Managed Care - September 2008 - (Page 50)

TOMORROW’S MEDICINE OraVerse Helps You Lose That Numbing Feeling A common gripe with oral anesthetics is the amount of time it takes for them to wear off Thomas Morrow, MD ew of the products previously described in Tomorrow’s Medicine will ever be used personally by the readers, as most are for rare conditions. But most of us will find phentolamine mesylate (OraVerse) of interest, and many will eventually, however reluctantly, personally experience its benefits.. Most of us will at some time in our life experience the pure ecstasy of the dentist’s drill. Although dental procedures are psychologically painful, they are seldom physically painful because of the relative ease and comfort of the application of dental soft-tissue anesthetics. Typically, the dentist will apply a topical anesthetic, then inject a combination of epinephrine mixed with articaine, lidocaine, or a mixture of prilocaine or levonordefrin with mepivicaine. The caine anesthetics work by blocking neurotransmission. The premixed alpha-adrenergic agonist (either epinephrine or levonordefrin) provides a longer lasting and more profound level of anesthesia to the local tissue. However, the combination of the anesthetic with the vasoconstrictor comes with a cost: persistent numbness of the cheek, tongue, and lips — something most of us dread. This prolonged numbness interferes with talking, eating, and drinking and for many (including the author) is considered worse than the procedure itself. Because vasoconstriction, at least in theory, causes delayed clearing of the anesthetic, a reversal of the vasoconstriction was thought to be, and now has been proven to be, an effective approach to shortening the duration of anesthesia. OraVerse, an old and proven drug that is a nonselective alpha-adrenergic blocking agent, has been available in the United States since F 1952. It has been shown to reduce the mean duration of lip anesthesia as compared to placebo. Two studies Two double-blind randomized multicenter studies were performed to prove that people undergoing routine dental procedures would experience a shortened duration of soft-tissue anesthesia after a local injection of phentolamine mesylate. The first study consisted of 122 otherwise healthy people from 10 to 65 years old undergoing mandibular care. The second study consisted of 120 patients undergoing maxillary care. The dental procedures consisted of routine periodontal maintenance, restorative procedures, or repairing single crown. All participants received one or two cartridges of a premixed local anesthetic/vasoconstrictor before the dental treatment. At the conclusion of the dental procedure, 1.8 ml of study drug containing 0.4 mg phentolamine mesylate or placebo was injected per cartridge of local anesthetic used. In both studies, the primary endpoint was time to normal lip sensation as measured by patientreported response to palpation. The secondary endpoints included patient’s perception of altered function, sensation, appearance, and actual functional deficits in smiling, speaking, drinking, and drooling as assessed by both the patient and an observer blinded to the treatment. In the mandibular study, the time to recovery of tongue sensation was also a secondary endpoint. Patients were stratified by type and amount of anesthetic administered. OraVerse reduced the median time to recovery of normal sensation in the lower lip by 85 minutes (55 percent improvement) compared to control. The medial time to recovery of normal sensation in the upper lip was reduced by 83 minutes (62 percent improvement). In the Thomas Morrow, MD, is the immediate past president of the National Association of Managed Care Physicians. He has 23 years of managed care experience at the payer or health plan level. 50 MANAGED CARE / SEPTEMBER 2008

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Managed Care - September 2008 Editor’s Memo Contents Legislation & Regulation News and Commentary Medication Management Compensation Monitor Archimedes Lends Hippocrates a Hand Some Other Predictive Modeling Programs Messing With Medicare Advantage The Trouble With MAC MedPAC’s Suggestions Sound Familiar The Leader in Patient Satisfaction Formulary Files Plan Watch Tomorrow’s Medicine Ad Index Outlook

Managed Care - September 2008

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