Local anesthetic news

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.

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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.

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Dentistry in transition! At face value this is a rather positive impact statement, given the general opinion held by the populace at large. However one must admit there are certain phrases, which our thought processes will not allow our brains to compute. It is like the parent being ambivalent about their kid’s promotion to a higher grade, yet being well aware Johnny’s skills are realistically one or two grades behind. There is the standard form letter, which accompanies this report card. ”It would be psychologically damaging to the kid if we had a ten year old sitting with eight year olds.” That is a fact of life, of which there is little we can do outside of cry victim.  

I accept that. However the term profound anesthesia is a dental term, referred to in any edition of Dr. Malamed’s handbook on local anesthesia or any other similar textbook. It is as explicit as the term pregnant. One is either pregnant or not.  My question obviously then is, why do we hear the explanation, “were it not for the dream team, O.J. would not be playing golf today”. There is an assumption that being completely numb, is like picking a lotto ticket or a good lawyer. To put it bluntly, a hypothesis consists either of a suggested explanation for a phenomenon or of a reasoned proposal suggesting a possible correlation between multiple phenomena (Wiki). 

For a dentist to truly eliminate residual sensation or even the slightest evidence of pain to the patient requires a pharmacological intervention which is achieved by reversing the polarity charges across the nerve sheath and by so doing, will block sodium transport. In a nutshell that is how the dentist freezes you. There is no magic; smoke, mirrors or even cartridge warmers. In fact, nothing other than the skill and the years of training and understanding certain biochemical interactions and of course the anatomy of one’s mouth. Some dentists can also arrive at the end result, (namely your comfort), by using other techniques to block sodium transport in either one specific area or to one or all quadrants of the mouth. This can be achieved at one sitting.  

For those patients who still suffer through a dental appointment, you should seek out one of the many thousand of dentists who have mastered that technique. Remember you are either pregnant or not. The same rule applies for being frozen. Now to be fare, the patient can be confused and equate pain with pressure. Pain is felt along the nerve, it is persistent and very recognizable. On the other hand pressure is transient. Its can quickly disappear as it appeared. Pressure will not follow you home and the slight soreness will disappear even without medication in most cases. However, one must accept that we are dealing with variables. Anatomical variables compounded by the ever presence of Murphy’s Law can and does throw a spanner in the works. There will be those challenging days in any dental operatory. 

Ah! Think of the beauty and the protection for our teeth. Never has our world been so versatile as it is today. Times were when people conversed, it was common practice to place their fingers to cover their teeth or an attempt to conceal mal odor. Dentists have collectively deleted that era with their skills of art knowledge of gum disease. Especially at this time of the year where folks get together to celebrate, it is the confident radiance of wide smiles across the room as though they were saying, “look at the work my dentist did”. These smiles are as fashionable today as it is to tote around a 450 ml of Evian water. Let us not change that trend. The patient must be frozen. Not only soft tissue. 

However what continues to be unexplainable is the ever-increasing incidences of trauma resulting from achieving profound anesthesia. This is the conflict that one has to deal with when they hear the term “Dentistry in transition”. As one popular dentist explained this scenario to me, “It is this expanding team based reconstructive approach which mandates the use of convergence technologies in order to ensure timely and accurate continuing education. His final tip was to concentrate on moving records, not patients.”   

If this terminology is aimed at a trend towards cosmetic dentistry and away from the traditional drill and fill, it does not negate the increasing failure to achieve profound anesthesia and the accompanying problems of physical trauma. It should never be a question of how much pain is the patient willing to endure to finally toss the bed-side glass with their dentures to have a permanent set of implants. Pain should never be a bargaining factor. Of course there is a price to be paid, but the patient has already made that decision, whether it be Whitening, Bonding, Porcelain veneers or crowns. The objective should be the same as it was in dental school when you delivered your first ever injection to a fellow student and he/she reciprocated. You made sure you did not cause pain to your buddy and that you did indeed freeze your fellow student. If this situation has changed and failures seem to be on the increase, what has changed?  Is it the converging technologies and the accompanying stress of entering un-chartered waters? Why is this? The ability to achieve anesthesia should not be relevant. 

At any addictive or compulsive behavior center, your first bit of advice one receives is that you are on your way to recovery simply by admitting there is a problem. If this problem is on the rise it may be completely out of your hands, however it still has an impact on your daily activity and unfortunately in dentistry, the denial to communicate will continue to fray that weak spot on the line and one day it will snap. 

Andy Warhol is credited with the following: “An artist is somebody who produces things that people don’t need to have”. Dentists are frequently referred as being artist. Earlier I referred to the beautiful smiles by which we are surrounded today. However there is no need to have to go through hell to acquire this. The action potential of local anesthetics and other agents are the domain of bio-chemistry and pharmacodynamics. While respecting the inevitable convergence of technologies in dental offices in this dynamic profession and life styles, Be kind, take your time. “It sure was good while it lasted”. Now it’s time to pay the piper. It’s all over but the crying. Too late to do anything but moan about it now.” (Chris Kristofferson.)

Contact us at localanesthetics@yahoo.ca  M.Sc. PharmD. CCPE   Please visit WWW.AnestheticsNews.com  Tel. 905-597-5688   

His girlfriend was unaware that he was taking steroids. She had noticed the larger muscles and a slight change in his manner…a bit more aggressive and the odd temper outrage, but he was handsome and any girl would have noticed him when he arrived at a party. For her, she had her perfect man and she was proud to show him off.

 He was athletic and she loved him to a fault…even the recent very obvious change in his foul smelling breath. She had a great relationship with his mother, who also loved him beyond all. The mother never thought of mentioning the standing weekly order to purchase a one-litre container of Listerine mouthwash as strange and a dead give away (pun intended) to future tragedy. She kind of thought it was excessive, but the pair were getting along so perfectly, it never dawned on her to question her son.

Alas! The clock was ticking. On his regular dental check-up and cleaning, the hygienist detected the mal odor, but dismissed it because there were no signs of periodontitis and x-rays confirmed her diagnosis. She did however; make a note on his chart about the obvious bad breath.Unknown to the hygienist, the chronic use of anabolic steroids for muscle building triggers a distinctive foul odor of the breath.

Alas, during one of his weekly football sessions, he fell and no pulse could be detected. Paramedics worked on him furiously during the trip to the nearest hospital emergency, unfortunately to no avail. He was dead at the tender age of twenty-two.Anabolic steroids are extremely toxic to the liver (hepatic) and cardiac organs. This is a heads-up to hygienists, dentists and family members. There are obvious physical signs such as the rounded face and bulky muscles. Now we know how important it must be for dentists and hygienists to stay current in a world of changing lifestyles and chronic abuse of compounds. Comments to author. mailto:localanesthetics@yahoo.ca M.Sc. PharmD. CCPE