- Email: [email protected]
Pressure or Pain in the Dental Chair?
Pressure or Pain in the Dental Chair? Cory M. Resnick DMD, MD PII: DOI: Reference:
S2352-4529(16)30071-8 doi: 10.1016/j.janh.2016.04.011 JANH 96
To appear in:
Journal of Anesthesia History
Please cite this article as: , Pressure or Pain in the Dental Chair?, Journal of Anesthesia History (2016), doi: 10.1016/j.janh.2016.04.011
This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT Title: Pressure or Pain in the Dental Chair?
SC NU
AC
CE
PT
ED
MA
Address correspondence to: Dr. Cory M. Resnick Boston Children’s Hospital Department of Plastic and Oral Surgery 300 Longwood Avenue Boston, MA 02115 Telephone: 617-355-6082 Fax: 617-738-1657 E-mail: [email protected]
RI P
T
Cory M. Resnick, DMD, MD Instructor, Harvard School of Dental Medicine, Department of Plastic and Oral Surgery, Boston Children’s Hospital, Boston, MA.
1
ACCEPTED MANUSCRIPT The authors of A Systematic Review of the Cervical Plexus Accessory Innervation and Its Role in Dental Anesthesia1 are to be commended for their thorough review of the history of
T
accessory innervation to the mandible and its relationship to the delivery of local anesthesia for
RI P
dental procedures in modern times. This manuscript reminds the reader of the import of studying the past in order to inform the present.
SC
The high failure rate of the inferior alveolar nerve (IAN) block in the daily practice of
NU
dentistry and dental specialties is indeed a significant problem. The very thought of undergoing a dental procedure is fear provoking for many patients, and this trepidation is largely rooted in the
MA
assumption that the procedure will be painful. While the use of local anesthetics dates back to 18422, their routine application for dental work in modern times has not alleviated this anxiety.
ED
Most adult patients can tolerate oral procedures when dense local anesthesia eliminates all pain
remains by some patients.
PT
from the procedure, but an inherent mistrust that local anesthetics can provide this level of relief
CE
In dental school, aspiring dentists are taught the mechanisms of nerve conduction and
AC
the ability of local anesthetics to interrupt the transference of pain sensations without eliminating pressure and proprioception. From this knowledge, combined with the common expression by patients of continued discomfort during procedures on lower teeth after an IAN block has been delivered, the mantra that these complaints are borne from “pressure, not pain” has become pervasive. I have heard this explanation provided to unhappy patients in the middle of their procedures by a host of dental providers that were trained by a range of institutions and over different decades. The idea that the patient is indeed feeling real pain due to accessory innervation by nerves that have not been anesthetized is rarely considered.
2
ACCEPTED MANUSCRIPT As a provider of both local anesthetics and intravenous anesthesia for certain dental procedures, I often receive referrals because a previous provider “could not get me numb”. I
T
must admit that my instinct when this happens is to assume that the first provider used inferior
RI P
technique in providing the IAN block, and I will have more success by repeating the same process. On many occasions, however, despite my confidence in my local anesthetic techniques,
SC
I have indeed had difficulty obtaining dense local anesthesia in some patients.
NU
The answer to this problem may lie in the inherent anatomic variability that should not be surprising in light of the common range of normal patterns for other structures in the face and
MA
throughout the body, such as the highly variable peripheral branching pattern of the facial nerve. Examples of this variability and the contribution of accessory neural innervation to the mandible
ED
are prevalent in my daily life, from the occasional impossibility of obtaining adequate anesthesia
PT
with standard IAN blocking techniques to the remarkable return of sensation to parts of the lower face thought to be innervated primarily by nerves that are known to have been severed. In the
CE
latter scenario, I and others have often observed a remarkable return of sensation to the lip and
AC
chin only weeks after sagittal split osteotomies (“jaw surgery”) during which the inferior alveolar nerve, which innervates these areas, was known to be cut. I have postulated to patients that there must be accessory innervation from cervical nerves that upregulate when the primary innervation is lost. As a regular reader and contributor to modern scientific literature, I was completely unaware of the work that has been done to elucidate this complicated topic since 1889. I now see that there have been many investigations in to this problem over more than a century. One strength of this historical piece compared to a typical meta-analysis is the inclusion in the current work of articles that are not available through online searches and that are written in non-English
3
ACCEPTED MANUSCRIPT languages; meta-analyses often exclude foreign works and those that are not readily available for review. As with scores of the world’s treasures, many great ideas originated long ago and in non-
T
English speaking nations. These deserve to be captured.
