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Contraindications
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ContraindicationsforLocalAnestheticTechniquesinDentistry
135
In this chapter, we review cases and circumstances in
which dental local anesthetic cannot be administered.
These include the following:
● Lack of patient cooperation.
● Very poor health (ASA IV).
● Severe coagulopathies.
● Injection site infection.
● Severe restricted mouth opening (trismus, ankylosis of
the temporomandibular joint).
In many situations where local anesthesia is contraindicated, we can turn to deep sedation or general anesthesia.
In other cases, the patient’s underlying condition must be
treated first.
LackofCooperationfromthePatient
A lack of patient cooperation is a contraindication for dental local anesthetic, since it can entail very serious consequences for both the patient and the dentist, as follows:
● Pricks and injuries in the patient’s mouth and face.
● Pricks on the dentist’s hands.
● Breakage of the needle in the patient’s mouth (Bacci
etal.2012).
PredisposingFactors
Certain situations and types of patients are more likely to
generate poor behavior, for example:
1) Preschool children under aged 5–6 years (pre- cooperators)
(Wright et al. 1991; Sharaf 1997; Tyrer 1999; LindStrömberg2001). Owing to their immaturity, they cannot understand the need to cooperate with the dentist
(Pinkham and Schroeder1975).
2) Patients with mental conditions, such as those with
Down syndrome or cerebral palsy (Pinkham and
Schroeder1975; Tyrer 1999; Hulland and Sigal 2000),
for the same reason as mentioned above, i.e., inability to
cooperate, although this depends on the severity of the
condition.
3) Patients with mental and psychiatric disorders
(Berggren and Meynert1984; Moore etal.1993; Hulland
and Sigal2000), such as the following:
⚪ autism (Hulland and Sigal2000; Lind- Strömberg2001)
⚪ acute neurosis (Scott etal.1984; Hägglin etal.2001)
⚪ schizophrenia (Seeman and Molin1976)
⚪ drug addiction and alcoholism (Pinkham and
Schroeder1975; Berggren and Meynert1984)
⚪ psychotropic drug use (Berggren and Meynert 1984;
Hulland and Sigal2000)
⚪ phobias (Hägglin etal.2001).
4) Patients with severe anxiety when receiving dental
treatment. In these cases, we can highlight a series of
characteristics:
● Basic anxiety. Around 10% of people have high levels
of anxiety with respect to dental treatment (Table8.1),
although they attend their appointments and try to
cope with their anxiety to complete treatment (Molin
and Seeman1970; Kleinknecht and Bernstein1978;
Hall and Edmondson1983; Scott etal.1984). A further 5% have phobias or experience uncontrolled
irrational and extreme fear (Table8.1). Patients with
phobias are not generally problematic with respect to
dental work since their systematic avoidance behavior will result in many canceled or broken appointments. Often, these patients only attend the dentist’s
office when their neglected dental needs have mushroomed into a frank dental emergency such as an
abscess, seeking acute dental treatment and possibly
analgesics and antibiotics (Ayer et al. 1983; Sokol
etal.1985; Locker and Liddle1991; Moore etal.1993).
To overcome their anxiety, these patients may benefit
from psychological treatment or possibly sedation or
general anesthesia (Moore etal.1993).
Local Anesthesia in Dentistry: A Locoregional Approach, First Edition. Jesús Calatayud and Mana Saraghi.
© 2024 John Wiley & Sons Ltd. Published 2024 by John Wiley & Sons Ltd.
Companion website: www.wiley.com/go/Calatayud/local
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Table8.1 Patients who experience anxiety when undergoing
dental treatment.
Levelofanxiety
Reference Low Medium High Phobia
Freidson and Feldman
(1958)
SIFO (1962) —
Gatchel etal. (1983) 71% 17% 5% 6%
Scott etal. (1984) 44% 25% 21% 10%
Rankin and Harris (1984) 65% 21% 8% 6%
Lindsay etal. (1987) 63% 22% 10% 5%
Milgrom etal. (1988) 80% 13% 4% 3%
Stouthard and
Hoogstraten (1990)
Locker and Liddle (1991) — — 8% 4%
Hakeberg etal. (1992) 59% 25% 11% 5%
Moore etal. (1993) 60% 30% 6% 4%
Kaakko etal. (1998) 39% 41% 17% 4%
Ragnarsson (1998) 72% 19% 10% 0.3%
Hägglin etal. (2001) — — 17% —
Percentages rounded to whole units.
