Anesthesia: To Block or Not to Block?

Dental providers can treat under local anesthesia if the patient is properly infused when indicated. There are no restrictions regarding the type of local anesthetic agent although those with vasoconstrictors may provide additional local hemostasis. In addition, dental providers must advise patients and parents of children with bleeding disorders about the risks of local oral trauma prior to the anesthetic wearing off.⁵⁰ There exist historic case reports of inferior alveolar nerve blocks leading to life threatening hemorrhage and airway compromise in individuals with untreated hemophilia. Therefore, nerve blocks in patients with bleeding disorders are controversial.

When considering use of an inferior alveolar nerve block, the following guidelines should be followed:

• Must be given with extreme caution and only by an experienced provider

• Administered only when the patient is properly infused with factor

• Administered only when absolutely necessary to achieve profound anesthesia. In these cases, the dental provider must weigh the risk-benefit before proceeding even in cases where the patient has been properly infused.

• Whenever possible, use 4% articaine 1:100,000 epi and local infiltration

• Avoid floor of mouth injections

• It is essential to understand the positive aspiration of a blood vessel and/or injury to muscle can result in airway blockage and death.^51,52 In the case of a positive aspiration, the dental provider must inform the patient as the patient will require factor concentrate replacement and/or emergency room treatment. The hematology team must also be contacted.

Other alternatives and considerations:

• The intraligamentary or interosseous techniques should be considered instead of the mandibular block.

• Buccal infiltration with articane can be used to anesthetize the lower molar teeth as an alternative to a mandibular block.