This Podcast is Buffering with Dr. Mic Falkel


Jarod Johnson 0:07
Welcome to the Sprig podcast, your source for the most relevant topics in pediatric dentistry. I’m your host, Dr. Jarod Johnson. Today we’re going to discuss one of the most difficult things we do in dentistry for kids, and that’s local anesthesia. And it can be something that is very hard to get through, especially with a nervous or anxious child. Using different products to become more successful and make a more comfortable injection can improve your practices production. No more failed operative treatments. Today we have Dr. Mick Falkel, one of the inventors of on pharma buffering solution for local anesthetic to discuss buffering anesthesia and how it can improve care at your office. Welcome on the show. Thanks for having me, Jarod. So what is buffering, local anesthetic? It may be something I know some people have thought of it in the past and are hesitant about it. But why did you guys go down this road to invent this product?

Mic Falkel 1:10
Great. Well, it’s great question. So buffering local anesthetic is, is there because essentially, our local anesthetic is packaged as an acid. And it doesn’t work as an acid. So our local anesthetics if you you know, when you take a look at your cartridge of local anesthetic, it’ll say line a cane HCl, articaine, HCl, any anesthetic, HCl and HCl is hydrochloric acid. And that’s used as a buffer to lower the pH. So local anesthetics themselves are assault. And they’re a weak base. And in chemistry, if you’d like weak base to go into solution and water, you add an acid, and it will go into solution. If you add a vasoconstrictor, you need to have a very acidic environment for that vasoconstrictors se epinephrine to be stable for a long period of time. So we’re anesthetics with a vasoconstrictor package at about 3.5. On the pH scale, that’s essentially the pH of lemon juice. So that’s why it stings when it goes in. But also when we’re adding anaesthetic into the body, we’re asking the body to raise the pH up to the point where it gets to physiologic pH, so that the acid form of the drug becomes the base form of the drug, which is lipid soluble. So the acid form of the drug is water soluble. The base form of the drug is lipid soluble. And of course, our nerves are made of lipids, the nerve membrane is made of lipids. So in order for that anesthetic to get through the nerve membrane and do what we needed to do, you need to turn it into a base. And so buffering of local anesthetic just does that for us, so that we can raise the pH of the local anesthetic immediately before injection. And then when we give the injection the anesthetic goes to work immediately. So that’s why we buffer local anesthetic.

Jarod Johnson 2:55
Yeah, so the that’s why it’s called onset because you’re making it immediately available to use for the patient. So essentially, you’re getting more profound anesthesia because you have more of the local anesthetic available. It’s quicker onset, and it reduces the stinging, which I think is probably one of the biggest things for the kids at my office, I’ve really worked on trying to give more painless injections, and I started off with purchasing adeno pan or computer aided device that goes at a certain speed. I noticed that improved and then I’d always thought about buffering, but I wasn’t so sure about it. And you guys had a little you had a deal at the time for an intro kit and I got that and it’s really been working well at my office because you don’t have the kid in the chair that you give the injection to and then they just lose it and that treatment gets rescheduled for sedation you can increase your production by just spending a little bit of money How do you

Mic Falkel 3:55
use I jump in there for a second Jared because you know, you guys are I mean your audience are pediatric dentist, and I’m a general dentist, and I don’t see that many children. I’d like to say my practice is you know, our my area is kind of newlyweds and nearly dads right and, and my my focus on the nearly dead, but saying that I do treat some children. And what I’ve learned over the last 35 years treating children is that you know, you have a small window of opportunity. And if you give local anesthetic and they go find something else to do while the child is marinating, and hopefully getting numb, sometimes you lose them just for that is that you’ve been away from them too long. If you can give local anesthetic not hurt them, and then start right away. You you have that window of opportunity where your management of the child becomes much easier. So even for somebody like me that’s untrained and treating children. It helps dramatically and in pediatric practices where everything is moving so quickly. To be able to sit down, give local anesthetic and go to work. And boy, does that work really nicely when it comes to patient management. And then of course, you’re so much more efficient. If you’re not getting up and moving around, you’re actually going to be able to do more dentistry in less period of time.

