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With the growing demand for tattoos on epidermal (skin) or mucous membrane areas for vanity pleasure, there is a need to clarity which is truly mucous membranes and those that are not; since not all membranes secrete mucus.  The mucous membranes are linings of mostly endodermal origin, covered in epithelium, which is a tissue, composed of layers of cells. Their function is involved in absorption and secretion. They line various body cavities that are exposed to the external environment and internal organs. They are at several places throughout the body that engages or are continuous with skin: such as at the nostrils, the lips, the ears, the genital area, and the anus. The sticky, thick fluid secreted by the mucous membranes and gland is termed mucus. Mucous membrane refers to where they are found in the body and not every mucous membrane secretes mucus.

Body cavities featuring mucous membrane include, the glans penis (head of the penis) also glans clitoris but the inside of the foreskin and clitoral hood are not mucous membranes; however, the urethra is a mucous membrane but to my knowledge no one has ever chosen that membrane for a tattoo. The secreted mucus traps the pathogen which is the biological name for an infectious agent, or more commonly germs that causes disease or illness to its host in the body, preventing any further activities of diseases.  However, if the immune system or “good” bacteria is damaged in any way (human immunodeficiency virus (HIV), or antibiotics being taken to kill other pathogens), such pathogenic bacteria that were being held at bay can proliferate or multiply and cause harm to the host. Such cases are called opportunistic infections. Patrons should never submit to tattoos if they are HIV positive or are taking antibiotics. Secreted mucus is not impervious to all pathogens (bacteria, germs).

In spite of pain, the vanity industry, mainly tattoo studios are on an exponential growth pattern. The reason for this is multi faceted ranging from being macho to being in style and more recently, the popular term is being pressured into taking a sip the “Kool-aid”. However; ironically, the mere fact each patron who strives to be unique, is now part of a well defined group. The end result is that more and more young people are into the epidermal dyes. My personal comment is that some tattoos are quite well implanted and attractive.

However, the industry will eventually level out as it does with attrition. Those who are anxious to have a tattoo implanted balanced by those who are anxious to have one removed.  Because pain is involved in both processes, it will depend on how well equipped, trained and qualified to deliver the goods painlessly, are the artists, permanent and visiting professionals to any of these studios.

Most individuals are incapable of conveying their pain threshold, since this is mostly psychogenic or physiological. I am sure each one of us can relate an incident whereby the end result would have appeared to be impossible. Scientifically, there is no way to measure what anyone is physically or mentally capable of enduring or achieving, since most dramatic exercises are done spontaneously (in vivo) rather than being hooked up to cathodes in a clinical situation. 

We have discussed previously the problems and disappointments of having a tattoo removed. We must now examine a painless way through which the artist can excel without the patron responding as though she/he were confronted by a hungry bear. Procedures are performed in the absence of pain and in certain cultures are likened unto religious rituals.

First there is a topical anesthetic known as EMLA which is a eutectic mixture of local anesthetics that can diffuses a relatively impervious barrier, such as intact skin. The latency period is about one hour before work can be started. This is probably not your first choice since onset of numbness is rather lengthy. However it may be considered as an adjunct to speed the onset of anesthesia as well as make the administration of local anesthesia into the skin more comfortable for the patron.

With this in mind, an alternative that is worth considering is techniques that do not involve the administration of a drug. It is Transcutaneous Electrical Nerve Stimulation which is the acronym for TENS. These machines can be purchased relatively inexpensive, but some professional advice may pay off in dividends.

At a low frequency setting of 2 Hz, the TENS will produce measureable changes in blood levels of serotonin, and beta endorphins. By contrast, serotonin levels in the blood increase in time. Beta endorphins are potent analgesics produced by the body in response to certain stimulation© Hughes J, SmithTW, Kosterlitz HW. (Identification of two related pentapeptides with some opiate agonist activity. Ref: Dr. Stan Malamed.

They work well on most muscles and soft tissue or in the lower back. Caution is advised if you are not familiar with this technology and could cause severe discomfort to the patron. Instructions for proper placements and settings of the cathodes for maximum efficacy together with a didactic course are highly recommended. As more studios move towards the painless methods, will take the art of tattooing to a higher level and the attraction of new clients, resulting in an expansion of the tattoo and vanity market. 

Centbucridine a quinolone is an alternative to lidocaine. Considerable research has been conducted into this agent and published mostly in Indian journals where henna tattoos are popular. Permanent deposition of dyes is undoubtedly seated in India and other South Asian countries. Referenced by Dr. Stan Malamed.To avoid excessive bleeding an anesthetic with a vasoconstrictor is advised. Winching from the patron can be disturbing and distracts from the perfection of the artistic project which in many cultures is religious and peaceful.

Local anesthetics can be sourced if your studio has the need and certified personnel to administer painless Parenteral injections. Training can be arranged through your local association or college. We can assist in this area of referrals.

Our site www.anestheticnews.com we strive to fill a void that has never been addressed…namely a closer relationship with your pharmacist.   M.Sc. PharmD. CCPE.

E-Mail: at localanesthetics@yahoo.ca

The area of the lower back is the most popular spot for tattoos in both sexes according to http://www.tattoos.lovetoknow.com as it is less confining for the artist on which to work. Another feature point is that it is not a spot that will be affected by minor weight gain fluctuations, so the design won’t shift or be damaged. For those that care about such things, the lower back tattoo is easy to hide. There’s no worry of how to cover it up for work or job interviews. Finally, and this is especially true for women, it is a spot that is generally considered to be a target that has appealing connotations of sexuality.

One possible low point is the pain. This is where the use of local anesthetics and or illicit compounds plays a disturbing part. A general rule of tattooing is that if the spot is normally covered by clothing, the skin may be more tender, and thus the lower back might be a more painful spot than others. Depending on the method for after-tattoo care, it is anatomically more demanding to stave off infection since that part of the anatomy acts as a gutter or to put it bluntly, it is the perfect conduit for run-off of body perspiration. The spot may be difficult to keep clean and dressed, if the client has no one to do the necessary swabbing and cleaning.

