G. Manani

Toward the Validation of Visual Analogue Scale for Anxiety

Anxiety is a relevant problem in dental practice. The Visual Analogue Scale for Anxiety (VAS-A), introduced in dentistry in 1988, has not yet been validated in large series. The aim of this study is to check VAS-A effectiveness in more than 1000 patients submitted to implantology. The VAS-A and the Dental Anxiety Scale (DAS) were administered preoperatively to 1114 patients (459 males and 655 females, age 54.7 ± 13.1 years). Statistical analysis was conducted with Pearson correlation coefficient, the receiver operating characteristic (ROC) curve, and McNemar tests. A close correlation between DAS and VAS-A was found (r  =  0.57, P < .0001); the VAS-A thresholds of dental anxiety and phobia were 5.1 and 7.0 cm, respectively. Despite a significant concordance of tests in 800 cases (72%), disagreement was found in the remaining 314 cases (28%), and low DAS was associated with high VAS-A (230 cases) or vice versa (84 cases). Our study confirms that VAS-A is a simple, sensitive, fast, and reliable tool in dental anxiety assessment. The rate of disagreement between VAS-A and DAS is probably due to different test sensitivities to different components of dental anxiety. VAS-A can be used effectively in the assessment of dental patients, using the values of 5.1 cm and 7.0 cm as cutoff values for anxiety and phobia, respectively.

Respiratory depression following administration of low dose buprenorphine as postoperative analgesic after fentanyl balanced anaesthesia

Opioids are among the most ancient and widely used drugs in anaesthesiology. The pharmacology of opioid analgesics and their receptors is a complex and not fully understood matter; even more complex are the interactions between different classes of opioids at both molecular and clinical levels. We want to report here a clinical observation to emphasize the importance of the theoretical basis of anaesthesiology. This paper contains a clinical observation of respiratory depression following the administration of buprenorphine as postoperative analgesic after balanced anaesthesia with fentanyl. The observed case is interpreted in the light of the pharmacokinetics and pharmacodynamics of the different classes of opioid drugs (agonists, agonists–antagonists, antagonists) and of the interactions with their respective receptors.

Isolated atrial fibrillation (IAF) after local anaesthesia with epinephrine in an anxious dental patient

Cardiac arrhythmias are not uncommon in dental practice, depending on many factors, including patient features, dental treatment and drugs administered. We describe a case of isolated atrial fibrillation (IAF) developed, in a young patient, soon after a supraperiosteal injection. The patient was admitted to hospital and recovered spontaneously. Since stress is a possible cause of IAF, this may has been triggered by endogenous and/or exogenous epinephrine. We highlight the need for careful preoperative evaluation, including anxiety assessment and treatment in all dental patients.

Sedation in dentistry: current sedation practice in Italy.

