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Death Related to Dental Treatment: A Systematic Review
Abstract
Objective:
The aim of this study was to identify factors associated with death in relation to dental care.
Study design:
A systematic review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. PubMed, Dental and Oral Sciences Source, Web of Science, and the Cochrane database were searched, and the references of all retrieved articles were analyzed. Studies were included if death had occurred within 90 days of the dental appointment, and if the patient's age, procedure, and information regarding cause or time of death were provided. Factors associated with death were assessed by multivariate analyses and logistic regression.
Results:
Fifty-six publications, including retrospective studies and case reports/series that reported 148 fatalities, were analyzed. On average, 2.6 deaths were reported per year. The leading cause of deaths was anesthesia/sedation/medication-related complications (n = 70). Other causes were cardiovascular events (n = 31), infection (n = 19), airway-respiratory complications (n = 18), bleeding (n = 5), and others (n = 5). Age (P < .0001), disease severity (P < .02), disease stability (P < .006), dental provider characteristics (P < .05), level of consciousness/sedation (P < .02), and drug effects (P < .03) had significant associations with death.
Conclusions:
Reports of death were rare; however, specific risk factors associated with dentistry were identified. A better understanding of these factors is important for the development of guidelines that help prevent fatalities in dentistry.
... [4] Several studies have published on morbidity following pediatric dental rehabilitation under GA with a wide range of reports from negligible to more than 90% of patients. [6][7][8] The most common complication was postoperative pain. [6][7][8] Sleep alteration was common in the first night after GA in several studies. ...
... [6][7][8] The most common complication was postoperative pain. [6][7][8] Sleep alteration was common in the first night after GA in several studies. [6][7][8][9][10][11] Holt et al. [6] reported that 21% and 20% of patients had nausea and vomiting, respectively. ...
... [6][7][8] Sleep alteration was common in the first night after GA in several studies. [6][7][8][9][10][11] Holt et al. [6] reported that 21% and 20% of patients had nausea and vomiting, respectively. Psychological changes such as crying, trouble sleeping, nightmares, and changes in children's ability to eat, reported in different studies. ...
Background: Children undergoing dental rehabilitations by general anesthesia (GA) commonly experience postoperative symptoms such as pain, fever, sore throat, and sleepiness. The aim of the present study was to investigate the specific complications of pediatric dental GA procedure.
Materials and Methods: In this observational study sample included 72 children attending GA for dental treatment at the School of Dentistry, Isfahan University of Medical Sciences. Children with American Society of Anesthesiologists physical status I and without any communication or mental health problems were included. GA protocol was standardized. A number of complications were recorded by parents via filling a questionnaire for 2 days postoperatively. Data were analyzed using SPSS statistical software by Wilcoxon and Chi-squared test. P < 0.05 considered as significant level.
Results: The most postoperative nonpsychological complications were dental pain (59.7 and 47.2% on days 1 and 2, respectively), followed by inability to eat normal (55.6 and 41.7% on days 1 and 2, respectively). All the patients' nonpsychological complaints had significantly decreased from day one to day two (P < 0.05). The most postoperative psychological complications were Attachments to parents (70.8 and 65.2% on days 1 and 2, respectively) followed by excessive crying (56.9 and 45.8% on days 1 and 2, respectively). All psychological complaints reduced by day two nonsignificantly except excessive crying which decreased significantly after 48 h (P = 0.004).
Conclusion: The most postoperative complications after dental rehabilitation under GA were attachments to parents, dental pain, and inability to eat normal and excessive crying, respectively.
... In 2017, Reuter et al [4] performed a systematic review examining deaths that were related to dental procedures. They reviewed various specialized literature libraries without date restrictions and extracted data from North America, Europe, Asia, and South America about causes and affected patients. ...
... The same applies to the fatality rates of minors having died related to a dental treatment. In comparison to Reuter et al [4], the PubMed literature review conducted in this study was restricted to the last 30 years and to publications from Europe, North America, and Australia. Therefore, a lower number of death cases were obtained in this study's PubMed search. ...
... This procedure was applied in order to use the same criteria in both the PubMed and online searches and to enable a reasonable comparison of the results. Reuter et al's publication [4], as well as this study, revealed a fatality value of 21% for the category cardiovascular system; in addition, as a main result, it can be concluded that in both works most fatalities were assigned to the category anesthesia, medication, or sedation. ...
Background
Fatalities rarely occur in dental offices. Implications for clinicians may be deduced from scientific publications and internet reports about deaths in dental offices.
Objective
Data involving deaths in dental facilities were analyzed using Google as well as the PubMed database. By comparing both sources, we examined how internet data may enhance knowledge about deaths in dental offices obtained from scientific medical publications, which causes of death are published online, and how associated life-threatening emergencies may be prevented.
Methods
To retrieve relevant information, we searched Google for country-specific incidents of death in dental practices using the following keywords: “death at the dentist,” “death in dental practice,” and “dying at the dentist.” For PubMed searches, the following keywords were used: “dentistry and mortality,” “death and dental treatment,” “dentistry and fatal outcome,” and “death and dentistry.” Deaths associated with dental treatment in a dental facility, attributable causes of death, and documented ages of the deceased were included in our analysis. Deaths occurring in maxillofacial surgery or pre-existing diseases involved in the death (eg, cancer and abscesses) were excluded. A total of 128 cases from online publications and 71 cases from PubMed publications that met the inclusion criteria were analyzed using chi-square statistics after exclusion of duplicates.
ResultsThe comparison between the fatalities from internet (n=117) and PubMed (n=71) publications revealed that more casualties affecting minors appeared online than in PubMed literature (online 68/117, 58.1%; PubMed 20/71, 28%; P
... Injury to it could result in necrosis of the flap. Fatal complications of the significant bleeding and hematoma caused by injury to the SMA or its branch have also been reported in implant dentistry [8]. These iatrogenic complications result from perforation of the lingual cortical bone and direct injury to the SMA or its branches, and bleeding can easily spread to the floor of the mouth and potentially result in airway obstruction. ...
... There have been many cases of injury to vascular bundles from the branches of the submandibular and sublingual arteries that enter through the lingual or lateral lingual foramen during dental implant placement surgery [8]. Because the SMA has abundant blood flow, injury to it can cause hemorrhage and hematoma in the floor of the mouth and potentially result in airway obstruction. ...
The submental artery usually runs anteriorly on the inferior surface of the mylohyoid muscle, giving branches to that muscle and to the anterior belly of the digastric muscle, finally supplying the submental skin. Branches of it often perforate the mylohyoid muscle and enter the sublingual space. During a routine anatomy dissection, we encountered a case in which the main trunk of the submental artery perforated the mylohyoid muscle, where the sublingual artery usually runs. No branches coursed anteriorly to supply the submental skin. To our knowledge, this submental artery variation has not been reported in the English literature. Any surgical procedure in the submandibular area, such as the axial pattern submental local flap, requires knowledge of such arterial variations.
... A lot of the "poor physical condition of the patient during dental treatment" reported in this study were after dental anesthesia. One of the leading causes of death reported in dentistry was anesthesia/medication-related [14]. Local anesthetics commonly used in dentistry contain epinephrine to constrict blood vessels and reduce bleeding; thus, they have been reported to increase blood pressure as a side effect [15]. ...
