Espertise · 2012-02-08 · of Anesthesia in Dentistry, is to promote these techniques and spread the word of modern patient management techniques. This presentation describes a sedative

From Local Infi ltration to General AnesthesiaEuropean Federation for the Advancement of Anesthesia in Dentistry (EFAAD)

Scientifi c FactsEspertise™

Scientifi c ConferenceMarch 27 – 28, 2008, Herzlyia, Israel

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Table of contents

Prof. Eliezer Kaufman, ChairmanHadassah University Hospital, Department of Oral Medicine, Hebrew University - Hadassah School of Dental Medicine, Jerusalem, Israel

Introduction ............................................................................................... 4 – 5

Christiane Stein3M ESPE AG, Germany

Greeting ..................................................................................................... 6 – 7

Dr. Jean-Frederic AndreGaillard, France

The Wonders of Sedation ........................................................................ 9 – 15

Elinor C.M. Bouvy-Berends, D.D.S.Patient Care Centre for Special Care Dentistry, CBT Rijnmond, The Netherlands

Dr. Jeroen W.B. Peters, PhDHan University, Nijmegen, The Netherlands

Assessing Pain in Children with cognitive Impairment in relation to Oral Health Care .............................................................. 16 – 29

Dr. Dr. Monika DaubländerUniversity of Mainz, Germany

New Technology and a new Drug for improved Local Anaesthesia .... 30 – 36

Dr. Sharon EladHospital Oral Medicine Service

Prof. Eliezer KaufmanThe Center for Sedation and Dental Anesthesia,Department of Oral Medicine, The Hebrew University – Hadassah School of Dental Medicine, Jerusalem, Israel

The cardiovascular Effect of Local Anesthesia with Articaine plus 1 : 200,000 Adrenaline versus Lidocaine plus 1:100,000 Adrenaline in medically compromised cardiac Patients: a prospective, randomized, double blinded Study ....................................................... 37 – 38

3Dr. Silvina Friedlander-Barenboim, Prof. Eliezer KaufmanThe Center for Sedation and Dental Anesthesia, The Hebrew University – Hadassah School of Dental Medicine, Jerusalem, Israel

V. DvoyrisDMD student, The Hebrew University – Hadassah School of Dental Medicine, Jerusalem, Israel

Does Granisetron eliminate the Gag Reflex? ....................................... 39 – 41

Dr. med. Dr. med. dent. Wolfgang JakobsSpeicher, Germany

Modern local Analgesia with Articaine – clinical and pharmacological Considerations ...................................... 42 – 48

Dr. Nigel D. Robb, TD, PhD, BDS, FDSRCEEd, FDS (Rest Dent), FDSRCPS, ILTMGlasgow Dental Hospital and School, Glasgow, UK

Sedation for Medically Complex Patients ............................................ 49 – 56

Prof. S.A. RabinovichMoscow State University of Medicine and Dentistry, Moscow, Russia

Modern Choice of Pain Control in Russian Dental Practice ................. 57 – 60

Dr. Andrea WraithRoyal Society of Medicine (RSM), Section of Anaesthesia, UK

Simple, Sensible and Safe: A common Sense Approach to medical Emergencies in the dental Surgery .................................... 61 – 62

4 On March 27 – 28, 2008, a scientific conference titled “From Local Infiltration to General Anesthesia” took place in Israel. The event combined the opening of the new Center for Sedation and Anesthesia in Dentistry at the Hebrew University-Hadassah School of Dental Medicine in Jerusalem and a scientific program in Herzlyia. It was organized by the Israeli branch of the European Federation for the Advancement of Anesthesia in Dentistry (EFAAD) and sponsored by 3M ESPE. Thirty-four guests from Germany, France, England, Scotland, Russia, the USA and Portugal made this special trip to participate in the events by giving lectures and presenting posters. They were joined by many Israeli colleagues.

In the opening ceremony of the Center for Sedation and Anesthesia in Dentistry, Prof. Mor Yosef, the general director of the Hadassah Medical Center, and Prof. Adam Shtabholz, the dean of the Hebrew University-Hadassah School of Dental Medicine, congratulated the guests and faculty on the new Center. Dr. Wolfgang Jacobs, a former president of EFAAD and IFDAS, gave a keynote lecture on the subject of pain and anxiety control in dentistry and Prof. Norman Trieger, a former president of ADSA, presented a brief history of sedation and anesthesia in dentistry.

Later in the evening, at a traditional 3M ESPE “round table meeting”, Dr. Sharon Elad presented the results of a scientific study “The Cardio-vascular Effects of Local Anesthesia with Articaine versus Lidocaine in Medically Compromised Cardiac Patients: A Retrospective Double Blind Study”.

Introduction

5On Friday the 28th of March, a scientific meeting, which consisted of state of the art lectures on the subject of anxiety and pain control, took place in Herzlyia. These two events were designed to share and distribute the knowledge and experience acquired in the field of anxiety and pain control to the dentist who is confronted every day with problems of patient management. This is the goal of our societies.

These events were made possible through the generous support of 3M ESPE which accompanies the dental community in its search to constantly improve the necessary tools for patient management. This goal would not be possible without the continuous sponsorship of research by companies such as 3M ESPE.

With kind regards,

Prof. Eliezer Kaufman, Chairman of the Center for Sedation and Anesthesia in Dentistry, Department of Oral Medicine, The Hebrew University – Hadassah School of Dental Medicine, Jerusalem Israel.

Herzlyia, Israel – March 27 – 28, 2008

6 It was a great pleasure for 3M ESPE to attend the conference “From Local Infiltration to General Anesthesia” in Jerusalem and Herzlyia, Israel. This top-level event focused on the exchange of scientific study results in the field of modern pain therapy and sedation as well as knowledge transfer to dentists worldwide. 3M ESPE continuously pursues and promotes the goal of pooling international knowledge to offer dentists around the globe professional support and to facilitate access to information about the latest findings and progress in the dental field. Therefore, 3M ESPE was delighted to support the inter-national conference as a major sponsor and to have the opportunity to share in this successful meeting.

The conference started with the official opening of the new Center for Dental Sedation and Anesthesia at the Department of Oral Medicine of the Hebrew University – Hadassah School of Dental Medicine, which

provided deep insights into daily practice of pain treatment and sedation methods. After the opening ceremony and a guided tour through the Center, a two-days top-class scientific program with renowned lecturers followed, and the presentation of highly interesting study results gave new impulses. In addition, the participants also had the opportunity to start conversations with lecturers and colleagues. In the evening, a Round Table Scientific Meeting was organized with Dr. Sharon Elad from Israel to present the results of a recently finalized study with Ubistesin. The evening programme was used intensively for an exchange of ideas and experience, to make international contacts and to take home a whole bundle of new ideas.

Greeting

73M ESPE would like to thank the president and organizer of the event, Prof. Eliezer Kaufman, as well as to all lecturers, who invigorated the conference with their outstanding talks and for the successful coopera-tion.

Finally, 3M ESPE wishes Prof. Kaufman great success with the new Center.

With kind regards,

Christiane Stein3M ESPE AGRegulatory and Scientific Affairs Manager for Dental Pharmaceuticals

Herzlyia, Israel – March 27 – 28, 2008

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Team of European Federation for the Advancement of Anaesthesia in Dentistry (EFAAD).

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IntroductionDentistry is moving. Techniques are changing everyday, for the better. Our patients can be successfully treated with amazing oral rehabilita-tions, esthetically and functionally. A famous Chinese quote states: “We do the impossible everyday, miracles take a little longer.”

Conservative, surgical and prosthetic techniques make rehabilitation wonders. Patient management techniques are the miracle, making dentists friendly and appreciated.

We are now in a position to offer everyone a solution, even for the disaster mouths still existing in our modern world. In Europe, sedation in many aspects is still considered the black sheep discipline in the world of dentistry. Consensus is rather hard to achieve in a continent with such different approaches.

Yet very safe and very easy techniques have been described for ambulatory dental treatment and widely used for years.

Dr. Jean-Frederic AndreGaillard, France

The Wonders of Sedation


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Dr. Jean-Frederic Andre

The goal of EFAAD, the European Federation for the Advancement of Anesthesia in Dentistry, is to promote these techniques and spread the word of modern patient management techniques.

This presentation describes a sedative technique using midazolam administered by the intravenous route. Patient acceptance is tremen-dous. There is no reason not to sedate our patients.

Implantology has opened up a new era in dentistry justifying the need for new surgical procedures, a new surgical environment, new training, and therefore new patient management techniques.

