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Office Based Anesthesia Guidelines Should Be Reviewed – Recent Thailand COVID Vaccine Study

The extension of the Emergency Use Authorization of COVID mRNA “vaccines” into the young adult/adolescent population has demonstrated – especially in male patients – an association of cardiac abnormalities namely perimyocarditis. I have been concerned about myocarditis as a risk factor for outpatient anesthesia – especially in oral surgery – since the demographic in question frequently undergoes elective removal of 3rd molars in office.

Up to now, these abnormalities have been observed post-vaccination. However, a very stunning prospective study out of Thailand has shed new light. The following information comes from Tracy Hoeg, MD, PhD off Twitter who has had further discussions with the authors pre-print:

  • Design: 301 13-18 year olds following dose 2 Pfizer
  • 18% had abnormal EKG post vax
  • 3.5% (7/202) males & 0 females developed myoperi/peri or subclinical myocarditis, 2 were hospitalized w/1 being observed in the ICU
  • All symptoms resolved within 14 days

The study is impressive because of extensive cardiac work-up pre- and post-vaccination so existing cardiac abnormalities could be determined. Prior to start of study, the researchers found <1% abnormal EKG and specified those as “normal variants”.


Here is Dr Peter McCollough’s review of the study:


There is no published study to evaluate the incidence of cardiac monitoring abnormalities or association with morbidity/mortality undergoing outpatient anesthesia in-office in the same cohort under similar circumstances. In my discussions with colleagues in the community however, there are anecdotal reports of increased frequency of cardiac ectopy (PVCs) and bigeminy in one case in a patient 1 month post-COVID. However I believe this study provides enough evidence for practitioners to consider – at the very least – tracking the vaccination history of their male patients and to possibly consider deferral of elective surgery for at least 2 weeks…possibly more…until we have more data.

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A Veritable Quandary?

One of the most common questions we hear from licensed dental healthcare professionals when considering the prospect of dropping their federal Drug Enforcement Agency (DEA) permit is “Can I do that?”

The answer is “Yes you can”.

Your professional license issued by the state in which you practice affords the ability to conduct patient care within the parameters set by law. This includes the ability to prescribe medications within the scope of those parameters including controlled substances – except for the requirement if you wish to prescribe same, you must obtain a federal permit from the US Drug Enforcement Administration to do so. Occasionally states may also require you obtain a state permit, but it is solely dependent on those states alone.

There may be matters of practicality. You are never under any mandate to prescribe controlled substances although certain privileges – such as the ability to administer sedation or anesthesia – will require the ability to procure anesthetic agents which are themselves controlled substances making the possession of a permit a necessity.

So, to reiterate: you are NEVER under any mandate, any requirement whatsoever to possess a federal DEA permit unless the scope of your practice requires itself. Beyond that, it is a choice.

We teach this in our state mandated safe opiate prescribing courses for dentists. In many ways, this is a benefit of practicing dentistry – even more so – it obviates the requirement for this continuing education not to mention the cost of the DEA permit. Check out our course offerings to find out more.

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A Shift In Thinking

We need to rethink the way acute pain is managed. We tend to think of non-steroidal anti-inflammatory or acetaminophen whether used alone or in combination (non-opiate multimodal anaglesic therapy) as “alternatives” to opiates…when in fact we should actually consider the converse…that opiates are the alternative to non-steroidal anti-inflammatory agents – alone or in combination.

We don’t need to look far beyond our own backyards. The wisdom tooth pain model is a valid and time tested. NSAIDs are the winner.

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Introducing eBytes – CE Dojo’s Microlearning Curriculum

CE Dojo announces it’s microlearning course series eBytes. Each microlearning course is a 15 minute vignette on a topic of clinical relevance in a distilled and concentrated manner.

CE Dojo is an nationally approved AGD PACE provider of continuing education. Microlearners can recieved CE credit for individual courses alone or in combination with other microcourses.