Incident reports are important for improving the quality and safety of medical care. Healthcare workers with less than one year of work experience have been reported to cause the most incidents, and the most common incident is “drug-related”. However, few studies have comprehensively analyzed incidents in dentistry, and the characteristics of dental incidents have not been understood. In this study, to understand the characteristics of dental incidents, we comprehensively analyzed 1291 incident reports submitted to the Tokyo Medical and Dental University Dental Hospital from April 2014 to March 2019. As a result, dental outpatient and dental wards had different types of incidents. In outpatient wards, incidents included many dentistry-specific incidents related to “procedures”. Among them, “poor physical condition of the patient during dental treatment” was the most common incident. In contrast, the most common incident from subjects with less than one year of work experience was “damage to soft tissues around the teeth”. Thus, to improve the quality and safety in dentistry, it is was considered necessary to analyze and understand the characteristics of dentistry-specific incidents and to take appropriate measures and educate dental professionals.
... Due to the high prevalence of poor oral hygiene, this risk may slightly be increased in patient populations as in our study, but again corresponds to the risk during oral hygiene practices carried out at home. Deaths associated with external toothbrushing have not been reported in the literature [40]. The well-documented risk of swallowing oral hygiene items to trigger the urge to vomit in eating disorders [41] does not exist with external toothbrushing and has not been described in the literature. ...
Background
To evaluate the success of plaque reduction after external toothbrushing by instructed laypeople versus dental professionals using either a manual or powered toothbrush. Longitudinal, randomized, parallel-group intervention study in periodontitis patients with reduced oral hygiene quality undergoing anti-infective therapy. Patients were randomly and equally assigned to one of four groups: laypeople using a manual or powered toothbrush or dental professionals using a manual or powered toothbrush. Plaque reduction (Quigley–Hein-Index (QHI), Marginal Plaque Index (MPI)), gingivitis (papilla bleeding index), and cleaning time (seconds) were investigated.
Results
Thirty-nine patients participated in the study. Neither the choice of toothbrush (p = 0.399) nor the use of a dental professional (p = 0.790) had a significant influence on plaque levels achieved. However, multivariate modeling indicated statistically significant differences in the external cleaning time between brushing groups, with longer time required by laypeople (p = 0.002) and longer use of the powered toothbrush (p = 0.024).
Conclusion
When the ability to carry out personal oral hygiene is reduced, external brushing by dental professionals or instructed laypeople who meet previously defined criteria such as sufficient personal oral hygiene at home could help to fill the emerging dental care gap. A combination of oral hygiene approaches adapted to the individual needs of the patients in need of external help is necessary for optimum oral hygiene.
Trial registration: German Clinical Trials register (https://www.germanctr.de; number DRKS00018779; date of registration 04/11/2019).
... Looking at dentistry itself, Nathan Reuter and his colleagues from the Department of Oral Health practice at the University of Kentucky, USA published a systematic review of death related to dental treatment in general in 2016 10 . They found dentistry itself to be very safe, with the mortality rate for pure, non-sedated dentistry to be less than 1 death per 10 million patients. ...
... При проведении длительных хирургических вмешательств в стоматологии и, в частности, в челюстно-лицевой хирургии специалисты часто встречаются с психоэмоциональными проблемами у пациентов [7]. Это снижает эффективность лечения, приводит к необходимости увеличения дозы анестетика, способствует послеоперационным осложнениям [8]. ...
3 (73) • 2020 15 www.akvarel2002.ru РУБРИКА №3 (74) • 2020 1 www.akvarel2002.ru ввЕДЕНИЕ в современных условиях при множественной хи-рургической санации, удалении ретенированных и дистопированных моляров, операции синус-лифтин-га, санирующей гайморотомии, ангулярной и трансску-ловой имплантации, тотальной имплантации, рекон-структивных операциях в полости рта, амбулаторной челюстно-лицевой хирургии, проведение хирургиче-ских вмешательств в условиях амбулаторной седации является условием качественного и безопасного лече-ния [1, 2]. Для вышеуказанных длительных операций на верхней и нижней челюстях внедряются методики мониторинга, анестезиологического пособия и анато-мически обоснованных подходов, особенно в имплан-тологической хирургии [3, 4]. Амбулаторная седация является фактором безопасности для лиц среднего и пожилого возраста в зависимости от функциональ-ного состояния организма и сопутствующей патологии. Специалисты используют общепризнанную классифи-кацию физического статуса пациентов [5, 6]. При проведении длительных хирургических вмеша-тельств в стоматологии и, в частности, в челюстно-ли-цевой хирургии специалисты часто встречаются с пси-хоэмоциональными проблемами у пациентов [7]. Это снижает эффективность лечения, приводит к необходи-мости увеличения дозы анестетика, способствует после-операционным осложнениям [8]. В статье представлены опыт и анализ результатов применения амбулаторной седации у групп пациентов с хирургическими вмешательствами на верхней челюсти. цЕль ИССлЕДОвАНИя Оценка возможностей стоматологической анестези-ологии для повышения эффективности и безопасности лечения пациентов при проведении хирургических вме-шательств в области верхней челюсти. мАТЕРИАлы И мЕТОДы Практический опыт проведения амбулаторной седа-ции в нашей практике хирургической стоматологии нако-плен с 1991 года. Переосмысление и развитие техноло-гических возможностей для проведения амбулаторной стоматологической седации и формирование методиче-ских подходов сформировались к началу 2000 года [9]. В период с января 2010 по январь 2020 года под на-шим наблюдением находился 521 пациент. Все пациенты обратились в клинику с патологией верхней челюсти: от-сутствие зубов, воспалительные процессы в области ча-сти имеющихся зубов, наличие одонтогенных синуситов, атрофия верхней челюсти. При проектировании результатов стоматологической и челюстно-лицевой имплантат-протезной реабилита-ции мы использовали разработанный алгоритм. Приме-нялась технология Wax-up, изготавливались операцион-ные шаблоны-ориентиры и слепочный прикусной модуль V. A. Put, A. A. Dolgalyav, N. I. Shaymieva, M. Kharlampos Annotation. In case of long-term surgical interventions in the oral cavity and maxillofacial area (sinus-lifting operations, maxillofacial surgery, angular and zygomatic implantation) an outpatient anesthesiological manual-medication sedation is relevant. Dental anesthesiology provides comfort and safety which is important for patients at risk and for age-related patients. The effectiveness and safety of outpatient surgery are provided by methods of anaesthetic intraoperative and postoperative monitoring of patients. Outpatient sedation allows to expand the possibilities of surgery. A condition for maintaining the patient's function after surgery is intraoperative immediate prosthetics that require additional time after surgery. It is necessary to train specialists in the rules and principles of working under sedation, especially in the oral cavity. Аннотация. При длительных хирургических вмешатель-ствах в полости рта и челюстно-лицевой области (операции синус-лифтинга, гайморотомии, ангулярной и трансскуловой имплантации) актуально амбулаторное анестезиологическое пособие-медикаментозная седация. Стоматологическая анестезиология обеспечивает комфорт и безопасность, что важно для пациентов группы риска, а также возрастных па-циентов. Эффективность и безопасность в амбулаторной хирургии обеспечивают методики анестезиологического ин-тра-и послеоперационного мониторинга пациентов. Амбу-латорная седация позволяет расширить возможности сто-матологической хирургии. Условие поддержания функции жевания пациента после хирургического вмешательства-интраоперационное немедленное протезирование, требую-щее дополнительного времени после операции. Необходимо обучение специалистов правилам и принципам работы в ус-ловиях седации, особенно в полости рта. Ключевые слова: стоматологическая анестезиология, седация, анестезиологическое пособие, трансскуловая им-плантация, ангулярная имплантация, интраоперационное не-посредственное протезирование, синус-лифтинг, гайморотомия, эффективность и безопасность лечения.
