Wednesday, February 4, 2009

Septocaine

Okay,

I have finished Jane Eyre. Let me put this into perspective. I read about 15 books a year. It took me 2 months to read this book.
IT SUCKED.
I am sorry all you woman that loved this book. I am sorry all you literature majors but there was not one redeeming thing about this book.
I said it that this book was for smart people. Well I was wrong. It is for people with sleeping issues.

I saw Gran Torino at the theater on Monday (reason I didn't blog). It was FANTASTIC.
I am not kidding. I left the theater wishing the movie was longer.
The characters were endearing (even though the acting was a little weak by the Asian boy) and you couldn't help but like all of them.
I haven't stopped talking about this movie all week.
I have heard good things about this Slum Dog Millionaire movie too.
Maybe next Monday.

Dentistry from the Heart is 9 days away. Things are falling into place.
I was interviewed by the Orlando Sentinel on Monday (another reason I didn't blog).
One of the things I battle with is publicity. I don't really want Dentistry from the Heart to be about John Gammichia. But I want the word to get out that people have need. I want the word to get out that 14 dentists are volunteering to meet this need. I want the word to get out that we are doing this because I want all the people that may have a need to learn about our day.

I went to dinner on Saturday night (with a gift card) to Bahama Breeze. Bahama Breeze is a Darden Restaurant, you know the same company that owns Red Lobster, Olive Garden). Season's 52 is also a high end Darden restaurant. We tried to get reservations there. When I say we tried this means they didn't have any reservations available. Yes you heard me correctly...they were so full they couldn't take our business.
So we went to Bahama Breeze and you know how much I don't want to belabor a point but it was packed. First we had to park in a different lot because their lot was full.
We went with another couple and they had to park farther away.
We took our time eating dinner and they were packed for the 2 and a half hours we were there.
Amazing.
And did you see another comment came in about the new Ferrari dealership that just opened in this person's town. The dealership sold 8, eight, ocho, in the first month it was open.

My boys basketball team won again. 32-30 in overtime.
Try coaching a "Christian" basketball game that is highly contested and very physical and not yell the F-bomb. This is tough for me to do.

Last thing.
I told you how funny my 5 year old boy is.
Well, my wife came in from running errands the other day and he welcomes her with, "Hello, my lady." (like in a British accent).
He is a riot.

Okay Topic de jour,
Septocaine.
I am going to come clean. I use Septocaine for everything. Local, blocks, kids, adults, everything.
I know you non-Septocaine users are gasping right now.
But I think over the last 5 years or so a lot of people are doing what I do.
Septocaine...anyplace anywhere.
Here is the benefit. It works and it works great. I don't ever have to stick someone more than 15 times anymore. I don't ever use more than 2 carps to get someone comfortable.
It is a deep anesthesia.
It is great for kids because a local works everywhere in the mouth. Drop it by the tooth and the kid is numb.
It is a bit expensive but I am more than happy to pay it.

But the knock on Septocaine is that it has a higher rate of people parasthesia.
Well this has yet to be founded in research papers. I have heard many of "gurus" say that this just isn't true. But what people are seeing in their offices is different than in the the research.

With this being said I got a call this morning that always make my butt sweat.
I had an emergency yesterday and I gave a lower block. He got good and numb. Last night his teeth were un numb and so was his tongue but not his lip.
What a great way to start your morning.

I have been using Septocaine almost exclusively for about 8 years. I think I have had this call 4 times. Two of them got better. The other two I never heard from again.

This morning I called my oral surgeon asking if there was a magic bullet that I might give him to help things along. Maybe a steroid or something.
But I have yet to hear from him. I also wrote to my old friend Michael at Reality to see what he knows about Septocaine and this is the response I got.


