LA Management of Special

Ptient
Iyad M.Abou Rabii
DDS. OMFS. MRes. PhD
 Patient with Special Needs
• The usual dental care scenario for those with special needs may
involve an uncooperative child.
• Depending on the level of special needs of the child, and the
patience and skill of the dentist, preventive and early restorative
care often lack.
• As the child ages, extensive oral decay, cavities, and infection
may occur.
• The parents of children with autism and other special needs
often search for an oral surgeon who may have enough
anesthesia training and experience to deeply sedate or do a
quick general anesthetic to remove the abscessed tooth or teeth.
• Through sedation dentistry and general anesthesia, we able to
provide top level dental care to patients with special needs
 Psychological Preparation
• Take your time. Although you may be able to perform the
dental procedure quickly, the behavior management of the
patient often will require more of your time and patience.
• Do a little of the procedure at a time. Giving the patient time
to adjust to the activity at hand allows for desensitization and for
an easier appointment next time.
• Speak the patient’s language. Simple sign-language skills are
helpful when working with hearing-impaired or nonverbal
clients.
 Psychological Preparation

• Practice show, tell and do. Throughout the appointment, break

the procedure down into small steps. At each step, show the
patient what you plan to do as you tell him or her about this step;
then perform the procedure in stages.
• Establish a relaxed atmosphere. Communicating in a soft
voice and using a gentle touch will go a long way toward
helping the patient relax.
 Children

• Children should have a comfortable experience

when going to the dentist. Local anesthetics are
an important tool for
• the control of pain and discomfort during
dental treatment
 What local anesthetic

• All local anesthetics have a low margin of safety

between the effective dose and the toxic dose. The
lethal dose for many local anesthetics is only 3
times that of the effective dose.
• Deaths following local anesthetic administration
are almost always a result of overdosage.
• The maximum safe dose of lidocaine for a child is
4.5 mg/kg per dental appointment.
 What local anesthetic
• Bupivicaine (Marcaine) is an amide local
anesthetic with a high toxic potential, and
should not be used in children. The
duration of anesthesia with bupivicaine
can be as long as 24 hours.
• Lidocaine is less toxic than many other
local anesthetics, because its interactions
with the cardiac sodium channel are “fast
in – fast out,” whereas a local anesthetic
such as bupivicaine is "fast in – slow out.”
• So the best LA to be used with children is
Lidocaine
 What Technique
• Local infiltration of anesthesia is sufficient for all dental
treatment procedures in 90% of cases even in the
mandible.
• Nerve bloc is not preferable, just in special cases.
• Local infiltration is less painful when done correctly
 Handicapped Patient
• Several issues arise concerning the use of local anesthesia
with this population. One of these is lip biting
– Consideration should be given to choosing a short-
acting local anesthetic to reduce the possibilityof post-
operative trauma from lip biting.
– Another choice would be to avoid mandibular blocks
and utilize infiltration, periodontal ligament
 Handicapped Patient
• A second issue with local anesthesia is the inability to
determine from a non-communicative patient when an
acceptable level of anesthesia has been obtained.
– When in doubt second injections and alternative routes
(e.g., buccal, mylohyoid, intraligamentary)
 Handicapped Patient
• An unresolved issue in treating these patients is that severely
retarded patients have a higher pain threshold than the general
population.
• Some clinicians therfore choose not to use local anesthetic when
the procedures involve minor restorative needs (e.g.,body pits or
minor occlusal decay).
• These patients are difficult to control. Injecting such a patient
can be extremely difficult and may pose a significant danger to
the patient and the staff.
• One must choose a shorter needle and/or a larger gauge needle
which is less likely to be bent or broken.
• However it is better to use general anesthesia with Handicapped
patients.
Patients receiving anticoagulation or suffering from
bleeding disorders
• oral procedures must be done at the beginning of the day
because this allows more time to deal with immediate re-
bleeding problems.
• Also the procedures must be performed early in the week,
allowing delayed re-bleeding episodes, usually occurring after
24-48 h, to be dealt with during the working weekdays.
• Local anesthetic containing a vasoconstrictor should be
administered by infiltration or by intraligamentary injection
wherever practical.
• Regional nerve blocks should be avoided when possible.
• Local vasoconstriction may be encouraged by infiltrating a
small amount of local anesthetic containing adrenaline
(epinephrine) close to the site of surgery.
 Pregnant woman
• Local anesthesia are not teratogenic, and may administered
to pregnancy patient is usual clinical doses.
• Large dose of prilocaine are know to cause
methemoglobinemia which could cause maternal & fetal
hypoxia.
• Local vasoconstriction
– Delay uptake from the site of injection
– Increase the effectiveness & duration
There is no specific contraindication to these
vasoconstrictors in a pregnant patient although it is prudent
to use minimal effective dose.
 Pregnant woman
• Lidocaine + vasoconstrictor: most common local anesthetic
used in dentistry extensively used in pregnancy with no
proven ill effects, Esters are better to be used.
• accidental intravascular injections of lidocaine pass through
the placenta but the concentrations are too low to harm fetus
• Drug classes:
B: lidocaine, prilocaine, etidocaine
C: mepivacaine, bupivacaine
Not yet assigned: Procaine
• The need for careful Hx taking & for aspiration & slow
injected technique is obvious
 For Information :
Pregnancy drug Clases

