Investigation of inhalational conscious sedation as a tool for reducing anxiety in adults undergoing exodontia

Inhaled methoxyflurane - an explorable alternative to nitrous oxide?

Nitrous oxide is a widely used and well-established form of inhalation sedation in dentistry. Its properties have a wide margin of safety and allow for anxious, paediatric and adult patients to receive dental treatment with minimal impact upon discharge. Nitrous oxide has drawbacks, however, including its environmental impact and need for specialist equipment. Methoxyflurane is another drug which could prove to be an alternative to nitrous oxide. Methoxyflurane's use has proved popular within emergency medicine in Australia and New Zealand for its potent analgesic effects and recognition of its anxiolytic effect. As a result, its use in invasive outpatient procedures has now become popular. Unfortunately, there is very limited evidence of its use within dentistry as a form of inhalation sedation and analgesic. A wider evidence base should be established, as methoxyflurane could prove to be an effective and environmentally friendly alternative to nitrous oxide.

Anesthetic Effect of 2% Amitriptyline Versus 2% Lidocaine: A Comparative Evaluation

Introduction A common dental problem is the fear of pain during needle prick for giving local anesthesia (LA). The needle prick pain during dental procedures often varies with sex and age. Perception of pain depends on various factors, which can be psychological and biological. This perception of pain may change the behavior of patients toward dental treatments. Traditionally, lidocaine gel formulation was utilized before the parenteral dosage form. The lidocaine gel formulation is considered the drug of choice for LA in dental surgery. Currently, amitriptyline has been utilized in dental practice because of its beneficial pharmacology. Hence, the present study has been undertaken to compare the anesthetic ability of amitriptyline as an intraoral topical anesthetic agent with lidocaine gel. Methods This study was a comparative clinical study between two medications' anesthetic properties. This study included 120 patients indicated for bilateral orthodontics (the subdivision of dentistry that emphasizes identifying necessary interventions for the malocclusion of teeth) procedures. All the subjects were divided into amitriptyline and lidocaine groups. Both anesthetic gels were applied at separate sites before the injection of LA. The time of the onset of anesthesia was noted and analyzed. Patients were selected on the basis of inclusion and exclusion criteria. Individuals aged 18 to 30 years who were systemically healthy and orthodontically indicated for bilateral premolar extraction were included in this study. Again, patients with a history of neurological disorders and allergies to amitriptyline and lidocaine were excluded from the current study. Results Significant differences emerged between groups at five and 10 minutes, with amitriptyline-induced partial numbness (36.7% and 6.7%). At 40 and 45 minutes, both groups showed varied partial and complete numbness, with amitriptyline leading to partial recovery (23.3% and 73.3% complete numbness, 23.3% partial recovery) and lidocaine resulting in partial recovery (81.7%). When comparing the visual analog scale (VAS) scores, both groups exhibited a similar simultaneous effect at 15 minutes. Nonetheless, amitriptyline displayed significantly lower scores at 25 and 35 minutes (p < 0.001) in comparison to lidocaine. Similar observations were made when controlling for pain intensity. Conclusion It was concluded that amitriptyline holds both anesthetic and analgesic properties. Nevertheless, this study was unable to generalize the study findings because of the small sample size and being a single-center study. However, the VAS scores of anesthetic and analgesic pharmacodynamics properties of amitriptyline were statistically significantly lower than lidocaine, particularly at 25 and 35 minutes. Additionally, amitriptyline-induced anesthetic and analgesic pharmacology, especially pharmacokinetics properties, depends on the location and pattern of pain.

Investigation of the effect of music listened to by patients with moderate dental anxiety during restoration of posterior occlusal dental caries

OBJECTIVE

The aim of this randomized controlled study was to investigate the effect of music therapy during restorative dental treatments on patients with moderate dental anxiety.

MATERIALS AND METHODS

Seventy patients were determined to have moderate dental anxiety by the Modified Dental Anxiety Scale (MDAS) and were divided randomly into two groups (n = 35). The first group did not listen to music during their restorative treatment (control group), and the second group listened to music of their choice (experimental group). Systolic blood pressure, diastolic blood pressure, heart rate, oxygen saturation, and body temperature were measured three times for each patient: once before the treatment, once after their dental caries were removed, and once at the end of the treatment. Salivary cortisol samples were taken from each patient before and after the treatment. The MDAS was re-administered to the patients at the end of the treatment, and the data were analyzed statistically.

