Journal of dental anesthesia and pain medicine最新文献

Vasovagal syncope is the most common medical emergency in dental practice and is characterized by a transient loss of consciousness during treatment. It may present as an isolated incident triggered by a specific stimulus or as a manifestation of an underlying systemic condition. Understanding the pathophysiology, clinical presentation, and progression of syncope is essential for accurate diagnosis and effective management. Early recognition of the three phases of presyncope, syncope, and recovery enables timely intervention and reduces the risk of complications. This review summarizes the current evidence on risk factors, preventive measures, and behavioral and pharmacological management strategies specific to dental settings. It also examines the dental procedures frequently associated with syncope and outlines the diagnostic workup to exclude alternative diagnoses. By integrating clinical insights with practical recommendations, this review supports dental professionals in the safe and effective management of vasovagal syncope in routine care.

Background: Sedation with midazolam in older patients with severe dementia can cause reactions that differ from those encountered in healthy individuals. We hypothesized that one reason for this is that electroencephalogram (EEG) responses to midazolam in patients with severe dementia may differ from those encountered in healthy individuals. In this study, we aimed to examine the effects of midazolam on EEG findings in older patients with severe dementia and compare them with those observed in older adults without dementia.

Methods: We included 25 patients aged ≥ 60 years, and allocated them to either the dementia (13 patients) or non-dementia (12 patients) group. Participants with a Mini-Mental State Examination score of ≤ 23, Functional Assessment Staging of Alzheimer's disease stage 6 or 7, and/or Clinical Dementia Rating of being "severe" were considered to have severe dementia. EEG electrodes were attached to patients' frontal pole (Fp2). Midazolam was administered until a modified Observer's Assessment of Alertness/Sedation (OAA/S) score of 2 was attained. Chi-square test, Mann-Whitney U test, and Wilcoxon signed-rank test were performed to assess between-group differences. Differences were considered statistically significant at P < 0.05.

Results: The power of the delta wave at baseline and immediately before treatment was higher in patients with dementia than that in the patients without dementia. Conversely, the power of the alpha wave was lower in the dementia group in the sedated state of the OAA/S 2. Regarding the changes within each group, the theta and beta waves in the dementia group decreased after midazolam administration.

Conclusion: Regarding EEG waveforms in the frontal pole, administration of midazolam significantly decreased the power of the fast wave (alpha wave) and increased the power of the slow wave (delta wave) in older patients with severe dementia compared with that in older patients without cognitive decline.

Background: Bleeding during nasotracheal intubation occurs in approximately 80% of cases, caused by injury to the turbinate or avulsion of the mucosa during the passage of the endotracheal tube (ETT). Anatomical variations and sudden changes in direction during the passage of the ETT aggravate the trauma. Among the mechanical and pharmacological methods described to minimize bleeding, the use of a soft malleable guide to railroad the ETT into the hypopharynx and the instillation of vasoconstrictor drops have been found to be effective. Studies comparing added dilation using a nasopharyngeal airway (NPA) dilator with a suction catheter guide are currently lacking. Thus, we hypothesized that the addition of serial dilation of the airway using an NPA over the suction catheter as a guide would improve navigability and minimize bleeding.

Methods: American Society of Anesthesiologists grade 1 and 2 patients requiring nasotracheal intubation (NTI) were randomized into two groups. In group A, NTI was performed using a suction catheter as a guide, while in group B, NTI was performed using a suction catheter and additional dilation using NPA. Anesthesia was similar in both groups. Navigability, bleeding, and secondary outcomes (number of attempts, side attempts, use of external laryngeal manipulation and Magill forceps, time taken, and hemodynamic changes) were assessed.

Results: Ninety patients were enrolled, with 43 and 47 in groups A and B, respectively. Although small improvements in navigability (P = 0.543) and bleeding (P = 0.453) were observed in group B, the differences were not statistically significant. Group B required significantly fewer external laryngeal maneuvers than group A (21 (48.8%) vs. 12 (25.5%), P = 0.022). No differences in the number of attempts, side attempts, time taken, Magill's forceps requirement, oxygen saturation (SPO₂), or hemodynamic changes were observed.

Conclusion: NPA dilation resulted in improvements in navigability and bleeding.

