UPGRADES TO YOUR ANESTHESIA TOOL BELT

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1 UPGRADES TO YOUR ANESTHESIA TOOL BELT BERNADETTE ALVEAR FA, DDS ASSISTANT PROFESSOR - DEPT OF PREVENTIVE AND RESTORATIVE DENTISTRY UNIV OF THE PACIFIC, ARTHUR A DUGONI SCHOOL OF DENTISTRY STANISLAUS DENTAL SOCIETY JUNE 2017

2 THANK YOU

3 OBJECTIVES Review Anesthesia Examine the tool belt Discuss Upgrades

4 REVIEW ANESTHESIA Dental Anxiety and Fear Contemporary pain free society

5 REVIEW ANESTHESIA Anesthesia needs to be Effective / Profound Reversible / Comfortable

6 REFLECTION Communication is key Subjective findings Verbally / Non verbally Transparent discussion

7 EXAMINE THE TOOL BELT

8 EXAMINE THE TOOL BELT

9 EXAMINE THE TOOL BELT - TECHNIQUES Infiltration Block Technique

10 EXAMINE THE TOOL BELT - TECHNIQUES Infiltrations - Supraperiosteal Commonly used for localized areas Great for pediatric, special health care needs Short simple procedures

11 EXAMINE THE TOOL BELT - TECHNIQUES Block Injections - closer in proximity to main nerve Larger Surface Area Anesthetized Longer Duration Anesthesia Possible for quadrant dentistry minimum 1.8 ml

12 EXAMINE THE TOOL BELT - TECHNIQUES Block Injection Technique - Maxillary V2 Maxillary Division Posterior Superior Alveolar Anterior Superior Alveolar

13 EXAMINE THE TOOL BELT - MAXILLARY TECHNIQUES V2 Maxillary Division Nerve Block Anesthesia to the hemimaxilla PSA approach GP approach

15 EXAMINE THE TOOL BELT - MAXILLARY TECHNIQUES Posterior Superior Alveolar Block

17 EXAMINE THE TOOL BELT - MAXILLARY TECHNIQUES Anterior Superior Alveolar Block

18 EXAMINE THE TOOL BELT - MANDIBULAR TECHNIQUES Block Injection Technique - Mandibular Inferior Alveolar Nerve Block Gow Gates Technique Vazirani Akinosi Technique

19 EXAMINE THE TOOL BELT - MANDIBULAR TECHNIQUES Inferior Alveolar Nerve Block Lingual Buccal

20 EXAMINE THE TOOL BELT - MANDIBULAR TECHNIQUES Inferior Alveolar Nerve Block Lingual Buccal

22 EXAMINE THE TOOL BELT - MANDIBULAR TECHNIQUES Gow-Gates Injection Patient uses bite block

24 EXAMINE THE TOOL BELT - MANDIBULAR TECHNIQUES Vazirani-Akinosi Closed mouth technique

26 EXAMINE THE TOOL BELT - ARMAMENTARIUM Needles Mandibular Blocks 25 or 27 gauge LONG

27 EXAMINE THE TOOL BELT - ARMAMENTARIUM Anesthetic Agents 2% Lidocaine HCl with epinephrine 1:100,000 (red) 2% Lidocaine HCl with epinephrine 1:50,000 (green) 3% Mepivacaine HCl (tan) 4% Prilocaine HCl (black) 4% Prilocaine HCl with epinephrine 1:200,000 (yellow) 4% Articaine HCl with epinephrine 1:100,000(gold) or 1:200,000 (silver) 0.5% Bupivacaine HCl with epinephrine 1:200,000

28 EXAMINE THE TOOL BELT - ARMAMENTARIUM 2% Lidocaine HCl 1:100,000 - red mins pulpal anesthesia (infiltration vs block) 3-4 hrs soft tissue 3.2 mg/lb max dose

