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Local Anesthesia 8 - Physical & Psychological Evaluation

Dr. Nanna Kreutzfeldt-Jensen

Medical History Questionnaire


Must be completed at the initial visit
Must be updated regularly (every 6 months)

Are you having pain or discomfort at this time?


The requirement for immediate treatment is gathered from this question
The dentist/therapist can decide what steps may be necessary to aid in achieving pain control
(sedation, oral analgesics etc.)
If there is chronic pain or inflammation present adequate analgesia is more difficult

Have you ever had a bad experience in the dental office?


Pursue the answers and evaluate
Sedation etc. may be needed

Are you allergic (itching, rash or swelling of hands, feet or eyes) or made sick by
penicillin, aspirin, codeine or any medications?
Evaluate carefully
If it is true allergy, G.A. may be an alternative
Handle as we talked about under general complications

Have you ever had excessive bleeding that required special treatment?
In the presence of bleeding disorders injection techniques with a greater incidence of positive
aspiration should be avoided
Must be investigated by G.P. before further treatment continues

Have you ever had heart failure?


The degree of heart failure must be assessed
If the patients demonstrate undue fatigue, shortness of breath at rest or unable to complete
normal functions without disability it likely demonstrates a decreased liver perfusion leading
to increased half-lives of the amides
In a significant heart failure a greater percentage of blood is delivered to the cerebral
circulation increasing the risk of overdose
ASA 3 and 4 heart failure is less tolerant to stress. Use psycho sedation (inhalation sedation)
Refer to G.P. for evaluation

Have you had heart disease or heart attack?


Patients should not receive dental care within 6 months of a myocardial infarction (ASA
4) because reinfarction is more likely to occur during this time
Cardiac risk patients: All ASA 1 and some ASA 2 and 3 may safely receive the concentrations
of vasopressor in L.A.
For the more severely cardiovascular compromised ASA 3 the vasopressor dose should be
limited
ASA 4 cardiovascular risk patient should not be treated at all.

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Angina Pectoris
Transient chest pain produced by myocardial ischemia relieved by rest or the administration of
a vasodilator
Any factor anxiety or inadequate pain control may provoke an anginal episode.
Use of vasopressors in stable angina is not contraindicated
Unstable angina represents an ASA 4 risk

High Blood Pressure


Patients with mild to moderate elevations in systolic or diastolic pressure are acceptable risks
for dental care, including the use of vasopressors
Hypertensive patients should have their blood pressure monitored at each appointment
and handled accordingly

Heart murmur, rheumatic fever, congenital heart lesions, scarlet fever or


mitral valve prolapse
Must undergo a more in depth evaluation to determine the degree of disability or stress
intolerance and weather antibiotic prophylaxis is necessary before treatment and L.A
Standard general prophylaxis:
Amoxicillin
o Adults: 2.0g; children 50 mg/kg 1 hour before treatment
Clindamycin (if allergic to penicillin)
o Adults: 600mg, children 20 mg/kg orally 1 hour before treatment

Artificial Heart valve


Need antibiotic prophylaxis before dental care
Consult the patients physician before initiating dental care

Heart Pacemaker
These patients usually do not require antibiotic prophylaxis.
L.A. with vasoconstrictors may be administered safely

Implanted Cardioverter/defribrillator
This device is not located within the heart there is no need for antibiotic prophylaxis
However, given the nature of the cardiac condition consultation with the patients cardiologist is
suggested before treatment

Heart Operation
In most cases these patients with proper treatment modification may safely receive dental
care including vasoconstrictors
Physician consultation is required

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Anemia
The presence of methemoglobinemia (congenital or idiopathic) is a relative contraindication to
the administration of prilocaine
Other forms of anaemia iron deficiency and sickle cell anaemia do not impact on the
administration of L.A. with or without vasoconstrictors

Stroke
Patients with a history of cerebrovascular accident or transient ischemic attack require
treatment modification to decrease the risk
Monitor blood pressure
Use minimal L.A. with vasoconstrictors if indicated
Be extra careful with regards to intravascular administration

