Assessing the duration of mandibular soft tissue anesthesia.

Dentists often employ solutions of 3 percent mepivacaine or 4 percent prilocaine without a vasoconstrictor in pediatric patients in an attempt to reduce the duration of mandibular soft tissue anesthesia. The authors compared the time course of soft tissue anesthesia produced by these solutions with that of 2 percent lidocaine plus 1:100,000 epinephrine in 60 adults. They found no reduction in the duration of soft tissue anesthesia when employing 3 percent mepivacaine or 4 percent prilocaine instead of 2 percent lido-epi. Combining these observations with local anesthetic dosage considerations, the authors recommend that 2 percent lido-epi be used when performing mandibular block injections in young children.

The use of magnetic resonance imaging to determine splint position in the management of internal derangements of the temporomandibular joint.

Internal derangements of the temporomandibular joint (TMJ) can elicit symptoms of pain, clicking and noises described subjectively as popping, grinding or grating. These symptoms may be the precursor of a more severe disease process such as degenerative joint disease (DJD) or osteoarthritis. The most common factor predisposing to degenerative changes within the TMJ is a displaced meniscus. Maintenance of a proper anatomic meniscal-condylar relationship is essential in preventing DJD. In the past, non-surgical treatment utilizing intraoral orthotic devices has been attempted to "recapture" the meniscus. The position of the meniscus was then evaluated merely by clinical examination due to the lack of modalities available to verify the meniscal position. The advent of magnetic resonance imaging (MRI) has changed this scenario. The meniscal position can now be visualized, thus enabling the practitioner to treat patients more effectively. Three case reports are presented in this study demonstrating the use of splint therapy utilizing MRI to determine meniscal position.

Primary care management of maxillofacial injuries in sports.

Injuries to the maxillofacial region sustained in sports related trauma are increasing in the United States. The pediatric (age 12 and younger) and teenage populations account for the greatest number of these injuries primarily due to increased team sports participation in these younger age groups. A severe injury to the maxillofacial region can have devastating psychological effects as well as being physically debilitating. Therefore, early treatment of soft tissue and bony injuries will minimize scarring and decrease potentially adverse psychological implications. Sports trauma is a frequent source of maxillofacial injuries especially in the younger population. Basic protective equipment, such as proper fitting helmets, mouth guards and face masks, are still not mandatory, or rules not enforced, in many youth hockey and football leagues. In addition, the increased popularity of multispeed bicycles, dirt bikes, and off-road vehicles (e.g. snowmobiles, go-carts) in the hands of unrestrained and unprotected children and adolescents has contributed to an increasing number of maxillofacial injuries in these groups.

Single dose and multidose analgesic study of ibuprofen and meclofenamate sodium after third molar surgery.

The purpose of this study was to compare the analgesic efficacy and safety of meclofenamate sodium with ibuprofen after dental impaction surgery. This study was double-blind and used a unique methodology. Patients (N = 254) were first randomized into the single dose phase of the study that included placebo, meclofenamate 50 mg, meclofenamate 100 mg, ibuprofen 200 mg, and ibuprofen 400 mg, followed by a 7-day multidose phase in which patients in the placebo group were rerandomized into one of the active treatment cells. In the single dose phase, all active treatments were significantly more efficacious than placebo for every summary analgesic measure. A positive dose-response was seen for both active drugs with meclofenamate 100 mg and ibuprofen 400 mg exhibiting the greatest efficacy for pain relief, pain reduction, time to remedication, and overall evaluation. Side effects were reported by 26 patients. They were evenly distributed among treatment groups with headache and drowsiness being the most common. During the multidose phase, there were only small differences in efficacy measures among active treatment groups. However, meclofenamate produced a higher incidence of stomach cramps and diarrhea than did ibuprofen (8.8% and 7.2% versus 0.8% and 0.8%). This study indicates that higher doses of nonsteroidal anti-inflammatory drugs are most effective immediately after surgery and that lower doses of these drugs can be used after the first postoperative day. The side effect profile of nonsteroidal anti-inflammatory analgesics is best observed with the use of a multidose study design.

Ibuprofen controlled-release formulation. A clinical trial in dental impaction pain.

