CDA Journal Volume 31, Number 10 Journal october 2003

departments 733 The Editor/Ethics, Trust, and Image 737 Impressions/ADA Sessions Heads to San Francisco 771 New Products/Product Listing 790 Dr. Bob/Dogs of Distinction features 749 EMERGENCY MEDICINE IN PEDIATRIC DENTISTRY: PREPARATION AND MANAGEMENT The contemporary dentist must be prepared to manage expeditiously and effectively pediatric dental emergencies. Stanley F. Malamed, DDS

757 SERUM MEPIVACAINE CONCENTRATIONS AFTER INTRAORAL INJECTION IN YOUNG CHILDREN This study leads researchers to conclude that 3 percent mepivacaine should not be used when relatively large volumes of local anesthetic must be administered to small children. Katherine L. Chin, DDS, MS; John A. Yagiela, DDS, PhD; Christine L. Quinn, DDS, MS; Kent R. Henderson, DDS; and Donald F. Duperon, DDS, MS

765 A PREDICTABLE PRECISION CAST FOR MULTI-UNIT SCREW-RETAINED IMPLANT PROSTHESIS: RATIONALE AND TECHNIQUE This article describes a technique derived from the premachined cylinder luting technique with the goal to predictably fabricate a highly precise master cast. Lambert J. Stumpel, III, DDS; Walter H. Haechler, MDT; and Edmond Bedrossian, DDS The Editor Jack F. Conley, DDS

Ethics, Trust, and Image

raditionally, dentistry has reached an agreement that seeks to been the beneficiary of a improve communication and collab- strong public image. Much oration that will lessen the complexi- of that reputation was at- ty in the payment of dental claims, tributed to the influence of ultimately enabling more-effective a strong Code of Ethics. service to patients. TwiceT in the past decade, we commented in Item: On June 29, the CDA this column on results of public opinion Board of Trustees adopted a plan polls conducted by the Gallup Organization that will help to revitalize the role that showed dentistry placing in the top and importance of the Code of five professions based upon public percep- Ethics in the future of the tions of trust and respect. Based solely upon California Dental Association. memory, the most recent of those polls that We believe that each of these we personally reviewed placed dentistry be- reports and actions is interrelat- tween second and fourth out of all profes- ed in explaining where den- sions surveyed. tistry’s image might presently be In recent years, many events have con- and where we might move it in tributed to an assault on that image. It is the future. easy to identify media activity that has The reference to a Gallup poll survey negatively affected the profession’s image. that measured dentistry’s image in compar- Legal matters involving use of amalgam ison with other professions, appeared in a and Proposition 65, and the ongoing ef- midyear dental newsletter. While we were Many forts of the anti-fluoridationists to under- not able to either confirm the date of the mine dentistry’s preventive efforts are just poll or validate its accuracy, we were not events have a few of the specific issues the media has surprised by this ranking and believe that communicated to the public. it shows that dentistry’s public image is contributed There have been some recent reports probably not as strong as it was a few years to an assault and events that offer a reality check for the ago. We have already listed some of the profession. They provide an opportunity to public issues that probably have negatively on dentistry’s reflect on our current and future efforts to influenced public opinion. There are also improve dentistry’s image. the individual surveys by journalists such image. Item: A recent Gallup poll shows dentistry as one commented on here in July 2002 ti- falling from No. 2 to No. 8 in public opinion tled “A Profession in Decay — Dentists’ when evaluating all professions with regard to Business Practices Increasingly Suspect” honesty, integrity, and trustworthiness. that not only damage the public image of Item: A different Gallup poll dated Aug. the profession but, realistically, point to 18, measuring the image of 25 business and abuses that have been occurring in some industry sectors, found the health care indus- dental practices. try, of which dentistry is a small part, next to In an effort to validate the preceding last in terms of positive image. Gallup poll results, we encountered the Item: On Aug. 20, it was announced that results of a different Gallup poll that eval- the American Dental Association and Aetna uated the public image of 25 business and

OCTOBER.2003.VOL.31.NO.10.CDA.JOURNAL 733 The Editor

industry sectors in the United States. The Another potential cause of patient dis- health care industry sector rankings were satisfaction and distrust arises out of the alarming. Out of 25 sectors, the only one marketing of cosmetic dentistry. Unlike with a lesser image was the oil and gas in- reparative restorative dentistry, periodontal dustry. You name it — automobile indus- therapy, or endodontic therapy that may try, banking, legal, education, sports, etc. resolve discomfort and restore function, — they all have had a better reputation cosmetic procedures such as bleaching are than the health care industry in each of elective. Elective procedures, particularly if the past three years, according to this they bring only short-term satisfaction, are public survey. far more likely to bring about dissatisfac- A potential Admittedly, dentistry is a very small tion and distrust. This will occur if patients segment of the health care industry, believe that the treatment was neither a cause of patient which includes medicine and hospitals as need nor want, that they were pressured by dissatisfaction the major players. However, we believe the dentist to “purchase” the treatment in that some key factors related to all mem- the first place, and the treatment is evalu- and distrust bers of this sector — namely rising costs ated by another dentist a relatively short and the relationships of dentists and term later with a recommendation to re- arises out of the other health care providers with the insur- place or repeat (i.e., bleaching). Therefore, marketing of ance carriers and benefit plans, may ex- our opinion is that some of the less tradi- plain this group’s unenviable position in tional, newer forms of therapy “marketed” cosmetic the eyes of the public. in dental offices today, if they fail, or fail to Some business practices of insurance live up to the expectation of the patient, dentistry. carriers resulted in the recent ADA legal are more likely to result in a lack of trust, action against some major carriers and are thus reducing the image of the profession part of a problem that has often alienated in general. patients from their dentists. Also, the fail- The ADA agreement reached with ure of many practitioners to educate their Aetna provides hope that in the future, patients about the benefits of their plan greater communication, education, and and to properly manage the claims for understanding can guide the relationships treatment they render, further strains rela- between dentist, patient, and third par- tionships with patients who believe that ties. With time and education, there their benefit plan will cover all of their should be much less opportunity for pa- needed dental treatment. When insuffi- tients to lose trust in their dentists as a re- cient communication between dentist and sult of a misunderstanding of their insur- patient occurs, and patients receive an un- ance benefit programs. expected billing for services or less than Finally, we look forward to seeing a re- anticipated benefits, the result is mistrust newed focus on ethics within the profes- and resentment — not necessarily with sion. The CDA board has taken a very their employer or dental plan, but with small step forward. The task force appoint- the dental practitioner or staff who failed ed to carry out this review has a large re- to properly inform them of what their fi- sponsibility. Bringing ethical principles nancial responsibility would be. Many and values back into the forefront of dental colleagues fail to recognize that it is their practice decision-making in the 21st centu- responsibility to educate patients about ry will be a major factor in helping to re- benefit plans. No one else has that re- store the public image of the dental profes- sponsibility today. sion to previous levels. CDA

734 CDA.JOURNAL.VOL.31.NO.10.OCTOBER.2003 Impressions

ADA Session Heads to San Francisco

he American Dental Association opportunities designed to enhance the com- will host its 144th Annual munity of dentistry. Session, Thursday, Oct. 23, More than 180 scientific programs are through Sunday, Oct. 26, 2003, planned for the Session. This year’s pro- at the Moscone Center in San gram offers C.E. options for every member t Francisco. The 2003 Session fea- of the dental team — dentists, hygienists, tures a variety of continuing education pro- dental assistants, business managers, busi- grams, technical exhibits, and networking ness assistants, and dental technicians. The

OCTOBER.2003.VOL.31.NO.10.CDA.JOURNAL 737 scientific program provides participants ADA Annual Session attendees will with the education needed to enhance their have the opportunity to earn more than professional knowledge and clinical skills. 30 C.E. units and select from more than These in-depth sessions will present the lat- 25 hands-on workshops. In addition, the est developments in dental-related subjects following specialized programs are such as endodontics, esthetic dentistry, con- available: ADA Women’s Health and servative operative dentistry, and finance. Leadership Program, Two-Day Esthetic Forum, Technology Day Program and Exhibits, and the Team Building Program. ADA Session Highlights Session attendees will also have the opportunity to extend their educational ADA/Sonicare Distinguished Speaker Series opportunities beyond the classroom. On Friday, Oct. 24, Rudy Giuliani looks back at the They will be able to interact with repre- leadership lessons learned in a lifetime of public service sentatives from the approximately 625 and how they came together to provide strength at a defining companies expected to participate in moment in America’s history. On Sunday, Oct. 26, Gen. H. the technical exhibition. The technical Norman Schwarzkopf defines universal principles of leadership exhibition will give them firsthand ex- and how they apply to every aspect of one’s life. posure to the latest in dental technology The ADA/Sonicare Distinguished Speaker Series is open to all registered attendees to enhance their patient treatment and — tickets are not required. An ADA Annual Session badge is required for entry. practice management. The California ADA Special Events — Dana Carvey and the Beach Boys Dental Association will be among the ADA offers the best in evening entertainment. On Friday night, Saturday Night exhibitors. Live alumnus Dana Carvey will share his comic viewpoints. The entertainment contin- Again this year, ADA will present ues on Saturday evening with the legendary Beach Boys. the Distinguished Speaker Series, featur- ing some of the world’s most renowned ADA Foundation Health Screening Program speakers. Keeping with Annual Session The ADA Foundation Health Screening Program has been conducted at the ADA tradition, ADA has planned a series of Annual Session since 1964. During that time, information gathered by the program evening entertainment and social has become the largest national database on the health of dental professionals. The events facilitating networking among program has provided invaluable data that has proved useful in developing clinical colleagues. policies and recommendations that make dental offices safer for patients and dental For more information on the 144th care providers. Annual Session and other ADA events, All dentists and hygienists who register for the Annual Session are invited to par- contact the American Dental Association ticipate in the ADAF Health Screening Program, which will be held in Moscone at 211 E. Chicago Ave., Ste. 200, Chicago, North — Hall D. IL 60611-2678; (312) 440-2388 or (800) Screening hours are 9 a.m. to 4 p.m. Thursday through Sunday of the Session. 232.1432; or [email protected] or watch for updated Session information at www.ada.org/goto/session.

738 CDA.JOURNAL.VOL.31.NO.10.OCTOBER.2003 Empathy Key to Providing Care to Parkinson’s Patient To provide competent oral health care lar cheilosis and further angular irritation to patients with Parkinson’s disease, den- by frequent blotting of the lips and mouth. tists must understand the disease, its treat- The incidence of xerostomia among ment, and its impact on the patient’s abil- patients with Parkinson’s is reported to be ity to undergo and respond to dental care, as high as 55 percent, the researchers according to an article in the May 2003 noted. Chronic xerostomia may result in Quintessence International. painful oral soft tissue problems and poor Researchers at the University of Texas tissue adaptation to prostheses. Health Science Center at San Antonio The researchers stressed wrote that Parkinson’s disease is the that dentists also should be fourth most common neurodegenerative sensitive to the needs of the pa- disorder in the elderly, affecting an esti- tient’s family and caregivers. mated half-million people. Oral health They said that an essential part care providers can expect to be called of any successful strategy to upon to care for patients with this progres- optimize the quality of sively debilitating disease, they noted. life for patients with When treating patients with Parkinson’s disease is Parkinson’s disease, dentists must exercise familiarity with and empathy and a positive regard, the re- access to available searchers say. Dentists should strive to resources. reach preventive and therapeutic goals with the same ethical, moral, and profes- sional standards of care appropriate in the management of other patients. Oral complications include oral motor and sensorimotor impairment, dysphagia, xerostomia, and burning mouth. The researchers noted that in patients with Parkinson’s disease, tremor is an early sign and generally affects the hands, lips, and tongue. Tremor and rigidity of the orofacial musculature may induce orofacial pain, temporomandibular joint discomfort, cracked teeth, soft tissue trau- ma, displaced restorations, attrition from ruminations, and ptyalism. At least 75 percent of patients with Parkinson’s dis- ease have disordered speech or voice, the researchers said. Another oral complication, dysphagia, is reported by as many as 50 percent of patients with Parkinson’s disease. Slowed swallowing can further contribute to ptyalism, which in turn can lead to angu-

OCTOBER.2003.VOL.31.NO.10.CDA.JOURNAL 739 Illinois Legislation Limits Who Can Split Tongues Only physicians and dentists can tooing, tongue splitting does have a subcul- legally perform the relatively new fad ture of popularity among young people in of tongue splitting, according to an their late teens and early 20s. The act seems Illinois law recently signed by Gov. to attract people who want to create a Rod R. Blagojevich. forked or lizard-like tongue. Too often the The new law, which is procedure is performed in tattoo parlors or the first of its kind to other locations that lack the necessary emer- be enacted in any gency equipment or sanitary environment. state, declares: “A The American Association of Oral and person may not Maxillofacial Surgeons reports that no oral perform tongue and maxillofacial surgery training institu- splitting on an- tions teach a tongue splitting procedure, other person un- though an oral surgeon would be qualified less the person to do so based on his or her hospital-based performing the surgical residency and training. tongue splitting While endorsing the governor’s decision, is licensed to prac- the oral surgeons’ association cautioned the tice medicine in all its public about pursuing the tongue splitting branches under the Medical procedure. Dr. Larry W. Nissen, president of Practice Act of 1987 or licensed under the the association, noted that, “Side effects can Illinois Dental Practice Act.” A first-time vi- include serious infection, as well as signifi- olation of this new law is considered a cant alteration in speech and taste. There Class A misdemeanor. A second offense is a are also many large blood vessels in the Class 4 felony. tongue that, if damaged, could lead to life- While not as popular as piercing or tat- threatening bleeding.”