Kidney Trouble
A small percentage of L.A. is excreted unmetabolised in the urine
Patients with kidney failure could attain high levels of L.A. in their blood increasing the risk of
overdose
However usual doses of L.A. do not pose any increased risk

Hay Fever, Sinus Trouble, Allergies, Hives


Requires a more complete dialogue history (as we talked about under general complications)

Thyroid Disease
Patients who are clinically hyperthyroid may demonstrate an exaggerated response to
vasopressors (sensitive to heat, sweat easily, increased body temperature, tachycardia, tremor
of the extremities etc.)
Such reactions can be prevented or minimised through the minimal use of adrenaline and
other vasopressors
Patients with surgical corrected or medication-controlled hyperthyroid respond in a
normal manner

Pain in Jaw Joints


The patient may be unable to open the mouth adequately
Choose alternative techniques

AIDS, hepatitis A, Hepatitis B, liver disease, drug addiction, hemophilia


All represent an increased risk of infection via blood, saliva (AIDS, Hep. a, b)
Increased risk of liver dysfunction (Hep. a, b; liver disease, drug addiction, hemophilia)
Thorough evaluation of the disorder is needed to determine the risk to the administrator and
the patient
With significant liver dysfunction L.A. half-lives may be prolonged and risk of overdose
exists

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Epilepsy or Seizures
Stress may provoke a seizure even in patients with well controlled epilepsy
Hypoglycemia and hyperventilation are two other causes of seizures.
Severe L.A. overdose reactions manifest themselves as tonic-clonic convulsions
L.A. is however NOT contraindicated

Fainting, dizzy spells, and nervousness


The nature of the problem should be determined before starting treatment.
Psycho sedation may be required

Psychiatric Treatment
Can usually receive L.A. with no increased risk
Tricyclic antidepressants and Monoamine oxidase inhibitors pose a minimal risk to the
administration of vasopressors provided that the dose is kept minimal
Is not a relative contraindication to administration of vasopressors

Bruise easily
A potential bleeding disorder must be evaluated before administering L.A.

Do you have any disease, condition, or problem not listed?


Malignant Hyperthermia: is a relative contraindication to dental care (was previously an
absolute)
Now: a relative contraindication means that a medical consultation should be obtained before
treatment
Atypical cholinesterase: relative contraindication, but only to the administration of ester L.A.

Pregnant, birth control, anticipating becoming pregnant?


Pregnancy represents a relative contraindication to elective dental care especially during the
first trimester
Consult with the patients physician before treatment start
LA and vasopressors are not teratogens during any trimester
However be conservative in administering any drugs to pregnant women.

Updating (every 6 months)


Has there been any change in your health since your last visit?
Are you now taking any drugs or medications?

Dialogue History
If disorders are present you must next discuss these with the patient to obtain as much
information as possible concerning the severity of the problem and its impact on the planned
dental care

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Physical Examination
The following minimum physical examination is recommended for dental patients
Visual Inspection:
o Patients posture
o Body movements
o Speech patterns
o Skin
Vital Signs:
o Blood Pressure
o Heart Rate
o Pulse
o Respiratory rate
o Temperature
o Height
o Weight
As a minimum it is recommended that blood pressure, heart rate, and pulse is monitored for all
patients seeking dental care

Vital Signs: blood pressure


Systolic Diastolic ASA Dental Treatment
<140 <90 1 Routine treatment
Recheck blood pressure at consecutive
140-159 90-94 2
appointments
Recheck within 5 min, routine treatment,
160-179 95-104 3a
consider stress reduction
Recheck within 5 min
180-199 105-114 3b
If still elevated seek medical consultation
Recheck within 5 min
>200 >115 4 Immediate medical consultation if elevated.
NO dental care

Vital Signs: Pulse


Can be measured at any readily accessible artery (the brachial or radial artery)
Heart rate: beats pr. minute
Heart rhythm (regular or irregular)
Quality of the pulse (thready, pounding, weak)
The normal resting adult heart rate ranges from 60-110 beats pr. min
Anxiety is the most frequent cause of an elevated heart rate
o Heart rhythm: an occasional premature ventricular contraction most often results from
smoking, fatigue, stress, drugs and medications (adrenaline), alcohol
o Is noted as a missing beat when pulse is taken
o If missing beats occur at a rate of 5 or more pr. minute medical consultation must be
considered (may indicate myocardial ischemia)

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Vasopressors are relatively contraindicated in patients with cardiac dysrhythmias
unresponsive to medical therapy

Determination of medical risk


Ask yourself the following questions:
1. Is the patient capable (physically and psychologically) of tolerating in relative safety the
stresses involved in the proposed treatment?
2. Does the patient represent a greater risk then normal during the treatment?
3. What modifications are necessary to minimise the risk?
4. Is the risk too great for the patient to be managed safely as an outpatient in the dental office?

