All I want for Xmas is my two front teeth
article written by anesthet.
There is a latent artist deep within each dentist. A quote from some unknown author. One of those many quotes often heard at a spring garden party after the hectic final exam where there is a thick layer of nihilism in every glass of wine. One wonders whether such a strange marriage resulted from the “shock and awe” of having used the Crane pick elevator for the first time on a set of stubborn wisdom teeth or whether it was due to the inner peace after having finally carved the perfect anatomy, into a composite; one never know where the artist is lurking. However what we do know is that dentistry is in transition which says there is a lot more to come.
Whitening has turned into a billion dollar market in less than five years and its popularity crosses both sexes. It’s that feeling one has when one is showing off the “bells and whistles” of their new car. It is fashionable, they feel and look great, so why not show off that bright, celebrity smile.
Bonding more commonly known as tooth-colored fillings can alter the shape or close spaces between teeth.
Porcelain veneer is probably the talk of the young and restless. This thin coat of enamel-like porcelain bonded directly to the surface of front teeth. The finished product can dramatically change the shape, size, color and position of one’s teeth.
Crowns somewhat less pricy, also referred to as caps are an alternative to veneers when a tooth’s structure is missing.
Implants are now on the continuing education budget of most dentists as they develop the skill of replacing missing teeth but without having to reduce adjacent teeth.
This gives you an overview of how the practice of dentistry has transitioned from the days of drill and fill to highly clinically skilled surgeons who practice on the one part of our anatomy that is firstly seen by our family and friends.
However these standards do not come cheaply. Which reminds me of the lyrics attributed to George Wiedner…“when an irresistible force meets an immoveable object”, in dentistry this is called “burn out”. This leads me into my segue. By far, the subject of anesthesiology attracts the largest audience of readers to websites and blogs on a world wide basis. Pain is still by a long shot (no pun intended) the main concern associated with any visit to a dental office. In spite of every aspect of the new décor and facilities that have been intentionally designed to reflect a much more relaxed, serene and contemporary environment, the nemesis of fear still ligers.
Dentists (GP’s) are rushed to maintain the high standards associated with the main revenue generators of their practices while staying as close as possible to their schedule.It is just not humanly possible to maintain all areas. Ironically it is the delivery of the local anesthetics that pays the price. I will credit my lay readers with the following terminologies because their comments make for interesting conversation at cocktail parties. Let me be the first to admit that my brother also practices dentistry and I would not in any way be discourteous to these dedicated and skilled clinicians. I hope my observations will be taken it in the way it was intended.
However I am hearing terms like haematoma, swelling of the venous plexus, trismus, necrosis, facial paralysis, and even more recently terms like unexplained paresthesia occurring after a non invasive procedure. Questions and blogs relating to local anesthesia, out number other problems in dentistry by as least three to one.
Ironically it remains the main reason why most people do not look forward to a visit with the dentist. According to Malamed’s Handbook on Local anesthesia, the rate of delivery should be at 1ml per minute. In other words the injection should take about 1.5 minutes to be properly given. The latest survey of dentists across North America is between 19 and 25 seconds and mostly as a bolus. My notes on Pharmacodynamics would seem to lend credibility to George Wiedner’s lyrics where “an irresistible force meets an immoveable object”. The end result is a clash between the pH of the tissue (7.4) and the pH of the local at (3.5) mostly delivered as a bolus after bone has been touched. Most of the RN base molecules are destroyed extracellularly (outside of the myelin sheath) resulting in too few base molecules crossing the sheath to effect or block sodium transport.
The situation is compounded when there is an extra layer of fatty tissue around the sheath or a build up of lactic acid as in the case of bruxism or grinders. Getting back to the classic reasons for local anesthesia failure, the thiophene is dynamic to the benzene molecule which superceded it by some thirty five years in Canada. It is just one of these developments whereby a forward thinking company decided to invest some venture capital; I am the first to admit that pharmaceutical companies have not come up with much since 1947 when Lidocaine was introduced. Some academics strongly feel that the addition of the more lipophilic molecule, the thiophene, may slightly increase the aromatic moity due to its spherical shape. It has been observed Malamed 3rd Ed that the anesthesia produced by a standard dose of any local anesthesia will vary to a great extent between different persons…(more to follow on these five classic reason for failure.) The duration of action may vary between a few minuits to up to an hour. Thinking “within the box’, here are the five basic reasons for failure:
· Anatomical variations such as a wide flaring Mandible (possible genetic) · Accessory innervations ( Anatomical-possible genetic) · Technical errors of administration – intravascular injections · Highly anxious patients. (psychogenic) · Stale dated anesthetics solution. (Supply chain – dealers etc)From anecdotal reports, it would appears that once the classic litmus test has been performed and failure to achieve the expected quality of anesthesia is still less than adequate to the patient or you, the onus is then shifted to other excuses. In my 25 years of investigating complaints, I would be hard pressed to count on the fingers of one hand the numbers of truly defective products which were as a result of the manufacturer). The manufacturing process is so regulated that a total batch of local anesthetics would suffer the same biological analysis and would involve a total recall and subsequent disposal. Both FDA and Canada will not ship fine pharmaceticals (or finished produced) if they have not met North Amreican standards.
To support this check list, it is standard procedure for companies to donate goodwill products to be used by dentists who willingly give of their time, to work long hours in condition that are less than adequate and often not safe. These dentists must be commended. There are numerous files of “thank you” letters and a willingness to revisit to see the fruits of their labor and the beautiful smiles of these young people. There has never been a mention of quality control deficits or any special requests for products not in standard production in the North American market. You may well say “never look a gift horse in the mouth”. These are all North American trained and practicing clinicians who have a strong desire to share their expertise with less fortunate people.
In the pharmaceutical world there is a constant evolution of drugs and their indications. Many of you may not have been around when Metronidazole was first introduced for vaginal infections, back in the sixties. Since then it has been used successfully as an antabuse-like drug for alcoholism. Today it is probably one of the most frequently prescribed compounds by peridontists. Nothing is constant. As Albert Einstein said…E=mc2. The object is to leave you with a solution and possible and update to the age old reasons for anesthetics failure.
Obviously our population is growing and the numbers of patients visiting dentist are on the increase; it therefore stands to reason that untoward incidents will follow. However I do strongly feel that pharmacodynamics needs to factored in. Delivered at the rate of 1ml/ml, if per chance a muscle or artery is slightly nicked the response from the patient would give you ample corrective time measures to avoid a dirty trismus or some other situation that eats into your time and a patient that is not too happy. So the question is whether the saving 50 seconds is worth it?
For any dentist(s) who are willing to take this challenge, (must be timed), I will visit an Eastern location (say NY) without an honararium. I will also demonstrate a didactic on never having to give a traditional nasopalatine injection. Finally, as a bonus I will demonstrate the techniques for bone (pulpal) anesthesia known as Mandibular Infiltration.(Drs. Aaron Dudkiewicz and Stephhane Sshwartz Journal of Canada Dent Association No.1 1987). I am sure any dealer would be be eager to grab an opportunty like this. the total lecture is about 3 hours.
Comments to author. localanesthetics@yahoo.ca WWW.AnestheticsNews.com
M.Sc. PharmD. CCPE Please visit http://www.anestheticsnews.com
WWW.AnestheticsNews.com</a> Haynes Darlington M.Sc. PharmD.
