The effect of arthrocentesis of the temporomandibular joint in patients with rheumatoid arthritis.

PURPOSE: This study evaluated the objective and subjective changes in a group of rheumatoid arthritic (RA) patients with temporomandibular joint (TMJ) complaints who were subjected to joint lysis and lavage. PATIENTS AND METHODS: Twelve females with previous documented RA underwent baseline assessment with erythrocyte sedimentation rate, physical examination of TMJ function, and a visual analog pain scale (VAPS). The VAPS and jaw function changes were recorded at 2-week intervals for 6 weeks after lysis and lavage under local anesthesia in an ambulatory setting. RESULTS: All patients showed statistically significant post-treatment improvement in their pain, and function was enhanced. CONCLUSION: TMJ arthrocentisis is a useful adjunct in the short-term management of the symptoms of rheumatoid arthritis.

Edema in the upper airway in patients with obstructive sleep apnea syndrome.

OBJECTIVE: The purpose of this study was to investigate the histologic alterations in the upper airway in patients with obstructive sleep apnea syndrome. STUDY DESIGN: Surgical specimens were obtained during non-laser-assisted uvulopalatopharyngoplasty from 5 adult patients (4 male and 1 female) with polysomnographically confirmed obstructive sleep apnea syndrome. RESULTS: In all of the specimens, interstitial edema was present with mild inflammatory reaction. Fat was not at all prominent. CONCLUSIONS: It is confirmed histologically that there is edema present in the upper airway in patients with obstructive sleep apnea syndrome. It is uncertain whether this edema is one of the causative mechanisms of the obstruction or a consequence of the syndrome.

Anecdotes from the history of anesthesia in dentistry.

I believe that dentists have made important contributions to anesthesiology and patient care. Medical anesthesiology is now being required to provide more same-day or ambulatory care. Where it was once good sport to criticize dentists providing brief anesthesia services for their patients, it has now become appropriate for physician anesthesiologists to use shorter-acting agents, improved physiologic monitoring, reversal agents, and early discharge as part of their care of patients. Anecdotes are informative and often provide us with nostalgic recognition and a smile. Ask yourself how you would have responded to the needs of your patients if you were practicing 40 or more yrs ago. We owe a major debt of gratitude to our gallant forebearers and an acknowledgement saying "Well done," and "God bless."

Israeli dentists: a survey of infection control office practices and care of medically compromised patients.

A survey was conducted by interviewing a randomly selected sample of practicing dentists in Israel in 1991. The aim of this study was to evaluate methods of infection control in current use and to learn about the access to care for medically compromised patients. One hundred seventeen dentists were interviewed. This group represented a majority of graduates from Israeli schools (66). With respect to infection control, only 28% of the population surveyed routinely uses gloves, but 43% use steam autoclave, and 70% use dry-heat sterilization. A very high percentage (87%) took a verbal medical history, while a small minority (27%) had their patients fill out a written questionnaire. Only occasionally was the name of the patient's physician requested or recorded, implying a flaw in interprofessional communications. Only 26% of the dentists said they would treat patients with hepatitis and/or AIDS. Only about half the dentists accepted patients on chemotherapy or radiotherapy or those who were taking anticoagulant drugs. Physical access for dental patients in wheelchair or stretcher was markedly limited, with referral to regional hospitals the routine for these patients.

Anesthesiology for dentists.

Finding the course to satisfy the requirement is not an easy matter. Fortunately, new educational programs are being developed.

Intravenous sedation in dentistry and oral surgery.

IV administration is the most precise and effective means of sedating a patient. Its desired effect is a comfortable and cooperative patient whose pain is alleviated by regional local anesthesia. It requires a patient who understands the difference between being lightly sedated and unconscious. Its primary purpose is to diminish anxiety and apprehension rather than to obtund protective reflexes. At all times, the patient should remain conscious and appropriately responsive to questions or commands. This state can be readily achieved in most patients by carefully titrating a single drug such as diazepam or midazolam to effect. The use of multiple drugs is to be discouraged, since it generally increases the level of sedation and the number of complications. Dosing should be individualized rather than averaged or arbitrary. The end point of titration is the patient's verbal acknowledgement of feeling more relaxed and the physical evidence of such relaxation. The "Verrill sign" indicates a level of deep sedation--too deep for most cases of conscious sedation in the office setting. I strongly oppose the routine use of narcotics for office sedation. Monitoring of vital signs before, during, and after surgery ensures the safety of the consciously sedated patient. The use of a pulse oximeter is an evolving standard in general anesthesia and may eventually prove important for patients receiving conscious sedation in the office setting.

An oral surgeon's approach to the fearful patient. Intravenous sedation and general anesthesia.

The oral surgeon's role in the management of the very apprehensive and/or phobic patient presents multiple challenges. It is important for the surgeon to recognize and even analyze some of the subtle changes that he and members of his staff feel when presented with these special patients. In general, they tend to disrupt the usual flow of practice and elicit behavior that may be defensive and threatening. Surgeons are temperamentally task oriented and may not be able to effectively manage such patients short of resorting to full general anesthesia. Appropriately administered and monitored, it may answer the acute surgical need while bypassing the underlying emotional situation. Referral of the patient to a special "dental phobia clinic" for follow-up care is definitely indicated, once the acute pain, swelling, or traumatic injury has been treated.

Propofol as an intravenous agent in general anesthesia and conscious sedation.

Propofol has been shown in clinical studies to be a safe, effective, hypnotic, and amnesic anesthetic agent at induction doses of 2-2.5 mg/kg and maintenance doses of approximately 9mg/kg per hour. Significant post-induction hypotension reported earlier can be reduced to a all in MAP of less than 25% when the drug is used alone (without nitrous oxide or narcotic premedication). Post-induction apnea is minimized by avoidance of pre-induction hyperventilation. Acute and long term venous tolerance is acceptable. Emergence from anesthesia induced and maintained with propofol is rapid, predictable and relatively free of postoperative complications. Incidence of drug interaction is low. Propofol causes no adrenocortical suppression and is not potentiated by ethanol, diazepam, amitriptyline or phenelzine. Preliminary investigation of propofol as an intravenous sedative agent at subanesthetic doses has been favorable.

Low occupational risk of human immunodeficiency virus infection among dental professionals.

We studied 1309 dental professionals (1132 dentists, 131 hygienists, and 46 assistants) without behavioral risk factors for the acquired immunodeficiency syndrome (AIDS) to determine their occupational risk for infection with human immunodeficiency virus (HIV). Subjects completed questionnaires on behavior; type, duration, and location of their dental practice; infection-control practices; and estimated numbers of potential occupational exposures to HIV. Serum samples were tested for antibodies to HIV and to hepatitis B surface antigen (unvaccinated subjects). Fifty-one percent of the subjects practiced in locations where many cases of AIDS have been reported. Seventy-two percent treated patients who had AIDS or were at increased risk for it. Ninety-four percent reported accidental puncturing of the skin with instruments used in treating patients. Adherence to recommended infection-control practices was infrequent. Twenty-one percent of unvaccinated subjects had antibodies to hepatitis B surface antigen. Only one dentist without a history of behavioral risk factors for AIDS had serum antibodies to HIV. We conclude that despite infrequent compliance with recommended infection-control precautions, frequent occupational exposure to persons at increased risk for HIV infection, and frequent accidental puncturing of the skin with sharp instruments, dental professionals are at low occupational risk for HIV infection.