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Sedation & Anesthesia in Dental Practice
“Current Status of
Pain Control in Dentistry” 2010 NATIONAL PRIMARY ORAL HEALTH CONFERENCE
Gaylord Palms Hotel, Orlando FL
O C T 2 0 1 0
• Mel Hawkins • Professor of Pharmacology, Department Chair
• Aurora Dental College • Toronto, Ontario, Canada
www.sedationdentistry.us [email protected]
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…a significant number of practitioners
experience STRESS related to local
anesthesia administration…
Simon et al, Quintessence International 1994
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…almost 19% admitted that at least at some time INJECTING local anesthesia had bothered them enough that they had reconsidered dentistry as a career AND that 6% considered these feelings to be a SERIOUS PROBLEM
Simon et al, Quintessence International 1994
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THE ELUSIVE
MANDIBULAR BLOCK
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A=86%
B=7%
C=7%
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Anatomical Anomalies:
Understanding the pterygomandibular
triangle
The concept of the “two inferior alveolar
nerve” theory
Dr. Patricia Blanton, Baylor University, Dallas, Texas
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Relationship of
Conventional (inferior alveolar)
Akinosi, closed mouth
Gow-Gates “condylar neck”
Hybrid, “mix and match” blocks
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Tips and Tricks
12 Tips and Tricks of
Putting It All Into Place
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Anatomical Variations:
Hard tissue anatomy
Connective tissue and Neurovascular anatomy
Reasons for Failure
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3 Major Factors:
Internal Oblique Ridge
Sphenomandibular fascial barrier
Risks: Nerves, Arteries
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Local Anesthesia:
Anatomical Influences:
The maxillary artery,
passes through the high
pterygomandibular triangle
region
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Local Anesthesia:
The Question is:
What is the risk of an intra
arterial injection?
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Clinically Unlikely INTERNAL MAXILLARY ARTERY CHARACTERISTICS:
Thick smooth muscle wall
Well innervated
Constricts or arteriospasms, eliminates lumen
Artery is mobile within the anatomical area
Pulse pressure
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Leonard M, Local Anesthesia Volume and
Success Rates, JADA Vol.
126(833) 1995
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Management of Pain and Anxiety in the
Dental Office
Dionne, Phero, Becker
Hawkins, J.M. Local Anesthesia Cpt. 13
Philadelphia, PA, W.B. Saunders 2002
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Local Anesthesia of the Oral Cavity
Jastak, Yagiela and Donaldson
Philadelphia, PA, W.B. Saunders 1998
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Condylar Neck
Mandibular Block
Gow-Gates 1973
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An Intraoral Approach,
Utilizing External Landmarks
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ANATOMICAL
CONSIDERATIONS
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Clinical
Technique
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Gow-Gates Summary
Onset: 5 - 15 minutes
Characteristic: posteriorÆforward
Duration: 3 - 4.5 hours pulpal
3 – 12 hours soft tissue
Post-op analgesia:
0.5% bupivacaine 1:200K epi
x 2 cartridges
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Lingual Infiltration
Advantages:
Thin cortical plate
Lingual foramina
Patient acceptance
Lingual nerve blocked already
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Lingual Infiltration
Disadvantages: Ballooning of tissue
Avoiding submandibular
salivary gland
Vision
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Lingual Infiltration Patient selection criteria
enhancement: Missing adjacent teeth
Thinner alveolar anatomy
Younger/older patients
Root anatomy visible
Vertical buccal shelf form
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Lingual Infiltration
Technique: Apical to mucogingval junction
Tissue expands
Avoid submandibular gland
Vision enhanced by position and tongue retraction
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Lingual Infiltration
Technique:
• Depth: 2-3 mm
• Time: 5 minutes
• Volume: 0.7 cc
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EFFICACY OF
LOCAL
ANESTHESIA
SOLUTIONS
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25 years of 4% articaine administration
Septocaine®, Zorcaine®, Astracaine®
Ultracaine®, Septanest®
with epinephrine 1:100,000 and 1:200,000
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Articaine
A statistically significant scientific study has just been published showing that 4%
articaine 1:100K performed more efficaciously than 2% lidocaine 1:100K in
controlled clinical administrations.
