Chapter 7

Preanesthetic Assessment

Copyright © 2012 by Mosby, an imprint of Elsevier Inc.

 Learning Objectives

• Determine how to interpret a patient’s medical history to assess the

relative risk of administering local anesthesia.
• Differentiate between relative and absolute contraindications.
• Discuss the role emotional status, blood pressure, and pulse have on
selection/utilization of local anesthetics.

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 Learning Objectives

• Evaluate blood pressure as it relates to administering local anesthesia.

• List the concerns for patients with malignant hyperthermia,
hyperthyroidism, methemoglobinemia, allergies, cocaine addiction, heart
conditions, stroke, diabetes, liver or kidney disease, atypical
plasmacholinesterase, and bleeding disorders when selecting local
anesthetics and scheduling treatment.

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 Learning Objectives

• Recite the prophylactic premedication dose for clindamycin and amoxicillin

for patients at risk for endocarditis.
• Explain the differences between synergism and antagonism with regard to
multiple drug administration.
• Describe the Drug/Drug Interactions that may occur between the
vasoconstrictor and other drugs.

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Importance of Preanesthetic Patient
Assessment
• Assists in the appropriate technique, agent selection, and dosage of
anesthetic
• Prevents or minimizes anesthetic complications or emergencies

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How to Effectively and Appropriately Evaluate a
Patient:
• Comprehensive health history
• Comprehensive dental history
• Dialog, conversation, questions, & LISTENING
• Observation
• Physical
• Psychological
• Consultation
• Best Practices – Staying Current !

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Physical Examination

• Visual Exam: Patient’s general health and well-being

• Posture
• Body movements
• Speech patterns
• Skin

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 Clinical signs of moderate anxiety
Modified from Darby M, Walsh M: Dental hygiene theory and practice, ed 3, St.
Louis, 2010, Saunders, Elsevier.

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 Effects of stress on the body

Darby M, Walsh M: Dental hygiene theory and practice, ed 3, St. Louis, 2010,
Saunders, Elsevier.
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Benefits of Taking Patients’ Vital Signs

• Provides a baseline for standard of comparison

• Identification of diagnosed or undiagnosed conditions
• May require modifications to treatment, drug
selection, and/or drug dosage
• Documentation

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What We Know About Blood Pressure (BP)

• Administration of a local anesthetic agent will elevate existing BP

• Administration of a local anesthetic agent will elevate existing BP of
an anxious patient even more
• If patient has high blood pressure, limit or avoid use of
vasoconstrictor

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 Adult BP guidelines
Darby M, Walsh M: Dental hygiene theory and practice, ed 3, St. Louis, 2010,
Saunders, Elsevier.
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 Proper placement of BP cuff
Darby M, Walsh M: Dental hygiene theory and practice, ed 3, St. Louis, 2010,
Saunders, Elsevier.
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 Common mistakes in BP detection
Darby M, Walsh M: Dental hygiene theory and practice, ed 3, St. Louis, 2010,
Saunders, Elsevier.
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 Acceptable ranges of heart rate
Modified from Potter PA, Perry AG: Fundamentals of nursing, ed 7, St. Louis,
2009, Mosby.
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 Factors that influence heart rate
Modified from Potter PA, Perry AG: Fundamentals of nursing, ed 7, St.
Louis, 2009, Mosby.
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 Acceptable ranges of respiratory rate
Modified from Potter PA, Perry AG: Fundamentals of nursing, ed 7, St. Louis,
2009, Mosby.
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 Weight
• PURPOSE: The weight of the patient is used to determine the patient’s
maximum recommended dose (MRD) of local anesthetic.
• Determine MRD before administering anesthetic
• Lower MRD for children with excess weight

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Psychological Evaluation: Attitude & Fears

• Past dental experiences – good, bad, indifferent

• Life stresses – divorce, death in family, trauma
• Medical stresses – angina, asthma, hyperventilation, seizures,
vasodepressor syncope
• Physical symptoms
• Increase in vital signs
• Observations – movements, skin color, sweats, posture, trembling, verbal
communication

