Introducing Cutting-Edge Services to Your Patients

Dentistry Today is pleased to present our Practice Pyramid Series, to assist today’s practitioners. Various leading clinicians will be featured, demonstrating the application of new technologies. Dr. Lou Shuman and Amy Morgan, both of the Pride Institute, will provide technological product introductions and practice management implications in each article. All technologies presented in this series are 2009 Pride Institute “Best of Class” Technology Winners, chosen through an unbiased assessment selection process in conjunction with a known technology expert, Dr. Larry Emmott.

I can’t tell you how many times I have heard from my patients: “Dr. Ruiz, can you do my work without anesthesia? I hate the feeling of being numb.” One of the best practice builders is painless anesthesia, and with proper technique, pain during the anesthetic injections should be very little. However, still remaining is the other really unpleasant part of being anesthetized, the 4 to 5 hours of postoperative numbness. We all dislike this part, and this unpleasantness is in many cases responsible for keeping our patients away from doing necessary dental treatment. In some cases, patients may even cancel an appointment if they suspect it may interfere with an important activity after their dental visit. Well, now we have a cutting-edge new drug, phentolamine mesylate (OraVerse [Novalar]), that may be the solution to these problems.

Figure 1. Supragingival preparation for a partial coverage all-ceramic onlay replacing the fractured cusp.

Figure 2. Restoration after cementation with a resin cement.

Figure 3. Preoperative view showing 2 old veneers with staining and poor morphology.

Figure 4. Immediate postoperative view of gingivectomy and temporary veneers.

Figure 5. One-week postoperative view of 2 bonded porcelain veneers.

WHAT IS ORAVERSE AND HOW IS IT USED
OraVerse is an FDA-approved anesthesia reversal drug which cuts the postoperative numbness time in half, and often even faster, without any known serious side effects. It is injected in a 1:1 ratio to the anesthetic quantity administered, after the procedure is finished.
OraVerse can be used for the most basic dental procedures where we would expect a minimum postoperative pain, such as hygiene procedures, fillings, and the preparation and cementation of supragingival indirect restorations (ie, porcelain onlays, veneers, and all-ceramic crowns). It should not be used on procedures where considerable post-operative pain is expected, such as after a crown preparation with deep retraction cord placement, periodontal surgery, endodontic procedures or oral surgery. In these cases, a longer postoperative numbness is desirable for the patient’s comfort. In all cases, it would be wise to recommend that the patient take 400 mg to 800 mg of ibuprofen to minimize any discomfort after the anesthesia is reversed.

How Phentolamine Mesylate Is Used in Our Practice
I have a busy private practice and implementation of new procedures or new things learned are important keys to success. OraVerse can be a great adjunctive service and practice builder which will enhance the patient’s perception of the practice and the value received for fees charged. It is important to understand that, although there is a small profit associated with it, its true value is as a practice builder in providing a new way to improve the overall dental experience for our patients.
Educating and informing our patients is always vital in implementing any new technique or technology, so in my practice we have placed a large display informing our patients that “Having a ‘fat lip’ for hours after your dental appointment is a thing of the past! Ask us about OraVerse.” We have also included quotes in our reception area slide presentation from satisfied patients who have experienced the positive effects of OraVerse. In our practice, anesthesia reversal is offered as an optional procedure. We charge a nominal fee to cover the cost of the drug and the additional time it will take to do the injection. The following clinical examples demonstrate how successful this additional service can be within the scope of many clinical procedures.

