Friday, February 27, 2009

septocaine...last time. I swear.

Before I get started...all you non dentist people might get lost on this blog (and might not make it to the end). But one thing I would like you to do is check out the AGD's non-dentist site. It is Knowyourteeth.com . Please check it out and let me know what you think.

Hi all,
Hope you had a good weekend.
Oh, my gosh the weather here in Florida is so beautiful. Today it is 65 degrees and breezy.
It is the kind of day you go to the outside shops and just walk around enjoying the day.
A day you just sit outside and read. A day you just open all the windows and watch a movie.
This time of year the azaleas are blooming. The tababuia trees are blooming. Soon the jasmine will be blooming and all will be well with my soul.
It is a Monday and I am off work so I will get right to it. I don't like to be on the computer when I am at home. It sends a wrong message to the kids.
But I have been thinking about this subject too long.
I told you that I was able to talk to all the dentists during Dentistry from the Heart.
I did my own little survey on Septocaine.
Most of the dentists were using Septocaine and most of them were using it for everything.
You know as a dentist that WAS using it for everything, it makes you feel okay. All dentist want to feel like they are a part of a group. Standing alone is tough. So if you are doing something that a lot of people are doing...it is okay.
When I read Reality, I just want to use the most popular brand.
And when I heard everyone was doing it...I felt okay.
And they all reported No Problems.
I have told you I am not giving blocks with Septocaine anymore.
So, I know you are wondering what AM I doing.
Well one of the things I did was at Dentistry from the Heart was I pinned down the oral surgeon and asked him how to give a block.
I know what you are thinking. A dentist 13 years out of school wondering how to give a block.
I know this looks bad. I was a little embarrassed but I know it was for the greater good.
I also know I am not the only one missing blocks because then Septocaine would not be so popular.
But I pinned him down and asked him to show me. So we went into the room and did it together on a patient (with lidocaine). He said most people go too high on their blocks.
He showed me what anatomical things to look for and told me exactly where to put the needle.
I have done a handful of blocks since then and I have to be honest with you....I still am about 70%.
One thing though, I have had an aversion to giving blocks. If I am doing a tooth that is premolar forward I use local. So really I only need a block if I am doing anything on the molars. Well what if I am doing an MO on #30 only. This is a filling that will take me about 10 minutes. If I do a block they will be numb for 2-4 hours.
So I starting using this...
.
This is the Paraject system by Septodont. I love, love, love it.
I have been using it for a month or two. It takes about 3 minutes to numb a tooth and it WORKS. I have used it about 60 times and it has only not worked once (and I am now thinking that might have been a fluke).
Basically this is a interligamental injection system. The needle is tiny. You give a little in the tissue around the tooth before starting and then push the tip at the MB line angle and squeeze the trigger. It is hard to do because you are forcing anaesthetic in a small space.
Then I put the needle in the furca space and maybe in the DB line angle.
It works so good that I have done 3 root canals with just this type of injections.
Patients love it.
They leave with out ever feeling numb.
Now I am using it for multiple teeth. Say if I have to do fillings on #18 and 19. Well it takes a little time but very effective.
So now, even though it was aggravating my assistance for awhile. I use Septocaine on the upper with the regular set-up (30 short), I use Septocaine with the regular set up from lower premolars forward.
If I am doing more than two teeth on the lower it is Lidocaine in the regular set up (for a block). And if I am doing 2 or less molars it is the Paraject with Septocaine.
I know it seems like a lot of work but...at least I am not sweating that once a year call from a patient that says his lip is still numb the next morning.
But that leads me to my last point.
I think it is becoming official that the side effect to giving a lower block with Septocaine MAY lead to more instances of parasthesia.
When does the memo come out?
Remember I was ticked off about the poor information chain when it came to the antibiotic premed thing. No one knew for about a year whether to change our protocol. And the physicians still aren't with it.
So who is going to come out and say something.
I don't think the dentists want to stop using it because it is so effective.
Septodont doesn't want to come out with it because it is selling like hot cakes.
Who is going to tell the dentist?
Or is <1%>
But if it is bad someone needs to stand up and say something.
If Septodont knows there is a problem then they need to take it off the market.
If there is a way to give the injection that will make it less of an issue...like if you give the injection slower or if you chill the solution it needs to be researched because a lot of people want to know.
I mean almost every dentist has an email address (and as the older guys retire the percentage of email-able dentists goes up). The information can travel very fast.
We need to figure out a way to make this happen.
What do you think?
Am I just talking crazy or am I making sense here?
Have a great start of your week.
john

16 comments:

Frank said...

interligamental injections can cause pulpal death. It is not recommended for vital teeth that are not having root canal. At least that is what I have read and was taught in school.

gatordmd said...

WHAT???!!!
Say it ain't so.
I will have to do my research.
I will let you know what I find out.
Thanks,
john

Anonymous said...