Stimulation of baroreceptors in the carotid sinus may increase vagal activity and decrease sympathetic activity. In rare cases, this can lead to carotid sinus hypersensitivity, which may cause hypotension, bradycardia, or even asystole. An 86-year-old man scheduled for elective thyroid surgery was admitted to the emergency room with repeated episodes of syncope followed by shock. These episodes were suspected to be caused by metastatic lymph nodes compressing the carotid sinus. In the operating room, a video laryngoscope was used for the first laryngoscopy attempt to minimize neck extension. Endotracheal intubation was successful on the first attempt, and the patient remained hemodynamically stable. Excessive neck extension during laryngoscopy and positioning to optimize the surgical field may trigger carotid sinus hypersensitivity. Therefore, measures to minimize neck extension, including use of video laryngoscopy, and careful monitoring during patient positioning are recommended.

Pain associated with anesthetic injections is a significant concern in pediatric dentistry and is often linked to dental fear and anxiety. Photobiomodulation (PBMT) may reduce pain symptoms in children during local anesthesia administration. This systematic review aimed to evaluate the current scientific evidence on the effectiveness of PBMT in reducing pain during local anesthesia administration in children. Data search was conducted in PubMed, Web of Science, Scopus, Cochrane CENTRAL, Embase, and BVS-MedLine/LILACS up to January 2025, without restrictions on language or year of publication. Two independent reviewers performed the data extraction and assessed the risk of bias (ROB-2 tool). A meta-analysis was performed, and the mean difference (MD), standardized mean difference (SMD), and 95% confidence interval (CI) were calculated. The strength of the evidence was also assessed. The electronic search identified 9,852 records, of which 10 studies met the eligibility criteria and were included in the qualitative synthesis. The analyzed studies employed different PBMT parameters, varying in wavelengths and energy densities. The meta-analysis included studies with placebo or topical anesthetic gel as control groups, and measured pain outcomes using the WBFPRS and FLACC scales. All included studies measured pain at the moment of needle insertion. Three studies comparing PBMT with a placebo, which contributed 14 comparisons. These studies demonstrated a moderate reduction in pain in favor of PBMT (SMD = -0.44; 95% CI: -0.59 to -0.29; I² = 0%), indicating a moderate effect favoring the intervention with consistent results across all scales. A sensitivity analysis confirmed the stability of the findings. A second meta-analysis of two split-mouth studies comparing PBMT with topical anesthetic gel demonstrated a large and significant reduction in pain with PBMT (MD = -3.30; 95% CI: -3.98 to -2.62, I² = 0%). PBMT may be beneficial in reducing pain during local anesthesia in children, although the current evidence remains limited. Further well-designed trials with standardized protocols are needed to strengthen the evidence and better inform its clinical applications. The review protocol was registered in PROSPERO under CRD42024539486.

Local anesthesia is essential for pain control and behavioral management in pediatric dentistry. Conventional anesthetic solutions often have low pH, causing injection discomfort and delayed onset. Buffering local anesthetics, typically with sodium bicarbonate, may enhance efficacy by increasing the pH, reducing injection pain, and accelerating onset. This study aimed to evaluate the clinical efficacy of buffered and unbuffered local anesthetic agents in pediatric dental patients, with an emphasis on the onset of anesthesia, patient-reported pain perception (subjective pain), and clinician-assessed pain responses (objective pain) during injection. A systematic literature search was conducted using PubMed, ScienceDirect, the Cochrane Library, LILACS, and Google Scholar for studies published between January 2000 and March 2025. Only randomized controlled trials (RCTs) specifically focused on pediatric patients aged 4-12 years comparing buffered and unbuffered local anesthetics were included. The risk of bias of the included studies was assessed using the Cochrane Risk of Bias 2.0 (ROB 2) tool. Meta-analyses using a random-effects model with standardized mean differences (SMD) accounted for variability across studies. The review protocol was prospectively registered with PROSPERO (CRD420251051999). Of the 138 records initially identified through the literature search, five RCTs met the eligibility criteria and were included. When compared with unbuffered solutions, buffered local anesthetics demonstrated a promising trend toward faster onset and reduced subjective pain. Meta-analysis revealed a significant reduction in subjective pain scores with buffered agents (SMD = -0.59, 95% CI: -1 to -0.17, P < 0.05, I² = 66%), whereas pooled effects on anesthesia onset (SMD = -1.55, 95% CI: -3.67 to 0.57, I² = 97%) and objective pain (SMD = -0.53, 95% CI: -1.2 to 0.15, I² = 82%) were not statistically significant. Risk of bias assessment indicated three low-risk studies, one with some concerns, and one high-risk study suggesting a cautious interpretation of the findings. Buffered local anesthetics reduced injection pain, accelerated the onset of pediatric dental procedures, and enhanced patient comfort. Objective pain outcomes are less consistent, but buffering is a promising and cost-effective adjunct to improve clinical experience. Nevertheless, additional high-quality RCTs with standardized protocols are recommended for additional evidence.

