ANESTHETIC RISK

ASSESSMENT FOR LOCAL AND

REGIONAL ANESTHESIA
 Anesthetic risk assessment

Influence générale des maladies:

The anesthetic risk is influenced by:
La technique de l'anesthésie locale;
•patient’s
Le typediseases and drugs administered
d'anesthésique
•technique
Le momentof local anesthesia
de l'anesthésie.
•type of local anesthetic
•moment of anesthesia.
 LOCAL ANESTHETICS

• In dental practice, different substances are used to

obtain reversible local anesthesia, allowing pain to
be completely eliminated in the majority of cases.
• The use of local anesthetics is widespread and
very safe, provided the technique is correct.
• Serious complications are rare.
LOCAL ANESTHETICS
• There are ester-type and amide-type LAs.
• They differ by their metabolism :
• esters are divided by hydrolysis in blood (plasma)
• amides by enzymatic way in the liver.

• Esters are seldomly used nowadays because

their metabolite, para-amino-benzoic acid, has
a high allergenic potential.

• LAs with or without vasoconstrictor

 INJECTION TECHNIQUE
• The injection of an anesthetic solution with or without
vasoconstrictor should always be done slowly (1ml per
minute) and in a fractionated way in order to monitor the
possible signs of a prejudicious effect of the injection.

• When the injection takes place in a well-vascularized

territory, a negative aspiration test is a constant
prerequisite to the injection of the anesthetic solution with
or without vasoconstrictor, in order to avoid intravascular
administration.

• The lowest effective dose is always recommended.

 INDICATIONS FOR
VASOCONSTRICTORS

• The association of a vasoconstrictor with the anesthetic

solution in local anesthesia by infiltration is indicated
because the vasoconstrictor:
• decreases the intravascular passage of the injected
anesthetic
• thus ensures an increase in the duration and depth of the
anaesthesia
• while reducing the systemic effects of the solution.
 INDICATIONS FOR
VASOCONSTRICTORS
• Local hemostasis techniques using vasoconstrictors, either
pure or mixed with anesthetic or astringent substances, have
not been the subject of any published evaluation with a
satisfactory level of evidence. They are therefore in the
empirical domain.

• The use of an anesthetic solution with added vasoconstrictor

as a means of decreasing bleeding and lowering the
threshold for analgesia in oral surgery patients under general
anesthesia helps to decrease the sympathetic response to
surgical aggression and to decrease the depth of general
anesthesia required
CHOICE OF VASOCONTRICTOR

• Adrenaline is industrially and medically the leading

vasoconstrictor used alone or in combination with a
local anesthetic in dentistry. It has the vastest case
history that confirms the high safety of this molecule.

• Non-catechol derivatives have not been shown to be

superior to date, even in patients who may not tolerate
catecholamines well.
 INDICATIONS ACCORDING TO THE
ANESTHETIC TECHNIQUE

• The use of a vasoconstrictor in punctual anesthesia

techniques (intrapulpal, intraligamentary and intraseptal
anesthesia) is not essential but significantly improves the
success rate, duration and depth of anesthesia
obtained.
• If the injection is performed under proper conditions, local damage
directly attributable to the vasoconstrictor is negligible and
reversible.
• The systemic effects of these injections exist but are most often
inferior to those observed in infiltration anesthesia.
INDICATIONS ACCORDING TO THE
ANESTHETIC TECHNIQUE

• The use of a vasoconstrictor in local anesthesia

techniques (supraperiosteal, nerve trunk anesthesia)
is not essential, but significantly improves the
success rate, duration and depth of anesthesia
obtained.
 INDICATIONS ACCORDING TO THE
ANESTHETIC TECHNIQUE
• The addition of a vasoconstrictor to the anesthetic solution is NOT
essential for inferior alveolar nerve block. The addition of
adrenaline increases the duration of anesthesia but does not seem to
have a decisive effect on the incidence of failure to obtain the
anesthesia.

• The results concerning the success rate of anesthesia are

contradictory.

