Local anesthetic news

  While dentistry continues to shed its old image and like the beautiful peony flower of spring which faithfully reminds us that like the tiny chicken pecks an exit through its shell to freedom, we too shall soon be shedding our cashmere coats and boots to behold endless fields of sheer beauty as spring transitions into summer.

Oral sciences, historically strut their new technologies at their largest shows in the spring each year in Cologne, Germany and
Chicago, Illinois. Dentistry is benefiting tremendously from world wide research and innovative minds.

When was the last time while walking the corridors of a dental/medical building have you heard that shrilling or the blasting burr from a dental drill? Most such procedures are now taken care by laser. It took a little while, but for the records it was Einstein’s law of Relativity and his work on the speed of light showed that gravity had the ability to bend light. That was the beginning of the laser beam.

It is probably more likely to hear waterfalls and to sense the aroma of Asian or Tropical fragrances seeping from dental offices as more and more dentists offer through third parties a “day” of indulging oneself in the spa or a total therapeutic massage work out. 

However there are time when it is necessary to administer pharmaceutical agents (drugs) during dental treatment. The first that comes to mind is the placement of a local anesthetic solution to disguise or numb the presence of pain. It is not unusual for patients to have a low threshold and may manifest a mild allergic hypersensitivity to this solution. At other times such reactions can be as a result of too rapid [ injection should take 45 – 60 seconds ] an injection and finally, a tiny bit of the solution may enter into the vascular system during administration which may cause a faint or light headed feeling.

Most anesthetic solutions do contain epinephrine, the main purpose of which, is to reduce bleeding and to constrict or retain the anesthetic solution in place for a longer period. It is more preferable to have a little numbness persisting after the procedure, than to have the patient regain sensitivity before the work is finished. At times during a lengthy procedure the patient may require a second injection.

The purpose of this article is to draw your attention to an the following article published and referenced under JADA (Journal of American Dental Association) which deals with epinephrine-impregnated retraction cords. 

Epinephrine acts as a vasoconstrictor when used in dental procedures; however it can act as a vasodilator if it is introduced intravascularly or systemically absorbed. Caution is advised when relative high concentration of epinephrine is impregnated into retraction cords. Please consult your dentist. 

DENTAL PRODUCT SPOTLIGHT

Gingival retraction Controlling blood, crevicular fluid, water and saliva while taking impressions is critical. Water and saliva can be controlled by air spray. Blood and crevicular fluid can be controlled by retraction cords, hemostatic agents, electrosurgery or rotary gingival curettage.¹ Retraction cords displace gingival tissue mechanically; they also can have a chemical action when impregnated with astringents and vasoconstrictors that cause tissue contraction and hemostasis. Electrosurgery creates a trough around the tooth by removing superficial cell layers from the gingival sulcus’ inner lining through application of an electric current. Rotary gingival curettage removes the sulcular epithelium with a high-speed diamond bur. Azzi and colleagues² studied the effect of retraction cords, electrosurgery and rotary gingival curettage on gingival recession and loss of attachment in dogs. They found that cords had the smallest effect on the gingiva and rotary curettage had the largest effect. Astringents impregnated in retraction cords include aluminum chloride, ferric sulfate, alum (potassium aluminum sulfate) and zinc chloride. Alum and ferric sulfate may be irritating and even corrosive at high concentrations, while increased concentrations of zinc chloride may damage bone and tissue permanently.³ The least irritating cords contain buffered aluminum chloride, which may be left in the sulcus for up to 15 minutes without permanent damage.⁴ Weir and Williams⁵ reported that soaking retraction cords in aluminum chloride solution enhances hemostasis. This led Runyan and colleagues¹ to study whether soaking cords in aluminum chloride solution has any effect on the ability of the cord to absorb moisture. They found that presoaking had no effect on fluid absorption and, therefore, may be a worthwhile adjunct. Gingival retraction cords containing epinephrine effectively control bleeding; however, from 24 to 92 percent of the epinephrine may be absorbed systemically.⁶ Epinephrine-impregnated retraction cord contains 8 percent racemic epinephrine. One study estimated the concentration of epinephrine absorbed systemically to be equivalent to approximately 3.9 cartridges of local anesthetic containing 1:100,000 l-epinephrine.⁷ This estimate is considerably lower than previous estimates because the authors calculated the actual amount of releasable epinephrine in the cord before retraction, which was found to be approximately one-half that of the labeled amount; based their final estimate on the more biologically active l-epinephrine; and found that presoaking in aluminum chloride removed approximately 25 percent of the racemic epinephrine in the cord. There are conflicting reports on whether epinephrine absorbed from retraction cords has any adverse physiological effects.^7–11 The potential epinephrine reactions that can occur following systemic absorption include increased anxiety after cord placement, limb tremor, diaphoresis, headache, florid appearance, tachycardia and elevated blood pressure.⁶ However, there are many variables that make it difficult to predict the physiological effect. These variables include the concentration of epinephrine absorbed from the cord; the length of time the cord is in the sulcus; the condition of the gingival tissue; the presence of crevicular fluid or saliva; individual patient response; and drug interactions with tricyclic antidepressants, nonselective ß-adrenergic antagonists, certain general anesthetics and cocaine.^10,11 Therefore, recommendations have been made to either limit or avoid use of such epinephrine-impregnated retraction cords.^7,10,11comments to author.  mailto:localanesthetics@yahoo.ca    M.Sc. PharmD. CCPE   WWW.Anestheticnews.com

Summer was once again approaching and while unlike the anticipation and eagerness I usually enjoyed each November, as I journeyed to my
Caribbean retreat for my fix of ultra violet rays, yet there was something almost homeopathic and  calming about the aging hammock with a good book and the almost deathly silence of summer by the lake.

On my usual November trip south, the captain would put us through  the “g force” as he challenged the physics of gravity prior to lift-off. I often thought how Albert Einstein could have ever imagined what it would have been like to travel along side the speed of light when my main concern was focused on whether this de-iced 700,000 lbs monster would continue to gain altitude. However as true to form the falling leaves of red and gold faded into white fluffy cumulus which seemed to be void of density as the shining machine sliced through them as effortless as a knife through butter. There you go.  

Life above the 49^th parallel had lasting memories for me. I lived the best of both worlds. Snow shoveling was replaced by an early walk where I summonsed my younger balancing skills at playing hopscotch through the sharp edged seashells being caressed by each gentle wave. In contrast, summer was spent mostly reclining in a hammock which over the years had formed itself like a large latex glove around my girth with each increasing year.  This posture allowed me together with my book of the day to blend in with the sparsely placed pine furniture in the large and opened verandah which surrounded the cottage on three sides. open and almost oblivious to the distant hum of a power boat on the lake.

Winter, albeit relaxing and therapeutic, was in deep contrast to the silence one experienced on most lakes north of the 49^th parallel. The mere experience for most northern tourists to afford a
Caribbean vacation was seen as a right of passage to gave way to any Freudian inhibition which may have not been completely resolved. In addition, there was the cooling and refreshing rum punch mixtures added to the rhythmic sound of the “steel band” made it a powerful prescription of feeling entitled to shed not only one’s pent-up stress, but at times parts of their already skimpy apparel. This resulting atmosphere is what most scholars of psychology refer to as the emerging passive-aggressive behavior. There you go.

In preparation for my summer retreat during the month of June, I was like the proverbial bull in the china store as I maneuvered my mini shopping cart from aisle to aisle through my favorite book store. This store offered an atmosphere not unlike a trade show with rows and rows of draped individual small tables throughout the aisles which seemed to add that much more square footage to advertise and promote authors and new releases. These arcades and display tables were managed independently by their own sales associates, a title by which they preferred to be addressed. There you go. 