Service Provides Information on Safety of Products The National Institutes of Health has unveiled a consumers guide that provides easy-to-understand information on the potential health effects of more than 2,000 ingredients contained in more than 4,000 common house- hold products. Some household products contain substances that can pose health risks if they are ingested or inhaled, or if they come in contact with eyes and skin. The National Library of Medicine’s Household Products Database (http://house- holdproducts. nlm.nih.gov) provides information in consumer-friendly lan- guage on many of these substances and their potential health effects. Information in the database is provided to the National Library of Medicine under a collaborative agreement and is derived from publicly avail- able sources, including brand-specific labels and in- formation provided by manufacturers and their web sites. The list of products covered will be expanded, and information for products currently in the database will be updated at least annually.

740 CDA.JOURNAL.VOL.31.NO.10.OCTOBER.2003 Scaling May Reduce Risk of Premature Births A nonsurgical dental procedure may re- planing and a placebo. duce the risk of preterm birth in pregnant “What this tells us is women with periodontal disease, according that scaling and root plan- to new study findings. Nearly 12 percent of ing may significantly reduce babies in the United States are born preterm a mother’s chance of hav- (before 37 completed weeks of pregnancy), ing a preterm birth,” said which increases their risk of death and last- Marjorie Jeffcoat, DMD, au- ing disabilities, such as mental retardation, thor of the study. “We found no evidence cerebral palsy, lung and gastrointestinal that the addition of an antibiotic to scaling problems, and vision and hearing loss. and root planing was of benefit in this The report was published in the Journal study. However, more research needs to be of Periodontology and is based on 366 preg- conducted to determine the reason for the nant women who had periodontitis and decrease in efficacy.” Trick or Treat found as much as an 84 percent reduction Previous research reported that peri- of premature births in women who were odontal infections cause a faster-than-nor- According to less than 35 weeks pregnant and who re- mal increase in the levels of prostaglandin Research!America, ceived scaling and root planing. and tumor necrosis factor molecules that Americans spent Researchers also found that adjunctive induce labor, thus causing premature de- nearly $2.025 billion metronidazole therapy did not improve livery before the fetus can grow to a nor- pregnancy outcome. In fact, women who mal birth weight. However, this is the first on Halloween candy were given the antibiotic after scaling and intervention study that offers advice on re- in 2002. root planing had more preterm births ducing the risk of premature births with That amount would than patients receiving scaling and root scaling and root planing therapy alone. fund the National Institute of Oral Cancer Exams Critical for High-Risk Adults Dental and Craniofacial Dental practitioners should improve whether cigarette smoking and alcohol use Research for almost the provision rates of oral cancer examina- were associated with receipt of an oral can- six years. tions, especially among current smokers cer exam. and edentulous alcohol users who The researchers found that current have not been to the dentist in the smokers were no more likely to have past year, wrote researchers in the received an exam than were patients spring 2003 issues of the Journal of who never smoked. The association Public Health Dentistry. between alcohol use and receipt of The conclusion is based on a an oral cancer exam were mixed, study of the findings of the 1998 and were generally more favorable National Health Interview Survey, among those who had a dental wrote Mark D. Macek, DDS, DrPH; visit in the last year. Britt C. Reid, DDS, PhD; and Janet The authors noted that evi- A. Yellowitz, DMD, MPH; of the dence relating the sensitivity of an Baltimore College of Dental Surgery. oral cancer exam to early The authors noted that cigarette detection and lower inci- smoking and alcohol use are risk fac- dence rates is still under tors for oral and pharyngeal cancer. question. They said, however, Recommendations for periodic oral that until a more sensitive de- cancer examinations highlight the impor- tection measure is discovered, the periodic tance of examining high-risk smokers and oral cancer exam represents the only tool alcohol users. Their investigation assessed available to health care practitioners.

OCTOBER.2003.VOL.31.NO.10.CDA.JOURNAL 741 Secondhand Smoke and Caries Linked in Children Young children who are exposed to sec- 4,000 children ages 4 through 11, ondhand smoke have a much higher rate the study found that children had of caries than do children who do not grow an increased risk of developing up around smokers, according to a study caries if they had high levels of co- published recently in the Journal of the tinine, a byproduct of nicotine that American Medical Association. is consistent with secondhand According to the Agency for Healthcare smoke exposure. Research and Quality, which supported the About 32 percent of the children with study, this is the first study in the United cotinine levels consistent with secondhand States to associate secondhand smoke with smoke exposure had carious surfaces in caries. Although the occurrence of caries in their primary teeth, compared with 18 per- children has declined dramatically in the cent of children with lower levels of coti- United States, little headway has been nine. The higher risk of developing cavities Honor made in reducing it among children living in tobacco-exposed children persisted after in poverty, who generally have less access controlling for other factors such as pover- Steven A. to dental care and appear to be more vul- ty and frequency of dental visits. Gold, DDS, of nerable to caries. The study did not find a similar associ- Santa Monica, Based on data from household inter- ation between secondhand smoke expo- Calif., won first views and health examinations of about sure and cavities in permanent teeth. place in the an- nual William J. Geis Award for editorial writing Upcoming Meetings with his essay “Healing or Hustling?” which appeared in 2003 the August 2002 issue of the Oct. 23-26 ADA Annual Session, San Francisco, (800) 232-1432. Journal of the California Dental Association. Gold is the associ- Nov. 2-7 U.S. Dental Tennis Association Annual Meeting, Palm Desert, Calif., (800) 445-2524. ate editor of the Journal. Nov. 8-9 International Conference on Evidence-Based Dentistry, Chicago, [email protected] Nov. 16-22 Annual Meeting of the U.S. Dental Golf Association, Scottsdale, Ariz., (631) 361-7127, [email protected]. Dec. 5-7 California Academy of General Dentistry Annual Meeting, San Diego, (877) 408-0738, www.cagd.org. 2004 March 3-6 Academy of Laser Dentistry 11th Annual Conference, Palm Springs, Calif., (954) 346- 3776, www.laserdentistry.org. April 15-18 CDA Spring Scientific Session, Anaheim, Calif., (866) CDA-MEMBER (232-6362). Sept. 8-11 International Federation of Endodontic Associations Sixth Endodontic World Congress, Brisbane, Queensland, Australia, www.ifea2004.im.com.au. Sept. 10-12 CDA Fall Scientific Session, San Francisco, (866) CDA-MEMBER (232-6362). Sept. 30-Oct. 3 ADA Annual Session, Orlando, Fla., (312) 440-2500. To have an event included on this list of nonprofit association meetings, please send the information to Upcoming Meetings, CDA Journal, P.O. Box 13749, Sacramento, CA 95853 or fax the information to (916) 443-2943.

742 CDA.JOURNAL.VOL.31.NO.10.OCTOBER.2003 New Products

New product information listed here is derived from news releases received look and feel, while freshening breath from the manufacturers. CDA does not endorse or recommend the products fast. The Rembrandt Whitening or procedures indicated, but provides this listing as a reader service. Wand contains a unique patented peroxide formula, which safely and effectively whitens teeth and freshens GC Occlusal Matrix System breath. Pain and sensitivity-free, the GC America has announced the Rembrandt Whitening Wand works launch of GC Occlusal Matrix System, tooth whitening magic anytime, any- a specially designed disposable tool place. For more information, call that aids in speedily achieving the (800) 548-3663. perfect occlusal surface. The Occlusal Matrix contains 50 pieces, 25 left and Wave, Wave MV, and Wave 25 right. The GC Occlusal Matrix HV Flowable Composites System also allows the user to under- SDI has introduced the take multiple restorations in different Wave, Wave MV, and Wave parts of the mouth. Simply connect HV ideal versatile, fluoride-re- the handles of a male (left) and fe- leasing, radiopaque, light- male (right) matrix together and ad- cured flowable composites de- just the shape to accommodate four signed for anterior and posteri- different sizes of full arches. For more or restorations. The range of information, call (708) 597-0900. viscosities ensures that the dentist has a choice for all clinical Composite Carriers situations. Some of the uses are Class Cosmedent has introduced a line V defects, small Class I and II restora- of Composite Carriers that allows for tions, gingival walls, pit-and-fissure easy placement of material in Class I, sealants, blocking of small undercuts, II, and III restorations. These are ideal enamel defect repair, abrasions, instruments to use for the deliv- minor core build-ups, porcelain re- ery of all composites to the cav- pair, and veneers. For more informa- ity preparation, and are avail- tion, call (800) 228-5166. able in three sizes (small, medi- um, and large) to ensure that GC Temp Advantage the dentist has exactly the GC America has announced amount of material needed. the launch of GC Temp Today’s stiffer composites are Advantage, a temporary ce- much easier to dispense with these in- ment for temporary crowns, in- struments, eliminating the inconve- lays, and onlays. GC Temp nience of working with unwieldy dis- Advantage is the only tempo- pensing guns that require enormous rary cement to successfully in- strength. For more information, call corporate all the critical addi- Cosmedent, Inc., at (800) 621-6729. tives that offer the best in temporary cements: fluoride, cholorhexidine, and Whitening Wand potassium nitrate. It is offered in an Rembrandt Oral Care Products affordable, easy-to-use automix sy- has introduced the Rembrandt ringe. The GC Temp Advantage pack- Whitening Wand. One swipe of the age contains one ready-to-use syringe easy-to-use sponge tip “wand” appli- and 10 mixing tips. The tips will be cator instantly adds brightness and available in refills of 10. For more in- shine to teeth for that “just-brushed” formation, visit www.gcamerica.com.

OCTOBER.2003.VOL.31.NO.10.CDA.JOURNAL 771 New Products

Ultra-Lume LED 5 SuperNatural Dentures and Ultradent Products, Inc., has intro- Partials duced the Ultra-Lume LED 5, the only Precision Ceramics is now of- LED light designed to meet all curing fering a revolutionary new den- needs. Ultra-Lume has greater than ture system that will allow den- 800mW/cm2 with a curing mode of tists and patients to enjoy the 10, 20, 30, or 40 seconds of benefits of premium denture cure time. The Ultra-Lume LED base materials processed with 5 has a tracking feature of one state-of-the-art injection equip- to four seconds. There is no re- ment. In addition to having a turn to a 20-second default; precise fit and a choice of conventional the time stays on the desired or flexible bases, SuperNatural Dentures setting. The Ultra-Lume LED 5 and Partials are the strongest and most fits into a handpiece holder, fracture-resistant material on the mar- thus is takes up no counter space. The ket. The laboratory includes a lifetime handpiece has a low-profile head, al- warranty certificate with every case. For lowing greater comfort for the patient more information, call (800) 223-6322 and eliminating stress on tissues and or visit www.pcdl-usa.com. the temporomandibular joint. The LED display on the handle indicates Level 356 Dental X-Ray the time. The handle is lightweight Film Processor and has a large, raised on-and-off Fischer Industries, Inc., has an- button. It is available with a 10- or nounced the Level 356, a new automat- 17-foot cord. For more information, ic X-ray dental film processor. The Level call (800) 552-5512. 356 can be used virtually anywhere be- cause it requires no plumbing or Hygenic Flexidam darkroom. It is compact, Non-Latex Dental Dam portable, economical in daily Coltene/Whaledent, Inc., has in- use, and simple to clean and troduced the Hygenic Flexidam maintain. It can accept any size Non-Latex Dental Dam. Hygenic film — from small intraoral Flexidam has an elastic elongation films to panoramic and cephalo- nine times its original length. metric films — on its 14-inch- This high level of elasticity wide feed tray. The Level 356 can also means Hygenic’s new non- develop panoramic and cephalometric latex dental dam has an ex- film side-by-side to save energy, chem- treme resistance to tearing istry, and time. The Level 356 is avail- and a resistance to puncture able online at www.fischerind.com or from bur and instrument con- by calling (800) 356-5911. tact. Because of the high elas- ticity of Hygenic Flexidam, the clini- Kodak DX4900 Dental Film cian is assured of a tight fit around Digitizer Accessory the preparation for moisture control Dentists can now digitize their and effective isolation. Hygenic dental film X-rays or color slides Flexidam Non-Latex Dental Dam is with the click of a camera shutter, powder-free, odorless, and available using a new accessory for the in a 6-inch-x-6-inch nonreflective vi- Kodak DX4900 Dental Digital olet color. For more information, call Camera Kit. The dental film digi- (800) 221-3046. tizer accessory allows dental pro-