The patient of today is informed of those developments but still today, surgery means expensive, painful procedures. In the meantime, the patient’s desire is to have esthetics, absence of pain, a minimum number of treatment sessions, a minimum number of correspondents, quick results and follow-up. The patient wants care and concern.

Our job is to provide this expected care and concern. Including surgical

stages in full mouth rehabilitation is quite common. That is where patient management techniques take effect. Treatment planning using sedation enables us to provide longer sessions, more work is done, and in better conditions with a comfortable and cooperative patient. We create the best working conditions, both for the dentist and patient.

Of course, sedation has a cost, but many benefits. Offering sedation to our patients goes along with our aspiration for excellence in offering the best treatment options and thus obtaining trust from patients as well as colleagues, and outstanding feedback from all.

IndicationsFear of dentistry –Long sessions for full-mouth rehabilitation –Surgical sessions: wisdom teeth removal –Implantology –

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MethodThe first step is always a thorough patient evaluation with recording of the vital signs. The first appointment also provides the opportunity to deeply explain the whys and wherefores of the technique.

Our intravenous sedation technique involves a single drug: midazolam, a benzodiazepine. The chosen presentation is 1 ml vials containing 5 mg of midazolam. The intravenous route enables titration of the drug, meaning that the sedative is delivered by increments of 1 mg through-out the procedure, in order to keep a constant plasmatic level.

The surgery needs to be equipped with an appropriate monitoring system including oxygen saturation, non-invasive blood pressure and pulse measurement. The machine is programmed to monitor the BP every 5 minutes. Vital signs are recorded, printed and kept in the patient’s file.

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Equipment also requires an IV line, a butterfly injection needle or an angiocath, saline for the infusion and a tourniquet.

The IV line is placed either on the dorsum of the hand or in the antecubital fossa.

The midazolam is administered 1 mg by 1 mg during the procedure in order to keep the patient conscious but comfortable and cooperative at all times.

A sedated patient responds to verbal commands and looks clinically relaxed.

The patient is kept under surveillance in the surgery at least one hour post operatively. He is discharged only with an accompanying person.

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A pre-op informed consent makes it clear that by no means should the patient work, drive or take any responsibility, professional or private 24 hours following the discharge.

Wonders of the IV routeAmong the many advantages of the intravenous route are:

titration of the sedative drug –quickest onset –possibility of administering drugs : antibiotics, NSAI, –emergency drugs, flumazenil (midazolam antagonist)possibility of collecting blood and building platelet rich fibrin (PRF) –

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Blood collection tubes and a dedicated centrifuge are needed in addition to the IV set-up.

The fabricated PRF membranes can be sutured on the surgical site for protection and enhancement of healing conditions.

Wonders of IV sedationIV sedation has all the following advantages:

comfort for the patient –comfort for the practitioner –cost-effective: 5 to 10 times cheaper than general anesthesia –3.5 times safer than GA –better, faster dentistry –simple procedure provided the team is trained –outstanding feedback from the patients and correspondents –

Patient feedbackThe numbers below speak for themselves. One of the effects of sedation with midazolam is anterograde amnesia. Although conscious during the procedure, the patient forgets all or most of the different steps. Not recalling the unpleasant steps of the patient-practitioner relationship shows we care and are concerned.

400

350

300

250

200

150

100

50

0

Do you recall any injection apart from the arm injection?

yes no

• 420 cases• 94,5 % of the patients have no memory of intra-buccal injections

397

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Conclusion100 % of the patients treated with intravenous sedation wish to have the same patient management technique, should they need a new procedure. Sedation has every reason to be integrated in our therapeutic arsenal. Training centers are available for dentists in Europe and the USA. Check the federation’s website for information: www.efaadonline.org.

350

300

250

200

150

100

50

0

Do you recall the different steps of the procedure?

yes partlyno

• 75,7 % of the patients don´t remember anything• 22,4 % of the patients remember bits and pieces of the procedure

318

94

8

450

400

350

300

250

200

150

100

50

0

Do you remember having endured pain during the procedure?

yes no

• 95,9 % of the patients have no memory of any pain403

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Introduction Pain is an important warning signal for discomfort or illness and pain is known to negatively influence quality of life. In assessing pain, self-report is the gold standard. But what if the child or adult is not capable of expressing his pain verbally, as is the case for people with cognitive impairment. Not only do these individuals have problems in communi-cating their pain, they are also at an increased risk of experiencing pain, particularly those living in an institutional setting (McGrath 1998, Terstegen et al. 2003). Exact data, however, are missing, so data about the risk and prevalence of pain in individuals with cognitive impairment can only be retrieved by indirect reasoning. In the Netherlands, about

Elinor C.M. Bouvy-Berends, D.D.S.Patient Care Centre for Special Care Dentistry,

CBT Rijnmond, The Netherlands

Dr. Jeroen W.B. Peters, PhDHan University, Nijmegen, The Netherlands

Assessing Pain in Children with cognitive Impairment in relation to

Oral Health Care

Assessing Pain in Children with cognitive Impairment in relation to Oral Health Care

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25 % of the healthy children experience one or more painful events every week: from bumps and bruises to headache and abdominal pain (Perquin et al. 2000). Children with severe cognitive impairments are believed to experience pain more frequently, but exact data are missing. Co-morbidity associated with the disability, like dislocation of hips, muscular spasm, gastro-oesophageale reflux or scoliosis, account for these increased episodes of pain lasting several hours each week (Breau et al. 2003). Yet these patients receive less pain medication in comparison with cognitively intact individuals (Malviya et al. 2001).

Casus Sebastian:

Sebastian was born with multiple congenital malformations based on the deletion of the long branch of chromosome 2. His psychomotoric development is severely retarded and the hypertonia of his muscles gives him discomfort and distress in his life.

Due to progress in medical science we see a decreasing morbidity and mortality for children with congenital disorders. However a lower mortality rate should not be replaced by increasing morbidity. In other words: if this child can live longer, the quality of that life should be acceptable.

His mother visits the Centre for Special Care Dentistry frequently, always with the same question: I can see that he is in pain. I feel guilty and worried. What is it this time: his ears, throat, stomach, guts, teething, decay?

Elinor C.M. Bouvy-Berends, DDSDr. Jeroen W.B. Peters

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Sebastian doesn’t like us to examine his oral cavity, let alone to treat him. Several times we treated him under general anaesthesia in the Sophia University Children’s Hospital, together with the ENT specialist or gastro-enterologist, in search of an explanation for his complaints. Unfortunately due to the additional dental malformations, dental care has been rather difficult and with unpredictable results.

His mother knows in the context of his daily life situation how to judge specific behavior that could express pain, but she is not always sure. This is especially the case for caregivers, nurses, doctors and dentists, not familiar with the child.

Can they objectively assess pain in this severely impaired child? It is demonstrated that not only parents, carers, doctors, and nurses are poor observers of the amount of pain experienced by the child. Dentists underestimate the child’s pain as well (Versloot et al. 2004). Inadequate pain expression by the cognitively impaired patient often leads to insufficient pain management in oral care (Hennequin et al. 2003). Finally, a delayed diagnosis of the presence and cause of pain may result in a setback in hospitalization and increased death rates (Weiner et al. 1999).

Pain sensitivity and behavioural responses to pain of children with cognitive impairment

Pain sensitivityOnly some decades ago, dentists seldom gave local anaesthesia in painful dental procedures to patients with a cognitive impairment in general and with Down’s syndrome specifically, as they could feel no pain. Due to the development of the discipline of special care dentistry, this practice is changing. Pain-free dentistry is now of paramount importance, especially for the cognitively impaired. Pain research is fundamental in providing the evidence of the mechanisms involved.

The belief that CI individuals are insensitive to pain is fortunately condemned, but still the general belief is that CI individuals have


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reduced pain sensitivity related to the degree of intellectual impairment (Breau et al. 2003).

It is noteworthy that it was a dentist who published a remarkable study on pain expression and stimulus location in individuals with Down’s syndrome (Hennequin, 2000).

In the first test, a group of DS patients and a control group of healthy volunteers (under the guidance of the researcher) placed an ice-cube wrapped in cling film on their temple and the inside of the wrist. Participants were instructed to indicate the moment when the stimulus became uncomfortable or painful. Latency time was significantly longer in the DS group.

In the second test, a cotton wool ball soaked in ethyl-chloride spray was placed by the clinician on specific sites on hands, the face and intra-orally, with the participants eyes closed. More individuals with

Down’s syndrome had difficulties in localising exactly the cold stimulus.

The results of this study could be explained by the more delayed and blunted response on pain stimulus and the psychomotor incompetence and cognitive deficiency to point out the location of the pain. Based on this study, it can be concluded that DS people are not insensitive to pain. Rather they express pain or discomfort more slowly and less precisely than the general population (Hennequin, 2003). It was concluded that these DS individuals have higher pain thresh-olds compared to controls.