Re:Septocaine 1 Hour, 5 Minutes ago

From Editorial Team Member Dr. David Winkler:In Scandinavia and the UK, articaine is no longer to be used for inferior dental alveolar blocks ... great for infiltrations. A number of cases have been reported with permanent problems! So, we're using it extensively for inflitrations but not for blocks.
From Editorial Team Member Dr. Stepen Poss:I use a lot of Septocaine (70%) for everything EXCEPT mandibular blocks because the manufacture did not recommend it because of problems with the mandibular nerve. This warning came about a year after I have been using it. No problems here. I love it and get profound anesthetic.
From Editorial Team Member Dr. David Hornbrook:I think it is personally one of top things I could not live without. I have not given mandibular blocks for close to 10 years. I infiltrate usually using ½ -3/4 of a carpule on the buccal on the mandibular teeth and sometimes ¼ carpule on the lingual for those second molars where there is a shallow buccal vestibule. I would not give mandibular blocks using Septocaine 4% due to reports of parasthesia. It is also great for the ASA in injection in the maxillary palate for anterior smile designs.
From Editorial Team Member Dr. Lori Trost:I have been using Septocaine for almost everything the past 2 years and have no experienced no problems. I find patients do very well with it.
From Editorial Team Member Dr. Gary Radz:Use it 100% of the time for lowers premolar and forward. Will use on lower 1st molars on smaller patients.Still use lidocaine for all uppers and all lower blocks, but "out there", there seems to be a lot of DDSs going to Septo.
From Editorial Team Member Dr. Nathan Birnbaum:While Septocaine is unique among local anesthetics in its ability to achieve excellent anesthesia of the mandibular first molars and second premolars by injecting it in the buccal and lingual vestibules in the approximate vicinity of the root apices, it does not work for mandibular second or third molars. Further, its administration is contraindicated for mandibular block injections, where the undesired effect of permanent paresthesia may occur. Septocaine is otherwise an excellent local anesthetic.... but not for "everything".
From Editorial Team Member Dr. Edward Lynch:I use this as my first choice for infiltrations. It is faster acting and seems to be more powerful than alternatives. The JIDA journal has recommended not using it for blocks. Serious complications have been associated with Septocaine. Long-term or transient paresthesia is among the worst of the reported side effects of Septocaine which occurs much more frequently than with lidocaine. It should be noted that almost all recorded cases of long term numbness or parasthesia in a dental setting are associated with a mandibular nerve block type injection and simple infiltration injections are generally thought to be immune from such complications. For this reason many dentists have abandoned using articaine for mandibular nerve blocks.
From Editorial Team Member Dr. Timothy Kosinski:I love Septacaine. Cannot use for blocks, NO BLOCKS! I use it routinely for maxillary cases. I infiltrate individual teeth even for implant procedures. No more blocks. Very nice anesthesia. Even SOME patients who have had a negative reaction to epinephrine in the past have shown no adverse affects, speeding heartrate, shaking. Cannot use on pediatrics, so still need traditional anesthetics.

UH, OH!!!!
I guess...no more blocks for me.

I would like to know what you guys do?
Do you use it?
Do you have issues?
Remember you can comment anonymously.

Let me know,
john

27 comments:

Anonymous said...

I have used Articaine for 6 years for everything, including blocks. I have had only a couple parathesias but they were temporary, nothing permanent. I've always heard it has been in use in Europe about 25 yrs and they routinely use it for blocks. Maybe I just wanted to hear that. Now you have me rethinking it's use for blocks.

Thanks!!!!!!!!!!!

Anonymous said...

I use it for infiltration, but not for blocks. I will need to look at the office, but if I remember correctly, the product information sheet that comes with Septocaine advises no blocks.

Anonymous said...

I use septocaine for all maxillary injections and lower premolars forward. I used to use it for mandibular blocks, had 2 lip parasthesias, one lasted about 3 months the other about 6 months( on an attorney's wife).

Anonymous said...

I have only ever used it on a block once. This was a very nice emergency patient in excrutiating pain. 2 carpules of lidocaine did nothing. I gave him oral informed consent for use of articaine for an inferior alveolar nerve block and advised him of possible parasthesia issues. He consented and got numb (no parasthesia issues). I was able to successfully do a pulpectomy and relieve his pain. I really do think articaine should be used for blocks in emergencies. I think if proper informed consent is given that should be protection enough in court (especially if any member of the jury has ever had a terrible toothache).

