Assessment of stress during periodontal surgery with intravenous sedation and with local anesthesia only

Comparison of hemodynamic changes with general or local anesthesia during dental treatment in pediatric patients: A prospective clinical study

BACKGROUND AND AIM

Severe hemodynamic fluctuations during dental treatment can trigger highly undesirable physical reactions. A study was made to determine whether the administration of propofol and sevoflurane contributes to the stabilization of hemodynamic parameters during dental treatment in pediatric patients versus the use of local anesthesia alone.

MATERIALS AND METHODS

Forty pediatric patients needing dental treatment were assigned to either general anesthesia with local anesthesia (study group [SG]) or local anesthesia alone (control group [CG]). Two percent sevoflurane in oxygen (100% oxygen, 5 L/min) and continuous propofol infusion (target-controlled infusion [TCI], 2 μg/mL) were used as general anesthesia agents in SG; and 2% lidocaine with 1:80,000 adrenaline was used as local anesthesia in both groups. Heart rate, blood pressure and oxygen saturation were measured before starting dental treatment (baseline) and every 10 min during dental treatment.

RESULTS

Blood pressure (p < .001), heart rate (p = .021) and oxygen saturation (p = .007) decreased substantially after the administration of general anesthesia. The levels of these parameters subsequently remained low and then recovered at the end of the procedure. On the other hand, the oxygen saturation values remained closer to baseline in SG versus CG. In contrast, the hemodynamic parameters experienced lesser fluctuations in CG than in SG.

CONCLUSIONS

General anesthesia affords more favorable cardiovascular parameters during the entire dental treatment in comparison to local anesthesia alone (blood pressure and heart rate decrease significantly and oxygen saturation proves more stable and with values closer to baseline), and allows dental treatment to be performed on healthy, lacking cooperative ability children who otherwise could not be treated with local anesthesia alone. No side effects were observed in either group.

Evaluation of hemodynamic changes and patient-reported outcome measures in surgical therapy with or without intravenous sedation: a prospective controlled clinical study

OBJECTIVES

To determine whether intravenous (IV) sedation would contribute to the stabilization of patients' hemodynamics during periodontal and oral surgical procedures, and to evaluate the patient-reported outcome measures (PROMs).

MATERIALS AND METHODS

Periodontal or oral surgery patients were recruited and distributed into two groups: (1) sedation group (SG): intravenous sedation plus local anesthesia; (2) control group (CG): local anesthesia only. Systolic and diastolic blood pressure (SBP, DBP), heart rate (HR), and oxygen saturation (SaO2), were monitored at 15-min intervals from sitting in the dental chair (baseline) until the end of the treatment. In addition, a subjective assessment of PROMs was obtained through a post-operative questionnaire.

RESULTS

Forty-nine patients (25 in SG and 24 in CG) were included. The highest SBP and DBP were significantly higher in CG compared to the SG (141.1 ± 18.4 and 133.6 ± 15.1, respectively in SBP; and 85.5 ± 11.0 and 82.9 ± 10.1, respectively in DBP), but no mean significant differences were found between groups (P value of 0.85 and 0.72 for systolic and diastolic BP, respectively). HR and SaO2 did not show statistical intra- and inter-group differences. The overall patient satisfaction score was significantly higher in the SG group compared to CG.

CONCLUSIONS

Intravenous moderate sedation seems to contribute to the stabilization of patient's hemodynamics, especially the systolic blood pressure, although small differences have been found.

CLINICAL RELEVANCE

Intravenous sedation seems to contribute to stabilize the hemodynamic values, and enhances the patient satisfaction after periodontal and oral surgical treatment in the dental office.

The Effect of Music on Preoperative Anxiety in an Operating Room: a Single-Blind Randomized Controlled Trial

OBJECTIVE

This study aimed to determine the effect of music as an intervention on relieving preoperative anxiety in patients with dental fear in an outpatient operating room (OR) before intravenous sedation (IVS).

METHODS

Sixty adult patients with dental fear undergoing dental surgery under IVS were divided into 2 groups (music and nonmusic). The music group listened to music in the waiting room until immediately before the initiation of IVS whereas the nonmusic group did not. Patient anxiety was objectively measured using heart rate variability (HRV) analysis to assess the low-frequency/high-frequency ratio as an indication of sympathetic or parasympathetic nervous system activity. Subjective preoperative anxiety was evaluated with a visual analog scale (VAS).

RESULTS

Heart rate variability analysis failed to demonstrate any significant difference between the 2 groups from baseline to start of IVS. There were also no significant differences between the 2 groups regarding changes in VAS scores.

CONCLUSION

Music intervention was not found to reduce preoperative anxiety in patients with dental fear before IVS in the dental outpatient OR as determined by HRV analysis or VAS scores.

Comparative evaluation of stress levels before, during, and after periodontal surgical procedures with and without nitrous oxide-oxygen inhalation sedation

CONTEXT

Periodontal surgical procedures produce varying degree of stress in all patients. Nitrous oxide-oxygen inhalation sedation is very effective for adult patients with mild-to-moderate anxiety due to dental procedures and needle phobia.

