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

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  

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

I was advised not to go into law because members of that profession were 3.6 times more likely to be depressed, than members of other professions and it’s not just because their jobs were more stressful. Job stress has little effect on happiness unless it is accompanied by a lack of control. For most professionals, such as dentistry, stress is rated at the high end of the scale. Apparently stress is evident only when results are difficult to reproduce. Dentists have to work with variables which are of an anatomical nature, hence the predictable or lack of it, puts them already at a disadvantage. This article may explain why dentists are stressed. They are caught between a rock and a hard place. On the one hand they are dealing with patients who hate the shrillness of the piercing sound of a drill or burr and on the other, the lack of scientific longitudinal studies dealing with biology vs technology. Ironically, replacing the drill, poses other biology problems which are yet to be evaluated over time. 

Lasers in some ways resemble the compound Vitamin E. In spite of the almost mystical image it has with the public, it remains one of these agents that some medical gurus have unanswered questions. The population at large says Vitamin E is good for everything but removing the grease from the kitchen sink. While the doctors are saying, “show me the clinical evidence”. When lasers were introduced for use in dental procedures it brought with it many attributes which dentists were screaming to have and were willing to pay the substantial price tag. Dentist felt if they could reduce or replace the use of drills, burs and maybe the shot, then dentistry would be perceived as less painful and improve traffic over and above acute procedures or emergency drop-ins.

This is a good time to revisit laser analgesia and anesthesia. Women love to tell the joke about men being lost, yet failing to stop and ask for directions. They would sooner drive around in circles. Dentists also have the perception that they are doing well at being pain free. For us lay people, according to dental text books on anesthesia, there has always been those files marked “difficult to freeze”. If your dentist is within that 15% range, then to him/her that is considered zero or perfection. However would you purchase a parachute or fire extinguisher with a label that says 15 % failure rate?  Let me make it perfectly clear, it is not a bad batch of anesthetic. If it were, then almost the entire continent would have the same problem.

Dentists are trained to diagnose and treat. If the diagnosis is accurate and the treatment completed then the job is done - fait accompli. Right? Let’s be honest, if you had company over for dinner and you knew the roast was overdone or something was just not quite right, would anyone be that discourteous to say, “by the way the roast was lousy”. Patients are mostly kind and will never tell you the truth. However unless you have not been in touch with the clinical side, most people hurt at the very thought of a visit to the dentist. For me, there is a disconnect here somewhere. Your own blogs admit it. This is not a gang up.  

The reality is that above and beyond that accepted 15% failure, we are aware of the times when there is a need to reinject or reach for that painful PDL. Yet other times when the patient is “numb” except on distal lingual line of a molar. How can someone be numb and still have residual sensation? The question is rhetorical, of course, but as dentists you are aware of accessory innervations and are supposed to know how to capture all nerves. If you translated that into English, a person could be half pregnant. I am serious. One is either frozen or not. If 15 % is being accepted, when do we see the benefits of higher post graduate education, more modern university facilities and yes, the tremendous work that researchers and pharmaceutical companies have been doing since 1947 when Astra introduced the first dental cartridge with Xylocaine? We are at the same 15 % failure rate as we were then. I am wiling to be proven wrong.

Yes, you have moved on to lasers, apex locators monitors and a myriad of new composites, but is the pain and discomfort still there? Yes, implants, Invisalign and TMJ’s are all up. Lab work has taken on new dimensions, but is the pain and discomfort still there? Forgive me for rhetorical questions. One dentist said to me about laser, I am all for this technology. I have 5 years clinically behind me with the laser and I have successfully removed large alloys, composites and done crown preps, however in a low whisper confessed that he wonders whether laser anesthesia/analgesia really worked. Here is a balanced one from the other side. The patient had a fracture (N0. 11) which was an abutment to a bridge. The nerve was exposed and vital she had a note from her medic to avoid amides. The procedure involved removing the nerve which would not have been possible before laser technology and the RCT was completed successfully.