Matthew said...

It's funny that articaine has been used for years in Europe and Canada--yes, even for mandibular blocks.
I use it on everything like you John. No problems in 5 years.

gatordmd said...

I am going to write a follow up blog on Septocaine.
Thanks for writing.
john

Anonymous said...

I have two comments, about Articaine, and its use in mandibular blocks. Although it is a rare occurence, the research done by Septodont,which was submitted to the FDA with thier approval filing, clearly indicates that there is an increased risk of parasthesia with Articaine. The research done compared it to a similiar number of lidocaine injections. So, the research is in.
Secondly, you posted a comment by Dr Hornbrook who teaches its use in the palate for anterior cosmetic cases. I think the doctor should have included a caveat along with that recommendation, as a number of serious cases of palatal tissue sloughing have occured when used in that position, and with the quantities he recommends.
Having said this, I routinely use Articaine in all infiltratable procedures.I will post anonymously as I may be party to a class action lawsuit against Septodont.

gatordmd said...

Thank you for your comment.
I am intrigued by the lawsuit.
Is someone going to sue Septodont or what? And you say you maybe party to a class action suit. Well which party are you on?
Tell us what you know.
Thanks
john

Anonymous said...

I never have a problem with lidocaine, so why switch? It doesn't matter what the science says, but it is real important what jury says. Sad, but true. I contend that operator technique is the real determinant in anesthetic efficacy.

Martin Edwards said...

HI,
I'm a UK dentist and have used 4% Articaine with epinephrine 1:100000 for everything for 10 years. So far only 1 problem with an ID block has occurred(which resolved in about four months. Somehow the recommendation not to use Articaine for nerve blocks has gotten right past me. With lots of respectable gurus like Ed Lynch and Dr Hornbrook taking issue with Articaine, now I'm nervous. I've never aspirated my dental injections in over thirty years, but am always very slow and careful, watching the patient, and constantly checking they are OK. I'm also very busy, with lots of procedures that I feel need ID blocks or Gow-Gates blocks every day and I'm really curious about folks who say they never give a block. I doubt they're starting RCT's in 'hot teeth, doing lower third molar surgery, or prepping lower second molars for abutments. Articaine is just great stuff. However, if the evidence is pointing to problems with blocks, I guess I'd better re-consider before I get one. Drat and double drat!

Anonymous said...

I feel you man. I was the same way. But one problem with parasthesia was enough to scare me. JUST ONE.
You are not alone and after this blog entry I received a ton of emails that you all didn't see that told me that they are not switching. I now, for individual molars, use Septocaine in the Paraject. Man this is awesome.
Root canals and extractions. It is real nice. For multiple teeth in the same quadrant I went back to Lidocaine with Septocaine locally. I still use Septo on all upper teeth.
I wish I didn't have to change, but I did.
john

Anonymous said...

I use articaine only for infiltration in my oral surgery practice. With lidocaine and mepivicaine working very well in my hands under almost all circumstances (local only, no sedation), I see no need to take the risk and use articaine in nerve blocks. Recently, two general dentists called me to ask for my opinion on articaine as a few of their patients developed paresthesia after articaine inferior alveolar blocks. One patient decided to sue and the law firm is now asking me for a legal opinion.

gatordmd said...

If anyone wants to know why I don't give Septocaine blocks anymore please refer to the last sentence of the previous comment.
john

Anonymous said...

FYI My husband had a Septocaine injection in 2005 and went to ER three times in 30 hours with severe allergic reaction. His mouth and throat swelled with first visit. Second visit couldn't breathe. Third visit his chest tissue was swelling and almost put him in cardiac arrest. Check your patient's allergy profile. We think my husband may be sulfite sensitive but not sure. He has been to three allergists and Septocaine has no allergy test like other novocaines. So if you use Septocaine know that sulfite sensitivity occurs 1 in 100 people but the degree varies. My husband went on 22 pills per day for three weeks to survive. Please review all patient allergy profiles. My husband also was given a line of Tagamet in ER which reversed his chest tissues from crushing his heart. Injections can be life changing. Just want to save another patient with allergies....

gatordmd said...

