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 predominate when the drug is administered incorrectly. Depending on the drug, there is some minimal room for minor errors. However; by and large, the rule of thumb is strict adherence to the written product monograph or the spoken word of 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. A classic example is aspirin which is on a roll with new indication being encountered almost on a yearly basis, yet ironically, this wonder drug probably would not have evaded the rigid FDA regulations, were it to be submitted for approval in present times.

This article is limited to dental procedures and with a little help from our friends, the word pain maybe non existent through out future dental appointments. 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.

There is a growing popularity now for dentists to ask you to slip a tiny pill under one’s tongue, if the procedure is long and may cause you unnecessary stress.The body’s 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 was noticed to be secreted endogenously (without one’s control) to produce the physiologically normal response to cope with any potentially stressful situation.

Today’s anxiety reactions in the developed world, are traceable back to the identical hormone which was released during periods of stress of our fore parents when foraging in dangerous territory to secure a meal. Our autonomic defense mechanisms are still as active today, albeit directed at other threatening situations in a modern world.

So what are the saber tooth tigers of today and why are they so dangerous? Our hormones are like computers and cannot determine the origin of stress, however they are 100 percent accurate at responding in no less a manner as they did for our fore parents who foraged for their very existence.When we experience excessive stress, whether from internal worry or perceived external discomfort, the body’s reaction to threatening stimuli can be of organic or psychogenic in origin. Nerve cells firing will activate the well known chemical adrenaline (epinephrine).

Sympathetic Nervous System (SNS) is a branch of our autonomic nervous system. It is always active at a basal level known as 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 interpret a variance, whether real or perceived…either biological or psychological in nature.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 are conditions of lifestyle whether it be rush hour traffic, single parent management, missing a deadline, bouncing a check, or having an argument with our partner. 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 autonomic nervous system will go to all extent to see such a balance is maintained 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 a degree of notoriety in western society. For example the story of the fairy tooth godmother where an exchange for something that has lost its usefulness (such as a baby tooth) is replaced for something of everlasting value.

These traditions carry significant personal values and stays with one throughout life.Unfortunately too may of us after we have taken on our own life tend to slowly drop the nightly ritual? University or college life, where there is less supervision and more freedom, gradually erodes the nightly floss and the one minute brushing which was part of one’s up bringing.By natural response, when an acute situation arises and you do have to make that visit to the dentist to correct an acute pain after a cold drink or at worst after a sip of your morning coffee, this is when the fear and guilt takes over and nervous adrenaline kicks in at the mere thought of a filling or the dreaded root canal.

The body’s defenses start to produce more endogenous epinephrine to balance the perceived threat of pain and the personal guilt that accompanies these situations.ironically, local anesthetics which the dentist will administer will contain epinephrine. So how can this be! Epinephrine in the hands of a dentist is converted into a vasoconstrictor. The direct opposite of how MD’s and paramedics use the same drug to revive a patient during a cardiac attack.

The dentist is trained to administer the local anesthetic in such a manner that it acts as a vasoconstrictor as opposed to a vasodilator.

The practice of dentistry can best be compared to a captain of a ship. In the same way every exit from the dock is a virginal experience for the captain, likewise for the dentist, each patient is unique with distinctive finger prints of their own idiosyncrasies, thus leaving little room for a cookie cutter style practice. The classic screen production of The perfect Storm is proof positive how nothing can be left but for the good graces of god.

As sophisticated as we are in our day to day life, our hypothalamus is the attack dog and responds appropriately to any given situationWe can therefore begin to see and understand the precision of our body’s protective autonomic nervous system at work. Scientists throughout the ages have been working and continue to investigate new compounds to assist in situations where the need to reduce and eliminate any possibility of anxiety or discomfort during an appointment with your dentist may cause you some concern.

A high profile example is the silent laser which for most procedures, now replaces the shrill and frightening whine of the dental drill. There are other examples where-by the dentist can induce therapeutic agents to produce a relaxing and calming effect prior to the needle.

Through continuing education courses dentists are acquiring new skills and equipment to make their patients more relaxed and comfortable. The experienced dentist has anatomical landmarks, which acts as the safety net and, which more or less reduces any accidental error.

Comments to localanesthetics@yahoo.ca M.Sc. PharmD. CCPE Please visit WWW.AnestheticNews.comAuthor: M.Sc. PharmD. 

