Patient safety: reducing the risk of wrong tooth extraction.

Over recent years there has been an increased emphasis on improving patient safety in all branches of medicine, with reducing wrong tooth extraction being a priority in dentistry. The true incidence of wrong tooth extraction is unknown but it is considered an avoidable harm and is a significant source of dental litigation. Interventions to reduce wrong tooth extraction include educational programmes encompassing human factor training, patient assisted identification, the use of checklists, marking of surgical sites and implementation of patient safety guidelines. Identified risk factors which make wrong tooth extraction more likely include; suboptimal checks and/or cross checking of relevant clinical information, unclear diagnosis, unclear documentation, ambiguity regarding notation of molar teeth, orthodontic extractions, and extractions where there are multiple carious teeth and extractions in the mixed dentition. Accurate and timely reporting of wrong tooth extraction incidents followed by analysis and sharing of findings together with implementation of improved practice will help to minimise risks of wrong tooth extraction.

Wrong tooth extraction: an examination of 'Never Event' data.

The NHS in England has identified several adverse incidents that involve patients, including operations done at the wrong site, as "never" events. We examined published data from the period April 2012 to October 2015 and found that "wrong tooth/teeth removed" is the most common "wrong site" event, and accounted for between 20% and 25% of wrong site surgery never events, and 6% - 9% of all "never" events. All "wrong tooth/teeth removed" events seem to have been reported only by hospitals or Community Trusts. It is important to find out how these events are recorded and to find ways to prevent them.

The implications of substance misuse for intravenous conscious sedation practice.

Substance misuse is a major health concern in the United Kingdom, as the consequences for individuals are significant and may include multisystem organ damage. It is important for the dentist to know which patients are misusing substances as some pharmacological agents routinely used in dental practice may be contraindicated. The dentist should be aware of the range of clinical presentations that may arise from substance misuse and when suspected, a thorough drug history must be obtained. Patients may require special consideration and further investigations when planning elective procedures, particularly under intravenous conscious sedation. Therefore, management within a specialist centre and liaison with other health professionals may be indicated to ensure treatment is provided safely.

Preventing wrong tooth extraction: experience in development and implementation of an outpatient safety checklist.

Extraction of the wrong tooth or teeth is a serious and avoidable clinical error causing harm to the patient. All NHS Trusts in England are required to use a surgical safety checklist in operating theatres to prevent incorrect site surgery and ensure safe management of patients. However, the majority of patients have dental extractions and other oral surgical procedures undertaken on an outpatient basis and these patients are also at risk of having an incorrect site surgical procedure such as a wrong tooth extraction. We describe our experience in developing, introducing and refining a surgical safety checklist for outpatient oral surgery along with the key strategic actions needed to ensure effective cultural change and optimum patient safety in the outpatient setting.

Improving patient safety in a UK dental hospital: long-term use of clinical audit.

The improvement of patient safety has been a long-term aim of healthcare organisations and following recent negative events within the UK, the focus on safety has rightly increased. For over twenty years, clinical audit has been the tool most frequently used to measure safety-related aspects of healthcare and when done so correctly, can lead to sustained improvements. This paper explains how clinical audit is used as a safety improvement tool in an English dental hospital and gives several examples of projects that have resulted in long-term improvements in secondary dental care.

Measuring patient safety in a UK dental hospital: development of a dental clinical effectiveness dashboard.

Patient safety is an important marker of quality for any healthcare organisation. In 2008, the British Government white paper entitled High quality care for all, resulting from a review led by Lord Darzi, identified patient safety as a key component of quality and discussed how it might be measured, analysed and acted upon. National and local clinically curated metrics were suggested, which could be displayed via a 'clinical dashboard'. This paper explains the development of a clinical effectiveness dashboard focused on patient safety in an English dental hospital and how it has helped us identify relevant patient safety issues in secondary dental care.

A comparative evaluation of intranasal dexmedetomidine, midazolam and ketamine for their sedative and analgesic properties: a triple blind randomized study.