772 CDA.JOURNAL.VOL.31.NO.10.OCTOBER.2003 New Products

fessionals to mount and photograph in- Commercial Air Sampler traoral X-ray films or photographic slides RGF Environmental Group has an- using the DX4900 camera with a close-up nounced the release of its Commercial lens. The digitized images can then be Air Sampler. The Air Sampler was de- easily transferred to office computers for signed for quick and accurate air qual- integration with electronic patient records, ity sampling using industry-standard for sharing with insurance companies, 100 mm aerobic petri dishes. This and for other electronic applications. For unique indoor air quality sampler more information, call (800) 933-8031 or works by drawing in 500 L of indoor visit www.kodak.com/go/dental. air and depositing the microbes onto a prepared petri dish. This dish is then Spray-On Ceramic Glaze incubated and numerated, providing By utilizing patent-pending technolo- an accurate representation of the air gy, Speedent Dental Supplies now offers quality in the test area. The Air the world’s first Dental Ceramic Sampler is easy to use, pre-calibrated, Spray-On Glaze for the produc- and a time-saving device (replaces set- tion of crowns and bridges. Spray- tling plate methods). For more infor- On Glaze is compatible with all mation, call (800) 842-7771. high-fusing porcelain systems and constructions, ranging from Microbrush X Applicator porcelain-fused-to-metal to milled Microbrush Corp. has introduced and pressed ceramic restorations the Microbrush X, the newest member with one firing. It is the quickest, easiest, of its popular family of Microbrush ap- and most versatile dental glaze applica- plicators. It is designed with a thinner, tion on the market. It will increase effi- longer brush tip to simplify application ciency, decrease in-process time, and re- for procedures involving confined ap- duce labor cost, all while providing a plications such as bonding posts and natural glaze. For more information, call inlays, onlay cementation, and subgin- (800) 706-0644. gival use. The shorter, stiffer brush fibers hold a fraction of a drop of ma- AllSolutions Fluoride Foam terial for precise placement and allow Dentsply Professional has introduced for scrubbing. For ease of use, the ap- AllSolutions Fluoride Foam, the first prod- plicator bends firmly to 90 degrees. The uct that combines great flavors in colored Microbrush X kit includes a cartridge foam with a new unique, dependable of 100 applicators and a Microbrush X nonaerosol dispensing pump. The foam dispenser. For more information, call is available in 2 percent neutral sodium (866) 866-8698. fluoride (mint and peach flavors) and 1.23 percent acidulated phos- Brushtime Bunny phate fluoride (mint and berry Brushtime Products, Inc., has an- cherry flavors) for professional nounced the release of the Brushtime topical application to aid in the Bunny, a teaching tool for any dental protection against dental caries. practice that treats children. It helps The 2 percent neutral sodium flu- dental hygienists give oral hygiene in- oride is a nonacidic fluoride that struction to children. The Brushtime is safe for patients with porcelain restora- Bunny is a 12-inch-high cartoon-style tions, composite restorations, sealants, rabbit holding a carrot in the right paw and xerostomia. For more information, and a toothbrush in the left. The call (800) 989-8825. bunny’s belly opens to reveal a mirror

OCTOBER.2003.VOL.31.NO.10.CDA.JOURNAL 773 New Products

and displays four important brush time HIPAA Compliance Folder tips. The carrot case is designed as a trav- Labels el case and includes a toothbrush, tooth- Recently enacted HIPAA regula- paste and dental floss, held together at tions say that patient health informa- the top with a cleverly disguised rinse tion must be protected and can no cup. Children find everything necessary longer appear on the outside of pa- for dental hygiene care in one place, and tient record folders. Now, the Dental the attractive bunny and motivating Record has labels to help dental song encourages them to keep using it. offices comply with those rules For more information, call (866) 508- and safeguard the protected 7400 or visit www.brushtimebunny.com. health information of their pa- tients. Two new labels can be Opalescence Mirrored Tray attached to the outside of the Cases patient’s dental record folder to Ultradent has introduced a new alert the office staff that the file way to carry and store direct semi-cus- is HIPAA-compliant. There is a bright tom-fitted or indirect custom-fitted pink, 1.5-inch-x-1.5-inch label made bleaching trays. These mirrored tray of sturdy Mylar, which reads “HIPAA cases come in colors that coordi- Compliant” and folds over the edge of nate with Opalescence flavors: the patient’s folder; and there is a 1- mint, melon, and regular (green, inch-x-1.5-inch blue label with the pink, and purple). The tray cases words “Privacy Notice” that can be af- can be purchased as a variety fixed to the outside face of the patient pack, or individual colors can be folder. For more information, call purchased in quantities of three. (800) 243-4675 or visit www.dental- The Opalescence mirrored tray record.com. case is durable, handy, and convenient. The built-in mirror allows the patient to Erkoscop Parallax Mirror check his or her progress. For more in- Easily visualize no-parallel situa- formation on Opalescence Mirrored tions during clinical treatment using Tray Cases, call (800) 552-5512. the Erkoscop Parallax Mirror. Erkoscop’s unique curved shape pro- Mini Air Purification System vides a parallax view of the entire RGF Environment Group has an- arch. Using the Erkoscop, it will be nounced its new air treatment system easy to see if preparations are paral- designed specifically for dental offices lel and, if necessary, make adjust- and labs. RGF’s APS Mini air treatment ments. This ensures that the bridge system is effective at reducing airborne framework will draw passively off the mercury, mold, bacteria, viruses, and preparations, which helps prevent other chemical odors. This commercial distortion of the bridge wax-up. A quality stainless steel air treatment sys- passive fit of the bridge framework tem utilizes RGF’s proprietary also guarantees resistance-free seat- Photohydroionization technology. This ing and precision fit. The Erkoscop is unit does not mask odors; it destroys $79. Call Glidewell Direct at (888) them. It is designed to be either wall- 303-3975 for more information. mounted (vertically or horizontally) or positioned on a workstation close to the Reach Clean Burst Dental odor source with its optional stainless Floss steel stand. For more information, call Patients can freshen breath and (800) 842-7771 or visit www.rgf.com. clean between teeth to remove odor-

774 CDA.JOURNAL.VOL.31.NO.10.OCTOBER.2003 New Products

causing debris in one step with new 3200cc), larger than most on the mar- Johnson & Johnson Reach Clean ket, to collect more waste and reduce Burst Floss. The floss leaves behind a the need for multiple liners for a given fresh, clean feeling with each use. procedure. For more information, call Combining intense, high-impact fla- (800) 337-6925. vor with superior cleaning, Johnson & Johnson Reach Clean Burst Floss is available in three flavors — icy pep- Crest Whitestrips Supreme permint, icy spearmint, and berry Procter & Gamble has announced mint. For more information, call the launch of Crest Whitestrips (212) 367-6923. Supreme, the newest generation of Crest Whitestrips Professional and an ProfessionalCare 7000 outstanding professionally dispensed, Series Power Toothbrushes at-home whitening option for patients. Oral-B Laboratories has introduced Clinical research shows that Crest the ProfessionalCare 7000 Series, the Whitestrips Supreme whitens at least brand’s most advanced line of premi- 65 percent better than commonly used um power toothbrushes. Headlining tray-based whitening systems. Crest this series is the Oral-B Pro- Whitestrips Supreme whitens up to 80 fessionalCare 7850 DLX, an exclusive percent better than the Crest professional model, featuring en- Whitestrips sold in retail stores and will hanced oscillations and a new be sold exclusively to dental profes- Professional Timer, all designed to sionals. Crest Whitestrips can also help make a noticeable difference in pa- grow a dental practice. Independent re- tients’ oral health. The Oral-B search conducted over a six-month pe- ProfessionalCare 7000 Series offers the riod has shown that dental practices fastest pulsating action available — that sold Crest Whitestrips Professional 40,000 pulsations per minute — and Strength had a 92 percent increase provides an oscillation speed of 8,800 in the number of patients who oscillations per minute, an increase of whitened their teeth. For more infor- 15 percent over the original Oral-B 3D mation, call (800) 543-2577 or visit Excel. For more information, call (800) www.dentalcare.com. 44-ORALB or visit www.oralb.com. —Compiled by Jennifer Hail ReliaFlex DeRoyal has introduced a surgical suction liner system called ReliaFlex that provides 28 percent more suction flow power than other liners while eliminating regurgitation and splash- ing. The increased suction flow deliv- ered by ReliaFlex better evacuates the surgical site of blood and other fluids, with more clarity leading to safer pa- tient care and more satisfied surgeons. Intense research and design went into engineering ReliaFlex liners to give them 20 percent larger diameter vacu- um ports and hoses. ReliaFlex comes in three canisters sizes (1300cc, 1800cc or

OCTOBER.2003.VOL.31.NO.10.CDA.JOURNAL 775 Emergencies

This article continues the theme of the September 2003 Journal: Managing Medical and Behavioral Changes in Children.

Emergency Medicine in Pediatric Dentistry: Preparation and Management Stanley F. Malamed, DDS

ABSTRACT edical emergencies can and do occur in the Medical emergencies can and do occur in the practice of dentistry. Although practice of dentistry. Most medical emergen- most emergencies take place in adults, serious problems can also develop in cies develop when the patient, commonly an younger patients. The contemporary dentist must be prepared to manage expedi- adult, is fearful or has inadequate pain Mcontrol. The most common emergen- tiously and effectively those few problems that do arise. Basic life support (as cies noted in adult dental patients in- necessary) is all that is required to manage many emergency situations, with the clude syncope (less than 50 percent), non-life-threatening allergy, acute addition of specific drug therapy in some others. Preparation of the office and anginal episodes, postural hypoten- sion, seizures, acute asthmatic attacks, staff includes basic life support (annually), pediatric advanced life support, devel- and hyperventilation.1 In the pediatric patient, the most opment of an emergency team, consideration for emergency medical services, common emergency situations seen in dentistry are associated with drug ad- and the availability of emergency drugs and equipment with the ability to use ministration, most often local anesthet- these items effectively. As with the adult patient, effective management of pain ics and/or central nervous system de- pressants used for sedation. It is this au- (local anesthesia) and anxiety (behavioral management, conscious sedation) will thor’s firm belief that the most likely scenario for a serious drug-related emer- minimize the development of medical emergencies. Author / Stanley F. Malamed, DDS, is a professor of anesthesia and medicine at the University of Southern California School of Dentistry.

OCTOBER.2003.VOL.31.NO.10.CDA.JOURNAL 749 Emergencies

gency developing in dentistry is the fol- lowing: a younger, lighter-weight child receiving multiple quadrants of dental treatment in the office of a younger, less-experienced, nonpediatric dentist (i.e., general practitioner).2 All dental practices must be pre- pared to manage potentially life-threat- ening emergencies, be the patient a child or adult. The following sections review the preparation of the dental of- Figure 1. Figure 2. fice and staff to successfully manage Mouth-to-mask ventilation. Head tilt-chin lift. medical emergencies that might arise in younger patients in the dental office. California has mandated BLS for li- be taught as mouth-to-mask ventila- The definitions of victims by age3 censure for many years. However, pos- tion, not mouth-to-mouth (Figure 1). are as follows: session of a valid CPR card is no guar- The importance of BLS as prepara- Infant: < 1 year antee that BLS can be adequately per- tion for managing medical emergencies Child: 1 to 8 years formed. In an unpublished study of en- in children is highlighted by the fact Adult: ≥ 8 years tering postdoctoral students (residents that the primary etiology of cardiac ar- in endodontics, periodontology, rest in children is airway problems, usu- Preparation prosthodontics, pediatric dentistry, oral ally airway obstruction or respiratory ar- The following four assets are critical and maxillofacial surgery, orthodon- rest (as might occur with overly deep in preparing the office and staff to rec- tics, and general practice) at the USC “conscious” sedation). The young child’s ognize and effectively manage medical School of Dentistry, 30 students “chal- heart is normally healthy. Coronary emergencies: lenged” the BLS-recertification course artery disease is essentially nonexistent ■ The ability to properly perform that is mandatory for them. All had in this age group. However, the healthy basic life support; been certified in BLS at the health care young heart will cease beating when de- ■ A functioning dental office emer- provider level within the previous six prived of oxygen for a prolonged period. gency team; months.4 The challenge consisted of At the moment a pediatric cardiac arrest ■ Access to emergency assistance; completing a 25-question written ex- occurs, there is no residual oxygen re- and amination with a grade of 80 percent or maining in the victim’s blood (all avail- ■ The availability of emergency better, and demonstrating “adequate” able oxygen has been utilized by the drugs and equipment. performance at one-person BLS on an dying cells). Acidosis and cellular (bio- adult victim. Only four of the students logical) death develop rapidly. U.S. sur- Basic Life Support successfully challenged the course (13 vival rates from out-of-hospital cardiac Basic life support (or cardiopul- percent). Most were unable to perform arrest in pediatric patients is from 3 per- monary resuscitation) is the single most “adequate” one-person CPR on an cent to 17 percent, and survivors are important step in preparation of the of- adult victim for one minute. often neurologically devastated.5,6 By fice and staff to successfully manage Recertification in BLS is recom- contrast, cardiac arrest in adults usually medical emergencies. BLS for health mended annually (in most venues, CPR develops secondary to advanced coro- care providers is defined as: Position, cards have a two-year expiry date). BLS nary artery disease. At the moment the Airway, Breathing, Circulation, and instructors should be brought into the adult heart goes into arrest, there re- Defibrillation. Most states mandate BLS dental office, with mannequins placed mains a reservoir of oxygen in the blood certification for licensure to practice as in the dental chair and on the floor in and tissues that will be utilized before a dentist. The majority of states also re- the reception room. It should be cellular death occurs. quire BLS certification for dental hy- mandatory for all office personnel to The very basic step of airway man- gienists, and some mandate certifica- participate in this training. For health agement (head tilt-chin lift) is critically tion for dental assistants. care providers, rescue breathing should important in saving the life of a child.