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Clonidine Revisted…Again…

We continuously endorse the use of over-the-counter analgesics (non-opiate multi-modal therapy) such as Advil (Ibuprofen), Aleve (Naproxen), and Tylenol (Acetaminophen) – alone or in combination – for most – if not all dental procedures…including surgery. In fact, we train doctors who participate in our state mandated opiate compliance webinar “Strategies For Acute Pain Management In Dentistry” how to move toward an opiate-free practice to ultimately forego their DEA registration.

There are, however, some exceptions. If, for example, you administer any form of sedation or general anesthesia dropping your DEA registration is a non-starter. But even if you don’t, some dentists may feel they need to retain their DEA permit to afford the ability to prescribe sedative agents like a benzodiazepine for their more anxious patients.

Or do you?

I wrote this brief article and published it on LinkedIn almost 5 years ago. With regard to the need to prescribe sedative agents – without a DEA permit – let me reintroduce all of you to Clonidine – again – for the first time!


10 Reasons An Oral & Maxillofacial Surgeon Should Consider Clonidine A More Routine Premedication For Office Anesthesia

While clinicians should be mindful that many of the peri-operative applications of alpha-2 agonists – like Clonidine – remain off label, there are nevertheless many good reasons to consider it’s prospective use on a more routine basis.

David MH Lambert, DDS – LinkedIn July 10, 2017

Clonidine is an imidazoline alpha-2 adrenergic agonist which was originally approved by the FDA in 1974 (Catapres – BI) as an antihypertensive agent. It’s use was initially limited by reports of Clonidine Withdrawal Syndrome – a symptom complex consisting of hypertension, tachycardia, agitation, and insomnia. However, it’s use has been repurposed resulting in unlabeled uses for ADHD, opiate and alcohol withdrawal, smoking cessation, mania and psychosis, and Tourette Syndrome to name a few. In 2010, extended release Clonidine was approved by the FDA for ADHD. It has also been used as a peri-operative adjuvant for anesthesia.

Here are 10 good reasons to consider the administration of Clonidine more routinely as a premedication for office-based anesthesia:

1) Wide margin of safety

Within the context of peri-operative use of Clonidine, there are few reports of activities consistent with syndromic withdrawal. It is safe and effective with a wide margin-of-safety.

2) Produces anxiolysis & sedation

Activation of alpha-2 receptors in the locus caeruleus – a small neuronal nucleus in the upper part of the brainstem which is responsible for wakefulness – results in sedation and anxiolysis. It is, however, devoid of any the addictive potential so commonly demonstrated by other, more commonly utilized agents, i.e. benzodiazepines.

3) Provides analgesia

Descending neural activity from the locus caeruleus decreases nociceptive input and potentially may produce hyperalgesia in combination with NMDA antagonists (i.e. ketamine) while reducing their untoward neurologic sequelae. 

4) Attenuates sympathoadrenal responses

The native activity of alpha-2 adrenergic agonism is sympatholytic resulting in a blunting of central sympathetic outflow – meaning the “fight-flight” system is down regulated.

6) Prevents shivering

Clonidine is the most widely studied alpha agonist for shivering control. It lowers the threshold for vasoconstriction in a linear dose response and is as effective as meperidine in termination.

7) Effective premedication to address “White Coat Syndrome” in normotensive or otherwise well controlled hypertensive patients.

Because Clonidine produces anxiolysis & sedation in addition to it’s native alpha-2 agonist activities, it is an ideal agent to use for patients with situational anxiety who are otherwise normotensive.

8) Provides another site of action in balanced anesthesia

Balanced anesthesia depends upon the administration of multiple agents with activity at differing loci and mechanisms of action. The advantage of this approach is lower overall dosages of all drugs resulting in greater safety and quicker recovery.

9) Prolongs nerve blockade

A plethora of studies have shown that a2 agonists when employed either alone or in combination with local anesthetics or opiate narcotics are highly effective adjuvants in the treatment of short-term pain.

10) Cardio-protective effects

Alpha-2 agonists have demonstrated efficacy in reducing intra-operative myocardial ischemia and post-operative tachycardia. 

