1. LA Management of Special Ptient
Iyad M.Abou Rabii

2. 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
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3. 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.
 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.
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4. 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
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5. 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.
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6. 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
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7. 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
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8. 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
 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)
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9. 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.
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10. 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.
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11. 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.
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12. 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
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13. 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.
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14. 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
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15. 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
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16. 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.
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17. Sedation : Who
 Autism or Other Special Needs
Our sedation dentistry practices are a solution for patients with physical or
mental challenges, and for individuals emotionally uncomfortable in the
traditional dental office setting. Dental anesthesia services can provide a
way to accomplish complete dental care in a more pleasant experience.
 Cancer
Patients dealing with cancer have enough to worry about without the
added stress of dental care. Treatments such as radiation and
chemotherapy often call for dental care that not all dentists are willing or
qualified to perform. When you need a dentist who understands the
complexities of cancer treatment, you can turn to Dr. Lee Lichtenstein and
staff.
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18. 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.
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19. 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.
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20. 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
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21. 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.
(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.
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22. 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.
(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.
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23. Don’t Forget other needs
 Antibiotics
 Drug-Drug interaction
 Drug physiological
 Post operation topical fluoride application

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24. Copyright notice
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Dr Iyad Abou Rabii
Iyad.abou.rabii@qudent.edu.sa
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