Daniel A Haas’s research while affiliated with University of Toronto and other places

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Publications (66)


Mortality and Morbidity in Office-Based General Anesthesia for Dentistry in Ontario
  • Article

September 2019

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91 Reads

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11 Citations

Anesthesia Progress

Alia El-Mowafy

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Hussein Haji

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[...]

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Daniel A. Haas

Our objective was to estimate the prevalence of mortality and serious morbidity for office-based deep sedation and general anesthesia (DS/GA) for dentistry in Ontario from 1996 to 2015. Data were collected retrospectively in 2 phases. Phase I involved the review of incidents, and phase II involved a survey of DS/GA providers. In phase I, cases involving serious injury or death for dentistry under DS/GA, sourced from the Office of the Chief Coroner of Ontario and from the Royal College of Dental Surgeons of Ontario (RCDSO), were reviewed. Phase II involved a survey of all RCDSO-registered providers of DS/GA in which they were asked to estimate the number of DS/GAs administered in 2015 and the number of years in practice since 1996. Clinician data were pooled to establish an overall number of DS/GAs administered in dental offices in Ontario from 1996 to 2015. Prevalence was calculated using phase I (numerator) and phase II (denominator) findings. The estimated prevalence of mortality in the 20-year period from 1996 to 2015 was 3 deaths in 3,742,068 cases, with an adjusted mortality rate of 0.8 deaths per 1 million cases. The estimated prevalence of serious morbidity was 1 injury in 3,742,068 cases, which adjusts to a serious morbidity rate of 0.25 per 1 million cases. The mortality rate found in this study was slightly lower than those published by earlier studies conducted in Ontario. The risk of serious morbidity was found to be low and similar to other studies investigating morbidity in office-based dental anesthesia.


Pharmacotherapy in Temporomandibular Disorders: A Review

July 2017

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408 Reads

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129 Citations

Journal (Canadian Dental Association)

Temporomandibular disorder (TMD) is a collective term that includes disorders of the temporomandibular joint (TMJ) and of the masticatory muscles and their associated structures. TMDs are characterized by pain, joint sounds and restricted mandibular movement, and drugs are widely used in the management of that pain. Pharmacological agents commonly used for the treatment of TMDs include non-steroidal anti-inflammatory drugs (NSAIDs), opioids, corticosteroids, muscle relaxants, antidepressants, anticonvulsants and benzodiazepines. In this paper, we discuss these agents and the potential adverse drug reactions and interactions associated with their use. Temporomandibular disorder (TMD) is a collective term used for a number of clinical problems that involve the masticatory muscle complex, the temporomandibular joint (TMJ) and associated structures. TMD is one of the most common disorders in the maxillofacial region. Signs and symptoms of TMD may include pain, impaired jaw function, malocclusion, deviation from the midline on opening or closing the jaw, limited range of motion, joint noises and locking.1 Among other signs and symptoms, headaches and sleep disturbances can appear concomitantly.2 This disorder is most prevalent in people aged 20-40 years.3 Approximately 33% of the population have at least 1 TMD symptom, and 3.6-7.0% of the population have TMD with sufficient severity to seek treatment.3 There is some evidence to suggest that anxiety, stress and other emotional disturbances exacerbate TMD.4 As many as 75% of patients with TMD have a significant psychological abnormality.5 Most TMD symptoms resolve over time, but, for a significant number of patients, this may take a year or more.3 Treatment is directed toward reducing pain and improving function. Many non-invasive therapies, such as self-care, physical therapy and appliance therapy, are commonly used for the treatment of TMD.3 Pharmacological intervention has been used for many years, and the most effective pharmacological agents for the treatment of TMD include analgesics, non-steroidal anti-inflammatory drugs (NSAIDs), opioids, corticosteroids, anxiolytics, muscle relaxants, antidepressants, anticonvulsants and benzodiazepines. However, we found only 1 relevant Cochrane study, which included 11 randomized controlled trials of pharmacotherapy for TMD.6 In this article, we review the pharmacology and research supporting the use of a host of pharmacologic agents that have been prescribed for patients who have TMD. The decision to select any of these agents depends on a full understanding of the drug's risks and benefits.