EDITOR: The power of patient sedation to blunt the stress response to surgery is important in dentistry [1,2]. The advantages of the available sedation techniques should be evident to teachers of Dental Schools, to dental students, to dentists, to all involved dental practitioners and, obviously, to dental patients [3–5]. Unfortunately, this knowledge is not so widely shared in Italy, so that the use of patient sedation is still a limited practice among Italian dentists [4,6]. We report information about the current sedation practice in Italy within both academic and private practice. An E-mail or telephone survey was performed in January 2005 to collect data about current sedation practice in Italy. The survey covered all the 33 Dental Schools of Italy and 110 private dental offices of the Veneto region in the northeast of Italy. Data from a previous study [6] of private dental practice in the Friuli Venezia Giulia region were added. The two Italian regions, Friuli Venezia Giulia and Veneto, have 5 730 000 inhabitants, about 10% of the whole Italian population. In Italy there are 18 921 dentists and 34 625 physicians working as dentists. Results from the survey on the education of undergraduate dental students and of private dental practice in Italy are reported in Table 1. Sedation in Italian Dental Schools is provided mainly by anaesthesiologists (94%) with the remainder by dentists (6%). In private dental practice the situation is different with the anaesthesiologists performing the sedation in about 20% of cases, the remainder being performed by dentists and physicians. Since the foundation of Dental Schools in Italy, in 1981, the teaching of Anaesthesia in Dentistry presented many problems defining a didactic model according to the goal of this specialty. This situation had not improved 20 yr later, after the introduction of the new European Standards (2001) in the academic didactic organization that included teaching of patient evaluation and information, anxiety and pain control, emergency prevention and treatment. This is due to a lack of clinical facilities in Dental Schools and theoretical but not practical adjustment to European Standards together with lack of information among dentists. In Italian Dental Schools all the sedation masters are anaesthesiologists with a clear preference toward topics for anaesthetists and not for dentists: many anaesthesiologists had little knowledge of the training presently available to dentists wishing to practise conscious sedation. It is of great concern that a considerable number of these anaesthesiologists do not feel that is appropriate for dentists to be administering even the simplest method of sedation including the use of nitrous oxide/oxygen inhalation. The sedation techniques taught and performed in the Dental Schools depend on the knowledge and wisdom of the teachers, skill of clinical staff and available resources of the Institution. Oral sedation is widely employed because it is simple to teach, to learn and to perform. Intravenous (i.v.) sedation needs special skill but is suitable for titration. Inhalation of nitrous oxide and oxygen is a relatively frequent technique, but intranasal and sublingual routes of drug administration are less used. The drugs studied in most of the Italian Dental Schools are benzodiazepines and nitrous oxide but general i.v. anaesthetics (ketamine, propofol, barbiturates, opioids, etc.) and halogenated anaesthetics (sevoflurane, desflurane) are, erroneously, also taught. We believe erroneously because these are topics for anaesthesiologists and not for dentists. Special sedation techniques, for children and/or disabled patients are carried out only in a minority of cases because these are considered, mostly, as patients for anaesthesiologists requiring general anaesthesia in the majority of the Institutions. Education is carried out on a theoretical basis, while practice on the patient is lacking in the majority of the Dental Schools. The nearly total absence of academic continuing education about this topic is evident as only two Universities perform such education: Bologna University, where Correspondence to: Gastone Zanette, Department of Medico-Surgical Specialties, Chair of General and Special Anaesthesiology in Dentistry, University of Padua, Via Giustiniani 2, 35100 Padova, Italy. E-mail: gastone.zanette@unipd.it; Tel: 39 49 8212041; Fax: 39 49 8218229

Comparison study between acupuncture and pentazocine analgesic and respiratory post-operative effects.

The authors studied the effects of acupuncture and pentazocine on post-operative respiratory function and pain management on patients hysterectomized by means of a subumbilical midline incision. The acupunctural technique consisted of GB-26, St-36, Sp-6 and auricular Shen-Men bilateral electrostimulation for 40 minutes. The analgesic effect of acupuncture was equivalent to that of 30 mg pentazocine, yet the most important effect of acupuncture consisted in a net increase of vital capacity during the period of acupuncture analgesia that lasted for 3-4 hr after stimulation; contrariwise, pentazocine did not cause any vital capacity increment and vital capacity remained at the levels observed prior to narcotic administration.

Undetected central core disease myopathy in an infant presenting for clubfoot surgery.

A 1‐year‐old child was scheduled for two stage bilateral clubfoot surgery. Preoperative evaluation was normal and total intravenous anesthesia with a continuous sciatic nerve block was performed. Two months later, before the second clubfoot correction, a hip subluxation was evident suggesting a provisional diagnosis of neuromuscular disease. Anesthesia was identical, except that a femoral nerve block, necessary to permit a diagnostic muscle biopsy was performed. The perioperative course was uneventful but result of the muscular biopsy was surprising in that central core disease was diagnosed. Although congenital myopathies of all grades and severity exist, they are often mild and underestimated. Patients affected by central core disease are considered susceptible to malignant hyperthermia. Because a high prevalence of myopathic changes is reported in children undergoing clubfoot surgery, anesthesiologists must take precautions including a hightened awareness of these events and a high index of suspicion.

Prevalence of unsuspected myopathy in infants presenting for clubfoot surgery

The objective of this study was an evaluation of the prevalence of myopathies in paediatric patients scheduled for orthopaedic surgery (clubfoot) performed under regional anaesthesia. Seventeen infants scheduled for lower limb orthopaedic surgery were studied to verify coexisting neuromuscular disorders with electromyography and muscle biopsy during surgery. All surgical procedures were performed under caudal block or spinal anaesthesia, associated with light general anaesthesia. No major cardiorespiratory, neurological or malignant hyperthermic complications (muscle rigidity, arrhythmias, hyperpyrexia) were observed. Combined neurological, electromyographic and biopsy studies showed a high rate of myopathic changes (70%). Performance of clubfoot surgery under light general anaesthesia with regional techniques was free from any problems. The high rate of myopathic changes (70%) observed in the muscle biopsies suggests that precautions should be taken with paediatric patients for clubfoot surgery and a regional anaesthesia technique with adequate monitoring may be helpful to prevent possible malignant hyperthermia related problems.