• Given the relationship between success rate and volume of solution

injected, the addition of a vasoconstrictor could be considered in the
prevention of systemic effects of local anesthetics
DOSAGE OF VASOCONSTRICTOR

•There are conflicting results regarding the ideal dosage

of adrenaline in 2% lidocaine solutions. The 1:200,000
solution gives a sufficient duration of action for the
majority of the dental procedures.

•For 4% articaine and 2% mepivacaine, 1:200,000

solutions should be preferred because they would likely
be better tolerated.
 DRUG INTERACTION

• Drug interaction is a relatively new problem in

medicine and dentistry.

• In many cases, unexpected effects can be

observed.

• In some subjects, the administration of two drugs

can cause an interaction between them or a
potentiation effect.
RECREATIONAL DRUGS?
• Although most patients will not admit to recreational
drug use, it is important to ask the question.

• This becomes especially important when the dentist is

considering the use of CNS depressant drugs for
sedation or local anesthetics with or without
vasoconstrictors, such as epinephrine.
 PATHOLOGIES CONTRAINDICATING
VASOCONSTRICTORS ASSOCIATED WITH
THE LOCAL ANESTHETIC

• Pheochromocytoma is an absolute contraindication to

vasoconstrictors. Patients with this condition should be managed in a
hospital with an intensive care unit when local anesthesia with or
without a vasoconstrictor is required.

• It seems advisable to avoid the combination of vasoconstrictors with

local anesthetic during conservative and especially non-conservative
treatment of bone irradiated above 40 Gy.

• Intraosseous injections of adrenalized local anesthetic should be

avoided in patients with arrhythmia.
 PATHOLOGIES THAT DO NOT
CONTRAINDICATE VASOCONSTRICTORS
ASSOCIATED WITH THE LOCAL
ANESTHETIC
• Stabilized hyper- and hypothyroid patients do not have major
disturbances when given corrective therapy and catecholamines. Although
the theoretical risk of thyroxin-adrenaline potentiating is serious, there are
no clinical reports.

• Vasoconstrictors associated with an anesthetic solution are not

contraindicated in a hypertensive subject stabilized by
antihypertensive treatment – just limit the dose

• In cases of blood pressure instability associated with other prognostic

factors, involving local anesthesia with vasoconstrictor should be carried
out in a hospital setting with a resuscitation facility and under monitoring.
 PATHOLOGIES THAT DO NOT
CONTRAINDICATE VASOCONSTRICTORS
ASSOCIATED WITH THE LOCAL
ANESTHETIC
• In atrial fibrillation that is balanced with appropriate therapy, control
of stress and therapeutic heart rate is essential and the use of local
anesthetics with vasoconstrictor is indicated - just limit the dose.

• Patients on digoxin and those with atrioventricular arrhythmias

should be treated under monitoring in a hospital setting with a
resuscitation facility when local anesthesia with or without a
vasoconstrictor is required

• Vasoconstrictors associated with an anesthetic solution are not

contraindicated in stabilized coronary heart disease - just limit the
dose.
 PATHOLOGIES THAT DO NOT
CONTRAINDICATE VASOCONSTRICTORS
ASSOCIATED WITH THE LOCAL
ANESTHETIC
• Vasoconstrictors associated with an anesthetic solution
are not contraindicated in asthmatic subjects in order
to control pain and avoid stress, which is probably the
main source of transition to an asthma attack in the
dental office.

• In the case of cortico-dependent asthma, the use of

an anesthetic without vasoconstrictor and therefore
without bisulfate (preservative component) is indicated.
 PATHOLOGIES THAT DO NOT
CONTRAINDICATE VASOCONSTRICTORS
ASSOCIATED WITH THE LOCAL
ANESTHETIC
• Vasoconstrictors in combination with anesthetic solution are not
contraindicated in patients who have healed viral or toxic liver
injury.
• In cases of severe progressive damage, assessment of liver
function is important. The total amount injected may have to
be reduced and the intervals between injections increased,
without prejudice to the use of an associated
vasoconstrictor

• Vasoconstrictors combined with an anesthetic solution are not

contraindicated in patients with renal dysfunction. Doses of all
drugs should be limited (slow clearance) and surgery (if on dialysis)
should be performed 24 hours after dialysis.
 PATHOLOGIES THAT DO NOT
CONTRAINDICATE VASOCONSTRICTORS
ASSOCIATED WITH THE LOCAL
ANESTHETIC
• Vasoconstrictors in combination with an anesthetic
solution are not contraindicated in patients with Type I
or Type II diabetes.