It was noticeably busy for a mid week morning in June. I carefully rechecked my BlackBerry organizer which for the most part tagged along with me like a faithful poodle with its unconditional love. From to time it would vibrate or other times it would emit a childlike whine to inform me of some event I had previously entered and may have completely forgotten about it. I lovingly referred to it as my dementia levee which faithfully protected any memory cells from overflowing my aging brain’s levee. A tap or two on  the sensitive touch screen revealed  nothing exceptional or urgent other than a memo to remind me to make a date to see the movie “Sex and the City” With Sarah Jessica Parker, Kim Cattrall. There you go. 

Why then was this excessive marketing atmosphere so evident throughout the store? Did the book industry secretly generate a Tiger Woods’ moment of mass marketing?  This certainly would have been the best kept secret, yet the solution was facing me right between the eyes. Historically, increased activity at book stores and movie houses has proven to be an accurate and reliable early leading indicator of impending recession as people at large have more free time. Ironically some business benefit from recession in the same way as the demand for steel increases during periods of war. 

Suspense novels are my passion and among others there were two on my short  list – namely “A prisoner of birth” by Jeffrey Archer and “The Pillars of the Earth” by Ken Follet. I also keep in touch and have a burning desire to be current with professional journals and especially editorials which, with some basic writing skills and strategetly placed references can be confused as scientific material. 

Over the many years of reading, I have developed an almost Sherlock Holmes analytical personality for articles. No more so than dentists are impulsively attracted to “the work” on one’s teeth or an architect inspecting the symmetry of a well placed keystone. These editorials/articles can often be detected by the format of their presentation, which is usually in the form of a question rather than the more accepted form of peer reviewed scientific study complete with investigating phenomena or purpose, an accepted methodology protocol and a conclusion. The pure sciences are becoming more and more diluted as such editorials begin their long “hear-say” or gossip walk through the hallowed corridors of famed teaching institutions.  Such articles presented under the guise of scientific material are for the most part self serving and do little to advance clinical efficacy with less unforeseen mishaps.  

However, there are the pundits of an evolving world where analytic jurisprudence is popular and where asking questions like, “What is law?” “What are the criteria for legal validity?” or “What is the relationship between law and morality?” and other such questions that legal philosophers may engage. (Wiki). 

An article this summer caught my attention under the heading of ethics and jurisprudence.  Here goes that question format - “Informed consent for Local Anesthesia - is it necessary?” There is implied dictum which takes the blame away from the operator and places it on a compound (amides) which dentists have been using successfully since 1947 to induce local anesthesia. If ever there was a case for longitudinal and sample size data, our stats people would have a heyday.   

Life styles through all aspects has changed and dental offices were no exception. I was as attentive to my oral health as I was to my physical health and over the  years I had noticed gradual subtle changes such as more pre clinical involvement with hygienists but perception is reality. I also noticed the office in greater detail. The Italian leather couches, slate tile floors and backlit etched glass in the patient lounge, exuded a definite warmth and elegant atmosphere. My dentist was considered to be one of the best, hence the ambience to go with her status. 

From the patient lounge I  was taken into a room with soft music and current magazines like Ophra, Vogue, Sports Illustrated, which all appeared to have been delivered that very morning. The dentist greeted me and after some small talk, asked me to place a tiny pill under my tongue which she explained would dissolve in a few minutes. Her assistant returned in about half an hour and led me into the operatory. By this time I was feeling very relaxed and comfortable.The local anesthetic solution was delivered through a computer-like electric tooth brush (minus the brush tip) and I felt absolutely nothing…no stick, not anything. I felt very relaxed throughout the procedure.  

This is where, in my humble opinion, and together with my graduate degree in pharmacy, may leave room for a clinical study to determine the use of oral or even intravenous sedation in general dentistry. The question is whether to circumvent the pain associated with what some dentists refer to as “pumping”. Is there need for added pharmacological interventions ( use of muscle relaxants) when a slower delivery ( 60 seconds) would have proven just as effective and with reduced cost to the office?  The term “ Infants practicing on mom’s high heels’ is probably not inappropriate here.  

To suggest a case for advocating informed consent for the use of local anesthetics after 60 years of successful clinical use in dentistry appears less substantive phenomena to identify such rare sequellae such as temporary amaurosis, paresthesia and even death which would seem to be classified as operator error rather than of a biochemical origin.  All clinical evidence would seem to beg the question. “Does this track record reasonably qualify to put local anesthetics (amides) under curfew or to “throw them under the bus?”

There is without doubt in general dentistry, a need to address the needle phobic patient, however a sudden move to give patients a “high” may increase patient traffic  prone to chemical addictiveness as the word get around, but with consequences not every dentist is willing to spend time, effort, legal and peer review in their selective associations. 

Anesthetics and aesthetics — they even sound as though they work together. Informed consent seems rather like infants practicing on mom’s high heels.  However for general dentistry with limited experience of these  powerful opioid analgesic with a potency approximately 81 times that of morphine (wiki) may increase the traffic you may live to regret.

Comments to author.  mailto:localanesthetics@yahoo.ca    M.Sc. PharmD. CCPE   WWW.Anestheticnews.com

Steven lost his taste for The Big Mac after a visit to his dentist. Dentist unable to explain: Could this be Dr. Watson’s first case of unexplained paresthesia? I was entering my sophomore year of engineering. This transition year would be taking me from broad-based general education to a more highly-focused mechanical engineering course through advanced studies in mathematics, science and systems. By all measurements, I was well positioned with my peers and my grades were above average. My freshman year was now over and I was literally pacing myself for the complexity of projects which eventually would see my skills put into practice. At this stage in my studies, I was like a sponge in the ocean soaking up all and every lecture I attended. Being pulled and pushed with every movement of the tide around me. No clear route was calculated on my internal GPS; however there was a steady wind which seemed to be pushing me on a definite course. Or so it appeared to me.

It was difficult to conceal my identity; I was from a small Midwestern town and attended a private high school with my siblings where we enjoyed a comfortable life as children of parents who were both professionals. My mother was a restorative hygienist and my dad, Dr. Watson, owned a well established dental practice.

I was now off campus and was fortunate to share a modest third story attic-like apartment with Steven, a student who was also in engineering, one year ahead of me. Our apartment was no more than 500 sq.ft. but comfortable and spotlessly clean, with a clear view across town where one could see the familiar Golden arches and where many a university student caught up on notes, while enjoying the special burger of the day. Steven was no exception. He loved to eat at the MacDonald’s; He was hooked on their Big Mac and ate there at least four or five tines a week. Our apartment consisted of a sitting area, a kitchen, a washroom and one bedroom with two single beds. I was beginning to feel more in charge of my life and free to come and go as I pleased. My room mate was friendly but somewhat quiet and deep within his thoughts, or so it appeared to me.

Our schedules were quite different, and we did not have a lot of time together other than the occasional small talk while having a coffee. We were not big on booze but enjoyed the odd beer. He had a part time job at a small computer repair store and would be home usually by midnight. The tempo and the anonymity of the North East were very fascinating and everyday I could feel maturity seeping into every move I made. I was at ease with myself and happy, especially when I heard from my folks.

Although it was never overtly pushed on me, the atmosphere at home during high school was subtlety an expectation of going on to undergraduate school in the East. I was the oldest of my siblings and now that I can reflect, both my parents were lovingly using me as their flagship.  “If Jim sets the pace, the others will follow”. I was fortunate in that I did not have to work during my semesters away from home. My mother saw to that. There were to be no excuses for failing grades. I lacked for nothing. However in no way was I pretentious. In fact I was often seen and not heard. Deep within me I knew I was popular albeit, shy. I was no “Brad Pitt”, but confident was I, or so it appeared to me.

