Local anesthetic news

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

PHA01-0108-1 

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

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

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

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

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

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

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

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

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

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

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

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

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

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

McGill
University). 

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

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

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.     

Comments to author. localanesthetics@yahoo.ca  WWW.AnestheticsNews.com    

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

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

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.

Comments to author. mailto:localanesthetics@yahoo.ca 

Author: M.Sc. PharmD. CCPE

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

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

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

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

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

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

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

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

The Oraqix® Patient Portal introduces dental patients to the first FDA approved subgingival anesthetic, Oraqix® and provides an overview of oral care and gum disease. Oraqix® (lidocaine and prilocaine periodontal gel) 2.5%/2.5% is a novel liquid oil non-injectable anesthetic that allows patients to experience needle-free scaling and/or root planing procedures. Oraqix® does not prevent gum disease or periodontitis.

Zingo is a ready-to-use, single-use topical. This is the latest FDA  approved needle-free system that delivers sterile lidocaine powder into the sulcus or epidermis of the skin and provide topical, analgesia in one to three minutes after administration. This potent rapid onset action, may be especially useful in pediatric procedures, which means the product can be incorporated into a procedure allowing uninterrupted care.

Traditional ester type gels (Benzocaine), which are well known to be allergenic, may be following a similar demise as did the ester type locals injectables. Please add your comments directly or e-mail at localanesthetics@yahoo.ca