RI P
The intersection of history and modern practice cannot be forgotten, and in fact warrants a more prominent role in the formal teaching of healthcare providers. As in this example, the
SC
study of history will provide a broader context for the daily experiences of the clinical provider
NU
and will impart depth and texture to our interactions with patients. I am reminded of time spent walking amongst the hollowed stacks of the rare and dusty books housed in Harvard Medical
MA
School’s Countway Library, and the countless lessons that could be learned by perusing their pages.
ED
In the busy and goal-driven life of the medical or dental student, however, there is little
PT
time for such pleasures. Many medical schools have recognized this need and have incorporated the history of medicine in to their curriculums3,4. Undoubtedly others will follow. I hope that this
CE
trend will soon extend to dental training as well.
AC
In conclusion, I would like to thank the authors for reminding me that every clinical experience and conundrum has been encountered by others before me. The value in these lessons from the past is immeasurable. Professional educators and practicing dental professionals would do well to review our archives as we charge in to the future.
References: 1. Kim D, Uzbelger Feldman D, Yang J: A Systematic Review of the Cervical Plexus Accessory Innervation and Its Role in Dental Anesthesia. In press.
4
ACCEPTED MANUSCRIPT 2. Reutsch YA, Boni T, Borgeat A. From cocaine to ropivacaine: the history of local anesthetic drugs. Curr Top Med Chem. 2001;1(3):175-182.
T
3. Shedlock J, Sims RH, Kubilius RK. Promoting and teaching the history of medicine in a
RI P
medical school curriculum. Journal of the Medical Library Association : JMLA. 2012;100(2):138-141. doi:10.3163/1536-5050.99.100.2.014.
SC
Caramiciu J, Arcella D, Desai MS.
CE
PT
ED
MA
NU
History of medicine in US medical school curricula. J Anesth Hist Med. 2015;1; 111-114. DOI: http://dx.doi.org/10.1016/j.janh.2015.02.010
AC
4.
5
S2352-4529(16)30071-8 doi: 10.1016/j.janh.2016.04.011 JANH 96
To appear in:
Journal of Anesthesia History
Please cite this article as: , Pressure or Pain in the Dental Chair?, Journal of Anesthesia History (2016), doi: 10.1016/j.janh.2016.04.011
This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT Title: Pressure or Pain in the Dental Chair?
SC NU
AC
CE
PT
ED
MA
Address correspondence to: Dr. Cory M. Resnick Boston Children’s Hospital Department of Plastic and Oral Surgery 300 Longwood Avenue Boston, MA 02115 Telephone: 617-355-6082 Fax: 617-738-1657 E-mail: [email protected]
RI P
T
Cory M. Resnick, DMD, MD Instructor, Harvard School of Dental Medicine, Department of Plastic and Oral Surgery, Boston Children’s Hospital, Boston, MA.
1
ACCEPTED MANUSCRIPT The authors of A Systematic Review of the Cervical Plexus Accessory Innervation and Its Role in Dental Anesthesia1 are to be commended for their thorough review of the history of
T
accessory innervation to the mandible and its relationship to the delivery of local anesthesia for
RI P
dental procedures in modern times. This manuscript reminds the reader of the import of studying the past in order to inform the present.
SC
The high failure rate of the inferior alveolar nerve (IAN) block in the daily practice of
NU
dentistry and dental specialties is indeed a significant problem. The very thought of undergoing a dental procedure is fear provoking for many patients, and this trepidation is largely rooted in the
MA
assumption that the procedure will be painful. While the use of local anesthetics dates back to 18422, their routine application for dental work in modern times has not alleviated this anxiety.
ED
Most adult patients can tolerate oral procedures when dense local anesthesia eliminates all pain
remains by some patients.