The group of Defrin from Israel developed a different protocol. In these tests the subjects were exposed to two different heat stimuli. In the first test the temperature was linearly increased till the moment that the stimulus was perceived as painful. At this moment the individual had to press a button to terminate the stimulus. The second test was designed to be independent of reaction time: the individuals received a series of gradually ascending temperature stimuli with a preset final temperature, after which the temperature of the probe returned to


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baseline. Immediately following each stimulus the individual was asked whether he had felt pain or not. They confirmed Hennequin’s findings regarding greater latency time, but also found that the Heat Pain Threshold in individuals with MR and Down’s syndrome was significantly lower than the control-group. From this work it would appear that individuals with CI are not only pain-sensitive, but also more sensitive to heat than normal. Neurological anomalies in the pain system could be a possible explanation.

So, the belief held by caregivers (Breau et al. 2003) and parents of a decreased sensitivity to pain in individuals with cognitive impairment is certainly questionable.

The development of the Checklist Pain Behavior (CPG) Self-report is the gold standard in pain assessment. But how far can you expect a young child to be capable of self-reporting? Studies showed that children and adults with CI are not able to use a VAS scale. Drawn faces scales as well as blocks of increasing volumes can be reliable used in those with mild CI (Boldingh et al. 2004, Fanurik et al. 1998), but not in those with moderate CI. So methods to measure pain in children with moderate to profound CI are mostly based on observed face and body reactions to pain.

For the healthy child, more than thirty observational instruments (checklists) have been developed in the last decade, based on non-verbal behavior to see if the child is in pain. There was a strong believe that these checklists would not be suitable for children with severe cognitive impairment. Reasoning that pain behavior in the CI group is too diverse and that physical impairment hampers the behavioral repertoire of CI children.

That complexity might explain why only five observational pain meas-ures have been developed specifically for the child with (profound) cognitive impairment (Terstegen et al. 2003, Duivenvoorden et al. 2006, Breau et al. Anesthesiology 2002; Breau et al. Pain 2002; Collignon et al. 2001; Hunt et al. 2004; Stallard 2002). These checklists


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show a great variation in the number and the nature of observations needed for a pain assessment (i.e., 10 – 31 items).

Of these five instruments, the Checklist Pain Behavior (CPG) seems to have the best clinical applicability for the present form of the CPG (Duivenvoorden et al. 2006). It comprises 10 observational pain behaviors of which five (indicators) are defined by facial expression and overall behaviour like bodily movements or agitation are ignored. Applying this checklist requires thorough instruction and training. A CD with video-clips to learn to interpret correctly facial activity is an effective tool for achieving a good level of inter-observer reliability among nurses and carers. To date, the Checklist Pain Behavior (CPG) is used in more than 20 institutions for severely disabled children and adults in the Netherlands.

In short, the CPG was developed in several phases. During the first phase the researchers conducted an extensive literature review, semi-structured interviews and a pilot study to retrieve an exhaustive list of all possible pain behaviors, resulting in a list of 209 pain behaviors. Then, a total of 73 children with profound to severe cognitive impair-ment were recorded on video-tape, i.e. two times before surgery when they were at home and 4 times after surgery at rest and when under-going nursing/medical care. All these video-tapes were scored for presence or absence of all 209 pain behaviors. During video-taping, the researcher, one of the parents of the children and a nurse scored independently whether the child was in pain and the amount of pain; these pain scores correlated highly. Twenty-three pain behaviors discriminated between the pre- and postoperative period. Of these 23 behaviors, only 10 discriminated between the presence and absence of pain, i.e. between a VAS < 4 and ≥ 4 (Terstegen et al. 2003, Duiven-voorden et al. 2006). These cut-off score was based on international paediatric pain standards: a VAS ≥ 4 indicates the presence of pain that should be treated.

These ten observable pain behaviours can be divided in four categories: facial expression, social behaviour, vocalization, physiological signs.


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Table 1 shows the specific behaviours in the present 10-item CPG. Not surprisingly, the most sensitive indicators in this research were from the category “facial expression”. Because most children have limited motoric abilities they hardly express themselves by motor behaviours other than by facial expressions. When taking the interna-tional literature into account, it is generally acknowledged that the face is the most sensitive and specific parameter to assess pain

(see http://www.face-and-emotion.com/dataface/general/homepage.jsp). It is important to know that facial expression in reaction to pain is not acquired; it belongs to someone’s own individual pattern. It has a universal meaning and is independent of cultural learning processes (Ekman et al. 1971 Izard 1994). It is demonstrated that individuals diagnosed with autism and thus restricted behavioural skills communi-cate their pain specifically by their facial expression (Nader et al.2004).

Table 1. Behavioral categories of the Checklist Pain Behavior (CPG).

10 item Checklist Pain Behavior (CPG)Face

Tense face –Grimace –Sad –Naso-labial furrow –Eye squeezed –

VocalizationCries softly –Moaning/Groaning –Penetrating sounds of restlessness –

Social BehaviorPanic, panic attacks –

Physiological signsTears –

(Terstegen et al, 2003, Duivenvoorden et al, 2006) http://dare.uva.nl/record/215221

Table 1


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The CPG is valid where postoperative pain can be expected. In situations of ongoing pain or daily pain, the CPG can also be used, however, the CPG should be applied several times to find out whether these scores changed and at which moments. The CPG could be used for assessment of the efficacy of pain relief by conducting scores before and after drug administration. To find out the existence of dental pain one could compare CPG scores before, during and after eating, or when brushing the upper teeth compared with brushing the lower teeth.

But can we do more to discriminate between sub-acute pain and dental pain for the severely impaired dental (child) patient?

The Dental Discomfort Questionnaire, DDQThe recognition of toothache in children (and adults) with a cognitive impairment can be very difficult: self-reporting is not an (reliable)

option. In paediatric dentistry this is comparable with preverbal children, toddlers and preschoolers. A study on the effects of dental caries on the quality of life in children showed that only 48 % of the children with carious lesions indicated that they had pain or discomfort; however they did manifest the effects of pain by changing their eating and sleep habits (Thomas & Primosch, 2002). Predicting the presence of decayed teeth with the risk of toothache based on specific behaviour can play an important role in seeking help in time, for any child and the child (and adult) with special needs in particular. Thus preventing vulnerable individuals experiencing pain and the progress of dental disease.

At ACTA, the Academic Centre for Dentistry in Amsterdam, an obser-vational pain measure has been developed to identify toothache based on different behaviours: the Dental Discomfort Questionnaire DDQ. This questionnaire was tested for the assessment of dental discomfort and pain in very young children, to predict toothache in preverbal children and its use in mentally disabled children (Versloot et al. 2006. Versloot, 2007). In this study a group of experienced paedodontists produced a list of behaviours that occur in young children with caries and toothache based on extensive interviews with parents of referred toddlers about behaviours that occur in young children with caries and


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toothache. The information resulted in the Dental Discomfort Question-naire, DDQ (see table 2).

The study population consisted of two groups: 94 children referred to dental clinics specialized in treating children, all with decayed teeth. The control group consisted of 52 children from a day-care centre, all without active and untreated diseased teeth.

Dental Discomfort Questionnaire 1. Problems with brushing upper teeth 2. Puts away something sweet to eat 3. Problems with brushing lower teeth 4. Bites with molar instead of front teeth 5. Chewing on one side 6. Problems chewing 7. Reaching for the cheek while eating 8. Crying during meals 9. Crying at night10. Earache at night11. Earache in the daytime12. Earache during eating

Observable behaviours in young children with caries and toothache in the Dental Discomfort Questionnaire

Items 9, 10, 11, 12 do not correlate with the existence of toothache.Items 2, 5 and 7 predictive for the presence of toothache in young children.

Pain in dentistry (2007), J.Versloot

http://dare.uva.nl/record/215221

Table 2


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The questionnaire consists of two parts. In the first part the parent is asked if he/she ever noticed that the child had toothache. The second part of the DDQ consists of 12 questions about behaviours possibly associated with toothache or discomfort due to caries. All the children (n = 146) were examined by paedodontists to assess the occurrence of dental caries. According to the reported toothache and the different behaviours by the parent and the presence of decayed teeth following examination, it could be concluded that children with decayed teeth have clearly more often toothache than children without decayed teeth. Psychometric analysis performed on the 12 items of the DDQ show that four items (crying at night, earache at night, earache in the daytime, earache during eating) do not correlate with the existence of toothache. With these four items removed, the DDQ-8 has a satisfactory reliability. In this study it is also demonstrated that the behaviours: ‘puts away something sweet to eat’, ’chewing on one side’ and ‘reaching for the cheek while eating’ are predictive for the presence of toothache (Versloot, thesis 2007) These behaviours could possibly be used as cues for parents, caregivers or teachers to help them recognize toothache in young children.

