Vasoconstrictors: indications and precautions

Principles of minimize bleeding and the transfusion of blood and its components in operated patients - surgical aspects

One of the target of perioperative tratment in surgery is decreasing intraoperative bleeding, which increases the number of perioperative procedures, mortality and treatment costs, and also causes the risk of transfusion of blood and its components. Trying to minimize the blood loss(mainly during the operation) as well as the need to transfuse blood and its components (broadly understood perioperative period) should be standard treatment for a patient undergoing a procedure. In the case of this method, the following steps should be taken: 1) in the preoperative period: identyfication of risk groups as quickly as possible, detecting and treating anemia, applying prehabilitation, modyfying anticoagulant treatment, considering donating one's own blood in some patients and in selected cases erythropoietin preparations; 2) in the perioperative period: aim for normothermia, normovolemia and normoglycemia, use of surgical methods that reduce bleeding, such as minimally invasive surgery, high-energy coagulation, local hemostatics, prevention of surgical site infection, proper transfusion of blood and its components if it occurs; 3) in the postoperative period: monitor the condition of patients, primarily for the detection of bleeding, rapid reoperation if required, suplementation (oral administration preferred) nutrition with microelements (iron) and vitamins, updating its general condition. All these activities, comprehensively and in surgical cooperation with the anesthesiologist, should reduce the blood loss and transfusion of blood and its components.

Does the presence and amount of epinephrine in 2% lidocaine affect its anesthetic efficacy in the management of symptomatic maxillary molars with irreversible pulpitis?

Background

This was a randomized controlled clinical trial that aimed to evaluate the anesthetic efficacy of 2% lidocaine combined with different concentrations of epinephrine (plain, 1:200,000 and 1:80,000) during endodontic treatment of maxillary molars with symptomatic irreversible pulpitis.

Methods

The trial included 144 adult patients who were randomly allocated to three treatment groups. All patients received buccal-plus-palatal infiltration. After 10 min, pulp sensibility testing was performed using an electric pulp test (EPT). If a tooth responded positively, anesthesia was considered to have failed. In the case of a negative EPT response, endodontic access was initiated under rubber dam isolation. The success of anesthesia was defined as having a pain score less than 55 on the Heft Parker visual analog scale (HP VAS), which was categorized as ‘no pain’ or ‘faint/weak/mild’ pain on the HP VAS. Baseline pre-injection and post-injection maximum heart rates were recorded. The Pearson chi-square test was used to analyze the anesthetic success rates at 5% significance.

Results

Plain 2% lidocaine and 2% lidocaine with 1:200,000 epinephrine and 1:80,000 epinephrine had anesthetic success rates of 18.75%, 72.9%, and 82.3%, respectively. Statistical analysis indicated significant differences between the groups (P < 0.001, χ² = 47.5, df = 2). The maximum heart rate increase was seen with 2% lidocaine solution with epinephrine.

Conclusion

Adding epinephrine to 2% lidocaine significantly improves its anesthetic success rates during the root canal treatment of maxillary molars with symptomatic irreversible pulpitis.

Tooth extraction without discontinuation of oral antithrombotic treatment: A prospective study

OBJECTIVE

To identify which variable, among those related to surgeries, to patients, or to antithrombotic treatments, could be considered as a bleeding indicator, and to analyze effectiveness of the local hemostatic protocols used, incidence of bleeding and healing index, depending on the number of extracted teeth, and patient antithrombotic treatment.

METHODS

Patients who underwent tooth extractions without interruption or reduction of antithrombotic treatment were prospectively followed. The exact two-tailed Fisher test was used to investigate the relationship between presence/absence of bleeding and type of hemostatic material. The effect of variables on the probability of bleeding and healing index was assessed by means of a multivariate logistic regression.

RESULTS

Two hundred and fifty-four procedures were analyzed. The incidence of bleeding was 15.75%. Severe bleeding occurred in only 6 patients (2.34%). The number of involved dental quadrants and pre-surgical antibiotic treatments were found to be positively related with bleeding. The use of vasoconstrictors during surgery resulted in a reduction of healing index scores.

