For more on this topic, go to www.dentaleconomics.com and search using the following key words: local anesthesia, patient satisfaction, dental anesthetic, Dr. Gregory L. Psaltis.
As I look back on my 34 years in dentistry, I reflect on how much progress has been made in the general area of patient satisfaction. Bonding, improved local anesthetic products and techniques, lasers, Invisalign, a variety of sedation regimens, implants, esthetic procedures, and many other changes have brought a higher degree of satisfaction to the public regarding their dental experiences. However, one aspect of the care we offer that has, until recently, continued to be bothersome for our clients is the duration of the nettlesome symptoms of the local anesthetic agents that provide comfort during dental procedures.
After the appointment, there is often an inability to speak clearly, difficulty drinking from cups and glasses, and in some cases, change in the patients’ appearance. As a pediatric dentist, the two to three hours’ duration of lip, cheek, and tongue symptoms often give rise to post-appointment trauma despite our best efforts to coach both children and their parents to avoid “chewing on the numb areas.” I can only imagine how adult patients must feel about this phenomenon, particularly if they are returning to a job that requires them to communicate clearly.
For teachers, lawyers, or others requiring verbal skills, the prospects of slurring words and potentially looking foolish cannot be attractive. Help has arrived in the form of OraVerse®, a local anesthesia reversal agent that was FDA approved in May 2008 and introduced for sale at the Chicago Midwinter Meeting in February 2009.
OraVerse (phentolamine mesylate) was developed by Novalar Pharmaceutical, Inc., and has been well accepted by private practitioners seeking to solve the postoperative numb lip, chin, and cheek problem for their patients. In several studies, OraVerse reliably and consistently reduced the time for the return of normal oral sensation and function to slightly less than one hour. This compares well with the usual two-plus hours during which the patient can expect to be in some way compromised.
OraVerse is an injectible agent that is packaged in a carpule exactly like all of our local anesthetics and can be used with the same syringe that is used routinely for local injections. In fact, it is in every way analogous to our standard injections — the placement of the agent is in the exact location where the local anesthetic has already been introduced.
The mechanism of action is that the phentolamine mesylate is a vasodilator, thus enabling faster uptake by the bloodstream of the local anesthetic and thus, a shorter duration of the symptoms.
My own experience with OraVerse has been very positive. As a pediatric practitioner, I often fret about the post-appointment trauma that children inflict on themselves due to the loss of sensation in their oral tissues. In spite of our best coaching, I still receive calls from concerned parents whose children “seem to have an infection” after a restorative visit.
The classic description always includes a swollen lip (or cheek), white patches in the mouth, and on some occasions, bleeding. If the parents of these children take them to their pediatricians, it is not unusual to have the child put on an antibiotic for the “infection.”
For experienced dental professionals, we can immediately identify this as self-inflicted trauma subsequent to the child’s normal curiosity leading to biting, pinching, or scratching on the numbed areas. In the pediatric setting, OraVerse is clearly also a potential adjunct to the care of special needs children (autistic, Down syndrome, Asperger’s, ADHD, etc.) who may not be able to easily follow the postoperative instructions. In cases like these, the idea that the duration can be shortened is especially appealing.
When presenting the possibility of reversing the symptoms to the parents of my patients, I was initially surprised that a certain percentage of parents expressed no interest in the service. The main reason given was because it represented “another injection.” There is no solution to this concern since OraVerse is only available in that form.
As it turns out, most practitioners have found that not everyone is accepting of the reversal for other reasons as well, including lack of awareness of the product, reluctance for unnamed reasons, or the added expense (when applicable). When incorporating OraVerse into your practice, it is important not to expect universal acceptance.
For the parents in my practice who wanted OraVerse, the feedback was nearly universally positive. My results were consistent with the findings of a larger study that included 27 dentists and 225 patients, in that nearly all patients in the study (94%) reported a shorter duration of numbness, most (84%) stated improved dental experience, and a significant majority (79%) expressed interest in receiving OraVerse again at future visits.
In my personal experience, the one parent who was less favorably inclined to have her child repeat the experience told me that she felt that the anesthetic “wore off too quickly” and that her son, as a result, had more pain from the fillings! As dentists, we can recognize that this was not actually the case — any postoperative pain is a function of the procedure, not the duration of the local anesthetic. It is hard to argue with a product that reduces the postoperative local anesthetic time.
As a part of the testing, I also asked parents if they would recommend it to others, and in several cases they said they had already done that, which would imply the potential for some marketing benefits of OraVerse as an option in your patients’ care.
The study results found that OraVerse was successful in reversing the symptoms for a variety of local anesthetics, including two of the most popular agents — lidocaine with epinephrine and articaine with epinephrine. The dosage is typically between one-half and two carpules, depending on the amount of local anesthetic used. The manufacturer’s recommendation is to use the same amount of OraVerse as the amount of local anesthetic delivered.
Dentists who have incorporated it into their practices comment on injecting OraVerse immediately after completion of the prepping in order to facilitate the reversal process even more quickly. By using the combination of long-acting local anesthetics and the reversal agent (as opposed to starting with short-acting agents), there is more control over hemostasis, and the profundity of the anesthetic remains higher during the procedure.
In talking with other dentists who are now routinely using OraVerse, I found a range of approaches to help cover the product’s cost. Some practitioners have simply adjusted their fees to accommodate the extra expense, while others have offered the product at a separate fixed fee so that the only patients paying are the ones who are actually receiving it.
There are also others who consider it to be a routine aspect of a restorative visit, much like nitrous oxide, and do not have a separate fee for it. They report that it makes their patients feel special and it tends to separate them from other dentists in their area. There is no insurance code that will allow for reimbursement if the dentist submits it to the insurer. Acceptance has been demonstrated to be high when the information about the benefits and the minimal risks involved have been presented in a matter-of-fact way.
Brochures are available for patient education, but it is important that your entire team is on the same page in terms of supporting the product so that accurate information can be given to patients to make their decisions. While use of OraVerse is not yet standard of care, its popularity and use is becoming increasingly mainstream and can be an effective tool for marketing.
Concerning the question of risks, reactions in the injection site occurred in only 5% of the cases in clinical studies, no different than 4% in the control group who did not receive OraVerse. This was not seen as a major problem for any of the dentists in the study and did not lead to any long-term problems.
As the profession continues to expand in ever increasing positive directions, yet another valuable tool has been added to our armamentarium. The possibility of making a patient’s postoperative experience more pleasant is another step in making that all-around improvement in the public’s perception of dental care. For more information about OraVerse, stop by the Novalar booth at all major dental meetings, visit www.OraVerse.com, call (888) 888-1441, or send an e-mail to [email protected].
Dr. Greg Psaltis has been in private pediatric practice for 28 years in Olympia, Wash. He is well published and lectures frequently on various dental topics. He also consults with private practices to enhance the systems, communications, and quality of life for doctors and team members. His e-mail is [email protected].