Now, Who Pays the Bill—Or Would That Be Fee?
Anesthesia Reversal Agents

Tom M. Limoli, Jr
limoli.com
When has the mere existence of a procedure code ever been a guarantee of reimbursement by either the patient or their benefit plan? It never has and it never will.
There is absolutely no question that a happy as well as comfortable patient is in fact a satisfied patient. Anesthesia reversal agents are nothing new in that they have been around in one way, shape or form for the last 20+ years. Also not new is the fact that they are not specifically identified by a definitive procedure code. Future revisions of CDT may or may not address this deficiency, but the facts of the matter remain the same—the code’s existence has nothing to do with its reimbursement via the benefit plan.
The observations of Amy Morgan concerning patient comfort and satisfaction are right on the money. However—in that benefit plans rarely, if ever, reimburse separately for the delivery of local anesthesia in conjunction with the completion of an operative or surgical procedure, why would they even consider paying for a simple anesthesia reversal agent? If I did not pay you to put it there what makes you think I would pay to nullify its effects? Hmmm, could be on to something here.
In today’s reality of politically motivated as well as entitlement driven healthcare financing, I recommend that the reimbursement of local anesthesia reversal agents be addressed in the dental office the same as bonding agents, cement bases, and cavity liners were addressed. Do it when you need to do it and don’t do it if you don’t. And as concerns its fee—it’s part of the global fee for the completed operative or surgical procedure.
See you on the road.

CASE 1
A very successful and busy 40-year-old TV producer was scheduled to do a porcelain onlay preparation on tooth No. 18 due to caries and a fractured disto-bucal cusp. After being seated, the patient stated that the only reason she was present at her appointment was because we offered the anesthesia reversal procedure. This is because she had an important meeting that evening, approximately 4 hours later, and she did not want to be numb for the event. I was careful not to promise that the anesthesia would be completely gone by the time of the meeting, but she was assured that with OraVerse, she should experience at least a 50% reduction the time she would feel the effect of the local anesthetic. We performed the supragingival preparation (Figure 1), and the following day she sent us an e-mail thanking us for offering OraVerse. Furthermore, she said that she wanted to have OraVerse administered after every subsequent procedure. Two weeks later, the restoration was cemented (Figure 2). If we had performed a traditional PFM crown, we would have had to place retraction cord in the gingival sulcus. If the patient had had considerable postoperative pain, this would have made the use of OraVerse less desirable, and as a result she may not have had a positive experience. Supragingival bonded restorations have many advantages, are typically easier to perform with less postoperative pain, and are much more gentle to the gingival tissue than any traditional subgingival PFM crown and bridge procedure.1

The Technological Implications of OraVerse

Lou Shuman, DMD
To cancel, or not to cancel? That is the question.
Sarah, a patient with a noontime appointment for a crown preparation, has been called upon by her boss to give an important impromptu presentation at 3 pm sharp. In all likelihood, Sarah’s tongue and lips will still be numb at 3 PM. What should she do?
Assuming that Sarah (1) cares about giving her best performance, and (2) isn’t in pain, we all know it’s a foregone conclusion: Nine times out of 10, Sarah will reschedule. A lose-lose for doctor and patient…that is, perhaps, until now.
Enter OraVerse, a new drug recently introduced by a company called Novalar at the Chicago Dental Society Midwinter Meeting in 2009. FDA-approved since May of 2008, OraVerse has been shown in recent studies to reverse the effects of soft-tissue anesthesia up to 80 to 85 minutes faster than what is normally expected when not administering the drug.

HOW IT WORKS
OraVerse (phentolamine mesylate) is an agent that helps to reverse the effect of the vasoconstrictor, which prevents blood from removing anesthetic from the mouth too quickly. OraVerse is thought to act by dilating the blood vessels, thereby speeding up blood flow to help carry the anesthetic away. From the patient’s perspective, the drug speeds up the return of normal sensation to the lips and mouth area following dental work.

OBSERVED BENEFITS

  • Effective results—In adult and adolescent clinical trials, OraVerse reduced the median time to recovery of normal sensation in the lower lip by 85 minutes (55%), and in the upper lip by 83 minutes (62%) compared to control.
  • Easy to administer—OraVerse is administered with a stand­ard syringe using the same location(s), same technique(s) (infiltration or block injection), and in the same proportion (1:1) as that used in the administration of the local anesthetic.
  • Safe—The most common adverse reaction with OraVerse is injection-site pain. According to Novalar, the clinical trials did not demonstrate an increased risk of complications. In multicenter, controlled, randomized double-blinded clinical trials there were no serious adverse events and no discontinuation due to adverse events. The majority of adverse events were mild and resolved within 48 hours.
  • Patients like it—Studies show that there is strong interest in the drug.
  • Children 6 years and older (more than 33 lbs) will be less likely to bite their tongue or lip due to the soft tissue anesthesia.

