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. 2007 Spring;54(1):36–39.

JDSA JOURNAL ABSTRACTS

PMCID: PMC1821131
Anesth Prog. 2007 Spring;54(1):36–39.

Clinical Analysis of Atypical Facial Pain without Established Proper Treatment in 915 Patients

Nagaaki Suzuki, Takao Shibaji, Saori Yamazaki, Masami Nakano, Akira Maeda, Masato Kawashima, Shigenari Mashu, Tetsuji Kawaguchi, Masahiko Shimada, Shigeharu Jinno, Masahiro Umino

J JPN DENT SOC ANESTHESIOL 2006; 34273- 281

Atypical facial pain (ATFP) has been defined as persistent idiopathic facial pain, and still lacks clear diagnostic criteria and proper treatment. Symptoms and the therapeutic effects of ATFP without an attributable disorder were analyzed in 915 patients (132 males and 783 females). In most of the patients, ATFP was developed after dental or maxillofacial surgical procedures. At their first visit to our clinic, 52.5% of the patients had been suffering from ATFP for more than a year. They complained of pain at their posterior teeth and gingival region 2.8 times more than at their anterior region. According to the SDS (Self-rating Depression Scale), 61.7% of the patients were in depressive state. According to TMI (Toho Medical Index), 19.3% of the patients were categorized in the autonomic imbalance type, 8.7% were in the neurotic type and 27.5% were in the psychosomatic type. For the treatment of ATFP, we usually combined physical therapy with psychotherapy. Brief psychotherapy and drug therapy were applied in the majority of patients. For the physical therapy, acupuncture, soft laser radiation therapy, and low frequency electrical stimulation therapy with surface electrodes were often applied. For drug therapy, kampo medicines, non-steroidal anti-inflammatory agents and anxiolytic drugs were prescribed very frequently. Antidepressants were often prescribed, too. In kampo medicines, Rikkosan, Kami-shoyosan, Keishika-jutsubuto and Saikokeishi-to were mainly prescribed for analgesic and sedative effects. For acupuncture, needles were frequently inserted in the facial meridian points. The duration of the treatment was for more than one year in 20.0%. The clinical results were as follows: Excellent: 19.5%, good: 44.0%, not relieved: 14.0%, got worse: 0.3%, and unknown: 22.2%. Excellent means that pain was completely abolished, good means that pain was improved compared to the baseline established at their first visit to our hospital. No significant side effects were experienced in any case. However, we could not evaluate the effectiveness of each of the therapeutic interventions since a variety and/or a combination of therapeutic modes were applied to the same patient.

It is suggested that undetected dental or maxillofacial disorders, nerve injury due to dental or maxillofacial surgery, psychological factor, and autonomic imbalance are factors which develop ATFP. We propose physical therapies combined with psychotherapies for the management of ATFP.

Anesth Prog. 2007 Spring;54(1):36–39.

Effects of Epinephrine on the Blood Flow of Levobupivacaine in the Rat Oral Mucosa—A Search by the Radioisotope (201TI) Clearance Method

Kazuaki Hanzawa, Tetsuya Nagoh, Kimito Sano, Tomio Kanri

J JPN DENT SOC ANESTHESIOL 2006; 34: 472- 477

The present study was undertaken to examine the effects of 1:80,000 epinephrine (added to levobupiva-caine) on the blood flow through the oral mucosa, using the radioisotope (201TI) clearance method. Twenty-four Wistar rats with a mean body weight of 613 ± 73 g were used for this study. An intraperitoneal injection of thiopental sodium (0.05 mg/g) was followed by injection of 0.15 ml of one of the following solutions, together with 0.05 ml of 201TI (3.7 MBq) into the gingival to the left of the left upper incisor of each rat: (1) 0.75% levobupivacaine combined with 1:80,000 epinephrine (the LvE group; n = 8), (2) 2% lidocaine combined with 1:80,000 epinephrine (LiE group; n = 8) or (3) 0.75% levobupivacaine (control group; n = 8). Clearance curves were prepared on the basis of the 201TI counts. An exponential curve approximation using the non-linear least squares method was used in order to calculate and compare the time constant (TC) and half life (T1/2) of the elimination phases I and II among the three groups. The following results were obtained.

1. Time constant: The TC during phase I was higher in the LvE group than in the LiE group or the control group, and the differences were statistically significant. The same parameter was also significantly higher in the LiE group than in the control group. The TC during phase II was significantly higher in the LvE group than in the control group. However, there was no significant difference in this parameter between the LvE group and the LiE group.

2. Half life: The half life during phase I was significantly longer in the LvE group than in the LiE group or the control group. The same parameter was also significantly longer in the LiE group than in the control group. During phase II, the half life was significantly longer in the LvE group than in the control group, however, there was no significant difference in this parameter between the LvE group and the LiE group.

