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Ankyloglossia
LETTERS TO
THE ED ITOR
ventures are often attributed to drug idiosyncracies or patient hypersen sitivity, when in fact the mishap is the result of the wrong technique, with the wrong drug or drugs, for the wrong pa tient. As reported, a 34-month-old boy re ceived intramuscularly 20 mg of alphaprodine and 25 mg of prometha zine. A prudent approach is to start an intravenous drip through w hich a drug or drugs of choice are introduced in small increments at calculated intervals. A bolus dose invites a point of no return. In Dr. Okuji’s report, the child was described as resting and responsive to verbal commands 15 minutes after the bolus dose. The operative procedure began shortly thereafter. Synthetic, narcotic, sedative, and analgesic agents are respiratory de pressants. Response to verbal com mands is important because these are used to instruct and remind the patient to breathe. I point this out to illustrate the fragility of a technique that places the responsibility of life-sustaining in structions on a frightened, drugged, 34-m onth-old boy w ith a c o m promised airway. Dr. Okuji properly noted that vital signs were not recorded. Too often, dependence on electronic and me chanical devices are misplaced. Reli able monitors in eyeball range of the dentist are cyanosis (nail beds, pallor, eyelids), and the variety of movements of the bared chest cage and muscula ture. These give early warnings of res piratory distress. Finally, I would like to comment on the resumption of the operative proce dure after resuscitation at a local hos pital shortly after clonic and tonic sei zures developed in a patient who was then referred to a major hospital. Prob lems tend to be cumulative and the de cision to postpone further treatment is not hard to make, especially when given the choice of a healthy child w ith u n fille d prim ary teeth, or a brain-damaged child with temporarily filled primary teeth. CONRAD E. MOSES, DDS WILMINGTON, DEL
□ It must jar the senses of any practic ing dentist who uses sedation tech niques to read Dr. Okuji’s report enti tled “Hypoxic encephalopathy after the administration of alphaprodine hydrochloride” (July 1981). .. . 694 ■ JADA, Vol. 103, November 1981
Use of drug regimens with indefen sible routes of administration should be assigned to the realm of the teratologist or to the pharmacologist who is researching drug combinations and dosages. THEODORE P. CROLL, DDS DOYLESTOWN, PENN
□ This letter is in reference to the arti cle by Dr. Okuji entitled “Hypoxic en cephalopathy after the administration of alphaprodine hydrochloride” (July 1981). It is a disservice to title this article “alphaprodine”; it should be titled, “polypharmacy.” The case report was that of a 34 month-old child who was medicated with diazepam, alphapro dine, promethazine, and injected with 2% lidocaine. The combination of drugs and their dosages given this child approaches amounts frequently given to adults to remove impacted third molars. No mention was made of the use of nitrous oxide I oxygen or oxygen alone by inhalation. Many practitioners believe that oxygen by inhalation is absolutely essential to maintain oxyhemoglobin saturation at satisfactory levels when intraveous sedatives are used. Alphaprodine is a relatively safe narcotic with a lower incidence of nausea, vomiting, and hypotension than meperidine. It has been used safely by obstetricians in childbirth for many years; respiratory depression certainly is one c o m p lic atio n in childbirth that no one wants, and it is not a problem if proper doses of Al phaprodine are used. Another important point that needs to be emphasized is that the respira tory depressant effect of large doses of alphaprodine can be mitigated by the addition of Levallorphan in the con centration of 1 mg Levallorphan to 60 mg alphaprodine. This combination does not materially affect the sedative I analgesic qualities of alphaprodine. It is regrettable that a drug such as alphaprodine with so many beneficial indications can be withdrawn from the market because of a few adverse reac tions caused by improper use. ALBERT F. STAPLES, DMD, PhD THE UNIVERSITY OF OKLAHOMA OKLAHOMA CITY
□ Author’s comment: I am in com plete agreement with Dr. Staples that alphaprodine is a clinically safe and beneficial agent when administered
judiciously. I think that Dr. Staples may be a bit harsh in describing the ar ticle title selection as a “disservice.” For title brevity, “alphaprodine” was chosen because it is the agent with respiratory depression properties. Also, the article did state that the dos age of alphaprodine should be reduced when used in conjunction with other agents. I cannot comment about the administration of nitrous-oxide I oxy gen or oxygen alone during the re ported case, because the medical rec ord made no mention of its use. Fi nally, I would hope that this case re port has reminded all practitioners th a t the a d m in is t r a t io n of any therapeutic agent should be done pru dently and with care. DAVID M. OKUJI, DDS GILROY, CALIF
Ankyloglossia □ In the photograph of the lesion of the tongue in the article, “Papillary, exophytic lesion of the tongue” (Au gust 1981), I notice the patient is “tongue-tied” (ankyloglossia). In their summary, the authors state, “The cause of this lesion is unknown.” I would like to venture an-educated guess that this lesion would not have formed if a lingual frenectomy had been done when the patient was a young child. Protrusion of the tongue would probably place the lesion right on the incisal edges of the lower in cisors. After the tongue had rubbed there for approximately 31 years, one would expect at least a callous to form. This case exhibits another reason for correcting ankyloglossia when it inter feres with normal tongue function. ROBERT F. RIMSTIDT, DDS BLOOMINGTON, IND
Radiopaque plastics □ I think that the Council on Dental Materials, Instruments, and Equip ment should include a requirement for all plastics used in the mouth to be radioscopic. I have seen previous com ments in articles about the need for radioscopic visibility in situations in which there is evidence that a person has ingested or aspirated dental plas tic. This has now happened to one of my patients. A radiologist thought he could detect the acrylic partial denture in the patient’s stomach at one time,