Recurrent laryngeal nerve (RLN) paralysis is a rare but clinically significant complication of general anesthesia associated with endotracheal intubation. We report a case of unilateral RLN paralysis that occurred after prolonged neck dissection under general anesthesia. A 77-year-old male patient with a history of hypertension, dyslipidemia, and myocardial infarction underwent right neck dissection and segmental mandibulectomy for mandibular gingival cancer. Tracheostomy was performed after general anesthesia induction, and a spiral endotracheal tube was inserted with the cuff pressure continuously maintained at 28 cmH₂O. The surgery lasted for over 15 h, with the patient's neck rotated to the right. No intraoperative complications were observed. Postoperatively, the patient presented with hoarseness and was diagnosed with left RLN paralysis. Fiberoptic examination revealed markedly reduced left arytenoid movement with incomplete glottic closure. Improvement in arytenoid mobility was noted on postoperative day (POD) 25 and phonation returned to normal by day 54. The likely mechanisms involve prolonged intubation, neck rotation, and compressive ischemia of the contralateral RLN. This case underscores the importance of careful cuff pressure monitoring and minimization of neck rotation during prolonged surgery to prevent this rare but potentially disabling complication.

Background: General anesthesia (GA) is widely used in pediatric dentistry when conventional behavioral management techniques are insufficient, particularly in young children and patients with disabilities. Although the use of GA has increased, comprehensive long-term analyses integrating both dental and anesthetic characteristics in pediatric dental settings remain limited.

Methods: This retrospective study included all patients aged <14 years who underwent dental treatment under GA between 2014 and 2023 at the Department of Pediatric Dentistry, Dankook University Jukjeon Dental Hospital, which serves as a regional disability oral health center. Data were extracted from the electronic medical and anesthesia records. Patient demographics, disability status, frequency of GA, types of dental procedures, feasibility of preanesthetic evaluation, anesthetic induction methods, airway management, duration of anesthesia, recovery time, and postoperative complications were reviewed.

Results: In total, 1,157 GA procedures were performed in 1,003 patients over a 10-year period, with a steady increase in the annual number of cases. Patients with disabilities comprised 40% of the study population. Caries-related treatments, including restorative, pulpal, and prosthodontic procedures, were performed more frequently in patients with disabilities, whereas minor oral surgery was predominant in patients without disabilities. Inhalational induction with sevoflurane and nasotracheal intubation were the predominant anesthetic approaches used in both groups. Most procedures lasted 60-119 min, and all patients were discharged on the same day. Postanesthesia complications were mild and self-limiting, with respiratory symptoms being the most common.

Conclusion: This 10-year retrospective review demonstrates the increasing use of GA in pediatric dentistry at a regional disability oral health center. Distinct differences in dental treatment patterns were observed according to disability status, whereas anesthetic management remained standardized and safe, with a low incidence of serious complications.

Background: Emergence agitation is an adverse complication following general anesthesia in patients undergoing orthognathic surgery and associated with anxiety and pain. Audiovisual distraction may reduce perioperative anxiety and pain. In this study, we aimed to investigate the feasibility of preoperative audiovisual distraction with video goggles in patients undergoing orthognathic surgery and estimate its potential for preventing emergence agitation.

Methods: A prospective, randomized, single-blinded pilot study was conducted in 40 patients undergoing orthognathic surgery under general anesthesia. Participants were randomly assigned to receive either preoperative audiovisual distraction with video goggles (intervention group) or standard care alone (control). A blinded outcome assessment was also performed. The predictor variable was the use of video goggles. The primary endpoint was postoperative agitation according to Aono's four-point scale. Secondary endpoints included agitation by the Richmond Agitation-Sedation Scale, postoperative pain, nausea, and vomiting measured using an 11-point numeric rating scale, length of stay in the recovery room, and the Quality of Recovery score. Descriptive statistics were calculated.

Results: Of the 43 screened patients, 42 consented to participate (consent rate: 97.7 %). Audiovisual distraction was successfully implemented in all patients in the intervention group. No adverse effects or harm were observed. Severe agitation was less frequent in patients who used video goggles (21%) than in the control group (40%). No clinically significant differences were observed in postoperative pain, nausea and vomiting, recovery room stay, or patient satisfaction.

Conclusion: For adults undergoing orthognathic surgery, audiovisual distraction prior to induction of general anesthesia is safe, feasible, and well-accepted. This may also influence the incidence of emergence agitation. Funding: The authors received no funding and declare no conflict of interest.Trial registration: Registered in the German Clinical Trials Register (DRKS00030349) on 05/10/2022.