Both 4% amides solutions articaine and prilocaine commonly used in dental procedures as a local anesthetic may produce methemoglobin especially in elderly and medically compromised patients but can be a problem in younger people with the congenital disorder. Such biotransformation of a metabolite into o-toluidine is dose related and can manifest itself within 3 to 6 hours, long after administration and long after the patient has left the operatory. The problem follows a set process where the body’s ferrous iron is oxidized into ferric iron, thereby blocking the enzyme methemoglobin reductase pathways.

Symptoms and signs will vary with the concentration blood levels of methemoglobin, but typically the patient will be fatigue, lethargic and a noticeable degree of hypoxia and respiratory distress. The skin assumes a pale grey pallor as a result of reduced amount of oxyhemoglobin in skin or mucous membrane and nail beds will appear cyanotic.

In most cases since the patient is no longer in the office, if paramedics are called Ironically, administration of 100 percent oxygen does not significantly improve the situation because the now ferric cannot surrender oxygen to tissue. If a sample of gingival (venous blood) is taken it may have the color of dark chocolate brown. It will not assume the bright red even when oxygen is infused.

This is no time to be a hero. The course of action is to call 911. Methylene blue is the preferred course of action, however by the time you have located it (assuming you have it) maybe too late. However for your wall chart of emergency actions, methylene blue 1 percent should be administered via slow I.V. (1.5mg/kg or roughly 0.7 mg /lb. This dose can be repeated q4h if cyanosis is still evident.

The mode of action of methylene blue is to convert ferric back to ferrous atoms. A word of caution, if you are in an isolated area and time is against you may try a parenteral (either I.M or I.V) administration of ascorbic acid (100 – 200 mg/day). Ascorbic acid can hasten the metabolic pathways that produce ferrous atoms. Be aware that methylene blue administered in excess unfortunately can itself cause methemoglobinemia.

Prilocaine or any of the 4 percent local anesthetic solutions should not cause undue concern unless given in excess of their absolute maximum dose. The presence of congenital methemoglobinemia remains a relative contraindication of either articaine or prilocaine.

Editorial Note:

Prilocaine is a lidocaine homologue and the only secondary amine local anesthetic that remains in clinical use. Prilocaine is biotransformed by hepatic amidase to aminophenol metabolites (i.e., ortho-toluidine and N-propylalanine), which subsequently can oxidize hemoglobin to methemoglobin. Administration of prilocaine in doses exceeding 400 mg has been associated with methemoglobinemia in adults.

Proportionately lower doses may cause this problem in children (1). Methemoglobin levels above 10% may result in clinical anoxia (2), and levels above 60% can cause stupor, coma, and death.

The findings in this report indicate that doses of prilocaine only slightly exceeding the recommended therapeutic dose have the potential to cause methemoglobinemia. The manufacturer’s package insert for prilocaine recommends a therapeutic dose of 4 mg/lb * (8 mg/kg) for “normal healthy adults,” with a maximum dose of 600 mg indicated for persons weighing 150 lbs (68 kg) or more.For persons weighing less than 150 lbs (68 kg), the maximum dose must be accurately adjusted for body weight to reduce the risk for adverse effects. The Food and Drug Administration (FDA) has investigated the incidents in this report and recommends that the manufacturer update the package insert for prilocaine to emphasize the importance of adjusting dosage for body weight, particularly for persons weighing less than 150 lbs (68 kg).

During January 1992-September 1993, FDA received nine reports of prilocaine-induced methemoglobinemia. However, methemoglobinemia may be underreported because 1) some persons may develop only mild symptoms that do not require medical care, 2) some cases may not be recognized as prilocaine-induced, and 3) only drug manufacturers are required by law to report these events.

Oral surgeons and other health practitioners should use accurate body weight information to calculate safe doses of prilocaine and should know that doses exceeding 4.0 mg per pound (8 mg/kg) of body weight pose a risk to healthy adults. The risk for adverse effects associated with prilocaine use is increased for infants, persons with underlying health problems (i.e., anemia or diseases affecting the respiratory or cardiovascular systems), persons with hereditary deficiencies of glucose-6-phosphate dehydrogenase and methemoglobin reductase, and persons taking other oxidant drugs (e.g., nitrite-containing medications, sulfonamides, antimalarials, or acetaminophen).

