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.

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

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.

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

PHA01-0108-1
 

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

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  

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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   

There is a latent artist deep within each dentist.  A quote from some unknown author. One of those many quotes often heard at a spring garden party after the hectic final exam where there is a thick layer of nihilism in every glass of wine. One wonders whether such a strange marriage resulted from the “shock and awe” of having used the Crane pick elevator for the first time on a set of stubborn wisdom teeth or whether it was due to the inner peace after having finally carved the perfect anatomy, into a composite; one never know where the artist is lurking. However what we do know is that dentistry is in transition which says there is a lot more to come.

Whitening has turned into a billion dollar market in less than five years and its popularity crosses both sexes.  It’s that feeling one has when one is showing off the “bells and whistles” of their new car. It is fashionable, they feel and look great, so why not show off that bright, celebrity smile.

Bonding more commonly known as tooth-colored fillings can alter the shape or close spaces between teeth. 

Porcelain veneer is probably the talk of the young and restless. This thin coat of enamel-like porcelain bonded directly to the surface of front teeth. The finished product can dramatically change the shape, size, color and position of one’s teeth. 

Crowns somewhat less pricy, also referred to as caps are an alternative to veneers when a tooth’s structure is missing. 

Implants are now on the continuing education budget of most dentists as they develop the skill of replacing missing teeth but without having to reduce adjacent teeth.  

This gives you an overview of how the practice of dentistry has transitioned from the days of drill and fill to highly clinically skilled surgeons who practice on the one part of our anatomy that is firstly seen by our family and friends.   

However these standards do not come cheaply. Which reminds me of the lyrics attributed to George Wiedner…“when an irresistible force meets an immoveable object”, in dentistry this is called “burn out”. This leads me into my segue. By far, the subject of anesthesiology attracts the largest audience of readers to websites and blogs on a world wide basis. Pain is still by a long shot (no pun intended) the main concern associated with any visit to a dental office. In spite of every aspect of the new décor and facilities that have been intentionally designed to reflect a much more relaxed, serene and contemporary environment, the nemesis of fear still ligers.

Dentists (GP’s) are rushed to maintain the high standards associated with the main revenue generators of their practices while staying as close as possible to their schedule.It is just not humanly possible to maintain all areas. Ironically it is the delivery of the local anesthetics that pays the price. I will credit my lay readers with the following terminologies because their comments make for interesting conversation at cocktail parties. Let me be the first to admit that my brother also practices dentistry and I would not in any way be discourteous to these dedicated and skilled clinicians. I hope my observations will be taken it in the way it was intended.

However I am hearing terms like haematoma, swelling of the venous plexus, trismus, necrosis, facial paralysis, and even more recently terms like unexplained paresthesia occurring after a non invasive procedure.  Questions and blogs relating to local anesthesia, out number other problems in dentistry by as least three to one.  

Ironically  it remains the main reason why most people do not look forward to a visit with the dentist. According to Malamed’s Handbook on Local anesthesia, the rate of delivery should be at 1ml per minute. In other words the injection should take about 1.5 minutes to be properly given. The latest survey of dentists across North America is between 19 and 25 seconds and mostly as a bolus. My notes on Pharmacodynamics  would seem to lend credibility to  George Wiedner’s lyrics where “an irresistible force meets an immoveable object”. The end result is a clash between the pH of the tissue (7.4) and the pH of the local at (3.5) mostly delivered as a bolus after bone has been touched. Most of the RN base molecules are destroyed extracellularly (outside of the myelin sheath) resulting in too few base molecules crossing the sheath to effect or block sodium transport.   

The situation is compounded when there is an extra layer of fatty tissue around the sheath or a build up of lactic acid as in the case of bruxism or grinders. Getting back to the classic reasons for local anesthesia failure, the thiophene is dynamic to the benzene molecule which superceded it by some thirty five years in Canada. It is just one of these developments whereby a forward thinking company decided to invest some venture capital; I am the first to admit that pharmaceutical companies have not come up with much since 1947 when Lidocaine was introduced. Some academics strongly feel that the addition of the more lipophilic molecule, the  thiophene, may slightly increase the aromatic moity due to its spherical shape. It has been observed Malamed 3^rd Ed that the anesthesia produced by a standard dose of  any local anesthesia will vary to a great extent between different persons…(more to follow on these five classic reason for failure.) The duration of action may vary between a few minuits to up to an hour. Thinking “within the box’, here are the five basic reasons for failure:

From anecdotal reports, it would appears that once the classic litmus test has been performed and failure to achieve the expected quality of anesthesia is still less than adequate to the patient or you,  the onus is then shifted to other excuses. In my 25 years of investigating complaints, I would be hard pressed to count on the fingers of one hand the numbers of truly defective products which were as a result of the manufacturer). The manufacturing process is so regulated that a total batch of local anesthetics would suffer the same biological analysis and would involve a total recall and subsequent disposal.  Both FDA and Canada will not ship fine pharmaceticals (or finished produced) if they have not met North Amreican standards.

