Pain Blocker

I hope this shot does the trick. If this is painful, these boots are walking… So goes the string of fearful thoughts that sometimes emerge as the patient sits, gazing up at the syringe, mouth agape. Although experts have long stated that local anesthetics are the safest and most effective drugs available for the prevention and management of dental pain, in reality patient loyalty is often directly proportionate to a clinician’s ability to skillfully administer the agent.

Local anesthesia, which stops pain by preventing stimulated nerve impulses from reaching the brain, is a staple of daily dental practice. Make no mistake, while some products offered by sales pros may fall into the “nonessential” category, local anesthetic materials do not. In addition to supplying clinicians with local agents, salespeople have an opportunity to equip clients with relevant supporting materials that help improve patient outcomes, maximize efficiency and safe practices, and allay patient fears. And while many traditional and time-honored delivery systems are still widely used, account executives can also offer some innovative products that have emerged in this category.

TRIED AND TRUE

While lidocaine, mepivacaine, prilocaine, bupivacaine and articaine — and the vasoconstrictor epinephrine — are the agents used by most clinicians in North America, our story focuses on the surrounding materials used in administering local anesthesia. With that said, a 1.7 ml or 1.8 ml local cartridge, syringe and a needle are the three traditional components used for administering locals.

Stanley Malamed, DDS, professor of anesthesia and medicine at the University of Southern California’s Ostrow School of Dentistry in Los Angeles, and author of the Handbook of Local Anesthesia, kicks off our discussion by stating that 99.9% of clinicians use a traditional syringe. “This system has been around for 180 years,” he says, “because it works.”

James Jesse, DDS, a Colton, California-based general practitioner and an assistant professor at Loma Linda University in Loma Linda, Calif., agrees, saying, “In my practice, about the only things that haven’t changed much over the years are a mirror, explorer, cotton pliers and the aspirating syringe. I do, however, use a variety of needles and anesthetic agents.”

There are eight types of syringes used for local anesthesia; among these, here are five examples of a nondisposable syringe:

  • Breech-loading, metallic, cartridge-type, aspirating
  • Breech-loading, plastic, cartridge-type, aspirating
  • Breech-loading, metallic, cartridge-type, self-aspirating
  • Pressure syringe for periodontal ligament injection
  • Jet injector (“needleless” syringe)

The metallic, cartridge-type aspirating syringe is most common in dental practice. This instrument, which is able to withstand repeated sterilization, is typically made of chrome-plated brass or stainless steel, and receives the cartridge from the side (as the term breechloading implies).

It also allows for an aspiration test — which is the highest criteria for a syringe — that must be carried out before injecting local anesthetic. At the end of the piston, a harpoon penetrates the thick rubber silicon stopper of an inserted cartridge. After inserting the needle into soft tissue, slight negative pressure is exerted on the thumb ring. This allows the clinician to see whether or not blood is visible in the cartridge. If it is, a blood vessel has been penetrated and the practitioner must find a different injection site.

The remaining three types include disposable syringes, “safety” syringes, and computer-controlled local anesthetic delivery (CCLAD) systems.

Generally, clinicians have a wide range of syringes to choose from, with most manufacturers offering slight variations on basic designs. Rather than pushing a particular make or model, sales pros should feel out a clinician’s preference. “They may all look alike, but there are subtle differences in syringes,” Malamed observes. “Basically, you have metal or plastic. Metal is reusable, and it can literally last decades. Plastic syringes are disposable. You use it once and it’s gone.”

Malamed goes on to state that thumb ring size should be considered. Because small thumbs can get lost in a large thumb ring, making it more difficult to aspirate, manufacturers offer syringes with standard or more diminutive ring sizes. Jesse concurs, advising, “Just be sure the clinician’s thumb comfortably fits the loop on the plunger.”

 

POINT of SALE

LOCAL ANESTHESIA DELIVERY

  • By providing clinicians with effective local anesthetic delivery systems and relevant ancillary materials, account executives can help dental teams build patient loyalty, improve outcomes, and maximize efficiency and safe practices.
  • Among the different types of delivery systems available, most clinicians prefer a traditional syringe. A metallic, cartridge-style, aspirating syringe is the most common type used for administering a local.
  • Every clinician should be stocked with long (32 mm) and short (20 mm) single-use disposable needles that have diameter sizes that fall in the range of 25, 27 or 30 gauge.
  • Other local anesthetic delivery systems include computer-controlled local anesthetic delivery (CCLAD) devices, jet injector or needleless devices, and syringes that contain a vibrating mechanism.