Jarod Johnson 5:17
And I think also, one of the big benefits of that is with COVID, and aerosol generating procedures. And if you look at what you do without you’d go in, and once you go in that room, you’re not able to leave like you could without changing your whole gown, you’re at 95, and a face shield. And if you look at being able to go ahead and give the injection and go ahead and start working sooner, that’s a huge benefit for you to not have to worry about changing all that pp. p. e, pp out and going to see another patient. So

Mic Falkel 5:52
yeah, we call that seat treatment complete. Right? So you’re awesome, sit down, treat the patient, finish the patient and then go on to something else. And then you can dramatically save on your PP equipment.

Jarod Johnson 6:05
And also you can add on, can you add on on like an emergency? If you have a patient come in, and you want to do treatment with them? And you can, can you find a way to fit them in by using it?

Mic Falkel 6:15
Well, yeah, so you know, not only and so I’m going to tell you a couple of things when it comes to that, but an emergency comes in quite often, they’re infected, and and what do we do when somebody is infected, we can’t get them numb, because the tissue that we’re injecting into you, we’re injecting into an acidic field, because an infection, the tissue can have a pH of five instead of 7.4. And so there’s no chance we can get them numb. So we generally give them antibiotics, send them home, come back in a few days, when we can actually get them comfortably, so that we can complete the procedure. But if you have buffered anaesthetic, you’re putting in at 7.4, and that tissue is at five, now you have a chance of getting them numb on the day that they come in for the emergency, you don’t have to put them on antibiotics, and you can treat the source of the infection. So not only can you fit in emergencies, because you have additional time, but you actually have the ability to treat the emergency at the same time. Now saying that, one thing I do in my practice is, you know, if somebody comes through hygiene, and they need a simple filling, something that once they’re numb is going to take me three, four or five minutes. I give them anaesthetic and go right to work. I just do the procedure right, then, you know the number one, not I can’t say it’s the number one, but a very commonly missed appointment is when you schedule that appointment for a single filling. And they just don’t show up because it’s a single filling. Well, the chance of them canceling when you already have them in the chair is zero, right? Because they’re already there. And so imagine what that does to your production. But it’s also a dramatic convenience for in your case, the parent, they do not have to come back to the office. So what I say to patients is, would you like me to fix that today? Or do you want me to ruin another day for you? And I’ve never had anybody say ruin another day for me? Everybody says yes, I’ll take that right away. And then and then they actually are happy that you did it. So it’s a really nice thing for add on appointments, not only emergencies, but actually right out of the hygiene department.

Jarod Johnson 8:12
They have something small and that you can you have time to fit them in and this can speed it up, it makes total sense, especially for kids, they have to miss school. Now that we’re back in school, the parents don’t have to take time off of work. And you also then just free up your time to see someone else that maybe has more extensive needs for treatment. I know at my office, we’re booked out for till November for treatment. And if you can have something quick that you can add on and do something simple, that frees up that time and makes everyone happy. So it’s just a great product to have available for your office. The other thing I like I personally one of the problems we really have in pediatric dentistry is those six year hypoplastic molars that are just really hard sometimes to get profound anesthesia, it really helps with those kids to have more of that local anesthetic available and you don’t have to put on SDF and then have them come back after you’ve tried to desensitize the tooth. It’s just something that I’ve seen, it’s been very effective, very effective to not have, I guess, failed treatment and increase your production. Are there any, I guess side effects of the buffering solution that you’re aware of?

Mic Falkel 9:20
Yeah. So you know, we’ve literally given 10s of millions of injections since we’ve opened, brought brought onset to the marketplace. I take every single call if there’s an adverse event, and adverse events are any in our company and adverse event is anybody who calls the company and has a clinical question, we labeled that an adverse event. A true adverse event means that there’s something that’s happened that’s not reversible. We’ve never had one that zero. But saying that and literally 10s of millions of calls. We have never had anybody talk to us about any event that isn’t already possibility of local anesthetic. Okay, so so anything that can happen, that is adverse with local anesthetic can happen with buffered anesthetic, because it’s essentially the same. When you put sodium bicarbonate, which is our buffer into local anesthetic, it becomes water, salt, and carbon dioxide. Those are all things except for carbon dioxide that are already in our anesthetic and carbon dioxide is our metabolite. So by the time it goes into the patient, it’s water, salt and carbon dioxide. And that’s all. And so there isn’t any adverse events that occur because of buffering anesthetic. There are adverse events that happened because of local anesthetic. Does that make sense?