The Dental Discomfort Questionnaire+ for the cognitive impaired

The objective of a follow-up study (Versloot et al. 2007) was to see whether the behaviours from the DDQ can help to identify toothache in cognitively impaired children with a limited capacity for self-reporting. Set up of this study: 58 children between 6 and 13 years of age. All pupils of a school for children with learning difficulties, with a wide range of learning disabilities, autistic traits, Down’s syndrome, cerebral palsy, behavioural difficulties and IQ below 50. Functioning at the same verbal level as two-to-four year olds.

For this population two additional questions were added: “Is your child producing more saliva?”"Is your child putting her/his hands in their mouth?” DDQ+.


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The authors found that children with cognitive impairments display mostly the same toothache-related behaviours as young children. For those chil-dren who displayed 4 or more toothache-related behaviours there was an 86 % probability that they were experiencing dental pain. A positive correlation was shown in this study between the total DDQ score and the dmfs/DMFS scores, indicating a relation between the severity of the caries and the score on the DDQ. These findings suggests that the DDQ+ would be a useful instrument in assisting parents of children with a cog-nitive impairment to identify when their child is experiencing dental pain.

DiscussionReturning to the casus of Sebastian: the use of the Checklist Pain Behaviour in combination with the Dental Discomfort Questionnaire could have specified pain-related behaviour of this profoundly cognitive impaired child as possible dental pain. This could have led directly to the decision to undertake timely dental treatment under general anaes-thesia GA. If, after the GA session, the scores of CPG would be 3 or less and the VAS less than or equal to 3 and the child would display 4 or fewer pain-related behaviours described in the DDQ, you might conclude that Sebastian is pain-free!

In summaryDS people are not insensitive to pain. Rather they express pain or –

discomfort more slowly and less precisely than the general population. Signs of potential discomfort or distress should be explained; obser-vational pain measures like the Checklist Pain Behavior CPG and the Dental Discomfort Questionnaire DDQ can be used in combination.In dental care for the cognitively impaired: use pain-control proce- –dures, even in the absence of obvious pain manifestations.The important aspect of early dental care is preventing children –from having pain and infection.


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Stallard P, Williams L, Velleman R, Lenton S, Mc Grath PJ, Taylor G. The development and evaluation of the pain indiactor for communica-tively impaired children (PICIC). Pain, 2002; 98:145-9.

Thomas CW, Primosch RE. Changes in incremental weight and well-being of children with rampant caries following complete dental rehabilitation. Pediatr Dent 2002; 24:9-13.

Terstegen CM, Koot HM, De Boer JB & Tibboel D (2003). Measuring pain in children with cognitive impairment. Pain response to surgical procedures. Pain 203, 103, 187-198.

Versloot J, Veerkamp JSJ, Hoogstraten J. Dental Discomfort Questionnaire: assessment of dental discomfort and/or pain in very young children. Community Dent Oral Epidemiol 2006; 34: 47-52.


29

http://www.face-and-emotion.com/dataface/general/homepage.jsp

Pain in dentistry (2007), J. Versloothttp://dare.uva.nl/record/215221

Elinor C.M. Bouvy-BerendsDr. Jeroen W.B. Peters

30

Introduction Local anaesthesia is crucial in modern and painless dental treatment. Many treatment opportunities cannot be performed with sufficient pain management.

Guido Fischer stated in his first textbook on this topic in 1911: “The severe pain caused by diseases of teeth and jaw is a sign of the

importance of these parts of the body. Local anesthesia is invaluable

for a dentist. It must be his goal to have a very good command of it

in all its scientific and technical aspects.”

Even in the 21st century there is need for training the dentist in these skills. Another German scientist, Heinrich Braun, who added the vasoconstrictor to the solution, also recognized very early during his experiments the importance of good local anesthesia: “I read about the possibility of producing an extract of the adrenal

gland of animals which constricts blood vessels. A few days later

Dr. Dr. Monika DaubländerUniversity of Mainz, Germany

New Technology and a new Drug for improved Local Anaesthesia


31I got a small amount of this extract, mixed it up with cocaine and

injected it into my forearm. Immediately I knew that this was the

dawn of a new period of local anesthesia”. The alternatives in these times were cooling and constriction of the area. Soon it became clear that the combination of drug, delivery system and technique are essen-tial for the result. With the synthesis of articaine in the early 1970’s there was a safe and potent drug available with a good ratio of analgesic potency (5) and toxicity (1.5) in comparison to procaine (table 1). The high plasma protein binding (95 %) is another advantage of this drug, as well as the combined metabolism (primarily as an ester locally, and secondarily as an amide in the liver). Therefore the risk of free articaine molecules in the blood that can bind at the receptors in brain, heart and vessels after a regularly applied local anaesthesia is low and also the amount of the drug that penetrates the placenta.

In Germany, 90 % of injections are performed with articaine, mostly in combination with epinephrine 1 : 200,000 (approximately 55 %) and less with an epinephrine concentration of 1 : 100,000 (45 %). The rate of side effects is 4.5 %. One reason for these side effects is an inadvert-ent partial intravasal injection in 20 % of cases. Under that condition, a small amount of LA and a remarkable quantity of epinephrine enters the intravasal space with the result of special systemic effects, such as tachycardia, high blood pressure.

To minimize these effects, we looked for a new articaine solution with a lower epinephrine concentration. In adult male baboons in the biomedi-cal research centre in Pretoria (South Africa) we studied these animals after systemic and local application of different local anesthetic solu-tions. In sum mary we found a greater cardiovascular depression after the intra ve nous injection of lidocaine compared with articaine (figure 1) and a stronger synergistic effect of articaine and catecholamines than in combination with lidocaine (figure 2). Even after consecutive injection of the two drugs, the cardiovascular effects of the catecholamines were pronounced. These results led to the idea of studying articaine prepa rations with epinephrine 1 : 300,000 and 1 : 400,000.

Dr. Dr. Monika Daubländer

32

Table 1: Characteristics of relevant local anesthetics

The most important questions were: 1. Can this amount of epinephrine still prevent fast and high resorption

of the LA from the site of injection?2. How much epinephrine reaches the blood after local infiltration? 3. Is there a lack of anaesthetic efficacy?

Even the solutions with a reduced epinephrine concentration were able to reduce the systemic LA plasma levels to 50 % (figure 3). After local application there was no statistical difference between the epinephrine levels of articaine without Epinephrine and the reduced concentrations (figure 4). The anaesthetic efficacy was tested in healthy volunteers with infiltration in the upper front teeth. The result was direct depend-ency of the area under the curve with the epinephrine concentration due to differences in duration of anaesthesia (figure 5). The solution with epinephrine 1 : 400,000 showed pulpal anaesthesia of 35 min, with epinephrine 1 : 200,000 of 45 min and 1 : 100,000 of 55 min.

These results underline the importance and the regulatory effect of the vasoconstrictor for this technique. This is different to conduction anaesthesia where the diffusion distance and barriers are larger. It seems that a reduced vasoconstrictor concentration leads to an advantage for better anaesthesia.

Another interesting result was the influence of the different drugs on the cerebral blood flow of the baboons. Even after local injection in the upper jaw, special effects could be measured. The LA (articaine and lidocaine)

Lidocaine Mepivacaine Bupivacaine Articaine

analgesic potency (relation: Procaine)

4.0 3.5 16.0 5.0

Molecular weight (Dalton)

234 245 288 284

pKa (25 °C) 7.91 7.76 8.16 7.80

partition coefficient

2.9 0.8 27.5 0.04

protein binding 64 77 96 95

systemic Toxicity (relation: Procaine = 1)

2.0 2.0 8.0 1.5


33

led to an enhanced cerebral blood flow due to vasodilatation and epine-phrine caused a decrease due to indirect effects of vasoconstriction (figure 6). The clinical implication of that result is probably to look for ideal combinations to achieve a steady state. In summary, this means that there is need for differentiated use of local anaesthetic and vasoconstric-tor dependent on the kind of treatment (duration and painfulness), risk factors of the patient, injection technique, needs of the patient and experi-ence of the dentist. Beside the drug, it is also necessary to look at the optimal delivery system. The dentist cannot precisely control rate or pressure with this simple mechanical (hand) system. The old premise that high injection pressure causes pain is well known and proven every day (figure 7). Therefore it is time to turn to better techniques. Computer con-trolled local anaesthesia devices (CCLAD) combine a micro motor and a

computer for higher precision and optimized injections (picture 1). Due to a controlled pressure there is an optimization in injection dynamics, reduc-tion of injection pain, quicker onset of anaesthesia and reduction of the volume needed. To decrease pain and anxiety of a local anesthetic injec-tion, pressure less than 306 mmHg (6 psi) should be used in movable mucosa. The correlation between tissue type and exit pressure can be measured and leads to the differentiation of 3 different kinds of injection sites. The highest pressure and density exists in the intraligamentary space, second is the palatinal mucosa and the lowest measurements can be found in the movable mucosa during infiltration and block anaesthesia.