Summary

While clinicians should be mindful that many of the peri-operative applications of alpha-2 agonists – like Clonidine – remain off label, there are many good reasons to consider it’s prospective use on a more routine basis. Though it may occasionally produce hypotension and bradycardia in a younger demographic, these patients often possess enough reserve so as to minimize the cardiovascular impact notwithstanding any appropriate intervention to address same. In an older population, the sedative effects of Clonidine – coupled with it’s native sympatholytic effects – make it the perfect pre-medication for management of situational anxiety in otherwise normotensive patients.

I have used Clonidine – safely – on a routine basis as a pre-medication for office based anesthesia for over 10 years mostly in combination with a weight based dosage of alprazolam. Please feel free to inquire more about the technique.

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Study: Naproxen More Effective Than Hydrocodone-Acetaminophen After Dental Surgery

More evidence that NSAIDs with or without acetaminophen are more effective in alleviating pain in the postoperative dental surgery pain model. A recent study from JBR Clinical research demonstrated some unanticipated findings:

“This study is important because the relative efficacy of these two commonly used pain medications has not been directly compared in a validated acute pain model, furthermore, this study is timely because options for reducing the use of opioids to control postoperative pain are highly desired and can provide clinicians with important alternatives when recommending appropriate analgesics.”

Todd Bertoch MD, CEO JBR Clinical Research

We would love to see a fixed OTC combination of naproxen with acetaminophen – much akin to Advil Dual Action – for the future!

David MH Lambert, DDS

Diplomate, ABOMS

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Opiate Crisis To Triple In Next 7 Years

This past February The Stanford- Lancet Commission on the North American Opioid Crisis released their Executive Summary on the state of the opiate crisis. This position paper reviews the past, the present, the future, and proposes remedies.

From 1999 to 2022 The Commission estimates 600,000 deaths in the US and Canada but projects that in between now and 2029 another 1.2 million deaths will occur. This is to say it is anticipated that the opiate crisis will accelerate over 600% of the baseline rate from 1999 to 2022 within the next 7 years.

The Executive Summary reviews the factors involved in the evolution of the opiate crisis and cites 3 broad remedies:

  • Stricter regulation of the pharmaceutical industry
  • Evidence-based public health policies that treat drug addiction as a chronic condition
  • Prioritization of prevention

In my most recent blog post The More Things Change I discussed an interview with Sam Quinones – author of the definitive evolution of the opiate crisis Dreamland and his recent segue The Least Of Us. In The Least Of Us Quinones chronicles the current status of the opiate crisis in the United States, how the drug cartels have shifted production to fentanyl, why fentanyl will continue to substituted in street heroin, cocaine, and methamphetamine, and why deaths will continue to rise.

As has been stated here and elsewhere, the opioid crisis is really 2 separate entities – the prescription and illicit drug crises. It is well established that prescription drug abuse is a gateway into illicit drug abuse and how greater awareness on the part of licensing boards and doctors has led to sharp declines in the prescribing of opiates for pain control. But today, most of the deaths are due to the abuse of illicit fentanyl. And illicit fentanyl – as stated by Quinones – is the cartel’s drug du jour.

While the Stanford – Lancet Commission on the North American Opioid Crisis predicts a massive increase in opioid related deaths over the next 7 years yet it is uncertain, what is their basis? Clearly, if there is this anticipated explosion of death, likewise there must be an anticipated increased fentanyl supply to meet this “demand”. And the increase in supply must be due to an anticipated increase in the importation of illicit fentanyl across our boarders.

Does the Stanford-Lancet Commission know something about our future southern boarder that the rest of us don’t?

If then the Executive Summary is just a veiled acknowledgement of the anticipated future exploitation of failed border policies then in essence what are proposed are platitudes masquerading as remedies. What is really required is little more honest assessment rather than obfuscation.

There was a time when the medical establishment could be relied upon to be accurate, incisive, insightful, and honest. The Lancet has in the past been known for it’s lack of candor. Perhaps it seeks greater credibility with it’s Stanford affiliation. Either way academics will no doubt applaud the Summary. However, until proper action is taken to stem the flow of illicit fentanyl into the US this whole esteemed exercise is little more than virtue signaling.

David MH Lambert, DDS

Diplomate, ABOMS

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The More Things Change…

Sam Quinones is widely credited for his 2015 book Dreamland as the definitive source for the genesis of the opiate crisis in the United States. His most recent book The Least Of Us details how the opiate crisis has now evolved to the more common abuse of fentanyl and it’s analogues apart from heroin at it’s epicenter.