OBJECTIVES: To evaluate and compare the efficacy and safety of Intranasal (IN) Dexmedetomidine, Midazolam and Ketamine in producing moderate sedation among uncooperative pediatric dental patients. STUDY DESIGN: This randomized triple blind comparative study comprises of eighty four ASA grade I children of both sexes aged 4-14 years, who were uncooperative and could not be managed by conventional behavior management techniques. All the children were randomized to receive one of the four drug groups Dexmedetomidine 1 microg/ kg (D1), 1.5 microg/kg (D2), Midazolam 0.2 mg/kg (M1) and Ketamine 5 mg/kg (K1) through IN route. These drug groups were assessed for efficacy and safety by gauging overall success rate and by monitoring vital signs, respectively. RESULTS: The onset of sedation was significantly rapid with M1 and K1 as compared to D1 and D2 (p = < 0.001). The overall success rate was highest in D2 (85.7%) followed by D1 (81%), K1 (66.7%) and M1 (61.9%), however, the difference among them was not statistically significant (p = > 0.05). Even though all the vital signs were within physiological limits, there was significant reduction in pulse rate (PR) (p = < 0.001) and systolic blood pressure (SBP) (p = < 0.05) among D1 and D2 as compared to M1 and K1. D1, D2 and K1 produced greater intra- and post-operative analgesia as compared to M1. There were no significant adverse effects with any group. CONCLUSION: Dexmedetomidine, Midazolam and Ketamine, all the three drugs evaluated in the present study can be used safely and effectively through IN route in uncooperative pediatric dental patients for producing moderate sedation.

An evaluation of Vitamin E and Pycnogenol in children suffering from oral mucositis during cancer chemotherapy.

OBJECTIVE: The purpose of the present study was to evaluate and compare the effectiveness of Vitamin E (E) and Pycnogenol (P) in treatment of Chemotherapy-Related Oral Mucositis (ChROM) in children. MATERIALS AND METHODS: A total of 72 children, aged between 6 and 15 years, with ChROM were selected and randomly divided into three groups after assessment of oral mucositis (OM) by WHO grading system. Glycerine (control), E, and P were topically applied in group I, II, and III, respectively, and the prognosis of OM was assessed by functional, objective, and subjective parameters. RESULTS: Patients of group II and III showed significant improvement when ChROM was analyzed through scoring systems - WHO grading, Oral Mucositis Assessment Scale (OMAS), and Children's International Mucositis Evaluation Scale (ChIMES) as compared to group I (P < 0.001); however, there was no significant difference between groups II and III. CONCLUSION: Both the drugs E and P per se are effective for treatment of OM with P being not effective for the treatment of severe mucositis (grade 4). Combination of E and P and additional agents may be tried for better results.

A comparative evaluation of intranasal midazolam, ketamine and their combination for sedation of young uncooperative pediatric dental patients: a triple blind randomized crossover trial.

OBJECTIVE: The purpose of this study was to evaluate and compare the efficacy and safety of intranasal (IN) administration of midazolam (M), ketamine (K) and their combination (MK) to produce moderate sedation in young, uncooperative pediatric dental patients. STUDY DESIGN: In this three stage crossover trial forty five uncooperative ASA type-1 children, who required dental treatment, were randomly assigned to receive one of the three drugs/combination by IN route during three subsequent visits. The efficacy and safety of the agents were assessed by overall success rate and by monitoring of vital signs, respectively. RESULTS: The onset of sedation was rapid with K as compared to M and MK. The difference was statistically significant (P < 0.01) between K and M. The overall success rate was 89% with K, MK was 84% and 69% with M. The difference between the overall success rates of K and M was statistically significant (P < 0.01). Vital signs were within physiological limits and there were no significant adverse effects with any medication. CONCLUSIONS: M, K and MK are safe and effective by IN route to produce moderate sedation for providing dental care to pediatric dental patients who have been otherwise indicated for treatment under general anesthesia.

A comparative evaluation of drops versus atomized administration of intranasal ketamine for the procedural sedation of young uncooperative pediatric dental patients: a prospective crossover trial.