● Dental local anesthesia is the factor that causes the
— — — 5%
— — 9–14%
39% 40% 18% 4%
Average 11.2 5.7%
Rounded average 10% 5%
highest levels of anxiety in patients undergoing dental treatment (Lautch1971; Gale1972; Meldman1972;
Berggren and Meynert1984; Scott etal.1984; LeClaire
etal.1988). Seeing the syringe and needle, and feeling
the prick of the needle are the most anxiety-
inducing
components of dental treatment.
● The behavior of anxious adults differs very little from
that of those who are not anxious (McGimpsey1977;
Kleinknecht and Bernstein 1978; Ayer et al. 1983;
Scott et al. 1984), therefore the health questionnaire
should include a direct question on fear of dental
treatment by category, for example five categories (no
fear to very frightened) to identify patients with high
degrees of anxiety (Kleinknecht and Bernstein1978;
Scott and Hirschman1982; Ayer etal.1983).
5) A history of behavioral problems and complications in
previous situations, such as in dental treatment, vaccination, venipuncture for blood sampling, etc. Such
behavior is thought to reoccur in around half of patients
with such a history (Persson 1969; HanningtonKiff1969; McGimpsey1977; Edmondson etal. 1978),
therefore an appropriate question should be included
on the health questionnaire.
EvaluationofRisk
The best way of evaluating the risk of poor behavior is at
the first visit, as follows:
● Review the patient’s health questionnaire to obtain
answers to the following questions:
1) How anxious and fearful does dental treatment
make you?
Not at all ◻
a lot ◻
A little ◻ Moderate ◻ Quite
A lot ◻
2) Have you ever experienced an abnormal reaction,
dizziness, or fainting at the dentist’s office or with
administration of local anesthetic, vaccinations,
blood donations, etc.? Yes ◻
No ◻
3) Are you being treated for any medical conditions?
(Open answer)
4) What medications are you taking, including pre-
scription, over-
the- counter, or herbal supplements?
(Open answer)
5) Do you use alcohol, tobacco, or any other substances?
(Open answer)
The first two questions have already been commented on
above, the last three provide us with information on the
mental and psychiatric status of the patient, as well as
about his/her medical problems and current medication
to determine whether there are absolute or relative contraindications for administration of dental local
anesthetic.
● The clinical examination at the first visit provides us
with information on the risk of poor behavior, especially
in the case of children since they are brought by their
parents. Therefore, apart from age and physical appearance, there are two key moments for predicting disruptive behavior at future visits to the dentist:
⚪ During intraoral radiography.
Difficulty performing these two maneuvers points to a
high risk for administration of local anesthesia at subsequent visits. In contrast, if the examination reveals that
the patient has undergone major restoration work and
complicated dental procedures and the parents report no
special measures having been taken (sedation, medication, etc.), then the patient is likely to behave well since
he/she has been able to undergo the above- mentioned
treatments.
ApproachtoBehavioralProblems
Patients with behavioral problems can be divided into
two groups:
⚪ Patients who can receive local anesthetic but for whom
this is very problematic (e.g., patients who experience
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vasovagal syncope, etc.). In these cases, local anesthesia
should be supplemented with methods to reduce anxiety,
such as a good psychological strategy based on management of the personal relationship with the dentist (Gale
etal. 1984; Maggirias and Locker2002) and conscious
sedation with short-
acting benzodiazepines (triazolam)
and/or nitrous oxide. However, such techniques are
beyond the scope of this book.
⚪ Patients who cannot receive local anesthetic. These
patients require general anesthetic, and adults may
require psychological or psychiatric care (Moore
etal.1993).
ASAIVPhysicalStatus
In 1963, the American Society of Anesthesiologists (ASA)
developed a classification of physical status, which is now
known as the ASA classification (Anonymous 1963;
ASA 2019). This was initially designed to evaluate the
threat to life of patients undergoing general anesthesia,
although since it was introduced it has been extended to
locoregional anesthesia and sedation, as is the case in dentistry (Malamed2007,2010). In this classification, we can
observe the following:
⚪ Some physicians consider patients with two or more con-
ditions to have a higher ASA level than that of each of the
conditions individually. For example, a patient with obesity and a stomach ulcer who is aged more than 65
(all ASA II conditions) is classed as ASA III because of the
fact that he/she has three conditions. ASA II means that
the systemic illnesses are well-
controlled. ASA III by definition means the conditions are not controlled. There is a
degree of subjectivity among clinicians and some will
consider a patient with multiple well-
controlled comorbidities as ASA III, but the author adheres to the definition of ASA II as well- controlled systemic diseases.
