Transcript local anesthetic solution without vasoconstrictor) should be used

Medical evaluation of the patients
• Prior to any dental procedure or administration of any drags ,
particularly , local anesthetic agents , the dental practitioner
should determine whether the patient can tolerate the procedure
or the drug safely or not . Specific modification in the treatment
are necessary to decrease the risk associated with the procedure
or the drugs . This is important , as the local anesthetic agents ,
like many other drugs , exert actions on many system of the body .
• local anesthetic agents undergo biotransformation in liver ( amides )
or blood (esters) . Hence , the functional status of these systems
should be determined before the administration of the drug . Further
, the local anesthetic agents are excreted through kidneys . Hence ,
status of kidneys should also be evaluated
Medical evaluation
Detailed medical history
The dental practitioner should get detailed information about the
current status of medical history at the first visit and record it as :
1History of major illness or been under treatment in the past.
These questions give you information about patient general health .
2The drugs the patient is taking presently , and medications
taking presently , and medications taken during the past 2 years .
3Is
the patient taking any antiplatelet or anticoagulant
medication .
4-
The medical status should be updated regularly in the records .
History of hospitalization
•
The patient should be asked if there is any previous hospitalization
and its cause also we should ask about how long did the patient stay in
the hospital , and even maternity history should be taken in case of
female patient .
Fear and anxiety or nervousness
•
The dental practitioner can determine whether any additional steps
as sedation , stress reduction protocol or anxiety reduction protocol
are required to aid in achieving pain control .
History of allergy to drugs
The patient should be asked about having allergy to any drugs as
1-
Drugs as penicillin , sulpha group of drugs , aspirin or codein .
2The incidence of true , documented , and reproducible allergy
to local anesthetic agents .
3Allergy not due the local anesthetic agent itself but due to any
constituents of the local anesthetic solution which could be the cause
of the allergy and those are :
a- Preservative to the vasoconstrictor such as sodium bi –
sulfite or Na meta – bisulfite .
b- General preservative such as Methylparaben
History of excessive
treatment
bleeding that required special
It is very important to ask the patient if he had any history of
excessive bleeding associated with the pervious dental treatment and
to prevent this complication from happing .
Patients with the following bleeding disorders are at risk of bleeding :
1-
Coagulation disorders .
2-
Bleeding disorders .
3-
Patients taking antiplatelet or anticoagulant drugs .
For these patients in insertion of an injection needle in the deeper soft
tissue of the oral cavity which are highly vascular in nature may lead to
sever bleeding which could be difficult to manage , in such cases
techniques which require deep penetration of the dental needle should
be avoided such as inferior dental nerve block , maxillary nerve block ,
and posterior superior nerve block . the dentist could use other
technique for those patients such as supraperiosteal injection and
periodontal ligament injection , also dentist should refer those patients
to their physician take all the necessary local hemostatic measures .
Past dental history
If there is a history of past bad experience in the dental office , if
any require use of additional procedure such as psycho-sedation
,also the dentist should ask the patient if there is any complication
associated with any previous dental treatment as fainting of the
patient during giving local anesthesia , sever bleeding associated
with any previous dental treatments
Major illness
1-
Cardiovascular diseases .
2-
Cerebrovascular accident as stroke .
3-
Renal disease such as chronic renal failure .
4-
Endocrine disease as diabetes mellitus and thyroid dysfunction .
5-
Respiratory disease as bronchial asthma .
6-
Neurological disorders as epilepsy .
7-
Patients with liver disease as viral hepatitis .
8-
Patients on psychiatric medications .
9-
Hematological disorders such as anemia and hemophilia .
10-
Pregnancy .
11.
Aids
Cardiovascular diseases
The patient might be having any of the following cardiovascular
disease which need modification of the treatment strategy :
aI.
Ischemic heart diseases
There are :
Angina pectoris : it is defined as an attack of transient chest pain
which is usually relieved by rest or administration of a vasodilator ,
angina is of two types either stable angina or unstable angina ,
stress , anxiety and inadequate pain control may precipitate an
angina attack during dental treatment so the patient should have a
morning appointment , reduce the stress during the procedure and
some time even use of plane anesthesia is needed .
II.
Myocardial infarction : patients with a history of a recent attack
(within or <6 months ) have increased risk during dental care or even
after the administration of local anesthetic drugs , such patients
shouldn`t receive any elective dental care within the first 6 month after
the myocardial infarction and after this period dental treatment could
be performed with appropriate modification and consultation with his
physician .
b. Congestive heart failure
•
Patient with heart failure are less tolerant to stress so anxiety
must be dealt with adequately , psycho-sedation is appropriate , also
those patients are not comfortable in the supine position because of
orthopnea and they are more comfortable in upright position .
c. Hypertension :
• It`s a medical condition where blood pressure in the arteries
persistently elevated , the blood pressure is expressed by two
measurements the systolic and the diastolic and when the blood
pressure is above 140mm hg/90mm hg then the patient is known to
be hypertensive .
• Patients with mild to moderate elevation in blood pressure are in
acceptable risk for dental care , including use of local anesthesia
with vasoconstrictors having higher dilution or avoided , all
hypertensive patients should follow compliance , they should make it
a point to take morning dose of medication , their blood pressure
should be checked at each appointment and be managed on the
basis on the most recent reading .
d.
Congenital heart disease , Rheumatic heart disease
Patients who fall in this categories are in risk of developing bacterial
endocarditis following any dental treatment especially surgical one
so they require prophylactic antibiotic before that dental treatment
and there is certain regimen for antibiotic prophylaxis which is
advised by the American heart association .
e. Artificial heart valve:
Patients with prosthetic heart valve antibiotic prophylaxis before any
dental care. also those patients are usually taking anti-coagulant
drugs which should be stopped or reduced gradually few days
before the surgical procedure in consultation with the patients
physician .