THE POINT OF IT

When supplying needles to a clinician, account executives should bear in mind that, aside from agents, this is potentially the most dangerous component of a delivery system. Pre-sterilized, single-use, disposable needles are constructed of stainless steel, platinum, or an iridium-platinum or ruthenium- platinum alloy.

Considering the variety of needle designs available, there are two chief considerations when helping clinicians remain well stocked: length and gauge. The needle’s bevel (or tip design) is another feature, but is not as important as the first two. Dental needles are available in two lengths: long and short — and a clinician should always have both sizes on hand. The average length of a short needle is 20 mm from hub to tip, while a long needle averages 32 mm.

The gauge marks needle diameter. Generally, three sizes are used in dentistry: 25, 27 and 30 gauge — with thinner needles having the higher number. Once again, you should defer to the clinician’s preference when supplying gauge size.

Jesse, for example, says he recommends a 30-gauge short to start with, and a 25-gauge short for inferior alveolar injections. He prefers a 30 gauge for all other injections.

Malamed, on the other hand, notes, “My ideal suggested armamentarium for any dentist or dental hygienist would be a 25-gauge long and a 27-gauge short needle. Bottom line: you need to have a long and a short. The length that clinicians choose depends on the kind of injection and how thick the soft tissue is they are going through.”

Interestingly, however, Malamed goes on to say that only about 3% of the needles supplied by manufacturers are 25 gauge. This is because the majority of practitioners use 30-gauge needles. The general thinking is that a thinner needle (e.g., 30 gauge) hurts less than a thicker needle. This, he says, is true up to a point. While 30-gauge needles are the most widely used, they are, according to Malamed, the needles that break most often — a rare occurrence, albeit a reality. And because he says there is no “perceptional difference” between a 25-, 27- and 30-gauge needle, he wants nothing to do with a 30 gauge.

 

TERMS TO KNOW

  • Aspiration: The withdrawal of fluid or tissue from the body. When administering a local anesthetic, an aspiration test allows the clinician to see whether or not a blood vessel has been penetrated.
  • Carpule: Another term for the cartridge used in a traditional local anesthetic syringe system.
  • CCLAD: An acronym for computer-controlled local anesthetic delivery.
  • Epinephrine: A vasoconstrictor agent that is added to dental anesthetics to increase their effectiveness.
  • Gate Control Theory: Various pain management strategies for administering local anesthetics are founded on this theory, which postulates that distraction and other stimuli can diminish the perception of pain.
  • Local Anesthetic: A drug that causes loss of sensation in specified locations by preventing nerve impulses from reaching the brain. This form of anesthesia does not induce a loss of consciousness.

COMPUTER DELIVERY

The first CCLAD system made its appearance in 1997. Since then, CCLAD technology has gradually become more popular. Compared to traditional hand injections, the distinguishing attribute of this device is its ability to utilize fixed, slow flow rates of injection delivery that lessen pain perception in adults and cause less pain-related episodes in children. Several clinical trials have shown the measurable benefits of this technology.

Malamed asserts that a CCLAD device makes delivery of anesthetics much easier than conventional syringe delivery. “I’m a big proponent,” he says. “It allows you to administer any injection more comfortably. The only perceived problem is cost. A traditional syringe isn’t expensive, but a CCLAD unit can cost up to $2000.” But as good as these machines are, Malamed explains that many dentists are leary of this kind of investment — although a knowledgable sales rep can help them understand the potential value this technology can add to a practice.

Other cited benefits of CCLAD technology include an increase in patient loyalty and referrals that result from reduced injection pain; reduced hand and finger strain among administering clinicians; and, on certain models, an automatic aspiration feature.

SURROUNDING ESSENTIALS

There are other supplies to keep in mind when positioning your clients for success when administering local anesthetics. Topical anesthetics are a prime example, as they are routinely used to numb the injection site prior to administering a local agent.

And because checking vitals is an important step in this procedure, a blood pressure monitoring system is a wise investment. Other peripheral sales opportunities include gauze dressing, cotton rolls and cotton pliers, as well as sharps containers and sterilization bags for nondisposable syringes that must be autoclaved after every use.