⚪ This classification of patients changes over time. For
example, a patient who has had a myocardial infarction
less than 3 months previously is classed as ASA IV,
although if he/she has recovered after 3 months and subsequent progress is good, then he/she can be considered
ASA III. If the condition continues to improve, the
patient can be considered ASA II.
Below, we describe each of the ASA levels and provide
examples, with emphasis on how local anesthesia is contraindicated in ASA IV cases.
ASAIPatients
● Definition: healthy patients, no smoking, no or minimal
alcohol use (ASA2019).
years
● Consequences: good tolerance of physical stress (pain)
and psychological stress (anxiety).
● Relevance in dentistry: can receive local anesthetics and
standard dental treatment with no danger.
ASAIIPatients
● Definition: patients with well- controlled systemic dis-
ease that does not cause limitations.
● Consequences: minor limitations to tolerance of physical
stress (pain) and psychological stress (anxiety).
● Relevance in dentistry: can receive local anesthetics and
standard dental treatment.
● Examples include but not limited to:
⚪ Healthy patients with special circumstances,
such as:
■ Pregnancy in a healthy woman (Malamed2007,2010;
ASA2019).
■ Healthy persons aged >65 years (Malamed
2007,2010).
■ Obesity, body mass index (BMI) 30–40
(McCarthy1982; Jastak etal.1995; ASA2019).
■ Patients who smoke tobacco (McCarthy and
Malamed1979; Abraham-
■ Social alcohol drinker (ASA2019).
⚪ Cardiovascular disease:
■ Controlled arterial hypertension (90–95/
140–160
mmHg) (Abraham- Inpijn et al. 1988;
Inpijn etal.1988).
Malamed2007; ASA2019).
■ Congestive heart failure (caused by myocardial
infarction, vascular disease, rheumatic disease, etc.)
that is moderate and does not cause limitations.
This is also said to be compensated congestive heart
failure (Malamed2007).
■ More than 6 months after a cerebrovascular acci-
dent that did not leave neurological sequelae.
■ Chronic orthostatic hypotension with vertigo or
dizziness (Malamed2007).
⚪ Endocrine- metabolic diseases:
■ Well- controlled diabetes (Malamed 2007, 2010;
Wilson etal.2008; ASA2019).
■ Well- controlled hypo- or hyperthyroidism, i.e., nor-
mal function (euthyroid) (McCarthy 1982;
Malamed2007,2010; Wilson etal.2008).
■ Plasma pseudocholinesterase deficiency (Malamed
2003).
⚪ Respiratory disease:
■ Well- controlled asthma (Malamed 2007, 2010;
Wilson etal.2008).
■ Nonacute upper airway disease (common cold,
influenza) (Malamed2007).
■ Chronic sinusitis (McCarthy and Malamed1979).
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⚪ Central nervous system (CNS) disease:
■ Well- controlled epilepsy with uncommon seizure
episodes (less frequent than once every 3
(Malamed2007; Wilson etal.2008).
■ Psychiatric disorders such as controlled depression
.
months)
(Jastak etal.1995).
■ Extreme fear of dental treatment (phobia)
(McCarthy and Malamed 1979; Malamed 2007).
These patients may require deep sedation or general anesthesia. Local anesthesia may be
contraindicated.
⚪ Other diseases:
■ Rheumatic diseases with chronic joint problems
(arthritis, etc.) that do not require corticosteroids
(Malamed2007).
■ Stomach ulcer (McCarthy1982; Malamed2007).
■ Increased intraocular pressure (glaucoma)
(McCarthy1982; Malamed2007).
■ Allergy to drugs, foods, or latex (McCarthy 1982;
Malamed2007).
ASAIIIPatients
● Definition: patients with severe or uncontrolled systemic
disease that limits activity but is not incapacitating (no
symptoms at rest or with normal exercise).
● Consequences: reduced tolerance to physical stress
(pain) and psychological stress (anxiety).