• In case of unbalanced and unstable diabetes, with

an abrupt change from hypo to hyperglycemia, the
quantities of local anesthetic with vasoconstrictor will
be moderated in order to take into account the
hyperglycemic character of adrenalin.
 PATHOLOGIES THAT DO NOT
CONTRAINDICATE VASOCONSTRICTORS
ASSOCIATED WITH THE LOCAL
ANESTHETIC

• Patients on bisphosphonate therapy for

malignant disease (e.g. Zometa)
• local and loco-regional anesthesia with low
concentration of vasoconstrictor is advisable if
infiltrated supraperiosteal.
 PHYSIOLOGICAL STATES AND
VASOCONSTRICTORS

•Vasoconstrictors combined with an anesthetic solution

are not contraindicated during pregnancy and lactation.
 LOCAL ANESTHESIA DURING
PREGNANCY

• 1. Using local anesthesia during pregnancy is

generally considered safe. The benefits and risks
must be considered.

• 2. Proper local anesthesia technique is a necessity.

• 1. aspiration to avoid intravascular injection
• 2. appropriate needle
• 3. accurate technique
• 4. attention to doses
 LOCAL ANESTHESIA DURING
PREGNANCY

• Ester-based anesthetics should be avoided due to the

potential for allergenicity.

• 4. PRILOCAINE should not be used due to the risk of

developing methhemoglobinemia in the fetus.

• 5. Although LIDOCAINE is considered the best

choice of anesthetic, articaine, mepivacaine, and
bupivacaine (FDA- Category C) can be used.
 LOCAL ANESTHESIA DURING
PREGNANCY
• 6. In the second and third trimesters, correct
positioning and heart rate monitoring are important
to avoid orthostatic hypotension.

• 7. During lactation, the use of local anesthetics

without vasoconstrictors may be considered to
avoid idiosyncratic reaction in the newborn, not to
the vasoconstrictor but to the preservative used to
stabilize the vasoconstrictor.
 SELECTION OF LOCAL
ANESTHETIC IN PEDIATRIC
DENTISTRY

• Vasoconstrictors associated with an anesthetic

solution are not contraindicated in children beyond
six months.

• The usual total dose of local anesthetic with or

without vasoconstrictor in healthy adults must be
divided by 3 below 15 kg and by 2 between 15 and
40 kg.
 SELECTION OF LOCAL
ANESTHETIC IN PEDIATRIC
DENTISTRY

● Short-acting local anesthetic solutions (e.g., 3%

mepivacaine, 4% prilocaine without a vasoconstrictor) are
excellent selections when the planned dental procedure is
limited to one quadrant/appointment.

● Intermediate duration local anesthetics are most often

used when two or more quadrants of treatment are
scheduled and/or when more invasive procedures are
considered (e.g., pulpotomy).
 SELECTION OF LOCAL
ANESTHETIC IN THE ELDERLY

• Vasoconstrictors combined with a local anesthetic

solution are not contraindicated in the elderly.

• The total dose of anesthetic with or without

vasoconstrictor must be adapted to the metabolic
state of the subject in question.
 SPECIAL CASES
• Patients on antiplatelet/anticoagulant agents
• Regional anesthesia (RA) is indicated only if local anesthesia
fails.

• Patients with hemophilia

• No regional anesthesia!!!
• Instead - local anesthesia
• No surgery in the dental office - only in the hospital

• Patients with von Willebrand Disease

• No surgery in the dental office - only in the hospital
• Avoid RA, intravascular injection
• Hemophilia-like precautions