Porphyria Educational Services

PORPHYRIA EDUCATIONAL SERVICES Bulletin Vol. 1 No. 13 March 1999
DENTAL ANESTHETICS AND THE PORPHYRIC

There are all kinds of anesthetics used by dentists for numbing your gums while they work on your teeth. Some are very safe, but a lot of the newer ones are considered unsafe. Why unsafe you ask? Many of the newer drugs are combinations of the older ones put together with others that are newer or are contraindicated for porphyrics. Old-fashioned Novacaine is one thing, but having that "caine" suffix included in newer dental anesthetics does not make it safe.

It is most important to remember that COCAINE is definitely an UNSAFE DRUG for porphyrics. Many of the drugs have trace amounts of cocaine contained within their compound makeup.

The following are today's leading dental anesthetics. Since every porphyric reacts to pharmaceuticals differently, These will be left as they appear within the dental drug handbook.

RAVOCAINE® HCl 0.4% NOVOCAIN ® 2% with LEVOPHED® 1:30,000 PROPOXYCAINE HCl, PROCAINE HCl, and NOREPINEPHRINE BITARTRATE INJECTION, USP This is manufactured by Cook-Waite from Kodak.

Description: A local anesthetic combination in the para-aminobenzoic acid ester group, containing propoxycaine HCl 4 mg, procaine HCl 20 mg, norepinephrine bitartrate 0.067 mg.

Pharmacology: Stabilizes the neuronal membrane and prevents the initiation and transmission of nerve impulses, thereby effecting local anesthesia. The onset of action is usually 2-5 minutes, and the duration of action is from 2-3 hours. Norepinephrine bitartrate is a sympathomimetic amine suitable for use as a vasoconstrictor in local anesthetic solutions. Indications: For the production of local anesthesia for dental procedures by infiltration injection or nerve block in adults and children.

Contraindications: Hypersensitivity to local anesthetics of the para-aminobenzoic acid ester group.

Precautions: The lowest dose that results in effective anesthesia should be used to avoid high plasma levels and serious undesirable systemic side effects, hypertension, arteriosclerotic heart disease, cerebral vascular insufficiency, heart block, thyrotoxicosis, and diabetes. Contains a sulfite that may cause allergic-type reactions including anaphylactic symptoms and life-threatening or less severe asthmatic episodes in certain susceptible people. Debilitated, elderly patients, acutely ill patients, and children should be given reduced doses commensurate with their weight and physical status.

Young children should be given minimal doses of both sedative and anesthetics, if both are used. It should be remembered that young children from porphyric families who have not yet been tested should avoid any unsafe anesthetic.

Patients with a history of drug sensitivity or allergy, pregnancy Category C, nursing mothers. Mild or even severe headaches may be produced by the systemic action of norepinephrine.

Drug Interactions: MAO inhibitors, tricyclic antidepressants, phenothiazines.

Adverse Reactions: CNS reactions are characterized by excitation and/or depression. Nervousness, dizziness, blurred vision, or tremors may occur followed by drowsiness, convulsions, unconsciousness, and possibly respiratory arrest. Depression of the myocardium, hypotension, profound bradycardia, and cardiac arrest. Allergic reactions, characterized by cutaneous lesions of delayed onset, or urticaria, edema, and other manifestations of allergy.

MARCAINE® HCl 0.5% with EPINEPHRINE 1:200,000 (BUPIVACAINE and EPINEPHRINE INJECTION, USP)
Cook-Waite from Kodak Description: Marcaine is related chemically and pharmacologically to the aminoacyl local anesthetics. It is a homologue of mepivacaine and is chemically related to lidocaine. All three of these anesthetics contain an amide linkage between the aromatic nucleus and the amino or piperdine group.

Pharmacology: Marcaine stabilizes the neuronal membrane and prevents the initiation and transmission of nerve impulses, thereby effecting local anesthesia. The onset of action following dental injections is usually 2-10 minutes and anesthesia may last 2 or 3 times longer than lidocaine and mepivacaine for dental use, in many patients up to 7 hours. The duration of anesthetic effect is prolonged by the addition of epinephrine 1:200,000.