THE ED ITOR
ventures are often attributed to drug idiosyncracies or patient hypersen sitivity, when in fact the mishap is the result of the wrong technique, with the wrong drug or drugs, for the wrong pa tient. As reported, a 34-month-old boy re ceived intramuscularly 20 mg of alphaprodine and 25 mg of prometha zine. A prudent approach is to start an intravenous drip through w hich a drug or drugs of choice are introduced in small increments at calculated intervals. A bolus dose invites a point of no return. In Dr. Okuji’s report, the child was described as resting and responsive to verbal commands 15 minutes after the bolus dose. The operative procedure began shortly thereafter. Synthetic, narcotic, sedative, and analgesic agents are respiratory de pressants. Response to verbal com mands is important because these are used to instruct and remind the patient to breathe. I point this out to illustrate the fragility of a technique that places the responsibility of life-sustaining in structions on a frightened, drugged, 34-m onth-old boy w ith a c o m promised airway. Dr. Okuji properly noted that vital signs were not recorded. Too often, dependence on electronic and me chanical devices are misplaced. Reli able monitors in eyeball range of the dentist are cyanosis (nail beds, pallor, eyelids), and the variety of movements of the bared chest cage and muscula ture. These give early warnings of res piratory distress. Finally, I would like to comment on the resumption of the operative proce dure after resuscitation at a local hos pital shortly after clonic and tonic sei zures developed in a patient who was then referred to a major hospital. Prob lems tend to be cumulative and the de cision to postpone further treatment is not hard to make, especially when given the choice of a healthy child w ith u n fille d prim ary teeth, or a brain-damaged child with temporarily filled primary teeth. CONRAD E. MOSES, DDS WILMINGTON, DEL
□ It must jar the senses of any practic ing dentist who uses sedation tech niques to read Dr. Okuji’s report enti tled “Hypoxic encephalopathy after the administration of alphaprodine hydrochloride” (July 1981). .. . 694 ■ JADA, Vol. 103, November 1981
Use of drug regimens with indefen sible routes of administration should be assigned to the realm of the teratologist or to the pharmacologist who is researching drug combinations and dosages. THEODORE P. CROLL, DDS DOYLESTOWN, PENN
□ This letter is in reference to the arti cle by Dr. Okuji entitled “Hypoxic en cephalopathy after the administration of alphaprodine hydrochloride” (July 1981). It is a disservice to title this article “alphaprodine”; it should be titled, “polypharmacy.” The case report was that of a 34 month-old child who was medicated with diazepam, alphapro dine, promethazine, and injected with 2% lidocaine. The combination of drugs and their dosages given this child approaches amounts frequently given to adults to remove impacted third molars. No mention was made of the use of nitrous oxide I oxygen or oxygen alone by inhalation. Many practitioners believe that oxygen by inhalation is absolutely essential to maintain oxyhemoglobin saturation at satisfactory levels when intraveous sedatives are used. Alphaprodine is a relatively safe narcotic with a lower incidence of nausea, vomiting, and hypotension than meperidine. It has been used safely by obstetricians in childbirth for many years; respiratory depression certainly is one c o m p lic atio n in childbirth that no one wants, and it is not a problem if proper doses of Al phaprodine are used. Another important point that needs to be emphasized is that the respira tory depressant effect of large doses of alphaprodine can be mitigated by the addition of Levallorphan in the con centration of 1 mg Levallorphan to 60 mg alphaprodine. This combination does not materially affect the sedative I analgesic qualities of alphaprodine. It is regrettable that a drug such as alphaprodine with so many beneficial indications can be withdrawn from the market because of a few adverse reac tions caused by improper use. ALBERT F. STAPLES, DMD, PhD THE UNIVERSITY OF OKLAHOMA OKLAHOMA CITY
□ Author’s comment: I am in com plete agreement with Dr. Staples that alphaprodine is a clinically safe and beneficial agent when administered
judiciously. I think that Dr. Staples may be a bit harsh in describing the ar ticle title selection as a “disservice.” For title brevity, “alphaprodine” was chosen because it is the agent with respiratory depression properties. Also, the article did state that the dos age of alphaprodine should be reduced when used in conjunction with other agents. I cannot comment about the administration of nitrous-oxide I oxy gen or oxygen alone during the re ported case, because the medical rec ord made no mention of its use. Fi nally, I would hope that this case re port has reminded all practitioners th a t the a d m in is t r a t io n of any therapeutic agent should be done pru dently and with care. DAVID M. OKUJI, DDS GILROY, CALIF
Ankyloglossia □ In the photograph of the lesion of the tongue in the article, “Papillary, exophytic lesion of the tongue” (Au gust 1981), I notice the patient is “tongue-tied” (ankyloglossia). In their summary, the authors state, “The cause of this lesion is unknown.” I would like to venture an-educated guess that this lesion would not have formed if a lingual frenectomy had been done when the patient was a young child. Protrusion of the tongue would probably place the lesion right on the incisal edges of the lower in cisors. After the tongue had rubbed there for approximately 31 years, one would expect at least a callous to form. This case exhibits another reason for correcting ankyloglossia when it inter feres with normal tongue function. ROBERT F. RIMSTIDT, DDS BLOOMINGTON, IND
Radiopaque plastics □ I think that the Council on Dental Materials, Instruments, and Equip ment should include a requirement for all plastics used in the mouth to be radioscopic. I have seen previous com ments in articles about the need for radioscopic visibility in situations in which there is evidence that a person has ingested or aspirated dental plas tic. This has now happened to one of my patients. A radiologist thought he could detect the acrylic partial denture in the patient’s stomach at one time,