750 CDA.JOURNAL.VOL.31.NO.10.OCTOBER.2003 Pediatric Advanced Life Support Box Because children are different from Pediatric Advanced Life Support adults, the author recommends that the dentist and staff in offices where signifi- Course Outline cant numbers of younger patients are The Chain of Survival and Emergency Medical Services for Children* treated successfully complete a course in Basic Life Support for the PALS Health Care Provider* pediatric advanced life support.7 Airway, Ventilation, and Management of Respiratory Distress and Failure* Similar to BLS, PALS stresses basic Fluid Therapy and Medications for Shock and Cardiac Arrest and advanced life support techniques Vascular Access* for younger patients. Offered through Rhythm Disturbances organizations such as hospitals, pedi- Postarrest Stabilization and Transport atric dental societies, and private edu- Trauma Resuscitation and Spinal Immobilization cational providers, the course outline is Children with Special Health Care Needs* presented in the box on this page. Toxicology* Neonatal Resuscitation PEDO Rapid Sequence Intubation PEDO is the acronym for Pediatric Sedation Issues for the PALS Provider* Emergencies in the Dental Office, a di- Coping with Death and Dying dactic and clinical course in emergency Ethical and Legal Aspects of CPR in Children* medicine designed for the entire staff *Denotes subjects of special interest to dentists treating children of the pediatric dental office. Sponsored by the American Academy of Pediatric Dentistry, the course pro- Table 1 vides in-depth, hands-on training in the prevention and management of Office emergency team specific emergency situations that arise Team member Responsibilities a more commonly in children. Member #1 1. Remain with victim (first person on scene 2. Activate office emergency system Emergency Team of emergency) 3. Basic life support as necessary The dental office emergency team Member #2 1. Bring emergency equipment* to scene consists of three individuals, each as- signed specific tasks to perform, as out- Member #3 1. Assist as necessary (and other members of a. Activate emergency medical services lined in Table 1. the dental office staff) b. Meet and escort EMS to office All members of the office emer- c. Assist with basic life support gency team should be interchangeable. d. Prepare emergency drugs for administration Although the proper and effective man- e. Monitor and record vital signs agement of the emergency situation is *Emergency equipment includes oxygen supply, emergency drugs, and, when appropriate, an automated external ultimately the dentist’s responsibility, defibrillator emergency management may be per- formed by any trained individual under supervision of the dentist. does not know what is happening; In an emergency, the ultimate responsi- knows, but does not like, what is happen- bility of the treating dentist is to keep Access to Emergency Medical Services ing; or ever feels uncomfortable with the the victim alive until he or she recovers Assistance in managing an emer- situation. The dentist should seek help as or help arrives on scene to take over gency should be sought as soon as the soon as possible in these situations. management of the situation. Though treating doctor “feels” it is needed, and a In virtually all situations, the most exceptions may exist, in most areas of “feeling” it is indeed. Emergency medical practical course for getting help is to California, EMS can be expected to ar- services should be sought if the dentist activate the EMS system by calling 911. rive on scene within five to 10 minutes.

OCTOBER.2003.VOL.31.NO.10.CDA.JOURNAL 751 Emergencies

Emergency Drugs and Equipment Table 2 Every dental office must have emer- gency drugs and equipment, as listed in Recommended Dental Office Emergency Drugs Tables 2 through 4. Minor modifica- Drug Indication Availability Recommended for kit tions are necessary in offices where Epinephrine Anaphylaxis 1:1000 (adult) 1 preloaded syringe children are treated (colored rows in (Adrenalin) (0.3 mg/dose) and 3 x 1 mL Tables 2 and 4). ampules of 1:1,000 In offices where central nervous sys- Epinephrine Anaphylaxis 1:2,000 (pediatric) 1 preloaded syringe tem depressant drugs are employed for (Adrenalin) (0.15 mg/dose) and 3 x 1 mL conscious sedation, antidotal drugs that ampules of 1:1,000 are available for specific sedative agents Diphenhydramine Allergic reactions 50 mg/mL 2-3 x 1 mL ampules must be included in the emergency (Benadryl) of 50 mg/mL drug kit (Table 3). If benzodiazepines Oxygen All emergencies “E” cylinder + Minimum 1, are used (e.g., diazepam, midazolam, tri- delivery devices preferable 2, “E” azolam), flumazenil must be available. cylinders Where opioids are employed, naloxone Albuterol Bronchospasm Metered aerosol 1 aerosol inhaler must be included in the emergency (Proventil, inhaler drug kit. Single doses of these drugs Ventolin) may be ineffective when administered Sugar Hypoglycemia Orange juice, 12-ounce bottle of to manage overdosage resulting from “insta-glucose” orange juice and/or orally administered or long-acting ben- 1 tube of “insta-glucose” zodiazepines and opioids. Aspirin Suspected 325 mg tablets 1-2 sealed tablets myocardial Basic Management infarction As described above, basic manage- Nitroglycerin Angina pectoris Metered spray 1 Nitrolingual ment of all medical emergencies fol- pumpspray lows the PABCD acronym, (position- ing, airway, breathing, circulation, and definitive care [in the BLS acronym, D Table 3 is defibrillation]). Antidotal Drugs It is first necessary to determine if the patient is conscious or uncon- Drug Indication Availability Recommended for kit scious. Unconsciousness is defined as Flumazenil Benzodiazepine 0.1 mg/mL 1 x 10mL the lack of response to sensory stimula- (Romazicon) antagonist multidose vial tion (e.g., lack of response to the Naloxone Opioid antagonist 0.4 mg/mL 2 x 1 mL ampule of 9 “shake and shout” maneuver). (Nascan) 0.4 mg/mL

Position As the most common cause of loss people in acute respiratory distress (e.g., Seeing the victim’s chest moving does of consciousness is hypotension, all un- acute asthmatic bronchospasm) auto- not guarantee that he or she is actually conscious patients are placed, at least matically assume an upright position to breathing (exchanging air), but simply initially, in a supine position with their improve ventilation. that he or she is trying to breath. feet elevated slightly. This position pro- Hearing and feeling the exchange of air vides an increase in cerebral blood flow Airway and Breathing against the rescuers cheek is the only with a minimum of interference with In the unconscious person, the head indication of successful ventilation. respiratory efforts.10 Conscious people tilt-chin lift maneuver must be per- In the absence of spontaneous respi- experiencing a medical emergency are formed (Figure 2) followed by an assess- ratory efforts (e.g., chest not moving), placed in whatever position they find ment of ventilation (“look, listen, feel”). controlled ventilation must be per- most comfortable. As an example, most An important point to remember: formed as expeditiously as possible. With

752 CDA.JOURNAL.VOL.31.NO.10.OCTOBER.2003 Table 4 the episode of bronchospasm does not terminate following two adequate doses Suggested Dental Office Emergency Equipment of the bronchodilator. Device Availability Recommended for kit Automated external Many 1 AED (pediatric AEDs are Generalized Tonic-Clonic Seizure defibrillator available)8 (“Grand Mal” Seizure) Recognition: Period of muscle Face masks Various sizes for children Several pediatric masks and rigidity (about 20 seconds) followed by and adults adult mask alternating muscle contraction and re- Dispoable syringes and 2 mL syringe with 20-gauge 2-3 sterile, disposable laxation lasting for about one to two needles needle syringes minutes. Spacer for bronchodilator Various manufacturers 1 “spacer” P: Position supine. inhaler A, B, C: Assessed as adequate (respi- ratory and cardiovascular stimulation a full face mask and positive pressure should be undertaken. If a diagnosis is usually occur during seizure). oxygen, the patient older than 8 is venti- made but appropriate treatment is not D: (1) Protect victim from injury. lated at a rate of one breath every five available or if the cause of the problem Keep victim in the dental chair; gently seconds, whereas a rate of one breath remains unknown, EMS should be hold onto arms and legs, preventing every three seconds is used for the infant sought immediately. Definitive man- uncontrolled movements, but do not and child victim.11 Each individual ven- agement of several common pediatric hold so tight as to prevent limited tilation should cease when the chest is emergencies follows. movement. seen to rise, as overventilation leads to (2) If parent or guardian is avail- gastric distension and regurgitation. Specific Emergencies able, bring him or her into the treat- ment room to assist in assessment of Circulation Acute Bronchospasm (Asthmatic victim. In pediatric medical emergencies, it Attack) (3) Summon EMS if parent or is likely that a palpable pulse will be pre- Recognition: Conscious patient in guardian of patient suggests it, or if the sent, especially in situations in which acute respiratory distress, demonstrat- seizure continues for more than two the airway and breathing are adequately ing wheezing, supraclavicular and in- minutes. and rapidly assessed and supported. tercostal retraction. Remember: Do not place any- Remember: Airway problems (e.g., P: Position comfortably — usually thing between the teeth of a con- obstruction, apnea) are the most com- upright vulsing person. mon cause of cardiac arrest in infants A, B, C: Assessed as adequate Most generalized tonic-clonic and children. (Victim is conscious and able to speak.) seizures will stop within one minute Palpation of the carotid artery pulse D: (1) Administer bronchodila- and almost always within two minutes is preferred in children 1 year or older tor. If patient’s inhaler is available, (thus the recommendation to seek EMS and adults, whereas the brachial pulse is allow him or her to use it. If the pa- with prolonged seizure activity). At the preferred in infants younger than 1 year. tient is younger and the parent or termination of the seizure, P, A, B, C, D In the absence of a palpable pulse, chest guardian is available, bring him or her must be reassessed, as follows: compression must be commenced, and into the treatment room to assist in P: Position supine. EMS summoned immediately. administration of bronchodilator. A, B, C: Assessed and managed as Many younger children require the needed. In most (but not all) post- Definitive Care use of a spacer to obtain adequate re- seizure situations, A must be managed, Following assessment and imple- lief with the inhaler. but B and C are assessed as adequate. mentation of the required steps of BLS, (2) Administer oxygen, via face- D: With help from the parent or the dentist must seek to determine the mask or nasal canula at a flow rate of 3 guardian, try to communicate with the cause of the problem (i.e., make a diag- to 5 liters per minute. patient, who is likely in a state similar nosis). Where a diagnosis is possible (3) Summon EMS if parent or to a deep physiologic sleep. Following a and appropriate treatment available, it guardian of the patient suggests it, or if generalized tonic-clonic seizure, the