Jarod Johnson 10:41
Yeah. I know, people are gonna also kind of ask, Is there a certain limit as far as besides the local anesthetic? Is there a certain limit on how how much onset can be used in young pediatric patient?

Mic Falkel 10:55
Sure. So I think what the question is, is does it does it change our safety profile of the local anesthesia? And what I would say is technically, it makes it the anesthetic safer, because we’re actually diluting the anesthetic. Okay, so if you think of it that way, you could actually use more anesthetic, I wouldn’t recommend that I would use the same numbers you always use for maximum dose, and you’re giving yourself a safety cushion, because you’re you’re diluting the anesthetic by 5%. So saying that there isn’t any onset requirement that changes your safety profile, it’s you use exactly the same safety profile and maximum dosages that you would use with local anesthetic, whichever local anesthetic you choose. And by the way, you can buffer all of our local anesthetics. I don’t generally recommend it for marcaine, which probably isn’t used in children very often, that’s the long acting anesthetic. But the other four anesthetics that we have available, use it exactly the same way for each one, and I wouldn’t change your maximum dose calculation at all.

Jarod Johnson 11:57
And then how does how does it? How does it actually work? Like let’s say, I know how it works, but how do you prepare your anesthetic? What’s the mechanism that you guys have designed and how does that

Mic Falkel 12:09
work here, so So, essentially, what you’re doing is you’re going to take your cartridge of local anesthetic, and you’re going to use a pen that we’ve developed, which is a piece of capital equipment, it’s a low cost piece of capital equipment that you’ll use over and over again, in our disposables our cartridge of bicarbonate that’s held at a perfect pH, which goes into the pen, and then what we call a cartridge connector. And so essentially, what our pen is a conduit from the cartridge of anesthetic to our cartridge of bicarbonate. Of course, we can’t add to a cartridge of bicarb cartridge of local anesthetic without subtracting some of the anesthetic otherwise, we pop the cork, which is the silicone plug. And so what our device does is we when you’re ready to give anesthetic and I mean ready I have my hands in their mouth, I’m ready to go, my assistant is going to add the the put the cartridge of anesthetic into our pen. And then they’re going to push a button which by which simultaneously adds by carbon into the cartridge of anesthetic and subtracts the same amount of anesthetic that fully charges the anesthetic with the bicarbonate. You take that out of the pen that literally takes two or three seconds, add it into your cartridge or into your syringe of for local anesthesia and give your injection. Now when you buffer a cartridge of anesthetic with our with our onset system, you want to do that within a minute of when you give the anesthetic so you’re not going to buffer your cartridges in the beginning of the day, you’re not going to buffer even in the beginning of the procedure. The reason that you want to buffer it and use it right away is to get maximum benefit is actually the carbon dioxide that I brought up earlier. That’s a catalyst to make local anesthetic work better. It’s also the most rapid form of transient anesthesia that we have available to us in our tool chest. And so if you have carbon dioxide that’s in solution, and you give the anesthetic and just have the weight of your thumb on the plunger, you can anesthetize the whole path of the needle. So say giving a mandibular block or doing it for a PSA where we’re traveling and further or a palatal injection that’s uncomfortable, you’re able to anesthetize the path of the needle. And it’s actually not the buffered anesthetic, it’s the carbon dioxide. The problem with carbon dioxide is it’s gas so it wants to come out of solution. And then it’s not viable for us to use. It’s not gonna hurt anything being in the cartridge, it’s just not going to get in the patient where we want it. So for maximum benefit, you want to buffer the anesthetic and use it right away. Now I know this is a verbal disk display or discussion of how it works. Best thing would be to go to on and there’s videos that you can see how easy the pen is to use. Since it literally it’s it’s a two or three second procedure.

Jarod Johnson 14:49
Yeah, it’s pretty once you get it figured out how to assemble the pen and where do you need to turn the dial it’s pretty easy to do. It’s not very hard to to go ahead and go through The process so you guys have made it super, super simple. Do you have any, like misconceptions that people are? What’s the biggest thing that makes people? Why aren’t we all doing this? If it works, so Well, what’s the big misconception and concern about?