Let me clarify a rumor surrounding low back tattoos and the ability to be given an epidural during child delivery. There are no contraindications to date; most pregnant women who have lower back tattoos can receive epidurals. The exception would be if the tattoo covers a large area and is still “fresh” — meaning the involved skin is still healing. Actually, very few studies have looked at the risks of epidurals in women with lower back tattoos. But there is no conclusive evidence Mayo Clinic of any adverse effects, such an increased risk of an infection. Most anesthesiologists will give an epidural block to a pregnant woman with a lower back tattoo. However, they may try to avoid placing the needle through the tattoo to avoid scaring that may disfigure the tattoo. If possible, the anesthesiologist will insert the needle through skin that isn’t tattooed. If you have a lower back tattoo and have questions or concerns regarding your ability to get an epidural, consult your doctor. 

Serum cholinesterase is a blood test that looks at certain enzymes which are complex proteins that cause a specific chemical change in other substances, without being changed themselves. For example, they can change starches, proteins, sugars into substances the body can use. Blood clotting is another example of enzymes at work. Enzymes are essential to all bodily functions. They are found in the mouth (saliva), stomach (gastric juice), intestines (pancreatic juice, intestinal juice, and intestinal mucosa, blood, and every other organ and cell in the body evidence evidence Mayo Clinic.

Ester local anesthetics have all but, been replaced now by amides which are safer compounds as a local anesthetic. Times were when esters induced a rapid rate of hydrolysis (elimination or breakdown of the anesthetic) by plasma pseudo cholinesterase which helps the nervous system to function properly. Suffice to say that if you have a low back tattoo, your worry of receiving an epidural is safe according to current clinical studies as mentioned in the above references.

However one section of the vanity cosmetic industry whose core competence is tattooing is growing exponentially, as more young and middle aged people want to sport a tattoo for any number of reasons, least of which is virility and looking sexy. However the problem of removal or reversal is far from perfected.

The process is painful and the results are for the most part unacceptable.  We have seen huge areas of scar tissue (skin growth) to atrophy which resembles the after affects of third degree burns. When skin atrophies, it becomes very thin and shiny. 

The claim is that laser Palomar Starlux 500 system uses the Lux1540 Fractional non-ablative hand piece to deliver a precise amount of light in an array of high precision micro beams. These micro beams apparently create narrow, deep columns of tissue coagulation while sparing the surrounding tissue from damage. The coagulated tissue within the columns initiates a natural healing process that accelerates the formation of new, healthy tissue. Coagulated cellular debris is expelled as the skin is resurfaced.  No longitudinal clinical studies published.

Laser is still in its infancy and there are more questions than answers. As a pharmacist who spent over 25 years in dentistry I have been exposed to laser technology. It is essential for any laser use be concerned about biology. What about thermal damage which a laser can cause due to the heat that is generated by the ablation of these materials? The ablation efficiency of the laser is still not subjected to longitudinal dermatological studies of materials and tissue.

Then the “snake oil” solutions of ointments balms and varnishes appear on the seen. This reminds me of the famous commercial with the old lady who asks…”where is the beef”?  It is sad when people shell out large sums of money only to see scar tissue or atrophy of the skin within a few weeks. We as pharmacists are in direct contact with physicians and dermatologists who see solutions to problems in a more scientific way and with clinical references.

The use of local anesthetics works by blocking sodium transport along the nerve. By reversing the polarity of the nerve, no sensation can reach the brain where it is interpreted. In other words sensation to the area of the nerve is blocked. Nerves travel up and down the spine, often called the central nervous system. It is critical not to damage these nerves with the needle. One must also remember there is bleeding which may impair viewing the area on which the artist is working. There is much to consider when having a tattoo removed without inducing scar tissue or the use of hydrocortisone which can cause thinning or atrophy of the skin. 

For more information regarding tattoo removal please seek professional advice to avoid permanent skin disfiguration.Enzymes are essential to all bodily functions. They are found in the mouth (saliva), stomach (gastric juice), intestines (pancreatic juice, intestinal juice, and intestinal mucosa), blood, and every other organ and cell in the body. Local anesthetics can be sourced.

Please e-mail us at localanesthetics@yahoo.ca  

Haynes Darlington.  M.Sc. PharmD. CCPE

Medrol is a synthetic corticosteroid. Corticosteroids are naturally occurring chemicals produced by the adrenal glands. Corticosteroids block inflammation and are used in a wide variety of inflammatory diseases. The use of Medrol as an anti inflamatory in dentistry is on the rise, as clinicians seek an angent more powerful than ibuprofen when so indicated. Here is a tip you may find helpful. Dosage requirements of any corticosteroids will vary among individuals and the diseases being treated. In general, LED (lowest effective dose) should be your goal. Corticosteroids given in multiple doses throughout the day are more effective but also more toxic than the same total daily dose given once daily, or every other day…Reason? hepatic (liver) funtion can be sluggish to recover. In medically compromised patients, you may want to consider a single dose rather than BID or Q4H.  Methylprednisolone should be taken with food.  Dosage compliance increases as frequency decreases. This rule is paramount in pharmacy 101. At our site www.anestheticnews.com we strive to fill a void that has never been addressed…namely a closer relationship with your pharmacist.   M.Sc. Phm. CCPE.

E-Mail: at localanesthetics@yahoo.ca

The world is abloom, from villages, to towns and of course to cities with a new type of business. Like the extensive color of our spring flowers, cosmetic studios have grown exponentially in recent years. In fact it is almost the in thing with young folk to have implanted a small diamond on the flare of the nose, as it is to see a tattoo on the shoulder of a middle age man.

Depending on one’s stage in life and one’s personality, vanity studios are competing for that elusive disposable income. Each has its unique azure of attractiveness and beckoning calls with their core competence whether it is aromatherapy, nails or hair extensions. Fluorescent signs that is no less apparent than our new suspended traffic lights of attention-grabbing colors of brighter reds greens and yellows. From strip malls and street stores to concealed exotic pastures of pure vanity, they are without doubt very apparent or to put it bluntly, “they are in your face.”

Times were when such store frontage was occupied by a 7 – 11, a hardware or shoe repair stores. This new terrain of personal care is predicted to multiply as the world works its way back from the jaws of economic recession. Each studio competing vigorously like fish in an aquarium out performing each other as flakes of food are spread on the surface of the air bubbling water as it ascends and descends in their tank. The feeding frenzy is likened onto the last available few tickets for a game between the Red sox and the Mariners.