It was during our second semester of my sophomore year that I started to have some concern about my room mate. He suffered from bruxism, commonly known as grinding of the teeth, typically accompanied by the clenching of the jaw. It is an oral para functional activity which is common in many humans. Bruxism  (Wiki) is caused by the activation of reflex chewing activity; it is not a learned habit. Through osmosis, I had picked up many dental terminologies over the years from both of my parents. This condition (grinding) was not unknown to me; however the situation was causing me restless nights. I talked to my dad during one of our weekly “how are you” conversations and he suggested that Steven should see a local dentist, because of possibly damage to his teeth. It was not difficult to share my concern with Steven, because his girlfriend also thought he should see a dentist.

We (Steven, his girlfriend Veronica and I) had now become much closer. Steven opened up a bit more and at times could be quite comical. I was seeing the other side of him. We started to hang out on a more regular basis. Steven had appreciated my father’s professional advice and did in fact go to see a dentist associated to our engineering faculty. The diagnosis was confirmed. There was some small initial damage which had started to erode the enamel of his molars. The dentist was able to have a guard fitted in Steven’s mouth with which he could sleep comfortably at night. A follow-up appointment was scheduled in a couple of weeks to make sure the protective appliance was fitting comfortably. However the dentist noticed there was an old amalgam filling on his LR bi-cuspid which was overhung and was a floss shredder. The dentist advised Steven it should be replaced with a more modern white filling. Amalgams are for the most part now dated. The trend is to natural color composite fillings. This was good news for Steven because the silver amalgam was a nuisance and unsightly for a youngster. The date was set for the replacement filling and all would be well, or so it appeared to me.

Steven showed up for his 9:00 AM dental appointment which would have given him ample time to get back to class and by noon the anesthetic would have worn off giving him sufficient time to enjoy his big Mac. However things did not go as was planned. Steven still had a numb jaw and although he tried to disregard this persistent strange feeling, it was apparent that he had indeed lost all taste for his favorite Big Mac and fries.  On the third day Steven called his dentist to explain jokingly that he had lost all taste for any food and in particular, his craving for a Big Mac fix. The dentist reassured him that some people react that way to local anesthetics but the numbness and tingling sensation would soon disappear and normal full sensitivity would be back. Steven apprehensively took his word, but after day five, the condition had not improved and Steven was in a panic and wanted another opinion.

Without knowledge of the total situation, my father was privileged only to “hear-say” and cautioned me that it could be a case of paresthesia, which is a potentially serious pitfall for which dentists hope never to encounter during the life of their practice. My dad did not want to be involved for obvious reasons. I was now on the horns of a dilemma. After-all Steven was my trusted friend and room mate.

Unexplained paresthesia:

Steven was now withdrawn and depressed. He had lost weight and his essays were suffering. Veronica accompanied him to the guidance counselor and a decision was made that he should see a neurologist. Paresthesia was in fact the diagnosis. This condition was explained to Steven and the prognosis was good because he had a simply and uncomplicated infiltration of the anesthetic and was not exposed to a full nerve block. There were still unanswered questions. Why would this occur? There was no truma to any neres.

Steven did his research and discovered that around this time a new local anesthetic called Septocaine had been approved by FDA for dental use in the U.S. Unlike most other anesthetic solutions which have a concentration of 2%, this new one was a 4% concentration. In other words, theoretically and pharmacologically speaking, all things being equal, or as the scientists would say, in vitro, one could use half the volume of the 4% solution to achieve what the 2% was capable of. Each one of us can have slight anatomical variations in the oral cavity, hence different responces.

For some unknown reason, dentists are in the habit of referring to volume (cartridges) used rather than by mg/ml. (actual mg given).As it turned out, Steven awoke now in its tenth day, to discover the paresthesia had been miraculously reversed and full sensitivity had returned to his tongue and soft tissue around his lip. No point of mentioning where he headed after he discovered there were no more pins and needles. All therapeutic compounds are accompanied with an index. The lesson to be learnt is that the product monographs included in any medication by FDA and are intended to be read. The term Minimal Effective Dose is alive and well. Following these instructions may avoid expensive and time consuming litigation.

Comments to author.  mailto:localanesthtics@yahoo.ca    M.Sc. PharmD. CCPE   WWW.AnestheticsNews.com

 http://tinyurl.com/2bsqsz

References: Haas DA, Lennon D   J Can Dent Assoc. 1995  

When did this all happen? To my astonishment there were Toto toilets and a spa? This has got to be one of the best kept secrets…WOW!  Times were when your twice a year visits to the dentist were the most nerve shattering and fearful experiences with which one had to endure. Just to look at the red asterisk on my calendar followed by Dr. Watson, automatically drove up my blood pressure.

Recently I developed an acute pain in my lower right jaw and had to get to the dentist in a hurry. Yes! the diagnosis was a seriously infected molar and a root canal, AKA,  an endodontic procedure had to be performed ASAP. I must admit I had not been getting regular check ups, so I had no one to blame but myself. A few painkillers kept me through the night until my appointment the next morning.

When I arrived for my appointment, feeling less pain because of the painkillers, I noticed the office in greater detail. The Italian leather couches, slate tile floors and backlit etched glass in the Patient Lounge, exuded a definite warmth and elegant atmosphere. My endodontist was considered to be one of the best, hence the ambience to go with his status.

I was taken into a room with soft music and current magazines like Ophra, Vogue, Sports Illustrated, all appeared to have been delivered that very morning. I thought to myself, “where have I been”?  The dentist greeted me and after some small talk, asked me to place a tiny pill under my tongue which he explained would dissolve in a few minutes. His assistant returned in about half an hour and led me into the operatory. By this time I was feeling very relaxed and comfortable.

The local anesthetic solution was delivered through a computer-like electric tooth brush (minus the brush tip) and I felt absolutely nothing…no stick, not anything. I felt very relaxed throughout the procedure. When he was finished about one hour later, all I felt was a tiny residue of the anesthetic but was quite awake without any pain.I was escorted back to the ante room and relaxed with a magazine for about 15 minutes.

Here is where the surprise and fun started.This Dental Practice in which every aspect of its facilities had been intentionally designed to reflect a much more relaxed, serene and contemporary environment for the patient and which incorporated both a series of Dental Spa like services as well as Non-Dental Spa Services was extremely well planned. The more traditional Spa services such as massage, manicures, facials and pedicures was performed in a dedicated, private Spa Treatment room separate from the rest of the clinic.

I had written the day off because I knew I would be in no condition to return to work. I was offered a complementary spa-like services which included a wide variety of treatments and services. It was as if I had entered into the 22^nd century. I walked out of that office feeling like a million dollars. This experience has stayed with me ever since.  I have been told that such facilities are quite the trend even in small towns. I have already booked my follow up appointment, this time the asterisk is in Green. Comments to localanesthetics@yahoo.ca 

Author: M.Sc. PharmD. (patient’s story on file).        

Dentists may be currently looking at significant leading indicators without recognizing they are the real Four Pinocchio’s. There is nothing false about them.  Virgil’s epic poem of The Trojan horse may have already entered into the courtyard. However me thinks the shrinking of the world wide GDP, the $8 trillion housing bubble and the lack luster of the China Olympics are permanent impressions. These indicators are the final cast. From here they go directly to disposable income.

