Cleft lip and palate: recommendations for dental anesthetic procedure based on anatomic evidences

Patients with cleft lip and palate usually present dental anomalies of number, shape, structure and position in the cleft area and the general dentist is frequently asked to restore or extract those teeth. Considering that several anatomic variations are expected in teeth adjacent to cleft areas and that knowledge of these variations by general dentists is required for optimal treatment, the objectives of this paper are: 1) to describe changes in the innervation pattern of anterior teeth and soft tissue caused by the presence of a cleft, 2) to describe a local anesthetic procedure in unilateral and bilateral clefts, and 3) to provide recommendations to improve anesthetic procedures in patients with cleft lip and palate. The cases of 2 patients are presented: one with complete unilateral cleft lip and palate, and the other with complete bilateral cleft lip and palate. The patients underwent local anesthesia in the cleft area in order to extract teeth with poor bone support. The modified anesthetic procedure, respecting the altered course of nerves in the cleft maxilla and soft tissue alterations at the cleft site, was accomplished successfully and the tooth extraction was performed with no pain to the patients. General dentists should be aware of the anatomic variations in nerve courses in the cleft area to offer high quality treatment to patients with cleft lip and palate.

Felypressin Increases Blood Pressure During Dental Procedures in Hypertensive Patients

Background: Felypressin has been added to local anesthetic to increase the length of the anesthetic effect and reduce toxicity during dental procedures. However, the effect on blood pressure remains uncertain, and this may be highly relevant in the dental treatment of hypertensive patients. Objective: To investigate the effect of felypressin on blood pressure in hypertensive patients with controlled BP. Methods: 71 subjects with these characteristics and in need of periodontal treatment were studied. After 10 minutes of rest, local anesthesia (prilocaine) was infiltrated with and without addition of felypressin. Then, a deep subgingival scaling was performed. Blood pressure was measured by an automated oscillometric device (DIXTAL DX2010). Ten minutes after the administration of the anesthetic, peak anesthetic action was recorded. The State-Trait Anxiety Inventory (STAI) was used to assess the patients' trait anxiety. Results: Systolic blood pressure increased after anesthesia, regardless of association with felypressin, throughout the dental procedure (p<0.05) and this response can be explained, at least in part, by the trait anxiety levels of the subjects. However, a further increase in diastolic blood pressure was observed when prilocaine was associated with felypressin (p<0.05), but this response did not change with trait anxiety levels. Conclusion: Felypressin increased the diastolic blood pressure of hypertensive patients with controlled blood pressure. Patients with high trait anxiety presented increases in systolic blood pressure upon some procedures, suggesting that an increase in blood pressure might also be related to fear or anxiety. (Arq Bras Cardiol 2012;99(2):724-731)

Percutaneous sciatic nerve block with tramadol induces analgesia and motor blockade in two animal pain models

Local anesthetic efficacy of tramadol has been reported following intradermal application. Our aim was to investigate the effect of perineural tramadol as the sole analgesic in two pain models. Male Wistar rats (280-380 g; N = 5/group) were used in these experiments. A neurostimulation-guided sciatic nerve block was performed and 2% lidocaine or tramadol (1.25 and 5 mg) was perineurally injected in two different animal pain models. In the flinching behavior test, the number of flinches was evaluated and in the plantar incision model, mechanical and heat thresholds were measured. Motor effects of lidocaine and tramadol were quantified and a motor block score elaborated. Tramadol, 1.25 mg, completely blocked the first and reduced the second phase of the flinching behavior test. In the plantar incision model, tramadol (1.25 mg) increased both paw withdrawal latency in response to radiant heat (8.3 +/- 1.1, 12.7 +/- 1.8, 8.4 +/- 0.8, and 11.1 +/- 3.3 s) and mechanical threshold in response to von Frey filaments (459 +/- 82.8, 447.5 +/- 91.7, 320.1 +/- 120, 126.43 +/- 92.8 mN) at 5, 15, 30, and 60 min, respectively. Sham block or contralateral sciatic nerve block did not differ from perineural saline injection throughout the study in either model. The effect of tramadol was not antagonized by intraperitoneal naloxone. High dose tramadol (5 mg) blocked motor function as well as 2% lidocaine. In conclusion, tramadol blocks nociception and motor function in vivo similar to local anesthetics.

Are antibiotics necessary after lower third molar removal?