Ontario Dentists' Estimation of Patient Interest in Anesthesia

January 2017

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41 Reads

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2 Citations

Journal (Canadian Dental Association)

Objective: To investigate Ontario dentists’ perceptions of patient interest in sedation and general anesthesia (GA) during treatment and patient fear and avoidance of dental treatment. Methods: Using the Royal College of Dental Surgeons of Ontario roster, we randomly selected 3001 practising Ontario dentists, from among those who listed an email address, to complete a 16-question survey by mail or online. Demographic information (e.g., gender, size and type of primary practice, and years of experience) was collected as well as dentist reports of patient interest in sedation/GA and level of fear regarding treatment. Analysis included sample t-tests to compare Ontario dentist responses with patient responses to a 2002 national survey. Results: 1076 dentists participated (37.9% response rate), comprised of 69.7% males, 84.4% general practitioners, 0.5–42 years of practice (mean 20.6 years), and 40.6% from cities with a population larger than 500,000. Dentists underestimated patients’ interest in sedation/GA, with dentists and patients reporting patients “Not interested” as 66.8% and 43.9%, respectively, and “Interested depending on cost,” 19.8% v. 42.3%. Dentists also underestimated patient interest in sedation/GA for specific dental procedures including scaling, fillings/crowns, root canal therapy and periodontal surgery (p < 0.01). Dentists overestimated patient fear levels (“Somewhat afraid,” 19.9% v. 9.8%; “Very afraid,” 10.6% v. 2.0%; “Terrified,” 6.0% v. 3.5%) and the proportion of patients avoiding dental care (13.3% v. 7.6%). Conclusion: Dentists underestimate patients’ preference for sedation/GA and overestimate their fear and avoidance of dental care. The significant disparities between the views of dentists and patients may affect the availability and provision of sedation and general anesthesia in Ontario dental practices.


Drug therapy during pregnancy: Implications for dental practice

April 2016

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329 Reads

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30 Citations

British dental journal official journal of the British Dental Association: BDJ online

Pregnancy is accompanied by various physiological and physical changes, including those found in the cardiovascular, respiratory, gastrointestinal, renal and haematological systems. These alterations in the pregnant patient may potentially affect drug pharmacokinetics. Also, pharmacotherapy presents a unique matter due to the potential teratogenic effects of certain drugs. Although medications prescribed by dentists are generally safe during pregnancy, some modifications may be needed. In this article we will discuss the changes in the physiology during pregnancy and its impact on drug therapy. Specific emphasis will be given to the drugs commonly given by dentists, namely, local anaesthetics, analgesics, antibiotics and sedatives.


Postoperative Pain in Children After Dentistry Under General Anesthesia

December 2015

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46 Reads

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19 Citations

Anesthesia Progress

The objective of this study was to determine the prevalence, severity, and duration of postoperative pain in children undergoing general anesthesia for dentistry. This prospective cross-sectional study included 33 American Society of Anesthesiology (ASA) Class I and II children 4-6 years old requiring multiple dental procedures, including at least 1 extraction, and/or pulpectomy, and/or pulpotomy of the primary dentition. Exclusion criteria were children who were developmentally delayed, cognitively impaired, born prematurely, taking psychotropic medications, or recorded baseline pain or analgesic use. The primary outcome of pain was measured by parents using the validated Faces Pain Scale-Revised (FPS-R) and Parents' Postoperative Pain Measure (PPPM) during the first 72 hours at home. The results showed that moderate-to-severe postoperative pain, defined as FPS-R ≥ 6, was reported in 48.5% of children. The prevalence of moderate-to-severe pain was 29.0% by FPS-R and 40.0% by PPPM at 2 hours after discharge. Pain subsided over 3 days. Postoperative pain scores increased significantly from baseline (P < .001, Wilcoxon matched pairs signed rank test). Moderately good correlation between the 2 pain measures existed 2 and 12 hours from discharge (Spearman rhos correlation coefficients of 0.604 and 0.603, P < .005). In conclusion, children do experience moderate-to-severe pain postoperatively. Although parents successfully used pain scales, they infrequently administered analgesics.