It is essential for any laser used in dentistry as an alternative to a drill be concerned about biology. What about thermal damage which a laser can cause due to the heat that is generated by the ablation of these materials. The ablation efficiency of the Er:YAG laser (?=2.94) on dental materials and one must allow for timely removal of amalgam and composite dental restorations. While it would appear that I am not cutting much slack to dentists who are working through the difficult transition, I am really on your side and wish to present to the public a better image than what exists today. From a distance what I see is a ‘first on the block mentality’. This attitude is directed at fellow dentists down the hall as well as to patients in general. Unfortunately the soldiers are not all instep. There is a disconnect. When expectations are set and results of the climax turn into a whopping anti climax, you have one hell of a task to regain that spot.

Here you are all decked out with the bells whistles and flashing colored lights in each operatory and you are wearing the amber eye protectors and the atmosphere looks impeccable, yet when the local is delivered and the expectation is that the procedure will start now, there is the wait while the dentist is off to another patient or to the hygienist. When they eventually return, that is the anti climax. After 15 minutes and I am jumping each time a gloved finger or probe enters my mouth. This never happened in dental school. You gave the local and right away your colleague was frozen. Now it is reasonable for the dentist to have to move from room to room, but the reason given is bogus. When given correctly, anesthetics work within 30 seconds at the first time. Show me in any text book where 25 seconds is the recommended delivery time. They all say 1ml/min. There is the problem.   

The term to “marinate” is not usually used by dentists, but we in pharmacy are familiar with the terminology. It basically means that the dentist may start injecting at multiple locations, with a hope that luck may be on his/her side and the patient will be frozen. My advice, speaking as a pharmacist and having the knowledge of how most drugs work, is that these multiple shots are warnings of trouble ahead. The flashing yellow is on and it may be telling you that the first injection did not do the job. The second and third (all the same drug, just by a different manufacturer’s name) will magically perform a trick from the turtle to the rabbit. (Sorry folk! this is an inside joke) your dentist may want to explain.

The dentist could sit with for an hour and explain in a similar way the salesman gave a demo at the trade show. However, you the patient are not interested with precision or smear layers. All you want is to feel nothing. To put it bluntly, you want to be fully frozen throughout the procedure. As a comparison, think of a knee implant under conscious sedation. The patient hears the saw and is aware, but there is no pain.

The biology of laser usage is still not known. It is an attempt to spare the patient the thought of a burr, drill and vibration. However, when we are dealing with living body parts, biology of structure, function, growth, origin, evolution and distribution must be factored in with longitudinal specific clinical studies. There are some prominent opinion leaders in perio who have refused to continue to lecture on closed flap crown lengthening. An area of concern is laser plume virus survival and thermal damage. Dental laser technology is here to stay because there are times when the alternative would have been general anesthesia because of severe anaphylactic shock if a local were used. However I fore see a revisit to closed technique because of the risk of bone necrosis.

A recent published article in the Journal of Periodontology, conducted at the University of Missouri, Kansas. Mullins, S.L., et al. - The purpose of this pilot study was to evaluate, by scanning electron microscopy (SEM), the surface effects of 3-CO2 laser treatment on the root surfaces and soft tissues and to investigate the effects of 3-CO2 laser on periodontal pathogenic bacteria compared to negative controls…A one-time use of the 3-CO2 laser in periodontal pockets did not sterilize or substantially reduce subgingival bacterial populations compared to negative controls.

In this age of better skills, more accurate and definitive diagnostic equipment and excellent patient compliance, there is obvious something missing when we hear the comment . . . “hang on there, we are just about finished.” Life styles have changed. That is one of my lecture topics. I hope you are not too deep in the forest to see the trees.

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

Please visit   http://www.anestheticsnews.com       http://tinyurl.com/2bsqsz  

 Reports of true allergic reactions to local anaesthetics are uncommon. Investigation finds most of these reactions to be of psychogenic origin. A confirmed allergy to an amide is rare; the ester topical procaine is somewhat more allergenic. An allergy to one ester rules out using another ester, as the allergenic component is the breakdown product para-aminobenzoic acid (PABA), and all esters are metabolized to this product. Conversely, an allergy to one amide does not rule out using another amide. Epinephrine has not been shown to have any serious allergenic potential.