Thank you so much for your comment.
I kept your comment on my emails for this long marinating on what you said.
I still don't know what do say except thank you for letting us know.
We go through the day trying to be diligent and trying to serve our patients and sometimes you hear stories like yours and you have to stop.
Now we are all aware to be extra careful with sulfite allergies.

Hope things are well,
john

Beth Mann said...

My sister had a dental implant several years ago and Septocaine was used as the numbing agent. Her mouth has never been the same since. It's affected her job and her personal life. It's more than just a numb sensation she experiences - it's a burning, painful numb sensation she feels every day of her life. It's an "overkill" medication with serious side effects. My sister's life will never be the same.

gatordmd said...

Beth,

As you can see by the many comments on this subject, this is a pretty hot topic in dentistry.
I am sure sorry about your sister. I can understand your frustration and maybe a little anger about all this.
Now, coming from the dentist side...
Lidocaine is the old standby drug when trying to get someone numb. Now I think I am a pretty good dentist and I was reinjecting almost 60% of the time to get someone numb enough to do any dentistry. It was frustrating for me and for my patient. And when you did get someone numb it didn't last very long.
Now this new stuff comes along and I was getting people numb on the first try (about 95% of the time) and it was a "deep" numbing that kept the patient comfortable for a long time.
I jumped in with both feet.
And you can see why many dentist jumped all over it as well. Then the stories and data started to come out on this product.
But the problem say with me is that I hated to give up something that worked. I mean really working.
I did end up giving it up but it was tough.
I think you will see less and less dentists using it (especially for blocks) because the side effects are bad.
But Beth what people don't understand is that parasthesia (the numbness of the lip) can happen with lidocaine as well.
Just in a little less instances.
This is where dentists will argue.
If you have to give the lidocaine patients twice the amount of drugs as septocaine aren't twice as likely to have side effects?

I know this won't bring the feeling back in your sisters lip but...
I hope this helps.

john

md said...

Hi everyone.

I am a UK patient who has just experienced paresthesia following lidocaine mandibular block. I am lucky enough to have had a reasonable education and expected to find much more science about this than I've seen so far. First, there appears to be no central clearing house for patients who suffer this. I would have thought gathering data would be really useful on a country by country basis. I'm about 2 weeks into my trauma (and thats what it feels like) but apart from massess and masses of anecdotal evidence, there is nothing structured out there I can find. Big questions I'd like to see addressed are:

1. What's my dentist's track record on this, good, average or poor? Mine says it's a random event, so most should be average assuming large practices. But how do we know its not a skill related accident?

2. Where can I go to report my experience in a structured national 'clearing house'. I cant learn from others, nor can they learn from me, except by trawling the week for anecdotal advise.

3. What can I do? I have seen ad-hoc reports about Vitamins, but what the evidence base for that?

4. All I found by way of advice from both my dentist and doctor was to do nothing. I cannot find any evidential basis for that advise! I suspect patient may just get weary and give up on reporting it. Doesn't the dental profession have an obligation to do more about an issue that positively, damages patients, even if its accidental and not intended?

5. I have noticed there is occasionally a "them and us" attitude of some dentists to their patients. I think that is regretable and something the profression should move to change. The Dental Associations could do more in this regard, and look less like a dentist's union.

6. What now. I couldnt face this agin, what are my options? Will my dentist accept this level of input?

Daniel

MaverickDMD said...

Hey John. There is no problem with articaine. The 2 problems that do exist are the needle and American culture. I just visited the US and while watching TV was astounded to see ads promoting how great a drug was only to be followed by one that promoted a class action suit against another drug. I remember about 10 years ago when drug ads first appeared on TV -what a joke I thought. Needles stick nerves now and again. There is no "safe zone" for IA blocks like there is for injecting to avoid the sciatic nerve. If we rethink an IA block as a pterygomandibular space infiltration, we don't come close to the IA nerve and if we use a buccal approach we avoid the lingual nerve. Needles injure nerves, not anesthetics. I'm building a blog and a video on how to inject away from the lingual nerve and IA nerve while getting a IA block to work. I"ve been using articaine for 20 years and have had 3 paresthesias all resolved. I'm not god, but since 2001 I've been using a different technique for a block and have not encountered paresthesia - no needle collision with a nerve = no paresthesia. More importantly a "reinjection" technique is important as injecting into numb tissue gives the operator no warning of injury to a nerve due to a needle collision.