Indications: For the production of local anesthesia for dental procedures binfiltration injection or nerve block in adults.

Contraindications: Hypersensitivity to it or to any local anesthetic agent of the amide-type or to other components of MARCAINE solutions.

Precautions: Existence of hypertension, arteriosclerotic heart disease, cerebral vascular insufficiency, heart block, thyrotoxicosis and diabetes, patients receiving drugs likely to produce alterations in blood pressure. Not recommended for children under 12. Contains a SULFITE that may cause allergic-type reactions. **Remember that porphyrics can not use any of the Sulpha containing type drugs. Debilitated, elderly patients and acutely ill patients should be given reduced doses. Patients should be cautioned about the possibility of inadvertent trauma to tongue, lips, and buccal mucosa and advised not to chew solid foods or test the anesthetized area by biting or probing. Changes in sensorium such as excitation, disorientation, drowsiness may be early indications of a high blood level of the drug and may occur following inadvertent intravascular administration or rapid absorption. Use cautiously in areas with limited blood supply. Peripheral vascular disease, severe LIVER disease.

**Please note that hepatic porphyrias are considered liver disease.

Use with caution when there is inflammation and/or sepsis in the region of the proposed injection.
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Drug Interactions: Monoamine oxidase inhibitors, tricyclic antidepressants, vasopressor drugs, ergot-type oxytocic drugs, phenothiazines, butyrophenones.

Adverse Reactions: Blood pressure changes (usually hypotension), cardiac arrest, allergic reactions, hypersensitivity, transient facial swelling and puffiness, CNS reactions are characterized by excitation or depression. Nervousness, dizziness, blurred vision, or tremors, followed by drowsiness, convulsions, unconsciousness, and possibly respiratory arrest. Nausea, vomiting, chills, constriction of the pupils, tinnitus, depression of the myocardium, edema.

LIDOCAINE HCl 2% and EPINEPHRINE 1:50,000 INJECTION LIDOCAINE HCl 2% and EPINEPHRINE 1:100,000 INJECTION (LIDOCAINE and EPINEPHRINE INJECTION,USP)
Cook-Waite from Kodak Description: Lidocaine HCl injections are sterile nonpyrogenic isotonic solutions that contain a local anesthetic agent with epinephrine (as bitartrate) and are administered parenterally by injection.

Pharmacology: Lidocaine stabilizes the neuronal membrane by inhibiting the ionic fluxes required for the initiation and conduction of impulses, thereby effecting local anesthetic action.

Onset and duration of anesthesia: infiltration anesthesia, time of onset averages less than 2 minutes. Lidocaine provides an average pulp anesthesia of at least 60 minutes with an average duration of soft tissue anesthesia of approximately 2.5 hours. When used for nerve block the time of onset averages 2-4 minutes Lidocaine provides an average pulp anesthesia of at least 90 minutes with an average duration of soft tissue anesthesia of 3.25 hours.

Contraindications: Hypersensitivity to local anesthetics of the amide type.

Precautions: Contains sodium metabisulfite, a SULFITE that may cause allergic-type reactions. [*Remember again that this is a part of the Sulfa family of drugs.] Debilitated, elderly patients, acutely ill patients, and children should be given reduced doses commensurate with their age and physical condition. Used with caution in patients with severe shock or heart block. Used cautiously in areas of the body supplied by end arteries or having otherwise compromised blood supply, or patients with peripheral vascular disease, hypertensive vascular disease, hepatic disease, or impaired cardiovascular function.

Drug Interactions: Monoamine oxidase inhibitors, tricyclic antidepressants or phenothiazines, vasopressor drugs, ergot-type oxytocic drugs.