Adam Smith in his greatest book “The Wealth of Nations” frequently refers to the market place almost likened to an organism because it reacts to stimuli. Demand and supply sensory impulses provoke the market in no lesser a manner than a life is governed by physiological needs. Some of these responses may be sympathomimetic like a rush of adrenaline when the body is deemed to be in danger. This metaphor is best explained how one reacts if a sharp object is hurdled at one’s eye. The result is that these hormones are much faster at coordinating motor nerves to respond in a millisecond to protect or reduce damage to the eye.

As a pharmacist let me share with you a few words of advice you should know before, like a fish, you’ve decided to take a grab at that hook with the life less worm dangling in the water. There are many over-the-counter creams, solutions, sprays etc to reduce pain from sharp pricks or severe sunburn. Some people say pain is like sub zero temperatures…it is all in your mind. In fact many East European people will refuse local anesthesia when visiting their dentists because they will sooner withstand the pain of the procedure than to walk around with a numb lip for a couple of hours. As a comment, may I suggest “that depends on the type of procedure one is having?”

Topical anesthetics cannot penetrate intact skin but will penetrate abraded skin or mucous membranes such as the tissue of the mouth to about 2-3 mm. The topical application typically has a higher concentration than when that same agent is administered by a needle. The down side is that a higher concentration also leads to a greater potential of toxicity. With the exception of cocaine, topical anesthetics contain no substances that will constrict vessels in the same way as local anesthetics.

Unfortunately such drugs are ripe for seepage out of hospitals, clinics and registered therapeutic massage studios. Even expired stock of local anesthetics destined for FDA supervised disposal, will not all make it to the grave yard. In addition to strict controls set in place as an audit by these agencies, they are dealers who have access to such products. The possibility of availability of these products on the “street”or in the wrong hands is therefore a concern. An excellent comparison is the leakage or availability of anabolic steroids in the sporting market, even as the Beijing Games celebrate their opening ceremony.

The situation that begs the question, is there a coincidence of the exponential growth of these vanity tattoo studios and the linear graph of street cocaine? Without vasoconstriction, vascular absorption is rapid and levels in the blood can conceivably reach concentrations similar to those when it (cocaine) is administered parentally or by the direct intravenous route.

Some topical anesthetics e.g., benzocaine and lidocaine base are insoluble in water. They are however soluble in alcohol, propylene glycol and other such solutions for surface application. They are slowly absorbed into the cardiovascular system and therefore are less likely to produce an overdose reaction. May I remind you that local anesthetic benzocaine is an ester type drug and through hydrolysis, part of the drug is broken down by the liver. Part of the drug will be converted to a substance called P.A.B.A. (para-aminobenzoic acid) which has a high potential to cause allergies. Dentists have stopped the use of it because of potentially allergic reactions.

Finally, Tetracaine, although not easily available is the most powerful topical anesthetic ever manufactured. It is extremely effective, more so than benzocaine type products such as Hurricaine®. Many dentists often used it to remove milk teeth in infants without the need for anesthetic by the needle. However it was withdrawn in North America because it is also an ester (P.A.B.A) but primarily because it was manufactured in a spray propelled by chlorofloro carbons which affects the ozone layer of the universe. However careful shopping may find you a source. It was used extensively in the vanity market for electrolysis, permanent eyeliner make-up and for eye brows especially in the South Asian Market. ”Comment, and you thought those picture models were air brushed!”

Contrary to popular believes the vanity markets, physio therapy increases during a recession. Patrons may be depressed and feel obligated to treat them selves to something special. All markets report the vanity industry is as recession proof as florists. Birth rates also increase as people naturally have more free time. Both movie theaters and book stores experience a surge in sales for the same reason.

Of course, they are many other vanity salons which are reasonably safe from side effects, such as nail extensions, henna hand and skin art, hair extensions, manicures, pedicures and the whole ball of wax. The future looks good for these entrepreneurs since the search for that special uniqueness and beauty drive both men and women to continue in search of the new “you.”

My personal advice is to do your home work on products that may be allergenic. Also as a final reminder that sun lotions contain substances that may cause mild hypersensitivity to more severe reactions because they contain para-aminobenzoic acid and methylparaben. Please discuss any concerns with your doctor or your pharmacist.

Comments to author. localanesthetics@yahoo.ca M.Sc. PharmD. CCPE
Please visit WWW.AnestheticNews.com 

Some say Plato was the original snob traceable back to his Socratic dialogue, “The Republic”, where his views were clearly expressed that countries should only be ruled by philosopher-kings. A presentation by early philosophers, whether for their scholarly allure or, as one author referred to it as liken to “chocolate for the ears”? This never fails to generate interesting conversation while avoiding the golden rule of never discussing politics and religion during a relaxing dinner.The quotes of philosophers of the medieval times are as timeless as the ether that surrounds us from quantum to the extreme cosmos. Albert Einstein once expressed his doubts of the true qualitative evidence of quantum physics based on causality of entanglement and certainty. In one of his many sharp rebuttals, he questioned, if no one is in the forest and a tree falls, what certainty is there that there was a sound? Reality is unquestionably real.

Necessity is the mother of inventions. This is a classic and as WIKI describes it   from a speech by Leo Melamed “Today, I will speak of change, of need, but mostly of “necessity, the mother of invention”. Victor Hugo succinctly expressed it in 1852 in his History of Crime: “A stand can be made against invasion by an army; no stand can be made against invasion by an idea.” Hugo did not invent the thought, rather he inherited it from a long line of literary stars beginning with the original version Mater Artium Necessitas an undated anonymous Latin saying of ancient Rome.  The Latin poet, Pesius Flaccus, was the first known author to use it in literature, circa 50 A.D. He put it, “the stomach is the teacher of the arts and the dispenser of invention.” The saying took one form or another throughout the ensuing history of great literary thought until some 1500 years later when Leonardo Da Vinci wrote, “Necessity is the mistress and guardian of nature.” William Shakespeare in his Julius Caesar wrote, “Nature must obey necessity,” and the English dramatist, William Wycherly, in 1671, said it in the form we know it today. However it is said, it is no less true. Necessity will produce the indicated invention.”

I recently saw a dental bid (apron) which caught my eye with the sharpness of that of a seagull making a bull’s eye capture of a minnow some 30 feet above the surface of the lake. The apron read “I am going to sue you”. Giving that now is the crazy period of print satire, it still caught my attention as I pondered what would be the genesis of such a statement. Most of us have had our share of lawyer jokes, however this dental bib carried a sinister and certainly a direct message.