Anonymous said...

All I can say is that each and every one of the dentists above have been playing with fire and with no regard for your patients. As someone who is dealing with paraesthesia following a dental surgery using articaine, I can say it is life changing. You would not believe the excruciating pain, nor the ways it has changed my life. I was always healthy, never had the need for medications. I now survive only because of Tegretol. The pain has affected my family, my work, my friends. It has been 8 months but it feels like 8 years. I am glad I am 50, because the thought that this pain could last the rest of my life makes me glad I likely won't live another 50.
So all you dentists who love this drug because it numbs your patients quickly and saves you time, I pray that you will never encounter a patient like me. My dentist would like to cry for referring me to the specialist who did this, my doctor friends advise me to seek an attorney, and the specialist who did the procedure has been silent, out of fear, I assume. I am just too tired and in too much pain to deal with it all.

So dentists, PLEASE use Lidocaine. I now know I would never have agreed to the use of articaine, with 4 times the side effects. An extra shot and a few minutes of your time is nothing compared to the possibility of ruining a patient's life. You may get away with it for a year, maybe your whole career, but if you EVER have a patient with a paraesthesis, you will regret using that medicine. And you will remember that I am one of those patients you hope will "go away".

Jess said...

There really isn't any literature contraindicating the use of articaine (unless I didn't look hard enough) for blocks. Having said that, and having done a facial nerve block accidentally using articaine in a patient who just would not go numb via any other means for a wisdom tooth extraction, I tend to use lignocaine for blocks.

I'm happy to use articaine blocks if it's all I have or it's a very difficult LA, but I tend to use articaine for most infiltrations especially for extractions.

If a block is done well there is no reason why lignocaine shouldn't work just as well as articaine.

Again, having said all that, I also use bupivacaine routinely for dental work under GA, including for blocks. Whether this makes me a terrible person I don't know. What are your thoughts on bupivacaine blocks?

gatordmd said...

Jess,

It sounds like you have given this lots of thought and I think this is what our patients are looking for. Someone that thinks instead of doing thing rote.
I feel the same with you about lidocaine and how it works. And I too have done some looking around for literature on the subject.

About bupivacaine...I don't know anything about it.

john

Anonymous said...

Hello All,

I am a patient who was injured from an injection of Articaine in a lower mandibular block procedure for a root canal. I now have a long term dysesthesia that is horrific in nature. I'm approaching 4 years of sheer torture with a burning tongue (right side) altered taste sensations, and a stiff feeling on the right side of my tongue. This has affected every facet of my life, it is truly a nightmare. Dentistry Today conducted studies on research already presented regarding the use of articaine and showed that when it is used exclusively for mandibular blocks, there is a whopping 1 in 21% chance of getting a paresthesia from the procedure. All studies lump all of the different procedures together along with the different anesthetics, so they show injury as a rarity but in reality it is not. Also articaine has shown to be possibly neurotoxic to the lingual nerve. I felt no jolt or outward pain when I was injected. Articaine contains a thiol (sulfer) ring that acts like a solvent allowing the stuff to penetrate tissue and bone with ease. Thus, just being in the vicinity of the lingual nerve can potentially damage it from a chemical burn. Please use lidocaine instead... it is far safer and all research shows it works as well.

Barb said...

Hello!

I'm a general practice dentist using Septo for a couple of years now on everything. Am I reading right in the studies that if the needle doesn't penetrate as far in the mandibular block area that it is safe to use Septo? Or when contact is made with the nerve is when permanent anesthesia occurs? The stories from patients alone have scared me into going back to Lido. So I wait a little bit longer to get numb. Get to know your patients better and talk with them! :)

Anonymous said...