ReferencesAstra Pharmaceutical Products, Inc. Brief summary of prescribing information: Citanest Plain{Registered} and Citanest{Registered} Forte {Package insert}. Westborough, Massachusetts: Astra Pharmaceutical Products, Inc, 1992.

National Academy of Sciences. The health effects of nitrate, nitrite, and N-nitroso compounds. Washington, DC: National Academy Press, 1981.

Disclaimer All MMWR HTML versions of articles are electronic conversions from ASCII text into HTML. This conversion may have resulted in character translation or format errors in the HTML version. Users should not rely on this HTML document, but are referred to the electronic PDF version and/or the original MMWR paper copy for the official text, figures, and tables. An original paper copy of this issue can be obtained from the Superintendent of Documents, U.S. Government Printing Office (GPO), Washington, DC 20402-9371; telephone: (202) 512-1800. Contact GPO for current prices.

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 Whoopi’s Goldberg’s trismus? A trismus is caused by a physical damage to a motor nerve in the mouth usually after the administration of a local anesthetic although not exclusive to that procedure.

The disturbance of the main trigeminal nerve causes a spasm of the masticatory muscles, which results in a swelling and the inability to fully open one’s mouth. Enjoying meals is a challenge and is without doubt an under statement. Eating is probably at the bottom of the list of things in which one wants to indulge. At such time, liquids and soups are about all you can tolerate during the period of the trismus.

Most post-injection pain from the dental needle is short lived, however should a trismus manifests itself, because of its very etiology cannot be ignored. It can be minor but some times it can become a more chronic (long lasting) and complicated problem for both the dentist and patient to manage. Accidental damage such as a nick to a large muscle or a blood vessel within the far reaches of the mouth and in the area of the inferior alveolar posterior mandibular bone is the Achilles’ heel facing most dentists. One’s hereditary anatomical variances can play a root cause of such an unfortunate experience. The volume and the speed associated with the injection also plays a major role.

Some dentists, with all good intentions will submerge the local anesthetic cartridge in a solution of alcohol or cold sterilizing solution before engaging it into the syringe for administration. The residual contaminate (alcohol or cold sterilizing) on the diaphragm of the cartridge will produce irritation of the tissue and muscle which potentially leads to a trismus.

Bleeding or hemorrhage can also be a contributing factor. A large volume of blood can produce tissue irritation, causing a domino effect on muscle dysfunction as the blood is resorbed causing a low-grade infection and thus a trismus. Finally, large volumes of local anesthetics into one area will cause the tissue to expand beyond reasonable taughtness, which is yet another factor that may cause the development of the dreaded trismus.

While severe or chronic trismuses are rare in dental practices, they can be a nuisance. If there is difficulty and pain to open one’s mouth widely directly after a dental appointment where a local anesthetic was administered, a call to your dentist will probably result in a prescription for Ibuprofen and a muscle relaxant to manage the early stages of muscle spasm and inflammation. Heat therapy such as placing a warm moist towels for 10 – 15 minutes several times during the day will also help.A persistent trismus may require short bouts of physiotherapy of the jaw both vertically and laterally like a lamb chewing its cud. In virtually all cases of mild trismus which are attended to promptly at the onset of discomfort, patients report improvement within 48 hours.The following prevention are recommended by Dr. Stanley Malamed.

• Use a sharp, sterile,disposable needle.
• Properly care for and handle dental local anesthetic cartridge.
• Cleanse the site of injection with an antiseptic solution prior to needle penetration.
• Use aseptic technique. Contaminated needles should be changed immediately.
• Practice atraumatic insertion and injection technique.
• Avoid repeat injections and multiple insertions through knowledge of anatomy and proper technique. Use regional nerve blocks instead of local infiltration (supraperiosteal injection wherever possible and rational.
• Use minimum effective volumes of local anesthetic. Refer to specific protocols for recommendations.

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The toxicity of local anesthetics:

The place of ropivacaine and levobupivacaine.

Regional anesthesia

Current Opinion in Anaesthesiology. 21(5):645-650, October 2008.

Zink, Wolfgang; Graf, Bernhard M

Abstract: Purpose of review: Ropivacaine and levobupivacaine were developed after evidence of bupivacaine-related severe toxicity. Despite a comparable analgesic profile, quantitative differences become evident with regard to their specific rate of systemic toxicity. The present article provides a concise review of the toxic potencies of levobupivacaine and ropivacaine.