Disneyland is the name of the four theme parks around the world. (Anaheim, Paris, Tokyo and Hong Kong. Is there room for more Pinocchio’s?  How about adding the following for good grace?  Al Gore inventing the internet, John Kerry was a sharp shooting Rambo, Bill Clinton drifted around Harlem mixing with black folk, and Barack Obama claims he never heard the Reverend Wright’s racial comments. And to be current, now Hilary claims she was under sniper attack in Bosnia during 1996.      

In the board room of today’s large conglomerates, the term “leading indicators” is probably on the title of each power point slide presentation. This term is as critical as a GPS “never-lost” system offered at any major airport car rental service or to be more precise, the three-stage SM-3 missile capable of a bull’s-eye at 130 miles above the
Pacific Ocean.

Today’s financial tight rope that CEO’s must balance is probably as taxing as “Black Monday” of 1987 which took a 34% free fall over a three week period before the parachute finally opened.

In a democracy we do have the right to free speech so long as one does not cry “fire” in a crowded theatre. However; in the same voice there is no way of predicting with infinite accuracy, whether there will be a domino effect after the recent Bear Stearns and JP Morgan Chase’s shot gun marriage arranged by the Federal Reserve with the expected plunge of the Stock markets worldwide. Unfortunately most of these 14,000 employees will loose their jobs and their dental benefits.

In such uncertain times, dental discretionary income is on the front line. The cruises, the exotic vacations, the summer cottages; even the car replacement, are all put on hold. It is therefore understandable that certain types of personal care will be under a hierarchy list. The tummy- tuck or the botox treatment may have to take second place to a root canal, a broken filling or a painful ache when you are having your morning coffee. And finally, the Whitening, the Bonding, the porcelain veneer, the crowns and implants will unfortunately be excluded until the situation improves.  

There was at least one sanguine voice, that of U.S. President George Bush against the backdrop of a global credit crisis reassuring us that its ( U.S.) biggest consumer economy remained “fundamentally sound”. Does this qualify as a fifth Pinocchio?

A year ago it all seemed within easy reach. The streets around
Tiananmen Square were celebrating the countdown to the Republic’s first ever Olympic Games with choreography and fireworks, the likes of which no other nation could match the harmless beauty of such awe.

As trivial as the opening paragraphs appear to be, there is a serious side and a suggested prescription for the “R” word.

In the recession of 1987, dentists and their suppliers felt the brunt of the lack of disposable income. However the irony of certain cosmetic intervention is that very high end and expensive reconstruction procedures are recession proof simply because there will always be the filthy rich who can afford what they want in spite of a shrinking worldwide GDP.

In order to understand the putative relationships between excellent oral education and a lack there of, is to understand the inverse square law.  As preventative care of both deciduous and permanent teeth increases, there is a corresponding decrease in overall dental imperfections and the need to treat simple caries.

Dentistry has gone through many changes away from “drill ’n fill”. Thanks to fluoride and years of community education and training to the public at large. Practices have moved on to cosmetics and other converging technologies.

This unfortunately is the quid pro quo for general dentistry until the economy turns around. Back In 1987, revenues for general dentistry were less geared to cosmetic procedures. We were in a totally different clinical situation where the emphasis was on acute procedures and treatment. After year 2000 they was a massive swing to cosmetic procedures.    

According to Maslow’s hierchy of needs, we could be at best, one tier down on the familiar pyramid of esteem needs, or at worst, one tier up from biological and physical fulfillment.

The following is my prescription to ride through the “Perfect storm” of the “R” word.  

• Stay liquid (cash).
• Pay with cash or debit Card.
• One credit card with zero balance each statement.
•  Retire 8 cylinder vehicles.
•  Caution in stocks other than bargain blue chip.
•  Lock in low long term mortgages.

Comments to mailto:localanesthetics@yahoo.ca   visit http://www.anestheticsnews.com“    Author: M.Sc. PharmD.

This year, the entire world will look towards Asia with the celebration of the first ever Olympic Games in the People’s Republic of China. The Beijing Games will be a unique opportunity to bring Olympic education and values to the youth of China and the entire Asian continent.Few events in the western world excluding the 2008 elections in the U.S. in recent memory have stirred the kind of emotion that the Olympics in Beijing has; despite the fact that so few people have yet seen parts of the engineering structure of the stadia plans.

The 2008 Summer Olympics will be celebrated from August 8, 2008 to August 24, 2008, with the opening ceremony commencing on 08 August at 8 pm at the Beijing National Stadium in Beijing. Some events will be held in other cities of China. The program for the Beijing 2008 Games is quite similar to that of the Athens Games held in 2004. The 2008 Olympics will see the return of 28 sports, and will hold 302 events, making it the largest to date.

Self-medication has become a popular way of life and it is on the incline, however; during the Olympics it can carry a heavy price. In 1994 Silken Laumann, won the Rotsee Regatta in Switzerland as the only female single at the World Rowing Championships in Indianapolis. Unfortunately she fell victim to an OTC (over the counter) Benadryl to treat a cold.

The Olympics are frequently referred to as “the happy games”. In more than one way this name is a befitting description. At night, it is not unusual for one to readily distinguish the relaxing aroma of marijuana throughout the villages where frat-like atmospheres are dotted like stars in the sky. The muffled lyrics of The Rapping Rhinstone can be heard two hundred meters away. Are these just words?. These apparent innocent gatherings are only a harbinger of the more sinister and foreboding under belly of the Olympics where the powerful compounds are being administered parenterally to quench the thirst of the cries for Higher, faster, stronger.

Niacin, or nicotinic acid commonly referred to as Vitamin βз, is an over the counter (OTC) vitamin supplement. It is a potent vasodilator, which means it dilates blood vessels thereby increasing circulation of plasma volume through the kidneys on its complex circuitous route through the body. It is frequently prescribed, among other indications, to reduce cholesterol by increasing HDL ( the good ones) and lowering LDL (the bad ones).Historically, niacin (βз) usage is associated with a cutaneous (outer skin) “flush”, more readily seen in light skin Caucasians than in dark skin people. It is this term “flushing” which has taken on legs of its own, resulting in ambiguous interpretations in the world of sports. This drug is being highly sought after by youngsters in competitive sports, whereby it is incorrectly classified as a detoxifying agent, which may be used as a firewall against detecting the use of performance enhancing drugs. This is false information and requires some friendly professional words of caution.

While on the subject of self-medication and compounds to boost performance in competitive sports, cyanocobalamin or β12 is also on the high demand list. It is thought to be important in maintaining the nervous system.(U.S Pharmacist.) An insulating fatty sheath of myelin surrounds nerves. β12 plays a vital role in the metabolism of fatty acids essential for the maintenance of myelin. Local anesthetics are capable of penetrating the fatty myelin resulting in a pain free injection of β12. Absorption of β12 requires the secretion from the cells lining of the stomach of a glycoprotein, known as intrinsic factor. Alternatively requiring a parenteral (needle) administration.

The American Society of Health-System Pharmacists discourages using niacin (βз) for the treatment of abnormalities of fat metabolism (breakdown) without physician supervision. To fully understand cholesterol readings by lay people is a complex matter. It is not just a number, but rather a value with its own fingerprint and for clinically significance is best expressed as a ratio between HDL and LDL. The Center for Drug Evaluation and Research maintains this position, stating that drug therapy for dyslipidemia should not be an OTC due to the need for proper diagnosis and management; likewise, pharmacists should discourage patients from self-treating dyslipidemia.