Pharmacotherapy for the Elderly Dental Patient

September 2015

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211 Reads

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25 Citations

Journal (Canadian Dental Association)

Current demographic data clearly show that the North American population is aging, and projections suggest that the percentage of older people will increase. The elderly often suffer from multiple chronic conditions that affect their quality of life, use of health services, morbidity and mortality. Also, in those of advanced age, the pharmacokinetics and pharmacodynamics of many drugs are altered. Polypharmacy increases the incidence of adverse drug reactions and drug interactions in this population. Thus, the dentist must be continually aware of the pharmacologic status of each patient and consider the likelihood of interactions between drugs prescribed by the dentist, drugs prescribed by the physician and drugs that are self-administered, including over-the-counter medications and natural supplements. In this article, we discuss pharmacokinetic and pharmacodynamic changes in the elderly patient, polypharmacy and the changes in prescribing for our dental patients. Specific emphasis is placed on the drugs commonly prescribed by dentists: local anesthetics, analgesics and antibiotics.


Evaluation of an Online Dental Module Based on Design Research

June 2014

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41 Reads

Objectives: Design Research is a formative approach to test and refine educational designs. It is based on the concept of progressive refinement; instructional designs are constantly revised based on experience, until robust versions are developed. Design research approaches go beyond measures of learning/outcomes. They also include process measures to observe how the elements of a design function. Design research methodology was used to inform refinements in a screen-based dental anesthesia program. The program includes instructional videos of local anesthesia techniques, an interactive module on mandibular anatomy, and a virtual patient practice module. Feedback includes knowledge of results (“correct”/”incorrect”) and transparent reality (layering back anatomical structures to reveal location of injection in underlying muscle, nerves & bones). We measured outcome (accuracy) and process measures (interactions with program, interpretation of feedback). Methods: 20 dental students talked aloud as they interacted with the program. Paired sample t-tests compared accuracy of insertion point, angle and depth on the 1st and the 7th practice case. Video recording captured the students’ use and interpretation of the practice feedback. Results: Insertion point accuracy improved with practice (1st case: 24% vs 7th case: 71%, p<.01). Depth of insertion accuracy did not improve (1st: 86% vs 7th: 95%, p=.16), possibly due to a ceiling effect. Needle angle accuracy did not improve (1st: 48% vs 7th: 48%, p=1.0). The video recordings revealed some challenges in the functionality of the program, as well as further refinements that are required to increase the usefulness of the feedback provided to the students by the program. Conclusion: Design Research, using outcome and process measures, revealed how the program could be refined to target specific aspects of the program that are not conducive to learning.


Postoperative Pain in Children after Dental Rehabilitation under General Anesthesia

March 2014

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38 Reads

Objective: Healthcare providers and parents may downplay pediatric procedural pain. Collective interpretation of previous studies on postoperative pain following pediatric dentistry under general anesthesia (GA) is difficult with the variability in age, demographics and pain assessment tools that have been used. The objective of this study was to determine the prevalence, severity, and duration of postoperative pain in children undergoing GA for comprehensive dentistry. Method: This prospective cross-sectional study included n=33 ASA I or II English-speaking children 4 to 6 years of age undergoing dentistry under GA in an ambulatory surgicenter. Multiple dental procedures were required including at least one extraction, and/or pulpectomy and/or pulpotomy of the primary dentition. Exclusion criteria were children who were developmentally delayed, cognitively impaired, born prematurely, taking psychotropic medications, recorded baseline pain or analgesic use. The primary outcome of pain was measured by parents using validated child self-report Faces Pain Scale-Revised (FPS-R) and Parents’ Postoperative Pain Measure (PPPM) in recovery and then at home, 2, 12, 24, 48, and 72 hours postoperatively. The GA technique avoided use of opioids present post-operatively. Analgesic administration was monitored. Result: The prevalence of moderate-severe pain was 29.0% by FPS-R and 40.0% by PPPM at 2 hours after discharge. Pain subsided over 3 days. Postoperative pain scores increased significantly from baseline (p<0.001, Wilcoxon matched pairs signed rank test). Moderately good correlation between the 2 pain measures existed 2 and 12 hours from discharge as evident by Spearman’s rhos correlation coefficients of 0.604 and 0.603 (p<0.005). Moderate correlation (Spearman’s rhos=0.382, 0.392, p<0.05) occurred at 48- and 72-hour assessments. Ninety-six percent of parents were satisfied with the pain assessment tools. Although parents successfully used validated pain measures at home, they infrequently administered analgesics. Conclusion: Moderate-severe postoperative pain is prevalent in children after dentistry under GA which would justify appropriate management.