OCTOBER.2003.VOL.31.NO.10.CDA.JOURNAL 753 Emergencies

victim is quite disoriented. As the par- to a dose of 1.0 mg if an opioid was ad- anesthetic-induced seizure often ceases ent or guardian has seen this and done ministered. Naloxone may be adminis- in less than one minute. In the absence this before, allow him or her to talk tered intramuscularly, in a dosage of of an adequate airway and ventilation, with the patient to reorient the patient 0.01 mg/kg every two to three minutes carbon dioxide is retained, the patient to both space and time. until the patient is responsive. becomes acidotic, and the seizure Remember: Most morbidity and Remember: Specific antidotal ther- threshold of the local anesthetic de- mortality associated with seizures oc- apy may not be effective following the creases, leading to more prolonged and curs in the postseizure period because oral administration of central nervous more intense seizure.13 the rescuer does not do enough for the system depressants; and antidotal (2) Unconsciousness — the basic victim (P, A, B, C) therapy should be administered intra- protocol for management of the un- venously, if possible. Naloxone may be conscious patient is followed when a Sedation Overdose administered intramuscularly. local anesthetic overdose manifests it- Recognition: Lack of response to self as loss of consciousness. Proper sensory stimulation. management of airway and breath- Consider. An overdose of sedation ing, as needed, will minimize occur- is general anesthesia. Effective manage- Basic life support rence of cardiac arrest. As the cerebral ment of a patient receiving general concentration of the local anesthetic anesthesia is predicated on airway man- (as necessary) is decreases (through redistribution of agement and breathing. Therefore, this the drug out of the brain) conscious- should not represent an emergency in all that is required ness returns. the office of a doctor who is trained to (3) Summon EMS if consciousness administer general anesthesia to chil- to manage many is not restored in two minutes or if the dren or adults. patient is not breathing. P: Position supine. emergency A, B, C: Assessed and managed as Final comments necessary. In most cases, A alone is re- situations, with the Medical emergencies can and do quired; whereas A and B will be needed occur in the practice of dentistry. in a few situations. C will generally be addition of specific Although most emergencies take place in present if A and B are properly assessed adults, serious problems can also develop and managed. drug therapy in in younger patients. The contemporary D: (1) Monitor patient, using pulse dentist must be prepared to manage ex- oximeterb (and blood pressure and some others. peditiously and effectively those few heart rate/rhythm). problems that do arise. Basic life support (2) Stimulate patient periodically (as necessary) is all that is required to (verbally and/or squeezing the trapez- manage many emergency situations, ius muscle) seeking response. Local Anesthetic Overdose with the addition of specific drug thera- 3) Antidotal therapy: If sedative A true overdose of local anesthetic py in some others. Preparation of the of- drugs were administered parenterally, should be always preventable.2 fice and staff includes basic life support and intravenous access is available, ad- Recognition. Generalized tonic- (annually), pediatric advanced life sup- minister flumazenil IV in a dose of 0.2 clonic seizure or unconsciousness, gen- port, development of an emergency mg (2 mL) in 15 seconds waiting 45 erally developing five to 40 minutes team, consideration for emergency med- seconds to evaluate recovery where after local anesthetic administration. ical services, and the availability of emer- benzodiazepines were administered. If P: Position supine. gency drugs and equipment with the recovery is not adequate at one minute, A, B, C: Assessed and administered ability to use these items effectively. As an additional dose of 0.2 mg may be as needed. with the adult patient, effective manage- administered. Repeat every minute D: (1) Generalized tonic-clonic ment of pain (local anesthesia) and anxi- until recovery occurs or a dose of 1.0 seizure — follow protocol for ety (behavioral management, conscious mg has been delivered. Titrate nalox- seizures (above). With proper airway sedation) will minimize the development one IV at 0.1 mg. (0.25 mL) per minute management and ventilation, a local of medical emergencies. CDA

754 CDA.JOURNAL.VOL.31.NO.10.OCTOBER.2003 Notes / a. PEDO — contact the American Academy of Pediatric Dentistry for dates of future PEDO courses. www.aapd.org, 800.544.2174. b. The doctor using oral sedation (in children younger than 13) or parenteral (intramuscular or intravenous) sedation must have a pulse oximeter in the dental office, as per the Dental Practice Act, Part 3, California Code of Regulations.

References / 1. Malamed SF, Managing medical emergencies. J Am Dent Assoc 124:40-53, 1993. 2. Malamed SF, Allergic and toxic reactions to local anesthetics. Dent Today 22:114-21, 2003. 3. International Consensus on Science. Guidelines 2000 for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation 102(suppl):1-23, 2000. 4. Malamed SF, Retention of BLS skills by post- doctoral students at a US dental school. Unpublished results, 1999. 5. Pitetti R, Glustein JZ, Bhende MS, Prehospital care and outcome of pediatric out-of- hospital cardiac arrest. Prehosp Emerg Care 6:283- 90, 2002. 6. Schindler MB, Bohn D, Cox PN, et al, Outcome of out-of-hospital cardiac or respiratory arrest in children. N Engl J Med 335:1473-9, 1996. 7. American Heart Association, PALS Provider Manual. American Heart Association, Dallas, 2002, 8. Malamed SF, Automated external defibrilla- tors, part 2: application. Dent Today 22:52-5, 2003. 9. American Dental Association, Council on Dental Education, Guidelines for teaching the comprehensive control of pain and anxiety in den- tistry. J Dent Educ 36:62-7, 1972. 10. Erie JK, Effect of position on ventilation. In Faust RJ, ed, Anesthesiology Review. Churchill Livingstone, New York, 1991. 11. American Heart Association. Handbook of Emergency Cardiovascular Care for Healthcare Providers. American Heart Association, Dallas, 2000. 12. Bachmann-MB, Biscoping J, et al, Pharmacokinetics and pharmacodynamics of local anesthetics (in German), Anaesthesiol Reanim 16:359-73, 1991.

To request a printed copy of this article, please contact / Stanley F. Malamed, DDS, USC School of Dentistry, 925 W. 34th St., Los Angeles, CA 90089- 0641, [email protected].

OCTOBER.2003.VOL.31.NO.10.CDA.JOURNAL 755 Mepivacaine

This article continues the theme of the September 2003 Journal: Managing Medical and Behavioral Changes in Children.

Serum Mepivacaine Concentrations After Intraoral Injection in Young Children Katherine L. Chin, DDS, MS; John A. Yagiela, DDS, PhD; Christine L. Quinn, DDS, MS; Kent R. Henderson, DDS; and Donald F. Duperon, DDS, MS

epivacaine (Carbocaine, ABSTRACT Polocaine, Scandonest, The authors measured plasma concentrations of mepivacaine in 36 children from etc.), introduced clini- cally in 1955, is widely the ages of 2 to 5 years who received dental care under light general anesthesia. used by dentists for in- traoral anesthesia. As a 2 The subjects were randomly assigned to receive either 2 percent mepivacaine hy- percent hydrochloride solution with M1:20,000 levonordefrin, mepivacaine is drochloride with 1:20,000 levonordefrin or 3 percent mepivacaine hydrochloride similar in onset, duration, efficacy, and safety to the more commonly used for- without vasoconstrictor. The volume of anesthetic injected depended on the mulation of 2 percent lidocaine HCl 1-3 planned procedures for each patient. Blood samples (3 mL) were drawn from an with 1:100,000 epinephrine. As a 3 percent HCl solution without vasocon- intravenous line before and 5, 10, 20, 30, 45, and 60 minutes after mepivacaine strictor, mepivacaine combines high ef- ficacy with a relatively short duration injection. The serum was collected and analyzed by gas-liquid chromatography. of pulpal anesthesia, at least after max- illary supraperiosteal injection.4 The 3 Mean serum concentrations, normalized to a dose of 1 mg/kg body weight, percent formulation is often preferred by general dentists for use in young reached a peak of 0.67 ± 0.42 µg/mL (mean ± SD) after 3 percent mepivacaine children, presumably because of a per- and 0.63 ± 0.21 µg/mL after 2 percent mepivacaine with levonordefrin. Authors / Katherine L. Chin, DDS, MS, is a former resident in the Section of Pediatric Dentistry, Levonordefrin had no significant effect on the plasma concentrations. However, Division of Associated Clinical Specialties, at the University of California at Los Angeles School of because of the higher concentration of mepivacaine in the 3 percent formulation, Dentistry and is currently in private practice in Englewood, Colo. John A. Yagiela, DDS, PhD, is professor and it was potentially 1.5 times as toxic (P<0.002) on a volume basis. Statistical analy- chair of diagnostic and surgical sciences at the UCLA School of Dentistry and professor of anes- thesiology at the David Geffen School of Medicine sis also suggested that the maximum recommended dose of 3 mg/lb could result at UCLA. Christine L. Quinn, DDS, MS, is clinical pro- in potentially toxic blood concentrations in a small percentage of pediatric pa- fessor of anesthesiology in the Division of Diagnostic and Surgical Sciences at the UCLA School of Dentistry. tients. The authors conclude that 3 percent mepivacaine should not be used when Kent R. Henderson, DDS, is a former dental student at the UCLA School of Dentistry and is currently in private practice in Glendora, Calif. relatively large volumes of local anesthetic must be administered to small children Donald F. Duperon, DDS, MS, is professor and chair of the Section of Pediatric Dentistry, Division of Associated Clinical Specialties, at the and recommend that the maximum dose of mepivacaine not exceed 5 mg/kg. UCLA School of Dentistry.

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ceived reduced risk of postoperative lip, as a 3 percent solution without vaso- thesia was maintained with propofol tongue, and cheek biting.5,6 constrictor or as a 2 percent solution (Diprivan) infused as needed. Significant toxic reactions, includ- with 1:20,000 levonordefrin. The Each patient was randomly as- ing fatalities, have been reported in study’s purpose was to help verify max- signed before treatment to receive in- children given 3 percent mepiva- imum dosage limits for mepivacaine in traoral injection of either 2 percent caine.7-9 Early signs of toxicity, usually children and ultimately increase the mepivacaine HCl with 1:20,000 lev- excitatory in nature, develop in hu- safety of local anesthetics in dentistry. onordefrin (Polocaine with mans when the plasma concentration Levonordefrin) or 3 percent mepiva- exceeds 5 µg/mL.10 Seizures may occur Methods caine HCL (Polocaine). The operator when plasma concentrations reach 6 to This study, approved by the UCLA was informed of the manufacturer’s 10 µg/mL.11 A massive overdose can re- Human Subjects Protection Committee, recommended maximum dose of sult in respiratory and cardiac arrest. enrolled 36 healthy children from the mepivacaine (3 mg/lb) and of the ran- One such report described a 16.4-kg, 5- ages of 2 to 5 years who were scheduled domly assigned formulation to be ad- year-old patient receiving an unknown to receive full-mouth rehabilitation ministered to the patient. The volume concentration of nitrous oxide who of anesthetic injected depended on was administered five cartridges (9 mL) the planned procedures as determined of 3 percent mepivacaine in less than With no published by the operator. All mepivacaine in- five minutes.7 The patient began seiz- data on blood jections were given at the beginning ing shortly thereafter and suffered car- of treatment over a three-minute peri- diopulmonary arrest. The child was re- concentrations of od using preweighed cartridges. Two suscitated but died four days later from percent lidocaine HCl with 1:100,000 anoxic brain injury secondary to car- mepivacaine after epinephrine (Xylocaine with epineph- diopulmonary arrest. intraoral injection rine) was used if additional local anes- Clinicians depend on maximum thetic was needed intraoperatively. All dosage guidelines for determining safe in young children, dispensed mepivacaine anesthetic car- quantities of local anesthetic for their it is not firmly tridges were retrieved immediately patients. For mepivacaine, the maxi- after treatment. Used cartridges were mum recommended dosage is 6.6 established if these weighed to determine the injected mg/kg, or 3 mg/lb, up to a total dose dose. of 400 mg.12 Unfortunately, with no recommendations Blood samples (3 mL) were drawn published data on blood concentra- are appropriate. before and at 5, 10, 20, 30, 45, and 60 tions of mepivacaine after intraoral minutes after mepivacaine injection. injection in young children, it is not If the dental treatment was finished firmly established if these recommen- under light general anesthesia at the before 60 minutes, blood collection dations are appropriate. An additional University of California at Los Angeles ceased when the IV line was removed concern regarding safety in children is Pediatric Dental Clinic. After parental during the recovery period. The blood that general dentists are more likely to informed consent was obtained for ac- samples were drawn through the IV exceed maximum recommended quiring blood samples, the following line, which was equipped with a stop- dosages of local anesthetic in patients characteristics were recorded for each cock. Saline dilution was minimized weighing less than 20 kg.6 Finally, a patient: weight, sex, age, and ethnicity. by turning off the IV drip approxi- nationwide survey of pediatric den- Deep sedation was then introduced mately 15 seconds before blood sam- tists revealed that only half of these with an intramuscular injection of 2.5 pling and then withdrawing 3 mL of practitioners used exact body weight mg/kg ketamine HCl (Ketalar), 0.1 blood before obtaining each sample. to determine anesthetic dosage.13 mg/kg midazolam HCl (Versed), and 6 The blood was allowed to clot and In this study, the authors deter- to 8 µg/kg glycopyrrolate (Robinul). then centrifuged at 2000 g for 10 min- mined the serum concentrations of Intravenous access was obtained with a utes. The serum was collected and mepivacaine in young children when 20-gauge catheter (Angiocath) once the stored at -20 degrees Celsius for subse- the local anesthetic was administered child was sedated. Light general anes- quent analysis. The serum concentra-

758 CDA.JOURNAL.VOL.31.NO.10.OCTOBER.2003 tions of mepivacaine were determined by gas chromatography essentially ac- cording to the method of Zylber-Katz and colleagues.14 Mepivacaine was extracted into 3 mL of n-hexane from 0.5-mL serum samples diluted with 0.5 mL of triple distilled water to which 0.1 mL of 4 N NaOH was added to convert the local anesthetic to the free base form. Cyclizine (1 µg) was also added as an internal standard. The samples were gently shaken (one minute) and cen- trifuged (2000 g, 10 minutes). The top organic phase was removed and gently shaken (one minute) with 0.5 mL 4 N HCl and centrifuged again (2000 g, five minutes). The samples were stored in tightly capped cen- trifuge tubes in an ice bath for injec- tion into the gas chromatograph. All chemicals were obtained from Sigma (St. Louis, Mo.). For drug measurement, 1 µL of the lower aqueous phase was withdrawn with a 10-µL microsyringe (Hewlett Packard, Co., Palo Alto, Calif.) and in- jected into a gas chromatograph (Hewlett Packard Model 6890). A 30- m (0.32-mm inner diameter, 0.25-µm film thickness) cross-linked 5 percent- diphylene-95 percent-dimethylsilox- ane copolymer capillary column (Hewlett Packard Model HP-5) was used. The oven was programmed to escalate in temperature from 75 de- grees Celsius to 175 degrees Celsius at a rate of 50° C/min, with a hold time of 1 minute at 175 degrees Celsius, and from 175 degrees Celsius to 250 degrees Celsius at a rate of 25° C/min, with a hold time of 2.5 minutes at the final temperature. Helium was the car- rier gas. The temperatures of the injec- tion port and detector were 310 de- grees Celsius and 325 degrees Celsius, respectively. Peak areas were recorded as measured by the HP 6890 Series

