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Local Anesthetics: Dentistry’S Most Important Drugs Stanley Malamed, Dds Thursday, February 20 C119 LOCAL ANESTHETICS: DENTISTRY’S MOST IMPORTANT DRUGS STANLEY MALAMED, DDS THURSDAY, FEBRUARY 20 DISCLAIMER: This work, audio recordings and the accompanying handout, are the intellectual property of the clinician, and permission has been granted to the Chicago Dental Society, its members, successors and assigns, for the unrestricted, absolute, perpetual, worldwide right to distribute solely as an educational material at the scientific program being presented at the 2011 Midwinter Meeting. Permission has been granted for this work to be shared for non-commercial education purposes only. No other use, including reproduction, retransmission in any form or by any means or editing of the information may be made without the written permission of the author. The Chicago Dental Society does not assume any responsibility or liability for the content, accuracy, or compliance with applicable laws, and the Chicago Dental Society shall not be sued for any claim involving the distribution of this work. Chicago Dental Society MWM & REGIONAL MEETING COURSE EVALUATION Speaker: Date: Subject: Number of attendees: PLEASE RATE YOUR SPEAKER AS TO: Excellent Good Fair Poor N/A • Subject selected ................................ 4 3 2 1 0 • Timeliness of subject ......................... 4 3 2 1 0 • Comprehensiveness ........................... 4 3 2 1 0 • Meeting your expectations ................ 4 3 2 1 0 • Content level ..................................... 4 3 2 1 0 • Delivery .............................................. 4 3 2 1 0 • Voice quality ...................................... 4 3 2 1 0 • Holding your interest ......................... 4 3 2 1 0 • Appropriate audiovisuals ................... 4 3 2 1 0 • Effective audiovisuals ........................ 4 3 2 1 0 • Overall evaluation of speaker ............ 4 3 2 1 0 • Overall evaluation of program ........... 4 3 2 1 0 Should this speaker be invited for future meetings? Yes q No q What topics of interest would you like to see covered in the future? Comments (use reverse if you need additional space): Name (requested but not required—please print): RETURN EVALUATION CARD TO: DO NOT FOLD CARD. FOR CDS PERMANENT FILES. Chicago Dental Society Aloysius F. Kleszynski, DDS 401 N. Michigan Ave., Suite 200, Chicago, IL 60611-5585 What’s New in LOCAL ANESTHESIA Dr. Stanley F. Malamed Dentist Anesthesiologist Emeritus Professor of Dentistry Ostrow School of Dentistry of U.S.C. Los Angeles, CA, USA © 2013 Dr. Stanley F. Malamed! All Rights Reserved 1 2 What’s New in Local Anesthesia Stanley F. Malamed, D.D.S. © 2013 Dr. Stanley F. Malamed! [email protected] © 2013 Dr. Stanley F. Malamed! All Rights Reserved All Rights Reserved 3 4 What’s New in Local Anesthesia DISCLOSURE (1) What’s Available ! ! (2) What’s New: I am a paid consultant to:! Nasal mist for maxillary anesthesia ! Septodont, Inc.! Buffered local anesthetic Onpharma! Reversing local anesthesia C-CLAD Articaine & mandibular infiltration in adults © 2013 Dr. Stanley F. Malamed! © 2013 Dr. Stanley F. Malamed! All Rights Reserved All Rights Reserved 5 6 Our most common fears PAIN Public speaking Going to the dentist The DENTIST The greatest fear Heights Mice dental patients have Flying Other/no fears is FEAR of PAIN 0 5 10 15 20 25 30 © 2013 Dr. Stanley F. Malamed! © 2013 Dr. Stanley F. Malamed! All Rights