APRIL Nerve Damage History of Anesthesia Journal Surgical Templates CDA Journal Volume 35, Number 4 Journal april 2007 departments 237 The Editor/A Little Help Here 240 Letter to the Editor/Articaine vs. Lidocaine 247 Impressions/Well-supported Workers Reflect a Well-supported Leader 302 Dr. Bob/Raiders of the Lost Arch features 259 HALITOSIS UPDATE: A REVIEW OF CAUSES, DIAGNOSES AND TREATMENTS This report looks at the phenomenon of malodorous breath, which persists in a society rife with scientific and medical advancements. Also reviewed are the primary causes, diagnoses, treatments, and research frontiers. Sean S. Lee, DDS; Wu Zhang, MD; and Yiming Li, DDS, MSD, PhD 271 PERMANENT NERVE DAMAGE FROM INFERIOR ALVEOLAR NERVE BLOCKs — AN UPDATE TO INCLUDE ARTICAINE The Department of Oral and Maxillofacial Surgery at the University of California, San Francisco, conducted a three-year study of referred patients diagnosed with damage to the inferior alveolar and/or lingual nerve that only resulted from an inferior alveolar nerve block. M. Anthony Pogrel, DDS, MD 275 THE HISTORY OF LOCAL ANESTHESIA It is through the efforts and brilliance of our pioneers that the profession has eliminated the association of pain with dental services, adding immeasurably to the human good. Malvin E. Ring, DDS 283 USE OF PRIMARY TOOTH AS A SURGICAL GUIDE IN IMPLANT INSERTION: A CASE REPORT A variety of surgical templates are being used routinely in implant dentistry to guide a surgeon in proper implant insertion. A clinical case and related technique are presented in this article. Len Tolstunov, DDS Editor CDA JOURNAL, VOL 35, N 4 º A Little Help Here ALAN L. FELSENFELD, DDS hen my youngest grand- daughter was 3, she under- It is hard to imagine took a mission to build the world’s largest tower efficiency of operation without of Legos. There was a long Wperiod of silence as she toiled diligently in good supporting staff. the next room followed by a crashing sound that could only be the tower falling down on her table. Expecting a cry of dismay or tears, it was surprising to hear a wee voice calling and clinical aspects of our offices. The hours, and significant benefits. Perusal of out in a plaintive plea “I need a little help ability to see numerous patients with the Web sites of those and similar compa- here.” Terribly cute at the time, but it made an attendant increase in productivity is nies reveal that employees are eligible for me realize that all of us need help in the enhanced with a multiple-assistant office. packages that variably include health care performance of our jobs. Those procedures that are legally delegat- (medical, dental, drugs, and vision) The California Dental Association com- able to assistants with tiered levels of insurance, disability and life insurance, missioned a study designed to evaluate the ability and credential will be assigned al- pension plans, educational opportunities numbers of hygienists and the purported lowing the supervising dentist to care for for career development, bonus plans, legal need for additional personnel and educa- more patients and deliver better care. It plans, stock purchase options, dependent tional resources. Included in the study was is hard to imagine efficiency of operation care, and long-term care programs. For a parallel assessment of dental assistants without good supporting staff. individuals who stay with these employers, in an effort to see if there was a sufficient Most of our assistants are young peo- promotion into management positions is number to support clinical practitioners. It ple, mostly women, who are high school possible with career potential and salaries was surprising to learn that the hygienist- graduates seeking a career as opposed that can approach six figures. It is an easy dentist ratios did not validate any specific to pursuing a full college education. The option for a young person to be enticed by shortages in our state. Similar evaluation training for these new assistants is varied. this in choosing a career. of dental assistants indicated there was a The work experience pathway, where The problem for dentistry is to con- more pronounced scarcity of personnel to on-the-job education is possible, is the vince these individuals that being a dental assist in clinical care. educational track elected by many dental assistant and part of a health care team There are reported instances where assistants. Other means of obtaining the has many rewards that are not necessarily dentists practice without any assistants at skills and knowledge necessary for the quantifiable. The good feeling of treating all, and there are several practices where career may be from community colleges, disease, providing care to patients, see- the dentist has but one assistant, but vocational educational programs in school ing immediate outcomes for the efforts more than 95 percent of dentists have districts, and commercial schools. Each expended, and helping people are many of multiple dental assistants. The number of of these institutional programs