This is not to say that dentists have been sitting on their hands and not spending good money to create a more inviting environment. Large sums are being channeled through advertising agencies and some dentists have even moved to promote their services through their own blogging sites. However the marketing mix has failed to penetrate the pulp of a culture that has largely seen dentistry as   PRN (pro re nate), a latin term that pharmacists understand as “when the need arises”. The strong message that sticks out here is as captivating as an Egyptian Ankh decorating the door as an all night 7 -11.  and as appealing as trying to make a silk purse out of a sow’s ear. The term impulse buying certainly would not be an appropriate expression of how the public at large sees the dental office. Fear is still the average response after 25 years of my anecdotal interviews.

In case this analysis is misunderstood, let me clarify the situation. There is enough critical mass in populated towns and cities for dentists to practice and enjoy a comfortable life dealing with schedule appointments and the odd acute situations to fix a broken denture or even a painful acute root canal that has recently flared up. However this passive agenda is mindful of the giant auto industry of North America before Japan decided to move in. With a healthy dental research manufacturing Industry showing off their duly approved products each year, it appears that the public at large have not embraced their appointments to the same extent as other statements of vanity. The move to that level of “must-have” has yet to mature. 

From liposuction to lips, from bunions to calf muscles, from-laugh lines to brow lifts, have all been surgically modified, yet simple diastemas (spaces between teeth) and mandibular prognathism (over bite) are so noticeably off the radar even among prominent and powerful individuals in the Western world. This therefore begs the question, “why is there still such fear to visit the now upgraded and relaxing atmosphere of your dental office?  As necessity is the mother of invention so then complacency leads to problems. Hazelden.

MacDonald’s and Apple  Mac (”I” products) were capable of holding on to the big one that did not get away. Botox and silicone have followed suit with their huge grab of disposable income. These companies have been able to carve out a market directly in contract to “pro re nate” where dentistry is generally directed more and more at the almost identical target market. A detailed comparison, shows a similar core competence — namely a fashion statement directed at the youth market.

Dentistry is no less a pure science than neurology, yet one can hardly deny the growth or the expansion of the clinical use of Botox and silicone which are not absolutely free of discomfort. However it would be difficult to win an argument that Botox and silicone have not been successful at selling their products inspite of some period of discomfort. They, like I-pods have been successful at gaining market share of disposable income while general dentistry treading water dealing with regular appointments, acute or emergency situations while loosing more than their share of disposable income target for vanity.

There lies the veneer that covers the complexity which defies all principals of marketing gurus. Successful marketers are governed by the five “P’s” of the marketing mix. These are :PRODUCT, PRICE, PROMOTION, PLACE and PEOPLE. These principals all seem to be in place, yet any recent graduate dentist will tell you the tattoo office next door always seem to have a full waiting room although such visits to these cosmetic offices which are growing exponentially, in spite of much more pain for longer periods of time, to which no dentist would subject a patient.

The Roman monks of the middle ages who wore the cilice belt studded with sharp metal barbs, which when drawn a notch tighter delivered  the necessary penance and discipline before entering the house of God. This was their discipline or corporal mortification as they chanted , “Ahhh pain is good” as the barbs drew blood.

Let me again assure the general public at large, dentistry is a very lucrative, stable and highly profitable profession where appointments are mostly taken; in any typical day for many general practitioners of dentistry, it could be accurately classified as unremarkable.  Were it not to have to work around the odd drop-in emergency and acute situations, the flow of traffic for regular check-ups would be as exciting as watching a sterilizing instrument go through its cycles. Most dental offices are on auto pilot. Situations which rarely occur and classified as a panic environment may be what some peers would classify as operator error. These foreboding episodes can range from separation of an endodontic file, an anesthetic needle to the term known as “pumping” of local anesthetic in less than the recommended time of 60 seconds.

Certainly there are time when the test of one’s diagnostic skills freezes any dentist like the bright xenon lights of their BMW catches a deer of guard at night. There will be times when the recognition, identification, and treatment of certain perio (gum disease) could cause some stress, because of the need to avoid the possibility of systemic secondary infection. Systemic antibacterial therapy to prevent grave and possible fatal conditions such as meningitis, pericarditis, rheumatic fever, pneumonia, and even septicemia infections. However all practitioner are trained hopefully for such eventualities.

While botox and silicone have suffered their share of adverse publicity, they pale in comparison to any of the above episodes faced by a general dental practitioner. However the almost addictive search for vanity still maintains an intriguing appeal. Some experts say dentists are basically conservative and feel any “push” will be met with the typical answer. “let me think about it”.  Then why does one get the impression that general dentistry is not on target and that [dentistry] is less successful on selling a closure of clinical cosmetic diagnosis? The above is in no way intended to reduce the seriousness of a clinical diagnosis to a situation that may be interpreted as a frivolous cosmetic vanity.

After world war II, marketing was a simple exercise.  It was straight forward job. Management gave orders; “we have a warehouse of widgets”. your job is to go out and sell them. As marketing moved to a graduate degree with more universities focused on business disciplines in financial accounting, Laura Allan of Queen’s University Executive MBA moved to an exact science where the 5 “P” of marketing took on a new direction. Perception is reality.  lf customers do perceive what they are purchasing is exactly what they must have, then the marketing mix would have been a success.

Current graduates in business and marketing use this mix. The patented “whitening for life program” is aimed at just that concept. Sell the patient on what they want. Eventually any other clinical diagnoses will be more readily accepted.

Dentists and hygienist may have to adjust, step back to see the big picture from the patient’s point of readiness. Emergencies will continue because of their very nature — emergencies. Regular check-up will also continue because everyone has a guilt feeling if the bare necessities of plaque removal is being neglected. However what will drive a fearless and closer relationship is that both patient and dentist will experience a win - win situation.      mailto:localanesthetics@yahoo.ca” M.Sc. PharmD. CCPE.

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While dentistry continues to shed its old image and like the beautiful peony flower of spring which faithfully reminds us that like the tiny chicken pecks an exit through its shell to freedom, we too shall soon be shedding our cashmere coats and boots to behold endless fields of sheer beauty as spring transitions into summer.

Oral sciences, historically strut their new technologies at their largest shows in the spring each year in Cologne, Germany and Chicago, Illinois. Dentistry is benefiting tremendously from world wide research and innovative minds.