● Relevance for dentistry: patients can receive local anes-
thetic and standard dental treatment. However, it is
important to take into account the following:
⚪ If in doubt, the patient’s doctor should be consulted.
⚪ The patient may require additional measures such as
sedation to reduce anxiety (oral, intravenous, intramuscular drugs, inhaled nitrous oxide, hypnosis),
antibiotics, etc. Treatment of medically compromised
patients is beyond the scope of this book. Excellent
texts are available on this subject. Here, we only
address the use of locoregional anesthetic in ASA III
patients.
⚪ ASA III patients, especially those with cardiovascular
disease, do not present further severe complications
(arrhythmia, angina pectoris, myocardial infarction,
etc.), although they do have increased minor complications such as tachycardia, dizziness, shaking, etc. It
is therefore recommended that appointments do not
exceed 30 minutes, where possible, since the number of
complications can increase if the session is longer
(Hughes etal.1966; Daubländer etal.1997).
⚪ Some authors suggest using vasoconstrictor- free anes-
thetic solutions. However, this is somewhat problematic because pain– a key factor in ASA III patients– is
not well controlled. Anesthetic solutions with
epinephrine should be used with caution (see
Chapter10).
● Examples include but are not limited to:
⚪ Patients with special circumstances, such as:
■ Morbid obesity (BMI > 40) (ASA2019).
■ Alcohol dependence or abuse (ASA2019).
■ Active hepatitis (ASA2019).
⚪ Cardiovascular disease:
■ Uncontrolled arterial hypertension with moderate
blood pressure values of around
95–115/160–200
mmHg (McCarthy1982; Abraham-
Inpijn etal.1988; Malamed2007,2010).
■ Congestive heart failure (caused by myocardial
infarction, vascular disease, rheumatic disease, etc.)
with breathing difficulty (dyspnea) during exercise
or with nervous tension, although not at rest. This is
decompensated congestive heart failure
(Malamed2007).
■ Implanted pacemaker (ASA2019).
■ More than 3 months after any of the following:
– Cerebrovascular accident that has left neurologi-
cal sequelae (McCarthy and Malamed 1979;
Malamed2007,2010; Wilson etal.2008).
– Heart attack (angina pectoris or acute myocardial
infarction) (McCarthy and Malamed 1979;
Abraham- Inpijn etal.1988; Malamed2007,2010;
Wilson etal.2008).
– Coronary bypass surgery (Perusse etal.1992a).
– Stents in coronary artery disease (ASA2019).
■ Heart transplant: surgical denervation resulting
from removal of the nerve endings in the heart
leaves the heart hypersensitive to the action of catecholamines (Carleton etal.1969; Roca etal.1993;
Meechan etal.2002).
■ Clotting disorders:
– Platelet count >30 000–50 000 (Finucane
etal.2004; Scully and Cawson2005).
– Oral anticoagulants (warfarin, acenocoumarol)
with international normalized ratio (INR) levels
<3.5–4 (Table8.3).
– Hemophiliac patients with clotting factor
>30–50% (we can assume that clotting factor has
been added) (Evans and Aledort 1978;
Segelman 1978; Katz and Terezhalmy 1988;
Jastak etal.1995).
⚪ Endocrine- metabolic diseases:
■ Poorly controlled diabetes (Malamed 2007, 2010;
Wilson etal.2008; ASA2019).
■ Poorly controlled symptomatic hypo- or hyperthy-
roidism (Greenwood and Meechan 2003;
Malamed2007,2010).
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⚪ Respiratory diseases:
■ Poorly controlled asthma (Malamed 2007: Wilson
etal.2008).
■ Poorly controlled chronic obstructive pulmonary
disease (bronchitis, emphysema) with no breathing
difficulty (dyspnea) in habitual daily activities
(Malamed2007; Wilson etal.2008).
⚪ CNS diseases:
■ Epilepsy controlled by drugs but with fewer than
one seizure episode per month (Malamed2007).
⚪ Kidney diseases:
■ More than 3 months after a kidney transplant.
■ Chronic kidney failure requiring regular hemodial-
ysis (Malamed2007; ASA2019).
⚪ Other diseases:
■ Rheumatic disease with chronic joint problems
(arthritis, etc.) requiring corticosteroids
(Malamed2007).
■ Cancer treated on an outpatient basis.