Managing Simulated Patient Crises: Relationships Between Stress and Performance

March 2013

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23 Reads

Objectives: Acute stress has been shown to degrade performance. We hypothesized that dental teams with greater subjective and physiologic stress would experience deficits in patient management and teamwork during simulated medical crises. Methods: Each team (N=22) of one general practice dentist and one assistant participated in four different medical emergency scenarios of equal difficulty. Participants completed demographics and a knowledge pre-test. Scenarios were video recorded and independently scored by four trained raters: patient management was assessed by checklists (Ck) previously developed through a Delphi method and a global rating scale (pGRS); teamwork was assessed using the Global Assessment of Obstetric Team Performance modified to the dental context (GATP) and a global rating scale (tGRS). Pre and post-scenario stress was measured by self-reported anxiety (STAI-Y1) and salivary cortisol. Relationships between stress and performance across all for scenarios were evaluated using Pearson correlation (R). Results: All scales demonstrated good inter-rater reliability (ICC Ck=0.85; pGRS=0.76; GATP=0.759; tGRS=0.79). Post-scenario anxiety levels were negatively associated with Ck, pGRS, GATP, and tGRS scores (R=-.16 to -.26, p<.01), indicating that greater anxiety was associated with lower patient management and teamwork performance. Cortisol levels post-scenario were negatively associated with GATP scores (R-.125, p=.049). Clinical experience was negatively correlated with anxiety (r=-.25, p<.01) and cortisol levels (R=-.164, p<.01). Knowledge was negatively associated with cortisol levels post-scenario (R=-.276, p=<.01). Conclusions: Although correlations were overall low, these findings suggest that greater subjective and physiologic stress experienced by dental team members is related to weaker patient management and team performance during simulated medical emergencies. In addition, higher knowledge and clinical experience was associated with lower stress levels post-scenarios. Dental professionals may therefore benefit from didactic and simulated experiences in patient crises to reduce stress and enhance performance during medical emergencies.


Ontario Dentists’ Views and Practice of Sedation and General Anesthesia

March 2013

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30 Reads

Data support patients’ demand for sedation during dental treatment; however, little is known about the availability and provision of sedation and general anesthesia (GA) by dentists. Objectives: (1) to investigate the perceptions Ontario dentists have towards the use of sedation and GA for patients; (2) to investigate specific patterns of sedation and GA use in Ontario dental practices; and (3) to compare dentist and patient responses (obtained from a previous study) regarding patient preference for sedation/GA and if dentists are able to identify fear. Method: From the provincial regulatory body’s databases, 3001 practicing dentists were invited to complete a self-administered questionnaire. A mixed mode format offered mailed and web survey options. Data analysis included descriptive statistics, means, standard deviation, and frequency. The relationship between dentist responses and demographic variables was assessed with mixed ANOVA followed by independent samples t-tests or one-way ANOVAs. Result: Study participants (n=1076; 37.9% response rate) were 69.7% male, 83.0% general practitioners, practicing 0.5-42 years (mean 20.6 years), with 40.6% from cities >500,000. 60.2% of respondents provided sedation. Dentists estimated patients’ disinterest in sedation/GA adjuncts to be higher (66.8%) than patient stated preference (43.9%). Patients’ preference for sedation/GA by service was also underestimated for specific procedures (p<0.001) except for extractions. Barriers to care were cost (72.2%) for providers; lack of training (38.2%) and patient demand (25.3%) for non-providers. From the specified dental procedures, dentists reported use of sedation highest for extractions with nitrous oxide being most commonly used (5.7% frequency). Dentists’ (D) also overestimated patients’ (P) level of fear, reporting them to be somewhat afraid 19.95% (D) vs. 9.8% (P); very afraid 10.6% (D) vs. 2.0% (P); and terrified 6.0% (D) vs. 3.5% (P). Conclusion: This study confirms differences between dentists’ use and estimation of patient demand for sedation/GA.