29 EXAMINE THE TOOL BELT - ARMAMENTARIUM 2% Lidocaine HCl 1:100,000 - red For pediatric patients < 10 yrs old 0.9 ml minimum for effective anesthesia 2.0 mg/lb max dose

30 EXAMINE THE TOOL BELT - ARMAMENTARIUM 3% Mepivacaine HCl - tan mins of pulpal anesthesia (infiltration vs block) 3-4 hrs of soft tissue anesthesia 3.0 mg/lb max dose

31 EXAMINE THE TOOL BELT - ARMAMENTARIUM 4% Prilocaine HCl - black mins of pulpal anesthesia (infiltration vs block) 3-4 hrs soft tissue anesthesia 4.0 mg/lb max dose

32 EXAMINE THE TOOL BELT - ARMAMENTARIUM 4% Prilocaine HCl with epinephrine 1:200,000 - yellow minutes of pulpal anesthesia (infiltration vs block) 3-4 hrs soft tissue 4.0 mg/lb max dose

33 EXAMINE THE TOOL BELT - ARMAMENTARIUM 4% Articaine HCl with epinephrine 1:100,000 (gold)or 1:200,000 (silver) min pulpal anesthesia (infiltration vs block) 3-4 hrs soft tissue anesthesia 3.2 mg/lb max dose

34 EXAMINE THE TOOL BELT - ARMAMENTARIUM 0.5% Bupivacaine HCl 1:200,000 - blue mins pulpal anesthesia (infiltration vs block) 5-7 hrs soft tissue anesthesia 0.6 mg/lb max dose

35 EXAMINE THE TOOL BELT What s the best tool? Comfortable with technique Appropriate for planned procedure Meets patients needs

36 BREAK

37 UPGRADES TO TOOL BELT Patient Comfort Needle-less Profound Reversible

38 UPGRADES TO TOOL BELT - PATIENT COMFORT Orapharma s Onset (R) 8.4% sodium bicarbonate Faster Onset Profound anesthesia

40 UPGRADES TO TOOL BELT - PATIENT COMFORT Anutra Medical (R) Longer Shelf Life Dispenser, Cassette, Disposable Syringe

42 UPGRADES TO TOOL BELT - PATIENT COMFORT The Wand STA (R) Computer controlled local anesthesia device (C-CLAD) Slower rate of delivery Handpiece esthetic

44 UPGRADES TO TOOL BELT - PATIENT COMFORT Dental Vibe Cordless and Rechargeable Retraction Device Addresses Gate Theory of Pain

46 UPGRADES TO TOOL BELT - NEEDLE-LESS Kovanaze (R) Intranasal spray 0.5% Oxymetazoline + 3% Tetracaine HCl Pulpal anesthesia to anterior teeth and premolars Important Safety Information: The most common adverse reactions to KOVANAZE occurring in 10% of patients include a runny nose, nasal congestion, watery eyes, nasal discomfort, and sore throat. KOVANAZE is contraindicated in patients with a history of allergy to tetracaine, benzyl alcohol, other ester local anesthetics, p-aminobenzoic acid (PABA), oxymetazoline, or any other component of the product. Some clinical trial patients experienced an increase in blood pressure so blood pressure should be monitored. In addition, patients should be carefully monitored for dysphagia. KOVANAZE is not recommended for use in patients with a history of frequent nose bleeds. KOVANAZE, like other local anesthetics, may cause methemoglobinemia. Concomitant use of monoamine oxidase inhibitors, nonselective beta adrenergic antagonist, or tricyclic antidepressants may cause hypertension and is not recommended. Discontinue use of oxymetazoline-containing products 24 hours prior to KOVANAZE administration. Avoid concomitant use of intranasal products.

UPGRADES TO TOOL BELT - NEEDLE-LESS Important Safety Information: The most common adverse reactions to KOVANAZE occurring in 10% of patients include a runny nose, nasal

KOVANAZE is contraindicated in patients with a history of allergy to tetracaine, benzyl alcohol, other ester local anesthetics, p-aminobenzoic acid (PABA), oxymetazoline, or any

In addition, patients should be carefully monitored for dysphagia. KOVANAZE is not recommended for use in patients with a history of frequent nose bleeds.