As described above, the drug retention time in the oral mucosa during phase I was significantly longer in the LvE group than in the LiE group. This finding indicates that the drug transfer into the blood during the early phase after dosing is lower when levobupivacaine rather than lidocaine is administered in combination with 1:80,000 epinephrine. This difference is probably attributable to the fact that levobupivacaine has vasoconstrictive actions while lidocaine has vasodilatory actions. The concomitant administration of epinephrine is expected to reduce the incidence of poisoning by the local anesthetic. Furthermore, since the drug retention time during phases I and II was significantly longer in the LvE group than in the control group, the addition of epinephrine to levobupivacaine is considered to be highly useful, which can potentially expand its clinical use.

Anesth Prog. 2007 Spring;54(1):36–39.

Intravenous Administration of Propofol Causes an Increase in Trigeminal Spinal Nucleus Neuronal Activity in Rats—Fos Analysis

Ieko Kubota, Emi Shoda, Takashi Hitosugi, Sono Suzuki, Yoshiyuki Tsuboi, Yoshiyuki Oi, Koichi Iwata

J JPN DENT SOC ANESTHESIOL 2006; 34: 478- 484

Propofol is one of the most widely used sedative agents in the clinic. It has a strong sedative effect but no analgesic effect. However, the neuronal mechanism underlying the lack of analgesic effect during propofol administration is not known. Fos expression in the trigeminal spinal nucleus neurons was precisely analyzed following intravenous injection of propofol at different sedative levels. Sprague-Dawley rats were divided into two groups (light and deep sedative levels) based on the electroence-phalogram (EEG) analysis. The rats were perfused, their brainstems were removed, and Fos immunohistochemistry was performed. We also infused lidocaine into the jugular vein to test whether propofol directly activates the nociceptors innervated in the vein. Many Fos protein-LI cells were expressed in the trigeminal spinal nucleus interpolaris and caudalis transition zone (Vi/Vc zone) and caudal Vc with two peaks. The number of Fos protein-LI cells was significantly greater in Vi/Vc zone at the deep level compared with that of light level. The Fos expression in Vi/Vc zone was significantly depressed following pretreatment with iv infusion of lidocaine before propofol administration. These results suggest that intravenous injection of propofol is involved in the increased activity of trigeminal spinal nucleus neurons, resulting in the central sensitization of the trigeminal pain pathways. It is also suggested that the intravenous nociceptors would be involved in an increment of the Vc neuronal activity.

Anesth Prog. 2007 Spring;54(1):36–39.

The Efficacy of Intravenous Sedation in Combination with Dexmedetomidine and Midazolam in Oral and Maxillofacial Surgery

Aiji Boku, Yoshinari Morimoto, Hiroshi Hanamoto, Hajime Kagamiuchi, Hitoshi Niwa

J JPN DENT SOC ANESTHESIOL 2006; 34: 485- 491

Dexmedetomidine (DEX) is a highly selective 2-adrenergic agonist with sedative, analgesic and anxiolytic effects without respiratory depression. In addition, it stabilizes the hemodynamics with diminishing sympathetic responses to stress. Recently, DEX has been used for conscious sedation in endotracheally intubated patients undergoing respiratory support in the intensive care units. However, there are few reports of intraoperative sedation for oral and maxillofacial surgery. In this report, we studied the efficacy of DEX in combination with Midazolam (MDZ) for intraoperative conscious sedation in oral and maxillofacial surgery.

Sixteen patients who were scheduled for the installation of a dental implant, surgical anchor implant for orthodontic treatment, or surgical tooth extraction under local anesthesia were enrolled in this study. Atropin sulfate (0.01 mg/kg) and meperidine (1.0 mg/kg) were injected intra-muscularly as premedication 20 min prior to entering the operating room. After the blood pressure, electrocardiogram, arterial oxygen saturation (SpO2) and Bispectal Index (BIS) monitors were placed, oxygen (3 l/min) was administered through a nasal cannula. After the intravenous route was obtained, MDZ (0.04 mg/kg) was injected intravenously, followed by 6.0 μg/hr of DEX administered as a loading dose for 10 min. Then, 0.7 μg/kg/hr of DEX was continued during the operation. MDZ (0.02 mg/kg) was repeated an hour after the first administration. DEX was given in combination with MDZ because our preliminary study demonstrated that sedation with DEX alone had a poor amnesic effect.

We investigated the changes in perioperative mean arterial pressure (MAP), heart rate (HR), BIS, intra- and postoperative complications (body motion, cough reflex and snoring), intraoperative memories and patients' satisfaction score (visual analogue scale: VAS). Although, MAP (91.3 mmHg →79.8 mmHg) and HR (84.3 beat/min →66.4 beat/min) decreased compared to control values during the loading and initial maintenance doses of DEX administration, the decreased MAP and HR were maintained stable throughout the operation (Fig. 1, 2). No severe circulatory changes requiring treatment were observed. There was also less respiratory depression. In only one patient, SpO2 decreased to 88% after the repeated injections of MDZ; however, the decreased SpO2 was recovered quickly by verbal stimulation. Although BIS remained at the control value after the first MDZ injection, it decreased after the administration of DEX (97.0 →84.5) (Fig. 3). A small number of cases experienced body motion, cough reflex and snoring, but they did not significantly disrupt the operation. We experienced inadequate amnesic effect in some patients (Table 1), but almost sufficient sedation was achieved, judged by the patients’ satisfaction which was high (8.1 in VAS).