Reserved All Rights Reserved 7 8 Local anesthetics" Worldwide Articaine! Bupivacaine! Yet, LOCAL ANESTHETICS are the SAFEST and MOST EFFECTIVE drugs in medicine for Lidocaine! the PREVENTION & MANAGEMENT of pain Mepivacaine! Prilocaine © 2013 Dr. Stanley F. Malamed! © 2013 Dr. Stanley F. Malamed! All Rights Reserved All Rights Reserved 9 10 ESTERS 1885 to late 1940’s Deposit a Local Cocaine! Anesthetic Close to a Procaine! Nerve and It Tetracaine! WILL Benzocaine ! Produce Pain Control Chloroprocaine! Propoxycaine © 2013 Dr. Stanley F. Malamed! © 2013 Dr. Stanley F. Malamed! All Rights Reserved All Rights Reserved 11 12 AMIDES BUPIVACAINE HCL! ETIDOCAINE HCl! 1976 (2000 USA) Articaine LIDOCAINE HCL! MEPIVACAINE HCL! PRILOCAINE HCL © 2013 Dr. Stanley F. Malamed! © 2013 Dr. Stanley F. Malamed! All Rights Reserved All Rights Reserved 13 14 Local Anesthetic Clinical Duration Based on expected clinical duration of pulpal anesthesia:! Procaine Cocaine Tetracaine ! Hybrid Normal Distribution Curve ! ! Short-acting = ~30 minutes! Lidocaine Prilocaine Intermediate-acting = ~60 minutes! Mepivacaine Articaine © 2013 Dr. Stanley F. Malamed! Long-acting = 90 minutes or greater © 2013 Dr. Stanley F. Malamed! All Rights Reserved All Rights Reserved 15 16 All injectable local anesthetics are VASODILATORS! Short - duration LAs - USA Cocaine Blood flow through area is INCREASED Drug Onset (textbook) Pulpal Soft Tissue Mepivacaine 20 - 40 min! 3 - 5 min Infiltration - Nerve 2 - 3 hours 3% block Prilocaine 10 - 60 min! 3 - 5 min Infiltration - Nerve 2 - 4 hours LA diffuses OUT of AREA more rapidly 4% block © 2013 Dr. Stanley F. Malamed! © 2013 Dr. Stanley F. Malamed! All Rights Reserved All Rights Reserved 17 18 To increase DURATION, and! PLAIN LAs to increase DEPTH, of anesthesia, ! provide a a VASOCONSTRICTOR is added to the LA solution SHORT-DURATION of Worldwide USA Epinephrine NOT AS PROFOUND Epinephrine Norepinephrine anesthesia Levonordefrin Felypressin © 2013 Dr. Stanley F. Malamed! © 2013 Dr. Stanley F. Malamed! All Rights Reserved All Rights Reserved 19 20 Intermediate - duration LAs - USA Through addition of a vasoconstrictor, the ensuing BLOOD LEVEL of the local Drug Onset (textbook) Pulpal Soft Tissue anesthetic is significantly decreased, Epi! Articaine 4% 1:100k! 2 - 3 min 60 min 3 - 5 hours thereby minimizing risk of overdose 1:200k! (toxic reaction) Lidocaine Epi ! 3 - 5 min 60 min 3 - 5 hours 2% 1:50k, 1:100k Mepivacaine Levonordefrin 3 - 5 min 60 min 3 - 5 hours 2% 1:20k Epinephrine Levonordefrin Prilocaine Epi! 3 - 5 min 60 min 3 - 8 hours 4% 1:200k Epi = Epinephrine (Adrenalin) © 2013 Dr. Stanley F. Malamed! © 2013 Dr. Stanley F. Malamed! All Rights Reserved All Rights Reserved 21 22 Anesthetic blood levels Long - duration LAs - USA Epinephrine Peak blood Injection site Anesthetic Dose (mg) dilution level Drug Onset (textbook) Pulpal Soft Tissue Infiltration Mepivacaine 5 mg/kg None 1.2 10 min Bupivacaine Epi 90 - 180 up to 12 Infiltration Mepivacaine 5 mg/kg 1:200,000 0.7 20 min 6 -10 min 0.5% 1:200k min! hours (up to 7 hours) Infiltration Lidocaine 400 None 2 10 min Infiltration Lidocaine 400 1:200,000 1 20 min © 2013 Dr. Stanley F. Malamed! © 2013 Dr. Stanley F. Malamed! All Rights Reserved All Rights Reserved 23 24 Maximum recommended therapeutic dosages Drug Mg/kg Absolute maximum Whats’s New! Articaine HCl 7 n/a in! Bupivacaine HCl *** 90 Lidocaine HCl 7 500 Local Anesthesia Mepivacaine HCl 6.6 400 Prilocaine HCl 8 600 © 2013 Dr. Stanley