To support this check list, it is standard procedure for companies to donate goodwill products to be used by dentists who willingly give of their time, to work long hours in condition that are less than adequate and often not safe. These dentists must be commended.  There are numerous files of “thank you” letters and a willingness to revisit to see the fruits of their labor and the beautiful smiles of these young people. There has never been a mention of quality control deficits or any special requests for products not in standard production in the North American market. You may well say “never look a gift horse in the mouth”. These are all North American trained and practicing clinicians who have a strong desire to share their expertise with less fortunate people.

In the pharmaceutical world there is a constant evolution of drugs and their indications. Many of you may not have been around when Metronidazole was first introduced for vaginal infections, back in the sixties. Since then it has been used successfully as an antabuse-like drug for alcoholism. Today it is probably one of the most frequently prescribed compounds by peridontists. Nothing is constant. As Albert Einstein said…E=mc2. The object is to leave you with a solution and possible and update to the age old reasons for anesthetics failure.

Obviously our population is growing and the numbers of patients visiting dentist are on the increase; it therefore stands to reason that untoward incidents will follow. However I do strongly feel that pharmacodynamics needs to factored in. Delivered at the rate of 1ml/ml, if per chance a muscle or artery is slightly nicked the response from the patient would give you ample corrective time measures to avoid a dirty trismus or some other situation that eats into your time and a patient that is not too happy. So the question is whether the saving 50 seconds is worth it? 

For any dentist(s) who are willing to take this challenge, (must be timed), I will visit an Eastern location (say NY) without an honararium. I will also demonstrate a didactic on never having to give a traditional nasopalatine injection. Finally, as a bonus I will demonstrate the techniques for bone (pulpal) anesthesia known as Mandibular Infiltration.(Drs. Aaron Dudkiewicz and Stephhane Sshwartz Journal of Canada Dent Association No.1 1987). I am sure any dealer would be be eager to grab an opportunty like this. the total lecture is about 3 hours.     

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 M.Sc. PharmD. CCPE   Please visit http://www.anestheticsnews.com

WWW.AnestheticsNews.com</a>     Haynes Darlington M.Sc. PharmD.

This magic machine, our body, has the ability to respond to foreign substances just as the beautiful swan constantly removes old feathers to make room for fresh ones. Our body is like a gatekeeper in order to ensure a state of perfect homeostasis. There are times when pharmacological intervention dictates the necessity in order to correct certain ailments. For example psyllium fibre may be absent in our diet and as such, a supplement maybe required in order to reestablish normal regularity. However when a pharmacological intervention is the preferred plan of action to assist in treating a condition, it is the responsibility of the clinician or pharmacist to make sure the drug is taken properly and in accordance with the product monograph as issued by FDA or some other regulatory agency. Failing to follow these instructions can result in a response, which can be out of phase by 180 degrees.

There are numerous examples where the opposite effect is predominating when the drug is administered incorrectly. Depending on the drug, there is some minimal room for small errors. However; by and large, the rule of thumb is strict adherence to the written or spoken word by your clinician or pharmacist. Then there is the experimental phase of drugs, whereby longitudinal studies do reveal new indication for drugs that never existed when they were first investigated. Aspirin is one obvious compound that keeps going and going and going.

This article is limited to dental procedures and the drugs, which may be necessary to complete a procedure. If per chance the local anesthetic is deposited as little as one MM off the intended target, The response can produce results that are as equally scary for the patient as it is for the dentist. The fundamental response can be traced to the base or foundation of one’s every day management of stress. The “flight or fight” response, originally discovered by Harvard physiologist Walter Cannon in (1915) where the hormone adrenaline or epinephrine, secreted endogenously to produce the physiologically normal response to cope with any potentially stressful situation.

What are the saber tooth tigers of today and why are they so dangerous?