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 Common Origins of dental fear
Darby M, Walsh M: Dental hygiene theory and practice, ed 3, St. Louis, 2010,
Saunders, Elsevier.
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 Clinical signs of moderate anxiety
Modified from Darby M, Walsh M: Dental hygiene theory and practice, ed
3, St. Louis, 2010, Saunders, Elsevier.
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 Brief Review

• Pain threshold is the point at which a sensation starts to be painful and

discomfort results. Pain threshold may vary between and among individuals.
• Pain perception is a neurologic experience of pain and related to the process
of receiving pain stimuli and transmission of these stimuli to the brain. Differs
little between individuals.
• Pain reaction is the personal interpretation and response.

Copyright © 2012 by Mosby, an imprint of Elsevier

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 Effects of stress on the body
Darby M, Walsh M: Dental hygiene theory and practice, ed 3, St. Louis, 2010,
Saunders, Elsevier.
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 Stress reduction protocols
Modified from Darby M, Walsh M: Dental hygiene theory and practice, ed 3, St.
Louis, 2010, Saunders, Elsevier.
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Benefits of adequate pain control and nonsurgical
periodontal therapy
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 Selection of Local Anesthetic for the Anxious
Patient
• Local anesthetics, absorbed into the system and prior to biotransformation,
will affect the CNS and the CVS
• Low blood levels – Anticonvulsant properties
• High blood levels - CNS depression
• Much higher levels – biphasic
• Phase I - excitatory signs
• Phase II – depressive signs

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 Selection of Local Anesthetic for the Anxious
Patient
• The potentially adverse actions of the released catecholamines on
cardiovascular function in the patient with clinically significant heart or
blood vessel disease warrants the inclusion of vasoconstrictors, even in
limited amounts, in the local anesthetic solution.
• Anesthetic with 1:200,000 epinephrine – safely receive 4.4 cartridges

Copyright © 2012 by Mosby, an imprint of Elsevier

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 ASA physical classification system
Little JW, Falace DA, Miller CS, Phodus NL: Dental management of the medically
compromised patient, ed 7, St. Louis, 2008, Mosby.
Malamed SF: Handbook of local anesthesia, ed 5, St. Louis, 2004, Mosby.
Copyright © 2012 by Mosby, an imprint of Elsevier
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 Modifications to The Use of Vasoconstrictors
Modified from Little JW, Falace DA, Miller CS, Phodus NL: Dental
management of the medically compromised patient, ed 7, St. Louis, 2008,
Mosby.
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2 Categories of Contraindications to Local
Anesthetics and Vasoconstrictors
• Absolute contraindication – the administration of the offending drug
increases the possibility of a life-threatening situation and should not be
administered to the individual under any circumstances.
• Relative contraindication – the administration of the offending drug is
preferably avoided because of the increased possibility of an adverse reaction
to the drug.

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Relative contraindication
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commonly prescribed tricyclic antidepressants
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Tricyclic Antidepressants PLUS Local Anesthetics
with Vasoconstrictor

• + epinephrine = Increase in blood pressure twofold

• + levonordefrin and norepinephrine = Increase in blood pressure fivefold
• + patient with arrhythmias = even greater concern

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commonly prescribed non-selective beta blockers
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Nonselective Beta Blockers
• + epinephrine (not to exceed 0.04 mg per appointment) Watch for
possible reactions!
• Monitor and document preanesthetic and postanesthetic vital signs
• Monitor patient throughout treatment

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Cardiac Drugs

• Digitalis glycosides (used for treatment of congestive heart failure) +

epinephrine = increased potential for cardiac arrhythmias

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Adrenergic Neuron Blockers (Phenothiazine)

• Phenothiazine is an alpha blocker that antagonizes the beta effects of

epinephrine.
• Phenothiazine (such as Haldol and Thorazine) may reverse the pressor
effect of vasoconstrictors resulting in an increased risk of hypotension.
• Relative contraindication; administer minimal effective dose.

