Monday, March 1, 2010

Anesthesia & Legal Issues

This is as close to a diary as I have ever had. Mrs. Hill would tell you that even in High School I wasn't good at keeping the required "journal" for English class.

That said, I have nothing on my mind today that the voices are telling me to share, so I am simply sitting here while waiting on a patient to get numb and writing what comes to mind - stream '0 consciousness-like.

I used Lidocaine on the patient I am waiting on. That is remarkable only in that I switched back from using Septocaine about 2 weeks ago after rereading Dr. G's blog posts from last year. I know the whole debate and have ignored it for the past couple of years because Septocaine works so unbelievably well on blocks but, finally, took the scary stories to heart and changed.

Since changing, I have had to reinject about every 4th patient. I don't care what the studies may show. With Septocaine I may have had to reinject every 30th patient, and then it was most likely due to me being in a hurry and trying to start the procedure to soon after injecting. With Lidocaine, I'll wait 10 minutes go in, start drilling and the patient will jump and I have to reinject. Sure, they won't have permanent numbness, but it takes 10 more minutes of my time and an additional $3 carpule of Lido (please read sarcasm here). I miss my Septocaine, but I will not go back to it for blocks until I get the all clear from the researchers.

And since we are talking about anesthesia, anyone using that reversal agent? I initially laughed at the idea, but now am thinking it could be a great service to offer my businessmen/women clients who have early morning appointments - they can get back to work without numbness. If I did that, though, I'm thinking I should charge for the reversal. The CDT codes state that anesthesia is included in the procedure code but nothing is said about reversal agents.

Anyone doing this? Do you charge? How effective is it really?

Final thought before I go back and see how ineffective the Lidocaine was on this patient - I am speaking to the Mississippi AGD/ADA in 2 weeks on malpractice issues in the dental practice. Now, after you get over your shock at people being gullible enough to invite me to speak at a Continuing Education meeting, I am soliciting your help. Since I am an attorney I tend to overlook some basic legal issues that non-attorneys may want to learn about. Anything that you would like to hear more about as a practicing dentist in regard to malpractice/legal issues? If we get some good questions/responses I will blog the answers in future posts.

And if you are from Mississippi and are going to the meeting (and happen to have internet access/indoor plumbing/literacy - so joking, I married a woman from Arkansas to grant them some genetic diversity) any topics you want me to talk about in particular?

That's it for now, the voices want to argue about what direction to stressout today. Plus I need to go see if this patient is numb.

Have a great day!



Anonymous said...

Prilocaine or carbocaine followed by lidocaine works really well for me on lower manidbular block. I almost always give 2 carpules on the lower.

Anonymous said...

just so you know, i also read john's article last year, and i re-evaluated articaine usage for my blocks as well. i did alot of research, and a surprisingly large numbers of articles have been written on the safely of articaine. i was very relieved to find out that NOT ONE of them gave me a reason to stop using articaine due to safety issues for blocks (and yes, the articles DIRECTLY ADDRESSED THIS). these articles did address the potential for what john had noticed, but upon further investigation, articaine was shown to be very, very safe. if i can search out any of these articles for you, i will. i know that at least one of them was by dr.malamud, who is (basically) the authority on local anesthetic and medical emergencies in the dental office in north america. there was NO safety concern addressed that said "don't use articaine", or even "use it carefully"....i breathed a huge sigh of relief, as i was exactly like you and switched to lidocaine while i researched articaine. i wish i could say that i am a superior dentist when it comes to injections, but i had the exact same problems you're describing....basically i ended up just doing 2 full carps on blocks, in slightly different areas (one low and one slightly higher) every time...basically thinking that "double the amount has to work better". to make a long story short, i'm 100% back to articaine. you should really put the effort into reading the literature before you pull your hair out by using lidocaine for no reason. take my word for it, there is no scientific evidence (therefore if something bad like paraesthesia did happen, you are legally exhonerated in using articaine) that says that you need to go back to lidocaine for blocks. i would check it out if i were you. i did, and i feel confident with articaine again. i also feel that i am NOT putting my patients at any unsafe risk by using it. take care. jamie

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gatordmd said...

Great stuff Jamie,
Thank you for your comment.
I am going to put it back on the blog.
I appreciate all that you have done. It is going to make a lot of people sleep better at night.

Anonymous said...

no problem. just as a disclaimer, i don't want people to take my word for it simply...i'm recommending for people to do their own research. i'm kicking myself that i can't actually recall where (or the authors) i read the articles about articaine, but i definitely read at least 3 articles that talked about the issue specifically, and gave articaine the safety "thumbs up" (i think the basis of the articles was that articaine has NOT BEEN SHOWN TO BE ANY WORSE at potential parasthesia than any other anesthetic...and a bunch of research to back it up)...that was good enough for me, ha! basically, don't take my word for it (i have been wrong in the past...once....i think it was in the late nineties). the articles/research are out there. take care you guys. hope things are picking up a bit for you in your practices. all the best.


Anonymous said...

I agree with Jamie. I've read all the research carefully and statistically articaine is the same as all others. It's just that it's used more commonly so paresthesias occur more commonly but not dispropionately. It is the needle that does the damage, not the local. I always give 2 carps, the first with a 30 gauge really slowly. I wait a minute then bounce down the medial surface of the mandible until I reach the pterygomandibular space (noticed by reduction in back pressure clinically with a bent 25 short) as indicated on the pan by measuring off the distal of the seven. This provides for keeping away from the lingual nerve and also if you do strike anything it is a very low velocity collision and allows the operator to realize what is going on. Having a patient jump with the single shot technique as taught in school does not allow for any useful information - everyone jumps when you go right to the target on the first throw. I've been using articaine for 19 years here in canada and it's funny how it only became a problem when it was introduced into the Excited States. I'll continue to use this local as my experience and research tells me it is just fine. G

Anonymous said...

For those of you who claim not to have found a valid reason not to use articaine, you should review this study published by Dentistry Today. The risk associated with the use of articaine for lower mandibular blocks is thru the roof!
Go to

You will be shocked.


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