Anesthesia Progress is the official publication of the American Dental Society of Anesthesiology (ADSA). The quarterly journal is dedicated to providing a better understanding of the advances being made in the science of pain and anxiety control in dentistry. The journal invites submissions of review articles, reports on clinical techniques, case reports, and conference summaries. To learn more about the ADSA, visit: http://www.adsahome.org/.

Anesthesia Progress

	Anesthesia is an ongoing challenge in dentistry, especially when working to correct severe disease of the tooth pulp (irreversible pulpitis which causes spontaneous tooth pain) in adult teeth. The difficulty tends to be compounded when dentists work with pediatric patients who have irreversible pulpitis from dental caries of their permanent teeth.

	Young, permanent teeth in children have a larger pulp, which increases the blood and nerve supply in young teeth, thereby also increasing sensitivity. Determining the correct method of anesthesia to assist dentists in fixing these young, diseased teeth is imperative.

	Researchers from the Chiang Mai University in Thailand published a novel study in the current issue of 

 that compared the success rates of pulpal anesthesia in children pre-medicated with ibuprofen when local anesthesia was combined with inhalation of nitrous oxide with oxygen or with oxygen alone.

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	The researchers performed a single-blind study in which 33 children with pulpitis of a permanent molar were included. The children were evaluated preoperatively for fear and anxiety using the Facial Image Scale and pain using the Wong-Baker FACES Pain Rating Scale (WBFPS) in case this affected their intraoperative pain perception. During the procedure, pain perception was measured with the WBFPS. Both scales are easily understandable by children and use pictures of faces that express emotions. Each child was given ibuprofen with a meal approximately one hour before the procedure. Seventeen children were then randomly assigned to the nitrous oxide group and 16 to the oxygen group. Once the gas was administered, the children were given nerve blocks to numb the area, and once numb, the procedure commenced.

The researchers measured the success of the procedure based on the results of the WBFSP. The WBFSP is rated on a zero to 10 scale correlating to “does not hurt” to “hurts the worst.” The method of anesthesia was considered a failure if the score was higher than four during any part of the procedure. Overall, the results showed a success rate of 71 percent in the nitrous oxide group; this was 52 percent higher than the success rate of the oxygen group. Compared with previous local anesthesia studies using nitrous oxide but without preoperative ibuprofen, these results showed an increased success rate in the combination of ibuprofen before the procedure and nitrous oxide during the procedure.

	Given these results, the researchers concluded that local anesthesia with nitrous oxide inhalation sedation combined with preoperative ibuprofen could have an increased success rate of pulpal anesthesia in cases of severe pulpitis in pediatric patients. They also believe that these results will benefit from further studies using a larger sample size.

	The full text of the article, “Effect of Nitrous Oxide on Pulpal Anesthesia: A Preliminary Study,” Anesthesia Progress, Vol. 65, No. 3, 2018, is available online at 

http://www.anesthesiaprogress.org/doi/full/10.2344/anpr-65-02-08

Articles

Researchers in Thailand discovered that local anesthesia combined with preoperative ibuprofen could have an increased success rate in young patients.

Nitrous oxide found to increase success rates of pediatric dental procedures

	Dentist anesthesiologists are a unique medical provider. Their training is related more closely to medical anesthesiologists than to dentists in that they do not receive clinical training in dental or oral surgery. 

	During their three-year residency program, dentist anesthesiologists receive most of their training in a hospital-based setting, performing a minimum of 800 cases of general anesthesia, of which at least 125 must be performed on children younger than seven years of age. However, very little is known about the post-residency practice characteristics of dentist anesthesiologists.

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Researchers from the Indiana University School of Dentistry in Indianapolis, Brigham and Women’s Hospital in Boston, and the University of California at San Diego recently published a study in the current issue of 

 that examines the procedural differences between dentist and physician anesthesiologists. Using two main dental databases, the National Anesthesia Clinical Outcomes Registry (NACOR) and the Society for Ambulatory Anesthesia Clinical Outcomes Registry (SCOR), for dental and oral surgery procedures, the researchers compared 7,133 office-based procedures performed by dentist anesthesiologists with 106,420 in-hospital procedures provided by physician anesthesiologists.

	The information from the SCOR database focused on office-based settings, while NACOR included hospital-based. The data showed that in both groups children six years and younger were the predominant recipients receiving anesthetic dental treatment (two-thirds of NACOR patients; three-fourths of SCOR patients); however, the average age for SCOR was approximately nine years and for NACOR approximately 12 years. The researchers also found a 46 percent longer surgical time for the cases from the NACOR database versus those from the SCOR. Both databases noted that early childhood caries (tooth decay) was the main diagnosis for the dental procedures needing anesthesia.