Cerebrovascular accident , stroke
•
Those patients are at high risk for complications following dental
treatment within the first 6 months after the acute attack and after the
first 6 months , their condition require modification of the treatment to
decrease the risk of the dental treatment . the guidelines are as follows
1- Monitor the blood pressure .
2- Those patients are usually taking anti-coagulant drugs which
should be stopped or reduced gradually prior to any dental treatment .
3- Use minimum dose of the local anesthetic agent .
Renal disease ( chronic renal failure ) :
A small percentage (<10%) of local anesthetic agent is
excreted unchanged by the kidney in the urine . the
patients with chronic renal failure achieve high levels
of local anesthetic agent in the blood , thereby
increasing the risk local anesthetic overdose .
Endocrine disease
1-
Diabetes mellitus
Those patients are mostly susceptible to delay healing and infection
after dental treatment because of high level of sugar in the blood so
uncontrolled patients should be referred to their physician to control
their blood sugar level before any dental treatment also the surgical
procedure is carried out under antibiotic cover .
• 2-
Thyroid dysfunctions
• The signs and symptoms of hyperthyroidism include sensitivity to
heat , easy sweating , tachycardia , palpitation weight loss ,
increased body temperature , tremor of the extremities , increased
nerves ness , patients with hyperthyroidism are sensitive to
catechlamines and may demonstrate an exaggerated response to
vasopressor include in local anesthetic solution so for those patients
plane anesthesia (local anesthetic solution without vasoconstrictor)
should be used .
Respiratory diseases
•
Patients with respiratory disease such as bronchial asthma , are
treated with stress reduction protocol . They should use the inhaler
on the day of surgery , and also keep it with them during the dental
or surgical procedure . The medication for bronchodilatation should
be kept handy , incase of an emergency . if the patient is using
corticosteroids its necessary to consult his physician double his dose
of steroid .
Neurological disorder
Epilepsy
• For epileptic patient the main problem which may happened on the
dental chair is the epilepsy fit , the epilepsy fit may occur due to
several causes as stress , hypoglycemia , hyperventilation . Stress
may provoke seizures even in patients with well – controlled epilepsy
so stress reduction protocol should be employed to minimize the risk
of seizures development during treatment and there are other
precautions should be taken by the dentist during the dental
treatment .
• Patients with liver disease
• Patients with liver disease especially with a history of viral hepatitis must
be managed as though they are potentially infectious to the dentist and to
other patients , in a dental office infection can be expedited through
several routs including direct contact with blood , oral fluids , or other
secretions , or by indirect contact with contaminated instruments and
operatory equipment`s . and because there is an increased risk of infection
via the blood or the saliva to the dentist or to other patients , thorough
evaluation of the disease should be carried out to assess the degree of the
risk to both the practitioner and to the patient before any dental treatment .
also it is recommended that the dental professionals should receive
immunization against hepatitis and should use individual protective
equipment`s such as gloves , head cap , masks , etc. and the instruments
used should be sterile separately .
•.
• In significant liver dysfunction the half – life of amide local
anesthetic agent may be significantly prolonged thereby increasing
the risk of overdose . the local anesthetic agent are detoxified in the
liver , and hence , should only be used if approved by the treating
physician
• Patients with psychiatric ailments and on medications
• Patients under psychiatric care , for neurosis , psychosis , and
depression usually take psychiatric drugs to alter the behavior
patterns , there are 2 types of these drugs which are
1- TC antidepressants .
2- MAO inhibitors .
•
These drugs pose a minimal risk to the administration of local
anesthetic agent with vasoconstrictor so plane local anesthesia
should be used for those patients .
• Hematological disorders
• Anemia
• There are various forms of anemia which are as follows
• 1-
Methemoglobinemia
• 2-
Iron deficiency anemia
• 3-
Sickle cell anemia
•
Methemoglobinemia , which can be congenital , or acquired is a
relative
•
Contraindication to the use of Prilocaine , other forms of anemia do
not pose any problem for the administration of local anesthetic
solution with or without vasoconstrictors .
• Deficiencies such as hemophilia , Leukemia , Thrombolytic purpura ,
and thalassemia
• In all these disorders , the deficiencies are corrected with the help of
the hematologist and with the necessary precautions of local
hemostatic measures , surgical intervention can be undertaken .
local anesthesia by block technique , lingual infiltration injection , or
injection into floor of the mouth must not used in absence of factor
VIII replacement because of the risk of hemorrhage hazarding the
air way and being life threatening , infiltrations as intraligamentary ,
intraosseous , or intra pulpal injection are still safer .
Pregnancy
It is relative contraindication for elective dental care , especially in the
first and the third trimesters , consultation with the patients physician
is necessary prior to oral surgical procedures involving use of local
anesthesia , particularly if there is history of any problems with the
previous pregnancies or if the patient is a primigravida .
local anesthetic agents and vasoconstrictors are not teratogens and
may be administered to pregnant patients during any trimester .
however it is important to be conservative in administering any drug
to a pregnant patient . local anesthetic agents containing felypressin
such as Citanest fort (Prilocaine and Octapressin ) has got oxytocic
properties but lidocaine can be safely used .
AIDS
In a patient who is known case of AIDS conservative dental treatment
could be done with several precautions as using face mask , head cap ,
and double gloves , today special kit is available for single patient use .
The instruments used are sterilized by chemical sterilization by
immersing in 1% sodium hypochlorite for 10 hours followed double
autoclaving .