ASA (American Society of Anesthesiologists)


1. Normal, healthy patient No treatment modifications
Possible stress reduction and
2. Patient with mild to moderate systemic disease
other modifications
3. Patient with severe systemic disease that limits
Stress reduction and medical consultation
activity but is not incapacitating
Care contraindicated
4. Patient with severe systemic disease that limits
Non-invasive emergency care
activity and is a constant treat to life
Medical consultation
5. Moribund patient not expected to survive 24 hours
Hospitalised, Dental care palliative only
with or without the operation
6. Clinically dead patient

Stress reduction Protocol


1. Sedation: evening before, and morning of appointment
2. Sedation: intra-operative
3. Effective pain control
4. Morning appointment
5. Time factor: do not exceed patients tolerance
6. Hot humid weather
7. Postoperative prescriptions
8. Postoperative phone call
9. ASA 3 and 4: possible general anesthesia
If there is any doubt concerning a patients ability to tolerate these stresses, medical
consultation should be obtained

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Drug-Drug Interactions
Amide L.A. (ex lidocaine) with H2- receptor blocker (Cimetidine) competes with lidocaine by
binding to hepatic oxidative enzymes. This means an increased half-life in the circulating L.A.
With typical use this interaction is of little clinical significance.
However in the presence of congestive heart failure there is more blood going to the brain
instead of the liver. More blood and higher concentration to the brain increase the risk of an
overdose.
This is a relative contraindication
Minimal doses of Amide L.A. should be administered

Summation Interactions with Local Anesthetics


Combinations of L.A. may be administered together without unnecessary increase in overdose
reactions
To minimise this risk, the total dose of all L.A. should not exceed the maximum recommended
dose of the drugs used

Sulfonamides and Esters


Ester L.A. (procaine) may inhibit the bacteriostatic action of the sulfonamides
(chemotherapeutical with bacteriostatic action)
With the uncommon use of sulfonamides today and the extremely rare administration of ester
L.A. this interaction is unlikely to be noted

Local anesthetics with Opioid Aedation


Sedation with opioid analgesics may increase the risk of developing local anesthetics
overdose.
This is of primary concern in children.
Use minimal doses of L.A.

Vasoconstrictor and Tricyclic Antidepressant


Tricyclic antidepressants are prescribed in the management of major depression
The interaction has been reported to have resulted in a series of hypertensive crises
The administration of noradrenalin and levonordefrin should be avoided in patients receiving
tricyclic antidepressants
Patients receiving adrenaline containing L.A. should be administered the smallest
effective dose

Vasoconstrictors and nonselective B-blocker


The administration of vasopressors in patients being treated with non-selective B-blockers
(angina pectoris, hypertensio artialis, arhythmias) increase the likelihood of a serious elevation
of the blood pressure
Reactions have occurred with relative small amounts of adrenaline

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Monitor pre and postoperative vital signs
Vasoconstrictor with General Anesthetic
There is an increased possibility of cardiac dysrhythmias.
Discuss this with the anesthesiologist before L.A. administration

Vasoconstrictor with Cocaine


L.A. containing vasoconstrictors should not be administered to patients who have used
cocaine on the day of their appointment
Possess significant stimulatory properties on CNS and CVS. Frequently seen high blood
pressure, can result in cardiac arrest etc. If a vasopressor is accidentally intravascularly
administered increase the risk.