Citations (52)


... Según se ha visto, la prevalencia estimada de mortalidad en la etapa de 20 años de 1996 a 2015 fue de 3 muertes en 3 742 068 casos, con una tasa de mortalidad apretada de 0,8 muertes por 1 millón de casos, y la prevalencia calculada de morbilidad severa fue de 1 lesión en 3 742 068 casos, lo que se ajusta a un ritmo de estado grave de 0,25 por 1 millón de situaciones (16) . ...

Reference:

La muerte al brindar la anestesia en odontología-Death when providing anesthesia in dentistry
Mortality and Morbidity in Office-Based General Anesthesia for Dentistry in Ontario
  • Citing Article
  • September 2019

Anesthesia Progress

... Findings suggest that non-COX selective NSAIDs may be effective for TMJ pain but are equivocal with regard to masticatory muscle pain. [22][23][24][25] When effective, the pain intensity is typically reduced by 2-3 points on a scale of 0-10. Topical administration of diclofenac solution (16 mg/ml, 10 drops, four times a day) in a single study of 36 patients with TMJ pain, appeared as effective as orally administered diclofenac for pain relief with fewer reports of epigastric pain. ...

Pharmacotherapy in Temporomandibular Disorders: A Review
  • Citing Article
  • July 2017

Journal (Canadian Dental Association)

... Anxiety in patients can sometimes be reduced by behavioral interventions [4,5], but in some cases, pharmacological treatments will still be required [6]. Two Canadian studies has reported that dentists underestimate patients' preference for sedation [7] and that dentists express several barriers for offering sedation to their patients [8]. ...

Ontario Dentists' Estimation of Patient Interest in Anesthesia
  • Citing Article
  • January 2017

Journal (Canadian Dental Association)

... It is up to the dentist to present the correct pain management for these patients for analgesia [5]. Regarding non-steroidal anti-inflammatory drugs (NSAIDs), more caution is required when prescribing to pregnant women, as they pose a higher risk compared to analgesics, according to the Food and Drug Administration (FDA), especially in the third trimester due to greater risks to fetal health [6]. Concerning opioids, typically used for acute pain, their use must be cautious, in the correct and allowed doses, to avoid possible adverse effects. ...

Drug therapy during pregnancy: Implications for dental practice
  • Citing Article
  • April 2016

British dental journal official journal of the British Dental Association: BDJ online

... Frequently used medications include NSAIDs, opioids, corticosteroids, and benzodiazepines (Freesmeyer et NSAIDs and analgesics are effective in alleviating pain in the head, mandibular muscles, face, neck, or shoulders, including referred pain. However, their side effects, such as gastric erosion, ulcers, and gastrointestinal bleeding, are significant, particularly in elderly patients, who are more susceptible to these adverse effects compared to younger individuals (Ouanounou & Haas, 2015). Studies have demonstrated that oral pharmacotherapy alone cannot cure TMJOA, and its efficacy is inferior to physical therapy and minimally invasive injection treatments. ...

Pharmacotherapy for the Elderly Dental Patient
  • Citing Article
  • September 2015

Journal (Canadian Dental Association)

... Despite growing evidence on pain management challenges in pediatric and adolescent dental patients (Mathias et al. 2020;Martens et al. 2018;Nisii et al. 2022), there is limited literature addressing pain specifically associated with mandibular germectomy in young adolescents. Most research on pain management in adolescent dentistry pertains to contexts such as restorative procedures (Mathias et al. 2020), specific pain management techniques (Dezfouli and Khosravi 2020), and the use of local (Garret-Bernardin et al. 2017) and general anesthesia (McGrath 1994;Wong et al. 2015) for non surgical dental interventions. Among the limited evidence in the literature, Mitchell et al. address pain management after third molar extraction in adolescents, focusing on opioid prescriptions in the United States, where hydrocodone is commonly used despite its contribution to overdose risks (Mitchell et al. 2022;Mutlu et al. 2013). ...

Postoperative Pain in Children After Dentistry Under General Anesthesia
  • Citing Article
  • December 2015

Anesthesia Progress

... The sample size was based on the previous studies that used a similar methodology. 14,15,23 A total of 16 (n = 16) adult volunteers (19-33 years of age, 7 females and 9 males) participated in this study, which was approved by the Research Ethics Committee of São Leopoldo Mandic School of Dentistry. ...

The effect of smoking on the bioavailability of metronidazole in plasma and saliva
  • Citing Article
  • February 2012

The Journal of the American Dental Association