Conscious Sedation in Dentistry

Efficacy of continuous intravenous remimazolam versus midazolam in the extraction of impacted wisdom teeth: protocol of a randomised controlled trial

INTRODUCTION

Benzodiazepines such as midazolam are widely used to moderately sedate patients during impacted wisdom tooth extraction to reduce anxiety in outpatient surgery. This present protocol was designed to determine whether continuous intravenous remimazolam, a new ultrashort-acting benzodiazepine, produces superior postoperative recovery quality to that of midazolam in patients undergoing extraction of impacted wisdom teeth.

METHODS AND ANALYSIS

This study is a multicentre randomised controlled trial conducted at Peking Union Medical College Hospital, Beijing Anzhen Hospital and Beijing Shijitan Hospital in China. Approximately 150 participants undergoing extraction of impacted mandibular wisdom teeth will be randomly allocated to two groups (remimazolam and midazolam). The participants will be administered standard interventions to ensure they achieve a sedation level of III on the Ramsay sedation scale during the treatment. Preoperative and anaesthesia management and surgical techniques will be standardised for all participants. The primary outcome is recovery time for complete alertness and the secondary outcomes are anterograde amnesia during and after surgery, and interruption during operation for poor compliance or safety concerns.

ETHICS AND DISSEMINATION

This study has been approved by the Ethics Review Committee of Peking Union Medical College Hospital (approval number: ZS-3142), Beijing Anzhen Hospital (approval number: KS2022082) and Beijing Shijitan Hospital (approval number: 2023-4).

TRIAL REGISTRATION NUMBER

NCT05350085.

Conscious Sedation for Dental Treatments in Subjects with Intellectual Disability: A Systematic Review and Meta-Analysis

This systematic review and meta-analysis was aimed to investigate the conscious sedation efficiency in patients with intellectual disability undergoing dental treatment (PROSPERO CRD42022344292). Four scientific databases were searched by ad-hoc prepared strings. The literature search yielded 731 papers: 426 were selected, 42 were obtained in full-text format, and 4 more were added after hand searching. Fourteen studies were finally included, 11 of which were included in the meta-analysis (random effect model). A high heterogeneity in the drugs used and route of administration was retrieved. Success rate, occurrence of side effects, and deep sedation occurrence were combined to give an overall efficiency of each drug. N₂O/O₂ reported the highest efficiency (effect size = 0.90; p < 0.01) and proved to be more efficient when used alone. Nine papers reported a success rate of sedation of 80% or more. The prevalence of side effects (6 studies) ranged from 3% to 40%. Enteral and parenteral benzodiazepines showed the same overall efficiency (effect size = 0.86). No meta-analysis has yet been conducted to define the most effective and safest way to achieve conscious sedation in patients with intellectual disability; nitrous oxide appears to be the best choice to perform conscious sedation in patients with intellectual disability undergoing dental treatment.

Analgesia-based Sedation for Oral Surgery in Patients With Chronic Respiratory Obstructive Disease

Chronic obstructive pulmonary disease (COPD) is a risk factor for postoperative cardiovascular and respiratory complications. Thus, intravenous sedation can be a better option than general anesthesia for surgery in patients with severe COPD. Herein, we present 2 cases of analgesia-based sedation in patients with severe COPD who underwent oral surgery. The current study aimed to discuss these cases to provide knowledge about the appropriate sedation management in patients with this disease. In the current cases, the patients received sufficient analgesia and minimum sedation (analgesia-based sedation). Moreover, dexmedetomidine was used for maintaining sedation and fentanyl for analgesic effects. Furthermore, we focused on providing the maximum analgesic effect of local anesthesia. The patients' vital signs were stable. They did not have any psychological or physical complaints, such as anxiety and pain, during the procedure. Then, they were discharged from the hospital without any complications. Thus, analgesia-based sedation can be an alternative option for oral surgery in patients with COPD.