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 Cocaine
• A local anesthetic drug that significantly stimulates the CNS and CVS
• Stimulates the release of norepinephrine
• Inhibits the adrenergic nerve reuptake causing:
• Tachycardia
• Severe hypertension
• Arrhythmias
• Cocaine + vasoconstrictor = myocardial infarction
• Do not administer vasoconstrictor

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Vasoconstrictors & Cardiovascular Disease
Interactions
• Vasoconstrictors are an absolute contraindication:
• BP > 200/115
• Heart attack or stroke within last 6 months
• History of severe cardiovascular disease
• Daily episodes of angina pectoris or unstable angina
• Cardiac dysrhythmias
• Coronary artery bypass surgery within last 6 months

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Vasoconstrictors & Uncontrolled
Hyperthyroidism
• Vasoconstrictors are an absolute contraindication
• Sensitive to catecholamines, which may cause an exaggerated response to
vasoconstrictors
• Use could result in cardiac stimulation, thyroid crisis, thyroid storm
• Controlled hyperthyroidism – relative contraindication
• Minimum effective dose epinephrine (not to exceed 0.04 mg per appt.)

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Vasoconstrictors & Uncontrolled Diabetes
• Refer to physician prior to treatment
• Use of vasoconstrictor is absolute contraindication
• Controlled diabetes – relative contraindication
• Minimum effective dose epinephrine not to exceed 0.04 mg per appointment

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absolute contraindications
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Allergies
• Esters or Amides?
• Why do patients claim that they are allergic to local anesthetics?
• Misinformation
• Misdiagnosis
• Confusion of rapid adrenergic symptoms from vasoconstrictor or a local
anesthetic overdose with an allergic reaction

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True allergic reactions:
Absolute contraindication
• Sodium bisulfite or metabisulfite
• Sulfites

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• Ester Derivative Anesthetic Drug/Drug Interactions
• Cholinesterase inhibitors
• Sulfonamides
• Atypical plasma cholinesterase
• Amide Derivative Anesthetic Drug/Drug Interactions
• Cimetidine (Tagamet)
• Beta blockers
• Malignant hyperthemia
• Methemoglobinemia
• Liver disease
• Kidney disease
• Pregnancy
• Bleeding disorders

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Ester Derivative Anesthetic Drug/Drug Interactions
Cholinesterase Inhibitors

• Treatment of myasthenia gravis & glaucoma

• Relative contraindication to ester anesthetics because if cholinesterase is
inhibited, the ester derivatives that are metabolized primarily in the
bloodstream by plasma cholinesterase are more slowly broken down and
systemic toxicity may result.
• Administer amide – injectable and topical

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Ester Derivative Anesthetic Drug/Drug Interactions
Sulfonamides

• Remember that ester local anesthetics undergo hydrolysis to PABA

• Problem: Sulfonamides competitively inhibit PABA in microorganisms
• Meaning: PABA may antagonize the antibacterial activity of sulfonamines,
rendering them ineffective
• Administer amide – injectable and topical

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Ester Derivative Anesthetic Drug/Drug Interactions
Atypical Plasma Cholinesterase

• Remember cholinesterase enzymes metabolize ester anesthetics and the

amide articaine
• Atypical plasma pseudocholinesterace is an uncommon autosomal recessive
genetic trait
• 1 in every 2820 individuals
• Administer amide anesthetics – except articaine

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Amide Derivative Anesthetic Drug/Drug Interactions
Cimetidine (Tagamet)

• Type of antihistamine that blocks the release of stomach acid; used to

treat stomach or intestinal ulcers
• Decreases hepatic blood flow and inhibits hepatic metabolism of amides
• Increases the half-life of amide anesthetic, thus increasing the risk of toxic
overdose
• Relative contraindication – administer minimum effective dose

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Amide Derivative Anesthetic Drug/Drug Interactions
Beta Blockers