200

190

180

170

160

150

140

130

120

mm

Hg

Figure 1: Systolic blood pressure after intravenous injection of local anesthetics (Articaine/Lidocaine)

0:00 1:00 2:00 3:00 5:00 12:00 12:30 13:00 13:30 14:00 15:00 16:00 17:00 18:00 19:00

Arti-Ventilated

Arti spontaneous

Lido spontaneous

Lido-Ventilated

min:sec

Intervention


34280

260

240

220

200

180

160

140

mm

Hg

Figure 2: Systolic blood pressure after intravenous injection of Articaineand vasoconstrictor (epinephrine vs. Norepinephrine)

– 5:00 0:00 0:20 0:40 1:00 1:20 1:40 2:00 3:00 5:00 12:00 13:00 14:00 15:00

min:sec

Intervention

Adr 100

Arti + Adr 100 Arti + Noradr 50

Noradr 50

Arti

4

3

2

1

0

mik

rog/

ml

Figure 3: Plasma levels of local anesthetics after maxillary infiltrationanesthesia (Articaine/Lidocaine)

12:00 13:00 14:00 15:00 17:00 20:00 22:00 27:00 32:00 42:00 52:00

min:sec

Arti + Adr 200

Arti + Adr 300 Lido + Adr 200

Arti + Adr 400

Arti

1000

800

600

400

200

0

pico

g/m

l

Figure 4: Epinephrine levels after maxillary infiltration anesthesia

12:00 13:00 14:00 15:00 17:00 20:00 22:00 27:00 32:00

min:sec

Arti + Adr 200

Arti + Adr 300 Lido + Adr 200

Arti + Adr 400

Arti


35

In addition to causing pain, a high pressure injection into the intraliga-mentary space can cause tissue damage. Therefore online feedback of the exit pressure at the tip of the needle can improve the injection, indicating a wrong position of the cannula tip and prevent harm of the patient’s tissues.

The single tooth anaesthesia unit (STA) with its rationaleGuidance to the target –Identification of the specific tissue –Continuous Feedback (Visual & Audible) during the injection –Detection of occlusion & leakage is able to provide the dentist with –all these options to increase the quality and efficacy of the injection.

Specially when treating children and anxious patients, these advantages become evident and reduce not only the stress of the patient, but also the dentist’s. In conclusion, it takes a good drug, as well as an adequate delivery system, to optimize the key benefits of local anaesthesia in mod-ern dentistry. Especially for the PDL and other “limited” applications, a 4 % solution offers the advantage of volume reduction and consecutively reducing injection time and is therefore preferable. The reduction of the epinephrine concentration can minimize cardiovascular side effects, as well as soft tissue anaesthesia. Both are desirable effects for the patient.

Picture 1: STA – Unit™ (Milestone)


36


2200

2000

1800

1600

1400

1200

1000

800

600

400

200

0

Inte

nsity

and

dur

atio

n

Figure 5: Intensity and duraction of maxillary infiltration anesthesia withArticaine and different concentrations of epinephrine (area under the curve)

Arti

+ Ad

r 100

Arti

+ Ad

r 200

Arti

+ Ad

r 300

Arti

+ Ad

r 400Arti

400

350

300

250

200

150

100

50

0

Pres

sure

Figure 7: Injection pressure and tissue type (Box and whisker)

Tissue Type

1 2 3 4

2: palatal injection

3: block anesthesia

4: buccal infiltration

1: PDL

Figure 6: Cerebral Blood flow after systemic and local injection of Articaineand epinephrine

2,52,42,32,22,12,01,91,81,71,61,5

0 1 2 3 4 50 1 2 3 4 5

CBF

– Ra

tio

Difference local anesthetic

All Articaine groups

r = 0.6588

p = 0.0029

2,62,52,42,32,22,12,01,91,81,71,61,5

CBF

– Ra

tio

Difference epinephrine

All Articaine groups

r = –0.6655

p = 0.0068

-100 0 100 200 300 400 500 600

37

ObjectivesThis study compared cardiovascular safety profiles of 2 local anesthet-ics (LA): articaine (Ubistesin™) versus standard lidocaine solution in cardiovascular patients.

Study Design Fifty cardiovascular patients were randomly assigned to dental treatment using 1.8 ml of one of two LA injections: articaine 4 % and adrenaline 1 : 200,000 or lidocaine 2 % and adrenaline 1 : 100,000.

The cardiovascular Effect of Local Anesthesia with Articaine plus 1 : 200,000 Adrenaline versus Lidocaine plus 1:100,000 Adrenaline in medically compro-mised cardiac Patients: a prospective, randomized, double blinded Study.

Dr. Sharon Elad*, Prof. Eliezer Kaufman***Hospital Oral Medicine Service,

**The Center for Sedation and Dental Anesthesia,Department of Oral Medicine, Hebrew University –

Hadassah School of Dental Medicine, Jerusalem, Israel

The cardiovascular Effect of Local Anesthesia with Articaine plus 1 : 200,000 Adrenaline versus Lidocaine

plus 1 : 100,000 Adrenaline in medically compromised cardiac Patients: a prospective, randomized, double blinded Study.

38

A computerized system enabled continuous longitudinal data collection: electrocardiography (ECG), O2 saturation, blood pressure (BP), and heart rate (HR). Patients scored pain level at the end of the LA injection (on a 0 to 10 scale).

ResultsThere were no clinical severe adverse effects. One transient local parasthesia occurred (lidocaine group), which lasted 4 weeks. There were no statistically significant differences between the 2 groups in HR, systolic or diastolic-BP, and O2 saturation. Age, gender, jaw treated, treatment duration, and the pain level did not influence the results of the comparison. In 3 patients asymptomatic ischemic changes were noted on ECG (1 in the lidocaine group and 2 in the articaine group). CONCLUSIONS: LA with articaine 4 % with adrenaline 1 : 200,000 was comparably as safe as LA with standard concentra-tions of lidocaine and adrenaline in cardiovascular patients. Cardiac ischemic changes on ECG did not appear to be related to the LA.

Time-Points & Time-Intervals Compared Between the Two Groups

PublishedS. Elad, D. Admon, M. Redmi, E. Naveh, E. Benzki, S. Ayalon, A. Tuchband, H. Lutan, E. KaufmanOral Surg Oral Med Oral Pathol Oral Radiol Endod. 2008 Jun; 105 (6): 725-30

Pre-TreatmentBaselinemonitoring

Baseline + 5’ LA LA + 5’ Treatment + 4’

Δ (Treatment + 4’) - LAΔ (LA + 5’) - LA

Time axis

Dental TreatmentLA

1 2 3 4

Dr. Sharon Elad, Prof. Eliezer Kaufman

39

IntroductionThe gag reflex is a primitive physiological defence mechanism, tailored to prevent entrance of foreign bodies to the trachea during eating. We might encounter the gagging in various patients coming to seek routine treatment at the dental practice. Some of the patients have such a severe reflex that the treatment will be of lowered quality, or will not succeed at all. There is no common treatment that can completely prevent the gag reflex. We suggest that selective 5-HT3 antagonists, used mainly as antiemetics, may relieve gagging. The objective of the

Dr. Silvina Friedlander-Barenboim, Prof. Eliezer KaufmanThe Center for Sedation and Dental Anesthesia, The

Hebrew University – Hadassah School of Dental Medicine, Jerusalem, Israel

V. DvoyrisDMD student, The Hebrew University – Hadassah School

of Dental Medicine, Jerusalem, Israel

Does Granisetron eliminate the Gag Reflex?

A cross-over, double blinded, placebo-controlled pilot study


40

study was to examine the prophylactic effect of Granisetron during routine dental treatment, as a first step in establishing a prophylactic protocol for extensive gaggers.