47 UPGRADES TO TOOL BELT - NEEDLE-LESS Important Safety Information: The most common adverse reactions to KOVANAZE occurring in 10% of patients include a runny nose, nasal congestion, watery eyes, nasal discomfort, and sore throat. KOVANAZE is contraindicated in patients with a history of allergy to tetracaine, benzyl alcohol, other ester local anesthetics, p-aminobenzoic acid (PABA), oxymetazoline, or any other component of the product. Some clinical trial patients experienced an increase in blood pressure so blood pressure should be monitored. In addition, patients should be carefully monitored for dysphagia. KOVANAZE is not recommended for use in patients with a history of frequent nose bleeds. KOVANAZE, like other local anesthetics, may cause methemoglobinemia. Concomitant use of monoamine oxidase inhibitors, nonselective beta adrenergic antagonist, or tricyclic antidepressants may cause hypertension and is not recommended. Discontinue use of oxymetazoline-containing products 24 hours prior to KOVANAZE administration. Avoid concomitant use of intranasal products.

48 UPGRADES TO TOOL BELT - NEEDLE-LESS Oraquix (R) 25 mg / ml Prilocaine 25 mg / ml Lidocaine Eutecitic Mixture of Local Anesthesia (EMLA) FDA approved for scaling and root planing

50 UPGRADES TO TOOL BELT - PROFOUND ANESTHESIA Intraosseous Systems Stabident(R), X-tip System(R), Anesto(R), Comfort Control SyringeR) Direct placement into cancellous bone 0.9 ml minutes pulpal anesthesia

51 UPGRADES TO TOOL BELT - PROFOUND ANESTHESIA Intraosseous Systems Post - op discomfort Increase in heart rate

52 UPGRADES TO TOOL BELT - REVERSAL Septodont s Oraverse (R) Phentolamine Mesylate Vasodilator Soft tissue reversal

53 UPGRADES TO TOOL BELT What does my patient population look like? Do I need the upgrade? Am I willing to spend on overhead?

54 ??? - BALVEAR@PACIFIC.EDU

55 ENJOY YOUR WEEKEND AND SAFE TRAVELS

56 Be Joyful B Fa

57 RESOURCES 1) ADA survey. Influences on dental visits. ADA News 1998; 11: 4. 2) Crawford S, Nissen L, Wong S, Dowling E. Quantification of patient fears regarding dental injections and patient perceptions of a local noninjectable anesthetic gel. Compend Contin Educ Dent 2005; 26 (2 Suppl 1): ) Nakai Y, Milgrom P, Mancl L, Coldwell SE, Domoto PK, Ramsay DS. Effectiveness of local anesthesia in pediatric dental practice. JADA 2000; 131 (12): ) Berggren, Ulf, and Gunnell Meynert. "Dental fear and avoidance: causes, symptoms, and consequences." The Journal of the American Dental Association (1984): ) Gatchel, Robert J., et al. "The prevalence of dental fear and avoidance: a recent survey study." Journal of the American Dental Association (1939) (1983): ) Milgrom, P., L. Fiset, and P. Weinstein. "Prevalence of dental fear and relationship to utilization and self-reported health." J. Dent. Res 47 (1986): ) Malamed, S. F. "Pain and anxiety control in dentistry." Journal of the California Dental Association (1993): ) Hawkins, J. Mel, and Paul A. Moore. "Local anesthesia: advances in agents and techniques." Dental Clinics 46.4 (2002): ) Deepika, A., et al. "Effectiveness of two flavored topical anesthetic agents in reducing injection pain in children: a comparative study." Journal of Clinical Pediatric Dentistry 37.1 (2012): ) Haas, Daniel A. "An update on local anesthetics in dentistry." Journal-Canadian Dental Association 68.9 (2002): ) Malamed, Stanley F. "Buffering local anesthetics in dentistry." The pulse 44.1 (2011): ) Malamed, Stanley F. Handbook of local anesthesia. Elsevier Health Sciences, 2014: ) Srinivasan, Narasimhan, et al. "Comparison of anesthetic efficacy of 4% articaine and 2% lidocaine for maxillary buccal infiltration in patients with irreversible pulpitis." Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology, and Endodontology (2009): ) Haase, Andrew, et al. "Comparing anesthetic efficacy of articaine versus lidocaine as a supplemental buccal infiltration of the mandibular first molar after an inferior alveolar nerve block." The Journal of the American Dental Association (2008): ) Fa, Bernadette Alvear, and Eve Cuny. "Preliminary evidence supports modification of retraction technique to prevent needlestick injuries." Anesthesia Progress 63.4 (2016):