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	In reviewing the data, the researchers found a clear correlation between early childhood caries and the need for anesthesia during dental procedures. Given that this is the most common disease among children six years and younger, with more than 4.5 million cases developing each year, pediatric dentists need dentist anesthesiologists. The researchers also found that the overall cost of pediatric dental procedures with anesthesia performed in a hospital-based setting has increased between three and four times than that of 20 years ago. Currently, an 84-percent cost savings is found when anesthesia is administered in an office-based setting.

	Overall, there is a consistent trend with more dental anesthetic procedures being performed in an office-based setting, particularly for pediatric dentistry. The researchers have found that, “The anesthesia care provided by dentist anesthesiologists is also separate and distinct from anesthesia provided by oral and maxillofacial surgeons. Oral surgeons are the only other dentists who can legally administer general anesthesia; however, they receive approximately six months of general anesthesia training. Dentist anesthesiologists provide care to younger patients for procedures of longer duration using an independent anesthesia provider model versus oral and maxillofacial surgeons who use the operator-anesthesia model for shorter procedures on older patients.”

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	More research in this field is necessary because the data collected from the SCOR and NACOR are fairly limited as to the amount of information that is collected from providers on a volunteer level. The researchers concluded that despite the limitations on data collection, they are confident that, “Office-based anesthesia rendered by dentist anesthesiologists is clearly a unique and efficient mode of anesthesia care for dentistry.” They also believe that the increasing trend in office-based procedures with dentist anesthesiologists will continue.

	Full text of the article, “Comparison of Anesthesia for Dental/Oral Surgery by Office-based Dentist Anesthesiologists versus Operating Room-based Physician Anesthesiologists,” 

, Vol. 64, No. 4, 2017, is now available. 

Researchers discovered a surprising trend in where dental anesthesia is being performed.

Study finds office-based dental anesthesia is on the rise

	Dental checkups during early childhood are just as important as regular wellness checks by a pediatrician. By kindergarten, 40 percent of children have been diagnosed with early tooth decay or cavities, which can have a negative impact on their overall health. A significant number of these cases will require dental treatment. Due to the anxiety level associated with children and dental procedures, researchers are looking into the effectiveness and post-treatment effects of sedatives used during procedures.

	Researchers from The Ohio State University in Columbus, Ohio, working with a private clinician out of Charleston, South Carolina, recently published a study in the current issue of 

. The study investigates three different regimens for the use of the most commonly used pediatric sedative, midazolam: oral midazolam alone, nasal midazolam, or oral midazolam in combination with other sedative/analgesic medications. The goal was to find a single sedative or a combination of drugs that would reduce both anxiety and uncooperative behavior during dental procedures.

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	The researchers studied a total of 650 cases of sedation that took place over 24 months in a hospital-based pediatric dental clinic staffed by pediatric dentistry residents. Success rates were determined by procedure completion, behavior during sedation, sedation effectiveness, and number of teeth treated. Patient demographics were fairly balanced with 333 boys and 317 girls ranging in age from 2 to 3 (125), 3 to 4 (161), 4 to 5 (125), and 6 and older (145).
	
	Although the cases were all relatively short in duration, the results of the study showed that all three regimens had completion rates of more than 85 percent. Oral midazolam alone proved to be the most effective of the three, followed by nasal midazolam, and then the combination of pharmaceuticals. Complications observed by both clinicians and caregivers were very low with fewer than 4 percent of cases reporting post-procedural nausea or vomiting; approximately 62 percent of these cases involved the combination regimen. Paradoxical reaction, where the sedative caused the opposite effect due to loss of the child’s emotional control, was only present in 6 percent of cases and there was no significant difference among the sedation regimens.
	
	Overall, the researchers found that all three regimens were proven to be effective and safe for children undergoing dental procedures. The researchers note, “In our study, midazolam in several forms and combinations proved effective and safe with minimal side effects. We can recommend these uses of midazolam for necessary treatment in young children.”
	
	The full study, “

Safety and Efficacy of 3 Pediatric Midazolam Moderate Regimens

,” appeared in Anesthesia Progress, Vol. 64, No. 2, 2017.






Dental checkups during early childhood are just as important as regular wellness checks by a pediatrician. By kindergarten, 40 percent of children have been diagnosed with early tooth decay or cavities, which can have a negative impact on their overall health. A significant number of these cases will require dental treatment.