Pharmacists have an important role in the proper and safe use of niacin by educating other health care professionals about differences among products. Pharmacists should also educate patients and discourage the use of OTC niacin if dyslipidemia (elevation of plasma cholesterol – Merck Manual) is present. Furthermore, a prescription for ER niacin should not be substituted with any OTC niacin (βз) because there is not an approved generic equivalent to the prescription-only product. (U.S. Pharmacist). The term “flushing” is associated with increased blood circulation, and has no relationship to cleansing or detoxifying the blood of steroids and human growth hormone.

What must it have been like for Jesse Owens? With the turmoil of racial practices throughout those years in Nazi Germany. Can anyone imagine what he must have experienced? This was the real thing. No camouflage with Stanozolol that was not yet synthesized in 1936.

The ultimate adrenaline rush accompanied by uncontrollable patriotic emotions at being at the center position when the medal was being placed; words will never describe this moment.

Fashion is likened unto a tsunami; and niacin is that powerful engulfing force which like a micro-organism has infected the very tissues of athletes worldwide in their attempt to disguised the use of illicit compounds.

Unfortunately the zeitgeist of today’s competitive sport is so well cloned with the pill and the needle, that its amoeba like fission has engulfed not only the interest of the general public, but also the U.S. Congress to introduce the sporting world to two new influential political action groups: Republicans for Roger Clemens while Democrats sided with Brian McNamee.

The brotherhood of the needle (a phrase dubbed) after the Olympics in Seoul, 1988, is alive and well. Like a snake that has lost part of its tail, basement labs are working overtime to sprout a new one. Trainers and athletes worldwide are like hackers in their attempt to decode the latest spy ware in spite of increasingly sophisticated tests. For the betting man, the summer of 2008 will no doubt also have its place in history where “All the world will have been a stage and all the men and women will have been merely players”, (As you like it – Shakespeare) long after the closing ceremonies are over, the adrenaline has decreased, the lactic acid has dissipated and the tears of joy or disappointment have left their trail on the faces of our youth.

Each country no doubt will have embedded with their team a staff off physicians, dentists physiotherapist and hygienist, which makes good sense in a country where the practices of healing arts maybe dissimilar to ours in the western world and in an atmosphere one can almost predict with certainty the mere pressure of differences in professional training will be the perfect incubator to experience a Macaca Moment.

 “The world will never starve for the want of wonders”. – Gilbert. K. Chesterton (1875 – 1936). As profound as this statement is, it transcends time and culture. Anabolic steroids where not on the radar in Chesterton’s time.

Comments to author. localanesthetics@yahoo.ca  M.Sc. PharmD. CCPE
Please visit WWW.AnestheticsNews.com

Dentistry is in transition and so are life styles. What a sudden move away from drill and fill!  We are into implants, laser technology and whitening for life marketing spins. If ever there was a case for poetic justice, this certainly is it. Aristotle himself a man for change, argued the case for poetry over history because it demonstrates what must or should occur rather than what the pundits forecast.

The man dubbed the father of modern dentistry in the 17 th century Pierre Fauchard would be as uncomfortable in to-day’s dental operatory as a pilot from World War II in the cockpit of the Airbus 380.

Dentists still have to work around the foreboding needle phobia. However, the change of the future looks encouraging with the first FDA approved needle free anesthesia product for scaling and root planing.

This is the story of Frank and his wife Flavia. They were the perfect couple. Flavia was a bit trendier and into the change from the traditional soccer mom, but by no means could one describe her as “the vanilla flavor of the day”. She had the smarts, and a solid head for business, probably groomed by her father who, like many Italians emigrated from Italy to find their fortune in the Western world, the land of opportunity. Frank and Flavia were comfortably set. They were off to a good start after their wedding, with the help of her dad and family, pretty well owned their first home sooner than most of their friends. 

Flavia had been pressuring Frank to get some cosmetic work done on his teeth. The daily espresso coffees and his mother’s blueberry pies were beginning to seriously test the strength of a solid Roman Catholic marriage. Flavia’s desire to pop an impromptu kiss on Frank was starting to wane because of his discolored teeth. She wondered how can “I persuade him to change? To go for a dental check-up”? Her goal for Frank was to have his teeth cosmetically changed to show off the fashionable celebrity white-teeth-smile and nothing was going to stop her desire for hope and change.

The whitening of teeth has become a billion-dollar business and celebrities have had no small part in raising the bar for the perfect smile. Another cosmetic fashion statement which is showing its colors is the art of tattooing one’s body parts. I mentioned this purposely, because a visit to the tattooing studio is far more popular that a visit to the dentist, although, ironically there is a common factor, namely pain. Why is this?  Why is it that people will pay huge sums of after-tax dollars to have a tattoo sculptured in sensitive parts of the anatomy and yet be hesitant to visit the dentist? Maybe vanity is more powerful than oral health! Or maybe the School of Body Art has out-marketed the college of dentistry?  How often have you seen a young woman/man flashing a tattoo, but in need of obvious orthodontic or other dental work?  We have to rely on anecdotal reports in the absence of a truly scientific study.

Back to my friends Frank and Flavia. Researchers have come to the rescue with a product that brings effective needle-free anesthesia for patients during scaling and/or root planing procedures. Oraqix®  fits the perfect scenario for a patient who is needle phobic. This product is the first FDA approved system for the above indications. There are some very desirable properties to Oraqix; apart from a rapid onset of action, the return to sensitivity is within twenty minutes, thereby making it the perfect product for example, a lunchtime appointment. Sensation is restored before leaving the dental office. Uncontrollable chewing of the lip is a common after-effect of residual anesthetics. Oraqix® allows the patient to return to normal activity without the embarrassing drooling.

Hopefully this addition to dental armamentarium will allay the fear of the dreaded needle. Fear of finding other latent problems incurring a cost is an irrational decision. Why should one have two standards for maintaining perfect health?  Oral health is no less important that physical health. The diagnosis of oral cancer is by far more often seen by the dentist than by medical doctors. If for no other reason it makes good sense to keep the oral cavity healthy and free of possible terminal diseases.

Four out of five Americans claim a desire for whiter teeth. Never before have so many options been available. Nu-pro® White gold® is a dentist prescribed take-home system that has been designed to address the patient’s tooth whitening requirements and offers two formulations with dramatic results in one to two weeks. Who are the best candidates for do-it-yourself whiteners? Before you spend a dime on whitening your smile, your dentist will explain what is best for you and the reason why. Teeth should be healthy without cavities or recession of the gums thereby exposing sensitive root structure.  If whitening agents come in contact with an open area on a tooth with a clear path to the nerve center of your tooth, you won’t care what color your teeth are because they will have to peel you off the ceiling.

 You need to have a proper evaluation by your dentist.   A talk to your dentist will determine if you do have tooth discoloration and what is the cause. There are two major ways teeth become discolored. Teeth naturally discolor as we age, and we all have lighter or darker teeth, just as we have different complexions. Everyday habits and food consumption penetrate the tooth’s enamel to cause extrinsic and intrinsic stains: There are as many reasons for tooth discoloration as there are solutions. Over-the-counter whitening doesn’t work if the discoloration comes from an injury to a tooth, for example. Also, if you have teeth that have tooth-colored fillings or crowns that are dark or discolored, again, over-the-counter whiteners do not whiten porcelain or tooth colored filling materials.

Stains can be caused by foods such as coffee, tea, red wine, and nicotine. Rule of thumb, if it stains your carpet, it can stain your teeth.  What kind of results can we expect from an over-the-counter product? Today Over-the-counter whitening products work differently and better than ever before because the technology has changed so dramatically. Will your teeth look as different as if you had full mouth veneers? No. But if you have a pretty smile, that you want whiter and brighter, the newest over-the-counter options are very effective. Here’s a look at some of the latest options.  Most people hate the messy trays you stick in your mouth. What are the alternatives?