AIM

The present study was designed to perform periodontal surgical procedures under nitrous oxide-oxygen inhalation sedation and assess whether this technique actually reduces stress physiologically, in comparison to local anesthesia alone (LA) during lengthy periodontal surgical procedures.

SETTINGS AND DESIGN

This was a randomized, split-mouth, cross-over study.

MATERIALS AND METHODS

A total of 16 patients were selected for this randomized, split-mouth, cross-over study. One surgical session (SS) was performed under local anesthesia aided by nitrous oxide-oxygen inhalation sedation, and the other SS was performed on the contralateral quadrant under LA. For each session, blood samples to measure and evaluate serum cortisol levels were obtained, and vital parameters including blood pressure, heart rate, respiratory rate, and arterial blood oxygen saturation were monitored before, during, and after periodontal surgical procedures.

STATISTICAL ANALYSIS USED

Paired t-test and repeated measure ANOVA.

RESULTS

The findings of the present study revealed a statistically significant decrease in serum cortisol levels, blood pressure and pulse rate and a statistically significant increase in respiratory rate and arterial blood oxygen saturation during periodontal surgical procedures under nitrous oxide inhalation sedation.

CONCLUSION

Nitrous oxide-oxygen inhalation sedation for periodontal surgical procedures is capable of reducing stress physiologically, in comparison to LA during lengthy periodontal surgical procedures.

Music before Dental Surgery Suppresses Sympathetic Activity Derived from Preoperative Anxiety: A Randomized Controlled Trial

The aim of this study was to estimate the relieving effect of music intervention on preoperative anxiety by using heart rate variability (HRV) analysis. In this randomized controlled trial, 86 adult patients were scheduled to undergo impacted tooth extraction under intravenous sedation and local anesthesia and were classified as either fearful or nonfearful based on a questionnaire. Thereafter, the patients were subdivided into 2 groups: those who listened to music from the time that they arrived at the outpatient clinic until immediately before entering the operating room and those who did not listen to music. The effect of music intervention was evaluated by assessing 1) the low-frequency/high-frequency ratio of HRV, in which positive changes indicate increased sympathetic nervous activity, and 2) the coefficient of component variance for high frequency, in which positive changes indicate increased parasympathetic nervous activity, assessed by means of HRV analysis. Subjective preoperative anxiety was evaluated on a visual analog scale. For fearful patients, the mean magnitude of low-frequency/high frequency changes from baseline among those who listened to music was significantly lower as compared with those who did not listen to music (in the private room: -1.45 ± 1.88 vs. 1.05 ± 1.88, P = 0.0096, 95% confidence interval of effect size = -4.52 to -0.48, Cohen's d = -0.75; in the operating waiting room: -2.18 ± 2.39 vs. -0.10 ± 3.37, P = 0.011, 95% confidence interval of effect size = -3.94 to -0.22, Cohen's d = -0.71, respectively). Visual analog scale scores were also significantly different. Coefficient of component variance for high frequency and heart rate did not differ significantly between the 2 groups. From the perspective of autonomic nervous activity, music intervention is useful for relieving anxiety in patients with dental fear before they enter a dental outpatient operating room. Music intervention may relieve anxiety by reducing sympathetic nervous activity, while parasympathetic nervous activity is not involved (UMIN000016882). Knowledge Transfer Statement: The results of this study revealed that music intervention is useful for clinicians when planning preoperative anxiety management of patients with dental fear who undergo impacted tooth extraction under intravenous sedation and local anesthesia. As a bridging intervention, music intervention enables stress management to continue uninterrupted from the patient's arrival at the dental outpatient clinic to intravenous sedation until completion of the dental surgery. With consideration of cost-effectiveness, absence of adverse physical effects, immediate effect, safety in terms of not using drugs, and lack of concerns about recovery, this information could lead to more appropriate decisions regarding anxiety management in dentistry.

Comparative evaluation of oxygen saturation during periodontal surgery with or without oral conscious sedation in anxious patients

Context:

Stress and anxiety during dental procedure can alter respiratory rate and thereby alter oxygen saturation in the blood, leading to emergencies like syncope. It can be prevented by preoperative intravenous sedation. However, it can lead to respiratory depression. Hence, this study was carried out to analyze the effect of oral conscious sedation on oxygen saturation during periodontal surgery in anxious patients.

Aim:

The aim was to compare the oxygen saturation levels during periodontal surgery with and without oral conscious sedation using diazepam in anxious patients.

Settings and Design:

Randomized clinical trial.

Materials and Methods:

The study population consisted of 20 generalized periodontitis patients, identified as anxious for dental treatment with dental anxiety scale. A randomized split-mouth design was used with one quadrant of surgery involving preoperative oral sedation (diazepam), and the second without it. Oxygen saturation was monitored by pulse oximetry. Data were recorded at 5 time periods during the surgery.

Statistical Analysis Used:

Mann–Whitney U-test.

