the importance of the evaluation of the emotional status as a vital component of a comprehensive medical history.

The effectiveness of 1.5% etidocaine HCl with epinephrine 1:200,000 and 2% lidocaine HCl with epinephrine 1:100,000 in oral surgery: a clinical comparison.

A clinical comparison of 28 patients was done in a double-blind fashion to evaluate the effectiveness of 1.5 etidocaine with epinephrine 1:200,000 and 2% lidocaine with epinephrine 1:100,000 in oral surgery. The patients selected had no medical problems, but required the extraction of bilaterally impacted third molars. Each subject served as his or her own control with etidocaine being used to produce local anesthesia on one side of the face, and lidocaine on the opposite side. The results were evaluated to allow a comparison of the onset and quality of anesthesia; the duration of lip numbness and the onset of postoperative pain; and the incidence, type, and severity of adverse reactions. Both lidocaine and etidocaine were similar in onset and quality of anesthesia. No adverse reactions were observed with either agent. The two anesthetics differed mainly in their durations of action. Etidocaine proved 2.16 times longer acting than lidocaine with respect to recovery from lower lip numbness and 1.75 times longer acting than lidocaine with respect to the onset of postoperative pain. Therefore, the conclusion was reached that 1.5% etidocaine with epinephrine 1:200,000 is an effective local anesthetic for use in oral surgery because it has a rapid onset, provides profound anesthesia, and possesses a longer duration of action than 2% lidocaine with epinephrine 1:100,000. The final characteristic is of particular value as the onset of postoperative pain is significantly delayed.

Cardiorespiratory effects of meperidine, diazepam, and methohexital conscious sedation.

The effects of conscious sedation on the respiratory and cardiovascular systems of seven healthy volunteers were studied. With mean dosages of meperidine, 0.41 mg/kg, diazepam, 0.13 mg/kg, and methohexital titrated incrementally to effect, there were statistically significant changes in PaO2, PaCO2, and arterial blood pH, and no statistically significant change in cardiac output as determined by arterial blood gas analysis and impedance cardiac output monitoring. No clinically significant changes were observed in cardiorespiratory function, and all patients were conscious according to the definition proposed by the American Dental Society of Anesthesiology. The variation in PaO2 showed only marginal statistical significance. There was no clinical indication for supplemental oxygen.