... SARS-CoV-2 transmission by both small and large particle aerosol [10] Lung and oral virus load and viral aerosol emissions in the early stages of disease or asymptomatic patients [11] SARSCoV-2 stability and viability in aerosol [12] and different ventilation conditions in dental settings Role of oral rinses in preventing the transmission of SARS-CoV-2 [13,14] Features of PPE, methods of donning and doffing, and training of practical relevance to dentistry [7,15,16] Safety and operatory protocols for surgical dental care [17] The overall economic evaluations in relation to infective adverse events [18][19][20] and patient safety [21]. ...
Up to now, dental implantology and regenerative bone surgery are considered non elective dental surgeries. We think that DI and RBS should be re-proposed to patients
with attention for many knowledge gaps including the lasting disabilities COVID-19 survivors and the expected cellular consequence on osteogenesis.
... No quantitative measure for dental-related local anesthetic (LA) population safety exists for children. [1][2][3][4] Instead, case reports, [5][6][7][8][9][10][11] insurance claim reviews, 1,12 surveys of dental boards, 13 analyses of United States Food and Drug Administration (FDA) adverse events reporting, 14 provider surveys, [14][15][16][17][18] reviews of media reports, 2 reviews of coroner's reports, 19 and systematic reviews of these sources 20 have been used to describe adverse events related to LA. There are myriad reports of LA events (Figure 1), but the true volume, repetition in reporting, and missed events are unknown due to a lack of a central national clearinghouse, no mandated reporting regulations, fear of litigation, and other factors. ...
Purpose:
The purpose of this study was to use National Poison Data System (NPDS) data to identify cases of local anesthetic (LA) adverse events related to dentistry for children.
Methods:
NPDS data were queried for all human cases from 2004 to 2018 that identified a parenteral LA agent as the substance, in children 12 years old and younger, which led to a medical outcome classification ranging from moderate to death. For cases that met inclusion criteria, deidentified records with case notes were requested.
Results:
Twenty-seven dental cases that met review criteria and had available case notes were reviewed. Most subjects were female ( N equals 20 out of 27, 74 percent), and the average subject age was 6.8 years. Twenty cases (74 percent) had a moderate effect, seven cases (26 percent) had a major effect, and no fatalities were reported. The most common clinical effects classification was a seizure ( N equals 13, 48 percent). One case of LA overdose was identified.
Conclusions:
No cases of permanent damage or fatal outcomes were found. Seizure activity following the administration of local anesthetic was the most common event, suggesting intravascular administration or a toxic dose.
... This, coupled with the recent report from The Royal Colleges of England, Edinburgh, and Glasgow [2] 'The Ibbetson Report' which includes sedation for general dental practice brings to a conclusion, or nearly so, the unjustifiable exposure to risk for patients seeking simple dental treatment using techniques of Local Anaesthesia, General Anaesthesia and/or Conscious Sedation. These relatively recent guidelines present the findings of a systematic review on 'Death related to dental treatment: a systematic review' [3]. It is clear from the summary of the reports in this systematic review that the authors have not considered the significance of the 'Hospital v Outpatient' setting. ...
Background:
Following the inception of the National Health Service in 1948 dental treatment under General Anesthesia (GA) became easily available. An unexpected consequence of this was a disconcerting number of deaths associated with GA. Over the decades since 1948 there have been a number of specialist medical society, royal college, and government working parties deliberating on the appropriateness of GA being conducted in general dental practice and community dental practice.
Methods:
The figures for the number of general anaesthetics per annum in England and Wales were obtained from the general dental services board, the community dental service, and records from hospital inpatient episodes. The number of deaths per annum were obtained from coroners' enquiries and dental protection societies.
Findings:
Prior to 2001 there is a strong correlation between the number of GA's per annum and deaths. Since 2001, when the UK government directed that all GAs for dentistry must be administered in a hospital with Intensive Care facilities the number of deaths per annum has reduced to nil.
Interpretation:
The change in the arrangements under which GA for dentistry are administered was coincident with improved training and knowledge of GA for dentistry. This has led to a cessation of deaths associated with GA for dentistry. The incidence rate is now estimated at less than 1 death per 3.5 million GAs.
... On the other hand, fatal ones caused by respiratory complications and bleeding remained the same, and those caused by cardiovascular events or those linked to anesthesia are decreasing. 12 The implementation of CI procedures is beneficial because it has led to a 65 percent reduction in infections in a stomatology clinic in one year. 13 Chen et al. reported that the implementation of hand hygiene alone has resulted in a substantial cost/benefit gain ($1 invested vs. $23,7 saved). ...
... About 4-17% of AEs are due to infection [4,5]. The iatrogenic infectious risk in dentistry has not been quantify closely yet [6,7], but recently, some outbreaks caused by infective agents, mainly blood-borne viruses and water-borne bacteria, have been documented in dental set- tings based on molecular biological assays and/or retrospective investigations [8][9][10][11]. ...
... esthetics, [48][49][50][51][52][53][54][55] evidence-based dentistry, [56][57][58][59][60][61][62][63][64][65][66][67][68] general topics in implant dentistry, [69][70][71][72][73][74][75][76][77][78][79][80][81] general topics in prosthodontics, [82][83][84][85] geriatrics, [86][87][88][89][90][91][92][93][94][95][96][97][98][99] implant-supported fixed prosthodontics, [100][101][102][103][104][105][106][107][108] implant-assisted removable prosthodontics, [109][110][111][112][113][114][115][116][117] implant surgery, [118][119][120][121][122] maintenance, 123 mastication, [124][125][126] materials science, [127][128][129][130][131][132][133][134][135][136][137] occlusion, 138 pathology and disease, [139][140][141][142][143][144][145][146][147][148][149][150][151][152] peri-implant conditions, [153][154][155][156][157][158][159][160][161][162][163][164][165][166][167][168][169][170] pharmacology, [171][172][173][174][175][176][177] practice considerations, [178][179][180][181] preprosthetic surgery, [182][183][184][185][186][187][188][189][190][191][192] radiology, [193][194][195] statistics, [196][197][198][199][200][201][202][203][204][205][206][207][208] temporomandibular disorders (TMDs) and orofacial pain, [209][210][211][212][213][214][215][216][217][218][219] and treatment success/survival. [220][221][222] Readers may also be interested to know that a ninth edition of the Glossary of Prosthodontic Terms was published in 2017. ...
Problem: There are countless numbers of scientific studies published in countless scientific journals on subjects related to restorative dentistry. Purpose: The purpose of this article is to review pertinent scientific studies published in 2017 on topics of interest to restorative dentists. Methods and materials: The authors, considered to be experts in their disciplines searched the scientific literature in 7 different areas (prosthodontics, periodontics, dental materials, occlusion and temporomandibular disorders, sleep-disordered breathing, oral medicine and oral and maxillofacial surgery and dental caries). Pertinent articles were either identified and referenced or reviewed. Results: A total of 437 articles in 7 disciplines were identified or reviewed. Conclusions: An impressive amount of scientific literature related to restorative dentistry was published in 2017. The evidence presented in this article can assist dentists in the practice of contemporary evidence-based dentistry.
