Morton Rosenberg

Iatrogenic Subcutaneous Emphysema of Dental and Surgical Origin: A Literature Review

PURPOSE Subcutaneous emphysema arises when air is forced beneath the tissue, leading to swelling, crepitus on palpation, and potential to spread along the fascial planes. The goal of this literature review is to alert the oral and maxillofacial surgeon to the inciting factors, diagnosis, and management of subcutaneous emphysema. PATIENTS AND METHODS A comprehensive search of the medical and dental literature from 1993 to 2008 was performed using PubMed, and yielded 32 case reports of subcutaneous emphysema. Only cases associated with dental or surgical procedures were included. Cases of trauma were excluded. RESULTS Sixteen of the 32 cases were linked to the use of air-driven handpieces. Other cases involved a CO(2) laser, a NO(2) cryomachine, an air abrasive system, endotracheal intubation/ventilation, and patient activities after surgical procedures. Of the cases reviewed, 5 resulted in significant complications after subcutaneous emphysema. CONCLUSION Although rare, iatrogenic subcutaneous emphysema can have serious and potentially life-threatening effects. Care should be taken when using air-driven handpieces or performing endotracheal intubation/ventilation. Additionally, instructions should be given to patients after procedures violating the epithelium to reduce the incidence of subcutaneous emphysema. When subcutaneous emphysema does arise, it must be quickly diagnosed and properly managed to reduce further complications.

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.

Transcutaneous electrical nerve stimulation for the relief of postoperative pain.

&NA; The pain‐killing abilities of electricity were known as far back as the ancient Egyptians and Hippocrates, but it was not until 1965 when Melzack and Wall [10] proposed the “gate theory of pain” that clinical interest was re‐awakened. This theory postulated that a “gate” for pain existed in the substantia gelatinosa of the posterior spinal horns and that modification of the perception of pain might be possible by blocking the “gate” with non‐painful stimuli. They suggested that selective stimulation of large diameter myelinated cutaneous afferent nerve fibers could set a process in motion which would close the “gate” to information coming over smaller pain‐carrying fibers. The first clinical application of this theory centered around the relief of chronic pain by surgical placement of dorsal column stimulators [1] and implantation of stimulating devices around large peripheral nerves to block pain sensations. Transcutaneous electrical nerve stimulation was first employed in an attempt to select patients for implantable devices and then as a therapeutic device to alleviate chronic pain [2,4,6,9,11]. The next logical step was to apply this modality to patients in the immediate postoperative period to decrease incisional pain. Hymes et al. [8] noted a decrease in atelectasis, ileus, postoperative pain and days spent in intensive care in patients using transcutaneous electrical stimulation. Vanderank and McGrath [9] reported that 77% of their patients treated with stimulators experienced some relief of postoperative pain.

Guidelines for intraoperative monitoring of dental patients undergoing conscious sedation, deep sedation, and general anesthesia

The promulgation and adoption of intraoperative monitoring standards in medicine for anesthesia has resulted in early detection of untoward events during sedation and anesthesia, lowering of malpractice premiums, and an improvement in the quality of care. The American Dental Society of Anesthesiology has devised specific, detailed monitoring standards with universal applicability in the dental setting.

Salivary Cortisol, Salivary Alpha Amylase, and the Dental Anxiety Scale

The aim of this study was to investigate the correlation between dental anxiety, salivary cortisol, and salivary alpha amylase (sAA) levels. Furthermore, the aim was to look into individual differences such as age, race, gender, any existing pain, or traumatic dental experience and their effect on dental anxiety. This study followed a cross-sectional design and included a convenience sample of 46. Every patient was asked to complete the Dental Anxiety Scale (DAS) and a basic demographic/dental history questionnaire. A saliva sample, utilizing the method of passive drooling, was then collected in 2-mL cryovials. Samples were analyzed for salivary cortisol and sAA levels by Salimetrics. Significant associations were observed between DAS scores and presence of pain and history of traumatic dental experience. However, no significant correlations were observed between DAS, cortisol, and sAA levels. Our study reconfirms that dental anxiety is associated with presence of pain and a history of traumatic dental experience. On the other hand, our study was the first to our knowledge to test the correlation between the DAS and sAA; nevertheless, our results failed to show any significant correlation between dental anxiety, cortisol, and sAA levels.

Paradoxical Reaction Following Administration of a Benzodiazepine

d c i e ince their introduction in 1955, benzodiazepines ave become one of the most widely used classes of rugs for perioperative sedation in dentistry. Alhough the benzodiazepines are generally safe and ffective drugs to reduce anxiety and produce amneia when used in proper doses, occasionally the adinistration of benzodiazepines may elicit signs of ostility, aggression, and agitation. This phenomenon s known as a paradoxical reaction. The following ase report illustrates such an incident and reviews ossible mechanisms and treatment options of paraoxical reactions after intravenous benzodiazepine dministration.

Drug abuse in oral and maxillofacial training programs

Concern about drug dependence in other medical specialties involving constant exposure to anesthetic and sedative drugs prompted a survey of oral and maxillofacial surgery programs. One hundred sixteen programs were surveyed; 78.5% responded, and 51% of the responding programs reported at least one suspected incident of drug dependence. Twenty-six confirmed cases were reported. Meperidine and fentanyl were the most frequently abused substances. Behavioral changes and information supplied by co-workers were the most frequent reasons for confrontation of residents suspected of drug abuse by superiors. Detailed follow-up information was often sketchy and unavailable. Drug abuse may be more common than usually thought in oral and maxillofacial surgery programs and on the same level as that observed in anesthesia training programs.

Regional anesthesia and invasive techniques to manage head and neck pain

Regional anesthesia of the head and neck is an effective method of obtaining surgical anesthesia for various procedures. Diagnostic and therapeutic head and neck blocks can also assist with the diagnosis and management of many chronic pain conditions, including headache, postherpetic neuralgia, and cancer pain in this region. Gamma knife surgery offers a unique approach to the management of refractory trigeminal neuralgia. Because of the proximity of so many critical structures adjacent to these nerves, a solid understanding of the anatomical basis of these nerve blocks is necessary. Appropriate patient selection, monitoring, proper injection technique, knowledge of the pharmacokinetics and pharmacodynamics of local anesthetics and vasoconstrictors, possible drug interactions, and recommended doses will ensure safe and successful application of head and neck nerve blockade.

Patient-controlled analgesia

Acute postoperative pain often is unrelieved by conventional intramuscular and intravenous analgesic therapy. Difficulties arise from determining severity of pain, appropriate dosing, dosing intervals, health professional attitudes towards opioid administration, and the pharmacodynamics and pharmacokinetics of analgesics themselves. Patient-controlled analgesia (PCA) is a safe, effective, and increasingly popular method used to treat postoperative pain that may be applicable for patients after major oral and maxillofacial surgical procedures.

Development of a comprehensive operating room pharmacy

The justification, implementation, and services of a comprehensive on-site operating room (OR) pharmacy are reviewed. Justification was accomplished through audits of controlled substance accountability, drug preparation, labeling and storage, and cost analyses of drug waste and potential savings. Implementation was achieved through the joint efforts of the Department of Anesthesia, Pharmacy, and Nursing. Services of the OR pharmacy are dynamic and include standardized drug preparation, case-by-case drug distribution and patient billing, controlled substance accountability, provision of drug information, and clinical research support. This pharmacy has proven cost effective and has become integral to the daily function of the OR.