It may be best to avoid a vasoconstrictor if there is a documented allergy to sulfites, as metabisulfite is added as an antioxidant whenever a vasoconstrictor is added. A vasoconstrictor can be used with patients who have an allergy to sulphur, as there is no cross-allergenicity with sulfites. We welcome comments at www.anestheticsnews.com e-mail at localanesthetics@yahoo.ca

There is no scientific way of measuring endogenous secretions of epinephrine during a routine dental procedure. Many sources report that endogenous  epinephrine will vary depending on the level of psychogenic reaction of each patient and also the type and duration of the procedure being performed.We, however can measure very accurately the quantity of exogenous epinephrine being administered by the concentration and the volume of the local anesthetic being administered.  E.g. a solution containing 1:100,000 of epinephrine, if 5.5 cartridges were given, the amount of epinephrine would be 0.1 mg.  (10 ml of 1:100,000 = 0.1mg).  We welcome your comments at  www.anestheticsnews.com or e-mail at localanesthetics@yahoo.ca

Methemoglobinemia values of less than 20% usually do not produce any clinical symtoms. The usual clinical signs of this condition are seen mostly in medically compromised patients, where cyanosis of the nail beds and lips may be seen. Although the possibility of methemoglobinemia occurring in dental patients is extremely rare, we suggest not to use prilocaine because the metabolite toluidine is present during metabolism. Methemoglobinemia can be rapidly reversed by the use of 1 - 2 mg/kg of body weight of methylene blue administed intravenously over a five minuite period. However, we always suggest a call to 911 as your first action in any emergency. Please visit our course topics at http://www.anestheticsnews.com or e-mail us at localanesthetics@yahoo.ca  (M.Sc. Phm  CCPE)

The age-old enigma! Why should I use a 25 G needle? Will it not cause more pain?

The advantages of using a 25 G needle on a typical contra lateral IANB are multi faceted.

• Patients cannot tell the difference between a 25  or 27 G
• There is less pressure on your thumb
•  There is less deflection of the needle
•  Positive aspiration is visible more easily
•  The 25 G doubles as a measure to the bone
•  The hub is never buried

Most text books advocate the use of the 25  G needle. We invite you to visit useful tips at www.anestheticsnews.com.  Our corses are all ADA  C.E.R.P. certified. E-mail us at localanesthetics@yahoo.ca

Dentists who do venipuncture…is this an instrument you could use? 

Hemophilia affects infants and adults alike. Learning to perform IV injections is a necessary and critical skill. The new Venoscope 2 can help. The new device allows the average person, professional or not, to effectively locate and evaluate multiple IV sites for future IV access. It will give the family the luxury of mobility in travelling and recreation that they would normally be very reluctant to pursue for fear of being unable to administer factor in case of an emergency while away from home. Some factor providers have taken the position that by providing a Venoscope II to their clients, they enhance the quality of life for the whole family. 
The Venoscope  II was developed by a paramedic to aid in locating and evaluating peripheral veins for IV therapy and blood draws. The basic idea is “if you can see it, you can stick it”. The new Venoscope 2 transilluminator does this by directing a very bright light into the subcutaneous tissue so that it produces an orange glow when the external room lights are dimmed. When the light passes over a vein, the vein absorbs the light and the vein shows up as a dark line between the dual arms of the light. You can verify that it is in fact a suitable vein by depressing the arms and observing the vein collapse and refill when you release the pressure. We call this blanching the vein. If it does not blanch, it is not a suitable vein. It may even be a tendon which you definitely do not want to stick. At this point, you may mark the “target vein” and proceed with the stick or simply reverse the light with the vein located between the arms and proceed with the stick between the arms. You can ask someone to hold the light or attach the light to the patient’s arm with the Velstretch Strap. Check their sight at www.venoscope.com  Please feel welcomed to submit your your comments or e-mail at localanesthetics@yahoo.ca

We frequently get questions re the availability of esters for local anesthesia. Apparently there is still the understanding that an ester type local anesthetic is the preferred solution for patients with malignant hyperthermia. Esters (as locals) were discontinued in 1994.  Any amide local anesthetic can be used. Please see the this link from Dr. Haas U of T. We invite you to visit our site  at www.anestheticsnews.com

Malignant hyperthermia may occur when patients with this genetic disorder are exposed to inhalation general anaesthetics or succinylcholine. Previous recommendations, now known to be wrong, precluded the use of specific local anaesthetics. Today it is well accepted that all local anaesthetics are safe to use in patients who are susceptible to malignant hyperthermia.

Ref. Daniel A. Haas, BSc, D.D.S., BScD, PhD, FRCD(C)

Please e-mail us at localanesthetics@yahoo.ca