... In conclusion, the European recommendations regarding conscious sedation, should be regarded as the safest and simplest way of managing the patient, able to improve safety through emergency prevention rather than being a cause of adverse events, while the use of deep sedation and general anesthesia should be indicated in selected, non-collaborating patients only. A routine use of deep sedation and general anesthesia is affected by a higher risk of severe complication and deaths, a fact and a concern of US dentists and insurances (Yagiela, 2001;Chicka et al., 2012;Lee et al., 2013;Reuter et al., 2017). In our experience, we performed more than 15,000 intravenous conscious sedations using our dedicated protocol, with no complications at all (1,179 cases have been published elsewhere, Manani et al., 2005). ...
Dental anxiety (DA) can be considered as a universal phenomenon with a high prevalence worldwide; DA and pain are also the main causes for medical emergencies in the dental office, so their prevention is an essential part of patient safety and overall quality of care. Being DA and its consequences closely related to the fight-or-flight reaction, it seems reasonable to argue that the odyssey of DA began way back in the distant past, and has since probably evolved in parallel with the development of fight-or-flight reactions, implicit memory and knowledge, and ultimately consciousness. Basic emotions are related to survival functions in an inseparable psychosomatic unity that enable an immediate response to critical situations rather than generating knowledge, which is why many anxious patients are unaware of the cause of their anxiety. Archeological findings suggest that humans have been surprisingly skillful and knowledgeable since prehistory. Neanderthals used medicinal plants; and relics of dental tools bear witness to a kind of Neolithic proto-dentistry. In the two millennia BC, Egyptian and Greek physicians used both plants (such as papaver somniferum) and incubation (a forerunner of modern hypnosis, e.g., in the sleep temples dedicated to Asclepius) in the attempt to provide some form of therapy and painless surgery, whereas modern scientific medicine strongly understated the role of subjectivity and mind-body approaches until recently. DA has a wide range of causes and its management is far from being a matter of identifying the ideal sedative drug. A patient's proper management must include assessing his/her dental anxiety, ensuring good communications, and providing information (iatrosedation), effective local anesthesia, hypnosis, and/or a wise use of sedative drugs where necessary. Any weak link in this chain can cause avoidable suffering, mistrust, and emergencies, as well as having lifelong psychological consequences. Iatrosedation and hypnosis are no less relevant than drugs and should be considered as primary tools for the management of DA. Unlike pharmacological sedation, they allow to help patients cope with the dental procedure and also overcome their anxiety: achieving the latter may enable them to face future dental care autonomously, whereas pharmacological sedation can only afford a transient respite.
Amaç: Çocuklarda birçok tedavi lokal anestezi yardımıyla yapılabilse de özellikle kooperasyon kurulamayan ve ek sistemik rahatsızlığı ya da özel bir engel durumu olan çocuklarda tedavilerin genel anestezi/sedasyon altında yapılması gerekmektedir. Genel anestezi altında dental tedaviler maliyeti ve risk faktörlerinden dolayı aileler için son tercih olsa da günümüzde uzun sürede tamamlanabilecek tedavilerin genel anestezi altında aynı seansta güvenilir bir şekilde yapılabilmesi bu tedavi seçeneğinin kullanılmasını yaygınlaştırmaktadır. Gereç ve Yöntemler: Bu çalışma, Başkent Üniversitesi Konya Uygulama ve Araştırma Merkezi Pedodonti Kliniği’ ne muayene ve tedavi amaçlı başvuran ve tedavileri genel anestezi/sedasyon altında tamamlanan 1-14 yaş aralığına sahip toplam 1536 çocuk hastanın klinik kayıtlarının retrospektifolarak incelenmesi ile gerçekleştirilmiştir. Bulgular: Genel anestezi/sedasyon altında tedavileri yapılan hastalara 5144 adet restoratif dolgu, 4653 adet pulpa amputasyonu (pulpotomi), 732 adet kanal tedavisi, 967 adet paslanmaz çelik kron uygulaması, 48 adet pediatrik zirkonyum kron uygulaması, 2871 adet diş çekimi, 221 adet fissür örtücü, 23 adet kistik cerrahi, 47 adet labial frenektomi ve 8 adet lingual frenektomi uygulanmıştır. Bu hastaların 28’ inde (% 1.82) tekrar tedavi gereksinimi duyulmuş ve kısa süreli işlemler için entübe olmadan sadece sedasyon uygulaması ile tedavi altına alınmışlardır. Sonuç: Çocuk diş hekimliğinde genel anestezi/sedasyon altında dental tedaviler, tek seansta tüm dental işlemlerin bitirilmesine olanak sağlaması, tedavi başarısında kooperasyon etkenini ortadan kaldırması ve özellikle engelli çocuklarda yaşam kalitesini yükseltmesi ile sıklıkla tercih edilen bir uygulamadır.
In modern dental practice, the use of sedation to eliminate the fear and anxiety of the patient has become frequent. Unfortunately, according to the legislation, the concept of sedation is inseparable from anesthesia and it can only be performed by an anesthesiologist in a group or Department of Anesthesiology and Resuscitation. The article is devoted to a detailed comprehensive review of sedation in dental and surgical interventions in the maxillofacial area. It details the physiological and pathophysiological data of stress and psycho-emotional discomfort. The article indicates drugs for sedation, methods of their administration, features of application, possible complications. Such methods of parenteral sedation as intranasal, inhalation, intravenous are described in detail. Specific problems of sedation, for example, psychomotor agitation in the application of propofol or cough in deep sedation are indicated. It describes the modern data on intraoperative monitoring as an important component of patient safety during sedation. In addition to the Harvard standard the use of capnography and monitoring the depth of sedation by using bispectral index (BIS) is recommended.
Objectives:
Mortality on the dental chair is a rare and underreported event. This study aimed to identify all deaths which occurred during dental procedures in Italy.
Methods:
We searched Pubmed/Medline, Scopus, and internet archives looking for patients who died before, during or after a dental procedure in Italy from 1990 to 2019.
Results:
All the 36 identified fatal events were reported by national or regional newspapers and none was reported by scientific databases. Interestingly, no cases regarding patients < 16 years-old were found and there was no variation in the number of reported deaths over the years. Most of the cases (n=29) occurred in out-of-hospital private dental offices. Tooth extraction represented the most frequent culprit operation (39%), while myocardial infarction (28%) was the leading cause of death, followed by cardiac arrest (25%), allergies (11%) and infections (8%). In four cases death was preprocedural, in 10 intraprocedural and in 21 postprocedural. In 17 cases a temporal association between injection of anesthesia/sedation and death was observed.
Conclusion:
This is the first report on Italian dental procedure related deaths. Most of these deaths were only temporally associated with a dental procedure and could not to be attributed to malpractice. This article is protected by copyright. All rights reserved.