Materials and methodsTwenty-five healthy volunteers participated in this double-blind cross-over placebo-controlled trial. Both Granisetron and placebo were admin-istered intravenously to each volunteer on two different appointments, in random order. The doses of Granisetron and placebo were equal for all volunteers. The levels of gagging were measured by inserting a swab into the mouth and measuring its depth. Blood pressure, pulse and O2 saturation were recorded during the trial session. The recorded results were analyzed using tests for non-parametric values (P = 0.05).

Results There was a significant increase of the depth of swab insertion after the administration of both the placebo and the drug. The effect of the drug was statistically greater among volunteers with low body mass. There was no statistically significant change in volunteers’ heart rate, blood pressure and O2 saturation after the injection of both drug and placebo. No adverse effects were reported.

DiscussionIn most volunteers (78 %) the depth of insertion significantly increased (by 5 mm or more) after the injection. There is a possibility that the gag reflex decreased as the patients became more relaxed and acquainted with the procedure. There was a positive trend in drug action – the drug effect increased proportionally to the increase of drug dosage per kilogram of body mass. Some placebo effect was noticed as well. It is possible that the recommended dosage of antiemetic Granisetron won’t be enough for prevention of dental gagging. We believe that Granisetron injection of higher dosage will have effect on the prevention of gagging during dental treatment. However, the true efficacy of Granisetron in this treatment protocol is yet to be fully established.

Dr. Silvina Friedlander-Barenboim, Prof. Eliezer KaufmanDvoyris V.

41

25

20

15

10

5

0

– 5

–10

Chan

ge in

dep

th o

f sw

ab in

sert

ion

(mm

)

The effect of dosage on gagging stimulation

Dosage (µg/kg)

20.0 30.0 40.0 50.0 60.0 70.0 80.0

Log. (Depth of swab insertion post drug)

Log. (Depth of swab insertion post placebo)

Depth of swab insertion post drug

Depth os swab insertion post placebo

y = 2.628 ln(x) – 1.586

y = 4.83 ln(x) + 26.47


42

IntroductionThe almost proverbial fear of dentists and dental surgical procedures in particular is extremely widespread, in spite of the development of modern local anaesthetics and the latest treatment methods. In an article published in 1999 in the Dental Health Advisor journal, 21 % of the adults surveyed disclosed their fear of dental treatment. The fear of visiting the dentist therefore ranked second in the list of fear-induc-ing situations disclosed by the respondents, only topped by the number of respondents who state their fear speaking in public. The relationship between fear and pain with dental therapy explains why especially den-tists have been instrumental in the development of modern anaesthetic procedures.

In 1844, the dentist Horace Wells was able to perform the first tooth extraction using laughing gas. His colleague Thomas Morton was the first to succeed in using ether to perform general anaesthesia in 1846.

Modern Local Analgesia with Articaine – clinical and pharmacological Considerations

Dr. med. Dr. med. dent. Wolfgang JakobsSpeicher, Germany

Modern Local Analgesia with Articaine – clinical and

pharmacological Considerations

43

The aim of anaesthetic techniques in dentistry and oral-surgery is to exclude pain for performing pain-free dental treatment; furthermore, the reduction of fear and stress, as well as improvement in patient compliance, especially for prolonged, invasive dental or dental surgical therapy, also constitute the spectrum of dental anaesthesia. The anaesthetic techniques in dentistry and oral-surgery are intended to ensure that all possible and necessary procedures can be undertaken painlessly and free of the negative influences of fear and stress and that the patient’s vital functions, such as cardiovascular functions, breathing, oxygen saturation, etc. are monitored. The demands placed on anaesthetic techniques in dentistry and oral-surgery have trans-formed over recent years. Firstly, the therapy spectrum of modern dentistry has become far broader and along with it also the challenges facing dental anaesthesia. Simply excluding pain is often not sufficient for extensive implant surgical treatment or large-scale restorative or periodontal treatment. Moreover, higher volumes of local anaesthetic have to be administrated for more extensive procedures.

Life expectancy is on the rise in all the industrial countries; in Germany the average lifespan for men is approximately 74 years, for women it is around 80 years. 80 % of 80-year-old patients suffer from at least one chronic disease, a large proportion of the elderly are plagued by several chronic diseases. The typical older patient permanently takes three pharmaceutical preparations, some take up to 15 different drugs as their long-term medication. There exists a direct correlation between age and the intake of medication. The oldest 20 % of the population take more than 60 % of the prescribed pharmaceutical preparations. The number of unwanted side-effects rises with the number of prepa-rations taken. Unwanted side-effects are defined as all toxic or unin-tended pharmaceutical effects with a therapeutic dosage of a drug administrated for therapy, diagnosis or prophylaxis of a disease. Identification of the patient’s risk factors, their history of pre-existing diseases and permanent medication have to be considered for local anaesthesia in dental treatment. Age-related physiological changes can affect the metabolism of the local anaesthetic and may increase the risk of toxic reactions in the case of modified phamacokinetics of

Dr. med. Dr. med. dent. Wolfgang Jakobs

44

the preparation. Age-related changes affecting the metabolism of local anaesthetics are caused by changes in the liver function due to a decline in liver perfusion and regression of the liver parenchyma. The metabolic activity of the liver may decline with age. Age-related changes can also have an impact on the elimination of local anaesthetics. The glomerular filtration rate may be reduced by up to 30 % among older patients. Further age-related changes that can influence the pharmacokinetics of the local anaesthetic include reduced serum albumin levels, physiological changes, such as a decline in the water fraction and rise in fat fraction of body weight. In the context of age-related changes, the question arises whether modified dosage recom-mendations for older patients are necessary on account of changes in pharmacokinetics.

Publications indicate that the maximum dosage, e.g. of lidocaine in local anaesthesia of older risk patients, should be reduced. Malholm, Hansen (1986) recommend a reduced maximal dosage of local anaes-thesia for older patients. Evernessy demonstrated in his studies that the clearance of lidocaine in older risk patients was significantly reduced. In a clinical study, we compared the serum levels of articaine and lido-caine following submucosal infiltration in older patients. The aim of the

study was to investigate the pharmacokinetics of articaine and lidocaine in older patients following submucosal injection. A recommended maxi-mum dosage of 7.5 mg per kg body weight is given for lidocaine as an amide-type local anaesthetic.

The metabolism of lidocaine primarily takes place in the microsomes of the liver through the enzyme carboxylesterase. Up to 90 % of the injected lidocaine is subject to biotransformation in the liver, approx. 10 % is eliminated unmodified through diuresis. The plasma half-lives published for lidocaine are between 100 and 300 minutes. For articaine – an amide-type local anaesthetic with a thiophene structure – there is also a maximum dosage of 7.5 mg per kg body weight. Unlike lidocaine, articaine is metabolised both in the liver as well as in tissue and plasma through esterases. The articainic acid resulting has no significant local anaesthetic effect. The plasma half-life for articaine has been cited in


45

various studies as just 20 – 30 minutes. Eleven patients (table 1) aged 65 years and older from ASA groups II or III received 80 mg lidocaine or 80 mg articaine in a randomised sequence by submucosal injection in the region of the gingivobuccal fold of the maxilla (region 13 – 17). The time span between the two investigations was two weeks. The results are presented in the following table.

Table 1: Pharmacokinetics of Articaine and Lidocaine in elderly patients

¹ trend ² p < 0.0.5

Source: 11th International Dental Congress on Modern Pain Control; Pharmacokinetic Parameters after Repeated Submucosal Injection of Articaine and Lidocaine with Epinephrine, October 2006

The study showed no significant difference between the maximum plasma concentration of articaine and lidocaine in older patients (diagram 1), but significant differences between the two preparations with regard to the time of maximum serum concentration and the half-life values. For lidocaine we see that an elevated risk of accumulation exists for subsequent injection due to the prolonged half-life in older patients. There is a tendency to attain toxic plasma levels as a result of the prolonged half-life of lidocaine. Articaine offers a high degree of safety, especially for injection of higher dosages at time intervals (fractionated local anaesthesia). Because of its fast metabolisation, the use of articaine is preferable if dosages of local anaesthesia are administered (diagram 2 – 5).

Lidocaine Articaine

cmax 389.9 ng/ml 323 ng/ml¹

t max 32 min 19.5 min²

t 1/2 163.9 min 27.7 min²

subjects male/age famale/age

11 6 5

age/min 66 66

age/max 82 73

age/years (mean) 72.83 69.8

Body-weight/kg

weight/min 60 68

weight/max 90 90

weight (mean) 76.5 75.4


46

400

350

300

250

200

150

100

50

0

ng/m

l

Diagram 1: Plasma-concentrations of Articaine and Lidocaine in elderly Patients

time t 1 – t 11 5 min – 180 min

1 2 3 4 5 6 7 8 9 10 11

Articaine Lidocaine

1

0,8

0,6

0,4

0,2

0

Diagram 3: Serum levels of Articaine Lidocaine (mg/ml) after repeated injection

0 15 30 45 60 75 90 105 120 135 150 165 180

Articaine Lidocaine

360

300

240

180

120

60

0

Diagram 2: t1/2 life (median)

2

339

1

43

t (m

in.)