OBJECTIVE: The objective of this study was to compare and evaluate the efficacy and safety of drops and atomized administration of intranasal ketamine (INK) in terms of behavioral response for agent acceptance during administration and for agent efficacy and safety for the sedation of young uncooperative pediatric dental patients. STUDY DESIGN: Thirty-four uncooperative ASA grade-1 children, requiring dental treatment were randomly assigned to receive INK as drops and atomized spray in one of the subsequent visit. This was a two stage cross-over trial and each child received INK by both modes of administration. The vital signs were monitored continuously during each visit. RESULTS: A statistically significant difference in patients acceptance (P < 0.0001) was observed in the atomized administration when compared to drops administration for the procedural event of drug administration. Moreover there were also significant differences (P < 0.05) between onset of sedation and recovery time between two groups. All the vital signs were within normal physiological limits and there were no significant adverse effects in either group. CONCLUSIONS: INK is safe and effective by either mode of intranasal (IN) drug administration for moderate sedation in facilitating dental care for anxious and uncooperative pediatric dental patients. Moreover, INK when administered with the mucosal atomization device, the acceptance of the drug was associated with less aversive reaction, rapid onset and recovery of sedation, as compared to the drop administration of the same agent.

Midazolam-fentanyl analgo-sedation in pediatric dental patients--a pilot study.

OBJECTIVE: The objective of this study was to comparatively evaluate the effectiveness ofsubmucosalfentanyl when administered in conjunction with oral midazolam during pediatric procedural sedations. STUDY DESIGN: Twenty three uncooperative ASA type I children who met the selection criteria were randomly assigned to receive either submucosal fentanyl (3 microg/kg) or placebo, along with oral midazolam (0.5 mg/kg). A triple blind, 2-stage cross-over design was adopted so that each child received both the regimens. RESULTS: Transient oxygen desaturation was observed in 4 children who were sedated with the combination of oral midazolam and submucosalfentanyl. The overall success was 73.91% with oral midazolam and submucosal fentanyl regimen and 47.83% for oral midazolam and submucosal placebo regimen. The chances of 'satisfactorily'completing a 45 minute dental procedure in an uncooperative pediatric patient was 2.8 times more, when submucosalfentanyl was used along with oral midazolam. CONCLUSION: Submucosal fentanyl appears to improve the short working time associated with oral midazolam. But the oxygen desaturation associated with this regimen necessitates further studies to evaluate the efficacy of this combination at relatively lower doses before being used routinely for pediatric procedural sedation and analgesia.

A comparative evaluation of agents producing analgo-sedation in pediatric dental patients.

OBJECTIVE: Procedural sedation and analgesia (PSA) has reduced the need for general anesthesia (GA) for many surgical procedures in pediatric patients. The objective of this study was to evaluate the efficacy of four analgo-sedative combinations- midazolam plus ketamine (MK), midazolam plus tramadol (MT), promethazine plus tramadol (PT) and promethazine plus ketamine (PK) in facilitating dental treatment of uncooperative children. STUDY DESIGN: Thirty six uncooperative ASA type I children who required extensive dental treatment were randomly assigned to receive one of the four analgo-sedative combinations during each visit. A 4-stage cross-over design was adopted so that each child received all the four combinations. Safety was monitored through vital signs and side effects. RESULTS: The overall success was 81% with MK, 69% for PK, 67% for MT and 42% for PT and the difference between the success rates of these agents was statistically significant (p < 0.001). The required dental treatment could be successfully completed at least during 3 sessions in 23 children (62.2%). CONCLUSIONS: Segmental dental treatment under analgo-sedation can be considered as a viable alternative before considering patients for dental management under GA. MK and MT were found to be safe and effective for sedating pediatric dental patients.

Hepatitis C virus NS3-4A serine protease inhibitors: SAR of new P1 derivatives of SCH 503034.

Substitutions on the P(1) cyclobutyl side chain of SCH 503034 were studied by introduction of hydroxyl and fluoro substituents. Additionally, effects of fluoro substitution on other P1 moieties were evaluated.

Hepatitis C virus NS3-4A serine protease inhibitors: SAR of P'2 moiety with improved potency.

We have discovered that introduction of appropriate amino acid derivatives at P'2 position improved the binding potency of P3-capped alpha-ketoamide inhibitors of HCV NS3 serine protease. X-ray crystal structure of one of the inhibitors (43) bound to the protease revealed the importance of the P'2 moiety.

Hepatitis C virus NS3-4A serine protease inhibitors: use of a P2-P1 cyclopropyl alanine combination for improved potency.