Prevalence of Emergence Delirium and Associated Factors among Older Patients Who Underwent Elective Surgery: A Multicenter Observational Study

Background

Emergence delirium is a common and serious postoperative complication in older surgical patients. It occurs at any time in the perioperative period, during or immediately following emergence from general anesthesia. Unfortunately, it is highly associated with postoperative complications such as a decrease in functional capacity, prolonged hospital stay, an increase in health care costs, and morbidity and mortality. The goal of this study was to determine the prevalence of emergence delirium and associated factors among older patients who underwent elective surgery in the teaching hospitals of Ethiopia at the postanesthesia care unit in 2021.

Methods

A multicenter prospective observational study was conducted at the postanesthetic care unit in the four teaching hospitals of Ethiopia. Older surgical patients admitted to the postanesthesia care unit who underwent elective surgery in the four teaching hospitals of Ethiopia were selected by using simple random sampling. Pretested structured questionnaire was used to collect data. Data were entered into EpiData (version 4.6) and exported to the SPSS (version 25.0). Binary logistic regression was used to identify factors independently associated with the emergence delirium.

Results

Out of 384 older patients included in the study, the prevalence of emergence delirium was 27.6%. Preoperative low hemoglobin levels (AOR: 2.0, 95% CI; 1.77–3.46), opioid (AOR: 8.0, 95% CI; 3.22–27.8), anticholinergic premedications (AOR: 8.5, 95% CI; 6.85–17.35), and postoperative pain (AOR: 3.10, 95 CI; 2.07–9.84) at PACU were independently associated with emergence delirium.

Conclusion

The prevalence of emergence delirium was high among older patients who underwent elective surgery. Opioid and anticholinergic premedication, low preoperative hemoglobin, and the presence of postoperative pain were independently associated with the emergence delirium. Adequate preoperative optimization and postoperative analgesia may reduce the prevalence of emergence delirium.

Estimating the Need for Sedation in Patients with Dental Anxiety and Medical Complexities Reporting to Tertiary Care Dental Hospital Using the IOSN Tool

Objectives

To provide consistent method for assessment of sedation need among patients undergoing dental treatment based on specific risk factors that is dental anxiety, medical status, and treatment complexity of needed dental treatment using IOSN (indication of sedation need) tool for assisting the clinician in decision making process.

Methods

A total of 237 patients aged ≥12, ASA I and II were enrolled in the study. A structured questionnaire comprising of three sections was distributed among the participants. Section 1 comprises details about age, gender, literacy level, occupation, monthly income, and previous dental treatment history. Section 2 is based on Modified Dental Anxiety Scale which is a questionnaire comprising of five questions ranging from “not anxious” to “extremely anxious.” The third section was based on using the IOSN tool comprising three components: MDAS (Modified Dental Anxiety Scale) rank score, Systemic Health (ASA status) rank score, and treatment complexity rank scores. The total of three scores was then computed to determine the total rank score which suggested the sedation need. History of past traumatic dental experiences was also inquired from each patient.

Results

A total of 237 patients aged ≥12, ASA I and II were enrolled in the study, out of which 56.1% were female. Statistical analysis was conducted by using the IBM SPSS Statistics 23 software. Based on the MDAS score, 47/237 (19.8%) participants were found to be highly anxious related to dental procedures. 34.6% of the participants showed to have a high sedation need while performing a dental procedure. The sedation need was found to be significantly associated with the female gender with a significant p value of (p=0.016), higher education status (p=0.016), and history of previous traumatic dental experience (p < 0.001).

Conclusion

A simple assessment tool can enable clinicians in their decision making to identify patients in need for dental treatment under sedation based on patient-specific risk factors such as past traumatic dental experiences. Need for sedation can be assessed by information on patient anxiety level towards dental treatment, medical history, and complexity of planned dental treatment. The IOSN tool is a simple and quick assessment tool that can be applied for preprocedural assessment of sedation need for dental treatment.

Effectiveness and safety of oral sedation in adult patients undergoing dental procedures: a systematic review

OBJECTIVES

It can be challenging to manage patients who are anxious during dental procedures. There is a lack of evidence regarding the effectiveness and safety of oral sedation in adults. This study evaluated the effectiveness and safety of oral sedation in patients undergoing dental procedures.

DESIGN

Systematic review.