Articaine P = 0,0011

Lidocaine


47

Source: ADSA Annual Session 2003; Regional/Local Anesthesia: Geriatric Experience with Articaine, Lidocaine, Prilocaine

Another important aspect is the use of vasoconstrictive additives, par-ticularly in local anaesthesia of older patients. According to recommen-dations from the American Heart Association, if vasoconstrictive addi-tives are used, epinephrine in a maximum concentration of 1 : 100,000 should be administrated. Latest recommendations stipulate that an epinephrine concentration of 1 : 200,000 is sufficient for routine dental procedures; epinephrine can be omitted for purely conservative treat-ments or administrated at a dosage of 1 : 400,000. Special therapy concepts for the treatment of older risk patients recommend restricting the maximum dosage of epinephrine for use with local anaesthetics with vasoconstrictive additives to 40 microgram.

2.000

1.500

1.000

500

0

0 5 10 15 20 25 30 35 40 45 50 55 60 75 90min

ng/m

l

80 mg 3 × 80 mg 240 mg

Diagram 4: Serum Levels of Articaine (Articaine 80 mg, 3 × 80 mg, 240 mg)

7.000

6.000

5.000

4.000

3.000

2.000

1.000

00 5 10 15 20 25 30 45 60 75 90

min

ng/m

l

80 mg 3 × 80 mg 240 mg

Diagram 5: Serum levels of Aricainic-acid (Articaine 80 mg, 3 × 80 mg, 240 mg)


48

Calculation example:40 µg = 8 ml local anaesthetic with epinephrine 1 : 200,00040 µg = 4 ml local anaesthetic with epinephrine 1 : 100,000

The maximum dosage recommendation for epinephrine as a vasocon-strictor in local anaesthesia of healthy adults is 200 µg or 250 µg.

200 µg corresponds to a 40 ml local anaesthetic solution with epinephrine additive of 1 : 200,000. The treatment recommendation for older risk patients can be summarised on the basis of the American Society of Anesthesiologists (ASA) risk classification as follows:

ASA II detailed medical history – Dental treatment with LA (articaine), blood pressure monitoring,

pulse oximetry, dosage reduction depending on the maximum dosage of epinephrine, possibly sedation (in case of cardiovascular problems: epinephrine dosage reduction 40 µg, equivalent to 8 ml LA with epinephrine 1 : 200,000)

ASA III, ASA IV – Special therapy concepts, anaesthesiological stand-by, monitoring of

vital functions, pulse oxometry, ECG, intravenous access, possibly sedation, O2 insufflation, local anaesthetic without vasoconstrictor additives 40 µg epinephrine


49

Sedation for Medically Complex Patients

Dr. Nigel D. Robb, TD, PhD, BDS, FDSRCEEd, FDS (Rest Dent), FDSRCPS, ILTM

Glasgow Dental Hospital and School Glasgow, UK


IntroductionConscious sedation was introduced to clinical practice many years ago as a method of managing patients who were thought to be too medically compromised to safely undergo treatment under general anaesthesia. Thus there is a long history of sedation techniques being used for the management of medically compromised patients.

This history is frequently forgotten by those who seek to limit the access to sedation for medically compromised patients.

Who is medically compromised?This apparently simple question is becoming more difficult to answer as medical advances improve the prognosis of many conditions which a generation ago would have had a high mortality. The best way to assess medical compromise is to use the American Association of Anaestheisologists’ classification of Anaesthetic risk that was originally published in 1964. The classification is reproduced in table 1.

50


ASA I‘normal’ & healthy –well able to tolerate physiological stress –little or no anxiety –normotensive –

ASA IIextreme anxiety –extremes of age –pregnancy –mild systemic disease –obesity (BMI > 30) –mild hypertension (140 – 159/90 – 94 mmHg) –

ASA IIISevere systemic disease, limiting activity –but not incapacitatingHypertension < 199/114 mmHg –

ASA IVIncapacitating disease which is a constant –threat to lifeHypertension > 200/115 mmHg –

ASA VA patient with end stage disease, not expected –to survive 24 hours

ASA VIClinically Brain dead awaiting –organ harvest

Table 1

51

In assessing risk those who are in ASA groups 1 and 2 can be considered as not having a significant medical compromise, although it must be remembered that severe anxiety can raise a patient from ASA 1 to ASA 2. Thus in considering sedation for medically complex patients, we should be concentrating on those with an ASA classification of 3 or greater.

Patients in ASA groups 5 and 6 can be excluded, as dental treatment is not going to be performed. Thus we are dealing with those in groups 3 & 4. These are patients whose lifestyle is significantly affected by their medical condition. Despite the advances in pharmacological management of disease processes, patients who are in these groups are inherently more unstable than those who are ASA 1 or 2.

Patient AssessmentThe most important part of the care of any patient who requires sedation is the patient assessment. This is particularly the case when dealing with medically compromised patients. The purpose of the assessment is to reach a decision as to whether it is appropriate or necessary to use a sedation technique in the management of that particular patient having the specific dental treatment on that occasion.

If conscious sedation is appropriate then the assessment must also determine the type of sedation to be provided.

Nature, severity and stability of the patient’s medical condition.It is of fundamental importance to have an understanding of the patients’ underlying medical condition. The guidance available in the UK suggests that “a thorough medical dental and social history be taken prior to each course of treatment.”

This is part of the “careful and thorough assessment of the patient” that “ensures that the correct decisions are made regarding the planning of treatment” (1).


1 Conscious Sedation in the Provision of Dental Care. Standing Advisory Committee on Dental Sedation. Department of Health. London 2003

52


The team providing the treatment should take the medical history from the patient. Frequently this is an underestimated part of the consultation process. There is evidence that between 10 and 32 % of medical histories have significant errors of omission (2,3).

As part of the history taking there should be an exploration of the pattern of the patient’s disease. Most notably are there times of the year or times of day when the patient is better able to cope with treatment. If so treatment should be organised accordingly,

It may also be necessary to involve the patient’s carers in the history taking.

In cases of doubt further advice should be sought from the medical teams looking after the patient. In such cases the letters written to the physicians or surgeons should be both courteous and professional, giving an indication of what information is available and also what information is required.

During the history taking the opportunity to physically evaluate the patient should be taken physically evaluate the patient. This evaluation would include an assessment of the patient’s respiration (rate, depth and sounds), colour, demeanour and the presence of easily visible veins on the back of the hands – assuming that intravenous sedation is being planned.

Physical evaluation of the patientIn the United Kingdom it is rare for dentists to carry out a physical evaluation on routine patients, but those who are to have sedation should have their blood pressure checked. This will allow the inves-tigation of potentially undiagnosed hypertension.

2 Scully et.al. 'Reliability of a self administered questionnaire for screening for medical problems in dentistry' Comm Dent Oral Epidemiology 1983;1:105-8

3 Brady et.al. 'Validity of health history data collected from dental patients & patients perceptions of health status' JADA 1980;101:642-645

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At the end of the patient’s assessment the ASA Classification should be determined and recorded.

Where should patients is treated?Patients who are assessed as ASA I or ASA II can be treated by an operator/sedationist in a primary care environment. These patients are inherently stable and thus are extremely low risk.

Patients who are ASA III are inherently less stable and the signs and symptoms of deterioration may be masked by sedation. Thus these patients, although frequently better managed under sedation should be referred to a “specialist” environment for management. The important feature is that the team who are managing the patient are both trained and experienced in the management of medically compromised patients under conscious sedation. This will allow the early detection of problems.

Patients who are ASA IV should only receive emergency care in a secondary care setting until such time as their medical condition has been stabilised.

Patients who are ASA V or ASA VI do not need dental treatment.

Other options for ASA III and IV patients.ASA III patients may be managed with local anaesthesia alone or in combination with non pharmacological anxiety management techniques. In some cases there may be advantages to having a separate seditionist who is able to concentrate fully on the monitoring of the patient rather than assuming the dual responsibilities of both sedating the patient and providing the dental treatment.

Treatment under general anaesthesia should not be completely discounted as a good general anaesthetic is better than a poor sedation.


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ASA IV patients should only receive urgent treatment under close supervision.

In all cases it is important that the team who are managing the patients are capable of monitoring the patient’s clinical condition and responding to any changes.