Recent findings: As lipophilicity is known to be a major determinant in local anesthetic toxicity, the clinical safety profile of ropivacaine seems to be more favorable than that of levobupivacaine. Experimental studies and case reports confirm this hypothesis, showing that ropivacaine is characterized by fewer (cardio) toxic effects and, most probably, a greater margin of safety. Both agents also may dose dependently damage neurons and skeletal muscle tissue at the injection site. Although their specific rate of neurotoxicity appears to be rather low, levobupivacaine is characterized by an outstanding myotoxic potential.

Summary: Compared with bupivacaine, both agents may be considered as ‘more well tolerated’ but not as ‘totally well tolerated’, as they are still capable of inducing systemic and local toxicity. However, ropivacaine seems to have the greatest margin of safety of all long-acting local anesthetics at present.

(C) 2008 Lippincott Williams & Wilkins, Inc.

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Compliments of:  Current opinion in Anesthesiology.

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? President Bush’s statement that the economy is strong, Mc Cain’s belief that we can drill from sea to sea, Bill Clinton drifted around Harlem mixing with black folk, and Barack Obama’s determination to visit all 57 States in the Union. Finally to be current, Sarah Palin’s unobstructed view of Moscow from her bedroom.

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 profound as the evidence of green gases now embracing our planet, or to be more precise, a dentists’ ability to deliver a bull’s eye shot to freeze the main nerve in a patient’s mouth with local anesthetic.

Today’s financial tight rope that CEO’s must balance is probably more taxing than“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 bailout bill for Wall Street was signed into legislation by President Bush. This new bailout includes earmarks for wooden arrows et al to the tune of $ 800 billion. Unfortunately most of the now unemployed will loose their dental benefits among others.

In such uncertain times, one’s dental discretionary income is on the front line. The cruises, the exotic vacations; 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 an acute root canal, a broken filling or a painful ache when one is having their morning coffee. And finally, the whitening, the bonding, the porcelain veneer, the crowns and implants will unfortunately be excluded until Wall Street is out of I.C.U and the overall economy improves.

There is no foreseeable light in the tunnel as Republicans and Democrats fight to inherit occupancy of the White House with all the problems and pleasures that come with it.

The loss of approximately 100,000 jobs per month, over powers the questionable “surge” and the reduction in loss of life of our men and women in Iraq. Does the “surge” qualify as a fifth Pinocchio?

A year ago it all seemed within easy reach. We were told our economy was strong and 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 were fortunate to dodge the full force of the bullet. Quite ironically due to the transition of the marketplace and the converging technologies of certain cosmetic procedures, the very high end and expensive reconstructive surgery is recession proof simply because there will always be the filthy rich who can afford what they want in spite of a shrinking worldwide GDP.

The question therefore is; what should the average GP dentist do during the few weeks or months before the eye of the hurricane arrives. Should they move to higher ground which is insulated from recession? Or should they become mavericks and stay open to treat and serve those patients who refuse to move into safe shelters? Moving to higher ground entails given up time to take continuing education courses. My empathy is with them as they arrive at the horns of this dilemma. From all indications this recession looks to be in the classification of category five.

The following synopsis can be used as a matrix to pinpoint the status of any GP dental clinic. 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 directed to the public at large. Practices have therefore moved on to cosmetics and other converging technologies.

This unfortunately is the quid pro for general dentistry until the economy turns around. Back In 1987, revenues for general dentistry were less geared to cosmetic procedures. They were in a totally different clinical situation where the emphasis was on acute procedures and treatment. After year 2000 there was a massive swing to cosmetic dentistry.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 chips.
• Avoid purchasing expensive equipment.

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When researchers isolated certain compounds from wine, the antibacterial effects of the compounds killed nearly 100 per cent of bacteria that cause dental problems and sore throat. Even though these compounds had less antibacterial punch when consumed along with wine, the research showed that both red and white wines were effective in eliminating bacteria.

And now for the catch; the acids in wine temporarily soften the enamel that protects your teeth.

Dr. David Bartlett of the Academy of General Dentistry in San Diego. CA. said that after eating acidic foods it’s best to wait at least 20 minutes before brushing your teeth.