Here at CE Dojo and in the past as Old Well Consulting, we have painstakingly chronicled the association of opiate abuse and early adolescent exposure to prescription opiates both here on this blog and in our popular webinar Strategies For Acute Pain Management In Dentistry. Unfortunately, Dentistry has been identified in many studies as one of the most frequent prescribers of opiates to this vulnerable age demographic.

Even more unfortunately, I have my own suspicions why Dentistry is being identified. Sam Quinones was recently interviewed by Drug Free NJ about his most recent book but I honestly was startled by a comment he made. When discussing how adolescents and young adults are particularly at risk for opiate addiction the indications for prescription opiate use was raised. Quinones stated at roughly 59 minutes into the webinar…unequivocally that athletic injuries – and wisdom tooth removal (M3) – were the usual culprits.

Did I say “wisdom tooth removal”? I had a hunch…but the 900 lb gorilla in the room just beat his chest.

And you know who this really points to, right? You got it – oral and maxillofacial surgeons (OMS).

I am just the messenger, but I think we (OMS) all need to take very critical stock of what has been stated. M3 removal is part of the core of procedures routinely performed on a daily basis by OMS and it is a strong revenue source for practices all across the country. While there has been much research into evidence based support of elective M3 removal, the question becomes which public health concern (morbidity from delayed M3 removal versus prospective opiate addiction) takes precedence?

I have thought about Mr Quinones statements for over a month now – how can these seemingly competing sets of concerns be best addressed? Here’s what I have concluded:

  • Limiting opiate exposure and use in favor of over-the-counter (OTC) analgesics is obviously key.
  • Using less potent opioids (hydrocodone vs oxycodone) would be supportive.
  • Consider use of liposomal bupivicaine (Exparel) for extended pain control
  • Timing surgery to optimize ease of removal would really seem to be the most important factor to decrease post-operative discomfort and maximize the effectiveness of OTC analgesics.
  • Earlier than ideal surgery to accommodate a referral is frankly unethical and should be discouraged
    • Example – an orthodontist who is uncomfortable with management of serial extractions will need to push removal of M3 necessitating much earlier surgery in addition to lower incisor gingival grafting due to arch expansion.
  • Providing a small quantity of prescription opioid analgesics under direct parental supervision for “rescue” would seem appropriate in some circumstances.

It is up to us (OMS) to be good stewards of responsible opiate prescribing to one of our more common and most vulnerable patient demographics. If we do not take the lead, others will do so for us. Recent events in North Carolina regarding office-based general anesthesia are case-in-point. Continuing “cookie cutter” approaches to patient management should be replaced by individualized care. Referring general practitioners can further help their patients by differentiating and acknowledging preventive versus medically necessary care, and supporting specialty recommendations to defer care to optimize post-operative management in favor of OTC analgesics.

David MH Lambert, DDS

Diplomate, American Board of Oral & Maxillofacial Surgery


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Opiate Epidemic Disproportionately Worsening in High School Age Demographic

A pre-print citation in medRxiv is demonstrating a near 100% increase in opiate related deaths in the high school age demographic (ages 14-18) from 2019 to 2020 alone.  Illicitly manufactured fentanyl once again appears to be the usual suspect.  This study calculated drug overdose deaths by 5 year age groups over the 11 year period from 2010 to 2021 but also compared racial and regional differences . 

American Indian or Alaska Native (AIAN) adolescents, Latinx adolescents, and adolescents in the West census region within the high school age demographic were disproportionately affected, overdose death rates 2.15, 1.31, and 1.68 times the national average in 2021, respectively.  Fatalities involving fentanyl tripled from 2019 to 2020 representing over 3/4 of adolescent overdose deaths in 2021.

These findings again reinforce the premise that adolescents are particularly susceptible to opiate addiction.  While these finding implicate illicitly manufactured fentanyl as the most common cause of death, it cannot be emphasized enough the need for clinicians to reduce exposure to prescription opiates as gateway drugs to street opiates.