In addition, some clinicians like to place mouth props and retraction devices before administering injections. Also, a rep might provide lubricant for syringe maintenance. Replacement pistons and harpoons are also available. Essential products to have on hand when things take a turn for the worse include portable oxygen systems, ammonia inhalent to be used after a syncope (or fainting) episode, and an emergency drug kit.

 

STARRING ROLES

Joining the key players in local anesthesia products —traditional syringes, anesthetic cartridges, disposable needles and CCLAD devices — is a host of other technologies that can potentially improve the local anesthetic experience.

OraVerse from Septodont, for example, is the only local dental anesthesia reversal agent on the market. The injectable formulation — phentolamine mesylate — safely reduces the duration of numbness. “If you are using a local anesthetic drug that contains epinephrine, the numbing will last from three to five hours,” notes Stanley Malamed, DDS, author of the Handbook of Local Anesthesia and a professor of anesthesia and medicine at the University of Southern California’s Ostrow School of Dentistry in Los Angeles. “OraVerse reverses the numbness, allowing a businessperson, for example, to go back to his or her meeting and give a presentation. The person’s face won’t be distorted, and he or she won’t have to worry about drooling.”

For years, practitioners have buffered sealed cartridges of local anesthetics themselves to reduce the pain of injections, not from needle penetration, but from the burning sensation that results from the highly acidic pH level of the anesthetic. A new technology, the Onset mixing pen by direct-seller Onpharma, allows clinicians to easily blend sodium bicarbonate with a local anesthetic, which lowers the pH level to make the injection more comfortable for the patient.

Other approaches to minimize discomfort or anxiety associated with the administration of local anesthetics include jet injectors and needleless delivery systems. An example of the latter is Oraqix from DENTSPLY Pharmaceutical. Indicated for scaling and root planing, it uses a proprietary syringe-and-cartridge system to deliver a needle-free anesthetic directly into periodontal pockets. Syringes are also available with vibrating technology that relies on gate control theory, which postulates that overwhelming stimuli and distraction can minimize pain. Of course, playing music or showing a Finding Nemo video to a child during treatment falls under this technique as well.

SOON TO BE DELIVERED

Commenting on future trends and delivery systems, Jesse foresees the emergence of pure forms of local anesthetics. Malamed references nasal-mist delivery systems that can anesthetize the maxillary, a development that, in some cases, will provide an option to avoid injections entirely while still ensuring patient comfort.

Here’s our prediction. No matter where technology takes us, knowledgeable sales professionals who provide clinicians with an ensemble of effective local anesthetic supplies can help stop pain cold.

BONUS WEB CONTENT : ANATOMY OF A LOCAL ANESTHETIC CARTRIDGE

In providing clinicians with local anesthetic cartridges, dental sales professionals should be fluent in the different components of a glass cylinder cartridge, as well as a color-coded band system designed to identify various types of anesthetic drugs.

Also referred to as “carpules” by dental professionals, local anesthetic cartridges are made up of four parts:

  • Stopper: Also termed the plunger or bung, this black stopper at the end of the cartridge is made of silicon rubber, a material that allows for smooth gliding. A harpoon on an aspirating syringe is designed to gently embed into the rubber stopper. The stopper is slightly indented from the rim of the glass cartridge.
  • Cylindrical Glass Tube: Though cartridges are able to contain 2 ml of solution, local anesthetic carpules manufactured in the United States contain 1.7 ml or 1.8 ml of solution.
  • Aluminum Cap: Located at the opposite end of the cartridge, the silver-colored cap holds the diaphragm.”
  • Diaphragm: A semipermeable membrane, typically made of latex rubber, that the needle penetrates as it enters the cartridge.

Also displayed on the cartridge are the contents of the local anesthetic drug. As mentioned in the main text, local anesthetic agents used by most clinicians in North America include articaine, lidocaine, mepivacaine, prilocaine, and bupivacaine.

Sales pros will also notice that a drug-identifying, color-coded band is shown on every cartridge, marked close to the plunger. Responding to concerns that different color-coding schemes were being used by manufacturers to market the same local anesthetic product, in 2003 the American Dental Association (ADA) established a colorcoding system designed to label all injectable local anesthetics. Most companies that market local anesthetic drugs in the United States today continue to use this system. To view the ADA-implemented color coding system, visit ada.org/2516.aspx.

MENTOR January 2013, 4(01): 36–39.

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