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months, with a mean age of 47 ± 12 months. The study population was 12 ethnically diverse, including 46 per- f(x) = 3.81x - 0.098 cent Hispanic, 43 percent Caucasian, 2 10 R = 0.99 and 11 percent African-American chil- dren. No toxic reactions to the local anesthetic were observed, nor were 8 there any adverse effects from the den- tal treatments or anesthetic agents. 6 The sedative and anesthetic agents did not interfere with mepiva- caine measurements in our study, 4 which is in accordance with the find- ings of others.15 In addition, there 2 was no independent effect of age or Mepivacaine/cyclizine ratio Mepivacaine/cyclizine race on the results. Figure 2 illustrates the injected 0 dose of mepivacaine for the each study 0 0.5 1 1.5 2 2.5 3 3.5 patient. The mean injected dose for 3 Mepivacaine concentration (µg/mL) percent mepivacaine was 4.42 ± 1.38 mg/kg. This value was almost exactly 50 percent (49.3 percent) higher than Figure 1. Standard mepivacaine analysis curve prepared by adding cyclizine (1 µg) and mepivacaine the 2.96 ± 1.13 mg/kg mean for 2 per- (0-1.6 µg) to drug-free serum samples. cent mepivacaine with levonordefrin. This difference indicates that the in- Integrator. Each measurement was time. Student’s t-test was used to com- jected volumes for the two anesthetic made in triplicate, with the mean pare patient characteristics, mepiva- formulations were essentially identical. value used for analysis. caine dosages and volumes, peak Figure 3 shows the mean serum Drug-free serum was analyzed to de- serum concentrations, and times to mepivacaine concentrations versus termine that no extraneous peaks were peak concentration. Linear regression time after local anesthetic injection for detected that could possibly interfere forced through the origin was used to 31 subjects. (Data from four subjects with the mepivacaine and cyclizine correlate the injected dose with the were lost during sample preparation. peaks. To ensure that peaks from the peak concentration of mepivacaine. Only insignificant changes would have other therapeutic agents used would All statistical analyses were performed resulted from their exclusion in Table not interfere with those of mepivacaine using Systat, version 5.2 for 1 and the mean dosing data.) The val- and cyclizine, ketamine, midazolam, Macintosh (SPSS, Inc., Chicago). ues are normalized to an injection dose propofol, and lidocaine with epineph- of 1 mg/kg. The 3 percent formulation rine were added to drug-free serum and Results resulted in slightly higher mean serum analyzed. Standard curves were con- The results of one subject could not concentrations from 10 to 45 minutes structed from controls containing 0, be used because of a failure to record after injection. These differences were 0.1, 0.2, 0.4, 0.8, and 1.6 µg mepiva- the body weight. Descriptive data from not statistically significant overall or at caine added to the drug-free serum to the remaining 35 subjects, as listed in any time period. The normalized peak permit calculation of unknown mepi- Table 1, demonstrate that the random- serum concentration was reached with vacaine concentrations (Figure 1). ization method resulted in two similar both formulations at 30 minutes. The An analysis of variance with re- test groups. Overall, the body weight normalized mean peak concentration peated measures was used to compare ranged from 11 to 24 kg, with a mean without respect to time (not shown in the serum concentrations of mepiva- (± SD) weight of 17.3 ± 4.3 kg. The age Figure 3) was 8 percent higher in the 3 caine for the two drug treatments over of the subjects ranged from 25 to 67 percent mepivacaine group (0.67 ±

760 CDA.JOURNAL.VOL.31.NO.10.OCTOBER.2003 0.42 µg/mL versus 0.63 ± 0.21 µg/mL). Table 1 All of the differences between the two formulations could be attributed to a Subject Data by Treatment Group single subject whose concentrations 2% mepivacaine were more than three standard devia- 3% mepivacaine + levonordefrin tions above the mean. Excluding this Age (mo) 47 ± 13* 47 ± 12* subject would result in a mean of 0.58 Weight (kg) 16.7 ± 3.7* 18.1 ± 5.0* ± 0.18 µg/mL for the peak mepivacaine concentration in the 3 percent mepiva- Race (His/Cauc/Af-Am) 8/9/3† caine group. *Mean ± SD The peak serum concentration for †Numbers of Hispanic/Caucasian/African-American children enrolled each patient is plotted in Figure 4 as a function of the injected dose. Because there was no significant difference be- gression calculation based on the as- Discussion tween the normalized peak serum con- sumption that some of the drug was The mean peak serum concentra- centrations for the two formulations, injected intravascularly or a mistake tions described here for children are data for the two test groups were com- occurred in recording the injected vol- similar to those reported previously by bined. The outlier (indicated by an as- ume of anesthetic. Goebel and colleagues for adults after terisk) was omitted from the linear re- intraoral injection (0.69 µg/mL for 3

7 2% M + L Mean ± S D 6 3% M 2.96 ± 1.13 4.42 ± 1.38 5 P = 0.002 4

3

Injected dose (mg/kg) 2

1

0 Subjects

Figure 2. Injected dose of mepivacaine by body weight. Each bar represents a single subject.

OCTOBER.2003.VOL.31.NO.10.CDA.JOURNAL 761 Mepivacaine

percent mepivacaine and 0.62 µg/mL for 2 percent mepivacaine with 0.7 *Normalized to an injected 1:20,000 levonordefrin when normal- dose of 1 mg/kg ized to a 1 mg/kg injected dose of 0.6 mepivacaine).16,17 As with this study, they found no significant influence of 0.5 levonordefrin on peak mepivacaine concentrations, which also occurred 30 0.4 minutes after injection. The regression equation shown in 0.3 Figure 4 indicates that a dose of 1 2% M + L mg/kg will, on average, result in a 3% M peak serum concentration of 0.56 0.2 µg/mL. For a maximum recommended dose of 6.6 mg/kg (3 mg/lb), this rela-

Serum mepivacaine (µg/mL) Serum mepivacaine 0.1 tionship would yield a mean concen- tration of 3.7 µg/mL, a relatively high 0 but safe value. However, the 95 per- 0102030405060 cent prediction limits for the regres- Time (min) sion equation indicate that 2.5 per- cent of children would achieve a peak serum concentration of at least 5 Figure 3. Serum mepivacaine concentrations normalized to an injected dose of 1 mg/kg. Bars indi- cate the standard errors. M = mepivacaine; L = levonordefrin µg/mL, the maximum “safe” concen- tration. Using the pooled mean of 0.60 µg/mL calculated from the mea- 6 sured peak serum concentrations nor- * malized to an injection dose of 1 mg/kg, and the pooled standard devi- 5 ation of 0.19 µg/mL (both values ex- f(x) = 0.560x cluding the outlier), the authors can R2 = 0.523 also estimate that 2.5 percent of the 4 population would have a serum con- centration of at least 5 µg/mL at an 3 injection dose of only 5.1 mg/kg. These two methods of estimation use different statistical assumptions. 2 Regression analysis assumes that the residual errors are normally distrib- uted, whereas the normalized data cal- Serum mepivacaine (µg/mL) Serum mepivacaine 1 culation assumes that the serum con- centrations themselves are normally 0 distributed once they have been nor- 0 1234567 malized to an injection dose of 1 Dose (mg/kg) mg/kg. Although the assumption un- derlying the linear regression has a slightly better fit with the data, nei- Figure 4. Linear regression of the pooled peak serum concentrations. Each point represents a single subject. A single outlier, not used in the regression analysis, is indicated by an asterisk (*). The 95 percent ther assumption could be rejected at prediction limits are indicated by lines above and below the regression line the P = 0.1 level of confidence; and

762 CDA.JOURNAL.VOL.31.NO.10.OCTOBER.2003 caution dictates using the more con- be considered. In dentistry, the use of servative estimate of risk. Therefore, local anesthetic cartridges with a lim- to ensure that the vast majority of pa- The fact that ited volume of solution greatly re- tients will have a peak serum concen- the subject’s duces this risk in adults. But very tration below 5 µg/mL, the injected small children are not protected by dose should not exceed 5 mg/kg. mepivacaine this volume limitation because the The single outlier in this study de- concentration was content of one cartridge may be suffi- serves special comment. Although a cient to cause systemic toxicity. One laboratory error of some kind could high at all times after way to avoid intravascular deposition have occurred, the fact that the sub- baseline and that of local anesthetics is to limit the use ject’s mepivacaine concentration was of nerve blocks and use suprape- high at all times after baseline and other samples riosteal injections whenever possible. that other samples assayed at the Several reports have shown that infil- same time were within normal limits assayed at the tration in the pediatric mandible is as suggests that the measurements were same time were effective as the inferior alveolar nerve accurate. A possible mistake more block when simple dental procedures consistent with the measured data is within normal limits are performed.20,21 that the injected dose was underesti- suggests that the mated because one or more used car- Conclusion tridges were either not weighed accu- measurements were Because levonordefrin does not sig- rately or not weighed at all. nificantly affect the peak serum con- Subsequent review of the patient’s accurate. centration of mepivacaine after intrao- chart, however, revealed no evidence ral injection, the 3 percent formula- in support of a larger dose being given. injection techniques. For example, tion is potentially 1.5 times as toxic as It is also possible that some of the when administering an inferior alveo- the 2 percent formulation when given drug was injected intravascularly by lar nerve block, many dentists will in- in the same volume. Therefore, the au- mistake. A misadventure of this kind ject one cartridge regardless of the thors believe that 3 percent mepiva- should normally have resulted in a type or strength of anesthetic used or caine should not be used when rela- high peak serum concentration occur- even the size of the patient.6 These tively large volumes of local anesthetic ring almost immediately after injec- tendencies compound the risk of local must be administered to small chil- tion. Since the first sample was taken anesthetic overdose when 3 percent dren and that the dosage of mepiva- five minutes after injection, there may mepivacaine is used in lieu of a 2 per- caine with or without vasoconstrictor have been sufficient time for the drug cent local anesthetic formulation with should not exceed 5 mg/kg. CDA to be distributed such that the five- vasoconstrictor simply because 50 per- minute value was not high compared cent more local anesthetic is given. References / 1. Sadove MS, Vernino D, et al, An evaluation of mepivacaine hydrochloride. J Oral to later measurements. A final, dis- Young children with low body weights Surg 20:399-404, 1962. turbing possibility is that the outlier are at special risk for receiving relative- 2. Stibbs GD, Korn JH, An evaluation of the local anesthetic mepivacaine hydrochloride, in op- represents a truly idiopathic response ly large amounts of local anesthetic. erative dentistry. J Prosthet Dent 14:355-64,1964. to injected mepivacaine. Other investi- Since the primary reason dentists cite 3. Hinkley SA, Reader A, et al, An evaluation of 4 percent prilocaine with 1:200,000 epinephrine gators have also reported individual for selecting 3 percent mepivacaine and 2 percent mepivacaine with 1:20,000 lev- subjects with unusually high serum over less concentrated local anesthet- onordefrin compared with 2 percent lidocaine with 1:100,000 epinephrine for inferior alveolar concentrations of mepivacaine.18,19 As ics — that being reduced cheek, lip, nerve block. Anesth Prog 38:84-9, 1991. in this study, no adverse event oc- and tongue biting — is debatable and 4. Mumford JM, Geddes IC, Trial of Carbocaine in conservative dentistry. Br Dent J curred despite these “toxic” values. unproved, the increased toxic poten- 110:92-4, 1961. Local anesthetics are often not ad- tial of the formulation should limit its 5. Hersh EV, Hermann DG, et al, Assessing the duration of mandibular soft tissue anesthesia. J Am ministered according to concentration routine use.5 Dent Assoc 126:1531-6, 1995. or dose but rather according to the Finally, accidental intravascular 6. Cheatham BD, Primosch RE, Courts FJ, A survey of local anesthetic usage in pediatric pa- volumes normally used for particular injection of the local anesthetic must tients by Florida dentists. ASDC J Dent Child

