- Email: [email protected]
Drugs used for parenteral sedation in dentistry
543
CURRENT LITERATURE
helping devise management strategies. The author feels that explanations for the development of pain, which are primarily described as being muscular in etiology, are not based on scientific research and do not coincide with features of muscular type pain found in other parts of the body. He disputes that diagnostic modalities such as electromyography differentiate muscle problems in the patient with pain from the patient with symptoms. It is also stated that chronic spasm of a facial muscle is a concept that has never been shown in fact to be present when critically evaluated. Finally, the hypothesis that emotional disturbances are the root of this problem are disputed, based on the lack of sound data. He concludes that although pain-dysfunction syndrome has been ascribed to many disorders in the facial region, many of those disorders are actually due to structural disturbances in the TMJ itself and, therefore, efforts should be made to distinguish disorders in which documentable joint pathology can be found. He feels that if a muscle disorder is felt to be present, more precise diagnostic modalities should be used to document their presence before treatment, and that the same should be done for disturbances felt to be of psychiatric origin. He points out that disturbances in joint, muscle, or dental function can cause problems in either of the other two areas; therefore, the primary and secondary symptoms should be distinguished to allow that separation before treatment. Finally, it is stated that the term pain-dysfunction syndrome should not be used as a waste basket for problems without documented pathology. Rather, use of the term “pain of unknown origin” would be more appropriate.-J.R. HUPP Reprint requests to Dr Reynolds: Department of Medicine, Howard University Hospital, 2041 Georgia Ave NW, Washington, DC 20060. TMJ Complications Associated With Superior Repositioning of the Maxilla. Kahnberg K. J Cranio Pratt 6:312, 1988 The author of this study suspected that there was a higher incidence of temporomandibular joint (TMJ) symptoms in patients following superior repositioning of the maxilla. He therefore performed a retrospective clinical study of 13 patients who had isolated LeFort I impactions for either open bite deformities or vertical maxillary excess. None of these patients had documented symptoms relatable to TMJ dysfunction based on documentation in the records or on the patients’ postoperative memories of their preoperative state. Ten of the patients had open bite deformities, and 11 of the patients were females. Posterior impactions varied from 4 to 8 mm, with a mean of 6 mm. All patients had skeletal fixation as well as 7 weeks of intermaxillary fixation. Six patients experienced no postoperative symptoms relatable to the TMJ, but the remaining seven all had signs of TMJ dysfunction including the appearance of reciprocal clicking in four patients, reduced maximal opening in one patient, and muscle and palpable tenderness over the condyle in two patients. The symptoms of TMJ disturbance developed within the first 6 months following surgery, but on postoperative TMJ radiographs there were no demonstrable bony changes in follow-ups ranging from 6 to 30 months. The author postulates that the symptoms are due to a new position of the condylar head within the glenoid fossa as well as a change in positioning of the muscles of mastication. He also theorizes that the new position of the
condyle causes a squeezing of the disc. He suggests that in some cases a bimaxillary surgical approach might have been preferable and also states that patients should be prepared for the possibility of the appearance of TMJ symptoms following such surgery.-J.R. HUPP Reprint request to Dr Kahnberg: Department of Oral Surgery, Faculty of Odontology, University of Umea, 701 87 Umea, Sweden. The Effect of Smoking on Immediate Post-Extraction Socket Filling With Blood and on the Incidence of Painful Socket. Meechan JG, MacGregor IDM, Rogers SN, et al. Br J Oral Maxillofac Surg 26:402, 1988 This study investigated whether the habit of smoking reduced the blood supply to extraction sockets, and secondly, determined if smoking inthrenced the incidence of dry socket following intra-alveolar dental extractions. Blood supply to the extraction sites was determined by the level of blood filling in the postextraction socket. Data were collected on 3,541 extractions performed under local anesthesia on 2,417 adult patients. Postoperative socket filling with blood was found to be significantly reduced in smokers as compared with nonsmokers. ‘There was a higher incidence of dry socket in heavy smokers (20 or more cigarettes per day) as compared with nonsmokers. There was a significant relationship between immediate postextraction socket blood level and the incidence of dry socket: poorer filling was most likely to result in a dry socket. In conclusion, smoking appeared to have an adverse effect through its vasoconstrictive and fibrinolytic activities on the healing of extraction woulds.