requires the reasons we became dentists. These good assistants needed to support an individu- classes, practical and office experience, feelings can be afforded to, and are enjoyed al dentist varies, but an estimate of three and clinical and conceptual examinations. by, our assistants as well. The problem is to four per practitioner could be consid- For the young individual who is not that we cannot demonstrate those intan- ered to be a workable, conservative ratio. a “student” type, there are alternative gibles until such time as the individual has Given the more than 30,000 dentists in careers. Dentistry has to compete with gone through the training and is working in the state and the relatively rapid turnover corporate entities such as Starbucks, practice and can appreciate them. of assistants for a multitude of factors, Ralphs, or Costco for entry-level indi- The option of stocking shelves or one can appreciate that the employment viduals. Unfortunately for dentistry, there serving as a checker at Ralphs, assisting pool needs to be large. Most of us practice is a plethora of employment opportunities customers at Costco who are purchasing with multiple assistants in the business that are replete with good salaries, flexible large quantities of items they usually do APRIL 2007 237 CDA JOURNAL, VOL 35, N º 4 not need at great discount, or serving up yet another Double-Double animal style at In-N-Out Burger pales in comparison to the House self-actualization values of dental assisting. It is difficult to compete with industry in the recruitment and retention of assistants, and this is a priority we need to consider and act on to continue to provide safe and efficient care to our patients. REFERENCES 1. Pourat N, Roby D, et al, Is There a Shortage of Dental Hygienists and Assistants in California? Findings from the 2003 California Dental Survey. Los Angeles: UCLA Center for Health Policy Research, November 2005. Address comments, letters, and questions to the editor at [email protected]. McKenzie 238 A P R I L 2 0 0 7 Letters CDA JOURNAL, VOL 35, N 4 º Articaine vs. Lidocaine n article in the December issue lofacial Surgery Program at Highland evidence that the risks of paresthesia and of the Journal of the California Hospital, publicly stated that articaine is nausea are higher with articaine than Dental Association by Stan- not used, or is seldom used, at University with lidocaine.”2 ley Malamed, DDS, “Local of Southern California. According to Dr. At least three times the FDA has Anesthetics: Dentistry’s Most Caputo, Dr. Malamed said articaine was required changes in the product insert for AImportant Drugs, Clinical Update 2006” restricted for “political reasons.” articaine because of reports of adverse appears to be written to promote the use While appearing to promote the events to the FDA. One of the changes of articaine and nullify the reports of par- use of articaine, the author endeavors is listed as “Persistent paresthesias of esthesia rates up to 20x that of lidocaine. to nullify the global findings that the the lips, tongue, and oral tissues have The word “articaine” appears 7 times, drug is associated with very significant been reported with the use of articaine three times noted as “articaine is very hydrochloride with slow, incomplete, or popular,” and once as “it is increasingly no recovery. These postmarketing events popular in the United States.” The article have been reported chiefly following uses the word “superiority” four times AT LEAST THREE TIMES nerve blocks in the mandible and have with the local anesthetic, “superior” once, the FDA has required involved the trigeminal nerve and its and “advantage” once. branches.”3,4 An article demonstrating Dr. Malamed reports claims that changes in the product articaine has up to a 20x higher pares- articaine works faster, works better, is ef- insert for articaine thesia rate than lidocaine can be seen fective more often, gets the patient numb at dentistrytoday.com.5 Contrary to the when other local anesthetics fail, and that because of reports portrayal by Dr. Malamed, Hillerup and endodontists have become “enamored” of adverse events Jensen concluded, “This indicates that with the drug. Terms used for the other during the two-year period mentioned, amide local anesthetics are “very effective to the FDA. Articaine produced a more than 20-fold in general,” “darned good,” and “more tra- higher incidence of injection injury when ditional.” Although there are many stud- applied for mandibular block analgesia.” ies, including Septodont’s FDA study on increases in paresthesias with mandibular The increased paresthesia rate with Septocaine, that the efficacy of lidocaine block injections. Very few of the pos- articaine has been noted by a large dental for local anesthesia is unsurpassed, he sible references reporting the increased clinic, government agencies, and dental only listed a clinical trial where articaine paresthesias with articaine are included, insurance carriers (SAFECO in 200, had better results than lidocaine.