CONCLUSIONS

Tooth extractions in patients on antithrombotic treatment were found to be free from significant bleeding although the involvement of more than 1 quadrant in the same procedure should be avoided.

A comprehensive review of topical hemostatic agents: The good, the bad, and the novel

Uncontrolled exsanguination remains the leading cause of death for trauma patients, many of whom die in the pre-hospital setting. Without expedient intervention, trauma-associated hemorrhage induces a host of systemic responses and acute coagulopathy of trauma. For this reason, health care providers and prehospital personal face the challenge of swift and effective hemorrhage control. The utilization of adjuncts to facilitate hemostasis was first recorded in 1886. Commercially available products haves since expanded to include topical hemostats, surgical sealants, and adhesives. The ideal product balances efficacy, with safety practicality and cost-effectiveness. This review of hemostasis provides a guide for successful implementation and simultaneously highlights future opportunities.

Anaesthetic efficacy of 2% lidocaine with different concentrations of epinephrine (1:80,000 and 1:200,000) in intraligamentary injection after a failed primary inferior alveolar nerve block: a randomized double-blind study

Introduction: The present study evaluated the anaesthetic efficacy of 2% lidocaine with 1:80,000 epinephrine vs. 2% lidocaine with 1:200,000 given as supplemental intraligamentary injections after a failed inferior alveolar nerve block (IANB) in patients with symptomatic irreversible pulpitis. The effect of these solutions on the heart rate was also evaluated.Methods: One-hundred-eighteen adult patients with symptomatic irreversible pulpits in a mandibular first or second molar, received an initial IANB with 2% lidocaine with 1:80,000 epinephrine. Pain during the endodontic treatment was assessed using a visual analogue scale (Heft-Parker VAS). Eighty-eight patients with unsuccessful anaesthesia were randomly allocated to one of the two treatment groups: one group received 0.6 mL/root of supplementary intraligamentary injection of 2% lidocaine with 1:80,000 epinephrine; while the second group received 2% lidocaine with 1:200,000 epinephrine. Endodontic treatment was re-initiated. Success after primary injection or supplementary injection was defined as no or mild pain (pain score ≤54 mm on HP VAS) during access preparation and root canal instrumentation. Heart rate was monitored using a finger pulse oximeter. The anaesthetic success rates were analyzed with the Pearson chi-square test at 5% significance levels. The heart rate changes were analyzed using the t-test.Results: The anaesthetic success rate in patients receiving supplementary intraligamentary injections in 1:80,000 epinephrine group was 82%, while the intraligamentary injections with 2% lidocaine with 1:200,000 epinephrine were successful in 57% of cases. The difference was statistically significant (χ²=6.4, p = .011). There was no significant effect of both the anaesthetic agents on the mean heart rate.Conclusions: Both 2% lidocaine with 1:80,000 epinephrine and 2% lidocaine with 1:200,000 epinephrine improved the success rates after a failed primary anaesthetic injection. The 1:80,000 epinephrine group was significantly more successful.

Anesthetic Considerations for Patients on Antidepressant Therapy - Part II

Millions of patients take antidepressant medications in the United States for the treatment of depression or anxiety disorders. Some antidepressants are prescribed off-label to treat problems such as chronic pain, low energy, and menstrual symptoms. Antidepressants are a broad and expansive group of medications, but the more common drug classes include tricyclic antidepressants, selective serotonin reuptake inhibitors, serotonin-norepinephrine reuptake inhibitors, and monoamine oxidase inhibitors. A miscellaneous or "atypical" category covers other agents. Some herbal supplements that claim to have antidepressant activity will also be discussed. Part I of this series reviewed antidepressant pharmacology, adverse effects, and drug interactions with adrenergic agonists. In part II, drug-drug interactions with sedation and general anesthetics, bleeding effects, and serotonin syndrome will be discussed.