--B.T. PORTER Reprint requests to Dr Meechan: The Dental School, The University of Newcastle upon Tyne, Framlington Place, Newcastle upon Tyne NE2 4BW. Osteomyelitis of the Mandible. Calhoun KH, Shapiro RD, Stiemberg CM, et al. Arch Otolaryngol Head Neck Surg 114:1157, 1988 This study reviewed the characteristics and clinical courses of 60 patients with mandibular bone infections. Fifteen patients had posttraumatic osteomyelitis, 13 had odontogenic osteomyelitis, four had postoperative osteomyelitis, and 28 had osteoradionecrosis. The types of surgical procedures and the use of adjunctive hyperbaric oxygen were described. Minimal differences in presentation or response to treatment were found in the four different groups of patients. A proposal for a clinical staging system for mandibular bone infections was introduced, which was based on degree of bony involvement and host factors. The results of the clinical study support treatment of these lesions by surgery and antibiotic coverage based on the stage of the disease process.-B.T. PORTER Reprint requests to Dr Calhoun: Department of Otolaryngology, University of Texas Medical Branch, Galveston, TX 775.50. Drugs Used for Parenteral Sedation in Dentistry. RA, Gift HC. Anesth Prog 35:199, 1988
Dionne
Despite the remarkable safety record of sedation and anesthesia in dentistry, a recent NIH consensus confer-
CURRENT LITERATURE
ence confiied the need to identify commonly used drugs or drug combinations so that well-controlled clinical trials of efficacy and safety can be performed. A questionnaire was sent to a random sample of Fellows of the American Dental Society of Anesthesiology (ADSA). More than two thirds of fellows are oral and maxillofacial surgeons. A 53% response rate yielded 264 usable responses. The most common single drug sedation technique used by 52% of respondents utilizes benzodiazepines (BZD), with nearly equal use of midazolam and diazepam. Barbiturates (BRB) were used as single drugs by 22%, and nacrotics (N) were infrequently used alone. Drug combinations widely used included BZD plus N plus BRB, or BZD plus N, or BZD plus BRB. Meperidine and fentanyl were the most commonly used narcotics, and methohexital the most commonly used barbiturate. Altogether, 82 different intravenous drug techniques were identified. Six per cent of respondents used oral premeditation, namely diazepam; 3% used intramuscular premeditation, with diazepam and ketamine the most popular. Of the respondents who use general anesthesia, 64% administer the anesthetic and perform the dental procedure. The remaining 36% stated the anesthetic is administered by either another dentist, a nurse anesthetist, or an anesthesiologist. The author indicates that further research is needed to ascertain uses of sedation by members of the dental profession other than oral and maxillofacial surgeons.-J. DEMBO Reprint requests to Dr Dionne: National Institute of Dental Re-
search, NIH, Bldg 10, Room 3C-442, !XNJORockville Pike, Bethesda, MD 208%.
Branchial Remnants: A Review of 58 Cases. Doi 0, Hutson JM, Myers NA, et al. J Pediatr Surg 23:789, 1988 This is a 13-year review of 58 operated patients (66 branchial remnants). Twelve per cent (8) were considered to be of first branchial cleft origin, 67% (44) from the second cleft, and 3% (2) from the third or fourth clefts; the origins of 18% (12) were difficult to determine. Eighty-seven per cent of the patients with skin tags and external fistulae were <5 years old at time of operation, and eight patients with cysts, but no fistula, were >9 years old at time of surgery. Pathologic findings showed squamous, columnar, and mixed epithelium. Lymphoid tissue was found in 31 patients. Hospitalization was generally short, with the exception for first cleft defects with fistula, where four of eight patients stayed >5 days. There was a 7% (4) recurrence rate involving first branchial remnants (3) and one second branchial cyst. Operative excision is the treatment of choice for branchial remnants. The authors concluded that in view of these findings, first branchial remnants must be excised with extra care.-D.E. WILLIAMS Reprint requests to Dr Doi: Department of Pediatric Surgery, Mothers and Children’s Medical Centre, Kure National Hospital, 3-l Aoyama-cho, Kure City, Hiroshima, 737 Japan.