58 RESOURCES 16) Makary MA, Al-Attar A, Holzmueller CG, Sexton JB, Syin D, Gilson MM, Sulkowski MS, Pronovost PJ. Needlestick injuries among surgeons in training. New England Journal of Medicine. 2007;356(26): ) David HT, Aminzadeh KK, Kae AH, Radomsky SC. Instrument retraction to avoid needle-stick injuries during intraoral local anesthesia. Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology, and Endodontology. 2007;103(3):e ) Ogle, Orrett E., and Ghazal Mahjoubi. "Local anesthesia: agents, techniques, and complications." Dental Clinics of North America 56.1 (2012): ) Davies, Robert John. "Buffering the pain of local anaesthetics: a systematic review." Emergency Medicine 15.1 (2003): ) Malamed, S. F., S. Tavana, and M. Falkel. "Faster onset and more comfortable injection with alkalinized 2% lidocaine with epinephrine 1: 100,000." Compendium of continuing education in dentistry (Jamesburg, NJ: 1995) 34 (2013): ) Melzack R, Wall PD. Pain mechanisms: a new theory. Science. 1965;150: ) Dickenson AH. Gate control theory of pain stands the test of time. Br J Anaesth. 2002;88: ) Ching, David, Matthew Finkelman, and Cheen Y. Loo. "Effect of the DentalVibe injection system on pain during local anesthesia injections in adolescent patients." Pediatric dentistry 36.1 (2014): ) Thoppe-Dhamodhara, Yogesh-Kumar, et al. "Cartridge syringe vs computer controlled local anesthetic delivery system: Pain related behaviour over two sequential visits a randomized controlled trial." Journal of clinical and experimental dentistry 7.4 (2015): e ) Hersh, Elliot V., et al. "Double-masked, randomized, placebo-controlled study to evaluate the efficacy and tolerability of intranasal K305 (3% tetracaine plus 0.05% oxymetazoline) in anesthetizing maxillary teeth." The Journal of the American Dental Association (2016): ) Hersh, Elliot V., et al. "Reversal of soft-tissue local anesthesia with phentolamine mesylate in adolescents and adults." The Journal of the American Dental Association (2008): ) Tavares, Mary, et al. "Reversal of soft-tissue local anesthesia with phentolamine mesylate in pediatric patients." The Journal of the American Dental Association (2008): ) Hersh E, Lindemeyer R. Phentolamine mesylate for accelerating recovery from lip and tongue anesthesia. Dent Clin North Am 2010;54(4):

Safety. Local anesthetics were first introduced in the 1880s by A. N. E. S. T. H. E. S. I. A. general practice feature. by Elizabeth J.

Safety. Local anesthetics were first introduced in the 1880s by A. N. E. S. T. H. E. S. I. A. general practice feature. by Elizabeth J. Safety A. N. E. S. T. H. E. S. I. A by Elizabeth J. Fleming, DDS Local anesthetics were first introduced in the 880s by William Halsted, MD, when he found injectable cocaine to be useful for surgeries.