Just a quick note from Indiana--My associate joined my practice 18 years ago. It was a "match-up" by a classmate specialist who thought we would work well together. We have the type of relationship you talked about: running ideas by each other, discussing materials, theories and the differences of opinion are far outweighed by the consensus. It was like getting married after one date and having a GREAT marriage! I added a second associate because the first worked out so well and it was a lot more work: the assistants had been spoiled and brainwashed by the two of us and now the third looks "wrong' when she does things differently. It is gradually getting smoothed out though (going on 4 years now--long process). We've beaten the odds so far; I think it will be different when I have to add the person who will take over from me though. (both of these gals will retire before me.....)

Cynthia Becker, DDS
My Dental Care
9905 Allisonville Road
Fishers, IN 46038
317-849-0999
317-849-5641 Fax

Anonymous said...

There is a software for handhelds or PC's called Lexi-comp which gives updates on complications of drugs and interactions of drugs way before they become general knowlege. They recently gave an alert that there have now been spontaneous femur fractures with long term users of bisphosphonates and I don't think that is general knowlege either. I know the last 4 seminars I have been to with the AGD (implants, Oral surgery, Periodontal tissue grafting, and special patient care) the presenters have all mentioned the issue with the blocks and Septocaine. Maybe they are better informed than the run-of-the-milll dentist out there......

Cynthia Becker, DDS
www.MyDentalCare.com

gatordmd said...

Great stuff Cynthia.
Thank you for the feedback.
I think the associate thing has so much to do with personality. And as you say how they interact with staff.
4 years...you are right that is a long time. For me it took a long time for our staff to realize I was a different type of dentist then my dad and I wasn't going anywhere. And it was longer than 4years.
I appreciate your comments,
john

jamie said...

I agree with the comment about pulpal problems occuring when doing intraligamentary injections on vital teeth. My understanding is that the presence of vasoconstrictor acting directly (or very near) the apex causes decreased blood flow near the apex, therefore can "cut off" normal blood flow to the canal. In theory, local anesthetic directly to the tooth receiving the work is great, but I still think using the "old faithful" IA nerve block with ANY type of amide local is the best way to go. Articaine is great, but I haven't really noted huge differences with Septanest and blocks. Where it shines is with great bone penetration when giving infiltrations. There are surprisingly alot of guys who swear by Articaine for infiltrations in the mandibular, even on molars. If you still want to use the ligmajet, you could consider researching the pulpal effects of using a local WITHOUT epi for the injection. Just my 2 bits. Oh, and by the way, I do really enjoy your blog.

gatordmd said...

GREAT COMMENT JAMIE.
Thank you for commenting.
I appreciate your feedback and I really appreciate you liking the blog.
I hope you hang around for a long time.
john

Anonymous said...

My dentist used septocaine on me (3 carps of septo) for a root canal on my #3 don't know what kind of block he did but I could not move that side of my face until the numbness wore off, then had lots of pain & itching and a dilated eye that never healed. It would still focus, Pupil just stayed larger than the other. All of the doctors kept saying it couldn't have been from the dental work so I went back in 2 years later and had #2 filling, same thing again, now I have lots of itching & pain in the cheekbone area and my pupil became worse that day, now it is totally "blown" & fixed. I have photophobia, and no focusing ability. I think this is pretty rare but for it to happen twice is just too crazy! I will never have this drug again! I have had other work done all my life with no problems from lidocaine. Just thought people should know. thanks, Cindy in Oklahoma

gatordmd said...

Thanks for writing Cindy from Oklahoma (go gators).
I it a pretty rare occurance for there to be adverse reactions to any anaesthetic in the maxilla.
But your right, twice is too much of a coincidence.
Thanks for writing.
I hope you liked the blog.
Write anytime,
john

Mauricio said...

"Am I just talking crazy or am I making sense here?"...Well, you are probably just "talking crazy", John. Sorry.

You are perpetuating a scientifically unsubstantiated myth by claiming articaine can cause paraesthesia.

The "cornerstone" article on this subject was published in 1993 (Haas), and, even though this was NOT a scientific study (just an analysis of reports received by the Royal College of Dental Surgeons in Ontario), it's now what most people use to argue against the safety of articaine. As a reminder, his conclusions were that paresthesias can happen in 1:785,000 injections with ANY anesthetic solution, and that, when using 4% drugs, the incidence is roughly 1:500,000. If the average dentist gives around 1,800-2,000 injections/year, HOW LONG do you need to practice before causing a paresthesia to one of your patients? A few hundred years?

In reality, studies as the ones by Krafft & Hickel or Harn & Durham actually speak of up to of 7.7% and 3.62% incidents during IAN blocks respectively. These studies show that the actual injection is more likely to cause nerve damage than the anesthetic solution itself.