Assessment of Perloperative Risk in the Patient With Diabetes Mellitus. Mackenzie CR, Charlson ME. Surg Gyneco1 Obstet 167:293, 1988 Caring for patients period
is challenging
with diabetes in the perioperative and often dficult. A study was un-
dertaken to define the characteristics that identify patients with diabetes who are at high risk for complications in the postoperative period. The hospital charts of 282 diabetics who underwent surgical procedures were reviewed. The presence of comorbid disease such as chronic hypertension, ischemic heart disease, etc, was tabulated. Overall, 15% of the patients had significant complications. Younger patients had fewer postoperative complications. The presence of diabetic end-organ disease was associated with a higher incidence of postoperative complications. Eleven percent of patients had noncardiac complications. The presence of diabetic endorgan disease, congestive failure or valvular disease, and peripheral vascular disease accompanied by infection present on admission were significantly associated with noncardiac complications. Postoperative infections developed in 6% of patients. Patients with cardiac problems had 7.6 times greater odds of serious postoperative infection. Seven percent of patients had either postoperative congestive heart failure or acute myocardial infarction. The significant predictors of cardiac complications were preexisting congestive heart failure or valvular heart disease and age >75 years. The degree of glucose control was not correlated with cardiac complications. Four per cent of patients died after the first surgical procedure. Death was predicted only by the presence of the major preoperative cardiac risk factors of congestive cardiac failure or valvular heart disease. The degree of glucose control did not predict postoperative mortality. The authors conclude that in patients with diabetes mellitus postoperative complications can be predicted from the presence of readily identifiable preoperative clinical characteristics.-S.J. MCKENNA Reprint requests to Dr MacKenzie: The Hospital for Special Surgery, 535 70th St, Rm 226, New York, NY 10021.
Safety Precautions in the Management of Patients With Pacemakers When Electrocautery Operations are Performed. Erdman S, Levinsky L, Servadio C, et al. Surg Gynecol Obstet 167:311, 1988 General surgical procedures in pacemaker carriers have become common in recent years. A study was undertaken to point out the safety precautions taken when using electrocautery in pacemaker carrier patients. Eleven urologic surgical procedures were performed on ten patients with implanted pacemakers. All of the pacemakers were functioning in a ventricular pacingand-sensing-inhibited (VVI) mode or in a double-pacing, double-sensing-inhibited (DDD) mode. The electrocautery circuit was kept well below the pacemaker by a low placement of the electrocautery ground plate. The surgeon was advised to use the electrocautery apparatus in short, repetitive bursts. The pacemakers of all the patients continued to function properly during the procedures. No pacemaker dysfunction occurred. Two potential hazards exist in patients with pacemakers undergoing surgical treatment with electrocautery. One is asystole caused by electrical interference of the sensing circuit in the synchronous type pacemaker. The other hazard is ventricular fibrillation caused by an additional source of electrical energy passing through the body. The first hazard is preventable by converting the pacemaker to a fixed rate or magnet rate mode. The second hazard is diminished by placement of the electrocautery circuit below the
CURRENT LITERATURE
helping devise management strategies. The author feels that explanations for the development of pain, which are primarily described as being muscular in etiology, are not based on scientific research and do not coincide with features of muscular type pain found in other parts of the body. He disputes that diagnostic modalities such as electromyography differentiate muscle problems in the patient with pain from the patient with symptoms. It is also stated that chronic spasm of a facial muscle is a concept that has never been shown in fact to be present when critically evaluated. Finally, the hypothesis that emotional disturbances are the root of this problem are disputed, based on the lack of sound data. He concludes that although pain-dysfunction syndrome has been ascribed to many disorders in the facial region, many of those disorders are actually due to structural disturbances in the TMJ itself and, therefore, efforts should be made to distinguish disorders in which documentable joint pathology can be found. He feels that if a muscle disorder is felt to be present, more precise diagnostic modalities should be used to document their presence before treatment, and that the same should be done for disturbances felt to be of psychiatric origin. He points out that disturbances in joint, muscle, or dental function can cause problems in either of the other two areas; therefore, the primary and secondary symptoms should be distinguished to allow that separation before treatment. Finally, it is stated that the term pain-dysfunction syndrome should not be used as a waste basket for problems without documented pathology. Rather, use of the term “pain of unknown origin” would be more appropriate.