Crest White strips, night effects (liquid strip gel). Crest White strips continue to be the OTC gold standard in whitening — and a beauty secret for millions of Americans, (mostly women). When you look in dressing cabinets, you see them right next to the lipsticks. Whiter teeth give women confidence and make them look younger and prettier. A great new whitening product is hitting store shelves now. It’s called Night Effects and it’s very exciting because it works while you sleep. The first generation products made to whiten teeth while we sleep included a tray and stuff oozing out of it. I dare you to sleep with that unit in your mouth and not destroy your bed linen. Bearing in mind that these are all Over-the-counter products. Dental prescribed take-home products are still the most effective. So what has been improved for the OTC shopper?  

Night Effects is great for a couple of reasons: First, it’s good for people whom for whatever reason, cannot whiten during the day. Second, the coating sticks to your teeth. You’ve heard me say that for a product to work, the whitening agent has to stay in contact with the teeth. The problem with some of the other over-the-counter products is that they tend to quickly wash away when they come in contact with saliva, food or drink. Night Effects appears to be the first paint-on product to address this problem. The patent process they use is as follows. Immediately after applying the gel, the product forms a liquid strip coating that stays on your teeth overnight. The liquid strip slowly releases the whitening ingredient into your teeth to remove stains and loosen stain-causing build-up. In the morning, you simply brush the liquid strip coating and stains away.

 Researchers have overcome the overnight challenge by developing a silicon-based gel applied with a brush. Secondly, it is not water soluble like other paint-on products. Because of this new technology, the whitening gel stays on your teeth for hours while you sleep.  Over-the-counter whitening serves a selected market, however for the clinically accepted procedures, it is best to have your dentist involved.

Please click on the prescribing info button to the right of the screen  for information about containdications, warnings, cautions and precautions.

PHA01-0108-1 

Comments to author. mailto:localanesthetics@yahoo.ca M.Sc. PharmD. CCPE WWW.AnestheticsNews.com    

This is my confession. I am a twenty four year old female of average build. I run five kilometers every day and I alpine ski in the winter. I watch what I eat and would consider myself to be in good shape. However; I do have one vice which is the reason for my confession. My dental work has been fairly extensive over the years, but I have an excellent insurance plan. The work was being done on my upper right where there is a bridge. The bridge was failing hence the need for a dental assessment and treatment. On this visit I was given two shots of anesthetic within a half hour. Each shot was expelled in about 15 to 20 seconds. Through the over head monitor I could see the blanching (gum lost the pink color. It was now white). I should add this was not a store top office. This Dental Practice in which every aspect of its facilities had been intentionally designed to reflect a much more relaxed, serene and contemporary environment for the well-off patient was located in a medical building. It was outfitted with the latest toys and computerized gadgets. It was like the cockpit of an Airbus 380. At a guess I would put my dentist to be in his middle forties and to me he looked and conducted himself every bit of a successful and up-to-date dentist.

This is my confession. As a patient, on my dental visits, I want the dentist to be current on all techniques of administering the anesthetic within reason, to make my visit a pain free experience. My choice of words is deliberate because I do not want to be heavily sedated. Drugs may control fear and anxiety, but do not fully control pain. And furthermore it is said they can cause confusion and/or respiratory depression. I am also aware that sedative drugs can stay in your system for two to three days after ingestion.  Neither do I want the application of nitrous “laughing gas” since there appears to be some ambiguity surrounding the duration of how long one should be under this application. Furthermore how can I tell the scavenger system has not exceeded its service date? However having said that, I am aware that all clinicians practice to the best of their ability and are not cavalier and will not knowingly push the envelope which could cause harm to their patients. However we have heard of situations which could have been avoided. Shift does happen.   

This is my confession. After each shot he excused himself while he went to another operatory. He was darting from room to room and between taking telephone calls he was reviewing the work of his hygienist. He was busier than a one armed paper hanger. I felt somewhat neglected like an infant left imprisoned in a crib. Even the assistant left the room. I was lonely. I thought how nice it would be to climb out of the chair and stroll around the room and indulge. As I mentioned I have had above average dental work over and above regular cleaning of tartar during my college days and still do. I knew a sudden rise from the supine position would be more foreboding than the painful shots which I suffered through. Deep within me, I knew some thing had gone a rye more so on this particular appointment. After each shot the pain grew exponentially. My tissue felt expanded and throbbing. I felt the tingling and had no control of my drooling but I was not frozen. Prior to my visit I had searched the internet which said that local anesthetics are used to control regional pain through their ability to block sensitivity by preventing sodium transport across the nerve. They also mentioned that failure to block that action potential was possible either through anatomical reasons or operator errors and skill. Who am I to delve into my oral anatomical variances? I am Caucasian and my mouth does not appear to be different from people of my build. Furthermore on previous occasions I was completely frozen where the procedure was completed successfully and painlessly.

This is my confession. During one period when I was left alone as he darted to another room, my upper right jaw felt just like it was about to explode, I overheard a one sided conversation between my dentist and someone else who I guessed was also a dentist. The letters A.M.S.A. (which) meant nothing to me were as clear as a bell and for some strange reason I paid attention as a sixth sense completely took control of my very being. These letters were scorched into my memory. The constant in and out of the room where I sat and a quick probe, suddenly confirmed that something was not going according to plan. As I said, I could only hear one side of the conversation but the sweat and the look on his face spoke a thousand words. Together with the tightness and throbbing dull pain confirmed he was conferring with a colleague. I distinctly overheard the  letters A.M.S.A…silence…followed by the phrase “a regular syringe.”… Silence…then the word “twice”. Ah! Yes the conversation was about me. There was a problem.

This is my confession. A few moments of silence, then he entered without his assistant and his face said it all. As he sat and with his heels rolled his stool towards me, he reached up and turned on the overhead halogen light while focusing it at me. Not a word was spoken but this automatically prompted me to open my mouth. He probed with his gloved finger and a miniature reflector or mirror for about 5 seconds but which felt like 10 minutes. He lifted his anti splatter orange transparent eye shades and said. “I am going to refer you to a specialist friend of mine”. The bib around my neck was unclipped and he gently assisted me out of the chair. His sincerity was cloned over his face and his shoulders drooped like tender tulips on a hot day. “It will be about a week to ten days, in the mean time I will order a prescription for Ibuprofen 400 mg to be taken twice a day with a meal.” His saddened tone was strict orders that I should call him if the throbbing still persisted.

This is my confession. When I finally got home I instantly took one ibuprofen with a glass of milk because I had no appetite and the interior of my palate was too sore to chew on food anyway. I had some Tylenol and together with the Ibuprofen, I made it through the night. The letters A.M.S.A still hounded me like a puppy following my footsteps. I anxiously wanted to see what Google had to say. Wow…there were sites upon sites that discussed this technical term and there I was before my laptop like a misfit in dental school doing oral anatomy 101. However after half an hour of reading dental clinical studies, I managed to get the acronym for A.M.S.A.  To explain it would achieve nothing since it describes a special type of injection used on the upper jaw. It is apparently one of the most difficult injections to master and one of the articles suggested that it was more effectively done slowly through some sort of computerized delivery system. Why did he not have that gadget? After all, to me his operatories lacked for nothing. The dull pain was still apparent but kept under control by the pills. Could I dare have a peep at it? I was nervous and scared. I took the challenge and what I saw was gross. I immediately called his office and left a message. My call was returned at about 8:32 AM. I explained what I had seen and he calmed me by identifying the condition as palatal necrosis, which meant nothing to me. He continued; “because of the mouth is rich with a strong blood supply, together with the anti inflammatory drugs, healing will be rapid.” My dentist has a calming voice and I felt somewhat more at ease.