Background/purpose
Hypertension is a risk factor for stroke and heart disease. Psycho-social reasons are thought to influence blood pressure fluctuation in the dental clinic, but no previous studies have investigated these relationships. In this study, we analyzed a correlation between patients’ blood pressure values and their backgrounds.
Materials and methods
We measured blood pressure in 4990 outpatients at our hospital. After determining the age groups in which blood pressure deviated from national averages, patients were classified into the Hypertension group and Normal group. Differences between these groups with regard to the prevalence of systemic disease, dental history and reasons for dental consultation were analyzed.
Results
Average systolic blood pressure of males in their 20's, 30's, 40's and females in their 20's, 30's, 40's, 50's was significantly higher than national averages. In these age groups, disease prevalence was significantly higher in the Hypertension group than in the Normal group. Furthermore, the Hypertension group expressed psycho-social reasons for dental consultation more frequently than the Normal group.
Conclusion
Relatively younger patients tended to show higher systolic blood pressure. It was suggested that psycho-social backgrounds as well as medical causes influenced the blood pressure increase.
The article describes sedation in dentistry and out-patient maxillofacial surgery. The definitions of sedation, psychoemotional comfort and discomfort are thoroughly described and introduced. A special emphasis is put on pathophysiology of psychoemotional discomfort and peri-operative stress. According to modern data, the objectives to be achieved by an anesthesiologist have been reviewed: provision of psychoemotional inhibition (as a basis of comfort staying in a dental chair), but not depression of consciousness as it used to be before.
With much detail it analyzes complication occurring during anesthesia; their correlations with age, concurrent conditions, anesthetic agent and doctor's professional level are highlighted.
The article presents a clinical picture of sedation depending on the depression of consciousness, respiration, and hemodynamics (ADA and ASA, 2016). It depicts thoroughly the state of minimal sedation (anxiolysis), moderate sedation (awake sedation), deep sedation and general anesthesia. Special attention is paid to the provision of patient's safety related to supporting airway patency and hemodynamics.
The article presents methods of sedation from the position of modern global data and personal experience of authors. Methods of medication administration are mentioned: enteral, parenteral, including intra-nasal which is fairly popular of late.
Special attention is paid to specific problems of sedation, presence of motion activity, psychoemotional agitation, compulsive coughing. Potential causes of these events are described, in particular, correlation between psychoemotional agitation with dysregulation of GABA-ergic and dopaminergic systems.
Current data on the intra-operative monitoring are presented, as an important component of the patient's safety during sedation. Additionally to Harvard Standard, it is recommended to use capnography and monitoring of sedation depth through bispectral index.
Purpose:
The aim of the paper is to identify, review, analyze, and summarize available evidence in three areas on the use of cross-sectional imaging, specifically maxillofacial cone beam computed tomography (CBCT) in pre- and postoperative dental implant therapy: (1) Available clinical use guidelines, (2) indications and contraindications for use, and (3) assessment of associated radiation dose risk.
Materials and methods:
Three focused questions were developed to address the aims. A systematic literature review was performed using a PICO-based search strategy based on MeSH key words specific to each focused question of English-language publications indexed in the MEDLINE database retrospectively from October 31, 2012. These results were supplemented by a hand search and gray literature search.
Results:
Twelve publications were identified providing guidelines for the use of cross-sectional radiography, particularly CBCT imaging, for the pre- and/or postoperative assessment of potential dental implant sites. The publications discovered by the PICO strategy (43 articles), hand (12), and gray literature searches (1) for the second focus question regarding indications and contraindications for CBCT use in implant dentistry were either cohort or case-controlled studies. For the third question on the assessment of associated radiation dose risk, a total of 22 articles were included. Publication characteristics and themes were summarized in tabular format.
Conclusions:
The reported indications for CBCT use in implant dentistry vary from preoperative analysis regarding specific anatomic considerations, site development using grafts, and computer-assisted treatment planning to postoperative evaluation focusing on complications due to damage of neurovascular structures. Effective doses for different CBCT devices exhibit a wide range with the lowest dose being almost 100 times less than the highest dose. Significant dose reduction can be achieved by adjusting operating parameters, including exposure factors and reducing the field of view (FOV) to the actual region of interest.
A 23-year-old woman was mortally afraid of dental interventions and decided to have her four wisdom teeth removed by outpatient surgery under endotracheal anaesthesia. According to the files, the patient was categorized as ASA I and Mallampati II, and surgery was considered an elective routine intervention. Soon after initiation of anaesthesia, O2 saturation and blood pressure dropped, and the young woman died shortly afterwards in spite of immediate resuscitation measures. At first, an allergic reaction to succinylcholine, which had been administered as a muscle relaxant, was suspected. Autopsy and histological examination showed haemorrhagic pulmonary oedema and a defined lesion in the midportion of the oesophageal mucosa in spite of correct placement of the endotracheal breathing tube. Ultimately, misintubation into the oesophagus, which had not been noticed at first, was determined as cause of death.
A 69-year-old man, previously independent and with a pre-existing metallic aortic valve, presented with a history of fevers, confusion and malaise and was diagnosed with prosthetic valve endocarditis. Blood cultures taken on presentation grew Streptococcus sanguinis and vegetations were confirmed on transoesophageal echocardiogram. He had had a dental procedure 10 days before presentation but had not received prophylactic antibiotics; he had been receiving antibiotic prophylaxis for dental treatment up until the change in NICE guidelines in 2008. He was treated with high dose antibiotics and was referred for cardiothoracic surgery, but developed a cerebrovascular event, thought to be embolic, and deteriorated and died. Given that the patient had a metallic aortic valve and poor dentition, and therefore was at increased risk of infective endocarditis, should the new guidelines have been followed so rigidly, particularly as American and European guidelines still recommend the use of antibiotic prophylaxis in this patient group?
Materials used for dental impressions are usually safe. This study describes a case of fatal anaphylaxis that appeared immediately after the oral mucosa came into contact with an alginate paste used for dental impressions. The cadaveric examination and the postmortem toxicology report confirmed that the cause of death was anaphylactic shock. The patient was affected by both cardiovascular and lung diseases that worsened the condition and forbade the use of epinephrine. To the authors' knowledge, dental impression materials, and alginate in particular, have not been reported previously as being a cause of anaphylaxis.
Three serial cases of fatal venous air embolism were reported after mandibular prosthetic dental surgery. Initially attributed to anesthetic factors, the deaths resulted from intraosseous irrigation with coolant tap water and air. Pulmonary edema was seen on chest roentgenograms and might have suggested the cause of death.
A 52-year-old woman had a fatal intracerebral hemorrhage after dental manipulation. Normotensive in the past, the initial blood pressure was high but rapidly returned to normal. Necropsy showed no vascular malformation or evidence of hypertensive vascular disease. Clinical and experimental data show that stimulation of trigeminal fibers can cause important changes in blood pressure and pulse.
Two cases of local anaesthetic overdose and death are described. The patients, a four-year-old child and a 68-year old female, received local anaesthetic doses greatly in excess of those recommended. Their overdose reactions are described as well as subsequent management. The paper reviews the causes of local anaesthetic overdose, its signs and symptoms, and the recommended management of these reactions. Specific discussion as to the cause of death of these two patients and of the means to prevent such occurrences in the future concludes the paper.
Background:
The authors performed a systematic search of the literature to identify the frequency of, risk of experiencing and factors associated with adrenal crises in dental patients.