■ Myasthenia gravis (rare disease involving skeletal
muscle weakness) that is stable and mild or moderate (Patil etal.2012).
■ Malignant hyperthermia. Patients who have had
this disease.
■ Patients who have received radiation on the maxil-
lofacial area at risk of osteoradionecrosis.
ASAIVPatients
● Definition: patients with severe systemic disease that is
incapacitating and is constantly life-
threatening. Patients
present symptoms at rest, for example fatigue, dizziness,
shortness of breath, or chest pain.
● Consequences: Poor tolerance of physical stress (pain)
and psychological stress (anxiety).
● Relevance for dentistry:
⚪ Local anesthesia and outpatient dental treatment are
contraindicated in ASA IV patients. These patients are
hospitalized.
⚪ The only outpatient treatment is prescription of drugs
such as analgesics, antibiotics, mouthwash, etc.
● Examples include but not limited to:
⚪ Cardiovascular disease:
■ Severe uncontrolled arterial hypertension, with(out)
treatment, with pressures of >115/>200 mmHg,
owing to the risk of heart attack or cerebrovascular
accident (McCarthy1982; Abraham- Inpijn etal.1988;
Malamed2007).
■ Congestive heart failure (caused by myocardial infarc-
tion, vascular disease, rheumatic disease, etc.) that
causes difficulty breathing (dyspnea) at rest (Perusse
etal.1992a; Malamed2007; Wilson etal.2008).
■ Unstable angina pectoris (Perusse et al. 1992a;
Wilson etal.2008).
■ Treatment- refractory arrhythmia (Perusse
etal.1992a).
■ Less than 3 months after:
– A cerebrovascular accident (McCarthy and
Malamed 1979; Malamed 2007; Wilson
etal.2008).
– Heart attack (angina pectoris or acute myocardial
infarction) (McCarthy and Malamed 1979;
Perusse et al. 1992a; Malamed 2007; Wilson
etal.2008).
– Coronary bypass surgery (Perusse etal.1992a).
– Stents in coronary artery disease (ASA2019).
■ Clotting disorders:
– Platelet count <30 000 (Finucane et al. 2004;
Scully and Cawson2005).
– Oral anticoagulants (warfarin, acenocoumarol)
with INR levels >3.5–4 (Table8.3).
– Hemophiliac patients with clotting factor lower
than 5%, which is usual (Evans and Aledort1978;
Segelman 1978; Katz and Terezhalmy 1988;
Jastak etal.1995; Correa etal.2006).
⚪ Endocrine- metabolic disease:
■ Poorly controlled or uncontrolled insulin-
dependent diabetes (Perusse et al. 1992b;
Malamed2007; Wilson etal.2008).
■ Poorly controlled hyperthyroidism, with frank signs
and symptoms (thyroid storm) (Greenwood and
Meechan2003; Little2006; Malamed2007).
⚪ Respiratory disease:
■ Asthma with frequent attacks that is difficult to
control and requires corticosteroids and admission
to hospital (Perusse et al. 1992b; Steinbacher and
Glick2001; Malamed2007).
■ Chronic obstructive pulmonary disease (bronchi-
tis, emphysema) leading to difficulty breathing
(dyspnea) at rest (Malamed 2007; Wilson
etal.2008).
■ Hereditary angioneurotic edema or angioedema
(Barclay and Edwards1971).
⚪ CNS disease:
■ Poorly controlled epilepsy with frequent seizures
(more than one per week and/or a history of status
epilepticus) (Malamed2007; Wilson etal.2008).
⚪ Kidney disease:
■ Within 3 months of a kidney transplant.
■ End state of renal disease not undergoing regularly
scheduled dialysis (ASA2019).
⚪ Other diseases:
■ Cancer with marked physical involvement, even if
the disease is being treated on an outpatient basis.
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■ Myasthenia gravis (rare disease involving musculo-
skeletal weakness) that is severe and uncontrolled
(Patil etal.2012).
ASAVPatients
● Definition: Dying patient who is unlikely to live more
than 24
● Relevance for dentistry. This type of patient is outside the
hours with or without surgery.
setting of dentistry, since he/she is hospitalized.