Objective. Patients (n = 110) free of antibiotics, operated on by 3 surgeons ranging in clinical experiences, were evaluated for infection. Study Design. In the preoperative period and during the second and seventh postoperative days, the following parameters were analyzed: pain, infection, swelling, trismus, body temperature, C-reactive protein levels (CRP), and salivary neutrophil counts (SNC). During surgery, the following parameters were analyzed: systolic, diastolic, and mean arterial pressure; oximetry; heart rate; anesthesia quality; local anesthetic amount; bleeding; surgery difficulty; and surgery duration. Results. There were some differences in the surgery duration, local anesthetic amount, anesthesia quality, bleeding, pain experienced, trismus, CRP, and SNC, and no changes in hemodynamic parameters, rescue analgesic medication, wound healing, swelling, body temperature, confirmed case of dry socket, or any other type of local infection. Particularly, no systemic infections were found after lower third molar removal (LTMR). Conclusions. This study suggests that antibiotic prescriptions are unnecessary after LTMR when preoperative infections are absent. (Oral Surg Oral Med Oral Pathol Oral Radiol 2012;114(suppl 5):S199-S208)

Influence of the dopaminergic system, CREB, and transcription factor-κB on cocaine neurotoxicity

Cocaine is a widely used drug and its abuse is associated with physical, psychiatric and social problems. Abnormalities in newborns have been demonstrated to be due to the toxic effects of cocaine during fetal development. The mechanism by which cocaine causes neurological damage is complex and involves interactions of the drug with several neurotransmitter systems, such as the increase of extracellular levels of dopamine and free radicals, and modulation of transcription factors. The aim of this review was to evaluate the importance of the dopaminergic system and the participation of inflammatory signaling in cocaine neurotoxicity. Our study showed that cocaine activates the transcription factors NF-κB and CREB, which regulate genes involved in cellular death. GBR 12909 (an inhibitor of dopamine reuptake), lidocaine (a local anesthetic), and dopamine did not activate NF-κB in the same way as cocaine. However, the attenuation of NF-κB activity after the pretreatment of the cells with SCH 23390, a D1 receptor antagonist, suggests that the activation of NF-κB by cocaine is, at least partially, due to activation of D1 receptors. NF-κB seems to have a protective role in these cells because its inhibition increased cellular death caused by cocaine. The increase in BDNF (brain-derived neurotrophic factor) mRNA can also be related to the protective role of both CREB and NF-κB transcription factors. An understanding of the mechanisms by which cocaine induces cell death in the brain will contribute to the development of new therapies for drug abusers, which can help to slow down the progress of degenerative processes.

Body temperature, Aldrete-Kroulik index, and patient discharge from the Post-Anesthetic Recovery Unit

Patient discharge from post-anesthetic recovery (PAR) depends, among other factors, on normothermia and the patient's score on the Aldrete-Kroulik index. The objective of this study was to verify the relationship between the Aldrete-Kroulik index and body temperature in patients. This study was performed at the University of Sao Paulo University Hospital. Convenience sampling was used, and the sample consisted of 60 patients of ages between 18 and 60 years who underwent general anesthesia. The patients' body temperature was obtained by tympanic measurement, and the Aldrete-Kroulik index was measured on admission and at discharge from post-anesthetic recovery. The data were processed using SPSS, considering a significance level of 5%, and the Spearman and Wilcoxon tests were applied. In conclusion, no significant correlation was found between the two parameters for discharge.

Chronic Pain after Cesarean Section. Influence of Anesthetic/Surgical Technique and Postoperative Analgesia

Cancado TO, Omais M, Ashmawi HA, Torres MLA - Chronic Pain after Cesarean Section. Influence of Anesthetic/Surgical Technique and Postoperative Analgesia. Background and objectives: Brazil ranks second among countries with the highest rates of cesarean section in the world. Little is known about the future consequences of this procedure on maternal health. This study investigated the influence of anesthetic/surgical technique and postoperative analgesia on the onset of chronic pain after three months of cesarean section. Method: This is a prospective randomized study of 443 patients undergoing cesarean section (elective and emergency), with different doses of hyperbaric bupivacaine 0.5% and opioids in spinal anesthesia. Patients were alocated into five groups as follow: G1 received hyperbaric bupivacaine (8 mg), sufentanil (2.5 mu g), and morphine (100 mu g); G2 received hyperbaric bupivacaine (10 mg), sufentanil (2.5 mu g), and morphine (100 mu g); G3 received hyperbaric bupivacaine (12.5 mg) and morphine (100 mu g); G4 received hyperbaric bupivacaine (15 mg) and morphine (100 mu g); G5 received hyperbaric bupivacaine (12.5 mg) and morphine (100 mu g), without perioperative anti-inflammatory. Pain at rest and in movement were evaluated in the immediate postoperative period. Phone contact was made after three months of surgery for identification of patients with chronic pain. Results: The incidence of chronic pain in the groups was G1 = 20%; G2 = 13%; G3 = 7.1%; G4 = 2.2%, and G5 = 20.3%. Patients who reported higher pain scores in the postoperative period had a higher incidence of chronic pain (p < 0.05). Conclusion: The incidence of chronic pain decreases with higher doses of local anesthetics and use of anti-inflammatory drugs. The higher pain scores in the postoperative period were associated with chronic pain development after three months of cesarean section.