Highly acidic foods include bananas, tomatoes, melons, asparagus, broccoli, peas, avocados, cauliflower, crabmeat, eggs, lobster, black olives, peanut butter, brown rice, and tofu.

How are your gums? When I asked that simple question in a recent e-Alert, I had no idea it would touch a nerve, but it did.

The subject was wine, specifically the antioxidant polyphenols in red wine. Canadian researchers report that these polyphenols may neutralize a compound that plays a key role in the development of periodontitis, an advanced form of gum disease. So far, however, the research has not developed to the point of testing red wine on live tissue.

But many gallons of red wine come into contact with live tissue (that is: gums) every day. With this in mind, I invited wine-drinking HSI members to let us know the quality of their gum health. As I write this, e-mails are still pouring in. Who knew wine aficionados would be such an effusive and forthcoming group when it comes to sharing intimate details about dental health?

Lets start with the basics. It seems that HSI members who regularly drink red wine tend to have good gum health. In fact, they outnumber wine drinkers with poor gum health by more than 5 to 1. Here are a few comments from the dozens of responses received:

JB: I am 71 and drink 12 glasses of red wine daily.
My dentist always tells me my teeth and gums are in great shape.

CC: My husband and I have a glass of wine every night (only red wine) and have good dental health. The dentist was in shock when he saw me as it had been a while. He said both my teeth and gums were in excellent shape.

DS: My gums are in better shape now than I can remember them being, and they have dramatically improved since I started drinking red wine on a daily basis about a year ago. Ive always had problems with loose teeth, but not any more.

AB: I drink wine daily. My dentist says my gums get better with each checkup.
Wine, but no roses.

But not all wine lovers enjoy the same results as the four above. Here is a member named JM: Having been a regular wine drinker of both red and white wine, I suffer nevertheless from gum disease for which I am being treated for the last two years.

And another member who also has the initials JM writes: I am a red-wine drinker. I have just lost my second tooth. The 23 glasses 45 times a week is not helping. I was actually wondering if it was part of the problem?

A member named JR would probably agree with that assessment. JR notes that alcohol may have a negative impact on gums. The problem? Alcohol dries the mouth and reduces saliva, which boosts the activity of bacteria and contributes to gum disease. She also quotes a University of Buffalo study that found a direct relationship between the amount of alcohol consumed and the severity of gum disease.

And JR adds another point: Alcohol consumption has a depleting effect on some nutrients necessary for healthy gums.

One piece of the puzzle; if alcohol promotes dental bacteria and depletes nutrients, how is it that so many HSI members who drink red wine enjoy good dental health? Granted, our e-Alert survey is not scientific, but maybe gum health among red-wine drinkers can be attributed to other healthy habits. I think it is safe to say that most (virtually all?) HSI members go out of their way to take good care of their health, and several of the e- mails reflect this, citing the use of supplements such as CoQ10 (shown to promote gum health), and nutrient- rich diets.

For instance, an HSI member named VC has very healthy gums and describes himself as a devotee of red wine. I always generously supplement with vitamin C before going to bed.

And an 80-year-old member named BY is also a red wine drinker with perfectly healthy gums. But other factors probably play a role in her dental health. She writes: Only organically grown fruits and vegetables come into our house and our meat is from local sources that we also know to be reliably nurtured (no antibiotics in the feed or by injection) and they are fed on grass in the fields in the spring and summer.

In short, health of any part of the body as well as the body as a whole is the result of good food, exercise and sufficient sleep as I am sure you know. No one thing can be responsible for good health.

Compliments of The Healthier Life.

Our site http://www.anestheticnews.comwe strive to fill a void that has never been addressed…namely a closer relationship with your pharmacist. M.Sc. PharmD. CCPE.E-Mail: at localanesthetics@yahoo.ca

Unlike condoms, which are made from latex, all dental local anesthetic cartridge plungers are manufactured from dry natural rubber, vulcanized at extremely high temperatures using triple valence bonding. This unique manufacturing process, rules out any possibility of leaching of latex into the local anesthetic solution.

Such impurities would be detected if they were present, through normal routine manufacturing checks. To date, there has never been a latex related allergic reaction reported to the FDA, directly associated with dental cartridge plungers. Latex sensitivity in a dental office is largely attributed to products manufactured using the wet rubber process.

