Donald P. Butler

Comparison of nonsteroidal anti-inflammatory drugs, ibuprofen and flurbiprofen, with methylprednisolone and placebo for acute pain, swelling, and trismus

Pain, swelling, loss of function, and hyperthermia are acute postoperative sequelae of inflammation due to tissue injury during surgical procedures. Pharmacologic strategies for minimizing the clinical manifestations of surgical trauma are often directed toward blocking the formation or inhibiting the effects of the biochemical mediators of acute inflammation. This study compared two nonsteroidal anti-inflammatory drugs (NSAIDs), flurbiprofen and ibuprofen, with a prototype glucocorticoid, methylprednisolone, in two replicate placebo-controlled studies for suppression of inflammation due to the surgical removal of impacted third molars. The results indicate that NSAIDs produce greater initial analgesia than do steroids, whereas steroids result in greater suppression of swelling and less loss of function. Examination of the pooled data from the two studies indicates that NSAID pretreatment results in a modest suppression of swelling in comparison with placebo. These data suggest that the acute analgesic effects of NSAIDs in the oral surgery model are due to suppression of a nociceptive process, presumably prostaglandin formation, rather than a generalized anti-inflammatory effect.

Predisposing and operative factors: Effect on the incidence of localized osteitis in mandibular third-molar surgery

Five hundred and four bilateral mandibular third-molar extraction sites were examined postoperatively for localized osteitis. All sites received a mechanical lavage of either 350 ml, or 175 ml. of sterile normal saline solution. No significant differences were observed relative to the effect of lavage volume on the incidence of iocalized osteitis. A preoperative antimicrobial mouthrinse of chloramine-T (sodium-p-toluene sulfonchloramide) was also used by one half of the patients. Although only slight differences were noted in healing with the different lavage volumes of the chloramine-T, certain predisposing factors contributed significant differences.

Occurrence of multiple dentigerous cysts in a patient with the Maroteaux-Lamy syndrome (mucopolysaccharidosis, type VI)

The mucopolysaccharidoses (MPS) are a group of genetic lysosomal storage diseases. These diseases result from a defect in specific lysosomal enzymes required for the degradation of specific mucopolysaccharides. These incompletely degraded saccharides accumulate in tissues and are excreted in the urine. A general characteristic of these diseases is dysostosis multiplex. Dental complications can be severe and include unerupted dentition, dentigerous cystlike follicles, malocclusions, condylar defects, and gingival hyperplasia. This report examines multiple dentigerous cysts in a patient with a deficiency in N-acetylgalactosamine-4-sulfatase, Maroteaux-Lamy syndrome (MPS VI). The inability to hydrolyze the sulfate group from N-acetylgalactosamine-4-sulfate residue of dermatan sulfate due to a deficiency in this enzyme results in the accumulation of dermatan sulfate in tissues and its excretion in the urine. Examination of dentigerous cyst fluid revealed glycosaminoglycan content of 397 microgram per milliliter. Compositional analyses revealed 60% hyaluronic acid, 30% chondroitin 4- and -6-sulfate, and only 10% dermatan sulfate. This was consistent with dentigerous cyst fluid derived from persons without mucopolysaccharide-storage disorders but distinctly different from glycosaminoglycans assayed from other body fluids of this patient.

Increased incidence of postoperative localized osteitis in mandibular third molar surgery associated with patients using oral contraceptives

Current literature has noted the various side effects of oral contraceptives. Oral surgeons have recently encountered an increased incidence of postoperative localized osteitis occurring with removal of manidibular third molars. This article documents the occurrence of this phenomenon among 105 women participating in a recent study at the Clinical Center of the National Institutes of Health.

Recovery following intravenous sedation during dental surgery performed under local anesthesia.

Recovery of psychomotor and perceptual performance from two combinations of intravenous sedatives was assessed in 124 oral surgical patients undergoing third molar extractions under local infiltration anesthesia. Ninety-four patients in the experimental group received 15 mg of diazepam and 20 to 200 mg of methohexital intravenously on one occasion and 12.5 mg of diazepam, 20 to 200 mg of methohexital, and 0.1 mg of fentanyl intravenously on another occasion in a randomized, crossover design. Thirty patients in the control group received saline placebo intravenously during a single surgery. Both drug combinations produced significantly prolonged decrements in performance in comparison to placebo. Reduction in the diazepam dose from 15 to 12.5 mg and the addition of fentanyl, a short-acting narcotic, produced greater sedation without prolonging recovery. Psychomotor function recovered to preoperative levels before perceptual performance. These results show that postsurgical deficits in psychomotor and perceptual function result from the sedative drugs and not from the effects of local anesthetics or physiologic and psychological responses to surgery. These results also suggest that psychomotor tests are inappropriate measures of recovery and that superior sedation with rapid recovery may be achieved with reduced doses of longer acting agents such as diazepam and with the addition of shorter acting agents that do not prolong recovery.

Evaluation by thoracic impedance cardiography of diazepam, placebo, and two drug combinations for intravenous sedation of dental outpatients

The cardiovascular and respiratory effects of three common intravenous premedicants were examined noninvasively in a population of 20 dental outpatients scheduled for surgical removal of third-molars. Two third molars from one side of the mouth were removed at each appointment. Group 1 received a diazepam titration (mean dose = 25.6 mgs) at one appointment and placebo at the other appointment. Group 2 received a combination of diazepam (12.5 mg), fentanyl (0.1 mg), and methohexital (mean dose = 18.0 mg) at one appointment and the combination of diazepam (15.0 mg) and methohexital (mean dose = 27.0 mg) at the other appointment. Noninvasive measurement of cardiac output revealed little change during intravenous drug administration, but a significant increase was seen in all groups following local anesthesia and during surgery. Heart rate was elevated and stroke volume decreased during administration of the two-drug combinations. Oxygen saturation was greatly decreased following the combination of diazepam, fentanyl, and methohexital. These findings indicate that the combination of diazepam, fentanyl, and methohexital results in decreased oxygen saturation, a transient decrease in stroke volume, and an elevated heart rate when used as an intravenous premedicant for dental outpatients.