F. Malamed! © 2013 Dr. Stanley F. Malamed! All Rights Reserved All Rights Reserved 25 26 Intranasal Local Anesthetic Mist Maxillary anesthesia without injection ! The LA ‘ON’ switch! The LA ‘OFF’ switch! C-CLAD! Articaine - mandibular infiltration © 2013 Dr. Stanley F. Malamed! Intranasal Local Anesthetic Mist © 2013 Dr. Stanley F. Malamed! All Rights Reserved All Rights Reserved 27 28 Intranasal Drug Administration Intranasal Drug Administration Illicit drugs: Cocaine © 2013 Dr. Stanley F. Malamed! © 2013 Dr. Stanley F. Malamed! All Rights Reserved All Rights Reserved 29 30 Intranasal Drug Administration Intranasal Drug Administration Emergency medicine! Pediatric grand mal status . Midazolam! Pediatric sedation (dentistry) . Midazolam © 2013 Dr. Stanley F. Malamed! © 2013 Dr. Stanley F. Malamed! All Rights Reserved All Rights Reserved 31 32 Intranasal Drug Administration Intranasal Sedation (Midazolam) Primarily YOUNGER pediatric patients! Common in management of STATUS EPILEPTICUS in children 1993 SEDATION 0.2 mg/kg © 2013 Dr. Stanley F. Malamed! © 2013 Dr. Stanley F. Malamed! All Rights Reserved All Rights Reserved 33 34 Intranasal Drug Administration As rapid onset as IM! May cause burning sensation! no needle ‘stick’! Disagreeable taste! Intranasal Equal potency to IM! Atomizer used! Equal duration to IM Above may increase patients combativeness Local Anesthesia MAD! Intranasal Atomizer Device © ©2013 2013 Dr. Dr. Stanley Stanley F. F.Malamed Malamed! ! © 2013 Dr. Stanley F. Malamed! AllAll Rights Rights Reserved Reserved All Rights Reserved 35 36 Maxillary anesthesia without injection Intranasal Local Anesthetic Mist Phase 2 clinical trial: 2009 Dr Sebastian Ciancio, SUNY Buffalo By mid - to late - 2014 (hopefully)! Nasal spray of Nasallocal Spray May End anesthetic Dental Needle Injections for Upper Teeth...provides pulpalhttp://www.buffalo.edu/news/9911?print=1 anesthesia to maxillary we will be able to administer! anterior teeth NEWS RELEASE Nasal Spray May End Dental Needle Injections for a local anesthetic intranasally ! Upper Teeth Repair Release Date: February 17, 2009 BUFFALO, N.Y. -- A nasal spray shown to numb the upper jaw is set to Contact be tested in an FDA Phase 3 trial, which will assess the spray's Lois Baker effectiveness compared to the current "gold standard" treatment -- [email protected] painful anesthesia injections. 716-645-5000 ext 1417 to provide profound pulpal anesthesia ! "A successful trial of this new dental anesthetic will change dental technology worldwide," said Sebastian Ciancio, D.D.S., University at Buffalo SUNY Distinguished Service Professor and chair of the Department of Periodontics and Endodontics. Ciancio directed the Phase 2 trial and will coordinate the Phase 3 trial. Between 6 and10 million dental needle injections are given daily, according to Ciancio. Results of the FDA Phase 2 trial, conducted in 48 subjects at the UB School of Dental Medicine, # # showed that the spray appears to be safe and effective. from 4 to 13 The Phase 3 trial will be carried out later in 2009 at the UB dental school and other clinical sites. Ciancio said that if the Phase 3 trial is successful, it may mean the end of injections for any dental work performed on the upper teeth. Ciancio and colleagues conducted the initial preliminary dental studies using the nasal spray, © 2013 Dr. Stanley F. Malamed! © 2013 Dr. Stanley F. Malamed! which is being developed by St.
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