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Is it safe to use vasoconstrictors in patients with sickle-cell disease?

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Sickle-cell and normal red blood cellsThis question was submitted by a general dentist: Is it safe to use vasoconstrictors in patients with sickle-cell disease? Which one is the best choice? Could I perform a painless dental extraction without vasoconstrictors in these cases?

Dr. George Sandor, DDS MD and Dr. Suham Alexander, Oasis Clinical Editor provided this initial response.

Sickle Cell Anemia 

Sickle cell anemia is a genetic disorder of hemoglobin synthesis occurring predominantly in African, Mediterranean and Asian populations. Affected individuals with carrying one allele have the sickle cell trait and may experience some sickling with exercise or in high altitudes due to lower oxygen tensions. In the USA, ~8% of the African American population carry this trait.

Patients who inherit both alleles have primarily “sickled” hemoglobin which results in sickle cell disease. Unfortunately, this leads to chronic hemolytic anemia which leads to a decrease in blood flow and subsequent ischemia, infarction and tissue death. A sickle cell crisis is an extreme manifestation of the disease in which patients suffer an enormous amount of pain lasting from 3 to 10 days. This usually affects the long bones, abdomen and lungs.

Radiographic Features 

Typically, radiographs of sickle cell patients will show a decrease in the trabecular pattern of bone and a less prominent “hair-on-end” appearance of bone in a skull radiograph.

Clinical Features 

  • Delayed eruption of teeth and dental hypoplasia
  • Pallor of oral mucosa
  • Jaundice of oral mucosa
  • Bone pain
  • Osteoporosis
  • occurrence of osteomyelitis, asymptomatic pulpal necrosis and mandibular paresthesia

Dental Management 

There are no contraindications to treating patients in a private dental office setting, but confirm the patient is in stable condition his/her physician. Dental visits should be short and stress-free.  It is wise to avoid long complex dental procedures due to an increased risk of acidosis. Prophylactic antibiotics should be used for major surgical procedures and if infection ensues, it should be treated aggressively.

Clinicians should be prudent with their use of local anesthetics. If the patient is symptom-free, 2% lidocaine with 1:200,000 can be safely administered for a routine extraction.

It is unadvisable to treat patients who are in a sickle crisis or have been having recurrent episodes. They will be more appropriately managed in a hospital setting.

References 

Neville, BW, Damm, DD, Allen, CM, Bouquot, JE. Oral and Maxillofacial Pathology. 2009. Saunders Elsevier. St. Louis, Missouri.

Excerpt from OASIS Help Medical Condition: Sickle Cell Anemia 

 

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