ClottingAbnormalities
In cases of severe clotting abnormalities, truncal block
with dental local anesthesia can damage vessels and cause
unstoppable internal bleeding. This can occur if tissues are
lax, leading to a dissecting hematoma that grows gradually
in the parapharyngeal and submandibular space, with
swelling of oral tissues, the face, and the neck as it advances
toward the mediastinum. There may also be difficulty swallowing (dysphagia) and opening the mouth (trismus),
appearance of bloody patches under the skin and oral
mucosa (ecchymosis), and, finally, breathing difficulties
resulting from compression of the airways by the hematoma (Archer and Zubrow 1954; Evans and Leake1964;
Evans and Aledort1978; Mulligan and Weitzel1988). Such
a dramatic clinical picture is very unusual and was associated with mandibular block in hemophiliacs (Archer and
Zubrow1954: Evans and Leake1964).
High-riskAnestheticTechniques
Not all dental local anesthetic techniques carry the same risk
of dissecting hematoma in predisposed patients. Hightechniques are characterized by specific factors. First, the
needle is inserted deep into the tissue and the damaged vessel may be at some distance from the surface. Second, the
tissues are very vascularized, with the result that it is easy to
damage a vessel (Evans and Aledort 1978; Mulligan and
Weitzel1988). Third, as the surrounding tissue is lax and
abundant, it cannot contain the hemorrhage owing to the
absence of pressure (Evans and Aledort1978; Mulligan and
Weitzel1988). Truncal block techniques are the most prob-
lematic (Jastak etal.1995; Wilde1998; Scully and Wolff2002):
⚪ Mandibular block (Sachs et al. 1978; Evans and
Aledort1978; Mulligan and Weitzel1988; Johnson and
Leary 1988; Brewer and Correa 2006; Zaliuniene
etal.2014).
⚪ Maxillary block, both with the high- tuberosity or zygo-
matic approach and with the transpalatal approach or
risk
greater palatine canal approach (Evans and Aledort1978;
Johnson and Leary1988).
⚪ Lingual nerve block or even infiltration of terminal
branches of the lingual nerve in the floor of the mouth
(Brewer and Correa2006; Zaliuniene etal.2014).
Furthermore, while the risk of causing a hemorrhage is
lower with these techniques than with extractions and oral
surgery (Mulligan and Weitzel1988; Dézsi etal.2017), it is
important to remember that bleeding in oral surgery is
external and easier to contain with local measures (gelatin
plugs, collagen, sutures, tranexamic acid, etc.). However,
hemorrhages caused by truncal block are internal and deep
and therefore not easily contained. In fact, there are almost
no local methods other than compression, and even this is
limited. Consequently, truncal block techniques carry a
greater risk than initially thought.
SystemicCausesoftheRiskofHemorrhage
Before commenting on the systemic causes of the risk of
hemorrhage, we must make three observations:
1) Patients generally arrive diagnosed and medicated, as
seen in the health questionnaire.
2) In case of doubt, the patient’s doctor or hematologist
should be consulted to determine the extent of the problem (Katz and Terezhalmy 1988; Brewer and
Correa2006; Zaliuniene etal.2014).
3) Clotting analyses (INR) in patients taking vitamin K
antagonists should be performed on the same day as the
dental procedure or no more than 48 hours later in order
to have reliable data on the situation at the time of the
procedure (Rooney1983; Blinder etal.1999; Scully and
Wolff2002).
AntiplateletAgents
Antiplatelet agents such as aspirin, clopidogrel, dipyridamole, ticlopidine, prasugrel, ticagrelor, etc. inhibit
platelet aggregation (basic function during the initial
phases of clotting). These drugs are prescribed to
patients who have had a heart attack (ischemic heart
disease) in the form of angina pectoris or myocardial
infarction, or patients who have had a cerebrovascular
accident (cerebral thrombosis) to ensure secondary prevention of thromboembolism.
If patients do not stop these medications, they may experience bleeding problems during oral surgery, although
these are less serious than previously thought (Ardekian
etal.2000; Little etal.2002; Becker2008). However, they
are not contraindicated for dental local anesthetics, not
even for truncal block (Dézsi etal. 2017). A 2014 review
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advised not modifying antiplatelet medication during
extractions or oral surgery since bleeding that is not
controlled with local treatment is minimal (0.2%) and can
be controlled in hospital without sequelae. Nevertheless,
although the consequences of stopping treatment are very
unusual (<1% of cases), they are very serious, with thromboembolic complications and myocardial infarction.
Hence, we transmit the idea that the patient must “bleed or
die” (Wahl2014).