Latex is a milky fluid that comes from the tropical rubber tree. Hundreds of everyday products contain latex. Repeated exposure to a protein in natural latex can make you more likely to develop a latex allergy which may have a genetic origin. In other words, one or both of your parents would also have been sensitive to that allergen.

If your immune system detects the protein, a reaction usually starts in minutes, thereby alerting the dentist. Your symptom could be a rash, asthma and in rare cases, anaphylactic shock from latex exposure.

However, anyone can develop an allergy to latex. The number of people who do is quite small considering the millions who are exposed every day to consumer products that contain natural rubber latex.

Individuals with an increased risk are those who have spina bifida and have undergone numerous surgeries, also those who are prone to any type of allergies, which include health care workers, rubber industry workers and others who have continuous contact with latex.

If you have had a prior allergic reaction to latex-containing objects, you should consult your physician who can try to determine the cause. Your physician also can determine the best strategy for dealing with a latex allergy. Until that is done, avoid contact with all latex products.

As a precaution you should inform your dental office staff so that your medical history can be updated and appropriate precautions can be taken before your next dental visit. However, as I mentioned the process of manufacturing dental cartridge plungers is unique and to date, to my knowledge, there has never been a latex related allergic reaction reported to the FDA, directly associated with dental cartridge plungers.

Ref. West Pharmaceutical Services.

Our site http://www.anestheticnews.com we strive to fill a void that has never been addressed…namely a closer relationship with your pharmacist. M.Sc. PharmD. CCPE.E-Mail: at localanesthetics@yahoo.ca

 

Failure to be anesthetized by local anesthetics during a dental visit can vary between patients. Even in very standardized experiments with human volunteers, the anesthesia produced by a standard dose of local anesthetic solution will vary to a great extent between different persons. The depth and duration may vary between a few minutes up to an hour. This, of course, means in practice that some patients will have an extended period of anesthesia, while others may have only a very short period and yet others may have residual sensation throughout the dental procedure.

In order to reduce the likelihood of a failure, the anesthetic solution should be delivered at the rate of 1mL /1minute. In other words if a full cartridge is being given it will take approximately just under two minutes and furthermore the dentist should start the procedure within 30 seconds of giving the injection since all anesthetic solutions with (one exception) have a short latency (onset) period.

If the solution is deposited by the infiltration method, it should be deposited at the apex of the tooth, as near to the bone as possible. A deposition at a distance from this area, or into a muscle, will significantly decrease the anesthetic effect.

The buffering capacity of the tissue will normally cause stabilization of the pH at the tissue level if the solution is given slowly and not as a bolus. Injection into infected zones often produce incomplete anesthesia because the infection focus produces acid waste which will lower the normal buffering capacity of the tissue. An acid pH will lower the anesthetic potency of an injected solution. Injections into infected areas can also spread the infection to adjacent areas.

In some patients the injection may fail due to a deviation in the position of the nerve. An exceptionally thick compact bone will constitute a diffusion barrier and make less effective an injection with the infiltration technique.

If all or part of the solution has been injected intravascularly there will be little or no anesthetic effect. All dentists avoid the phenomenon by performing aspiration during the injection. If sufficient quantity of the solution which contains epinephrine is introduced intravascularly, it may cause the patient to feel light headed and can trigger a fainting spell.

If insufficient anesthesia or analgesia becomes apparent in procedures of the anterior region of the lower jaw when a unilateral regional block is used, this may be due to un-anesthetized anastomosing or commonly referred to as accessory innervations. This can be as a result of an anatomical variation and will require the Gow Gates technique for delivering the solution. 

Patients react differently to medication, and this applies also to local anesthetics. An adequate dose in one patient may be insufficient in another. Moreover, anxiety and fear may cause a patient to complaint of pain. Sometimes pressure is disguised as pain. To isolate one from the other is easy. Pain will follow a patient home. Pressure will disappear as quickly as it appeared. If it is truly pain, this can be avoided by judicious psychological treatment of each patient, in some cases combined with suitable pre and post medications.