RESULTS

Only the diastolic blood pressure (P = 0.042) and the MDAS scores of the experimental group (P = 0.001) were significantly lower than the control group at the end of the treatment.

CONCLUSION

While music listening did not have an effect on the physiologic parameters of the patients during restorative treatment, it decreased the MDAS scores of the patients.

CLINICAL RELEVANCE

Although music therapy did not affect the physiological parameters during the restorative dental treatment, it may help to reduce patients' self reported anxiety level.

Advantages of Sedation With Remimazolam Compared to Midazolam for the Removal of Impacted Tooth in Patients With Dental Anxiety

PURPOSE

Although midazolam is commonly used to sedate patients with dental anxiety, it has shortcomings that reduce the satisfaction of patients and doctors. The aim of this study was therefore to explore the advantages of remimazolam as a sedative.

METHODS

The study design was a prospective randomized controlled trial. Patients with dental anxiety and who were to undergo impacted tooth removal were randomized into remimazolam and midazolam groups. They were sedated with remimazolam or midazolam prior to receiving nerve blocker. The predictor variable was the type of sedative, while the primary outcome variables were the onset time, awakening time, recovery time, and postoperative side effects. Secondary outcome variables were the Modified Dental Anxiety Scale score before and after surgery, patient satisfaction and comfort levels scores, and doctor satisfaction level scores. Other variables included the patient demographics and the operation time. Data were analyzed using the Student's t-test, Mann-Whitney test, χ² test, and two-way repeated measurement ANOVA test (SPSS Version 25.0).

RESULTS

A total of 83 patients were included in this study, with 42 randomized to the remimazolam group and 41 to the midazolam group. There were no significant differences between the two groups in terms of demographic features and operation time. Patients in the remimazolam group had significantly shorter onset time, awakening time, and recovery time compared to those in the midazolam group (each P < .001). Postoperative side effects were more frequent in the midazolam group (P < .001). Following surgery, the Modified Dental Anxiety Scale scores in both groups were significantly lower than prior to surgery (P < .001). Satisfaction levels scores for the patients and doctor were higher in the remimazolam group than in the midazolam group (P < .001).

CONCLUSIONS

The use of remimazolam results in faster onset, more rapid recovery, and lower incidence of postoperative side effects compared to midazolam, leading to improved satisfaction for patients and doctors. Remimazolam therefore appears to have several advantages over midazolam for the sedation of patients with dental anxiety associated with the removal of impacted teeth.

Delay of Dental Care: An Exploratory Study of Procrastination, Dental Attendance, and Self-Reported Oral Health

Delay of dental care is a problem for dental public health. The present study explored the relationship between procrastination and dental attendance, focusing on delay in seeking dental care. This hypothetical relation was compared to other avoidance-related factors affecting dental attendance. In addition, an inquiry into the reasons for delaying dental care was conducted. Students (n = 164) answered an internet-based questionnaire on socio-demographic factors, dental health, dental attendance, delay of dental care, reasons for the delay, procrastination (IPS), dental anxiety (MDAS), perceived stress (PSS) and oral health self-efficacy (OHSES). The study found no significant relation between procrastination and delay in dental care. However, procrastination was related differently to past, present, and future dental attendance and seemed to relate to oral health behavior. Delay of dental care was associated with higher dental anxiety and lower oral health self-efficacy. The cost of dental care was the most frequently given reason for the delay of dental care. Further research on the delay of dental care and dental attendance is warranted in understanding the behavior, implementing interventions, and improving the utilization of public dental care.

Patient's pre-operative dental anxiety is related to diastolic blood pressure and the need for post-surgical analgesia

In order to study the relationship of the patient’s anxiety level from Corah’s Dental Anxiety Scale (DAS) vs different physiological parameters: pre and post-operative blood pressure, and pre and post-operative heart rates, and subsequently, relate the results to the patient’s post-operative anti-inflammatory analgesic need, 185 patients requiring a simple dental extraction were recruited. They filled out the DAS in the waiting room prior to their procedure and once in the examination room, their preoperative blood pressure and heart rate was measured. Once the dental extraction had been completed, their blood pressure and heart rate were measured again. Before leaving the clinic, the patient was given an analgesic form in which they had to indicate whether or not they had required analgesia after the procedure. Diastolic blood pressure (DBP) showed statistically significant differences between pre-operative and post-operative (P = 0.001). DAS was related with pre-operative diastolic blood pressure (pre-DBP) (P = 0.001) and post-operative diastolic blood pressure (post-DBP) as well as pre-operative heart rate (pre-HR) (P = 0.027) and post-operative heart rate (post-HR) (P = 0.013). Patients with high levels of DAS tend to take more Ibuprofen 400 mg (P = 0.038). The different levels of anxiety will determine what type of anti-inflammatory analgesia the patient will take, if necessary.