Kanaa, MD et al, J.Endod 32:296-298,2006
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Sulfa,
Bactrim ®
IS NOT
Sulfur,
a nonmetallic element
IS NOT
Sulphite,
an antioxidant for epinephrine
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Metabolism,
Safety,
Toxicity,
and Children
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LOCAL ANESTHESIA
TOXICITY
MAXIMUM DOSAGES
AND
IMPLICATIONS
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Metabolism
Although classified as an amide local
anesthetic, the articaine molecule is 90%
inactivated by plasma cholinesterases and
only 10% by hepatic enzymes.
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Safety
The authors could not find a single mortality linked to articaine, in any age group, in it’s 29 year history of dental administration in Europe, Canada and now the U.S.A.
Hawkins, J. M., Moore, P. A. Local Anesthesia:
Advances in Agents and Techniques.,
Dent Clin N Am 46 (2002) 719-732
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Search
Furthermore, since the product has been available in
Germany and France since 1976 and has secured
~90% of the market for dental usage, the authors
expected to find reports of post op sequellae such
as lingual nerve and/or inferior alveolar nerve
paresthesia or dysesthesia.
Hawkins JM, Moore PA, Local Anesthesia:
Advances in Agents and Techniques, Dent Clin N Am 46 2002 719-732
Hawkins JM, Moore PA, Local Anesthesia:
Advances in Agents and Techniques,
Dent Clin N Am 46 (2002) 719-732
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Paresthesia Facts with respect to:
4% Articaine (Septocaine)
and
4% Prilocaine (Citanest)
Local Anesthetics
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Paresthesia Reports A Retrospective Study from 1995 Reported:
Prilocaine (15x) and articaine (20x) showed greater
frequency of paresthesia with mandibular block
anesthesia (cf. lidocaine).
(Data on duration not provided)
Haas, DA, Lennon, D. A 21 Year Retrospective Study
J. Can Dent Assoc 1995; 61(4):319-330
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Paresthesia Reports
The same study from 1995 reports an extremely low
overall frequency of paresthesia with mandibular
block anesthesia of:
14 in an estimated 11,000,000 injections
or
1 in 785,714
Haas, DA, Lennon, D. A 21 Year Retrospective Study
J. Can Dent Assoc 1995; 61(4):319-330
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Paresthesia Reports
“… it appears that informed consent is merited in
performing mandibular block and lingual block
injections with articaine and prilocaine…
…does the risk of paresthesia warrant use of
articaine and prilocaine for lingual nerve, inferior
alveolar nerve and other mandibular block
injections?”
Dower JS. A review of paresthesia in association with
administration of anesthesia. Dentistry Today 2003:22(2):65-69
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Data Assessment
Factors:
Neural
Research and reporting
Advanced or higher mandibular techniques
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Is there a proven “cause and effect” of dental paresthesia
with respect to 4% solutions?
Using dissecting microscope:
.02 ml of 4% articaine injected into rat sciatic n.
.01 ml of 4% articaine injected into cat lingual n.
After 30 days, animals sacrificed:
average axonal x-section areas were unchanged
when compared to uninjected (control) side.
Hoffmeister, Dutsch Zahnartzl, 46,828-830, 1991
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Is there a proven “cause and effect” of dental paresthesia
with respect to 4% solutions?
There is no evidence based data to conclude
that 4% prilocaine or 4% articaine is directly
or scientifically causitive of dental
paresthesia and/or hypesthesia.
Hawkins JM, Articaine: Truths, Myths and Potentials,
Academy of Dental Therapeutics and Stomatology. 9 2003
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Clinical (unpubl. data) Hands-on instruction,1982-present:
In approximately 2500 Dentist participation course, directly supervised injections (Akinosi, Gow-Gates) and in
Private practice,1976, 4 day week, 42 weeks/yr:
Administering over an estimated 12,000 high “hybrid” blocks using primarily 4% prilocaine from 1976-1982 and primarily 4% articaine from 1982, no paresthesias have been reported by the participants or experienced by the patients who have been treated in private practice.
Hawkins JM, Instructor and Private Practitioner,
Unpublished data, anectdotal, 1976 - present
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CONVENTIONAL MANDIBULAR ANESTHESIA
12 TIPS & TRICKS
Or
TRIALS & “DAMAGE CONTROL”
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WHAT’S NEW?