Fortunately, in our modern world we are not exposed to foraging for our daily sustenance, as did the cave man. However our hormones cannot determine the origin of stress and do respond in exactly the same way as did our fore parents.When we experience excessive stress, whether from internal worry or perceived external discomfort, bodily reaction can be triggered and can be organic or psychogenic. Nerve cells firing will activate the well-known chemical adrenaline (epinephrine). The Sympathetic Nervous System (SNS) is a branch of our autonomic nervous system. It is always active at a basal level called sympathetic tone and becomes more active during times of stress. In other words, stress is the condition that results when our environment transactions lead us to perceive a variance, whether real or not, between the demands of a situation and the resources available to us, whether they be real (biological or psychological).

Today, however, most of the saber tooth (no pun intended) tigers we encounter are not a threat to our physical survival. Today’s saber tooth tigers consist of rush hour traffic, single parent management, missing a deadline, bouncing a check or having an argument with our spouse. Nonetheless, these modern day episodes trigger the same adrenaline release. Road rage, is relatively new, but is a classic example of how powerful and alive is our autonomic nervous system. Homeostasis must be maintained at all times and our autononic nervous system will go to all extent to see that perfect condition is mainained and stable.When one has not been keeping regular visits with their dentist, there is a basic guilt that is inscribed in one’s brain. For most of us, it started during childhood. It was that nightly ritual…“have you brushed your teeth?. This question has attained, some degree of noterity status in western society. For example the book, The fairy tooth godmother where an exchange for something that has lost its usefulness (such as a tooth) for something of everlasting value carries significant personal values and  stays with one, even after one has flown the coup.

The body’s defences start to produce more endogenous epinephrine to balance the perceived threat of pain and the personal guilt that accompanies these situations. Guilt is powerful and can trigger our autonomic nervous ststem.Ironicly, the drug (local anesthetic) which the dentist most likely will be using, contains epinephrine. My earlier example of how therapeutic substances can produce more than one effect; dependant of how and where that drug is administered could not be more relevant than as in this scenario. The dentist needs to deposit the local anesthetic to bathe the nerve in such a way that it restricts or blocks any sensory impulses. This is called vasoconstriction.

It restricts the flow of blood in that specific area allowing the patient to be comfortable and without sensation of pain. Let us for the sake of comparison; see the effect of what would have been the result if the same drug had been administered into the vessel. The same drug would have affected vasodilatation or the opposite desired effect whereby anxiety and stress would be manifested. The experienced dentist has anatomical landmarks, which acts as the safety net and, which more or less reduces any accidental error.

The emphasis here is not to enter into clinical diagnosis, but rather to raise the profile of pharmacodynamics in a world of ever changing medications. Drugs administered incorrectly or directed to unintended receptors, will produce undesirable side effects.  As clinicians have found it necessary to specialize, I for see the day for specialized pharmacists. The complexity of structural algorithm of compounds is already exceeding our capacity.

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Author: M.Sc. PharmD. CCPE

          NaCl                                   +                           H 2  O

When dental anesthetic syringes are preloaded for lengthy periods (over 1 hour), the following chemical reaction is triggered. An electron avalanche is started by the needle making contact with the anesthetic solution over a lengthy period. This will cause two new compounds to be formed, namely, mild hydrochloric acid and sodium hydroxide which are both caustic. One of the hydrogen’s will be attracted to the chloride of the salt,  thereby starting the avalanche. This can cause a burning or stinging sensation when the dentist injects the solution. It is called “The Monday morning stinging/burning injection” because some dental assistants preload syringes on Friday afternoons, in preparation for Monday morning. The number of calls from dentists led us [the manufacturers] to investigate the origin of such phenomena. These occurrences still persist, however; we hope through our continuing ED courses, the word will spread.  Please contact us with your comments at mailto:localanesthetics@yahoo.ca . . .  your operatories will run that much smoother. “Things they never taught me in dental school”!    Author: M.Sc. PharmD. CCPE.

Are stronger medication seeping into dentistry? The usage of compounds like Versed, Demerol and Fentanyl were not so common five years ago in dentistry. Why the change? Are local anesthetics failing? or are these new meds being offered more readily?

Bupivacaine 0.5%, a tertiary amide compound commonly used to induce nerve block anesthesia in dental procedures, continues to mystify pharmacologists with its dual properties of producing analgesia after soft tissue anesthesia has worn off. Although structurally it resembles other amides such as lidocaine; however, in the hydrophilic section, it contains four extra carbons. We suspect this is responsible for its unique mode of action. This is a desirable feature, since it reduces the need to prescribe narcotic type pain killers. Its concentration of 0.5% of bupivacaine  puts it in a class of low toxicity. Another useful tip on current issues. Comments are welcomed. Contact us 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