Results:

No statistically significant difference between sedated and nonsedated patients in oxygen saturation with P = 0.683.

Conclusions:

Oral conscious sedation can be used for anxious patients during periodontal surgery for alleviation of anxiety and for better patient acceptance during surgical procedures without significant respiratory depression.

Cardiovascular Alterations After Injection of 2% Lidocaine With Norepinephrine 1:50,000 (Xylestesin) in Rats

The purpose of the present study is to determine the cardiovascular effects produced by intravascular injection of 2% lidocaine with 20 microg/mL of norepinephrine on systolic, diastolic, and mean arterial pressures and heart rate of rats at the following times: control period, during the injection (first 15 seconds), during the first minute, and at the end of 1, 2, 3, 4, 5, 10, 15, 20, 25, and 30 minutes after drug administration. The study was performed on 13 male Wistar rats with weights between 200 grams and 220 grams that were awake during the recording of these parameters. The dose administered was proportional to 1 cartridge of local anesthetic (1.8 mL) in an average-size human, which is equivalent to 0.51 mg/kg of lidocaine hydrochloride and 0.51 microg/kg of norepinephrine hydrochloride. The average time of injection was 15.7 seconds. The results of this study showed significant increases in systolic, diastolic, and mean arterial pressure and a noticeable decrease in heart rate. The greatest variation occurred in the systolic blood pressure. The greatest alterations occurred during injection and within the first minute following administration of the anesthetic solution. We would anticipate these changes in the parameters analyzed to be clinically significant. Thus, dentists using 2% lidocaine with norepinephrine 20 mug/mL should be very careful to avoid intravascular injection.

Steroid cover for dental patients on long-term steroid medication: proposed clinical guidelines based upon a critical review of the literature

Based to a great extent upon mainly anecdotal case reports and theory, there is a general acceptance that patients on long-term systemic steroid medication should receive supplementary glucocorticoids or "steroid cover" when undergoing certain types of stressful treatment including dentistry. The theoretical basis to this practice is that exogenous steroids suppress adrenal function to an extent that insufficient levels of cortisol can be produced in response to stress, posing the risk of acute adrenal crisis with hypotension and collapse. The purpose of this paper is to review relevant literature and propose clinical guidelines for dental practitioners. Of numerous reported cases of adrenal crisis following procedural interventions, few stand up to critical evaluation. Other reviewers have reached similar conclusions. A number of studies confirm the low likelihood of significant adrenal insufficiency even following major surgical procedures. Various authors have suggested modified guidelines for management of patients on steroid medications. Patients on long-term steroid medication do not require supplementary "steroid cover" for routine dentistry, including minor surgical procedures, under local anaesthesia. Patients undergoing general anaesthesia for surgical procedures may require supplementary steroids dependent upon the dose of steroid and duration of treatment.

Effects of Intravenous Midazolam and Diazepam on Patient Response, Percentage of Oxygen Saturation, and Hemodynamic Factors During Periodontal Surgery

BACKGROUND

The purpose of this double-masked study was to evaluate effects of intravenous sedation (IVS) using midazolam or diazepam during periodontal procedures on patient recall, psychomotor response, oxygen saturation, and hemodynamic factors.

METHODS

Seventeen patients received either two or three scheduled periodontal surgeries under IVS with midazolam, diazepam, or placebo control. Patients were monitored throughout the procedure for hemodynamic variables, percent oxygen saturation, level of recall of common objects presented at baseline, and psychomotor function via the perceptual speed test (PST).

RESULTS

Fifteen patients completed the study with average titrated dosages of 3.3 and 12.1 mg for midazolam and diazepam, respectively. Within the limitations of the study, there were few differences observed between the drugs with regard to hemodynamic variables, oxygen saturation, and overall percentage of objects recalled by patients sedated with either drug. However, midazolam was found to cause a greater incidence of amnesia lasting up to 30 minutes when compared to placebo. Patients on diazepam required an average of 15 minutes longer to recover accuracy as measured by the PST.

CONCLUSIONS

The results suggest that diazepam and midazolam each may have advantages for IVS. In procedures lasting over 45 minutes, diazepam appears to be more clinically advantageous including a wider margin of safety during titration and gradual recovery. Midazolam may be used for shorter procedures for faster onset of action, predictable amnesic effects, and relatively rapid recovery.

Cardiovascular responses induced by dental treatment

Changes in mean heart rate and mean systolic and diastolic blood pressure are induced in both the patient's anticipation of scheduled treatment and the actual dental treatment itself. Significant changes have been observed before application of a local anesthetic, during restorative treatment, during extractions, and when epinephrine-impregnated retraction cords were used. These cardiovascular responses may vary according to the local anesthetic used and the choice of vasoconstrictor. The individual changes in heart rate and blood pressure are affected by pain and such individual factors as age, gender, hypertension, dental experience, and psychological responses. Although for the most part the cardiovascular changes induced by dental treatment are limited and within the normal physiological variation, this review stresses the importance of eliminating pain and minimizing patient anxiety.