In conclusion, these patients can undergo truncal block
or lingual infiltrations.
OralVitaminKAntagonists:Anticoagulants
Oral vitamin K antagonists are coumarin derivatives such
as warfarin and acenocoumarol. They inactivate vitamin K,
thus reducing the action of clotting factors that depend on
it, namely factors II, VII, IX, and X. They are prescribed to
patients at risk of thromboembolism because of an underlying disease such as ischemic heart disease, a prosthetic
heart valve, atrial fibrillation, deep vein thrombosis, etc.
Consequently, they are not easily modified (Rooney 1983;
Benoliel etal.1986; Wahl1998,2000), and the current criterion is to maintain them during oral surgery and extractions (Wahl1998,2000).
The INR (International Normalized Ratio) is a clotting
index based on prothrombin time (PT), which, as a coefficient between the PT of an anticoagulated patient and
the PT of a control sample, represents a standardized
value. This is subsequently corrected according to the
International Sensitivity Index (ISI) and yields very stable
and comparable values (ICSH/ICTH1985; Steinberg and
Moores1995). The normal INR value is 1; the therapeutic
value is 2–5 (Scully and Wolff2002). Of note, the risk of
bleeding increases with the INR because coagulability is
reduced. As a guide, an INR of 3may indicate that clotting
time is three times longer than normal (while this is not
exactly the case, it is approximate and easy to understand).
Clinical trials have shown that patients taking oral anticoagulants who underwent extractions or minor oral surgery did not experience serious bleeding problems because
they were well controlled with local measures (Bailey and
Fordyce1983; Rooney 1983; Benoliel et al.1986; Devani
et al. 1998), even after mandibular block (Bailey and
Fordyce 1983; Devani et al. 1998; Bajkin and
Todorovic2012). Table8.2 shows mean INR values close to
3 and maximum values close to 4 recorded in clinical trials.
Table8.3 shows the maximum recommended INR levels at
which we can perform extractions and oral surgery without
stopping anticoagulant treatment. The absence of unanimity of criteria leads us to recommend a maximum INR
value of 4 for truncal block.
Table8.2 INR values inclinical trials involving patients who
underwent oral surgery, withbleeding controlled using local
measures.
INR
Reference Number Mean Maximum
Ramström etal. (1993) 45 — 4
Borea etal. (1993) 15 3.1 —
Gaspar etal. (1997) 32 2.5 3.5
Devani etal. (1998) 32 2.7 3.9
Blinder etal. (1999) 50 2.7 4
Bajkin and Todorovic (2012) 279 2.6 4
Average 2.72 3.88
Rounded average 3 4
Table8.3 Maximum INR levels recommended by various
authors forextractions andoral surgery.
INR≤ 3 INR≤3.5 INR≤ 4
Weibert (1992) Little etal.
Greenwood
(2008)
(2002)
Scully and
Wolff (2002)
Rhodus and
Little (2003)
Dézsi etal.
(2017)
Lippert and
Gutschik (1994)
Beirne and Koehler
(1996)
Schardt-
Perry etal. (2007)
Becker (2008)
Renton etal. (2013)
Milla and Orlandi
(2014)
Sacco (2000)
In conclusion, as a precautionary measure, we do not
recommend truncal block or lingual infiltrations in patients
with INR values >4.
DirectOralAnticoagulants
New oral anticoagulants, or direct oral anticoagulants, act
by directly inhibiting activated factor II (thrombin) with
dabigatran or activated factor X (Stuart- Power factor)
withrivaroxaban, apixaban, and edoxaban. These new oral
anticoagulants are more predictable and much easier to
manage (González etal.2016; Serrano- Sánchez etal.2017;
Hassona etal.2018). To date, we do not have specific information on their involvement in locoregional anesthesia,
although available data do seem to indicate that there are
no contraindications to truncal block and lingual infiltration with current doses and regimens (Caliskan etal.2017;
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142
Serrano- Sánchez et al. 2017; Bensi et al.2018; Hassona
etal.2018; Lababidi etal.2018).
In conclusion, based on currently available data, which
are in fact scarce, patients taking direct oral anticoagulants
can undergo truncal block and lingual infiltrations.