• Beta blockers are antihypertensives

• Share same effect as Tagamet
• Decreases hepatic blood flow and inhibits hepatic metabolism of amides
• Increases the risk of toxic overdose
• Relative contraindication – administer minimum effective dose

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Amide Derivative Anesthetic Drug/Drug Interactions
Malignant Hyperthermia

• An inherited syndrome triggered by exposure to certain drugs used for general

anesthesia and the neuromuscular blocking agent, succinylcholine.
• Produces uncontrolled skeletal muscle oxidative metabolism, which
overwhelms the body’s capacity to supply oxygen, remove carbon dioxide, and
regulate body temperature.
• Eventually leads to circulatory collapse & death
• Relative contraindication for patients with a history of malignant hyperthermia

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 Amide Derivative Anesthetic Drug/Drug
Interactions Methemoglobinemia

• A rare hereditary condition characterized by the inability of the blood to

bind to oxygen
• Produced by prilocaine & possibly topical benzocaine
• Prilocaine is metabolized to ortho-toluidine
• Relative contraindication to prilocaine

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Amide Derivative Anesthetic Drug/Drug Interactions
Liver Disease (Cirrhosis, Hepatitis B)

• Interrupts the biotransformation of the amides that are primarily

metabolized in the liver, which leads to systemic toxicity
• Relative contraindication – use minimum effective dose
• Alternatives:
• Articaine - metabolized in plasma
• Prilocaine – metabolized in lungs

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 Amide Derivative Anesthetic Drug/Drug
Interactions Kidney Disease
• Only a small percentage of unmetabolized local anesthetics are excreted by
the urine
• Patients who have significant renal dysfunction could possibly develop a
toxic level of anesthetic in their blood
• Risk is low; however, it is recommended to use the minimum effective dose

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Amide Derivative Anesthetic Drug/Drug
Interactions Pregnancy

• Local anesthetics administered during pregnancy are not teratogenic

• Relative contraindication to elective dental treatment
• Recommend consult with patient’s physician
• Elective dental hygiene care with anesthesia can occur in any trimester;
however, the conservative approach is to wait until second trimester
• Choose a drug in category B pregnancy class

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Pregnancy risk classification
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Amide Derivative Anesthetic Drug/Drug
Interactions Bleeding Disorders
• Assess patient for the potential to develop excessive bleeding as a
result of puncturing a blood vessel
• Injections that pose a greater risk of positive aspiration include: PSA,
IANB, IO
• Use infiltration anesthesia

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Copyright © 2012 by Mosby, an imprint of Elsevier
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Review: Dental Considerations
• Evaluate the patient’s physical ability to tolerate the administration of local
anesthesia or vasoconstrictor – through a comprehensive medical history!
• Evaluate the patient’s attitude and fears before anesthesia
• Consult with medical physician or specialist
• Calculate MRD prior to administration of drugs

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Review: Dental Considerations

• Implement stress reduction protocols

• Remember: true allergic reactions are rare; if an allergic reaction exists, it
will most likely be due to sodium bisulfite, the vasoconstrictor preservative
• Patients will confuse signs and symptoms of an anesthetic or
vasoconstrictor overdose with an allergic reaction

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Review: Dental Considerations
• Delay treatment if patient has had a heart attack or stroke within last 6
months
• Consider that a diminished liver function will increase the half-life of the
amides metabolized in the liver, increasing the risk for overdose
• Vasoconstrictors + cocaine use = life-threatening situation
• Take preanesthetic vital signs to establish a baseline

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Review: Dental Considerations

• Pain control throughout the appointment and postappointment will reduce

patient stress and anxiety
• Absolute drug contraindication means the drug should not be administered
under any circumstances
• Relative drug contraindication means the drug can be administered
judiciously but precautions should be taken

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Review: Dental Considerations

• Be familiar with all absolute and relative contraindications to local

anesthetic and vasoconstrictor drugs
• Review these contraindications periodically during practice: stay current!
• Avoid block injections (PSA, IO, IANB) on patients with bleeding disorders

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Questions ?

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