When should patients be treated under sedation?It is important to try to treat patients when they are as medically fit as possible. Consideration should be given to the time of year if the treatment is elective. Some patients have conditions that may be worse at specific times of year. An example would be that patients with chronic bronchitis tend to find that their disease is worse in winter months.

The time of day may be another important factor. The less disruption to the patient’s normal routine the better.

If the patient has a change in their medical treatment, then it is better to allow the patient to be settled on the new treatment regime prior to the treatment under sedation.

If the patient has regular visits then it may be advantageous to coordinate with those visits. An example would be that a patient who is taking warfarin may be better attending the day after they have had a regular INR test rather than having to undergo repeat investigations.

Choice of sedation techniqueAs with all patients, the sedation technique should be chosen as the most appropriate for the individual and the dental treatment to be performed on that occasion. There are no techniques that are either universally applicable or universally contraindicated.

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Inhalation sedationInhalation sedation has certain specific advantages. Firstly patients who receive inhalation sedation receive substantially more oxygen than those breathing room air. With the exception of patients who rely on hypoxic drive to stimulate ventilation, this is a distinct advantage.

The duration of treatment is much more flexible under inhalation sedation than any other form of sedation. This is related to the rapid excretion of nitrous oxide from the body. Thus it is extremely well suited to either protracted or very short procedures.

The recovery is rapid, and thus the patient can return to normal activities quickly after the appointment.

As nitrous oxide is not metabolised, there is minimal risk of drug interactions.

The disadvantages of nitrous oxide mainly relate to the lack of potency as a sedative. This means that there is an increased need for the seditionist to be good at behaviour management.

Other disadvantages include the need for nasal breathing throughout the treatment. This can be a problem for patients who are obligate mouth breathers. The equipment is also more intrusive in the surgery and thus may require a slightly larger dental surgery to ensure that it does not intrude too much.

Intravenous sedationIntravenous sedation’s main advantages relate to the fact that it produces a more profound sedation. The benzodiazepines are also muscle relaxants which is useful in managing patients with involuntary movement disorders.

The amnesia provided by intravenous sedation is one of the features that patients appreciate the most, particularly if the treatment is at all traumatic.


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The disadvantages of intravenous sedation include the fact that intravenous access is required. Many patients find intravenous cannulation a stressful process.

Benzodiazepines cause respiratory depression. Many medical conditions respond poorly to hypoxic states, and thus care needs to be exercised in this regard.

Intravenous sedation with benzodiazepines is less amenable to being lengthened or curtailed than inhalation sedation with nitrous oxide.

The recovery from intravenous sedation is more protracted than that from inhalation sedation, and there is a greater potential for drug interactions.

SummaryConscious sedation techniques are useful in the management of medi-cally compromised patients. The reduction in stress associated with the administration of sedation makes the aggravation of pre-existing medical conditions significantly less likely.

The sedated state means that the patient is not only less aware of the external environment (and so less anxious about the dental treatment), but they are also less aware of their internal state. This means that the patient may not recognise the early warning signs of deterioration. It is incumbent on the dental team to be able to monitor the patient and react to any changes. Sedation of medically compromised patients needs a well trained and experienced team to provide safe and effec-tive management.

Preparation of both the patient and the team is important. If there are any doubts regarding the suitability of a patient for sedation, then the team should seek further information from those involved in the patient’s medical management and more experienced dental sedationists.

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IntroductionLocal anesthetics and local anesthesia are of great benefit when treat-ing patients in dental practice. Complications may only occur in special risk patient. The dentist has the possibility of choosing between three main types of pain control in dentistry – local anesthesia, combined anesthesia with sedation and general anesthesia – depending on the patient’s need and the severity of the treatment.

ResultsProblems with local anesthesia may occur due to low effectiveness of local anesthetic substances used in former times, the variety of anatomic characteristics in the maxillofacial area, lack of knowledge and skills by dentists regarding modern pain control and a wide range of local anesthetics and dental instruments in the national market.

Prof. S.A. RabinovichMoscow State University of Medicine and Dentistry,

Moscow, Russia

Modern Choice of Pain Control in Russian Dental Practice


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The main components of modern technologies of local anesthesia in dentistry are knowledge and skills in medical science and dentistry, in local anesthetics, vasoconstrictors and methods of local anesthesia and in the application of instruments.

Several modern instruments for local anesthesia are available e.g. metal, single use and computer syringes.

A combination of local anesthesia and sedation is a solution for out-patient practice dentists to remove anxiety, fear and stress from their patients. Various groups of psychotropic drugs are used but mostly tranquilizers such as benzodiazepines (diazepam and midazolam). The substance midazolam (Dormicum) – the first water soluble benzo-diazepine – acts quickly and shortly with low toxicity.

Dormicum has raised the level of combined anesthesia. Benzodiazipins in general are toxic and drastic and can only be prescribed by anesthe-siologists, not by a dentist.

Prof. S.A. Rabinovich

New technology and larger and more long lasting manipulations require an adequate pain conrol.

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A new selective non-benzodiazepin anxiolytic drug without the side effects of its predecessors was created in Russia and is called Aphobazol with a high safety and tolerability profile. This substance may be used unprescribed.

There is a new generation of nootropic drug in Russia available, as used by astronauts under prolonged stress in space. The name of the drug is Phenotropil. Phenotropil is a unique neurometabolic drug and differs from other nootrops due to its higher activity, adaptogenic action, combination of nootropic, anxiolytic and psychostimulating action and with effectiveness after single use.

Anxiolyse without abuse liability is possible with H1-antihistamines hydroxyzine like Atarax.

Alternatives to the described chemical substances include sedative phytopreparations like Valeriana, Leonorus or drugs with ultra-small doses of antibodies to brain-specific protein S-100 or homeopathic products.


Prospective solutions to control anxiety and pain in Russian Dentistry

IFDAS EFAAD

Moscow State University of Medicine and Dentistry

Russian Ministry for Healthcare and Social Development

education

Development of newtechnologies

for pain controlRegional centres

Regional centresRegional centres courses

clinicscience

Russian National Pain Centre Insurance companies

Dental Association of Russia

Modern telecommunicationtechnologies

Championships on Pain Controland First Aid

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Besides pharmacological medicines, the application of iatrogenic sedation to remove a patient’s emotional tension and fear through the appropriate behaviour of a dentist is also possible.

An important requirement for out-patient dentists is to have the knowl-edge and skills about first aid management with a first aid kit and all necessary medicines at hand.

The third type of pain control is general anesthesia. Problems with gen-eral anesthesia are high anesthetic risk, adequate airway maintenance and high cost of treatment. Sevoran and Xenon are the best modern anesthetics. Advantages: easy to use, easy to manage, flexible use, cardio-vascular stability, respiratory profile, safety, environmental com-patibility of Xenon. Since the introduction of this kind of modern drug for inhalational and non-inhalational narcosis (e.g. Propofol) the risk of complications is reduced. A prerequisite for general anesthesia is the availability of high technology equipment.

Prof. S.A. Rabinovich

Local anesthesia together with deep sedation and general anesthesia.

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IntroductionA skill is best learnt through a combination of theory, basic technique acquisition, ‘dry runs’ in scenario sessions and practice in real life situations; once acquired it must be used regularly to retain compe-tence and confidence.

So what of the skills required to manage a patient who experiences a medical emergency in the dental clinic? Few dentists will have had practical training and experience in managing medical emergencies in real life situations, and fewer still will have access to facilities to regularly use their skills.

Simple, Sensible and Safe: A common Sense Approach to medical Emergencies in the dental Surgery

Dr. Andrea WraithSecretary-elect of EFAAD,

Council member of the Section of Anaesthesia of the Royal Society of Medicine (RSM), UK

Simple, Sensible and Safe: A common Sense Approach

to medical Emergencies in the dental Surgery

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Instead they have to rely on acquiring theoretical knowledge and practicing in simulated emergency scenarios to prepare them for that dreaded day when a patient has a problem.

So what should they do to ensure they are up to the job? The speaker’s view is that they should aim to acquire knowledge and skills that are simple and therefore easy to learn, practice and retain; sensible in that they are applicable to the given situation in terms of the likely presenting conditions, facilities available, support staff training and experience; safe so that they can feel confident the care they provide will not only potentially help the patient but will also not do any damage!

This talk will discuss what, in the speaker’s opinion, should be viewed as the core skills, knowledge, equipment and medications dentists

should have to enable them to confidently, effectively and safely manage medical emergencies in their clinics.

Dr. Andrea Wraith

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Notes:Notes:

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Documents

Espertise · 2012-02-08 · of Anesthesia in Dentistry, is to promote these techniques and spread the word of modern patient management techniques. This presentation describes a sedative