Adverse Reactions: CNS manifestations are excitatory and/or depressant characterized by lightheadedness, nervousness, apprehension, euphoria, confusion, dizziness, drowsiness, tinnitus, blurred or double vision, vomiting, sensations of heat, cold or numbness, twitching, tremors, convulsions, unconsciousness, respiratory depression and arrest. Drowsiness is usually an early sign of high blood level. Bradycardia, hypotension, and cardiovascular collapse which may lead to cardiac arrest. Allergic reactions are characterized by cutaneous lesions, urticaria, edema or anaphylactoid reactions and are extremely rare.

DURANEST® (ETIDOCAINE HCl) INJECTIONS FOR INFILTRATION AND NERVE BLOCK By Astra Description: Sterile aqueous solutions that contain a local anesthetic agent and are administered parenterally by injection.

Pharmacology: Etidocaine stabilized the neuronal membrane by inhibiting the ionic fluxes required for the initiation and conduction of impulses, thereby effecting local anesthetic action. Has a rapid onset (3-5 minutes) and prolonged duration of action (5-10 hours). Initial onset of sensory analgesia and motor blockade is rapid (usually 3-5 minutes) and similar to that produced by lidocaine.

Indications: Solutions are indicated for infiltration anesthesia, peripheral nerve blocks, and central neural block.

Contraindications: Hypersensitivity to local anesthetics of the amide type.

Precautions: To avoid intravascular injection, aspiration should be performed before the local anesthetic solution is injected. Contains sodium metabisufite, a SULFITE that may cause allergic-type reactions.[**Again remember this is from the Sulfa family of drugs.] The lowest dosage that results in effective anesthesia should be used.

Debilitated, elderly patients, acutely ill patients, and children should be given reduced doses commensurate with their age and physical condition. Use with caution in patients with severe shock or heart block, existing neurological disease, spinal deformities, septicemia, severe hypertension, peripheral vascular disease. Areas of the body supplied by end arteries or having otherwise compromised blood supply. Severe hepatic disease, impaired cardiovascular function. May be a potential triggering agent for familial malignant hyperthemia.

Drug Interactions: Monoamine oxidase inhibitors, tricyclic antidepressants or phenothiazines, vasopressor drugs, ergot-type oxytocic drugs.

Adverse Reactions: CNS manifestations are excitatory and/or depressant and may be characterized by lightheadedness, nervousness, apprehension, euphoria, confusion, dizziness, drowsiness, tinnitus, blurred or double vision, vomiting. Cardiovascular manifestations are usually depressant and are characterized by bradycardia, hypotension, and cardiovascular collapse which may lead to cardiac arrest. Allergic reactions are usually characterized by cutaneous lesions, uticaria, edema or anaphylactoid reactions. Drowsiness following the administration of etidocaine is usually an early sign of high blood level of the drug and may occur as a consequence of rapid absorption.

DYCLONE (DYCLONINE HCl) 0.5% and 1% TOPICAL SOLUTIONS, USP Astra Description: A local anesthetic agent administered topically. Dyclone 0.5% solution contains dyclonine HCl, 5 mg. Dyclone 1% solution contains dyclonine HCl, 10 mg.

Pharmacology: Affect surface anesthesia when applied topically to mucous membranes. Anesthesia usually occurs from 2-10 minutes after application and persists for approximately 30 minutes.

Indications: For anesthetizing accessible mucous membranes. May also be used to block the gag reflex, to relieve the pain of oral ulcers or stomatitis, and to relieve pain associated with anogenital lesions. Useful as a preinjection mucous membrane anesthetic or applied to the gums prior to scaling (prophylaxis).

Contraindications: Hypersensitivity to the local anesthetic or to other components of Dyclone solutions.

Precautions: Should not be injected into tissue or used in the eyes because of highly irritant properties.Use with extreme caution in the presence of sepsis or severely traumatized mucosa in the area of application since under such conditions there is the potential for rapid systemic absorption. Patients with severe shock or heart block. mothers. Safety and effectiveness in children under 12 have not been established.