Anesthetic Considerations for Patients on Antidepressant Therapy-Part I

Millions of patients take antidepressant medications in the United States for the treatment of depression or anxiety disorders. Some antidepressants are prescribed off-label to treat problems such as chronic pain, low energy, and menstrual symptoms. Antidepressants are a broad and expansive group of medications, but the more common drug classes include tricyclic antidepressants, selective serotonin reuptake inhibitors, serotonin-norepinephrine reuptake inhibitors, and monoamine oxidase inhibitors. A miscellaneous or "atypical" category covers other agents. Some herbal supplements that claim to have antidepressant activity will also be discussed. In Part I of this review, antidepressant pharmacology, adverse effects, and drug interactions with adrenergic agonists will be discussed. In part II, drug interactions with sedation and general anesthetics will be reviewed. Bleeding effects and serotonin syndrome implications in anesthetic practice will also be highlighted.

Effects of Mild Blast Traumatic Brain Injury on Cerebral Vascular, Histopathological, and Behavioral Outcomes in Rats

To determine the effects of mild blast-induced traumatic brain injury (bTBI), several groups of rats were subjected to blast injury or sham injury in a compressed air-driven shock tube. The effects of bTBI on relative cerebral perfusion (laser Doppler flowmetry [LDF]), and mean arterial blood pressure (MAP) cerebral vascular resistance were measured for 2 h post-bTBI. Dilator responses to reduced intravascular pressure were measured in isolated middle cerebral arterial (MCA) segments, ex vivo, 30 and 60 min post-bTBI. Neuronal injury was assessed (Fluoro-Jade C [FJC]) 24 and 48 h post-bTBI. Neurological outcomes (beam balance and walking tests) and working memory (Morris water maze [MWM]) were assessed 2 weeks post-bTBI. Because impact TBI (i.e., non-blast TBI) is often associated with reduced cerebral perfusion and impaired cerebrovascular function in part because of the generation of reactive oxygen and nitrogen species such as peroxynitrite (ONOO-), the effects of the administration of the ONOO- scavenger, penicillamine methyl ester (PenME), on cerebral perfusion and cerebral vascular resistance were measured for 2 h post-bTBI. Mild bTBI resulted in reduced relative cerebral perfusion and MCA dilator responses to reduced intravascular pressure, increases in cerebral vascular resistance and in the numbers of FJC-positive cells in the brain, and significantly impaired working memory. PenME administration resulted in significant reductions in cerebral vascular resistance and a trend toward increased cerebral perfusion, suggesting that ONOO- may contribute to blast-induced cerebral vascular dysfunction.

[Difficulty influence factors of dental caries clinical treatment]

Dental caries is a major disease that threaten human's oral healthy severely with the characteristics of high incidence, low rate of treatment and high rate of retreatment. At present, restorative treatment remains the main method for caries treatment. With the development of the Minimally Invasive Cosmetic Dentistry (MICD), reasonable application of various treatment technologies, maximum preservation of tooth tissues and realizing the maximization of treatment effects become problems that call for immediate solution in dental clinics. In addition, there still exist a large number of old restorations that need standard retreatments. Here, some difficulty influence factors of dental caries clinical treatment such as systemic and oral factors, individual caries susceptibility, treatment technologies and materials, retreatment methods of old restorations and technique sensitivity are analyzed, and corresponding processing strategies are also put forward.

Prime Drug Interplay in Dental Practice

Drug interaction is a negative representation of pharmacotherapy. In order to provide the best patient care possible, a thorough knowledge of how the drug interactions occur is needed for proper application in practice. Possible interactions among current medication and drugs being prescribed should be considered always. A thorough understanding of the mechanism of interactions among drugs is a must for the health care practitioner. Considering the astounding number of drugs patients may be taking, this task seems discouraging. The count of possible interactions in dental practice are less due to few number of drugs utilized and brief period of therapy, but still notable number are to be considered. The aim of present preview is to consider the manifold and multiplex nature of pharmacological drug-drug interaction in the general dental practice setting.

Hemodynamic changes following injection of local anesthetics with different concentrations of epinephrine during simple tooth extraction: A prospective randomized clinical trial

Background

Presence of epinephrine in local anesthetic cartridge increases the duration of local anesthesia (LA), decreases the risk of toxicity, and provides hemostasis. However, the unfavorable effects are increasing heart rate (HR) and raising blood pressure (BP). The aim was to evaluate hemodynamic changes in the BP, HR, and oxygen saturation (SpO2) of normal patients undergoing tooth extraction using LA with various epinephrine concentrations.