LowPlateletCounts
Specific diseases such as idiopathic thrombocytopenic
purpura, hypersplenism (excessive activity of the spleen),
chronic liver disease, etc. can reduce the number of circulating platelets during the initial phase of clotting. Platelet
counts are normally 150
although counts above 50
000–400 000 platelets/mm
3
000 platelets/mm
, while low,
involve no risk for extractions and oral surgery (Johnson
and Leary1988; Finucane etal. 2004; Renton etal.2013;
Bal et al. 2014). However, the limit for truncal block is
established at counts lower than 30
000 platelets/mm
(Finucane etal.2004; Scully and Cawson2005).
In conclusion, truncal block and lingual infiltration can
be used in patients with platelet counts >30
3
lets/mm
.
000 plate-
Hemophilia
Hemophilia is a congenital– generally inherited– clotting
factor disorder caused by lack or poor functioning of clotting factors. The most frequent diseases are as follows:
⚪ Factor VIII: hemophilia A or simply hemophilia.
⚪ Factor IX: hemophilia B or Christmas disease.
⚪ Factor XI: hemophilia C or Rosenthal syndrome.
⚪ von Willebrand factor deficiency: pseudohemophilia or
von Willebrand disease.
⚪ Other, rarer deficiencies include those of factors II, V,
VII, X, and XII. Even rarer deficiencies have been
reported (Katz and Terezhalmy1988).
It is interesting to remember that hemophilia C (Murphy
etal.1976; Sachs etal.1978) and von Willebrand disease
(Zakrzewska1983; Wilde1998) may occasionally go unnoticed and first manifest in the dentist’s office after extractions or oral surgery.
These diseases cause the most severe clotting disorders
and have led to the most dramatic cases of bleeding after
mandibular block (Archer and Zubrow 1954; Evans and
Leake1964). Truncal block and extractions, and oral surgery can be performed when clotting factor levels are
greater than 30–50% (Evans and Aledort 1978;
Segelman1978; Katz and Terezhalmy1988) or greater than
50–75% (Renton et al.2013), thus allowing us to assume
that clotting factor has been added. It is important to
remember that the normal level is 100% and that hemophiliacs have less than 5% (Mulkey 1976; Katz and
Terezhalmy 1988; Correa et al. 2006). Furthermore, if
clotting factor is added, the patient should not have
autoantibodies against the clotting factor (Segelman1978).
Other authors directly advise against truncal block techniques (Mulkey1976; Wilde1998).
In conclusion, truncal block and lingual infiltration can
only be used in hemophiliac patients when clotting factors
have been added and levels are above 30–50%. It is important to remember that patients with hemophilia are considered ASA IV if their disease is not controlled.
AlternativesandRecommendations
3
,
● Alternatives to truncal block in cases of clotting disor-
ders include the following:
⚪ Use of a supplementary technique such as the perio-
dontal ligament technique (Mulkey1976; Evans and
3
Aledort1978; Sachs etal.1978; Pin1987; Spuller1988;
Brewer and Correa2006; Zaliuniene etal.2014) or the
intraosseous technique (Brewer and Correa 2006;
Zaliuniene etal.2014).
⚪ Periapical infiltration can be used instead of mandibu-
lar block in children with temporary molars
(Dudkiewicz etal. 1987; Donohue et al. 1993). The
same approach can be applied in permanent molars in
adults, although treatment requires a potent solution,
such as articaine 4% with epinephrine 1:100.000
(Annex 31; Brewer and Correa 2006; Zaliuniene
etal.2014).
⚪ Alternatively, we can use electronic dental anesthesia
(EDA) (Savage1982), although this has a less potent
effect (see Chapter20).
● The preferred approach in these patients is local anes-
thetic with a vasoconstrictor (mainly epinephrine), if
there are no contraindications, because this helps to con-
trol bleeding (Mulkey 1976; Bisch et al. 1996; Devani
etal.1998; Scully and Wolff2002; Zaliuniene etal.2014)
and increases the efficacy of anesthesia.
OtherContraindications
InjectionSiteInfection
Injections in areas of the mouth with acute infection are
initially contraindicated for the following reasons:
1) The effect of the anesthetic is much less intense
(Lewis1919: Kramer and Mitton1973):
⚪ Neurodegenerative changes in the axons of the
inflamed area alter the thresholds of excitability and
extend along the course of the nerve (Najjar 1977;
Brown 1981; Wallace et al. 1985; Taylor and
Byers1990).
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