POTENTIAL CHALLENGES AND OTHER OBSERVATIONS

  • Not currently covered by dental insurance.
  • OraVerse comes in prepackaged inserts for syringes, and costs about $12.50 per injection.
  • Possible limited applicability since the mandibular block may be administered less frequently now for some routine dental procedures.
  • There is growing use of shorter acting dental anesthetics.
  • In some circumstances, increased duration of anesthesia may be warranted in the interest of optimizing patient comfort (ie, root canal therapy or oral surgery).
  • Not recommended for children less than 6 years of age, or for children who weigh less than 33 pounds (15 kg).
  • Phentolamine mesylate belongs to a class of drugs that can cause rapid heartbeats and irregular heart rhythms.

Such events have apparently been very uncommon with OraVerse. Clinicians should be alert to the signs and symptoms of these events, particularly in patients with a history of cardiovascular disease.
All in all, OraVerse brings very promising news for both dentists and patients. Hopefully soon, patients like Sarah will have more options when making decisions related to their dental appointments.

CASE 2
The next case was an actress and dancer in her late twenties who wanted to replace 2 porcelain veneers because of marginal staining and to improve form (Figure 3). The treatment plan included gingivectomy on the 2 centrals to improve gingival symmetry. She had been informed about OraVerse, and although she had requested to have it used at the time of the veneer preparations, I recommended against it. This is because I knew she would have postoperative pain after the gingivectomy (Figure 4). After the gingiva healed, the restorative work was finished. OraVerse was used during the final impressions and for final cementation of the supragingival veneers. The patient was very happy with the aesthetic results and the much reduced post-treatment anesthesia time (Figure 5).

Practice Management Ramifications for OraVerse

Amy Morgan
Every new piece of technology and each advance in clinical processes affects how you manage your practice—your team, your patients, your systems, and your statistics. In our premier article (Schroder, et al, Dentistry Today, September 2009), we talked about answering 8 questions (visit dentistrytoday.com to review these questions or the first Practice Pyramid Series article) before embracing new models and new methods. A proactive leader always analyzes the potential challenges and successes of an upgrade so that there is a plan to maximize success during implementation.
In this article, we are looking at Novalar’s OraVerse—a new pharmaceutical discovery that reduces residual soft-tissue numbing time, significantly. Following the 8 questions provides key insights on how to make this wonderful step in enhanced patient care a viable part of your practice culture.
If your vision is to create a comfortable patient experience for adults and children (older than age 6 years) customized to address their unique needs and concerns, then OraVerse is a welcome addition when it comes to procedures requiring anesthetic.
The cost is approximately $12.50 per injection. To maintain a viable, fresh stock of this new item in inventory and to make this addition profitable depends on the patient’s willingness to pay an appropriate additional fee. As of right now, there is no current dental terminology (CDT) procedural code for the additional injection. However, Novalar is currently working with ADA and the insurance companies to remedy this.

The doctor and team must be prepared to “inform before they perform” to make sure:

  • Shortened numbing time is a motivator for the patient.
  • Patient is willing to experience an additional injection.
  • Patient is willing to pay an additional fee for the injection.
  • Patient is willing to go beyond an “insurance mindset.”