When was the last time while walking the corridors of a dental/medical building have you heard that shrilling or the blasting burr from a dental drill? Most such procedures are now taken care by laser. It took a little while, but for the records it was Einstein’s law of Relativity and his work on the speed of light showed that gravity had the ability to bend light. That was the beginning of the laser beam.

It is probably more likely to hear waterfalls and to sense the aroma of Asian or Tropical fragrances seeping from dental offices as more and more dentists offer through third parties a “day” of indulging oneself in the spa or a total therapeutic massage work out. 

However there are time when it is necessary to administer pharmaceutical agents (drugs) during dental treatment. The first that comes to mind is the placement of a local anesthetic solution to disguise or numb the presence of pain. It is not unusual for patients to have a low threshold and may manifest a mild allergic hypersensitivity to this solution. At other times such reactions can be as a result of too rapid [ injection should take 45 – 60 seconds ] an injection and finally, a tiny bit of the solution may enter into the vascular system during administration which may cause a faint or light headed feeling.

Most anesthetic solutions do contain epinephrine, the main purpose of which, is to reduce bleeding and to constrict or retain the anesthetic solution in place for a longer period. It is more preferable to have a little numbness persisting after the procedure, than to have the patient regain sensitivity before the work is finished. At times during a lengthy procedure the patient may require a second injection.

The purpose of this article is to draw your attention to the following article published and referenced under JADA (Journal of American Dental Association) which deals with epinephrine-impregnated retraction cords.

Epinephrine acts as a vasoconstrictor when used in dental procedures; however it can act as a vasodilator if it is introduced intravascularly or systemically absorbed. Caution is advised when relative high concentration of epinephrine is impregnated into retraction cords. Please consult your dentist. 

Gingival retraction

Controlling blood, crevicular fluid, water and saliva while taking impressions is critical. Water and saliva can be controlled by air spray. Blood and crevicular fluid can be controlled by retraction cords, hemostatic agents, electrosurgery or rotary gingival curettage.¹

Retraction cords displace gingival tissue mechanically; they also can have a chemical action when impregnated with astringents and vasoconstrictors that cause tissue contraction and hemostasis. Electrosurgery creates a trough around the tooth by removing superficial cell layers from the gingival sulcus’ inner lining through application of an electric current. Rotary gingival curettage removes the sulcular epithelium with a high-speed diamond bur. Azzi and colleagues² studied the effect of retraction cords, electrosurgery and rotary gingival curettage on gingival recession and loss of attachment in dogs. They found that cords had the smallest effect on the gingiva and rotary curettage had the largest effect.

Astringents impregnated in retraction cords include aluminum chloride, ferric sulfate, alum (potassium aluminum sulfate) and zinc chloride. Alum and ferric sulfate may be irritating and even corrosive at high concentrations, while increased concentrations of zinc chloride may damage bone and tissue permanently.³ The least irritating cords contain buffered aluminum chloride, which may be left in the sulcus for up to 15 minutes without permanent damage.⁴

Weir and Williams⁵ reported that soaking retraction cords in aluminum chloride solution enhances hemostasis. This led Runyan and colleagues¹ to study whether soaking cords in aluminum chloride solution has any effect on the ability of the cord to absorb moisture. They found that presoaking had no effect on fluid absorption and, therefore, may be a worthwhile adjunct.

Gingival retraction cords containing epinephrine effectively control bleeding; however, from 24 to 92 percent of the epinephrine may be absorbed systemically.⁶ Epinephrine-impregnated retraction cord contains 8 percent racemic epinephrine. One study estimated the concentration of epinephrine absorbed systemically to be equivalent to approximately 3.9 cartridges of local anesthetic containing 1:100,000 l-epinephrine.⁷ This estimate is considerably lower than previous estimates because the authors calculated the actual amount of releasable epinephrine in the cord before retraction, which was found to be approximately one-half that of the labeled amount; based their final estimate on the more biologically active l-epinephrine; and found that presoaking in aluminum chloride removed approximately 25 percent of the racemic epinephrine in the cord.

There are conflicting reports on whether epinephrine absorbed from retraction cords has any adverse physiological effects.^7–11 The potential epinephrine reactions that can occur following systemic absorption include increased anxiety after cord placement, limb tremor, diaphoresis, headache, florid appearance, tachycardia and elevated blood pressure.⁶ However, there are many variables that make it difficult to predict the physiological effect. These variables include the concentration of epinephrine absorbed from the cord; the length of time the cord is in the sulcus; the condition of the gingival tissue; the presence of crevicular fluid or saliva; individual patient response; and drug interactions with tricyclic antidepressants, nonselective ß-adrenergic antagonists, certain general anesthetics and cocaine.^10,11 Therefore, recommendations have been made to either limit or avoid use of such epinephrine-impregnated retraction cords.^7,10,11

comments to author.  mailto:localanesthetics@yahoo.ca    M.Sc. PharmD. CCPE   WWW.Anestheticnews.com

 Summer was once again approaching and while unlike the anticipation and eagerness I usually enjoyed each November, as I journeyed to my Caribbean retreat for my fix of ultra violet rays, yet there was something almost homeopathic and  calming about the aging hammock with a good book and the almost deathly silence of summer by the lake.

On my usual November trip south, the captain would put us through  the “g force” as he challenged the physics of gravity prior to lift-off. I often thought how Albert Einstein could have ever imagined what it would have been like to travel along side the speed of light when my main concern was focused on whether this de-iced 700,000 lbs monster would continue to gain altitude. However as true to form the falling leaves of red and gold faded into white fluffy cumulus which seemed to be void of density as the shining machine sliced through them as effortless as a knife through butter. There you go.  

Life above the 49^th parallel had lasting memories for me. I lived the best of both worlds. Snow shoveling was replaced by an early walk where I summonsed my younger balancing skills at playing hopscotch through the sharp edged seashells being caressed by each gentle wave. In contrast, summer was spent mostly reclining in a hammock which over the years had formed itself like a large latex glove around my girth with each increasing year.  This posture allowed me together with my book of the day to blend in with the sparsely placed pine furniture in the large and opened verandah which surrounded the cottage on three sides. open and almost oblivious to the distant hum of a power boat on the lake.