Medications are grouped into 1 of 5 categories  based on the potential for

producing birth defects. The categories are A, B, C, D and X.  Generally
speaking, drugs that fall into either class A or B are considered safe and are
routinely used.  There may be exceptions.
Category A: Controlled studies in pregnant women fail to demonstrate a risk to
the fetus in the first trimester with no evidence of risk in later trimesters. The
possibility of harm appears remote.
Category B: Presumed safety based on animal studies, with no controlled
studies in pregnant women,   or animal studies have shown an adverse effect
that was not confirmed in controlled studies in women in the first trimester and
there is no evidence of a risk in later trimesters.
Category C:  Studies in women and animals are not available  or  studies in
animals have revealed adverse effects on the fetus and there are no controlled
studies in women.  Drugs should be given only if the potential benefits justify
the potential risk to the fetus.
Category D: There is positive evidence of human fetal risk (unsafe), however
in some cases such as a life-threatening illness the potential risk may be
justified if there are no other alternatives.
Category X: Highly unsafe: risk of use outweighs any potential benefit.  Drugs
in this category are contraindicated in women who are or may become
pregnant.
 GERIATRIC PATIENT
• When choosing an anesthetic, we are largely concerned
with the effect of the anesthetic agent upon the patient's
cardiovascular and respiratory systems.
• increased tissue sensitivity to drugs acting on the CNS
• Decreased hepatic size and blood flow may reduce hepatic
metabolism of drugs
• hypertension is common and can reduce renal function
• Same prevention procedures used with children
 LIVER DISORDERS

• Advanced liver diseases include:

Liver cirrhosis - Jaundice

• Potential complications:
1. Impaired drug detoxication e.g. sedative, analgesics, general
anesthesia.
2. Bleeding disorders ( decrease clotting factors, excess
fibrinolysis, impaired vitamin K absorption).
3. Transmission of viral hepatitis.
Management
Avoid LA metabolized in liver: Amides (Lidocaine, Mepicaine),
esters should be used
 Drug-Drug Interaction

• Local anesthetics and vasoconstrictor may interact

with other prescribed drugs.
• list of administrated drugs to the patient can play a
role in the local anesthetic choice.
 Sedation : Who
• Fear and Anxiety
Sedation dentistry is a great alternative for those who
suffer from fear, anxiety and phobias stemming from
dental appointments. With sedation dentistry, modern, safe
sedation techniques allow the fearful patient to have dental
procedures done without the anxiety.
• Low Pain Threshold
Many people perceive pain differently than others, or at a
much smaller stimulus. these patients will have their own
personal perception of pain altered and will be virtually
pain free during the dental treatment.
 Sedation : Who
• Active Gag Reflexes
Some patients will gag before the smallest X-ray film is even
placed in their mouth, or before they have a simple
impression taken. Using sedation, services even for the
simplest dental procedures can eliminate the problems
caused by gagging.
• Extensive Treatment
Sedation dentistry is great for sophisticated procedures such
as implant dentistry, or full mouth rehabilitation. Patients
having extended procedures such as periodontal surgery and
root canal therapy are more comfortable when these dental
procedures are done with our anesthesia services.
General Anesthesia for special Patients

• General anaesthesia is a procedure which is never

without risk (including the risk of death).
• In assessing the needs of an individual patient, due
regard should be given to all aspects of
behavioural management and anxiety control
before deciding to treat or refer for treatment
under general anaesthesia.
• General anaesthesia for dental treatment should
only be administered in a hospital setting with
critical care facilities
 Disadvantage of GA
• Apart from the risk of serious complications (which, while
very small, is still significantly higher than for conscious
IV sedation), general anesthesia has a few major
disadvantages:

(1) Complications are more likely with GA compared with

conscious sedation both during and after the procedure.
 Disadvantage of GA

(2) It's not recommended for routine dental work like

fillings. little bits of tooth, other debris or saliva could
enter the airway and produce airway obstruction or cause
illnesses like pneumonia.

(3) Laboratory tests, chest x-rays and ECG are often

required before having GA, because of the greater risks
involved.
 Disadvantage of GA
(4) Very advanced training and an anesthesia team are
required, and special equipment and facilities are needed.
GA introduces a number of technical problems for the
operator (i. e. dentist), especially when a "breathing tube"
is involved: the tongue is brought forward more into the
dentist's way by the airway tubing, the muscles are
paralysed so the operator is working against a dead weight
all the time.
 Disadvantage of GA

(5) Patient can't drink or eat for 6 hours before the

procedure (otherwise, vomiting is possible and this would
be extremely dangerous during GA).

(6) It's expensive.

(7) GA does nothing to reduce dental anxiety. The next

time the pateint need any work, or even a routine check-
up, you'll most likely be as afraid as ever.
 Don’t Forget other needs

• Antibiotics
• Drug-Drug interaction
• Drug physiological Interaction
• Post operation topical fluoride application
•
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Dr Iyad Abou Rabii
Iyad.abou.rabii@qudent.edu.sa