December 12, 2016
In the Nov. 7 issue of the ADA News there was a letter
from Dr. Stanley F. Malamed discussing the Oct. 4 My View discussion of EpiPens by Dr. Larry Sangrik, "EpiPens: Dental Necessity or Extravagance?
" Dr. Malamed was critical of a dentist using the much less costly system of an ampule of epinephrine, a standard syringe, filter needle and 1.5-inch 25-gauge needle for treatment of life threatening allergies.
I am a dental anesthesiologist. I have 48 years' experience teaching sedation and medical emergency programs to dentists. I have presented the option of using an ampule of epinephrine, a syringe and two needles vs. the use of EpiPens. More importantly, I have been a practicing general dentist for 53 years. I not only talk the talk, I have walked the walk.
There are several issues with EpiPens. The needle length was reported to be too short for 19 percent of patients in one study. The EpiPen needles are 1.43 cm, 3/8 of an inch long, and about 31-gauge. These are not long enough to get to the proper location, the vastas lateralis muscle on the anterior lateral aspect of the thigh, in some patients. This is particularly true in obese patients. There have been reports of the EpiPen's very small gage needles breaking off in the tissue of the thigh requiring surgery to remove. There have also been reports of medical staff injecting their thumbs when using an EpiPen. The EpiPens are not foolproof.
The cost of EpiPens has dramatically increased recently, getting close to $650 per pen. If you see adults and children, you would need three of each size to be replaced every two years. That is close to $4,000 every two years. At today's costs, in 53 years, I would have thrown away over $100,000 in unused EpiPens. I have never needed to use one.
I need three, maybe four, ampules of epinephrine in my emergency kit to have the same protection. An ampule of epinephrine costs about $5 each, $20 every two years. I also need appropriate syringes with a 25-gauge 1.5-inch needle and a filter needle to aspirate the epinephrine from the ampule. Add another $10 every two years for a couple of syringes and needles. This 25-gauge needle can be given through pants with little or no chance of breaking off the needle. Dr. Malamed has shown that 25-gauge needles are no more painful than 31-gauge needles for injections. This needle is no longer making it possible to always get it deep into the thigh tissue with little chance of breaking off the needle and losing it deep in the tissue.
As a practicing general dentist, I am a bit distressed by the low opinion Dr. Malamed expressed of the ability of a dentist to break the top off of an ampule, aspirate the contents with a filter needle, place the appropriate gage needle on the syringe and inject it into a patient's thigh. Our hand/eye coordination is tested many times every day while treating patients. We inject within an inch of eyes, major vessels, and nerves, placing restorations, doing surgery with sharp instruments — not to mention using high-speed handpieces operating at over 100,000 rpm all with the tongue darting around. These procedures require much more coordination than drawing up a drug and injecting it.
If a dentist is concerned about using an ampule and syringe combination, purchase 10 extra ampules and practice. Every two years when the drug has to be replaced, do not throw the ampules away. Open each one at a time, draw them up into a syringe using a filter needle, replace the needle with the 25-gauge needle and inject the epinepherine into a grapefruit. This is not unlike injecting through clothing into the thigh. I have tested myself and find that I can do this in under 15 seconds while giving a lecture on medical emergencies. I have never cut myself, poked myself or dropped anything on the floor while demonstrating this technique.
As an aside, a very important part of the emergency kit is your cell phone. If there is any doubt of what is happening, give the phone to an assistant and tell them to call 911.
My seven EMT patients plead with me, "Tell dentists to call while the patient is still alive; our save rate goes up when we start with an alive patient." In the case of anaphylaxis, give the epinephrine as required until the EMTs arrive. That patient needs to go to an emergency room for further treatment.
Fred Quarnstrom, D.D.S.