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59:401-7, 1992. 15. Giaufre E, Bruguerolle B, et al, Influence of The effectiveness of mandibular infiltration com- 7. Hersh EV, Helpin ML, Evans OB, Local midazolam on the plasma concentrations of mepi- pared to mandibular block anesthesia in treating anesthetic mortality: report of case. ASDC J Dent vacaine after lumbar epidural injection in children. primary molars in children. Pediatr Dent 18:301-5, Child 58:489-91,1991. Eur J Clin Pharmacol 38:91-2, 1990. 1996. 8. Berquist HC, The danger of mepivacaine 3 16. Goebel W, Allen G, Randall F, Circulating percent toxicity in children. J Calif Dent Assoc 3:13, serum levels of mepivacaine after dental injection. 1975. Anesth Prog 25:52-6, 1978. To request a printed copy of this article, please 9. Moore PA, Preventing local anesthesia toxi- 17. Goebel WM, Allen G, Randall F, The effect contact / John A. Yagiela, DDS, PhD, Division of city. J Am Dent Assoc 123:60-4, 1992. of commercial vasoconstrictor preparations on the Diagnostic and Surgical Sciences, UCLA School of 10. Jorfeldt L, Lofstrom B, et al, The effect of circulating venous serum level of mepivacaine and Dentistry, 10833 Le Conte Ave., Los Angeles, CA local anaesthetics on the central circulation and lidocaine. J Oral Med 35:91-6, 1980. 900095 or at [email protected]. respiration in man and dog. Acta Anaesthesiol Scand 18. Simon MAM, Gielen MJM, et al, Plasma 12:153-69, 1968. concentrations after high doses of mepivacaine 11. Covino BG, Physiology and pharmacology with epinephrine in the combined psoas compart- of local anesthetic agents. Anesth Prog 28:98-104, ment/sciatic nerve block. Reg Anesth 15:256-60, 1981. 1990. 12. Yagiela JA, Injectable and topical local 19. Hashizume Y, Yamaguchi S, et al, Pediatric anesthetics. In Ciancio SG, ed, ADA Guide to Dental caudal block with mepivacaine, bupivacaine or a Therapeutics, 2nd ed. ADA Publishing, Chicago, mixture of both drugs: requirement for postopera- 2000. tive analgesia and plasma concentration of local 13. Kohli K, Ngan P, et al, A survey of local anesthetics. J Clin Anesth 13:30-4, 2001. and topical anesthesia use by pediatric dentists in 20. Donohue D, Garcia-Godoy F, et al, the United States. Pediatr Dent 23:265-9, 2001. Evaluation of mandibular infiltration versus block 14. Zylber-Katz E, Granit L, Levy M, Gas-liquid anesthesia in pediatric dentistry. ASDC J Dent Child chromatographic determination of bupivacaine and 60:104-6, 1993. lidocaine in plasma. Clin Chem 24:1573-5, 1978. 21. Oulis CJ, Vadiakas GP, Vasilopoulou A,

764 CDA.JOURNAL.VOL.31.NO.10.OCTOBER.2003 Precision Cast

A Predictable Precision Cast for Multi-Unit Screw-Retained Implant Prosthesis: Rationale and Technique

Lambert J. Stumpel, III, DDS; Walter H. Haechler, MDT; and Edmond Bedrossian, DDS

ABSTRACT rom the early years of im- connection using conventional tech- plant dentistry, it was recog- niques.15-17 Potential discrepancies be- The aim of this article is to describe a nized that if implants were tween the oral situation and the mas- to be connected it was to be ter cast can be associated with impres- technique derived from the prema- done in a passive, nonstress- sion techniques,18-22 repositioning inducing manner.1-3 Recent techniques,23 and stone expansion.24-26 chined cylinder luting technique with Fliterature suggests a wide variation in In trying to improve definitive biological tolerances in relation to the precision, one of the techniques that the goal to predictably fabricate a detrimental effects from static loading, has been developed is the concept of highly precise master cast. An impres- as would be created by ill-fitting frame- intraorally luting premachined cylin- work-to-implant connections.4-7 The ders to the metal implant framework. sion can be taken directly at implant gold screw to the abutment in the Multiple variations of this technique Brånemark system creates a clamping have been described,27-29 all aiming at level or, with some technique modifica- force of 300 N.8 When the fit is incor- rect, some of these forces will be trans- tion, at the abutment level. ferred as axial and torque forces into the prosthetic components and the Concurrently, multiple techniques can bone implant interface. In vivo re- search9-11 confirms the introduction of be employed to fabricate the final considerable stresses when implants Authors / Lambert J. Stumpel, III, DDS, is in pri- framework with the assurance that a are connected using traditional pros- vate practice in San Francisco. He is also the direc- thetic techniques. tor of implant prosthetics, Surgical Implant Training, at the Highland Hospital Oral and framework that fits the cast will fit in The induction of unfavorable stress Maxillofacial Residency Program, University of the in the implant-suprastructure connec- Pacific, San Francisco. Dr. Stumpel is also an assis- tant clinical professor at the University of the mouth. This predictability improves tion may be responsible for loss of os- California San Francisco School of Dentistry, seointegration and failure of prosthet- Department of Restorative Dentistry. Walter H. Haechler, MDT, is a master dental 12-14 the workflow of the restoring dentist ic components. Discrepancies are technician in Corte Madera, Calif. inherent in the different stages of any Edmond Bedrossian, DDS, is in private prac- and laboratory technician since multi- tice in San Francisco. He is also the director of sur- framework production, due to differ- gical implant training at the Highland Hospital ent material and technique character- Oral and Maxillofacial Residency Program, ple framework try-ins and adjustments University of the Pacific. Dr. Bedrossian is also an istics. This has led authors to question associate professor and director of restorative im- the feasibility of attaining a complete- plant training at the University of the Pacific are eliminated. Advanced Education in General Dentistry, ly passive implant and suprastructure Residency Program.

OCTOBER.2003.VOL.31.NO.10.CDA.JOURNAL 765 Precision Cast

creating a passively fitting framework. acrylic resin base. the acrylic, unscrew the impression Improved fit compared to the result of 5. Modify impression copings copings, then remove the assembly conventional techniques has been (Nobel Biocare, Goteborg, Sweden) by from the primary cast, and push the confirmed by different authors.30-32 removing the hexagonal elements on copings and the vinyl spacers out of The aim of this article is to de- the internal aspects of these copings. the framework. scribe a technique derived from the This will eliminate any locking onto 8. Cast this wax framework in premachined cylinder luting tech- the external hex of the implants. The Chrome Cobalt (Jelenko JP, Jelenko, nique with the goal to predictably fab- external aspects of the copings are air Armonk, N.Y.). Reposition the cast ricate a highly precise master cast. An abraded with 50 µm of aluminum framework onto the impression cop- impression can be taken directly at im- oxide. This will enhance the future ings on the primary cast. The frame- plant level or, with some technique bonding between the luting compos- work shows a uniform space of approx- modification, at the abutment level. ite and the metal. Connect the modi- imately 0.5 mm circumferentially Concurrently, multiple techniques can fied copings to the implant analogs. around the titanium cylinders. This be employed to fabricate the final 6. A uniform spacer is created with space will eventually be filled with framework with the assurance that a help of a 3/16-x-1/8-inch vinyl tubing. composite resin. framework that fits the cast will fit in 9. Intraoral isolation is accom- the mouth. This predictability im- plished with a rubber dam and cheek proves the workflow of the restoring retractors. A sheet of rubber dam dentist and laboratory technician Multiple techniques (Hygenic Dental Dam, Coltene/ since multiple framework try-ins and Whaledent, Inc., Mahwah, N.J.) is adjustments are eliminated. can be employed placed over the impression copings on the primary cast, marked, and perfo- Technique to fabricate the rated with a rubber dam punch. This 1. Tighten implant level transfer rubber dam is placed over the copings impression copings (Nobel Biocare, final framework intraorally. When a more rigid setup Goteborg, Sweden) after confirming is required, a reinforced rubber dam complete seating with radiographs. with the assurance can be fabricated by placing a sheet of 2. Capture relationship of impres- ethylene vinyl acetate material over sion posts and soft tissue with that a framework the copings on the primary cast. The polyvinyl impression material (Extrude copings are marked and perforated Extra, Kerr, Romulus, Mich.) in a stock with a lab bur to a dimension of ap- tray (Coetray, GC America, Alsip, Ill.). that fits the cast proximately 8 mm. The outer dimen- 3. Connect implant level analogs to sions of the cast are transferred to the impression copings (Nobel Biocare, will fit in the mouth. EVA sheet. The EVA sheet is cut with Goteborg, Sweden). Inject gingival scissors according to this line. mask (Henry Schein, Inc., Melville, Multipurpose adhesive (Super 77, 3M, N.Y.), and form cast in stone (Tuff St. Paul, Minn.) is sprayed over this Rock Formula 44, Talladium Inc., The modified impression coping is EVA sheet, and a sheet of rubber dam Valencia, Calif.). heated over a Bunsen burner, pushed is placed over it. Once the glue has 4. Use this primary cast, after into the tubing, and cut to the desired dried, the extending part of the rub- mounting, for the conventional pros- height. The approximate spacer thick- ber dam is removed. This EVA/rubber thetic workup. The resulting implant- ness is 0.5 mm. dam sandwich is placed over the cop- supported trial setup is connected with 7. Fabricate a rigid pattern by con- ings on the primary cast. The copings two nonhexed temporary cylinders necting the impression copings togeth- are marked, and these markings are (Attachments International, Inc., San er with GC resin (GC America Inc., perforated with a rubber dam punch. Mateo, Calif.). The first cylinder is con- Alsip, Ill.). The connecting areas are ap- 10. Remove the intraoral healing nected on the primary cast to the try-in proximately 3 mm in diameter. For caps, and place the modified impres- base. The second cylinder is connected easy removal and separating between sion copings onto the implants. As intraorally with Triad gel (Dentsply vinyl and resin, a fine film of petrole- the hexagonal mating part has been International, Inc., York, Pa.) to the um jelly is applied. After hardening of removed, the copings will seat with-

766 CDA.JOURNAL.VOL.31.NO.10.OCTOBER.2003 out binding onto the implant flange. the impression (Extrude extra, Kerr, tray so that all the screws are accessi- Tighten the copings and place the Romulus, Ill.) — low viscosity is in- ble. Upon setting of the impression rubber dam over the copings. Fit the jected around the framework and material, loosen the screws. The luted cast framework — this should be non- high viscosity in the tray. Position the frame assembly is embedded within binding and passive — with some residual spacing between the bar and the copings. One will find that this spacing now can be less uniform then on the primary cast, indicating dis- crepancies between this cast and the intraoral situation. 11. Clean the surface of the im- pression coping with alcohol and dry completely. Exercise care as not to contaminate the metal surfaces with saliva. Mix Panavia F (Kuraray America, New York, N.Y.), a dual poly- merizing phosphate-modified luting composite resin with high bond strength to metals;33,34 and place in a needle tube syringe (Centrix, Shelton, Conn.). Position the framework over all the cylinders and hold in position as to create the best distribution of the available space between all cylin- ders and the intaglio of the frame- work. On the primary cast, this space was an even 0.5 mm; intraorally the distribution is most often different. Now inject the Panavia F between the cylinder and the framework, stabilize the framework so it is fitting passive- ly, then initiate polymerization of the luting composite resin with a curing light (Demetron 500, Kerr, Romulus, Mich.). As the light will only have ac- cess to the peripheral composite resin, the assembly is left in place for 10 minutes to complete the chemical polymerization step of the composite resin. At this time, the exact relative three-dimensional positions of all the implant platforms is now recorded. 12. The next step is to relate the implant position to the soft tissue. Remove the rubber dam from the bonded assembly by cutting it away. Create access in a stock tray so all the lab screws protrude trough it. A polyvinyl siloxane material is used for

OCTOBER.2003.VOL.31.NO.10.CDA.JOURNAL 767 Precision Cast

the pick-up impression. mask material (Gingival Mask, Henry sive and rigid, it will resist the ex- 13. Position new implant analogs Schein, Inc. Melville, N.Y.) is inject- panding stone from displacing the onto the cylinders of the framework. ed into the impression. After setting, analogs. This is in contrast to a simi- The analogs have a hexagonal top, minimal expansion stone (Tuff Rock lar assembly made in acrylic resin whereas the cylinders do not. The Formula 44, Talladium Inc., where the expanding forces can position of the hexagon is inconse- Valencia, Calif.) is poured into the bend the acrylic resin assembly, thus quential, as the definitive framework impression. The authors’ hypothesis creating inaccuracies. will not have the mating internal is that any expansion of the stone 14. Dental stone undergoes a de- hexagon. Tighten the analogs with will be of diminished consequences layed linear expansion,35 therefore similar tightness to the cylinders to as far as implant position is con- the cast is left undisturbed for 72 the implant platforms. Soft-tissue cerned. Since the assembly is mas- hours. Upon setting, the screws are

Figure 1. The primary cast with impression Figure 2. The EVA sheet is adapted to the cop- Figure 3. The modified impression coping. copings. ings and will function as a carrier for the rubber dam. The hexagonal component has been milled out.

Figure 4. The modified impression copings Figure 5. The reinforced rubber dam is Figure 6. Bird’s eye view showing the spac- are connected to the implants. placed. ing between the bar and the copings.