European Society of Anaesthesiology Task Force on Nitrous Oxide: a narrative review of its role in clinical practice

Nitrous oxide (N₂O) is one of the oldest drugs still in use in medicine. Despite its superior pharmacokinetic properties, controversy remains over its continued use in clinical practice, reflecting in part significant improvements in the pharmacology of other anaesthetic agents and developing awareness of its shortcomings. This narrative review describes current knowledge regarding the clinical use of N₂O based on a systematic and critical analysis of the available scientific literature. The pharmacological properties of N₂O are reviewed in detail along with current evidence for the indications and contraindications of this drug in specific settings, both in perioperative care and in procedural sedation. Novel potential applications for N₂O for the prevention or treatment of chronic pain and depression are also discussed. In view of the available evidence, we recommend that the supply of N₂O in hospitals be maintained while encouraging its economic delivery using modern low flow delivery systems. Future research into its potential novel applications in prevention or treatment of chronic conditions should be pursued to better identify its role place in the developing era of precision medicine.

Inhaled nitrous oxide can reduce the pain perception in post Caldwell-Luc operation patients-a randomised trial

To assess the efficiency of inhaled nitrous oxide (N₂O) for the reduce the perception pain in extraction of iodoform gauze packing strips in post Caldwell-Luc operation patients. This randomized single blind trial included a total of 47 patients, aged between 14–82 years, in which undergoing radical maxillary sinusotomy. Based on the randomization procedure, patients were treated with (experimental) or without (control) inhaled N₂O. The visual analogue scale scores (VAS scores) of the pain perception and the headache duration time were comparatively studied. The average VAS score for pain perception was 3.92 in the N₂O group and 7.87 in the control group. The average headache duration time was 0.12 hour in the N₂O group and 13.09 hours in the control group. Both VAS scores for pain perception during the treatment and the average headache duration time were significantly reduced in the inhaled N₂O group (P < 0.01). Reduced pain perception and headache duration time indicated that, the inhaled N₂O method might be viable in extraction of iodoform gauze packing strips in post Caldwell-Luc operation patients.

An investigation into the variability of primary care oral surgery contracts and tariffs in England and Wales (2014/2015)

Primary care oral surgery services vary markedly throughout the country but until now there has been a paucity of data on these services. The British Association of Oral Surgeons (BAOS) primary care group (the authors) were tasked to gather data around primary care oral surgery contracts and tariffs and provide evidence-based recommendations on the commissioning of these services. Following a freedom of information (FOI) request, data were obtained for 27 English local area teams and seven Welsh local health boards. The data demonstrated both regional and national variability with respect to primary care oral surgery contracts, concerning both contract type and level of remuneration. These differences are discussed and the authors make recommendations for standardising oral surgery contracts and tariffs.

Scales used to rate adult patients' psycho-emotional status in tooth extraction procedures: a systematic review

The aim of this study was to review scales used to assess anxiety, stress, and pain in dental patients undergoing a tooth extraction procedure and to propose a novel psycho-emotional rating scale based on the relevant literature and our own experience. An electronic literature search was conducted of the National Library of Medicine database MEDLINE (Ovid) and EMBASE databases between January 2005 and April 2016. Sequential screening at the title/abstract and full-text levels was performed. The review included all human prospective or retrospective follow-up studies and clinical trials, cohort studies, case-control studies, and case series that demonstrated at least one scale used to measure tooth extraction anxiety, stress, or pain. The search resulted in 32 articles meeting the inclusion criteria. None of the studies were found to be suitable in evaluating patient's stress, pain, and fear at once. Also, no scales were found that included both the doctor's and the patient's rating. In a few studies, vital signs as psycho-emotional status indicators were rated. Guidelines for a suitable questionnaire that could be used for rating the psycho-emotional status of patients undergoing tooth extraction are listed in the present research. Further studies are required for verification and validation of offered scale.