Material and Methods

A prospective randomized clinical trial was conducted on 120 patients who were divided randomly into 3 parallel groups according to the LA received. Group 1: lidocaine 2% with epinephrine 1:80,000 (L80). Group 2: articaine 4% with epinephrine 1:100,000 (A100). Group 3: articaine 4% with epinephrine 1:200,000 (A200). Inclusion criteria: normal patients whose BP < 140/90. Exclusion criteria: hypertension, cardiovascular disease, hyperthyroidism, pregnancy, and allergy to LA. BP, HR, and (SpO2) were evaluated in 3 different time points: 3 minutes before LA, 3 minutes after LA, and 3 minutes after extraction.

Results

Systolic blood pressure (SBP) significantly increased after injection of L80 and continued after extraction to be significant than pre-injection. SBP significantly increased after injection of A100 then decreased after extraction. In the group of A200, SBP insignificantly decreased after injection then increased after extraction. The increasing of SBP between time point 1and 2 was significantly higher in G1 than G3 (p=0.014). Diastolic blood pressure decreased after LA in the 3 groups; however it was significant only with L80, then increased after extraction for all.

Conclusions

The changings of DBP, HR and SpO2 after anesthesia and extraction showed no significant difference among the three groups. However, A200 had significant lesser effect on SBP than L80 and the least effect on other parameters. Therefore, A200 is considered safer than L80 and A100 and is recommended for LA before teeth extraction in normal patient.

Key words:Local anesthesia, lidocaine, epinephrine 1:80,000, articaine, epinephrine 1:100,000, epinephrine 1:200,000, tooth extraction.

Antidepressants relevant to oral and maxillofacial surgical practice

Background:

Depression is commonly associated with a high-carbohydrate diet, lack of interest in proper oral hygiene and xerostomia connected to the use of antidepressants. Patients often consult their dentists as a result of changes affecting the hard dental substance and the soft-tissues.

Aim:

The aim of this study was to identify adverse drug interactions between the antidepressants and medications commonly administered in dentistry in order to give practicing dentists an overview of the scientific literature.

Objective:

The objective is to identify the adverse drug interactions between antidepressants and medication commonly administered in dentistry.

Study Design:

The literature search was performed using PubMed, Cochrane and the specific search items. The review (1984-2009) focused on medicines used in dental practice (vasoconstrictors, non-opioid analgesics, non-steroidal anti-inflammatory drugs, antibiotics, antifungals and benzodiazepines).

Results:

There are various drug interactions between antidepressants and medicines used in dentistry. When two or more drugs are co-administered, a drug interaction must always be anticipated though many of the interactions are potential problems, but do not seem to be real clinical issues.

Conclusion:

The probability of a drug interaction can be minimized by careful history-taking, skillful dose adjustment and safe administration of the therapeutic agent.

Achieving hemostasis in dermatology - Part 1: Preoperative, intraoperative, and postoperative management

As dermatological procedures continue to become increasingly complex, improved methods and tools to achieve appropriate hemostasis become necessary. The methods for achieving adequate hemostasis are variable and depend greatly on the type of procedure performed and the unique characteristics of the individual patient. In Part 1 of this review, we discuss the preoperative, intraoperative, and postoperative management of patients undergoing dermatologic surgery. We address oral medications and supplements that affect hemostasis, hemostatic anesthesia, and intraoperative interventions such as suture ligation and heat-generating cautery devices. In Part 2 of this review, we will discuss topical hemostats. The authors conducted an extensive literature review using the following keywords: “hemostasis,” “dermatology,” “dermatological surgery,” “dermatologic sutures,” “electrosurgery,” “hemostatic anesthesia,” and “laser surgery.” Sources for this article were identified by searching the English literature in the Pubmed database for the time period from 1940 to March 2012. A thorough bibliography search was also conducted and key references were examined.

Clinical study of hemodynamic changes comparing 4% articaine hydrochloride with 1:100,000 and 1:200,000 epinephrine

OBJECTIVE

To evaluate hemodynamic changes with the use of 4% articaine and 2 different concentrations of epinephrine (1:100,000 and 1:200,000) in the surgical removal of symmetrically positioned lower third molars.

