Local Anesthesia in Dentistry: USE OF LOCAL ANESTHETICS DURING PREGNANCY

In: Anesthesia

24 Sep 2009

The adverse drug reactions during pregnancy may affect either the mother or the fetus. Hypersensitivity, allergy, or toxicity reactions in the mother may compromise her health and limit her ability to support a pregnancy. Fortunately, doses of local anesthetics in dentistry are usually relatively small and are generally unlikely to cause complications during pregnancy. All local anesthetics cross the placenta to some degree. Highest concentrations in the fetal circulation follow injection of prilocaine, and the lowest follow bupivacaine, with lidocaine in between.

Felypressin, which is a derivative of vasopressin and is related to oxytocin, has the potential to cause uterine contractions. Although this is a highly unlikely effect at the low dose of felypressin used in local anesthetics, it is best avoided during pregnancy. Lidocaine with epinephrine is commonly used for pregnant dental patients. cheap viagra professional

The performance of common dental treatments for a pregnant patient is highly variable. In a telephone survey using a standardized questionnaire, 78 resident dentists in Germany, Switzerland, and Austria were interviewed with respect to several aspects of the dental treatment of pregnant women. Only 58% of the interviewees decided clearly in favor of using local anesthetics, 59% supported the use of analgesics, 70% supported a possible antibiotic therapy, and 33% would agree with a radiological examination during pregnancy. In addition, according to references in the specialist literature, guidelines for the dental treatment, drug therapy, and radiological diagnosis of pregnant women are presented. The local anesthetics should have a high plasma protein bonding capability (Articaine, bupivacaine, etidocaine) and minimum epinephrine concentrations. Acetaminophen is the usual analgesic of choice for pregnant dental patients. If an antibiotic treatment is required, penicillin, cephalosporin, and erythromycin are recommended. In particular, during the first 3-month period, radiological examinations should be restricted to the absolute minimum and performed only if no rea­sonable alternative is available, although the radiological burden on the fetus falls 500,000 times short of the limit value of 50 mgray (5 rad) in the case of a micro-radiogram, and 50,000 times short of the limit value in the case of an orthopantomogram.

LOCAL ANESTHETICS IN CHILDREN

Fixed pediatric dosage recommendations for a given age range are no longer endorsed for local anesthetic and sedative agents. Available data suggest that adverse reactions in pediatric patients are commonly caused by inadequate dosage reduction. Maximum recommended doses of local anesthetics is based upon the weight of the child, usually expressed as milligrams per kilogram of body weight. For very obese children, the maximum dose should be calculated on the basis of lean-body weight or ideal weight, not the true body weight. The specific number of milligrams per kilogram used for calculating the maximum recommended dose differs among the various local anesthetics.
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MEDICAL-LEGAL CONSIDERATIONS

It is incumbent upon every dental practitioner to treat his or her patients in an appropriate way, taking into consideration both their dental needs and any special precautions related to their past medical history. To prevent any implication of negligence, a practitioner must administer appropriate treatment. Furthermore the patient should receive adequate information about the proposed dental treatment and must submit themselves willingly to a local anesthetic as a part of the proposed dental treatment after the benefits and risks are explained. Medico-legal complaints arising from administration of local anesthesia are few in number. There are, however, some particular complications arising directly from the local anesthetic drugs or their delivery that merit consideration.

Persisting anesthesia or paresthesia due to damage to various branches of the trigeminal nerve is a common complication in dental surgical procedures, especially associated with lower third molar removal. Cases relating to sensory loss of lingual nerve and inferior alveolar nerve following inferior dental block injections for restorative procedures have occasionally been presented as a legal complaint.

In a study of over 12,000 inferior dental block injections, all given for restorative treatment, 18 patients (0.15%) were found to have some lingual sensory disturbance following treatment. Of these 18 patients, 17 patients totally regained normal sensation within 6 months, and 1 patient still had a loss of sensation after 1 year (0.008%). Of the 12,000 patients, 856 (7%) experienced an “electric shock” type feeling in the tongue at the time of injection, suggesting that the tip of the anesthetic needle had touched the lingual nerve.
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Although the medico-legal issues tend to frighten the dental practitioner, statistical data demonstrate that if the current standards of practice are observed, the dentist is unlikely to run into these types of problems.


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Blog invites submissions of review articles, reports on clinical techniques, case reports, conference summaries, and articles of opinion pertinent to the control of pain and anxiety in dentistry.

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