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Most situations with which dentists are confronted today are a test of their artistic skills. The frequency with which they use all or some of these, especially injectable approaches makes a big difference in the comfort level of the patient during and after a dental procedure. There are approximately twelve basic techniques to administer local anesthesia to the upper (maxilla) and about half that for the lower (mandible). The more frequently each is used, the more proficient one becomes at them all. If one fails it is suggested not to modify it, but rather to move on to one of the other techniques. The important explanation is applicable to both patient and dentist. Clinical situations in dentistry are to some extent, moving more in line with medical treatment, whereby the clinician is expecting some input and cooperation from the patient so that it becomes a team effort. Gone are the days where clinicians were looked upon as mystical healers. Medical doctors and dentists need that important input from patients because healing is hastened and painless when the patient understands and is actively involved. I encourage you to read on. It will be presented in a pleasing manner which gives you a better insight into one’s oral anatomy. The holistic approach today is that patients do better when they are involved with the whole body. This trend has been growing for many years on the medical side; however, that desire to know, has been slow on the oral health side. New diagnostic equipment capable of detecting certain forms of oral cancer at specific developments is starting to make a difference with the public at large. Again it has been women who have picket up the gauntlet and are the ones most likely to ask questions. This may be more out of absolute clinical necessity, rather than by the nature of the beast. As an example women are more prone to develop grinding of the teeth and TMJ problems. Bruxism or grinding can be a serious problem. When we chew our food, we can deliver a force of over 150 pounds per square inch (psi) to our teeth. But when we grind our teeth at night, there's no food to absorb the impact, so the force on our teeth can be over 300 psi or more. That's enough to cause permanent damage to your teeth, including cracked and chipped enamel, hairline fractures, and even wearing down of the teeth to the gum line. The enamel may become so worn that dentin inside of the tooth is exposed. If bruxism isn't treated, it can lead to gum damage, loss of both natural teeth and restorations, and other more complicated jaw-related disorders such as the one I mentioned previously temporo-mandibular joint disorders). Over time, your teeth may become sensitive due to exposed dentin, and your jaws may even move out of proper balance. Grinding your teeth can also cause a wide variety of other symptoms including soreness and fatigue in your jaw and facial muscles, including ear and head aches. The corrective measures for bruxism involves fitted mouth guards and specific training on how to relax those muscles involved. Students attending high school and post secondary schools are very prone due to stress of meeting time lines etc. Fortunately, these stretching exercising together with the hardware do work. As youngsters develop and life styles change, bruxism does decrease and hopefully disappears. Whether it is true to say TMJ is seen more frequently in females than males is often questioned. The National Institute of Dental and Craniofacial Research (NIDCR) of the National Institutes of Health (NIH) indicate that over 10 million people in the United States suffer from TMJ problems at any given time. Both men and women experience TMJ problems; however, 90 percent of those seeking treatment are women in their childbearing years. Recent research indicates that more women seek medical care for a TMJ problem than men, and women are more likely than men to report ongoing pain. Physiological differences in pain signal processing may explain why more women suffer from TMJ conditions than men. In baboon studies, estrogen receptors were found in the temporomandibular joints of the female baboons, none were found in the males. Recent research has focused attention on the relationship between sex hormones and pain. A study conducted by Dr. Linda LeResche, University of Washington in Seattle, demonstrated that women on hormone replacement therapy were 77% more likely to seek treatment for jaw pain than those not undergoing such treatment. Also, women on oral contraceptive therapy were 19% more likely to seek treatment. Evidence is emerging in support of a biological explanation for why there are more women suffering from TMJ pain. It maybe that the diseases which affect the TM Joints are no different, really, than the diseases which affect other joints in the human anatomy. Rheumatoid, and Osteoarthritis; Inflammation of the Joint capsule; inflammation of the Synovial fluid, torn Ligaments, perforation, or tears in the rotator cuff. Internal derangement of the Condyle Head which is the knob-like projection that can be felt when one’s bottom jaw is extended to the fullest. Incidentally that is the approximate area that your dentist may direct the needle for those patients who complain that they are difficult to freeze. As a pharmacist I want to focus on the mode of action of drugs. Local anesthetics are drugs and therefore we need to be as equally informed as a dentist about these solutions. We frequently get calls from dentists requesting information on possible incompatibilities and any number of possible problematic patients. While we can not diagnose or treat, we frequently may offer suggestions if called when dealing with pharmacology and especially pharmacodynamics of other combination of drugs being used concurrently. Our training has to be current especially with new drugs (either legal or illicit) entering our communities. Dentists have in treat all types of patients with medical disabilities and the tremendous task to accommodate these patients. Think of any normal dental visit. It is not on the same par as an appointment with our masseur therapist. They see patients with tourettee syndrome, (Tics), grand mal seizures, spastic episodes and Down’s syndrome, just to name a few. To precisely place the anesthetic injection for a block requires the skill to avoid depositing the solution in a vessel, artery or a muscle. Any sudden movement could accidentally enter these areas. In my opening comments I mentioned there were well over a dozen techniques available and the more frequently they are used, gives that dentist an added advantage. I will reiterate, if one approach fails, then the alternative is not to modify it but rather change to one of the other techniques. There are a number of physiological and pharmacological reasons to change to another approach. The number one consideration is the sensitive pH with which one has to deal. Healthy tissue is at pH 7.4 and the anesthetic is at around 3.5. To deposit more solution will not only cause the tissue to expand and cause swelling, but will further increase acidity. It is not uncommon for some patents to have more branches of nerves than others. They all originate from one large valley. The trick is to get the main one before it branches off into many smaller ones. When you are going after a bee’s nest, you want to smoke out the “queen” then the colony of workers is disabled. There are other times when a kid is un-cooperative or has a disability and will not open their mouth wide enough. There is a very cool technique where the dentist can get a block even with clinched teeth. Yet another technique resulted from the researchers of a European pharmaceutical company. I am especially proud of this drug since I was on a team which was successful in gaining acceptance for this anesthetic to get approval in Canada and the FDA in the U.S. I have no financial or personal interest in this drug as is generically manufactured anyway. However because of its biochemical structure it can pass through bone, especially with children from the outer vestibule on to the lingual side. The beauty of such an anesthetic is that your dentist can completely freeze a kid without freezing the tongue. Recovery to sensitivity is rapid depending on the volume deposited. The more you give the longer it lasts. However as little as half a cartridge can fully freeze a patient. The article was published in JCDA under the title of Mandibular infiltration by Drs. Dudkiewicz, Schwartz and Laliberte. (Dept. of pedodontics, McGill University). The techniques of such administration are part of my webinar meetings or full live lecturers. Comments are welcomed to author. localanesthetics@yahoo.ca M.Sc. PharmD. CCPE
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TMJ, gow gates, akinosi, bruxism, grinding, pain, enamel,
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