STUDY DESIGN

A prospective, randomized, double-blind clinical trial was carried out involving 42 patients each undergoing 2 surgeries on separate occasions under local anesthesia with 4% articaine and either epinephrine 1:100,000 or 1:200,000. The following parameters were assessed at 4 different moments: systolic, diastolic, and mean blood pressure; heart rate; oxygen saturation; rate pressure product (RPP); and pressure rate quotient (PRQ).

RESULTS

The concentration of epinephrine did not affect diastolic blood pressure or oxygen saturation during the surgeries. Significant differences between were detected for heart rate, RPP, and PRQ (P < .05).

CONCLUSIONS

The epinephrine concentration (1:100,000 or 1:200,000) in a 4% articaine solution influences hemodynamic parameters without perceptible clinical changes in healthy patients undergoing lower third molar removal.

Cardiovascular responses to different stages of restorative dental treatment unaffected by local anaesthetic type

BACKGROUND

The aim of this study was to evaluate the cardiovascular effects of maxillary infiltration using 2% lidocaine with 1:100,000 adrenaline, 4% articaine with 1:200,000 adrenaline, and 4% articaine with 1:100,000 adrenaline in different stages during restorative dental procedures.

METHODS

Twenty healthy patients randomly received 1.8 mL of the three local anaesthetics. Systolic blood pressure, average blood pressure, diastolic blood pressure, and heart rate were evaluated by the oscillometric and photoplethysmograph methods in seven stages during the appointment.

RESULTS

Statistical analysis by ANOVA and Tukey tests of cardiovascular parameters did not show significant differences between the anaesthetic associations. There were significant differences for the parameters among different clinical stages.

CONCLUSIONS

The variation of cardiovascular parameters was similar for lidocaine and articaine with both adrenaline concentrations and showed no advantage of one drug over the other. Cardiovascular parameters were influenced by the stages of the dental procedures, which showed the effect of anxiety during restorative dental treatment.

Efficacy of anesthetic agents to delay pain onset after periodontal surgery

The aim of this study was to evaluate the influence of 2 anesthetic agents on patients' postoperative pain perception after periodontal surgery. For this parallel-group, double-blinded, randomized clinical trial, 36 open flap debridement surgeries were performed on patients who presented with periodontal disease with clinical signs of inflammation after nonsurgical treatment on at least 1 quadrant. Patients were allocated to 1 of the following groups: group 1, 2% lidocaine with 1 ∶ 100,000 epinephrine; group 2, 2% mepivacaine with 1 ∶ 100,000 norepinephrine. Pain intensity was assessed using the visual analog scale during the first 8 hours after surgery. All patients received 750-mg acetaminophen tablets, which they were instructed to take as a rescue medication if necessary. The results demonstrated that postoperative pain intensity was statistically lower in group 2 than in group 1 at the 1-, 2-, and 3-hour periods after surgery, although the pain intensity for all groups could be considered mild. In conclusion, patients in both groups reported similar mild pain after periodontal surgery.

Reversal of soft-tissue local anesthesia with phentolamine mesylate in adolescents and adults

BACKGROUND

The authors conducted two multicenter, randomized, double-blinded, controlled Phase III clinical trials to study the efficacy and safety of phentolamine mesylate (PM) in shortening the duration and burden of soft-tissue anesthesia. The study involved 484 subjects who received one of four commercially available local anesthetic solutions containing vasoconstrictors for restorative or scaling procedures.

METHODS

On completion of the dental procedure, subjects randomly received a PM or a sham injection (an injection in which a needle does not penetrate the soft tissue) in the same site as the local anesthetic injection. The investigators measured the duration of soft-tissue anesthesia by using standardized lip- and tongue-tapping procedures every five minutes for five hours. They also evaluated functional measures and subject-perceived altered function, sensation, appearance and safety.

RESULTS

Median recovery times in the lower lip and tongue for subjects in the PM group were 70 minutes and 60 minutes, respectively. Median recovery times in the lower lip and tongue for subjects in the sham group were 155 minutes and 125 minutes, respectively. Upper lip median recovery times were 50 minutes for subjects in the PM group and 133 minutes for subjects in the sham group. These differences were significant (P < .0001). Recovery from actual functional deficits and subject-perceived altered function, sensation and appearance also showed significant differences between the PM and the sham groups.