PT
from the procedure, but an inherent mistrust that local anesthetics can provide this level of relief
CE
In dental school, aspiring dentists are taught the mechanisms of nerve conduction and
AC
the ability of local anesthetics to interrupt the transference of pain sensations without eliminating pressure and proprioception. From this knowledge, combined with the common expression by patients of continued discomfort during procedures on lower teeth after an IAN block has been delivered, the mantra that these complaints are borne from “pressure, not pain” has become pervasive. I have heard this explanation provided to unhappy patients in the middle of their procedures by a host of dental providers that were trained by a range of institutions and over different decades. The idea that the patient is indeed feeling real pain due to accessory innervation by nerves that have not been anesthetized is rarely considered.
2
ACCEPTED MANUSCRIPT As a provider of both local anesthetics and intravenous anesthesia for certain dental procedures, I often receive referrals because a previous provider “could not get me numb”. I
T
must admit that my instinct when this happens is to assume that the first provider used inferior
RI P
technique in providing the IAN block, and I will have more success by repeating the same process. On many occasions, however, despite my confidence in my local anesthetic techniques,
SC
I have indeed had difficulty obtaining dense local anesthesia in some patients.
NU
The answer to this problem may lie in the inherent anatomic variability that should not be surprising in light of the common range of normal patterns for other structures in the face and
MA
throughout the body, such as the highly variable peripheral branching pattern of the facial nerve. Examples of this variability and the contribution of accessory neural innervation to the mandible
ED
are prevalent in my daily life, from the occasional impossibility of obtaining adequate anesthesia
PT
with standard IAN blocking techniques to the remarkable return of sensation to parts of the lower face thought to be innervated primarily by nerves that are known to have been severed. In the
CE
latter scenario, I and others have often observed a remarkable return of sensation to the lip and
AC
chin only weeks after sagittal split osteotomies (“jaw surgery”) during which the inferior alveolar nerve, which innervates these areas, was known to be cut. I have postulated to patients that there must be accessory innervation from cervical nerves that upregulate when the primary innervation is lost. As a regular reader and contributor to modern scientific literature, I was completely unaware of the work that has been done to elucidate this complicated topic since 1889. I now see that there have been many investigations in to this problem over more than a century. One strength of this historical piece compared to a typical meta-analysis is the inclusion in the current work of articles that are not available through online searches and that are written in non-English
3
ACCEPTED MANUSCRIPT languages; meta-analyses often exclude foreign works and those that are not readily available for review. As with scores of the world’s treasures, many great ideas originated long ago and in non-
T
English speaking nations. These deserve to be captured.
RI P
The intersection of history and modern practice cannot be forgotten, and in fact warrants a more prominent role in the formal teaching of healthcare providers. As in this example, the
SC
study of history will provide a broader context for the daily experiences of the clinical provider
NU
and will impart depth and texture to our interactions with patients. I am reminded of time spent walking amongst the hollowed stacks of the rare and dusty books housed in Harvard Medical
MA
School’s Countway Library, and the countless lessons that could be learned by perusing their pages.
ED
In the busy and goal-driven life of the medical or dental student, however, there is little
PT
time for such pleasures. Many medical schools have recognized this need and have incorporated the history of medicine in to their curriculums3,4. Undoubtedly others will follow. I hope that this
CE
trend will soon extend to dental training as well.
AC
In conclusion, I would like to thank the authors for reminding me that every clinical experience and conundrum has been encountered by others before me. The value in these lessons from the past is immeasurable. Professional educators and practicing dental professionals would do well to review our archives as we charge in to the future.
References: 1. Kim D, Uzbelger Feldman D, Yang J: A Systematic Review of the Cervical Plexus Accessory Innervation and Its Role in Dental Anesthesia. In press.
4
ACCEPTED MANUSCRIPT 2. Reutsch YA, Boni T, Borgeat A. From cocaine to ropivacaine: the history of local anesthetic drugs. Curr Top Med Chem. 2001;1(3):175-182.
T
3. Shedlock J, Sims RH, Kubilius RK. Promoting and teaching the history of medicine in a
RI P
medical school curriculum. Journal of the Medical Library Association : JMLA. 2012;100(2):138-141. doi:10.3163/1536-5050.99.100.2.014.
SC
Caramiciu J, Arcella D, Desai MS.
CE
PT
ED
MA
NU
History of medicine in US medical school curricula. J Anesth Hist Med. 2015;1; 111-114. DOI: http://dx.doi.org/10.1016/j.janh.2015.02.010
AC
4.
5