Figure 7. Buccal view — the bar is fitting Figure 8. Panavia F is injected in the space Figure 9. The bar is stabilized, and photo passively. between the bar and the copings polymerization is initiated.

768 CDA.JOURNAL.VOL.31.NO.10.OCTOBER.2003 loosened and the impression sepa- rated from the cast. The precision cast is trimmed on a dry trimmer and is then ready for the manufac- turing of the final framework for the multi-unit screw-retained implant prosthesis.

Summary Implant-supported frameworks re- quire a high level of precision of fit. Figure 10. The bonded assembly. Figure 11. The bar has been removed for il- lustrative purpose.

Figure 12. The rubber dam has been re- Figure 13. The pick-up impression is relating Figure 14. The final precision cast. moved, and the assembly is readied for a pick-up the soft tissue to the implant position. impression.

Figure 15. A maxillary impression bar. Figure 16. The final hybrid restoration. Figure 17. Radiographic depiction of final maxillary hybrid prosthesis.

Figure 18. An impression bar on the prima- Figure 19. Photo polymerization of the Figure 20. The screw-retained maxillary ry cast. Panavia F cement. hybrid.

OCTOBER.2003.VOL.31.NO.10.CDA.JOURNAL 769 Precision Cast

Well-fitting frameworks will minimize Implants Res 7:55-63, 1996. Comparison of strains produced in a bone simu- 11. Nissan J, Gross M, et al, Stress levels for lant between conventional cast and resin-luted prosthetic and biologic complications. well-fitting implant superstructures as a function implant frameworks. Int J Oral Maxillofac Clinically attaining this level of pros- of tightening force levels, tightening sequence, Implants 12:793-9, 1997. and different operators. J Prosthet Dent 86:20-3, 32. Watanabe F, Uno I, et al, Analysis of stress thetic precision is difficult, and many 2001. distribution in a screw-retained implant prosthesis. production techniques have been de- 12. Goodacre CJ, Kan JY, Rungcharassaeng K, Int J Oral Maxillofac Implants 15:209-18, 2000. Clinical complications of osseointegrated implants. 33. O’Keefe KL, Miller BH, Powers JM, In vitro veloped. The objective of the implant J Prosthet Dent 81:537-52, 1999. tensile bond strength of adhesive cements to new team is to deliver a high-quality 13. Kallus T, Bessing C, Loose gold screws fre- post materials. Int J Prosthodont 13:47-51, 2000. quently occur in full-arch fixed prostheses support- 34. Barkmeier WW, Latta MA, Laboratory restoration through a predictable pro- ed by osseointegrated implants after 5 years. Int J evaluation of a metal-priming agent for adhesive duction process. The predictability of Oral Maxillofac Implants 9:169-78, 1994. bonding. Quintessence Int 31:749-52, 2000.. 14. Tolman DE, Laney WR, Tissue-integrated 35. Heshmati RH, Nagy WW, et al, Delayed the process enables the control of prosthesis complications. Int J Oral Maxillofac linear expansion of improved dental stone. J time, cost, and quality. A framework Implants 7:477-84, 1992. Prosthet Dent 88:26-36, 2002. 15. Parel SM, Modified casting techniques for fitting a cast will only fit in the osseointegrated fixed prosthesis: A preliminary re- mouth if the cast is an accurate reflec- port. Int J Oral Maxillofac Imp 4:33-40, 1989. To request a printed copy of this article, please 16. Jemt T, Carlsson L, et al, In vivo load contact / Lambert J. Stumpel, III, DDS, 450 Sutter tion of the intraoral situation. The ob- measurements of osseointegrated implants sup- St., Suite 2530, San Francisco, CA 94108 or jective of the described technique is porting fixed or removable prostheses: a compar- [email protected]. ative pilot study. Int J Oral Maxillofac Imp 6:413- to generate a predictable precision 17, 1991. cast. The additional cost of the im- 17. Vigolo P, Majzoub Z, Gordioli G, Evaluation of the accuracy of three techniques pression bar is easily recouped with used for multiple implant abutment impressions. J the decrease in clinical and laboratory Prosthet Dent 88:186-92, 2003. 18. Humphries RM, Yaman P, Bloem TJ, The time. Improving the level of control accuracy of implant master casts constructed from of the production process will de- transfer impressions. Int J Oral Maxillofac Implants 5:331-6, 1990. crease the stress of the team serving 19. Barrett MG, de Rijk WG, Burgess JO, The the implant patient. CDA accuracy of six impression techniques for osseoin- tegrated implants. J Prosthodont 2:75-82, 1993. 20. Assif D, Marshak B, Schmidt A, Accuracy References / 1. Brånemark PI, Adell R, et al, of implant impression techniques. Int J Oral Osseointegrated titanium implants in the treat- Maxillofac Implants 11:216-22, 1996. ment of edentulousness. Biomaterials Jan 4:25-8, 21. Assif D, Nissan J, et al, Accuracy of im- 1983. plant impression splinted techniques: effect of 2. Rangert B, Jemt T, Jorneus L, Forces and splinting material. Int J Oral Maxillofac Implants moments on Brånemark implants. Int J Oral 14:885-8, 1999. Maxillofac Imp 4:241-7, 1989. 22. Carr AB, Master J, The accuracy of implant 3. Adell RM, Lekhol U, et al, A 15-year study verification casts compared with casts produced of osseointegrated implants in the treatment of the from a rigid transfer coping technique. J edentulous jaw. Int J Oral Surg 6:387-9, 1981. Prosthodont 5:248-52, 1996. 4. Duyck J, Ronold HJ, et al, The influence of 23. Liou AD, Nicholls JI, et al, Accuracy of re- static and dynamic loading on marginal bone reac- placing three tapered transfer impression copings tions around osseointegrated implants: an animal in two elastomeric impression materials. Int J experimental study. Clin Oral Implants Res 12:207- Prosthodont 6:377-83, 1993. 18, 2001. 24. Wee AG, Schneider RL, et al, Evaluation of 5. Michaels GC, Carr AB, Larsen PE, Effect of the accuracy of solid implant casts. J Prosthodont prosthetic superstructure accuracy on the os- 7:161-69, 1998. teointegrated implant bone interface. Oral Surg 25. Vigolo P, Millstein PL, Evaluation of mas- Oral Med Oral Pathol Oral Radiol Endod 83:198- ter cast techniques for multiple abutment implant 205, 1997. prostheses. Int J Oral Maxillofac Implants 8:439-46, 6. Carr AB, Gerard DA, Larsen PE, The re- 1993. sponse of bone in primates around unloaded 26. Wise M, Fit of implant-supported fixed dental implants supporting prostheses with dif- prostheses fabricated on master casts made from a ferent levels of fit. J Prosthet Dent 76:500-9, dental stone and a dental plaster. J Prosthet Dent 1996. 86:532-38, 2001. 7. Jemt T, Book K, Prosthesis misfit and mar- 27. Stumpel LJ III, The adhesive-corrected im- ginal bone loss in edentulous implant patients. Int plant framework. J Calif Dent Assoc 22:47-50, 52-3, J Oral Maxillofac Implants 11:620-5, 1996. 1994. 8. Rangert B, Gunne J, Sullivan D, Mechanical 28. Sellers GC, Direct assembly framework for aspects of Brånemark implant connected to a nat- osseointegrated implant prosthesis. J Prosthet Dent ural tooth: An in vitro study. Int J Oral Maxillofac 62:662-8, 1989. Imp 6:177-86, 1991. 29. Stumpel LJ III, Quon SJ, Adhesive abut- 9. Duyck J, Van Oosterwyck H, et al, Pre-load ment cylinder luting. J Prosthet Dent 69:398-400, on oral implants after screw tightening fixed full 1993. prostheses: an in vivo study. J Oral Rehabil 28:226- 30. Randi AP, Hsu AT, et al, Dimensional ac- 33, 2001. curacy and retentive strength of a retrievable ce- 10. Smedberg JI, Nilner K, et al, On the influ- ment-retained implant-supported prosthesis. Int J ence of superstructure connection on implant pre- Oral Maxillofac Implants 16:547-56, 2001. load: a methodological and clinical study. Clin Oral 31. Clelland NL, van Putten MC,

770 CDA.JOURNAL.VOL.31.NO.10.OCTOBER.2003 Dr. Bob Robert E. Horseman, DDS

Dogs of Distinction

ogs seem to be very much in the news lately. scratch was all she craved. Not that the peccadilloes of Hollywood and That’s why it is refreshing to read of sports figures are in any danger of being sup- doggy news such as this item out of Corbin, planted, but we take this as a healthy trend Ky. It seems 6-year-old Scooby loses his cool because dogs are guileless and what the during a thunderstorm and bolts across a world needs now is a moratorium on guile. highway, where he is hit by a car, injuring Unlike humans, for whom duplicity is a his tail and leg. According to Dr. Gerald d way of life, dogs such as Lassie, for example, Majors of the Corbin Animal Clinic, what have nothing to gain financially by demon- happens next is nothing short of amazing. strating forthrightness and integrity in their Scooby instantly realizes his predicament daily lives. Timmy was rescued inter- will not be cured by licking, so he hobbles, minably from wells, quicksand and other limps and drags himself through subdivi- adolescent katzenjammers, including death sions, minimalls, and three lanes of traffic by chocolate. Lassie’s innocence was never and presents himself at the doorstep of the compromised, even though she kvetched clinic. He is then refused admittance be- What the between pants that the kid must surely be cause being hit by anything less than a world needs retarded. A little extra kibble and an ear Mercedes Benz is not a covered benefit — now is a Continued on Page 789 moratorium on guile.

790 CDA.JOURNAL.VOL.31.NO.10.OCTOBER.2003 Dr. Bob

Something about an animal in the lap snoozing benignly without a care in the world, a small rivulet of drool moistening her dewlaps, apparently induces a similar effect in the patient.

Continued from Page 790 just kidding — of course he is cared for the club’s motto “Service Above Self.” plating the bottom line. and is recovering nicely, thank you. He thinks it could possibly be a threat If, in addition, Sophie can be The staff is still amazed that Scooby did to his banana interests. taught CPR and basic accounting, so the right thing without referring to a Dentistry may be on the verge of a much the better. Perhaps it is not too Global Positioning System or obtaining breakthrough that could see the acqui- far-fetched to anticipate canine assis- a specialty referral from his primary sition of high-tech curing lights and tants who can sniff out missing charts care vet. digital X-rays being put on the back or alert staff to deadbeat patients. Just south of Miami, the brain- burner. Enter Sophie, an 8-year-old Give this some serious thought, is child of Elena de Mesa is flourishing, poodle weighing in at about 20 our recommendation. Ask yourself how according to the National Enquirer, pounds. Sophie resides in Memphis, many of your present staff can be moti- that last bastion of journalistic in- Tenn., where a local dentist has found vated by a Milk Bone. Should you be a tegrity. Elena is a professional dog a viable substitute for Xanax. Sophie’s cat person, forget the whole thing. CDA trainer and certified canine behavior official job designation is that of dental specialist whose five-acre Totally Dog assistant, but instead of being profi- Daycamp nestled among the palm cient at taking X-rays and mixing ce- trees is a pooch paradise. It features a ment, she has expanded her natural in- bone-shaped swimming pool, sundeck clination to be a lap dog to that of and a doggie nap house. Each morn- being an animate sedative. ing, the Doggie Bus corrals the eager A patient arrives, as apprehensive as tailwaggers for a day of swimming, so- a cat six miles from sand. He or she re- cializing and indulging in indescrib- clines hesitantly in the chair, where- able delights of olfactory scanning. upon Sophie leaps nimbly into the pa- Snoopy never had it so good. tient’s lap, describes a couple of circles From Orange, Calif., comes the an- like dogs do, and settles down for the nouncement that a Labrador retriever duration of the dental procedure. named Novella has just been inducted Why this would have a calming effect into the Kiwanis Club, the first such on a nervous patient is not clear, but ap- nonhuman member of Kiwanis parently it does. Sophie is OK with a little International. Novella just graduated ear scratching and head patting, but the from seeing-eye training school and dentist has had to rule out tummy rub- now proudly wears the white Kiwanis bing and tickling a particular spot that medallion with the blue capital K causes the hind leg to oscillate vigorously around her neck. for fear of jiggling the whole chair. Naturally, this has members of the Something about an animal in the Lions Club figuring on ways to top this lap snoozing benignly without a care in media-grabbing event by inducting a the world, a small rivulet of drool moist- full-grown king of the jungle without ening her dewlaps, apparently induces a running afoul of various local laws or similar effect in the patient. That the dog endangering the lives of other mem- has canine teeth 2 cm long and might bers. Elsewhere it is rumored that a go- use them if disturbed, or that she pos- rilla named Cyril from an unnamed sesses a bladder with finite capacity, has zoo has been proposed for membership no relevancy if you can believe this den- by a Rotarian from Weehawken, N.J. tist’s clientele. Sophie’s payoff is a dog There is a hang-up in the application biscuit, a stipend bound to incur favor hinging upon Cyril’s interpretation of with overhead-obsessed dentists contem-