You want to avoid problems? Use Gow-Gates or Vazrani-Akinosi...ZERO reports of paresthesia in literature using those techniques. They take the lingual nerve out of the equation.

Why? Because using the traditional IAN block the lingual nerve is in the path of the needle when trying to reach the IAN. Your needle will make contact with the lingual nerve on the way in (electric shock sensation), or on the way out (with the barb you create in the needle tip after hitting the mandibular bone during the block).

HEARSAY is not science.

But do not take my word for it either. Read what authorities on the subject have to say.

As Malamed has said in other forums: "At this time, there exists absolutely no scientific evidence to support the concluding comment regarding the use of other local anesthetics for the mandibular block analgesia in place of articaine 4%."

You may want to read these:
http://www.drmalamed.com/downloads/Local_Anesthesia_drugs_CDA_2006.pdf

http://www.drmalamed.com/downloads/Permanent_Nerve_Damage_IA.pdf


Just my 2 cents.

Dr. Mauricio Diaz
Mississauga, ON

gatordmd said...

Maurico,
Good stuff.
Thanks for the comment.
Good articles also,
john

Chris said...

Is this the sort of thing I could ask my own dentist to use?

It's been 11 weeks since my lingual nerve was damaged by an anaesthetic injection during a root canal on my right lower first molar. The right side of my tongue is quite numb, and I have no sense of taste in the same area. I still have to have the crown placed, as well as a root canal/crown on the tooth behind it, and the same tooth on the OTHER side.

I'm extremely concerned that the injections for the work on the right side could compromise any possible further healing of the damaged nerve (though at 11 weeks I'm not particularly positive anyway). I'm also concerned (terrified might be a better way of putting it) that if anything happened on the left side, then the whole front 2/3 of my tongue would be completely numb with no sense of taste. What a nightmare.

I've been debating whether to speak to my dentist about the other nerve block techniques mentioned in a previous comment. I get the feeling they will just tell me to go elsewhere if I want such specialized treatment. I'm not even sure if there would be any real benefit, since they'd probably have to "learn" how to do it on me. I'm supposed to have the second root canal next Wednesday. The appointment is with an endodontist I've never seen before, and I don't have an opportunity to talk to him beforehand. I don't really know what to do.

gatordmd said...

Chris,
I am sorry it took me so long to return your comment. I wanted to marinate on it for a day or two.

I appreciate you situation but before I say anything I want you to know one thing...It is your mouth. If you don't want Septocaine you should tell the dentist at the beginning and if he is not willing to change then you are at the wrong dentist IMO. You are paying this dentist. He is giving you a service. You should have a say in the way you are treated.
Second, as you can see from the comments on this blog, the use of Septocaine is a very HOT topic.
And I am sure the dentist that gave you that injection that left you numb has had some sleepless nights.
It is on all of our minds all the time. We want to get people comfortable in our chair and it seems that Septocaine does a really good job at that.
And whether it is has a higher instances of leaving people numb (parasthesia) is what is the issue. Lots of studies happening as we speak.

About getting the crown on the side that is numb. The tooth has no feeling in it and routinely I do not give anesthetic to do crowns on root canaled teeth. I might have to get the gums numb but that is an entirely different animal and you don't have to give the shot in the same spot.
So I hope all this helps and if you want to talk to me more my personal email is Jgammichia@aol.com

john

Chris said...

Thanks for getting back to me. It's not so much the septocaine I'm concerned about as injections of any type into the area with the damaged nerve (i.e. the normal IAN block). I know it's really unlikely anything would happen, but I don't want any possibility that further damage could compromise my nerve healing.

I actually had a really good talk with the endodontist who will be doing the other root canals, and he agreed to try the intraligamental injection technique you mentioned in your original post (he has used it for other teeth, but not molars), followed by further anaesthetic once the tooth is open. I know this will probably be more painful than the regular block, but I'm willing to put up with quite a lot at this point.

I wouldn't have even known to ask about intraligamental injection before reading your blog post, so I really have to thank you for writing it. I'm feeling a lot better about having the root canals done now that I'm not concerned about the anaesthetic injections.

I've also noticed some improvement in sensation on the side of my tongue, as well as what seems like normal sensation on the inner gum, which makes me feel a lot more positive that it might actually return to normal. It's a very frustrating injury, though.

Chris said...

I just wanted to update to say I had the first of the two root canals done today using this technique.

I think my endodontist went a bit overboard numbing the area initially, so I ended up with the usual "half your face numb" thing for a few hours, but the intraligamental injection and subsequent pulpal injection worked spectacularly well. I didn't feel a thing during the procedure. He actually told me he was surprised by how well it worked.

Thank you again for the blog post that gave me the information to suggest this technique. Hopefully the next root canal will go just as well.

gatordmd said...

If you were thinking of sending me a gift or anything....I like cupcakes (and cash)

john

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