that many product information leaflets describe this formulation as preferred for most routine procedures. Based on current FDA guidelines, in which an absolute maximum dose for articaine is no longer provided, a 1:200,000 epinephrine dilution would allow up to 22 cartridges per appointment in a healthy patient (based on its epinephrine content). While within accepted guidelines for healthy patients, when considering epinephrine dosing, this amounts to 1584 mg of articaine (22 x 72 mg/cartridge), an excessive dose with even greater concerns of CNS toxicity, CVS toxicity and methemoglobin levels. Dentists and dental hygienists who use the smallest amounts needed to provide profound local anesthesia avoid approaching such extreme doses. In addition to insert updates for articaine, bupivacaine product information leaflets also establish no mg/lb maximum. The current recommendation for 0.5% bupivacaine, 1:200,000 epinephrine is an absolute maximum of 90 mg. While MRD per pound or kilogram information is no longer available in the U.S., the recommendations for bupivacaine are 0.9 mg/lb and 2.0 mg/kg in Canada.2 CLOSING THOUGHTS Although the FDA has provided MRD guidelines for local anesthetic drugs (Table 1), patient response to drug dosage is not always predictable. Two equal doses of the same anesthetic agent can produce markedly different responses, depending on the patient; for example, individuals who are less susceptible to an anesthetic may require higher-than-average doses in order to provide effective anesthesia. Consequently, the possibility of overdose is greater for these individuals. Others who do not fit easily into dose recommendations may experience effective anesthesia with less- than-typical doses. If typical doses are administered to these individuals, extensive and prolonged periods of anesthesia can result. In addition to observing MRDs, the administration of local anes- thetic drugs continues to be guided by several important factors, including the area to be anesthetized, vascularity of the tissues, tech- nique and individual tolerances. Perhaps the most important advice to follow comes from a similarly worded statement that may be found in all local anesthetic product inserts: “The lowest dosage needed to pro- vide effective anesthesia should be administered.”8 D REFERENCES 1 U.S. National Library of Medicine. DailyMed. Available at: dailymed.nlm.nih.gov/ dailymed/drugList.cfm?startsWith=All. Accessed October 28, 2017. 2. Malamed SF. Handbook of Local Anesthesia. 6th ed. St. Louis, Mo: Elsevier Mosby; 2013. 3. Malamed SF. Handbook of Local Anesthesia. 5th ed. St. Louis, Mo: Elsevier Mosby; 2004. 4. Bassett K, DiMarco A, Naughton D. Local Anesthesia for Dental Professionals. Upper Saddle River, NJ: Pearson; 2009. 5. Malamed SF. What’s new in local anesthesia. Dimensions of Dental Hygiene. 2013:11(7):21–22. 6. American Academy of Pediatric Dentistry. Guideline on Use of Local Anesthesia for Pediatric Dental Patients 2015. Available at: aapd.org/media/ policies_guidelines/ g_localanesthesia.pdf. Accessed October 28, 2017. 7. Drugs.com. Articaine and Epinephrine Injection. Available at: drugs.com/pro/articaine-and-epinephrine-injection.html. Accessed October 28, 2017. 8. U.S. National Library of Medicine. DailyMed: 4% articaine, 1:100,000 epinephrine product insert. Available at: dailymed.nlm.nih.gov/dailymed/archives/fdaDrug Info.cfm?archiveid=28573. Accessed October 28, 2017. 9. Durieux ME, Gin TG, Joanne MD. Methemoglobinemia related to local anesthetics: A summary of 242 episodes. Anesth Analg. 108;3:837–845. Our solutions for Bad Breath, Dry Mouth, and Gingivitis are all made in the USA and clinically tested for efficacy by independent laboratories and ongoing consumer panel studies. In a recent paper presented at ISBOR 2017 by a team from UCLA, TheraBreath formulas were found to help maintain greater biodiversity in the oral micro biome while helping to reduce bacteria linked to various oral health problems. Would you like to learn more? Visit THERABREA TH.CO AT OM/DENT ALPRO TA to read our studies, learn about our products, or request a Dental Professional sample kit. Circle 5 on card