Vasoconstrictor with Antipsychotic or other a-adrenoceptor Blocker


Hypotension as a result of antipsychotic overdose may be intensified
Use vasoconstrictor with caution

Vasoconstrictor with Adrenergic Neuronal Blocker


Phenothiazines are psychotropic drugs usually prescribed for the management of serious
psychotic disorders
The most common side effect is hypotension
The phenothiazines suppress the vasoconstricting actions of adrenaline permitting the milder
vasodilating actions to work unopposed. This will only happen because of an accidental
intravascular administration
Use the smallest volume possible for pain control

Vasoconstrictor with Thyroid Hormone


Summation of effects is possible when thyroid hormones is taken in excess.
Vasoconstrictor should be used with caution when clinical signs and symptoms indicating
hyperthyroidism are present.

Vasoconstrictor and Monoamine Oxidase Inhibitors


Monoamine oxidase inhibitors are prescribed in the management of major depression, certain
phobic-anxiety states and obsessive-compulsive disorders
They are capable of potentiating the actions of vasopressors by inhibiting their
biodegradation by the enzyme monoamine oxidase at the presynaptic neuron level

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Malignant Hyperthermia
Is one of the most intense and life-threatening complications associated with the administration
of general anesthesia
Occurrence 1:15000 in children and 1:50000 in adults
The syndrome is transmitted genetically by an autosomally dominant gene
Mostly in Canada and USA
Amide local anesthetics are not likely to trigger such episodes, thus is now categorised
as a relative contraindication
Mechanism: is a defect in the distribution of myoplasmic calcium.
Clinical signs and symptoms: tachycardia (high pulse), fever, tachypnea (extremely fast
breathing), cardiac dysrhyhmias, muscle rigidity, cyanosis (blue colour of skin due to a high
level of non-oxidised hemoglobin in the capillaries) and death
Occurs when the patient is exposed to a triggering agent, usually a drug used to induce or
maintain general anesthesia
The mortality has been decreased to 10% because of awareness and early recognition and
treatment
Dental Management:
o Contact the patients physician
o Dental management is possible in most cases
o With high risk patients you should refer to treatment in a hospital if MH should be
triggered
o You can use L.A. with vasoconstrictors
o Dantrolene effectively blocks the ca-ions release

Atypical Plasma Cholinesterase


Ester L.A. are hydrolysed in the blood by the enzyme plasma cholinesterase, which is
produced in the liver
1:2820 possess an atypical form of plasma cholinesterase
Autosomal recessive trait
Atypical Plasma Cholinesterase
Significance in Dentistry:
o Alert the doctor to the increased risk of prolonged apnea in patients receiving
succinylcholine during general anesthesia
o Is a relative contraindication for administration of ester L.A.

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Methemoglobinemia
Is a condition in which a cyanosis like state develops in the absence of cardiac or
respiratory abnormalities
Prilocaine can produce methemoglobinemia in patients with sub clinical methemoglobinemia
when administered in large doses
Administration of prilocaine with methemoglobinemia or other clinical syndromes in which the
oxygen carrying capacity of blood is reduced should be avoided
Topical anesthetic benzocaine in large doses can also induce this
Etiology: Hemoglobin, in the ferrous state, can carry oxygen that is available to the tissues.
Because hemoglobin in the erythrocyte is unstable it is continuous being oxidised to the ferric
form. The oxygen molecule is more firmly attached and cannot be released to the tissues
(methemoglobin)
An enzyme system continually reduces the ferric form to the ferrous form (methemoglobin
reductase)
As blood levels of methemoglobin increase, clinical signs of cyanosis and respiratory distress
become noticeable
Prilocaine, aniline derivates (crayons, ink, shoe polish, dermatologicals) can produce elevated
methemoglobin level
The production of methemoglobin by prilocaine is dose related
Clinical signs, symptoms and management
o Usually appears 3-4 hours after administration of large doses of prilocaine in healthy
patients, or a smaller dose in patients with the congenital disorder
o Has already left the office
o Respiratory distress, cyanotic mucous membranes and nails
o Unresponsive to oxygen administration (basis for diagnosis)
o Treatment: slow IV administration of 1% methylene blue
o The presence of congenital methemoglobinemia is a relative contraindication to
the administration of prilocaine
o Methemoglobinemia should not develop in a healthy dental patient, provided
doses remains within limits.

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