Our site http://www.anestheticnews.com we strive to fill a void that has never been addressed…namely a closer relationship with your pharmacist.   M.Sc. PharmD. CCPE.E-Mail: at localanesthetics@yahoo.ca

This EPIC concerns dentistry, however it could be applied to any of the health care disciplines. Until I started excerpts of this clinical report I was unaware that EPIC is really an acronym in many languages (Educational Program Innovations Center).  However, I shall KIS it (keep it simple) as Wikipedia explains it as though it was custom fitted for the latex hands of a dentist. “This EPIC applies a risk-based spiral development process. EPIC users manage the gathering of information from the marketplace and the stakeholders and refine that information through analysis and negotiation into a coherent, emerging solution that is embodied in a series of executable representations through the life of the project”. (Wiki).

“Kids taking care of kids”; is a far more commonly heard expression than “parents taking care of parents”.  Both are profound statements and carry with them an equal share of clinical situations that would be a heyday for a debating club of medics, dentists, psychologists, universities and all personnel involved in health and care giving. The matrix for parents taking care of parents is non linear and often more subjective than the matrix of kids taking care of kids. The variables are also more convoluted especially when there is more than one adult sibling.  

The term “opposites attract”, is full of truth for some people. However for others it can be the opposite. The life and career of Albert Einstein is proof absolute of the latter. Some people keep their relationship hopping with their individual eccentricities; while others revel in a competitive atmosphere. Renowned psychologist Kevin Leman has developed a personality compatibility test to help people see what their strengths are and what needs to be modified to stem sibling problems.  There are those who believe that individuals, who are too much alike, could be a harbinger of the more sinister and foreboding characteristics with a tendency to not only compete, but at all costs to have the last word.

“Parents taking care of parents”; is no less dramatic; therefore it attracts far less footage and editorials, than “kids raising kids”. This article is devoted to a synopsis of a clinical situation and I will resist the temptation to cover socials sciences and the complex modalities of our society. This epic is intended to highlight the eccentric behavior in adult siblings of which professionals such as clinicians are seeing more frequently.     

The story begins with mother Helen now entering her sixty eighth year. She is comfortably settled in the family house which is her pride and joy. This house was once the center of sleepovers, and giggling little girls; for the aromas of home-made baking and for the invisible love which tapped one’s cheek like the fragrance of a neutral eau de cologne as one enters the never closed front door.

Husband and dad Denis had succumbed the previous year to some form of malignant tumor of the throat which had metastasized soon after a routine visit to Dr. Smith, their family dentist. Helen is very comfortable and in charge of the home. She is usually busy with her hobby of preserving the produce of her bountiful back-yard garden. The shelves are never empty of tempting and tasty peppers, tomatoes and cucumbers in pressure sealed jars neatly arranged and stacked in the cold room off the basement.  Her unconditional love and closeness with her family are at the root of frequent visits from daughters Ann and Judy, now raising their own families.

Helen is in need of some dental work on her mandible but delays it until the pain is unbearable. She makes an appointment with Dr. Smith and manages to slip in on another patient’s cancellation. Both Ann and Judy are available to be with mother Helen for this appointment.

Dr. Smith diagnoses two carious and mildly infected teeth on either side of the anterior mandible that must be removed. Enters sibling rivalry and what was scheduled as a forty minute appointment appears destined to be prolonged as the epic of “parents taking care of parents” takes charge of a clinical situation when the two sisters argue the pros and cons of a repeat situation. Dr. Smith is not aware, but his eyes are moving back and forth as though he is watching Jelena Jankovic take on Serena Williams in a Grand Slam singles championship.

Dr. Smith is silent as one sibling disagreed with the other. The bone of contention is centered on the probable substantive perception that dad’s unexpected malignancy was in some way connected to his last dental visit where a local anesthetic was used; while the other argues it could have been just an outside chance of what is often described in clinical dogma as “a case of one”. Clinicians do not have that luxury of making diagnosis on a case of one.

Dr. Smith muses internally at a classic case of an eccentric anomaly which is attempting to link a malignancy to the administration of a local anesthetic and a rather uncomplicated dental appointment. He knows that it would be considered insensitive if he intervenes at this critical moment. Time is the answer; however Dr. Smith’s schedule is now painfully being backed-up as other patients arrive. 

Sibling rivalry is alive and well and like the autonomic nervous system, is on its own internal computer micro-processor like a GPS, which once set, will deliver you to the destination for which it was programmed. The more and more two siblings are in competition, the less likelihood of a reasonably solution will be achieved. 