-J.R. HUPP Reprint requests to Dr Reynolds: Department of Medicine, Howard University Hospital, 2041 Georgia Ave NW, Washington, DC 20060. TMJ Complications Associated With Superior Repositioning of the Maxilla. Kahnberg K. J Cranio Pratt 6:312, 1988 The author of this study suspected that there was a higher incidence of temporomandibular joint (TMJ) symptoms in patients following superior repositioning of the maxilla. He therefore performed a retrospective clinical study of 13 patients who had isolated LeFort I impactions for either open bite deformities or vertical maxillary excess. None of these patients had documented symptoms relatable to TMJ dysfunction based on documentation in the records or on the patients’ postoperative memories of their preoperative state. Ten of the patients had open bite deformities, and 11 of the patients were females. Posterior impactions varied from 4 to 8 mm, with a mean of 6 mm. All patients had skeletal fixation as well as 7 weeks of intermaxillary fixation. Six patients experienced no postoperative symptoms relatable to the TMJ, but the remaining seven all had signs of TMJ dysfunction including the appearance of reciprocal clicking in four patients, reduced maximal opening in one patient, and muscle and palpable tenderness over the condyle in two patients. The symptoms of TMJ disturbance developed within the first 6 months following surgery, but on postoperative TMJ radiographs there were no demonstrable bony changes in follow-ups ranging from 6 to 30 months. The author postulates that the symptoms are due to a new position of the condylar head within the glenoid fossa as well as a change in positioning of the muscles of mastication. He also theorizes that the new position of the
condyle causes a squeezing of the disc. He suggests that in some cases a bimaxillary surgical approach might have been preferable and also states that patients should be prepared for the possibility of the appearance of TMJ symptoms following such surgery.-J.R. HUPP Reprint request to Dr Kahnberg: Department of Oral Surgery, Faculty of Odontology, University of Umea, 701 87 Umea, Sweden. The Effect of Smoking on Immediate Post-Extraction Socket Filling With Blood and on the Incidence of Painful Socket. Meechan JG, MacGregor IDM, Rogers SN, et al. Br J Oral Maxillofac Surg 26:402, 1988 This study investigated whether the habit of smoking reduced the blood supply to extraction sockets, and secondly, determined if smoking inthrenced the incidence of dry socket following intra-alveolar dental extractions. Blood supply to the extraction sites was determined by the level of blood filling in the postextraction socket. Data were collected on 3,541 extractions performed under local anesthesia on 2,417 adult patients. Postoperative socket filling with blood was found to be significantly reduced in smokers as compared with nonsmokers. ‘There was a higher incidence of dry socket in heavy smokers (20 or more cigarettes per day) as compared with nonsmokers. There was a significant relationship between immediate postextraction socket blood level and the incidence of dry socket: poorer filling was most likely to result in a dry socket. In conclusion, smoking appeared to have an adverse effect through its vasoconstrictive and fibrinolytic activities on the healing of extraction woulds.--B.T. PORTER Reprint requests to Dr Meechan: The Dental School, The University of Newcastle upon Tyne, Framlington Place, Newcastle upon Tyne NE2 4BW. Osteomyelitis of the Mandible. Calhoun KH, Shapiro RD, Stiemberg CM, et al. Arch Otolaryngol Head Neck Surg 114:1157, 1988 This study reviewed the characteristics and clinical courses of 60 patients with mandibular bone infections. Fifteen patients had posttraumatic osteomyelitis, 13 had odontogenic osteomyelitis, four had postoperative osteomyelitis, and 28 had osteoradionecrosis. The types of surgical procedures and the use of adjunctive hyperbaric oxygen were described. Minimal differences in presentation or response to treatment were found in the four different groups of patients. A proposal for a clinical staging system for mandibular bone infections was introduced, which was based on degree of bony involvement and host factors. The results of the clinical study support treatment of these lesions by surgery and antibiotic coverage based on the stage of the disease process.-B.T. PORTER Reprint requests to Dr Calhoun: Department of Otolaryngology, University of Texas Medical Branch, Galveston, TX 775.50. Drugs Used for Parenteral Sedation in Dentistry. RA, Gift HC. Anesth Prog 35:199, 1988
Dionne
Despite the remarkable safety record of sedation and anesthesia in dentistry, a recent NIH consensus confer-
CURRENT LITERATURE
ence confiied the need to identify commonly used drugs or drug combinations so that well-controlled clinical trials of efficacy and safety can be performed. A questionnaire was sent to a random sample of Fellows of the American Dental Society of Anesthesiology (ADSA). More than two thirds of fellows are oral and maxillofacial surgeons. A 53% response rate yielded 264 usable responses. The most common single drug sedation technique used by 52% of respondents utilizes benzodiazepines (BZD), with nearly equal use of midazolam and diazepam. Barbiturates (BRB) were used as single drugs by 22%, and nacrotics (N) were infrequently used alone. Drug combinations widely used included BZD plus N plus BRB, or BZD plus N, or BZD plus BRB. Meperidine and fentanyl were the most commonly used narcotics, and methohexital the most commonly used barbiturate. Altogether, 82 different intravenous drug techniques were identified. Six per cent of respondents used oral premeditation, namely diazepam; 3% used intramuscular premeditation, with diazepam and ketamine the most popular. Of the respondents who use general anesthesia, 64% administer the anesthetic and perform the dental procedure. The remaining 36% stated the anesthetic is administered by either another dentist, a nurse anesthetist, or an anesthesiologist. The author indicates that further research is needed to ascertain uses of sedation by members of the dental profession other than oral and maxillofacial surgeons.-J. DEMBO Reprint requests to Dr Dionne: National Institute of Dental Re-
search, NIH, Bldg 10, Room 3C-442, !XNJORockville Pike, Bethesda, MD 208%.
