Daniel E. Becker

Essentials of Local Anesthetic Pharmacology

It is impossible to provide effective dental care without the use of local anesthetics. This drug class has an impressive history of safety and efficacy, but all local anesthetics have the potential to produce significant toxicity if used carelessly. The purpose of this review is to update the practitioner on issues regarding the basic pharmacology and clinical use of local anesthetic formulations.

Local Anesthetics: Review of Pharmacological Considerations

Local anesthetics have an impressive history of efficacy and safety in medical and dental practice. Their use is so routine, and adverse effects are so infrequent, that providers may understandably overlook many of their pharmacotherapeutic principles. The purpose of this continuing education article is to provide a review and update of essential pharmacology for the various local anesthetic formulations in current use. Technical considerations will be addressed in a subsequent article.

Nausea, Vomiting, and Hiccups: A Review of Mechanisms and Treatment

Nausea, vomiting, and hiccups are troubling complications associated with sedation and general anesthesia. This article will review the basic pathophysiology of these events and current recommendations for their prevention and management.

Nitrous oxide and the inhalation anesthetics.

Nitrous oxide is the most commonly used inhalation anesthetic in dentistry and is commonly used in emergency centers and ambulatory surgery centers as well. When used alone, it is incapable of producing general anesthesia reliably, but it may be combined with other inhalation and/or intravenous agents in deep sedative/general anesthetic techniques. However, as a single agent, it has impressive safety and is excellent for providing minimal and moderate sedation for apprehensive dental patients. To gain a full appreciation of the pharmacology, physiologic influences, and proper use of nitrous oxide, one must compare it with other inhalation anesthetics. The purpose of this CE article is to provide an overview of inhalation anesthetics in general and to address nitrous oxide more specifically in comparison.

Thermoregulation: Physiological and Clinical Considerations during Sedation and General Anesthesia

Mild hypothermia is common during deep sedation or general anesthesia and is frequently associated with patient discomfort and shivering. Greater declines in temperature can produce an even greater number of significant detrimental effects. This article reviews principles of thermoregulation and influences of anesthetic agents. An understanding of these will provide a foundation for strategies to reduce heat loss and better manage patient discomfort when it occurs.

Pain Management: Part 1: Managing Acute and Postoperative Dental Pain

Safe and effective management of acute dental pain can be accomplished with nonopioid and opioid analgesics. To formulate regimens properly, it is essential to appreciate basic pharmacological principles and appropriate dosage strategies for each of the available analgesic classes. This article will review the basic pharmacology of analgesic drug classes, including their relative efficacy for dental pain, and will suggest appropriate regimens based on pain intensity. Management of chronic pain will be addressed in the second part of this series.

Basic and Clinical Pharmacology of Glucocorticosteroids

Glucocorticosteroids are a product of the adrenal cortex and perform a staggering number of physiological effects essential for life. Their clinical use is largely predicated on their anti-inflammatory and immunosuppressive properties, but they also have notable efficacy in the prophylaxis of postoperative nausea and vomiting. This article reviews the basic functions of glucocorticoids and their clinical use in dental practice.

Adverse Drug Interactions

The potential for interactions with current medications should always be considered when administering or prescribing any drug. Considering the staggering number of drugs patients may be taking, this task can be daunting. Fortunately, drug classes employed in dental practice are relatively few in number and therapy is generally brief in duration. While this reduces the volume of potential interactions, there are still a significant number to be considered. This article will review basic principles of drug interactions and highlight those of greatest concern in dental practice.

Fundamentals of Electrocardiography Interpretation

The use of dynamic electrocardiogram (ECG) monitoring is regarded as a standard of care during general anesthesia and is strongly encouraged when providing deep sedation. Although significant cardiovascular changes rarely if ever can be attributed to mild or moderate sedation techniques, the American Dental Association recommends ECG monitoring for patients with significant cardiovascular disease. The purpose of this continuing education article is to review basic principals of ECG monitoring and interpretation.

Contemporary trends in acute pain management.

Purpose of reviewIn the management of acute pain, the ability to prevent the onset of pain in the immediate postoperative period, lessen its intensity, and interfere with the development of sensitization contributing to hyperalgesia for days following a procedure can greatly benefit the patient, rather than postoperative attempts to decrease pain after it has reached full intensity. Recent findingsPatients benefit from receiving optimal NSAID doses. These agents are effective, relatively safe, and reduce the need for opioids. In situations where pain can be anticipated, the NSAID may be optimized by preoperative administration and continuing to dose the NSAID on a regular schedule to minimize pain and inflammation. Selective COX-2 inhibitors can also prevent pain but without concern for effects on platelet function and have a longer duration of action than traditional NSAIDs. Once the dose of NSAID has been optimized, but pain persists, opioid use may be a consideration. A commercially available combination product containing opioid and acetaminophen may be a good option and is easy to prescribe. Acetaminophen’s site of action differs from that of NSAIDs, and acetaminophen’s analgesic effect is considered synergistic when combined with NSAIDs and opioids. When prescribing combination opioid and acetaminophen analgesic products or acetaminophen alone, the practitioner must caution the patient not to exceed 4 g of acetaminophen per day due to concerns with hepatic injury. Given that the patient has already been prescribed an optimal and/or ceiling dose of NSAID, combination products containing aspirin, an NSAID, should be avoided. As opioids have no ceiling dose, there are some situations where opioid dosing is better done with the opioid prescribed separately. This permits increasing the opioid to the needed analgesic dose with no concerns for acetaminophen toxicity. SummaryCareful selection of an effective analgesic regimen can prevent the stress and anxiety associated with acute postoperative pain and breakthrough pain. Pain prevention has greater benefits than attempts at rescue therapy when pain exacerbation occurs. A variety of pain management regimens are presented based on empirical estimates of pain intensity and an application of sound pharmacological principles.