Winter, albeit relaxing and therapeutic, was in deep contrast to the silence one experienced on most lakes north of the 49^th parallel. The mere experience for most northern tourists to afford a Caribbean vacation was seen as a right of passage to gave way to any Freudian inhibition which may have not been completely resolved. In addition, there was the cooling and refreshing rum punch mixtures added to the rhythmic sound of the “steel band” made it a powerful prescription of feeling entitled to shed not only one’s pent-up stress, but at times parts of their already skimpy apparel. This resulting atmosphere is what most scholars of psychology refer to as the emerging passive-aggressive behavior. There you go.

In preparation for my summer retreat during the month of June, I was like the proverbial bull in the china store as I maneuvered my mini shopping cart from aisle to aisle through my favorite book store. This store offered an atmosphere not unlike a trade show with rows and rows of draped individual small tables throughout the aisles which seemed to add that much more square footage to advertise and promote authors and new releases. These arcades and display tables were managed independently by their own sales associates, a title by which they preferred to be addressed. There you go.

It was noticeably busy for a mid week morning in June. I carefully rechecked my BlackBerry organizer which for the most part tagged along with me like a faithful poodle with its unconditional love. From time to time it would vibrate or other times it would emit a childlike whine to inform me of some event I had previously entered and may have completely forgotten about it. I lovingly referred to it as my dementia levee which faithfully protected any memory cells from overflowing my aging brain’s levee. A tap or two on  the sensitive touch screen revealed  nothing exceptional or urgent other than a memo to remind me to make a date to see the movie “Sex and the City” With Sarah Jessica Parker, Kim Cattrall. There you go.

Why then was this excessive marketing atmosphere so evident throughout the store? Did the book industry secretly generate a Tiger Woods’ moment of mass marketing?  This certainly would have been the best kept secret, yet the solution was facing me right between the eyes. Historically, increased activity at book stores and movie houses has proven to be an accurate and reliable early leading indicator of impending recession as people at large have more free time. Ironically some business benefit from recession in the same way as the demand for steel increases during periods of war.

Suspense novels are my passion and among others there were two on my short  list – namely “A prisoner of birth” by Jeffrey Archer and “The Pillars of the Earth” by Ken Follet. I also keep in touch and have a burning desire to be current with professional journals and especially editorials which, with some basic writing skills and strategetly placed references can be confused as scientific material.

Over the many years of reading, I have developed an almost Sherlock Holmes analytical personality for articles. No more so than dentists are impulsively attracted to “the work” on one’s teeth or an architect inspecting the symmetry of a well placed keystone. These editorials/articles can often be detected by the format of their presentation, which is usually in the form of a question rather than the more accepted form of peer reviewed scientific study complete with investigating phenomena or purpose, an accepted methodology protocol and a conclusion. The pure sciences are becoming more and more diluted as such editorials begin their long “hear-say” or gossip walk through the hallowed corridors of famed teaching institutions.  Such articles presented under the guise of scientific material are for the most part self serving and do little to advance clinical efficacy with less unforeseen mishaps.

However, there are the pundits of an evolving world where analytic jurisprudence is popular and where asking questions like, “What is law?” “What are the criteria for legal validity?” or “What is the relationship between law and morality?” and other such questions that legal philosophers may engage. (Wiki).

An article this summer caught my attention under the heading of ethics and jurisprudence.  Here goes that question format - “Informed consent for Local Anesthesia - is it necessary?” There is implied dictum which takes the blame away from the operator and places it on a compound (amides) which dentists have been using successfully since 1947 to induce local anesthesia. If ever there was a case for longitudinal and sample size data, our stats people would have a heyday.  

Life styles through all aspects have changed and dental offices were no exception. I was as attentive to my oral health as I was to my physical health and over the  years I had noticed gradual subtle changes such as more pre clinical involvement with hygienists but perception is reality. I also noticed the office in greater detail. The Italian leather couches, slate tile floors and backlit etched glass in the patient lounge, exuded a definite warmth and elegant atmosphere. My dentist was considered to be one of the best, hence the ambience to go with her status.

From the patient lounge I  was taken into a room with soft music and current magazines like Ophra, Vogue, Sports Illustrated, which all appeared to have been delivered that very morning. The dentist greeted me and after some small talk, asked me to place a tiny pill under my tongue which she explained would dissolve in a few minutes. Her assistant returned in about half an hour and led me into the operatory. By this time I was feeling very relaxed and comfortable.

The local anesthetic solution was delivered through a computer-like electric tooth brush (minus the brush tip) and I felt absolutely nothing…no stick, not anything. I felt very relaxed throughout the procedure.

This is where, in my humble opinion, and together with my graduate degree in pharmacy, may leave room for a clinical study to determine the use of oral or even intravenous sedation in general dentistry. The question is whether to circumvent the pain associated with what some dentists refer to as “pumping”. Is there need for added pharmacological interventions ( use of muscle relaxants) when a slower delivery ( 60 seconds) would have proven just as effective and with reduced cost to the office?  The term “ Infants practicing on mom’s high heels’ is probably not inappropriate here.

To suggest a case for advocating informed consent for the use of local anesthetics after 60 years of successful clinical use in dentistry appears less substantive phenomena to identify rare sequellae such as temporary amaurosis, paresthesia and even death which would seem to be classified as operator error rather than of a biochemical origin. All clinical evidence would seem to beg the question. “Does this track record reasonably qualify to put local anesthetics (amides) under curfew or to “throw them under the bus?”

There is without doubt in general dentistry, a need to address the needle phobic patient, however a sudden move to give patients a “high” may increase patient traffic  prone to chemical addictiveness as the word get around, but with consequences not every dentist is willing to spend time, effort, legal and peer review in their selective associations.

Anesthetics and aesthetics — they even sound as though they work together. Informed consent seems rather like infants practicing on mom’s high heels.  However for general dentistry with limited experience of these  powerful opioid analgesic with a potency approximately 81 times that of morphine (wiki) may increase the traffic dentists may live to regret.

comments to author.  mailto:localanesthetics@yahoo.ca    M.Sc. PharmD. CCPE   WWW.Anestheticnews.com

This year, the entire world will look towards Asia with the celebration of the first ever Olympic Games in the People’s Republic of China. The Beijing Games will be a unique opportunity to bring Olympic education and values to the youth of China and the entire Asian continent.Few events in the western world excluding the 2008 elections in the U.S. in recent memory have stirred the kind of emotion that the Olympics in Beijing has; despite the fact that so few people have yet seen parts of the engineering structure of the stadia plans.