Branchial Remnants: A Review of 58 Cases. Doi 0, Hutson JM, Myers NA, et al. J Pediatr Surg 23:789, 1988 This is a 13-year review of 58 operated patients (66 branchial remnants). Twelve per cent (8) were considered to be of first branchial cleft origin, 67% (44) from the second cleft, and 3% (2) from the third or fourth clefts; the origins of 18% (12) were difficult to determine. Eighty-seven per cent of the patients with skin tags and external fistulae were <5 years old at time of operation, and eight patients with cysts, but no fistula, were >9 years old at time of surgery. Pathologic findings showed squamous, columnar, and mixed epithelium. Lymphoid tissue was found in 31 patients. Hospitalization was generally short, with the exception for first cleft defects with fistula, where four of eight patients stayed >5 days. There was a 7% (4) recurrence rate involving first branchial remnants (3) and one second branchial cyst. Operative excision is the treatment of choice for branchial remnants. The authors concluded that in view of these findings, first branchial remnants must be excised with extra care.-D.E. WILLIAMS Reprint requests to Dr Doi: Department of Pediatric Surgery, Mothers and Children’s Medical Centre, Kure National Hospital, 3-l Aoyama-cho, Kure City, Hiroshima, 737 Japan.
Assessment of Perloperative Risk in the Patient With Diabetes Mellitus. Mackenzie CR, Charlson ME. Surg Gyneco1 Obstet 167:293, 1988 Caring for patients period
is challenging
with diabetes in the perioperative and often dficult. A study was un-
dertaken to define the characteristics that identify patients with diabetes who are at high risk for complications in the postoperative period. The hospital charts of 282 diabetics who underwent surgical procedures were reviewed. The presence of comorbid disease such as chronic hypertension, ischemic heart disease, etc, was tabulated. Overall, 15% of the patients had significant complications. Younger patients had fewer postoperative complications. The presence of diabetic end-organ disease was associated with a higher incidence of postoperative complications. Eleven percent of patients had noncardiac complications. The presence of diabetic endorgan disease, congestive failure or valvular disease, and peripheral vascular disease accompanied by infection present on admission were significantly associated with noncardiac complications. Postoperative infections developed in 6% of patients. Patients with cardiac problems had 7.6 times greater odds of serious postoperative infection. Seven percent of patients had either postoperative congestive heart failure or acute myocardial infarction. The significant predictors of cardiac complications were preexisting congestive heart failure or valvular heart disease and age >75 years. The degree of glucose control was not correlated with cardiac complications. Four per cent of patients died after the first surgical procedure. Death was predicted only by the presence of the major preoperative cardiac risk factors of congestive cardiac failure or valvular heart disease. The degree of glucose control did not predict postoperative mortality. The authors conclude that in patients with diabetes mellitus postoperative complications can be predicted from the presence of readily identifiable preoperative clinical characteristics.-S.J. MCKENNA Reprint requests to Dr MacKenzie: The Hospital for Special Surgery, 535 70th St, Rm 226, New York, NY 10021.
Safety Precautions in the Management of Patients With Pacemakers When Electrocautery Operations are Performed. Erdman S, Levinsky L, Servadio C, et al. Surg Gynecol Obstet 167:311, 1988 General surgical procedures in pacemaker carriers have become common in recent years. A study was undertaken to point out the safety precautions taken when using electrocautery in pacemaker carrier patients. Eleven urologic surgical procedures were performed on ten patients with implanted pacemakers. All of the pacemakers were functioning in a ventricular pacingand-sensing-inhibited (VVI) mode or in a double-pacing, double-sensing-inhibited (DDD) mode. The electrocautery circuit was kept well below the pacemaker by a low placement of the electrocautery ground plate. The surgeon was advised to use the electrocautery apparatus in short, repetitive bursts. The pacemakers of all the patients continued to function properly during the procedures. No pacemaker dysfunction occurred. Two potential hazards exist in patients with pacemakers undergoing surgical treatment with electrocautery. One is asystole caused by electrical interference of the sensing circuit in the synchronous type pacemaker. The other hazard is ventricular fibrillation caused by an additional source of electrical energy passing through the body. The first hazard is preventable by converting the pacemaker to a fixed rate or magnet rate mode. The second hazard is diminished by placement of the electrocautery circuit below the