METHODS

Randomised clinical trials (RCTs) compared the oral use of benzodiazepines and other medications with a placebo or other oral agents in adult patients. A search of the Cochrane (CENTRAL), MEDLINE (via Ovid), EMBASE (via Ovid) and Cumulative Index to Nursing and Allied Health Literature (via Ovid) databases was conducted, without any restrictions on language or date of publication. The primary outcomes included the adverse effects and anxiety level. The secondary outcomes included sedation, satisfaction with the treatment, heart rate, respiratory rate, blood pressure and oxygen saturation. Reviewers, independently and in pairs, assessed each citation for eligibility, performed the data extraction and assessed the risk of bias. A narrative synthesis of the data was provided.

RESULTS

A number of RCTs (n=327 patients) assessed the use of benzodiazepines (n=9) and herbal medicines (n=3). We found good satisfaction with treatment after the use of midazolam 7.5 mg or clonidine 150 µg and reduced anxiety with alprazolam (0.5 and 0.75 mg). Midazolam 15 mg promoted greater anxiety reduction than Passiflora incarnata L. 260 mg, while Valeriana officinalis 100 mg and Erythrina mulungu 500 mg were more effective than a placebo. More patients reported adverse effects with midazolam 15 mg. Diazepam 15 mg and V. officinalis 100 mg promoted less change in the heart rate and blood pressure than a placebo.

CONCLUSIONS

Given the limitations of the findings due to the quality of the included studies and the different comparisons made between interventions, further RCTs are required to confirm the effectiveness and safety of oral sedation in dentistry.

PROSPERO REGISTRATION NUMBER

CRD42017057142.

Computer-Controlled Local Anesthesia Complication: Surgical Retrieval of a Broken Dental Needle in Noncooperative Autistic Paediatric Patient

The article describes an unusual case of retrieval of 8 mm fragment of a broken 30-gauge 21 mm dental needle in a 6 y.o. noncooperative autistic male patient. The needle of a computer-controlled local anesthesia device was broken during an attempt to administer local anesthetic, in order to perform conservative treatment of teeth 55 and 54 by a pedodontist. Despite the fact that the patient was under nitrous oxide sedation, an unexpected movement of the patient occurred and resulted in needle breakage. Due to the lack of patient cooperation, the surgical retrieval of a broken needle was performed under general anesthesia as part of one-day surgery procedures. The purpose of the article is to emphasize careful decision-making in proper choice of dental instruments during treatment of noncooperative paediatric patients even under sedation and to suggest dentists to carry out treatment of such patients under general anesthesia.

An Overview of Diode Laser-Assisted Oral Surgery

Among all lasers with generally accepted surgical capabilities, the diode laser is most commonly used for the surgical removal of proliferating lesions and the photocoagulation of venous malformations of the oral cavity. The laser provides several advantages for clinicians, including an absence of intraoperative bleeding and no need for stitches. The laser benefits patients because it reduces postoperative edema and pain, with fast mucosal restoration during healing by second intention. We report a case series to highlight the capabilities of the diode laser in oral surgery procedures along with our suggestions.

Water Contamination Risks at the Dental Clinic

Dental clinics, furnished with an array of specialized equipment, are commonplace, particularly in industrialized countries. Minimizing the risk of infection at the dental practice requires the formulation and implementation of strict protocols. These protocols must address the real risk posed by water contamination, particularly given that water is both integral to the function of some dental equipment, and is typically administered directly to the patient. The water in the dental clinic may be of local origin or from a water main, this can be problematic since the clinician often has little assurance regarding the quality of water reaching the dental chair. Though most modern dental equipment includes self-sterilization protocols, care must be taken that water does not stagnate anywhere in the dental equipment or clinic. The management of water quality at the dental clinic is an important part of respecting the protocols needed to manage the risk of patient infections.

Milestones of Dentistry: Advent of Anesthetics in Oral Surgery

The history of dentistry, of course, has followed a constant development since the dawn of society. The dental profession, reserved in ancient times to people with special skills and high rank, after the Middle Ages was diminished and practiced by barbers. The pharmacological evolution of oral surgery techniques has led this branch, today as never before, to obtain a level of specialization and preparation comparable to all other specialist medical branches. Some milestones in the history of dentistry will be considered so as to finally understand how the importance of anesthetic drugs was of primary importance, and which drugs are used today.