Now here is my confession. During my college days I would occasionally have a toke of marijuana with my friends. It is not a big deal and I still have one every now and then especially if I am anxious or apprehensive over some event. I frequently used the internet and Facebook like all young people of my age and social lifestyle. It was during my search I read that marijuana has been shown to increase the activity of liver enzymes. It so happens that local anesthetics are broken down by the liver. Is this why I was not fully frozen? Or was it one of William Shakespeare’s Comedy of Errors being played out for me. What a coincidence!  An A.M.S.A technique which is difficult at the best of times being performed on a patient who did marijuana an hour before my dental appointment!

The contents of this mail was received by this author. I contemplated for quite some time whether I should post it. As I write, the outcome was never revealed to me. There was nothing through which it could be identified. I therefore opted to post it for what it is worth. However as a pharmacist I would qualify this as “a case of one” due to non clinical input and from one side only. However it is interesting to note a few points.

Comments to author. mailto:localanesthetics@yahoo.ca   M.Sc. PharmD. CCPE  

Please visit WWW.AnestheticsNews.com       http://tinyurl.com/2bsqsz

Do you consider yourself as having fear for the dental needle? Or that you do not feel completely frozen? Most situations with which dentists are confronted today are a test of their artistic skills. The frequency with which they use all or some of these, especially  injectable approaches makes a big difference in the comfort level of the patient during and after a dental procedure. There are approximately twelve basic techniques to administer local anesthesia to the upper (maxilla) and about half that for the lower (mandible).  The more frequently each is used, the more proficient one becomes at them all. If one fails it is suggested not to modify it, but rather to move on to one of the other techniques.  

The important explanation is applicable to both patient and dentist.  There are two techniques…the Gow gates and the Akinosi which work with people like you. You should ask for one of them, since they almost never fail. If the dentist is not willing, you maybe advised to seek another opinion. Remember we are living in a world of “moi”. You should not have to undergo unnecessary pain.  Clinical situations in dentistry are to some extent, moving more in line with medical treatment, whereby the clinician is expecting some input and cooperation from the patient so that it becomes a team effort. Gone are the days where clinicians were looked upon as mystical healers. Medical doctors and dentists need that important input from patients because healing is hastened and painless when the patient understands and is actively involved.  

I encourage you to read on. It will be presented in a pleasing manner which gives you a better insight into one’s oral anatomy. The holistic approach today is that patients do better when they are involved with the whole body. This trend has been growing for many years on the medical side; however, that desire to know, has been slow on the oral health side. 

New diagnostic equipment capable of detecting certain forms of oral cancer at specific developments is starting to make a difference with the public at large.    Again it has been women who have picket up the gauntlet and are the ones most likely to ask questions. This may be more out of absolute clinical necessity, rather than by the nature of the beast. As an example women are more prone to develop grinding of the teeth and TMJ problems. 

Bruxism or grinding can be a serious problem.  When we chew our food, we can deliver a force of over 150 pounds per square inch (psi) to our teeth. But when we grind our teeth at night, there’s no food to absorb the impact, so the force on our teeth can be over 300 psi or more. That’s enough to cause permanent damage to your teeth, including cracked and chipped enamel, hairline fractures, and even wearing down of the teeth to the gum line. The enamel may become so worn that dentin inside of the tooth is exposed. If bruxism isn’t treated, it can lead to gum damage, loss of both natural teeth and restorations, and other more complicated jaw-related disorders such as the one I mentioned previously temporo-mandibular joint disorders). Over time, your teeth may become sensitive due to exposed dentin, and your jaws may even move out of proper balance. Grinding your teeth can also cause a wide variety of other symptoms including soreness and fatigue in your jaw and facial muscles, including ear and head aches. The corrective measures for bruxism involves fitted mouth guards and specific training on how to relax those muscles involved. Students attending high school and post secondary schools are very prone due to stress of meeting time lines etc.  Fortunately, these stretching exercising together with the hardware do work. As youngsters develop and life styles change, bruxism does decrease and hopefully disappears.

Whether it is true to say TMJ is seen more frequently in females than males is often questioned. The National Institute of Dental and Craniofacial Research (NIDCR) of the National Institutes of Health (NIH) indicate that over 10 million people in the
United States suffer from TMJ problems at any given time. Both men and women experience TMJ problems; however, 90 percent of those seeking treatment are women in their childbearing years. Recent research indicates that more women seek medical care for a TMJ problem than men, and women are more likely than men to report ongoing pain. Physiological differences in pain signal processing may explain why more women suffer from TMJ conditions than men.

 In baboon studies, estrogen receptors were found in the temporomandibular joints of the female baboons, none were found in the males.Recent research has focused attention on the relationship between sex hormones and pain. A study conducted by Dr. Linda LeResche,
University of
Washington in
Seattle, demonstrated that women on hormone replacement therapy were 77% more likely to seek treatment for jaw pain than those not undergoing such treatment. Also, women on oral contraceptive therapy were 19% more likely to seek treatment. Evidence is emerging in support of a biological explanation for why there are more women suffering from TMJ pain.

It maybe that the diseases which affect the TM Joints are no different, really, than the diseases which affect other joints in the human anatomy. Rheumatoid, and Osteoarthritis; Inflammation of the Joint capsule; inflammation of the Synovial fluid, torn Ligaments, perforation, or tears in the rotator cuff. Internal derangement of the Condyle Head which is the knob-like projection that can be felt when one’s bottom jaw is extended to the fullest. Incidentally that is the approximate area that your dentist may direct the needle for those patients who complain that they are difficult to freeze.

 As a pharmacist I want to focus on the mode of action of drugs. Local anesthetics are drugs and therefore we need to be as equally informed as a dentist about these solutions. We frequently get calls from dentists requesting information on possible incompatibilities and any number of possible problematic patients. While we can not diagnose or treat, we frequently may offer suggestions if called when dealing with pharmacology and especially pharmacodynamics of other combination of drugs being used concurrently. Our training has to be current especially with new drugs (either legal or illicit) entering our communities.  

Dentists have in treat all types of patients with medical disabilities and the tremendous task to accommodate these patients. Think of any normal dental visit. It is not on the same par as an appointment with our masseur therapist.             They see patients with tourettee syndrome, (Tics), grand mal seizures, spastic episodes and Down’s syndrome, just to name a few.  

To precisely place the anesthetic injection for a block requires the skill to avoid depositing the solution in a vessel, artery or a muscle. Any sudden movement could accidentally enter these areas. In my opening comments I mentioned there were well over a dozen techniques available and the more frequently they are used, gives that dentist an added advantage. 

I will reiterate, if one approach fails, then the alternative is not to modify it but rather change to one of the other techniques. There are a number of physiological and pharmacological reasons to change to another approach. The number one consideration is the sensitive pH with which one has to deal. Healthy tissue is at pH 7.4 and the anesthetic is at around 3.5. To deposit more solution will not only cause the tissue to expand and cause swelling, but will further increase acidity. It is not uncommon for some patents to have more branches of nerves than others. They all originate from one large valley. The trick is to get the main one before it branches off into many smaller ones. When you are going after a bee’s nest, you want to smoke out the “queen” then the colony of workers is disabled. 