Which type of sedative is best for pediatric dental procedures?

	Before treatment, a dentist should have a sense of whether a patient is willing and able to cooperate during the procedure. This can be difficult to determine when the patient is a child. If a dentist could predict how a child is likely to respond to the usage of laughing gas, also known as nitrous oxide, the visit is more likely to be free of anxiety and fear.

	The authors of an article published in the 

 wanted to learn whether a child’s disposition is linked to successful usage of nitrous oxide. This form of sedation is often used by dentists treating children. Although 

 in general are prone to fear and discomfort in a dentist’s chair, research suggests that attitude is a key factor in how well a particular child will navigate a dental visit. However, no prior behavioral studies looked solely at nitrous oxide use.

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	The study included 48 patients, from three to eight years old, who were receiving dental care at a university-based clinic in Seattle, Washington. The children’s caregivers completed a validated behavior questionnaire, which the researchers used along with data from the patients’ charts to assess behavior and sedation success during the dental visit.

	The researchers found that the types of children successfully treated with nitrous oxide vary widely. When they focused on uncooperative children, they found that if scores were better in one temperament category, Effortful Control, laughing gas was more successful. Subscales of a few other characteristics were also helpful in predicting success during the dental visit.

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	Children who did well in the Effortful Control category had specific behavioral traits. For example, they could easily stop doing something when told “no” and could focus and become absorbed in a task, such as looking at a picture book. “It appears that children who are able to focus on a task and inhibit negative reactions are likely to be good candidates for treatment with nitrous oxide,” said lead-author Travis M. Nelson.

	The researchers concluded that, unsurprisingly, children who can overcome poor attitudes about a trip to dentist are most successful in receiving dental care. Those who can focus on the task and remain focused throughout the visit have the best ability to control negative reactions. The researchers suggested that those who cannot focus might be better candidates for oral sedation or general anesthesia.

Temperament as a Predictor of Nitrous Oxide Inhalation Sedation Success

,” Anesthesia Progress, Vol. 64, No. 1, 2017, is now available at 

http://www.anesthesiaprogress.org/doi/full/10.2344/anpr-63-03-01

If a dentist could predict how a child is likely to respond to the usage of laughing gas, also known as nitrous oxide, the visit is more likely to be free of anxiety and fear.

Study finds that certain type of children respond better to laughing gas

	The stress that oral surgery patients experience during a procedure can cause elevated heart rates and blood pressure during operations. To avoid these side effects, surgeons often request sedation or general anesthesia for their patients. However, finding the right dose of anesthetic can be its own challenge, especially when the dosage needed for each patient can vary greatly.

 found that male patients required a lower dosage of a sedative than female patients during oral surgery. This finding is consistent with general anesthesia knowledge, which suggests that females emerge from sedation earlier than males. The researchers were able to establish this finding by using an objective assessment tool known as the bispectral index (or BIS), which allowed them to evaluate sedation levels by a special form of brain wave monitoring beyond merely monitoring the patient’s breathing and reactions during surgery.

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	The authors of the study gathered data from 125 dental patients who were sedated for implant-related surgery. Propofol, a powerful general anesthetic often used during surgery, was given intravenously to each patient. The researchers sought to identify characteristics that affected the average infusion rate of the drug. They found that women generally needed far more Propofol to stay adequately sedated for the duration of the surgery. Elderly patients of either sex are also slow to wake from Propofol sedation, but the age range in the current study was too small to determine whether patient age was affecting the data.

	The authors noted that, on average, the women in the study weighed less than the men. This means that women generally need more Propofol per body weight than men to stay at the same level of sedation. The authors concluded that for adequate moderate sedation during implant surgery, women likely need to receive Propofol at a high rate.

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	Oral surgeons and dentist anesthesiologists should be able to give lower doses of anesthesia to male patients, making the sedation safer and more effective. The BIS tool used in this study is not routinely used during dental or medical treatment under sedation. Still, the authors noted that even when the tool is unavailable, the study’s results should help in determining the correct anesthesia dosage for patients undergoing minor oral surgery.

	Full text of the article “Female Patients Require a Higher Propofol Infusion Rate for Sedation,” 

, Vol. 63, No. 2, 2016, is now available at 

http://www.anesthesiaprogress.org/doi/full/10.2344/0003-3006-63.2.67

An article published in the current issue of the journal Anesthesia Progress found that male patients required a lower dosage of a sedative than female patients during oral surgery.