Adverse Reactions: CNS manifestations are excitatory and/or depressant and may be characterized by lightheadedness, nervousness, apprehension, euphoria, confusion, dizziness, drowsiness, tinnitus, blurred or double vision, vomiting, sensations of heat, cold, or numbness. Drowsiness following the administration of Dyclone is usually an early sign of a high blood level of the drug and may occur as a consequence of rapid absorption. Cardiovascular manifestations are usually depressant and are characterized by bradycardia, hypotension.

CITANEST® FORTE (PRILOCAINE and EPINEPHRINE INJECTION, USP) 4% INJECTION with EPINEPHRINE 1:200,000 Astra CITANEST® PLAIN(PRILOCAINE HCP) INJECTION, USP) 4% INJECTION Astra Description: Citanest Plain is a sterile isotonic solution containing 4% prilocaine HCl. Citanest Forte contains 4% prilocaine HCl and a vasoconstrictor, epinephrine (as bitartrate). Citanest Plain-maximum pain control averaging 20 minutes (infiltration), 60 minutes (nerve block).

Pharmacology: Prilocaine stabilizes the neuronal membrane by inhibiting the ionic fluxes required for the initiation and conduction of nerve impulses, thereby effecting local anesthetic action. Onset and duration of action: When used for infiltration injection in dental patients, the time of onset of anesthesia with Citanest Contraindications: Hypersensitivity to local anesthetics of the amide type or to any components of the injectable formulations, and in those rare patients with congenital or idiopathic methemoglobinemia.

Precautions: Citanest Forte contains a SULFITE that may cause allergic-type reactions including anaphylactic symptoms. Debilitated, elderly patients, acutely ill patients, and children should be given reduced doses commensurate with their age and physical condition. Patients with severe shock or heart block, vasoconstrictor should be used with caution in areas of the body supplied by end arteries or having otherwise compromised blood supply, peripheral vascular disease, hypertensive vascular disease, potent general anesthetic agents. Restlessness, anxiety, tinnitus, dizziness, blurred vision, tremors, depression or drowsiness should alert the practitioner to the possibility of central>nervous system toxicity. Hepatic disease, pregnancy Category B, nursing mothers. Drowsiness following the administration of prilocaine is usually an early sign of a high blood level of the drug and may occur as a consequence of rapid absorption. Cardiovascular manifestations are usually depressant and are characterized by bradycardia hypotension and cardiovascular collapse, which may lead to cardiac arrest.

Drug Interactions: MAO inhibitors, tricyclic antidepressants, phenothiazines, vasopressor drugs, ergot-type oxytocic drugs.

Adverse Reactions: Allergic reactions are characterized by cutaneous lesions, urticaria, edema or anaphylactoid reactions. CNS manifestations are excitatory and/or depressant and may be characterized by lightheadedness, nervousness, apprehension, euphoria, confusion, dizziness, drowsiness, tinnitus, blurred or double vision, vomiting, sensations of heat, cold or numbness, twitching, tremors, convulsions, unconsciousness, respiratory depression and arrest. Swelling and persistent parasthesia of the lips and oral tissue may occur.

CITANEST® FORTE (PRILOCAINE and EPINEPHRINE INJECTION, USP) 4% INJECTION with EPINEPHRINE 1:200,000 Astra CITANEST® PLAIN (PRILOCAINE HCL INJECTION, USP) 4% INJECTION Astra Description: Citanest Plain is a sterile isotonic solution containing 4% prilocaine HCl. Citanest Forte contains 4% prilocaine HCl and a vasoconstrictor, epinephrine (as bitartrate). Citanest Plain-maximum pain control averaging 20 minutes (infiltration), 60 minutes (nerve block).

Pharmacology: Prilocaine stabilizes the neuronal membrane by inhibiting the ionic fluxes required for the initiation and conduction of nerve impulses, thereby effecting local anesthetic action. Citanest Forte injections averages less than 3 minutes, with an average Contraindications: Hypersensitivity to local anesthetics of the amide type or to any components of theinjectable formulations, and in those rare patients with congenital or idiopathic methemoglobinemia.