However, it took over 2 hours to awaken completely after the end of DEX administration, and the postoperative observation time required a longer time. DEX is therefore not suitable for outpatient sedation.

In conclusion, DEX in combination with MDZ is useful for sedation during oral surgery because of less respiratory depression; however, it requires a prolonged recovery time.

Anesth Prog. 2007 Spring;54(1):36–39.

Evaluation of Intravenous Sedation following Free Tissue Transfer Reconstructive Surgery for Oral Cancer by Bispectral Index

Yuichiro Imai, Shigeru Tatebayashi, Kazuhiko Ohgi, Kumiko Aoki, Kunihisa Murakami, Yasutsugu Yamanaka, Kazuhiko Yamamoto, Tadaaki Kirita

J JPN DENT SOC ANESTHESIOL 2006; 34: 503- 508

We report the usefulness of Bispectral Index (BIS) in postoperative sedation after reconstruction with free tissue transfer for oral cancer.

We selected thirty patients who underwent various reconstructive surgeries with free tissue transfer after resection of oral cancer between April 2000 and March 2004 in our hospital. All patients belonged to Class 1 or 2 of the ASA classification. We obtained informed consent from all patients in advance and verbal consent on postoperative sedation with propofol. These patients underwent tracheostomy, tumor resection, and reconstructive surgery with free tissue transfer accompanied with vascular anastomosis.

These cases were randomly assigned to Group A (n = 15) (sedation with propofol based on the BIS) or Group B (n = 5) (sedation with propofol based on the Sedation Score). The rate of propofol administration in Group A was adjusted to maintain the BIS between 60 and 70, which was calculated by unipolar lead from 2 points from the right to the left of their foreheads using BIS monitoring. In contrast, the rate of the propofol administration in Group B was adjusted to maintain the Observer's Assessment of Alertness/Sedation Scale (OAA/S) between 1 and 2 Pentazocine (7.5–15 mg) was injected intravenously for pain management, as required. Postoperative mean blood pressure, heart rate, mean infusion rate of propofol, and analysis of blood gases were examined.

This study demonstrates that the mean infusion rate of propofol was higher in the sedation based on BIS than OAA/S. However, this did not affect the respiration status or hemodynamics. It was considered that BIS might allow for prompt adjustment of propofol administration rate, since BIS could detect changes in the depth of sedation immediately without stimulating the patients.

In conclusion, evaluation of intravenous sedation by BIS may be useful for the postoperative management of free tissue transfer reconstruction after the resection of oral cancer.

Anesth Prog. 2007 Spring;54(1):36–39.

A Questionnaire Survey of Tutorial Education for Dental Anesthesiology

Shigemasa Tomioka, Kazumi Takaishi, Nobuyoshi Nakajo

J JPN DENT SOC ANESTHESIOL 2006; 34: 509- 513

The University of Tokushima Graduate School introduced tutorial education in 2002 for fifth-year students before practical training. To assess the effectiveness for dental anesthesiology in a problem-based learning tutorial education system, we conducted a questionnaire survey for fifth-year dental school students in 2004–2005.

The questionnaire survey had five questions by selective or descriptive formula.

Question 1. Are you satisfied with the scenario used in the tutorial for dental anesthesiology?: Almost all students (97.%) were satisfied with scenarios for dental an-esthesiology (Fig. 1).

Question 2. Can you adequately learn about the subject of this scenario via a lecture only, tutorial only, or both?: The number of students who selected ‘tutorial only’ (41.8%) outnumbered the students who selected ‘lecture only’ (10.7%), although 46.7% of students replied the necessity of both a tutorial and a lecture (Fig. 2).

Question 3. How do you think about tutorial education using a scenario for dental anesthesiology?: Almost all students (99.1%) replied that scenarios for dental an-esthesiology seemed to be suitable for tutorial education in dentistry (Fig. 3).

Question 4. Which subfields of dentistry are well suited for a tutorial education?: The largest number of students indicated that oral and maxillofacial surgery is suited for a tutorial education, followed by dental anesthesiology. Other responses (in descending order of frequency) included conservation dentistry, prosthodontics, orthodontics, pediatric dentistry, oral and maxillofacial radiology and special care dentistry, preventive dentistry (Fig. 4).

Question 5. What scenarios in dental anesthesia scenarios should be covered using tutorials?: Responses included (in decreasing order of frequency) accidents during dental treatment, dental management of medically compromised patients, resuscitation, vital signs, monitoring, and local anesthesia.

These results suggest that many students have favorable impressions of a tutorial-based education compared to a traditional lecture-based education, and that they feel dental anesthesiology is a suitable subject for a tutorial-based education. Therefore, it appears to be useful to incorporate tutorial education as part of the clinical training in dental anesthesiology.

Articles from Anesthesia Progress are provided here courtesy of American Dental Society of Anesthesiology

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