The 2008 Summer Olympics will be celebrated from August 8, 2008 to August 24, 2008, with the opening ceremony commencing on 08 August at 8 pm at the Beijing National Stadium in Beijing. Some events will be held in other cities of China. The program for the Beijing 2008 Games is quite similar to that of the Athens Games held in 2004. The 2008 Olympics will see the return of 28 sports, and will hold 302 events, making it the largest to date.

Self-medication has become a popular way of life and it is on the incline, however; during the Olympics it can carry a heavy price. In 1994 Silken Laumann, won the Rotsee Regatta in Switzerland as the only female single at the World Rowing Championships in Indianapolis. Unfortunately she fell victim to an OTC (over the counter) Benadryl to treat a cold.

The Olympics are frequently referred to as “the happy games”. In more than one way this name is a befitting description. At night, it is not unusual for one to readily distinguish the relaxing aroma of marijuana throughout the villages where frat-like atmospheres are dotted like stars in the sky. The muffled lyrics of The Rapping Rhinstone can be heard two hundred meters away. Are these just words?. These apparent innocent gatherings are only a harbinger of the more sinister and foreboding under belly of the Olympics where the powerful compounds are being administered parenterally to quench the thirst of the cries for Higher, faster, stronger.

Niacin, or nicotinic acid commonly referred to as Vitamin ??, is an over the counter (OTC) vitamin supplement. It is a potent vasodilator, which means it dilates blood vessels thereby increasing circulation of plasma volume through the kidneys on its complex circuitous route through the body. It is frequently prescribed, among other indications, to reduce cholesterol by increasing HDL ( the good ones) and lowering LDL (the bad ones).Historically, niacin (??) usage is associated with a cutaneous (outer skin) “flush”, more readily seen in light skin Caucasians than in dark skin people. It is this term “flushing” which has taken on legs of its own, resulting in ambiguous interpretations in the world of sports. This drug is being highly sought after by youngsters in competitive sports, whereby it is incorrectly classified as a detoxifying agent, which may be used as a firewall against detecting the use of performance enhancing drugs. This is false information and requires some friendly professional words of caution.

While on the subject of self-medication and compounds to boost performance in competitive sports, cyanocobalamin or ?12 is also on the high demand list. It is thought to be important in maintaining the nervous system.(U.S Pharmacist.) An insulating fatty sheath of myelin surrounds nerves. ?12 plays a vital role in the metabolism of fatty acids essential for the maintenance of myelin. Local anesthetics are capable of penetrating the fatty myelin resulting in a pain free injection of ?12. Absorption of ?12 requires the secretion from the cells lining of the stomach of a glycoprotein, known as intrinsic factor. Alternatively requiring a parenteral (needle) administration.

The American Society of Health-System Pharmacists discourages using niacin (??) for the treatment of abnormalities of fat metabolism (breakdown) without physician supervision. To fully understand cholesterol readings by lay people is a complex matter. It is not just a number, but rather a value with its own fingerprint and for clinically significance is best expressed as a ratio between HDL and LDL. The Center for Drug Evaluation and Research maintains this position, stating that drug therapy for dyslipidemia should not be an OTC due to the need for proper diagnosis and management; likewise, pharmacists should discourage patients from self-treating dyslipidemia.

Pharmacists have an important role in the proper and safe use of niacin by educating other health care professionals about differences among products. Pharmacists should also educate patients and discourage the use of OTC niacin if dyslipidemia (elevation of plasma cholesterol – Merck Manual) is present. Furthermore, a prescription for ER niacin should not be substituted with any OTC niacin (??) because there is not an approved generic equivalent to the prescription-only product. (U.S. Pharmacist). The term “flushing” is associated with increased blood circulation, and has no relationship to cleansing or detoxifying the blood of steroids and human growth hormone.

What must it have been like for Jesse Owens? With the turmoil of racial practices throughout those years in Nazi Germany. Can anyone imagine what he must have experienced? This was the real thing. No camouflage with Stanozolol that was not yet synthesized in 1936.

The ultimate adrenaline rush accompanied by uncontrollable patriotic emotions at being at the center position when the medal was being placed; words will never describe this moment.

Fashion is likened unto a tsunami; and niacin is that powerful engulfing force which like a micro-organism has infected the very tissues of athletes worldwide in their attempt to disguised the use of illicit compounds.

Unfortunately the zeitgeist of today’s competitive sport is so well cloned with the pill and the needle, that its amoeba like fission has engulfed not only the interest of the general public, but also the U.S. Congress to introduce the sporting world to two new influential political action groups: Republicans for Roger Clemens while Democrats sided with Brian McNamee.

The brotherhood of the needle (a phrase dubbed) after the Olympics in Seoul, 1988, is alive and well. Like a snake that has lost part of its tail, basement labs are working overtime to sprout a new one. Trainers and athletes worldwide are like hackers in their attempt to decode the latest spy ware in spite of increasingly sophisticated tests. For the betting man, the summer of 2008 will no doubt also have its place in history where “All the world will have been a stage and all the men and women will have been merely players”, (As you like it – Shakespeare) long after the closing ceremonies are over, the adrenaline has decreased, the lactic acid has dissipated and the tears of joy or disappointment have left their trail on the faces of our youth.

Each country no doubt will have embedded with their team a staff off physicians, dentists physiotherapist and hygienist, which makes good sense in a country where the practices of healing arts maybe dissimilar to ours in the western world and in an atmosphere one can almost predict with certainty the mere pressure of differences in professional training will be the perfect incubator to experience a Macaca Moment.

 “The world will never starve for the want of wonders”. – Gilbert. K. Chesterton (1875 – 1936). As profound as this statement is, it transcends time and culture. Anabolic steroids where not on the radar in Chesterton’s time.

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Steven lost his taste for The Big Mac after a visit to his dentist. Dentist unable to explain: Could this be Dr. Watson’s first case of unexplained paresthesia? I was entering my sophomore year of engineering. This transition year would be taking me from broad-based general education to a more highly-focused mechanical engineering course through advanced studies in mathematics, science and systems. By all measurements, I was well positioned with my peers and my grades were above average. My freshman year was now over and I was literally pacing myself for the complexity of projects which eventually would see my skills put into practice. At this stage in my studies, I was like a sponge in the ocean soaking up all and every lecture I attended. Being pulled and pushed with every movement of the tide around me. No clear route was calculated on my internal GPS; however there was a steady wind which seemed to be pushing me on a definite course. Or so it appeared to me.