Nitrous oxide analgesia for bone marrow aspiration and biopsy - A randomized, controlled and patient blinded study

Background and aims Bone marrow aspiration and/or biopsy (BMAB), performed under local anaesthesia in adults, is a common and often painful procedure. Anxiety is known to intensify pain during the procedure. Nitrous oxide (N2O), known for its sedative and analgesic benefit in various short medical procedures and labour pain, could be advantageous also for pain relief during bone marrow examination. N2O acts rapidly and is eliminated in a couple of minutes once the inhalation is stopped, and occasional side effects (e.g. dizziness and nausea) are mild. The aim of this study was to compare the analgesic effects of inhaled 50% mixture of nitrous oxide and oxygen to 50% oxygen during bone marrow examination. Methods In this randomized, controlled, patient and observer blinded study patients received either 50% mixture of nitrous oxide and oxygen or 50% mixture of oxygen in air during bone marrow examination, in addition to local analgesia. Both patient groups comprised 35 adult patients. Pre-procedural anxiety and procedural pain were rated on the Numeral Rating Scale (NRS 0‒10). Cognitive function was measured before and 30 min after the procedure. Possible side effects were recorded. A telephone interview was performed 24 h later. Results There were no statistically significant differences in pain scores of the procedural steps (median NRS ranging 3.0‒4.0) between the study groups. High pain scores of 8‒10 comprised 0% vs. 8.6% of the scores during infiltration, 2.9% vs. 5.7% during puncture, 11.4% vs. 14.3% during aspiration and 2.9% vs. 2.9% during biopsy in N2O and 50% O2 groups, respectively (NS). Pre-procedural anxiety (median NRS 3.5 in both groups), measured in the outpatient clinic just prior to procedure, correlated with pain intensity during bone marrow aspiration (P = 0.045). There were no significant differences between side effects. During the BMAB four patients (3 in N2O group, 1 in 50% O2 group) reported dizziness and one patient in the N2O group reported nausea. Gas inhalation did not affect the cognitive function of the participants. In both groups the majority (>80%) of the patients was satisfied with the inhalation technique. During the 24 h interview, most of the participants were pain free and they did not report any serious adverse effects. Conclusions In spite of similar moderate to strong procedural pain in both groups and no benefit of N2O, most patients were satisfied with the inhalational techniques. We assume that the bedside presence of an anaesthesiologist and the distraction caused by the inhalational arrangements introduced positive context-sensitive therapeutic effect independent of the gas used. Pre-procedural anxiety predicted pain associated with bone marrow aspiration. Implications Inhaled 50% nitrous oxide was not an effective analgesic during bone marrow examination in our unselected outpatient population. Further studies should concentrate on its use with patients predicted to be at increased risk of suffering intense pain during the procedure, such as very anxious patients or those who have a painful history of previous bone marrow examinations.

The perioperative use of nitrous oxide: renaissance of an old gas or funeral of an ancient relict?

PURPOSE OF REVIEW

Conflicting reports about adverse events following nitrous oxide (N(2)O) application have spurred a discussion whether N(2)O should be abandoned from clinical practice. Concurrently, N(2)O is increasingly used as a single anesthetic agent in medical procedures. This article reviews and discusses reports about the present use of N(2)O.

RECENT FINDINGS

Multiple publications demonstrate an increasing use of N(2)O as a procedural analgesic and sedative. Results from the Evaluation of Nitrous Oxide in the Gas Mixture for Anesthesia trial have been contrasted by recent studies reporting no increased risk for perioperative complications, particularly related to the cardiovascular and cerebrovascular system. Recent studies show that electroencephalogram-based anesthesia depth monitoring is not compatible with the use of N(2)O because of its distinct influence on electroencephalogram wave patterns. The clinical relevance of the proposed neurotoxicity, immunosuppression and influence on methionine metabolism remains unclear. Recently, its acute and long-term analgesic potency has been proven. Occupational exposure might pose a relevant health hazard.

SUMMARY

Based on the present literature, abolishment of N(2)O is controversial. When avoided in patients at risk for adverse events, N(2)O is still a valuable supplement to general anesthesia and a potent procedural analgesic drug. In the latter, its use by nonanesthesiologists should be discouraged.