The Current Status of
Pain Control in
Dentistry
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1
OraVerse™ Phentolamine Mesylate Injection
“Reversing” Local
Anesthesia
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Phentolamine mesylate
reverses SOFT TISSUE
ANESTHESIA ONLY
Phentolamine mesylate
is NOT a LOCAL
ANESTHETIC reversal agent
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Adults and Adolescents: 60 Minute Efficacy Data
Time to Recovery of
Normal Lip Sensation
0171, Rev. 10/2008
Mandible
• Phentolamine mesylate accelerates the return to normal sensation by 85 min, 54.8%; p<0.000
41% phentolamine mesylate patients fully recovered in 60 minutes
7% for control patients
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Adults and Adolescents: 60 Minute Efficacy Data
Time to Recovery of
Normal Lip Sensation
0171, Rev. 10/2008
Maxilla
• Phentolamine mesylate accelerates return to normal sensation by 83 min. 62.3%; p<0.0001
• 59% phentolamine mesylate patients fully recovered in 60 minutes,
12% for control patients
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Post-surgery:
Bupivacaine HCl +NSAID are indicated
Following PDL (ILI) or Intraosseous (IO)
Phentolamine Mesylate
NOT suggested for:
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Local Anesthesia “Reversal” Agent
• OraVerse is indicated for reversal of soft-
tissue anesthesia, i.e., anesthesia of the lip
and tongue, and the associated functional
deficits.
• OraVerse is not recommended for use in
children less than 6 years of age or weighing
less than 15 kg (33 lbs)
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Administration and Dosage
Standard dental cartridge with distinctive
green label
Administered by injection with standard
dental syringe
Utilizes same injection site and identical
administration technique to that used for
the local anesthetic
1:1 ratio to local anesthetic (1/2, 1 or 2
cartridges)
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2
The Current Status of Pain
Control in Dentistry
ONSET™
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•Increasing the
effectiveness of local anesthetics
The Current Status of Pain
Control in Dentistry
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•Increasing the
comfort of LA injections
The Current Status of Pain
Control in Dentistry
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Staff who are . . . KIND,
PROFESSIONAL, CARING,
WARM, HELPFUL
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A dentist who:
DOES NOT HURT
AND
Can give a PAINLESS
INJECTION
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How to make the administration of local
anesthesia
PAINLESS
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Topical anesthetic
Stretching of the soft tissues
Gentle needle insertion
SLOW administration of the anesthetic solution
How to make the administration of
local anesthesia
PAINLESS
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How to make the administration of local
anesthesia
PAINLESS pH of LA solution:
LA with vasopressor pH 3.5 ~4.9
LA ‘plain’ pH 5.5~6.5
Administer small volume of ‘PLAIN’ drug before administration of LA + vasopressor
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Na Bicarbonate - NaHCO3
Used in medicine (ophthalmology, dermatology, plastics, urology) to increase both
COMFORT & SPEED of ONSET of LAs
J Am Acad Dermatol 54(1): 128-131, 2006
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Anesthetic cartridge
Onset™ System Components
5
Bicarbonate cartridge
Transfer needle
System assembled and ready to buffer anesthetic cartridge
Reusable dosing pen
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© 2008 Monterey Devices – Proprietary and Confidential
13 6 11 5 9 4 7 3 5 2 3 1 1
1 2 3 4 5 6
Time
to
Pulpal Anesthesia
(minutes)
Number of Participants at each 20 second time
interval
Standard Anesthetic Onset™ System
Failed Anesthetic
1
2
3
4
5
6
7
8
9
:20
:40
1
2
3
4
5
6
7
8
9
:20
:40
Number of Participants at each 20 second time interval
Average = 5:17
Minutes to Profound Numbness
Average:
5 minutes 17 seconds
Average:
1 minute 26 seconds
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The future of local anesthetic:
Onset
System™
ONSET™ Available
in the USA
2010
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3
The Current Status of Pain
Control in Dentistry
ACCUSPRAY ®
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Flumist® nasal delivery of
local anesthesia
No needle for teeth #3 – #14
Pulpal Anesthesia!
ACCUSPRAY ®
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World’s First Intranasal Dental Anesthetic currently in research and development
Utilizing the BD ACCUSPRAY® technology currently delivered with the Flumist® nasal product
The goal is to produce a regional block enabling operative dental procedures on number 3 through 14.
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Sedation & Anesthesia in Dental Practice
“Current Status of
Pain Control in Dentistry” 2010 NATIONAL PRIMARY ORAL HEALTH CONFERENCE
Gaylord Palms Hotel, Orlando FL
O C T 2 0 1 0
• Mel Hawkins • Professor of Pharmacology, Department Chair
• Aurora Dental College • Toronto, Ontario, Canada
www.sedationdentistry.us [email protected]