Mic Falkel 15:14
Sure. So, you know, it’s interesting when I started, you know, I like to say I’m an overnight success. It’s just been 20 years. And so 20 years ago, when I started lecturing about this, I asked, you know, I would ask audiences, because, you know, I lecture about local anesthesia as well. And so, you know, I’d have an audience of whatever, two or 300 people, and I’d say, how many people have heard of buffering, local anesthetic, and essentially, my hand would be the only one. And now 20 years later, when I say how many people have heard of buffering anesthetic? It’s most of if not all of the audience. But it is a good question, why wouldn’t we all do it because it makes the thing that is paramount to success in our procedures, which is the local anesthetic, much more successful. And I think the reason is, is cost, right, because we’re always trying to keep our costs down, right and overhead. And so we’re really picking up speed. Now, I think that coming back from the pandemic has made a big difference for our company. I hate to say we’re successful because of the pandemic, but you brought it up, pp is much more expensive than a little bit of extra cost for your local anesthetic. And so you’re actually saving money by not getting up and leaving the patient and having to change your your protective equipment every single time. But I think cost is the number one. I think the other thing is that look, local anesthetic does work. It just has limitations, right? And sometimes it fails. It always, almost always is uncomfortable for the patient. And we’ve gotten used to getting up and walking out of the room. So as dentists are looking for solutions for any one of those three problems, we pick up the we pick up that Slack, because we’re the best solution for that. So So why isn’t everybody using it? I think someday they will. Or maybe someday we’ll have an anesthetic that doesn’t work on a pH scale. And it goes in in the active form. But until then, you know, we have to use buffering to take care of those disadvantages and local anesthesia to give the best local anesthesia practice,

Jarod Johnson 17:19
if you will. And I think when people look at cost you don’t you also miss out the flip side is what we talked about earlier, one for me, it definitely was the PP that I didn’t want to have to do all that taken on and off and everything. And that was one of the main reasons I looked back into it. But the other thing that you mentioned was the production that you’re going to increase in your patience. And for me, also less failed apps failed up you don’t make any money on you just wasted money. But yeah, but you have made money yeah, it’s a lost caught opportunity to a business. And if you can reduce that just to one that you didn’t that already made up for the cost of it for the whole day so easily, easily. So it’s just something that we I think people look at as a disadvantage, when really it could be looked at as a advantage to is to be able to increase production.

Mic Falkel 18:17
Yeah, so what I would say there Jarod, if I could add is that you know that every dentist always wants to figure out what everything is per unit cost. And we’re on a multi use system. So once you’ve set it up, it’s good for a week in the pen, or 20 cartridges of local anaesthetic. So the way I look at that is essentially it comes out to be about $15 a day. So for $15 a day you can make it local anesthetic better for your patients, which is paramount, but dramatically better for you as a practitioner and the efficiency and and and and being able to increase your production. So it’s a small investment in a lot of what I look at a lot of return.

Jarod Johnson 19:02
Yeah, I felt the same way about the dentist and about he was a big investment, but it’s similar to this. It’s something that’s not going to you get to use it over and over again. It’s a one time incurred cost and then you pay for the solution with yours. But I was skeptical on it for over a year and a half when I finally got both the dental pen and onset and I hate to say it but some kids don’t even know that we’re given an injection. I had a kid the other day that said are you gonna give me a shot? He was 13. And I said I don’t know. Yeah, we go back to the room and his brother had local local MCs without nitrus he had it would night just because a little nervous, take the edge off a little bit. And he comes out of treatment goes up to the brothers. I didn’t have a shot. And I did give him a shot. He didn’t even feel it. So and the brothers all upset because he goes well I had a forum. It just is a great product to definitely help out. What does the research show on it, people are gonna ask that because there’s still going to be some skepticism about well doesn’t really work.