Methods:
The authors searched PubMed and Ovid MEDLINE (1947-June 20, 2012) and Embase (1974-2012) for English-language articles related to cases of adrenal crisis in dentistry and extracted and analyzed data from the articles. The six authors determined whether the cases identified met a consensus definition of adrenal crisis.
Results:
Of 148 articles identified in the initial screening, 34 articles were included in the final review, from which six cases met the criteria of adrenal crisis. The authors categorized four cases as "suggestive of adrenal crisis" and two cases as "consistent with adrenal crisis." Risk factors were significant adrenal insufficiency, pain, infection, having undergone an invasive procedure, having received a barbiturate general anesthetic, and poor health status and stability at the time of presentation. The authors estimated risk to be less than one in 650,000 in patients with adrenal insufficiency.
Conclusions:
Adrenal crisis is rare in dental patients, with only six reports of it having been published in the past 66 years. Risk is associated with unrecognized adrenal insufficiency, poor health status and stability at the time of treatment, pain, infection, having undergone an invasive procedure and having received a barbiturate general anesthetic.
Clinical implications:
Risk of adrenal crisis is reduced through proper evaluation of the patient, identification of risk factors and following appropriate preventive measures.
Be prepared to handle life-threatening dental emergencies! Medical Emergencies in the Dental Office, 7th Edition helps you learn the skills needed to manage medical emergencies in the dental office or clinic. It describes how to recognize and manage medical emergencies promptly and proactively, and details the resources that must be on hand to deal effectively with these situations. This edition includes new guidelines for drug-related emergencies, cardiac arrest, and more. Written by respected educator Dr. Stanley Malamed, this expert resource provides dental professionals with the tools for implementing a basic action plan for managing medical emergencies.
Deep sedation and general anesthesia are administered daily in dental offices, most commonly by oral and maxillofacial surgeons and dentist anesthesiologists.
The goal of deep sedation or general anesthesia is to establish a safe environment in which the patient is comfortable and cooperative. This requires meticulous care in which the practitioner balances the patient's depth of sedation and level of responsiveness while maintaining airway integrity, ventilation, and cardiovascular hemodynamics.
Using the available data and informational reports, the authors estimate that the incidence of death and brain injury associated with deep sedation or general anesthesia administered by all dentists most likely exceeds 1 per month.
Airway compromise is a significant contributing factor to anesthetic complications. The American Society of Anesthesiology closed claim analysis also concluded that human error contributed highly to anesthetic mishaps. The establishment of a patient safety database for anesthetic management in dentistry would allow for a more complete assessment of morbidity and mortality that could direct efforts to further increase safe anesthetic care.
Deep sedation and general anesthesia can be safely administered in the dental office. Optimization of patient care requires appropriate patient selection, selection of appropriate anesthetic agents, utilization of appropriate monitoring, and a highly trained anesthetic team. Achieving a highly trained anesthetic team requires emergency management preparation that can foster decision making, leadership, communication, and task management.
Copyright © 2015 American Dental Association. Published by Elsevier Inc. All rights reserved.
Purpose: This retrospective study documented the frequency of various complications associated with Outpatient anesthesia. Patients and Methods: A questionnaire was mailed to the 157 active members of the Massachusetts Society of Oral and Maxillofacial Surgeons (MSOMS) and all members responded. Morbidity data were obtained for the calendar year 1999. Mortality data included 1999 and the preceding 4 years. This continues our long-term survey of ambulatory oral surgical office deaths in Massachusetts since 1984. The data include anesthesia-related complications and all office deaths for the patients treated by these oral and maxillofacial surgeons. Results: The most common complication in our survey continues to be syncope, which occurred in I in 160 patients receiving local anesthesia. The incidences of other specific anesthetic problems are given. Two treatment-related deaths occurred among approximately 1,706,100 patients treated during the 5-year period of 1995 through 1999, for a mortality rate of 1/853,050. Conclusions: The results of this retrospective practitioner survey documented the specific incidence of untoward anesthetic events with outpatient anesthesia and found a mortality rate consistent with the 6 similar mortality studies since 1980. These 7 retrospective reviews found 34/28,399,193 outpatient deaths for an overall dental anesthesia mortality rate of 1/835,000. (C) 2003 American Association of Oral and Maxillofacial Surgeons.
Dental extraction of abscessed or infected teeth before cardiac operation is often performed to decrease perioperative infection and late endocarditis. Literature to support dental extraction before cardiac operation is limited. The goal of this study was to evaluate the risk of major adverse outcomes in patients undergoing dental extraction before cardiovascular surgical procedures.
A retrospective review was performed to identify patients who underwent dental extraction before planned cardiac operation. Major adverse outcomes within 30 days after dental extraction or until time of cardiac operation were recorded and defined as death, acute coronary syndrome, stroke, renal failure requiring dialysis, and need for postoperative mechanical ventilation.
Two hundred five patients underwent 208 dental extractions before 206 planned cardiac operations. Major adverse outcomes occurred in 16 of 205 patients (8%). Twelve patients (6%) died within 30 days after dental extraction, of which 6 (3%) occurred before cardiac operation, and 6 (3%) occurred after cardiac operation.
Patients with planned dental extraction before cardiac operation are at risk for major adverse outcomes, including a 3% risk of death before cardiac operation and an 8% risk of a major adverse outcome. The prevalence of major adverse outcomes should advise physicians to evaluate individualized risk of anesthesia and surgical procedures in this patient population.
Background. Although clinicians generally con' sider it safe to provide dental care far pregnant women, supporting clinical trial evidence is lacking. This study compares safety outcomes from a trial in which pregnant women received scaling and root planing and other dental treatments. Methods. The authnra randomly nssij-iiHi 823 woi to receive HCling and nmt planing either at 13 to 21 to three months after delivery They evaluated all sui dental treatment (EDT) needs, defined as the present severe caries or fractured Or ulwcjcKSL'd teeth; 3(51 will EDT at 13 to 21 weeks' gestation. The authors used I propensity-score adjustment to compare rales ofserii spontaneous abortions/stillbirths, fetal/congenital and tal Association (JADA) in 2008, examined the safety of periodontal treatment and dental care in a population of medically complex patients- pregnant women. The investigators used data collected from a large randomized controlled trial that showed that periodontal treatment did not reduce the rate of preterm birth.3 In that trial, 823 women having periodontitis were assigned randomly to receive periodontal scaling and root planing, either during pregnancy at 13 to 21 weeks' gestation or after delivery.
Necrotizing fasciitis (NF) is an uncommon infection, but potentially lethal, especially when associated with systemic disorders such as diabetes. The authors report a case of necrotizing fasciitis from odontogenic origin in a patient with uncontrolled diabetes mellitus. The initial diagnosis was based on clinical information, in which multiple necrosis areas in cervical and thoracic regions were observed. Wide antibiotic therapy was applied, followed by surgical drain age and debridement. Culture was positive for methicillin-resistant Staphylococcus aureus. Although the treatment is established, the patient dies after sepsis and failure of vital organs. Clearly, the morbidity associated to this infection, even in diabetic patients, can be minimized if an early diagnosis and effective debridement are done.
