The invention of local anesthetic is one of the most important advancements in both modern dentistry and modern medical surgery. Local anesthetics single handedly opened the door for a slew of modern advancements that are all based on one basic premise: a patient needs to be able to sit through and tolerate the proposed treatment for anything to be accomplished. As any dental patient can attest, being “numb” is a good thing, and I completely agree because, after all, I am a patient too! In general, most dental patients typically experience several hours of numbness after their procedure is complete. Depending on different factors, numbness can sometimes take 4 or 5 hours to wear off. I’m sure I’m not the only one that has thought it's quite unfortunate that “numbness” doesn’t work like a light switch. The ability to quickly turn numbness “on” and then quickly turn numbness “off” at the end of the appointment sure would be fantastic, wouldn't it? No longer would a patient be required to endure residual numbness into their work day after that simple 7:30am filling. No more challenging sales calls due to slurred or sloppy speech. No more rescheduling important business meetings to the afternoon because of the embarrassing “frozen face” or worse yet…drooling! For those not in the business world, think about how great it would be to simply eat lunch or dinner without fear of biting a big hole in your cheek because it was numb. While not as fast as a light switch, there is a fantastic solution to minimize all these nuisances! For the better part of the last year, I have been offering my patients a fantastic product named OraVerse which addresses this exact issue. It is an anesthetic reversal agent designed to reduce the duration of local anesthetic “numbness” to only 1-1.5 hours after it is administered. This safe and effective method of anesthetic reversal minimizes the above nuisances caused by lingering numbness. After using OraVerse, patients have reported back to me about how conference calls, board meetings, soccer games, and even first dates were all made possible by reversing their dental “numbness” with OraVerse.
Before we are able to effectively discuss an anesthetic reversal agent such as OraVerse, we first need to discuss how local anesthesia physiologically works. In most settings, local anesthesia usually involves the injection of an anesthetic drug via needle into the body or topical application to the surface. While other delivery methods exist today they are rarely, if ever, used in the field of dentistry and therefore we will ignore them for the time being. Local anesthetics work by blocking nerve impulses. At a cellular level, this occurs by blocking sodium channels in the nerve membranes. When sodium is blocked in this way, the nerve cannot fire nor conduct an electrical impulse. Without an impulse, sensation cannot be transmitted and therefore pain cannot be felt. Varieties of different local anesthetics are used in dentistry today, but all have a common ancestry: the coca plant/cocaine!
For hundreds, if not thousands of years, the leaves of the coca plant have been used by indigenous people as both a stimulant and anesthetic. It was from these leaves that Albert Niemann first isolated the modern drug cocaine in 1860.ⁱ The first clinical use of cocaine is often attributed to Sigmund Freud, who in 1884 started using it to wean patients away from a morphine addiction.ⁱⁱ Later that year, Dr. William Steward Halsted was the first to describe the injection of cocaine into a sensory nerve trunk to create local anesthesia appropriate for surgery.ⁱⁱⁱ A renowned British surgeon in his time, Halsted was the first to establish formal surgical training for physicians in America at Johns Hopkins University School of Medicine. Believe it or not, prior to that time surgery was a self-taught discipline amongst American physicians! Another interesting fact about Halsted is that in 1889 he invented rubber gloves and pioneered their use in medical/surgical setting. Unfortunately, Halsted began to use cocaine recreationally, as did many people of the time, and became quite addicted. Over the next few decades, the addictive properties of cocaine became more apparent and began to stir up a moral panic in the public media throughout the United States. The search for a less toxic and less addictive substitute anesthetic was on and eventually led to the development of Procaine (known better by it’s more famous trade name “Novocaine”) in 1904. Later in 1914, the Harrison Narcotics Tax Act outlawed the sale and distribution of cocaine in the United States.
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Novocaine may have less addictive properties compared to cocaine, but it had its problems as well. It took a very long time to set in, wore off too quickly, and was much less potent than cocaine and consequently required larger doses.⁴ Additionally, Novocaine is chemically classified as an Esther and therefore has a high potential to cause allergic reactions in humans due to the way it is metabolized in the body (creation of the potential allergen para-aino benzoic acid (PABA). With all this in mind, many dentists elected to continue using pain-relief methods of their past: ether, whiskey, and massive doses of Nitrous Oxide (Laughing gas). All three of these methods primarily relied on rendering the patient unconscious and while technically effective, they left something to desired in the area of patient safety. Because of this, many dentists elected to simply forego using any local anesthetic at all.
Eventually Lidocaine (Xylocaine) was invented in 1943 and became the first of the modern local anesthetic agents. When combined with a small amount of epinephrine (adrenalin) Lidocaine was found to produce profound anesthesia and revolutionized modern medical and dental procedures. Unlike Novocaine, Lidocaine is hypoallergenic since it is classified as an Amide and not an Esther. It is still the most widely used local anesthetic in America today. Other local anesthetics were invented to tweak and customize the properties of Lidocaine for certain situations. For example, Prilocaine (Citanest) was developed in 1959 for its minimal vasodilative properties. These properties eliminated the need for the addition of epinephrine, and thereby made this local anesthetic a safer option for patients with certain cardiovascular conditions.
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The breakthrough invention of Lidocaine caused less and less Novocaine to be administered in the dental profession. By the early 1980's, nearly all dentists in The United States had stopped using it. However, the use of the word "Novocaine" had become so engrained in the American vernacular that patients still routinely ask me "So you're going to give me a shot of Novocaine today right?" I typically don't correct them unless he or she works in a medical or dental profession. However, thanks to this newsletter forum, everyone can now be "in the know" that true Novocaine hasn't routinely been used by American dentists in over 30 years.