Intranasal flumazenil and naloxone to reverse over-sedation in a child undergoing dental restorations: comment.

SIR—We read with interest the article by Heard C. et al. (1), describing the nasal administration of multiple drugs to a dental pediatric outpatient in the dental office. The resulting deep sedation was successfully treated with the same technique: the nasal administration of specific antagonists. However, we would like to make some comments. First, we agree about the efficacy and safety of nasal midazolam to perform dental procedures which may otherwise have required a general anaesthesia (GA) (2). However, also in recent recommendations, intranasal midazolam administration in patients under 12 years is classified in the category of ‘alternative techniques’ and must be limited to skilled hospital personnel (3,4). It is important to remember that the apparent simplicity of intranasal sedation belies the potential for undesirable effects so that monitoring, discharge, and supervision requirements should be the same as those for intravenous sedation (5). Second, all standards and guidelines advocate titration of a single drug to be certain that the state of moderate (conscious) sedation does not progress to deep sedation or GA (3–6). When such a mixture of drugs (midazolam and sufentanil and nitrous oxide) is used how does one determine dosage? In what order and to what end point are the individual drugs given? At least four cases are reported (4) where a multi-drug intravenous technique (given outside a hospital setting) has been associated with significant patient morbidity, and we view the use of such methods in outpatient dentistry with some concern. The reported deep sedation is the logic consequence of the multiple drugs administration; we think that this scenario is simply indicative of airway obstruction secondary to over-sedation in a dental patient during intraoral instrumentation; it is our opinion that the resulting discussion should be about the safety of the employed sedation technique and not about the laryngospasm (7). Third, we have to conclude that the reported technique does not have a sufficient margin of safety for the general dental practice setting and that a more prudent approach is mandatory, i.e. GA in hospital setting. Decisions about GA can only be made on an individual patient basis, but it is strongly recommended that its use in dentistry should be limited to clinical situations in which it would be impossible to achieve adequate local anesthesia and to complete treatment without pain and for patients who, because of problems related to age ⁄ maturity or physical ⁄ mental disability, are unlikely to allow safe completion of treatment. The long-term aim in such patients should be the graduated introduction of treatment under local anesthesia using, if necessary, an intermediate stage employing conscious sedation techniques. Whilst the dangers of GA have been identified, the morbidity and mortality associated with sedation are not clearly defined (4,5,8). There is the need of more detailed and evidencebased guidelines on this topic, and only well-designed studies can help to answer the question. Finally, we have to remember that the cornerstone of management in dentistry remains the empathic approach to the patient supported by behavior management techniques. This is true also considering that it is impossible, today, to say which is the most effective sedation technique for anxious children (9). This absence of evidence to support current practice is alarming, but is not substantially different from many other areas in medicine.

The use of intranasal midazolam in the treatment of paediatric dental patients

A reply We agree that the data from Sim et al. above, are very encouraging. It presents a very different picture of cooling practice in Scotland than the published UK survey from Laver et al. [1]. Either therapeutic hypothermia has been adopted more quickly in Scotland than the rest of the UK or these results reflect a change in practice across the UK since 2005 when the Laver et al. survey took place.

Medical litigation as a result of awareness during general anaesthesia: a case report.

In the literature, little attention has been paid to the medico-legal implications of awareness during general anaesthesia, a complication which has been reported with an incidence of 0.5-2%. We present the case of a 39-year-old nurse who experienced awareness during salpingo-adnexectomy for tubo-ovarian pregnancy. The operation was performed as an emergency, due to severe haemorrhage. Anaesthesia was induced with 125 mg of thiopental sodium and 60 mg of succinylcholine, and then maintained with repeated doses of fentanyl and 7 mg of vecuronium. In the court settlement, medical liability was rejected, because her awareness during anaesthesia was ascribed to the need to use small quantities of anaesthetics, due to severe hypotension, and not to medical error. The case presented here and a brief review of the literature indicate that awareness during anaesthesia is not always a consequence of medical negligence.