Fusobacterium necrophorum, an obligate, anaerobic, filamentous, gram-negative rod, is thought to be a normal inhabitant of the mucous membranes in human beings. Fusobacterium species have been implicated in cases of Lemierre syndrome and other pathologic conditions. Their reported association with infective endocarditis is extremely rare. We describe the case of a previously healthy 34-year-old man who emergently presented with flu-like symptoms and dyspnea on exertion. He had recently undergone a dental procedure. Empiric antibiotic therapy was initiated. Blood cultures were positive for metronidazole-resistant F. necrophorum. A transesophageal echocardiogram revealed 2 mobile vegetations on the mitral valve. Despite the antibiotic therapy, the patient's respiratory status worsened and, after 3 weeks, he died. On the basis of the organism's pathophysiology and the patient's recent dental procedure, the oral cavity was the likely source of the bacteremia. Our patient's case underscores the importance of recognizing Fusobacterium bacteremia as a possible cause of endocarditis. To our knowledge, this is the first reported case of monomicrobial F. necrophorum endocarditis to have presented in a patient after the 2nd decade of life. In addition, it is apparently only the 4th report of F. necrophorum mitral valve endocarditis with case results derived from modern culture techniques.
A study of deaths associated with dentistry and dental disease in England and Wales between 1980 and 1989 has been undertaken. There were fewer deaths associated with dentistry than in the previous decade. Whilst most of the deaths are still associated with general anaesthesia, the total number has decreased, as has the percentage of deaths in which general anaesthesia was thought to play a significant part. There were only four deaths involving an operator/anaesthetist compared with 13 in the previous decade and all four took place between 1980 and 1983. However, there were two deaths associated with sedation techniques, both of which occurred after 1984, whereas there had been none in the previous decade. On the information available, it is still not possible to establish the role of the patient's posture in these deaths.
We here report an autopsy case of a man in his seventies who died from asphyxia due to compression of the trachea caused by postextraction bleeding after extraction of his left mandibular third molar by a dentist in private practice. On the morning after the tooth extraction, he had complained of dyspnea and became unconscious at home. Although he was brought to the emergency room by ambulance, he died 7 days later without regaining consciousness. Autopsy examination revealed that the lingual side of the alveolar bone was fractured at the extraction socket. Moreover, subcutaneous bleeding that extended from the extraction socket to the thyrohyoid ligament in the cervical region and deviation of the epiglottis due to the bleeding were observed. Histological findings revealed liver cirrhosis; there were no significant findings in other organs. On the basis of these findings, we concluded that alveolar bone fracture occurred during the extraction and that the bleeding spread to the cervical region. Thus, the patient had died from asphyxia resulting from airway obstruction caused by cervical subcutaneous bleeding derived from postextraction bleeding. We emphasize that tooth extraction may cause fatal complications in patients with bleeding tendencies, particularly in the elderly.
Mucormycosis is a life-threatening fungal infection that occurs in immunocompromised patients. The most common predisposing risk factor for mucormycosis is diabetes mellitus. Rhino-orbito-cerebral mucormycosis is the most common form in diabetic patients and is characterized by paranasal sinusitis, ophthalmoplegia with blindness, and unilateral proptosis with cellulitis, facial pain with swelling, headache, fever, rhinitis, granular or purulent nasal discharge, nasal ulceration, epistaxis, hemiplegia or stroke, and decreased mental function. Diabetic ketoacidosis is the most common and serious acute complication of diabetic patients. We herein report 2 cases of fatal rhino-orbito-cerebral mucormycosis in a patient with diabetic ketoacidosis.
Objective:
We conducted a review of the literature to assess risk for oral bleeding complications after dental procedures in patients on antiplatelet therapy.
Study design:
We conducted a search in Medline, Embase, and National Guideline Clearinghouse databases for studies involving patients on single and dual antiplatelet therapy that had invasive dental procedures or manipulations that induce oral bleeding.
Results:
The literature search yielded 15 studies that met inclusion criteria. There is a trend toward increased occurrence of immediate postoperative bleeding for dual antiplatelet therapy, but there is no increase in the occurrence of intra- or late postoperative bleeding complications.
Conclusions:
We found no clinically significant increased risk of postoperative bleeding complications from invasive dental procedures in patients on either single or dual antiplatelet therapy. These findings support the recommendation that there is no indication to alter or stop these drugs, and that local hemostatic measures are sufficient to control bleeding.
The purpose of this study of closed malpractice insurance claims was to provide descriptive data of adverse events related to child sedation and anesthesia in the dental office.
The malpractice claims databases of two professional liability carriers were searched using pre-determined keywords for all closed claims involving anesthesia in pediatric dental patients from 1993-2007.
The database searches resulted in 17 claims dealing with adverse anesthesia events of which 13 involved sedation, 3 involved local anesthesia alone, and 1 involved general anesthesia. Fifty-three percent of the claims involved patient death or permanent brain damage; in these claims, the average patient age was 3.6 years, 6 involved general dentists as the anesthesia provider, and 2 involved local anesthesia alone. Local anesthetic overdoses were observed in 41% of the claims. The location of adverse event occurrence was in the dental office where care was being provided in 71% of the claims. Of the 13 claims involving sedation, only 1 claim involved the use of physiologic monitoring.
Very young patients (≤ 3-years-old) are at greatest risk during administration of sedative and/or local anesthetic agents. Some practitioners are inadequately monitoring patients during sedation procedures. Adverse events have a high chance of occurring at the dental office where care is being provided.
A case is described of sudden death occurring after the use of a noradrenaline-containing local anaesthetic. Autopsy revealed a massive subarachnoid haemorrhage following a ruptured cerebral aneurysm. The noradrenaline in the local anaesthetic is thought to be an important factor in the cause of the rupture. It is recommended that preparations containing 1:25 000 noradrenaline not be used.
OMS National Insurance Company insures over 4700 oral and maxillofacial surgeons, 83% of the fellows and members of the American Association of Oral and Maxillofacial Surgeons. The company has over 10,000 closed malpractice claims involving oral and maxillofacial surgeons. Data and trends involving infections that developed following elective surgical procedures and trends involving patients with preexisting odontogenic infections with adverse outcomes are well known to the company. Seven percent of the 10,000+ closed claims involve infections. Recognition and diagnosis of the infection leads to appropriate and timely treatment of infections. Delayed recognition, consultation, and referral leads to delay in the institution of appropriate treatment and can lead to adverse outcomes.
A 6-year-old male child was scheduled for a dental procedure requiring conscious sedation. Prior to the procedure, the child was administered a dental cocktail containing chloral hydrate, hydroxyzine, and methadone. After returning from the dentist, the child appeared groggy and was allowed to sleep. A few hours later, he was found unresponsive, and following resuscitation attempts at a local medical center, he was pronounced dead. Toxicological analyses of femoral blood indicated the presence of hydroxyzine at less than 0.54 μg/mL, trichloroethanol (TCE) at 8.3 μg/mL, and methadone at 0.51 μg/mL. No meperidine was detected. The cause of death was reported to be due to the toxic effects of methadone. The toxicological analysis was corroborated by the analysis of the contents of the dental cocktail, which revealed the presence of hydroxyzine, chloral hydrate, and methadone. Residue from a control sample obtained from the same pharmacy, but administered to a different subject, was found to contain hydroxyzine, chloral hydrate, and meperidine. This report represents the first known fatality due to accidental substitution of methadone in a dental cocktail.