I am glad Barb found here way here. As a patient who unfortunately has had time to research articaine, I'd like to address her questions/concerns.

"I'm a general practice dentist using Septo for a couple of years now on everything."

Please read the insert in the drug package. Since 2006 the FDA has warned about mandibular blocks and articaine.

"Am I reading right in the studies that if the needle doesn't penetrate as far in the mandibular block area that it is safe to use Septo?

Is any drug "safe"? Every drug has risks, and articaine has been proven to have a much higher risk than some. 4 times greater than some. The risk of parasthesias is particularly high in mandibular blocks, but higher in every other category as well.

"Or when contact is made with the nerve is when permanent anesthesia occurs?"

How could you be sure you don't hit a nerve once you've injected the articaine? It's profound anesthesia is probably going to hide any nerve contact within seconds or minutes. "Permanent anesthesia" is different than parasthesia---believe me, I know! There is also some debate that articaine is neurotoxic, so just getting the drug near the nerve is as damaging as injecting it into the nerve.

"The stories from patients alone have scared me into going back to Lido."

There might be times when articaine is the drug of choice, but I was never given options along with the risks and benefits, and I know I would have made a different choice.

There are some very interesting recent studies. Check the JADA July 2010 study of parasthesia and mandibular blocks using articaine. Another study points out that the original studies in the US had conflicting data, which suggested the risk of parasthesias were much higher than originally reported. Also troubling to me is that articaine's most ardent supporter was a researcher paid by the manufacturer. Retrospective studies from every other country who have been using articaine longer than the US show a much higher risk of parasthesia compared to other anesthetics.

Using articaine for "everything" is like playing Russian roulette to me. Your patients might get lucky and be okay, but if not, they may endure what some of us unlucky souls have had to find out first hand. I say minimize the risk to your patients, even if that means you have to slow your practice down a bit. Or prepare to look your nerve damaged patients in the eye and say "I'm so sorry I did this". And once it does happen, get them the help they need quickly. Tears come to my eyes every time I think of how many times I said something wasn't right, and how many times my specialist looked away and did not help.

Anonymous said...

When I was 27, I attempted to chew a hard dinner role and and one of my molars broke open. Thankfully it didn't hurt. About a month before that, I had experienced a very bad case of pulpitis. It started in that tooth and spread to the rest of my mouth and I was in excruciating pain, but I didn't go to a dentist. It was probably that tooth needing a root canal.

Terrified this cracked tooth would start hurting at any second, I managed to get into see someone only to find the tooth couldn't be saved and I had multiple teeth in danger of meeting the same fate because I hadn't been to a dentist in over 12 years.

The reason for my hesitancy to seek regular dental care was simple. I don't numb well and when I was younger, dentists either would strap laughing gas on me and proceed despite the pain, or fill the tooth without digging out all of the decay because they just could NOT get me sufficiently numb.

During the dental work to save my other teeth, as predicted, on more than one occasion they could not get the tooth in question numb with typical anesthetics. A dental anesthesiologist even tried some of the less common nerve blocks. In the end, septocaine was the only thing that would numb the tooth sufficiently so it could be worked on.

Because this drug is the only thing that makes dental care for me possible, I ask that dentists be conservative in using it as many people are calling for it's ban due to the increased risk of nerve damage it might present. If it's taken off the market I can kiss my teeth goodbye.

Please save the septocaine for cases like me that really require it, and please be sure your patients are informed of the potential risks associated with it before you administer it to them.

I should say, I have had nerve blocks with the septocaine, however we have switched to doing a block with something else and adding septocaine infiltration.

Anonymous said...

I have been practicung for over 15 years in Canada and I have exclusively used articaine. I had one incident that patient was numb for 6 months after routine block several years ago. But then in the past week, I had one patient with complete paraestheisa of right side of tongue to lingual nerve and next day another patient this time tingling and slighlty numb on chin and tongue. I used a 25 guage needle for blocks to prevent injury in the past, but I have been researching this in detail and I have decided not to use articaine for blocks, I will use lidocaine and infiltrate with articaine. Just my 2 cents worth.

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