There are other times when a kid is un-cooperative or has a disability and will not open their mouth wide enough. There is a very cool technique where the dentist can get a block even with clinched teeth.  Yet another technique resulted from the researchers of a European pharmaceutical company. I am especially proud of this drug since I was on a team which was successful in gaining acceptance for this anesthetic to get approval in Canada and the FDA in the
U.S. I have no financial or personal interest in this drug as is generically manufactured anyway. However because of its biochemical structure it can pass through bone, especially with children from the outer vestibule on to the lingual side. The beauty of such an anesthetic is that your dentist can completely freeze a kid without freezing the tongue. Recovery to sensitivity is rapid depending on the volume deposited. The more you give the longer it lasts. However as little as half a cartridge can fully freeze a patient. The article was published in JCDA under the title of Mandibular infiltration by Drs. Dudkiewicz, Schwartz and Laliberte. (Dept. of pedodontics,

McGill
University). 

The techniques of such administration are part of my webinar meetings or full live lecturers.  

Comments are welcomed to author. mailto:localanesthetics@yahoo.ca   M.Sc. PharmD. CCPE  WWW.AnestheticsNews.com

Gloss phobia, more commonly called the fear of public speaking, is thought to be the most common of all phobias. As many as 75 percent of all people are afraid to speak in front of an audience. Without going in to all phobias and their rankings, my observation is that needle phobia in the dental office is by no means abnormal and ranks up there among the highest.Dentists still have to work around needle phobia. However, the future looks encouraging with the first FDA approved needle free anesthesia product for scaling and root planing.

This story is about my friend Sergio and his wife Lina. They were the perfect couple. Lina was a bit trendier, but by no means could one describe her as “the flavor of the day”. She had the smarts, and a solid head for business, probably groomed by her father who, like many Italians emigrated from Italy to find their fortune in the Western world, the land of opportunity. Sergio and Lina were comfortably set. They were off to a good start after their wedding, with the help of her dad and family, pretty well owned their first home sooner than most of their friends. 

Lina had been pressuring Sergio to get some cosmetic work done on his teeth. The daily espresso coffees and his mother’s blueberry pies were beginning to test the strength of a solid Roman Catholic marriage. Lina’s desire to pop an impromptu kiss on Sergio was starting to wane because of his discolored teeth. She wondered how can “I persuade him at least, to go for a dental check-up”? Her goal for Sergio was to have his teeth cosmetically improved to show off the fashionable celebrity white-teeth-smile and nothing was going to stop her. 

The whitening of teeth has become a billion-dollar business and celebrities have had no small part in raising the bar for the perfect smile. Another cosmetic fashion statement which is showing its colors is the art of tattooing one’s body parts. I mentioned this purposely, because a visit to the tattooing studio is far more popular that a visit to the dentist, although, ironically there is a common factor, namely pain. Why is this?  Why is it that people will pay huge sums of after-tax dollars to have a tattoo sculptured in sensitive parts of the anatomy and yet be hesitant to visit the dentist? Maybe vanity is more powerful than oral health! Or maybe the School of Body Art has out-marketed the college of dentistry?  How often have you seen a young woman/man flashing a tattoo, but in need of obvious orthodontic or other dental work?  We have to rely on anecdotal reports in the absence of a truly scientific study. 

Back to my friends Sergio and Lina. Researchers have come to the rescue with a product that brings effective needle-free anesthesia for patients during scaling and/or root planing procedures. Oraqix®  (Please click on the prescribing info button to the right of the screen  for information about contraindications, warnings, cautions and precautions).
fits the perfect scenario for a patient who is needle phobic. This product is the first FDA approved system for the above indications. There are some very desirable properties to Oraqix; apart from a rapid onset of action, the return to sensitivity is within twenty minutes, thereby making it the perfect product for example, a lunchtime appointment. Sensation is restored before leaving the dental office. Uncontrollable chewing of the lip is a common after-effect of residual anesthetics. Oraqix allows the patient to return to normal activity without the embarrassing drooling.

 Hopefully this addition to dental armamentarium will allay the fear of the dreaded needle. Fear of finding other latent problems incurring a cost is an irrational decision. Why should one have two standards for maintaining perfect health?  Oral health is no less important that physical health. The diagnosis of oral cancer is by far more often seen by the dentist than by medical doctors. If for no other reason it makes good sense to keep the oral cavity healthy and free of possible terminal diseases. 

Four out of five Americans claim a desire for whiter teeth. Never before have so many options been available. Nu-pro® White Gold®
is a dentist prescribed take-home system that has been designed to address the patient’s tooth whitening requirements and offers two formulations with dramatic results in one to two weeks. Who are the best candidates for do-it-yourself whiteners? Before you spend a dime on whitening your smile, your dentist will explain what is best for you and the reason why. Teeth should be healthy without cavities or recession of the gums thereby exposing sensitive root structure.  If whitening agents come in contact with an open area on a tooth with a clear path to the nerve center of your tooth, you won’t care what color your teeth are because they will have to peel you off the ceiling. 

You need to have a proper evaluation by your dentist.   A talk to your dentist will determine if you do have tooth discoloration and what is the cause. There are two major ways teeth become discolored. Teeth naturally discolor as we age, and we all have lighter or darker teeth, just as we have different complexions. Everyday habits and food consumption penetrate the tooth’s enamel to cause extrinsic and intrinsic stains: There are as many reasons for tooth discoloration as there are solutions. Over-the-counter whitening doesn’t work if the discoloration comes from an injury to a tooth, for example. Also, if you have teeth that have tooth-colored fillings or crowns that are dark or discolored, again, over-the-counter whiteners do not whiten porcelain or tooth colored filling materials.  

Stains can be caused by foods such as coffee, tea, red wine, and nicotine. Rule of thumb, if it stains your carpet, it can stain your teeth.  What kind of results can we expect from an over-the-counter product? Today Over-the-counter whitening products work differently and better than ever before because the technology has changed so dramatically. Will your teeth look as different as if you had full mouth veneers? No. But if you have a pretty smile, that you want whiter and brighter, the newest over-the-counter options are very effective. Here’s a look at some of the latest options.  Most people hate the messy trays you stick in your mouth. What are the alternatives? 

Crest White strips, night effects (liquid strip gel). Crest White strips continue to be the OTC gold standard in whitening — and a beauty secret for millions of Americans, (mostly women). When you look in dressing cabinets, you see them right next to the lipsticks. Whiter teeth give women confidence and make them look younger and prettier. A great new whitening product is hitting store shelves now. It’s called Night Effects and it’s very exciting because it works while you sleep. The first generation products made to whiten teeth while we sleep included a tray and stuff oozing out of it. I dare you to sleep with that unit in your mouth and not destroy your bed linen. Bearing in mind that these are all Over-the-counter products. Dental prescribed take-home products are still the most effective. So what has been improved for the OTC shopper? 

Night Effects is great for a couple of reasons: First, it’s good for people whom for whatever reason, cannot whiten during the day. Second, the coating sticks to your teeth. You’ve heard me say that for a product to work, the whitening agent has to stay in contact with the teeth. The problem with some of the other over-the-counter products is that they tend to quickly wash away when they come in contact with saliva, food or drink. Night Effects appears to be the first paint-on product to address this problem. The patent process they use is as follows. Immediately after applying the gel, the product forms a liquid strip coating that stays on your teeth overnight. The liquid strip slowly releases the whitening ingredient into your teeth to remove stains and loosen stain-causing build-up. In the morning, you simply brush the liquid strip coating and stains away.  

Researchers have overcome the overnight challenge by developing a silicon-based gel applied with a brush. Secondly, it is not water soluble like other paint-on products. Because of this new technology, the whitening gel stays on your teeth for hours while you sleep.  Over-the-counter whitening serves a selected market, however for the clinically accepted procedures, it is best to have your dentist involved.

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mailto:localanesthetics@yahoo.ca  M.Sc. PharmD. CCPE.