Your assistants will need to manage the inventory, and the entire team will need to be comfortable with the benefits so that they can inspire patients to embrace this new innovation. They must also be comfortable with the additional fee.
If the dentist and team are utilizing expanded duty assistants to create the temporary restoration, the scheduling system may need to be tweaked. In a traditional overlapped schedule, the last 20 to 30 minutes of a crown preparation is usually an assistant-only procedure, creating and placing the temporary crown. If the dentist chooses not to administer OraVerse at the end of the preparation, time will need to be allocated for the dentist to come back in the room to deliver the second injection. If the team elects to offer OraVerse in the hygiene chair, after scaling and root planing (and if state law does not allow the hygienist to administer injections), provisions will need to be made to bring the dentist back in a second time.
There is no doubt that this new pharmaceutical innovation is a tremendous boost to customer service and care. Not every patient will be interested—but many will. Marketing on the Web site, newsletters, and notes to your patient base will inspire patients of record. In new patient marketing, letting prospects know that the practice uses the latest techniques to enhance their patient experience—will make you enhance how patients feel about you and will help to distinguish your practice from others. So, have a staff meeting and tweak your inventory, fees, and scheduling to accommodate this new technique. Let your patients know you are doing everything possible to exceed their expectations and this will be a successful practice upgrade.

CASE 3
It is rare when I can use myself as an example of a satisfied patient, but this is one of those cases. Recently, I had to have a minor bilateral procedure on the maxillary arch. I was anesthetized for the procedure with one carpule of Septocaine (1:100,000 epinephrine) (Septodont) in each side. Immediately after the procedure was finished, I received one injection of OraVerse on the right side, and (by choice) nothing on the left. The left side was numb for 5 hours while the right side was back to normal within 1 hour. I had slight pain on the OraVerse side at the injection site (this is normal and expected) and took 2 (200 mg) ibuprofen tablets that took care of the pain in about 20 minutes. I wanted to experience first-hand the benefits of phentolamine mesylate. I am one of those patients who hates the feeling of being numb long after the treatment is done, and would use OraVerse every time that it is indicated.

CONCLUSION
When used as indicated, this new anesthesia reversal agent is an effective way to reduce the amount of time a patient feels numbness related to the administration of local anesthetics. It is a practice builder giving doctors an effective way to help their patients realize a more comfortable dental experience.


REFERENCE

  1. Ruiz JL. Supragingival dentistry using metal-free restorations. Dent Today. 2008;27:104-109.

Dr. Ruiz is course director of the USC Advanced Esthetic Dentistry Continuum and clinical instructor at USC, associate instructor and mentor at PCC Utah, teaching with Dr. Gordon Christensen, and is an independent evaluator of dental products for CRA. He is a Fellow of the AGD and practices general dentistry in the Studio District of Los Angeles, where he treats many stars and entertainers. He lectures both nationally and internationally on aesthetic dentistry and leadership. He can be reached at (818) 558-4332 or via email at ruiz@drruiz.com.

Disclosure: Dr. Ruiz reports no conflicts of interest.

Dr. Shuman is president of Pride Institute and is well known in the dental community for his leadership and expertise in the areas of strategic relations, emerging technologies, Internet strategy, practice management, and marketing. The Pride Institute’s goal is to utilize their reputation of integrity and fairness as a foundation in educating the community within the field of emerging technologies. He previously served as vice president of clinical education and then vice president of strategic relations for Align Technology for 7 years. He is a member of Dentistry Today’s Dental Advisory Board and has been listed in Dentistry Today’s Leaders in Continuing Education from 2004 to 2008, and is currently listed as a Leader in Dental Consulting. He is proud to be collaborating in this exciting new Dentistry Today article series. He can be reached via e-mail at lshumani@msn.com. Follow Dr. Lou Shuman on Google+, on Twitter (@LouShuman) or subscribe to Lou Shuman's posts on Facebook.

Disclosure: Dr. Shuman reports no conflicts of interest.

Ms. Morgan serves as the CEO of Pride Institute. She is a dental consultant and international lecturer. Over the years, Ms. Morgan has facilitated the successful revitalization of thousands of dental practices using Pride Management Systems. She can be reached at amym@prideinstitute.com.

Disclosure: Ms. Morgan reports no conflicts of interest.



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