Precautions: Citanest Forte contains a sulfite that may cause allergic-type reactions including anaphylactic symptoms. Debilitated, elderly patients, acutely ill patients, and children should be given reduced doses commensurate with their age and physical condition. Patients with severe shock or heart block, vasoconstrictor should be used with caution in areas of the body supplied by end arteries or having otherwise compromised blood supply, peripheral vascular disease, hypertensive vascular disease, potent general anesthetic agents. Restlessness, anxiety, tinnitus, dizziness, blurred vision, tremors, depression or drowsiness should alert the practitioner to the possibility of central nervous system toxicity. Hepatic disease, pregnancy Category B, nursing mothers. Drowsiness following the administration of prilocaine is usually an early sign of a high blood level of the drug and may occur as a consequence of rapid absorption. Cardiovascular manifestations are usually depressant and are characterized by bradycardia hypotension and cardiovascular collapse, which may lead to cardiac arrest.

Drug Interactions: MAO inhibitors, tricyclic antidepressants, phenothiazines, vasopressor drugs, ergot-type oxytocic drugs.

Adverse Reactions: Allergic reactions are characterized by cutaneous lesions, urticaria, edema or anaphylactoid reactions. CNS manifestations are excitatory and/or depressant and may be characterized by lightheadedness, nervousness, apprehension, euphoria, confusion, dizziness, drowsiness, tinnitus, blurred or double vision, vomiting, sensations of heat, cold or numbness, twitching, tremors, convulsions, unconsciousness, respiratory depression and arrest. Swelling and persistent parasthesia of the lips and oral tissue may occur.

CARBOCAINE® HCl 3% INJECTION (MEPIVACAINE HCl INJECTION, USP)
Cook-Waite from Kodak CARBOCAINE® HCl 2% WITH NEO-COBEFRIN® 1:20,000 INJECTION (MEPIVACAINE HCl and LEVONORDEFRIN INJECTION, USP) Cook-Waite from Kodak.

Description: Mepivacaine HCl is a tertiary amine used as a local anesthetic. Levonordeferin is a sympathomimetic amine used as a vasoconstrictor in local anesthetic solutions. Carbocaine® 3% 30 mg per ml mepivacaine HCl. Carbocaine® 2% with Neo-Cobefrin® 20 mg per ml mepivacaine HCl, 0.05 mg per ml levonordefrin.

Pharmacology: Carbocaine stabilizes the neuronal membrane and prevents the initiation and transmission of nerve impulses, thereby effecting local anesthesia.
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Indications: Production of local anesthesia for dental procedures by infiltration or nerve block in adults and children.

Contraindications: Hypersensitivity to amide-type local anesthetics.

Precautions: Contains a vasoconstrictor that should be used with extreme caution, existence of hypertension, arteriosclerotic heart disease, cerebral vascular insufficiency, thyrotoxicosis and diabetes. Contains a SULFITE that may cause allergic-type reactions. The lowest dose that results in effective anesthesia should be used. Debilitated, elderly patients, acutely ill patients, and children should be given reduced doses commensurate with their weight and physical status. History of severe disturbances of cardiac rhythm or heart block. Reduce doses if sedatives are employed. Changes in sensorium such as excitation, disorientation, drowsiness, may be early indications of a high blood level of the drug and may occur following inadvertent intravascular administration or rapid absorption of mepivacaine. Inflammation and/o.sepsis in the region of the proposed injections, Drug Interactions: Tricyclic antidepressants, monoamine oxidase inhibitors, ergot-type oxytocic drugs, phenothiazines, butyrophenones.

Adverse Reactions: CNS reactions are characterized by excitation and/or depression. Nervousness, dizziness, blurred vision, or tremors may occur followed by drowsiness, convulsions, unconsciousness, and possibly respiratory arrest, cardiovascular reactions are depressant. Anaphylactoid reactions to CARBOCAINE have occurred rarely.

All porphyrics must read these dental informational scjedules and then double-check against the latest UNSAFE DRUG lists.
Again, most of the dental anesthetics copntain sulfites and are a part of the SULFA DRUG family which have been traditionally unsafe for porphyrics.