Local anesthetic news

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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.

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Comments 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.