CONCLUSIONS

PM was efficacious and safe in reducing the duration of local anesthetic- induced soft-tissue numbness and its associated functional deficits.

CLINICAL IMPLICATIONS

Clinicians can use PM to accelerate reversal of soft-tissue anesthesia and the associated functional deficits.

Topical hemostatic agents: a review

Topical hemostatic agents play an important role in both common and specialized dermatologic procedures. These agents can be classified based on their mechanism of action and include physical or mechanical agents, caustic agents, biologic physical agents, and physiologic agents. Some agents induce protein coagulation and precipitation resulting in occlusion of small cutaneous vessels, while others take advantage of latter stages in the coagulation cascade, activating biologic responses to bleeding. Traditional and newer topical hemostatic agents are discussed in this review, and the benefits and costs of each agent will be provided.

Hyaluronidase increases the duration of mepivacaine in inferior alveolar nerve blocks

PURPOSE

To evaluate the duration of the effect of mepivacaine when hyaluronidase is injected immediately prior to the end of pulpal anesthesia.

PATIENTS AND METHODS

Forty bilateral, symmetrical third molar surgeries were performed in 20 healthy patients. Inferior alveolar nerve block was induced using 2.8 mL 2% mepivacaine with epinephrine. Hyaluronidase (75 turbidity-reducing units) or a placebo was injected 40 minutes after the beginning of pulpar anesthesia (randomized and double-blind trial). The duration of effect in the pulpal and gingival tissues was evaluated by response to painful electrical stimuli applied to the adjacent premolar, and by mechanical stimuli (pin prick) to the vestibular gingiva, respectively.

RESULTS

In both tissues, the duration of anesthetic effect with hyaluronidase was longer (P < .01) than with the placebo.

CONCLUSION

Hyaluronidase increases the duration of mepivacaine in inferior alveolar nerve blocks.

Alzheimer's disease

BACKGROUND

The authors review the clinical features, epidemiology, pathophysiology, medical management, dental findings and dental treatment of patients with Alzheimer's disease (AD).

STUDIES REVIEWED

The authors conducted MEDLINE searches for 2000 through 2005 using the terms "Alzheimer's disease," "geriatric," "epidemiology," "pathophysiology," "treatment" and "dentistry." Reports selected for further review included those published in English in peer-reviewed journals. The authors gave preference to articles reporting randomized, controlled trials.

RESULTS

AD is a progressive and fatal neurodegenerative disorder characterized by cognitive dysfunctions, particularly in learning and memory, and the emergence of behavioral abnormalities. Deficiencies in the cells responsible for storage and processing of information underlie the cognitive, functional and behavioral changes seen in patients with the disorder.

CLINICAL IMPLICATIONS

As the elderly population grows, increasing numbers of Americans with AD will require dental treatment. The prevalence of dental disease likely will be extensive, because of diminished salivary flow and patients' inability to perform appropriate oral hygiene techniques. Preventive dental education for the caregiver and use of saliva substitutes and anticaries agents by the patient are indicated.

Medication use and prescribing considerations for elderly patients

Older adults consume more medications than any other segment of the population. Increasing lifespan means that more people will live into old age, frequently with disabilities and conditions man-aged by medications. Age-associated physiologic changes, medication use patterns, and adverse drug effects and interactions place the older adult at high risk for medication-related problems. Older adults living in institutions, those with complex medical problems,and those who do not adhere to medication regimens are at highest risk for negative health outcomes from medication mishaps. Dentists must be able to identify older adults who are susceptible to adverse drug events and to recognize which medications are most likely to precipitate problems.

Patient-fabricated denture prostheses: a clinical report

This article describes 2 patients who presented with self-made dentures. Each patient had a different motivation for avoiding professional dental treatment. One patient made her own denture because she could not afford dental care, while the other could afford such care but avoided treatment due to a dental phobia. A discussion of diagnosis and treatment planning is presented for each situation.