Andrew Herlich

Traumatic onset of temporomandibular disorders: Positive effects of a standardized conservative treatment program

OBJECTIVE To compare presenting problems and response to treatment of chronic temporomandibular (TMD) patients who perceive the onset of their symptoms to be related to trauma with those who report symptoms of unknown origin. DESIGN Prospective treatment outcome study. SETTING Outpatient multidisciplinary pain treatment center at a university medical center. PATIENTS A total of 361 were evaluated initially, including 103 who perceived traumatic onset of symptoms and 258 who did not perceive onset to be related to trauma. Two hundred thirty-three (59 trauma and 174 nontrauma) returned for follow-up evaluation 6 months after the conclusion of treatment. INTERVENTIONS Standardized six-session treatment program consisting of intraoral appliance, biofeedback, and stress management training. OUTCOME MEASURES Clinical changes in muscle pain, temporomandibular joint pain, and mandibular opening. Self-report of change in perceived pain severity (MPQ--short form), depressive symptoms (BDI), catastrophizing about pain (CSQ--catastrophizing scale), MPI--interference scale, oral parafunctional habits, global evaluation of improvement, and use of pain medications at follow-up. RESULTS AND CONCLUSIONS Regression of onset type on pretreatment variables indicated that a small but statistically significant proportion of pretreatment variability (8.7%) could be accounted for by onset. Both traumatic and nontraumatic onset groups showed positive outcomes following treatment. No significant differences between groups were found for any of the clinical or self-reported outcome measures with the exception that a significantly higher percentage of the trauma group reported using pain medication at follow-up. These findings are in contrast with previous suggestions that post-traumatic TMD patients show poorer response to treatment than nontrauma TMD patients.

Comparison of propofol and methohexital continuous infusion techniques for conscious sedation.

PURPOSE Methohexital and propofol have been shown to be effective agents for continuous intravenous infusion to produce conscious sedation during oral surgical procedures. The current study was conducted to compare these techniques for intraoperative cardiopulmonary stability, patient cooperation, amnesia, comfort, recovery time, and postoperative nausea and vomiting. METHODS Seventy ASA Class I or Class II patients between the ages of 18 and 40 years, scheduled for surgical extraction of impacted third molars, were entered into the study. Thirty-five patients were assigned to group A (methohexital) and 35 were assigned to group B (propofol). Intravenous sedation was accomplished using premedication with 1.5 microg/kg of fentanyl and 0.05 mg/kg of midazolam followed by the continuous infusion of methohexital or propofol at a rate of 50 microg/kg/min. The infusion was then titrated to 100 microg/kg/min to accomplish a level of sedation in which the eyes were closed and the patients were responsive to verbal commands. Subjects were monitored for variability of heart rate, blood pressure, oxygen saturation, amnesia, comfort, cooperation, nausea and vomiting, and recovery time based on cognitive, perceptual, and psychomotor tests. RESULTS There was no statistical difference between the two medication groups except for heart rate, which was found to increase by 11 beats/min for group A and only three beats/min in group B. CONCLUSION A continuous infusion technique using either methohexital or propofol (50 to 100 microg/kg/min) was found to be safe and effective, with no clinically significant differences in cooperation, cardiopulmonary stability, recovery time, amnesia, comfort, and the incidence of nausea or vomiting. However, the cost-effectiveness of methohexital is superior to that of propofol.

Perioperative temperature elevation: not all hyperthermia is malignant hyperthermia.

The objective of this review is to assist the readers, anesthesiologists, intensivists, and emergency physicians in making a more accurate diagnosis of perioperative fever or hyperthermia and subsequently choose the proper course of treatment.

Anesthetic emergencies in oral surgery: malignant hyperthermia, endocrinopathy, and neurologic events.

Despite the impressive safety of office-based anesthesia, serious emergencies still occur. Early and appropriate treatment is likely to improve outcomes. This article discusses selected emergencies with backgrounds and rationale for emergent treatment.

Chronic Medications and Maxillofacial Surgery

The decision to continue or stop using chronic medication is maybe controversial, and it is important to understand the current guidelines utilizing evidence-based medicine. The controversy lies within the limited evidence regarding many medications and the importance of strategizing medication management on an individual basis. Much of what we do is in the gray zone. The more complicated patients take many medications. As patient’ disease states change, this influences when, where, and how a surgery is planned and how medications are administered. We have put a “bottom line” at the beginning of each section to facilitate a quick decision when necessary.

Drug–Drug Interactions as a Complication of Maxillofacial Surgery

All too often clinicians resort to a fixed regimen during the care of surgical patients in the perioperative period. The patient population is becoming increasingly ill, and it is commonplace for patients to be on several medications, which can potentially interact with those utilized in the perioperative period. Each drug that is used when managing these patients must be carefully evaluated for its potential interactions with anesthetic medications in the perioperative period. The goal for this chapter is to provide a framework to assist the clinician in understanding drug-drug interactions, which will be illustrated by examples of fatal to near-fatal reactions that have been documented in the literature.

Mechanisms of Anesthetic Action

In 1846 Oliver Wendell Holmes coined the term anesthesia from the Greek word “anaesthesia” meaning “without sensation,” after William T.G. Morton, a Boston dentist, performed the first public demonstration of an inhalational anesthetic (ether). The most accepted current definition of general anesthesia is “a drug-induced, reversible condition composed of the behavioral states of unconsciousness, amnesia, analgesia, and immobility along with physiological stability.” A major challenge to defining ideal state of general anesthesia is the fact that the site and mechanism of action of general anesthetics are not entirely known.