Some special patients are unable to tolerate dental care in outpatient dental offices. Providing dental care under general anesthesia in an operating room setting involves various medical, dental, and hospital issues and procedures that differ from outpatient care. This article reviews pertinent information for the dental management of patients who require general anesthesia.
Incluye bibliografia e índice
San Filippo syndrome is a hereditary lysosomal disorder resulting in the accumulation of mucopolysaccharides (mucopolysaccharidosis type II). A deficit in the enzyme required to break down heparan sulfate leads to its deposition in the connective tissue of many organs, particularly the brain, liver, heart, and spleen. The first symptoms-including mental deterioration, dimorphism, and behavioral changes such as hyperkinesis and aggressivity-present in childhood. Because this rare disorder has many anesthetic implications, we report the case of a 20-year-old man with San Filippo syndrome who underwent multiple tooth extraction under general combined anesthesia and a block of the second and third branches of the trigeminal nerve. This anesthetic combination provided satisfactory surgical conditions and recovery from anesthesia was rapid. Following surgery the patient developed a respiratory infection that led to severe respiratory failure and death.
Anesthesia-related morbidity is a serious risk to oral and maxillofacial surgery patients receiving outpatient surgery. Unfortunately, there is little data to track the risks of outpatient anesthesia to offer as an appeasement for these concerns. The most recent and comprehensive review is the American Association of Oral and Maxillofacial Surgeons (AAOMS) anesthesia study published in 2003. In an insurance claims analysis, Deegan presented data that the mortality risk in the oral surgery office was 19 deaths in 14,206,923 anesthetics administered.
The American Heart Association (AHA) published their revised guidelines in 2007 in which they markedly limited the recommendations for the use of antimicrobial prophylaxis for the prevention of infective endocarditis (IE), except for patients who are at highest risk of adverse outcomes. A recent focused update on valvular heart diseases changed the recommendation for antibiotic use for patients with many underlying heart conditions including mitral valve prolapse (MVP) which were considered as "low risk" heart defects. In this article, we argue that antibiotic prophylaxis should be considered until concrete clinical evidence is provided to dispute against the use of this strategy, especially for patients with MVP. This approach is cost efficient, and provides a chance to prevent a dreadful disease. We have also enlisted 2 clinical cases to support our argument. These are not uncommon clinical scenarios, and emphasize that IE can be fatal in spite of optimum treatment. Patients have the right to make the final decision, and they should be allowed to participate in choosing for or against this approach until adequate clinical evidence is available.
Morbidity and mortality (M&M) statistics have been used to determine the safety of pharmacosedation and general anesthesia for dental procedures. Although relevant, these data often do not describe what actually caused the problems. Descriptive data are needed to understand etiologic factors and to accurately set malpractice insurance rates, establish legislative regulations, and determine means of prevention. The purpose of this study was to characterize the factors involved in causing M&M in a national data base of dental patients who received either pharmacosedation or general anesthesia. Letters were sent to all state dental boards requesting detailed information on cases associated with M&M during the last 15 years. Follow-up letters and telephone contacts were made with noncompliant boards. Forty-three cases were reported from nine states, with mortality comprising 81.4% of the cases. The mean patient age was 18 years, with a range from 2 to 42 years. Seventy-five percent of the cases were classified as American Society of Anesthesiologists (ASA) class I, 21% as ASA II, and 4% as ASA III. The mean number of pharmacological agents used was three, with a range from one to seven. In 32% of the cases heart rate was monitored, in 23% respiration was monitored, in 23% blood pressure was monitored, in 8% tissue oxygen saturation was monitored, and in 4% heart rhythm was monitored. Fifty-nine percent of the practitioners performed basic life support as a part of resuscitative efforts, 21% performed some measure of advanced cardiac life support, and in 45% of the cases narcotic reversal was attempted.(ABSTRACT TRUNCATED AT 250 WORDS)
The case of a healthy five-year-old, thirty-six pound female patient scheduled for multiple extractions is reported. The child received a total dose of 270 mg of mepivacaine, instead of the correct dose of 72 mg, which resulted in multiple seizures, hospital admission, pneumonia, and death caused by anoxic brain injury secondary to cardiopulmonary arrest following the overdose.
Between October 6, 1986 and September 17, 1987, 11 patients underwent insertion of mandibular dental prostheses by the same oral surgeon. Three patients suffered cardiac arrest during surgery and subsequently died. Two of the patients who died had received general anaesthetics and the other had intravenous sedation given by three different anaesthetists. All three patients arrested suddenly, developing profound cyanosis and electrical mechanical dissociation, underwent prolonged resuscitative efforts, and had marked hypoxaemia and hypercapnia, despite cardiopulmonary resuscitation. Two other patients had signs of injection of air but survived, one suffering cardiac collapse and the other sustaining massive subcutaneous emphysema. Air embolism was produced by inadvertent injection of a mixture of air and water, passing through the hollow dental drill, directly into the mandible to the facial and pterygoid plexus veins and thence to the superior vena cava and right atrium.
Administration of exogenous glucocorticosteroids will cause adrenal suppression lasting for up to 12 months; however, the patient's stress response will return within 14 to 30 days. This difference occurs as a result of the effects of corticotropin-releasing factor on the autonomic nervous system and on visceral systems. A new protocol for glucocorticosteroid replacement therapy is proposed that is based on the patient's ability to respond to dental stress.
Death during dental anesthesia is relatively rare. Review of eight such cases which occurred in our county, including the different anesthetics used, revealed one apparent basic pattern that prevailed...a need for awareness that something might go wrong and recognition of the fact that it was going wrong.
The results of the fourth anesthesia morbidity and mortality survey of the members of the Southern California Society of Oral and Maxillofacial Surgeons is presented. A questionnaire was mailed to 203 active members in February 1988. All responded or were contacted by Society staff and a response obtained. Results were compared with the three previous studies and revealed trends in training, length of time in practice, modes of practice, equipment used, medications used, numbers of anesthetic procedures performed, and specific instances of morbidity and mortality. Over the 20-year period from 1968 through 1987, seven deaths occurred in more than 4,700,000 anesthetics given, a rate of one death in each 673,000 anesthetics administered.
A fatal case of disseminated intravascular coagulation, secondary to a previously undiagnosed prostatic carcinoma, occurred following tooth extraction. The nature of the condition and its variable presentation are discussed, as well as problems in diagnosis and management.
An analysis of 46 out of 48 dental anesthesia deaths occurring in England over a 6 yr period shows that 17 of these occurred in hospital and 29 arose in dental surgery practice. In deaths associated with dental surgery practice, hypoxia was the most common single cause of death, but there was a statistically significant association between death occurring as a result of the circulatory disorder and the recovery phase of the anesthetic, the most common disorder being acute pulmonary edema. Objective evidence that cerebral ischemia was a cause of death was found in only 2 cases. The mechanism of fainting is considered and its interrelation with pulmonary edema is discussed. Experimental evidence is also presented to show that hypoxia can simulate a syncopal attack with a low blood pressure, and a low cardiac output state with severe bradycardia. It is concluded that the prime concern should be to prevent hypoxia, and that the anesthetist should adopt the technique that in his hands offers the best protection against this hazard, rather than adopting a technique which minimizes the hazard of cerebral hypoperfusion at the risk of increasing the hazard of hypoxia.