Mic Falkel 20:02
Yeah. So well, I will tell you that, you know, I would like to say that I brought buffering the local anesthetic to the market, but I didn’t, it’s been around as long as local anesthetic has been around. So you can go to our website, go under the science tab and look for a we did a white paper that, you know, we’ll go through all of the research and it has all of the references. So you can actually go go deep if you really are that interested. And I know pediatric dentists are much more interested in research than general dentists are, generally general dentists don’t like to read papers and specialists do. But there’s been there’s been some some pediatric studies. And and actually, if you look at evidence based medicine, right, so the pinnacle of evidence based medicine is a Cochrane collaborative. So if you look at which is a meta analysis, and in medicine, if you make it to the Cochrane Collaborative for any procedure, that becomes what is technically the standard of care. And in 2010, the Cochrane collaborative looked at local anesthesia and buffering local anesthesia for adults and children. And said that it is a dramatic increase in the level of comfort for both children and adults, and should be practiced by all practitioners. Now that’s in medicine. But last time I checked, our teeth are in the human body, and that’s the same. And so in medicine, it is best practices to buffer your local anesthetic. And in dentistry, it’s becoming best practices to look to buffer local anesthetic, but there’s a tremendous amount of research with respect to local anesthesia and buffering local anesthesia throughout the body.

Jarod Johnson 21:42
That’s great, I didn’t know they actually had a Cochrane Review on that so that’s new to me and that’s that’s wonderful news to be able to have the science behind it for people that might be a little bit skeptical of joining but what if someone wants to purchase a system I know I don’t know if you saw this going on now but a while ago, you had an intro kit.

Mic Falkel 22:02
Yeah, so so what I would say is for your listeners, I I’ll give you a code and they can get the the same discount that you did. And that’s on the initial product and then and then if you if they have a good experience with it and they want to come become what we call a standing order customer which just means you get some amount and some amount of time and so that essentially we you know, kind of what kind of we set it and forget it, then we offer a discount for that as well. And so we’ll call the code your practice is called Arctic right? Yep, we’ll call it Arctic 21 and so if when they go to the website if they want to go and put in the code of Arctic 21 or call our number which is on the website and by the way, the website is on so ONPH ar and there’ll be a place for a code put in Arctic 21 and we’ll know where their customer or their their a friend of yours and therefore a friend of ours and we’re happy to give those discounts.

Jarod Johnson 23:04
Yeah, that’s wonderful. So I think the intro kit it came with three cartridges that came with I think four solutions and sodium bicarbonate and then the pen which is very well built very standard and then you also get a training session which I think is very important because I picked up the pen and I was like how does this thing even go together and they just said really quickly got them training video. He walked me through, you put this in here this one here the say you change it and here’s how you comp it and got me through it. So it was a really simple process to go through with your support and they’ve been a great team to work with in explaining things and checking back in to see if there’s any issues or how it’s been working for us at the office. So great customer support as well.

Mic Falkel 23:49
And and and and you don’t just get one training you get as many trainings as you need. So if you change out your staff and they you don’t have to worry about training them on the pen, we can you just give us a call and we’re happy to take care of going through another training session to make sure everybody on the staff is always ready to go. You know the way I look at it it’s just like setting up the top of my air you know it was kind of clumsy when we were in dental school but once you got it you got it and and it’s the same thing with our pen it’s it’s you know to set it up and take it apart takes a little bit of training but not very much to buffer a cartridge is literally a couple of seconds. And so once you’re up and running it’s it’s a no brainer.

Jarod Johnson 24:28
Well, thank you again doctor for coming on the show today. Is there anything else you want to let our listeners know about your product or anything coming up?

Mic Falkel 24:35
Well, I just say that you know, buffering anesthetic is is an opportunity to make local anesthetic the best it can possibly be. Which makes you know if your local anesthetic is the best that can be that helps you be the best dentist that you can possibly be. And when it comes to patient care and looking after children, I think that’s paramount. I think it is also true in it. But But boy, if the head of the spear is for taking care of people, his his children because they’re the most difficult guys have a very difficult job and if there’s anything we can do to make it easier, then we’re very happy and I think that making local anesthetic the best it can be makes your job easier.

Jarod Johnson 25:18
Absolutely. Well thanks again and hopefully we’ll get some more people on board with buffering. Perfect.

Mic Falkel 25:24
Well, thank you very much. Thanks for having me. And remember Arctic 21 at on farms calm.

Sprig 25:33
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