This double-blind study compared a controlled-release formulation of ibuprofen 600 mg with three doses of regular ibuprofen 200 mg and three doses of codeine 30 mg. Patients who had dental impaction surgery received the controlled-release ibuprofen, codeine, or regular ibuprofen when postoperative pain reached moderate to severe intensity. At 4 and 8 hours after dose 1, patients who had initially received the controlled-release ibuprofen received a placebo, and those taking ibuprofen and codeine received their second and third doses of those drugs. All doses of study medication or placebo appeared identical for each treatment. Subjects made evaluations hourly for 12 hours in a diary. The controlled-release ibuprofen had a comparable onset to ibuprofen, a higher peak effect, and was significantly more effective than ibuprofen at hour 4; the controlled-release ibuprofen was significantly more effective than codeine for all hourly observations through hour 9. Ibuprofen was significantly better than codeine only through hour 3. The controlled-release ibuprofen had the lowest incidence of side effects and codeine the highest. The single dose of the controlled-release ibuprofen formulation appeared as efficacious as three regular doses of ibuprofen 200 mg over a 12-hour period.

Narcotic receptor blockade and its effect on the analgesic response to placebo and ibuprofen after oral surgery.

The purpose of this study was to evaluate the contribution of endogenous opiates to the analgesic response after treatment with placebo, codeine, and ibuprofen after oral surgery. Eighty-one patients undergoing complicated dental extractions were pretreated with either a placebo or the narcotic antagonist naltrexone 50 mg, 30 minutes before surgery. After surgery, patients self administered one of three possible postsurgical medications, which included placebo, codeine 60 mg, and ibuprofen 400 mg, when their pain reached a moderate or severe intensity. The study was double-blind with the three postsurgical treatments being randomly allocated within each presurgical treatment block. Pain intensity, pain relief, pain half gone, and overall evaluations were assessed for up to 6 hours. Ibuprofen was significantly more efficacious (p < .05) than codeine or placebo for most analgesic measures. The administration of naltrexone before surgery reduced the analgesic response to both placebo and codeine. Pretreatment with naltrexone did not diminish the peak analgesic response to ibuprofen, but surprisingly prolonged (p < .05) the duration of its action. The results suggest that a blockade of endogenous opiates by naltrexone diminished the placebo response, but that naltrexone may prolong ibuprofen analgesia by some unknown mechanism.

Total temporomandibular joint reconstruction with a Delrin titanium implant.

Numerous alloplastic materials have been used for partial or total reconstruction of the temporomandibular joint in patients with fibrous or bony ankylosis, severe degenerative joint disease, or traumatic deformity, and for reconstruction following tumor resection and corrective surgery following multiple arthroplasties. We have had initial success with the use of a polyoxymethylene (Delrin) condylar head affixed to a pure titanium mesh for these reconstructive procedures. This versatile prosthesis does not require use of a separate glenoid fossa prosthesis. The surgical technique, as well as a historical perspective on alloplastic total joint prostheses used to date, is described in several patients.

Reconstructing the atrophic mandible with inferior border grafting and implants: a preliminary report.

Advanced mandibular atrophy is a serious surgical reconstruction challenge. Previous experience with an inferior border approach has been favorable. Predictably successful osseointegrated implants ultimately allow loading of the healed grafts. The technique described uses a freeze-dried, gamma-irradiated cadaver mandible packed with autogenous iliac crest bone. An extraoral approach allows augmentation without disrupting use of an intraoral prosthesis during healing. The incidence of infection and resorption can be reduced. Fewer problems with neurosensory disturbances common with some of the superior border, or sandwich osteotomy, grafting techniques were experienced. The use of implants to ultimately load the bone should result in less resorption than in those techniques using a conventional removable prosthesis.

Reversing intravenous sedation with flumazenil.

This study was designed to evaluate the effects of flumazenil in reversing sedation from midazolam and meperidine after oral surgical procedures. Of the 35 patients entered, efficacy was evaluated in 33 and safety in 34. Patients were tested for sedation, psychomotor skills, and memory during a 3-hour period and at a 24-hour follow-up. Flumazenil almost totally reversed the effects of sedation for approximately 2 hours, after which some loss of effect was observed. A number of central nervous system-related side effects were observed in the flumazenil group, but none of these was considered serious. One patient in the flumazenil group had an episode of hypotension that precluded further testing.

Nitrous oxide, Part I: Historical perspective and patient selection.

Nitrous oxide inhalation sedation has a remarkable history of efficacy and safety. This article, the first of a two-part series, will review the history, pharmacology, and patient selection criteria of nitrous oxide sedation.