Let’s be honest, being “numb” isn’t a ton of fun, but certainly beats the alternative during a dental procedure! But what about after the procedure is over? There are both advantages and disadvantages to being numb after you leave the office. The primary advantage of being numb after the procedure is completed is time. This “numb” time can provide a comfortable commute home from the office as well as allow a pain-free period in which the patient may fill pain prescriptions at the pharmacy or take over-the-counter pain medicine. Although these two instances can be advantageous, only a minimal period of “numb” time may be needed to complete either or both. The length of time an individual stays numb depends on a variety of factors including location of the injection, an individual's metabolism/genetics, physical activity, and dosage of the local anesthetic. Two patients receiving the same dose Lidocaine injection may experience a widely different timeframe in which they are numb. Some will be “waking up” minutes after leaving the office, while others may experience the numbness dissipating over four or five hours. Being numb for multiple hours is often quite an inconvenience for patients. Speech, facial cosmetics, tactile sensation, and of course chewing/eating are all affected and impaired by the anesthetic. Additionally, patients who are numb are far more likely to accidentally bite their cheek or tongue. Without sensory perception, these self inflicted wounds can be quite severe and take several weeks to heal.
Being able to control or “wake up” a patient’s numb lip or jaw with OraVerse is a very valuable ability. Patients are no longer forced to endure the multiple hours of numbness and resulting disadvantages. I have been using OraVerse over the past year and nowhere has this convenience been more apparent than at the 7:30am fillings appointment. Once the procedure is complete, their numbness is reversed with OraVerse, they commute to work, and by the time they reach their place of employment the numbness has completely worn off! It’s a typical day of work rather than a day half spent drooling with slurring speech. Several patients have been so thrilled with OraVerse, that one emailed me later that day describing how she was able to participate in an unscheduled sales videoconference later that morning unhindered by the anesthetic! And if you’re wondering, yes, she closed the sale.
So exactly what is OraVerse? OraVerse (phentolamine mesylate) is an injection that reverses soft tissue anesthesia (i.e. lip, tongue, and face) and the associated functional deficits resulting from a typical injection of local anesthetic containing a vasoconstrictor (ex. Lidocaine with epinephrine). It accelerates the return of normal sensation and function and helps reduce the unwanted and often unnecessary lingering soft tissue numbness after routine dental procedures. In clinical trials, the median time to recovery of normal sensation in the upper lip/face was 50 minutes for OraVerse patients vs. 133 minutes for the control group.⁵ In the lower lip/face the median was 70 minutes for OraVerse patients vs. 155 minutes for the control group.⁶ In my personal experience, patients whom which I’ve polled have reported slightly longer OraVerse times, in the range of 60 minutes for the upper lip/face and 80-90 minutes for the lower lip/face. As you can see in the graph, OraVerse cuts the typical “numb time” by MORE THAN HALF! Due to differences in body chemistry between individuals, I’ll generally tell patients that they can easily expect resolution of numb symptoms within 60-90 minutes after I deliver the OraVerse.
Not only is OraVerse quite effective but it’s quite safe as well. There are no known drug interactions with OraVerse. Best of all, administering OraVerse is painless because the injection is given while you are still numb! Adverse reactions to OraVerse are quite uncommon but those reported were centered on cardiovascular events. In my opinion, patients with significant cardiovascular histories or concern should carefully weigh the risk/benefits of using a reversal agent. OraVerse is not recommended for use in children less than 6 years of age or weighing less than 33lbs.⁷ Additionally, OraVerse has not been studies in pregnant or nursing women. I do not recommend using OraVerse on these patient groups and as a friendly reminder, ALWAYS inform your dental professional if you are, or think you may be pregnant.
OraVerse is a fantastic treatment option that I am proud to offer my patients. This elective procedure offers patients an opportunity to rapidly reverse the effect of dental anesthetic and minimize the myriad nuisances associated. I’m very proud that at the time of publication, the OraVerse website lists only one other dentist offering this fantastic product in surrounding towns. Whether you have a big event planned at work, something important to do in your personal life, or simply just don’ t like waiting hours and hours for the numbness to go away after your dental work is completed, OraVerse may be a great option for you so please feel free to ask me about it!
ⁱ Spiller, Martin S. "The Dental Local Anesthetics." http://doctorspiller.com/Local_Anesthetics/local_anesthetics.htm
ⁱⁱ Spiller, Martin S. "The Dental Local Anesthetics." http://doctorspiller.com/Local_Anesthetics/local_anesthetics.htm
ⁱⁱⁱ Spiller, Martin S. "The Dental Local Anesthetics." http://doctorspiller.com/Local_Anesthetics/local_anesthetics.htm
⁴ Spiller, Martin S. The ⁴Dental Local Anesthetics." http://doctorspiller.com/Local_Anesthetics/local_anesthetics.htm
⁵ Septodont. 2011. "OraVerse Highlights of Prescribing information"
⁶ Septodont. 2011. "OraVerse Highlights of Prescribing information"
⁷ Oraverse.com "Frequently Asked Questions." http://oraverse.com/patients/faq/index.html
If you would like to discuss this topic further, or have any suggestions for future topics, please feel free to contact me at my Downers Grove office.
Sincerely,
Eric G. Jackson, DDS, MAGD, FICOI, FICD, FADI
Oral Health Care Professionals, LLC