The daily planner is now dangerously behind schedule. The assistant is no less concerned than her boss who is cautiously attempting to inject a clinical solution which would calm the siblings. His reasonable and firm explanation about Denis’ (dad’s) unfortunate demise does the trick and the procedure is finally in process. An injection of half a cartridge of local anesthetic solution is slowly deposited into the mental foramen on both quadrants of Helen’s mandible. Dr. Smith is calm as  Helen’s head slumps lazily to one side almost simultaneously with the final extraction.  Still seated on his stool, with his heels, Dr. Smith pulls himself in the direction of the two sisters who are sitting in the operatory still somewhat tense.  With a calm and reassuring smile he informs them that all is well. However Ann still shows some apprehension.

Helen is gently raised by the dental assistant in the hydraulic dental chair and is about to be transferred to the wheel-chair with the helping and caring hands of Ann and Judy. Dr. Smith takes this opportunity to write a prescription for Ibuprofen which will see her through any discomfort and  hasten the healing process.

This synopsis speaks to the complex and contingency modalities facing clinicians in a dynamic world of dentistry. The art of practicing dentistry today involves mastering ever new and convergence technologies which in themselves are extremely challenging. Dr. Smith was caught between the crossfire of rapid firing catecholamines of parents taking care of parents where eccentric behavior clouded a simple clinical procedure that should have been completed in normal time. Unfortunately mastering such complexities is not taught in dental school and can only be slotted into on-the-job training.

Our site www.anestheticnews.com we strive to fill a void that has never been addressed…namely a closer relationship with your pharmacist.   M.Sc. PharmD. CCPE.E-Mail: at localanesthetics@yahoo.ca            

It is absolutely necessary for the needle to be sterile, not least because of the risk of spreading serum hepatitis. Absolute safety is possible only by using disposable needles and a fresh cartridge for every patient.

The injection, always preceded by aspiration, should be carried out so slowly that no counter-pressure is produced. This applies to the whole oral cavity except the hard palate. In this region the mucosa is very tightly adapted to the periosteum and some pressure is thus needed to introduce the solution. This pressure should be quite moderate to avoid tissue damage. Injection here should be given particularly slowly and the injected volume should normally be about 0.3mL. If articaine is your choice, because of its ability to diffuse across bone, you can reduce significantly the pain which is associated with the naso-palatine injections. Lift the lip and on either side of the frenulum, deposit 0.3 mL high on the buccal side. Then palpate the area for about 30 seconds. You will see the blanching on the lingual side. It is seldom necessary to deposit any solution on the lingual side, however if some residual sensitivity is apparent, a few drops can be introduced on the lingual side which will cause no pain because the soft tissue is already frozen.

When the needle is introduced into the tissue a few drops of solution can be deposited directly under the mucosa. More solution may then be injected drop by drop as the needle is gently advanced towards the bone through the tissue to the main deposition site. When advancing along a bone surface it has been suggested that the bevel of the needle tip should be orientated so as to avoid chafing of the periosteum and slides along the bone almost painlessly. The solution should be injected outside the periosteum (supraperiosteally). The tip of the needle should never be introduced directly into a foramen. The risk of damaging vessels and nerves is too great, and there may be complications such as hematoma and paresthesia or prolonged anesthesia. Unnecessary local complications like pain and trismus may be caused by injections into the medial pterygoid muscle during madibular injections.

After an injection a patient must never be left alone, because a possible unexpected reaction may occur at anytime. Many dentists do multi task and dart from one operatory to another. If the dentist does not remain with the patient, a nurse, certified assistant or a hygienist must always be present. The short latency period of modern local anesthetic solutions means that that there is no need to leave the patient while waiting for the anesthetic to take effect.

In some cases, premedication may be useful for the sedation of restless or frightened patients. The anxious patient feels mentally isolated and his/her ability to establish contact with other people is impaired. A proper sedation may help the dental surgeon to reach his/her patient from a psychological point of view. The most important factor is this connection, however, is that (you) the patient has confidence in their dental surgeon. This is ensured by the operator’s calm and confident manner. The patient should be informed in advance of the type of the procedure intended.

Our site http://www.anestheticnews.com we strive to fill a void that has never been addressed…namely a closer relationship with your pharmacist. M.Sc. PharmD. CCPE.E-Mail: at localanesthetics@yahoo.ca