Modification of the P(2) and P(1) side chains of earlier P(3)-capped alpha-ketoamide inhibitor of HCV NS3 serine protease 1 resulted in the discovery of compound 24 with about 10-fold improvement in potency.

An investigation of the effect on 27-gauge needle tips following a single local anaesthetic injection.

One hundred and forty one, 27-gauge local anaesthetic needles were collected, each following a single injection of local anaesthetic using four commonly performed local anaesthetic injection techniques. The needles were examined for needle tip damage under the scanning electron microscope. Ten unused needles were used as controls. Bone was contacted in 75 (59%) instances and, of these, 73 (97.3%) showed needle tip deformity. Of the four techniques used, bone contact was commonest with the inferior alveolar nerve block, occurring in 88% of instances.

Binding affinities and geometries of various metal ligands in peptide deformylase inhibitors.

Removal of the N-terminal formyl group from newly synthesized proteins by the enzyme peptide deformylase (PDF) is essential for normal growth of bacteria but not higher organisms. Recently, PDF has been explored as a target for novel antibiotics. Screening a collection of natural products for antimicrobial activity identified actinonin and two matlystatin analogs as potent PDF inhibitors. A number of synthetic analogs of these natural products were prepared and their inhibitory potency determined. Previous work has shown that PDF is an iron metalloproteinase also containing a catalytic glutamic acid residue. Ligation of the ferrous cation is an essential feature of potent inhibitors. The structures of actinonin, a matlystatin analog and a synthetic inhibitor complexed with PDF were determined by crystallography. A quantum mechanics/molecular mechanics (QM/MM) method was used to reproduce the geometry of known complexes, to predict the protonation state in the active site and to predict the geometry of additional complexes. The requirement for protonation of the active site glutamate anion is an important factor in understanding the potency of inhibitors with acidic iron-ligating groups such as hydroxamate and carboxylate. Even though potent inhibitors of PDF have been discovered, their bacteriostatic mechanism of action and the rapid development of resistance in vitro may limit their potential as antibacterial drugs.

A comparative evaluation of oral midazolam with other sedatives as premedication in pediatric dentistry.

The purpose of present study was to evaluate the safety and efficacy of orally administered midazolam in children as a sedative agent and to compare it with two other older agents, triclofos and promethazine. The study was conducted on ninety child patients requiring some short dental procedure. All the patients were with a good physical status (ASA-I). The ages ranged between 3 and 9 years. The patients were randomized into three study groups: Group 1, midazolam, Group II, triclofos and Group III, promethazine, on the basis of the drugs to be administered. After administration of drugs in each group, the effects were evaluated in terms of onset of action, sedative effect, ease of treatment completion, recovery time and postoperative amnesia. Midazolam was found to be the best drug among the three to produce conscious sedation in children.

Chiral high-performance liquid chromatographic analysis of antifungal SCH 56592 and evaluation of its chiral inversion in animals and humans.

SCH 56592 is a novel triazole antifungal agent that is active both orally and intravenously in animal models of infection. This compound is in Phase II-III clinical trials for the treatment of systemic fungal infections. SCH 56592 is a single enantiomer with four stereogenic centers; therefore, it was necessary to evaluate the possible chiral inversion of this drug candidate in animals and humans. Thus, chiral high-performance liquid chromatographic (HPLC) methods have been developed to separate SCH 56592 from its diastereomers and to evaluate its chiral inversion in rats, dogs, cynomolgus monkeys, and humans. Chiral HPLC analysis involved the use of a Chiralcel OD column set at 39 degrees C with a mobile phase of hexane-ethanol-diethylamine and a fluorescence detector set at an excitation wavelength of 270 nm and an emission wavelength of 390 nm. Plasma or serum samples were subjected to solid phase extraction on a C(2) cartridge followed by HPLC analysis. The method was sensitive with a limit of quantitation of 0.1 microg/ml in dog serum. The linearity was satisfactory, as shown by correlations of >0.997 and by visual examination of the calibration curves. The precision and accuracy were satisfactory, as indicated by coefficients of variation (CV) ranging from 1.1 to 12.1% and bias values ranging from -11.0 to 9.0%. Chiral HPLC analysis indicated that SCH 56592 was not subjected to chiral inversion in rats, dogs, cynomolgus monkeys, and humans.