It was difficult to conceal my identity; I was from a small Midwestern town and attended a private high school with my siblings where we enjoyed a comfortable life as children of parents who were both professionals. My mother was a restorative hygienist and my dad, Dr. Watson, owned a well established dental practice.

I was now off campus and was fortunate to share a modest third story attic-like apartment with Steven, a student who was also in engineering, one year ahead of me. Our apartment was no more than 500 sq.ft. but comfortable and spotlessly clean, with a clear view across town where one could see the familiar Golden arches and where many a university student caught up on notes, while enjoying the special burger of the day. Steven was no exception. He loved to eat at the MacDonald’s; He was hooked on their Big Mac and ate there at least four or five tines a week. Our apartment consisted of a sitting area, a kitchen, a washroom and one bedroom with two single beds. I was beginning to feel more in charge of my life and free to come and go as I pleased. My room mate was friendly but somewhat quiet and deep within his thoughts, or so it appeared to me.

Our schedules were quite different, and we did not have a lot of time together other than the occasional small talk while having a coffee. We were not big on booze but enjoyed the odd beer. He had a part time job at a small computer repair store and would be home usually by midnight. The tempo and the anonymity of the North East were very fascinating and everyday I could feel maturity seeping into every move I made. I was at ease with myself and happy, especially when I heard from my folks.

Although it was never overtly pushed on me, the atmosphere at home during high school was subtlety an expectation of going on to undergraduate school in the East. I was the oldest of my siblings and now that I can reflect, both my parents were lovingly using me as their flagship.  “If Jim sets the pace, the others will follow”. I was fortunate in that I did not have to work during my semesters away from home. My mother saw to that. There were to be no excuses for failing grades. I lacked for nothing. However in no way was I pretentious. In fact I was often seen and not heard. Deep within me I knew I was popular albeit, shy. I was no “Brad Pitt”, but confident was I, or so it appeared to me.

It was during our second semester of my sophomore year that I started to have some concern about my room mate. He suffered from bruxism, commonly known as grinding of the teeth, typically accompanied by the clenching of the jaw. It is an oral para functional activity which is common in many humans. Bruxism  (Wiki) is caused by the activation of reflex chewing activity; it is not a learned habit. Through osmosis, I had picked up many dental terminologies over the years from both of my parents. This condition (grinding) was not unknown to me; however the situation was causing me restless nights. I talked to my dad during one of our weekly “how are you” conversations and he suggested that Steven should see a local dentist, because of possibly damage to his teeth. It was not difficult to share my concern with Steven, because his girlfriend also thought he should see a dentist.

We (Steven, his girlfriend Veronica and I) had now become much closer. Steven opened up a bit more and at times could be quite comical. I was seeing the other side of him. We started to hang out on a more regular basis. Steven had appreciated my father’s professional advice and did in fact go to see a dentist associated to our engineering faculty. The diagnosis was confirmed. There was some small initial damage which had started to erode the enamel of his molars. The dentist was able to have a guard fitted in Steven’s mouth with which he could sleep comfortably at night. A follow-up appointment was scheduled in a couple of weeks to make sure the protective appliance was fitting comfortably. However the dentist noticed there was an old amalgam filling on his LR bi-cuspid which was overhung and was a floss shredder. The dentist advised Steven it should be replaced with a more modern white filling. Amalgams are for the most part now dated. The trend is to natural color composite fillings. This was good news for Steven because the silver amalgam was a nuisance and unsightly for a youngster. The date was set for the replacement filling and all would be well, or so it appeared to me.

Steven showed up for his 9:00 AM dental appointment which would have given him ample time to get back to class and by noon the anesthetic would have worn off giving him sufficient time to enjoy his big Mac. However things did not go as was planned. Steven still had a numb jaw and although he tried to disregard this persistent strange feeling, it was apparent that he had indeed lost all taste for his favorite Big Mac and fries.  On the third day Steven called his dentist to explain jokingly that he had lost all taste for any food and in particular, his craving for a Big Mac fix. The dentist reassured him that some people react that way to local anesthetics but the numbness and tingling sensation would soon disappear and normal full sensitivity would be back. Steven apprehensively took his word, but after day five, the condition had not improved and Steven was in a panic and wanted another opinion.

Without knowledge of the total situation, my father was privileged only to “hear-say” and cautioned me that it could be a case of paresthesia, which is a potentially serious pitfall for which dentists hope never to encounter during the life of their practice. My dad did not want to be involved for obvious reasons. I was now on the horns of a dilemma. After-all Steven was my trusted friend and room mate.

Unexplained paresthesia:

Steven was now withdrawn and depressed. He had lost weight and his essays were suffering. Veronica accompanied him to the guidance counselor and a decision was made that he should see a neurologist. Paresthesia was in fact the diagnosis. This condition was explained to Steven and the prognosis was good because he had a simply and uncomplicated infiltration of the anesthetic and was not exposed to a full nerve block. There were still unanswered questions. Why would this occur? There was no truma to any neres.

Steven did his research and discovered that around this time a new local anesthetic called Septocaine had been approved by FDA for dental use in the U.S. Unlike most other anesthetic solutions which have a concentration of 2%, this new one was a 4% concentration. In other words, theoretically and pharmacologically speaking, all things being equal, or as the scientists would say, in vitro, one could use half the volume of the 4% solution to achieve what the 2% was capable of. Each one of us can have slight anatomical variations in the oral cavity, hence different responces.

For some unknown reason, dentists are in the habit of referring to volume (cartridges) used rather than by mg/ml. (actual mg given).As it turned out, Steven awoke now in its tenth day, to discover the paresthesia had been miraculously reversed and full sensitivity had returned to his tongue and soft tissue around his lip. No point of mentioning where he headed after he discovered there were no more pins and needles. All therapeutic compounds are accompanied with an index. The lesson to be learnt is that the product monographs included in any medication by FDA and are intended to be read. The term Minimal Effective Dose is alive and well. Following these instructions may avoid expensive and time consuming litigation.

Comments to author.  mailto:localanesthtics@yahoo.ca    M.Sc. PharmD. CCPE   WWW.AnestheticNews.com

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References: Haas DA, Lennon D   J Can Dent Assoc. 1995