The dentistry planned is ambitious. A 47-year-old woman requires fillings, buildups and crowns—not to mention 11 extractions. The doctor is concerned about possible interactions between epi and the patient’s prescription Pristiq™. How great is the likelihood of a bleeding complication given the link between this drug and a decrease in platelet production? A member of DOCS Education writes:
I am planning an ambitious appointment--or two--for a 47-year-old patient. The woman needs endo, fillings, buildups, crowns, 11 extractions, significant alveoloplasty of the maxillary arch and delivery of an immediate interim denture.
Among the patient’s current medications are Lipitor™ and Pristiq™ (desvenlaxofine). My usual protocol entails Valium™ the night before, incremental triazolam and standard septocaine 1:100,000.
I am concerned about the possibility of interaction between Pristiq™ and epi. (When taken with epi, Pristiq™ is associated with increasing that drug’s tachycardic and vasopressor effects. Pristiq™ has been shown to decrease platelet production as well.)
There’s no way I’m doing this surgery without epi. It won’t be a quick process because it involves recontouring the ridge almost from molar to molar.
Of course I’ll be seeking a medical consult; however, I fear the physician will simply tell me not to worry and go ahead as planned.
Should I worry about the potential for bleeding?
Dr. Leslie Fang, a member of the DOCS Education faculty, responds:
There’s no evidence of epinephrine reversal with these drugs. There shouldn’t be a problem with excessive bleeding on the basis of drug/drug interaction. Do obtain a platelet count. The effect of Pristiq™ on platelets is usually minor. If the platelet count exceeds 100,000 you needn’t worry about bleeding.
You are correct—without vasoconstrictors these sessions would be difficult.
Dr. Anthony Feck, Dean of DOCS Education faculty responds:
Pristiq™ is an SNRI. While the potential exists for all SNRIs to deplete platelets, it isn’t a contraindication to surgical procedures, especially when no other contributing factors exist to affect the clotting process. Good surgical technique and primary closure will assist you in keeping bleeding to a minimum. Given this, I wouldn’t hesitate to proceed with your planned procedure in this patient, along with the judicious use of vasoconstrictors.
Dr. Jerome Wellbrock, responds:
Using articaine 1:200,000 compared to 1:100,000 would allow you to give twice the amount of articaine while maintaining the same dose of epinephrine. Your duration of action of local anesthesia would probably not differ significantly but your effect on vasoconstriction for the control of bleeding would certainly be reduced. Administer local anesthetic with epi slowly and carefully monitor the patient—especially her pulse and blood pressure. You might consider either scheduling longer appointment times or more appointments to accomplish this much dentistry.
If you’re working in multiple quadrants at the same appointment place your local and complete or nearly complete the work in that quadrant before placing local in the next quadrant. This way you can more safely spread the amount of local with epi you need to use over a greater time period. Your patient will have metabolized a portion of the local administered initially before you deliver subsequent amounts of local. If you consider the first appointment a trial you’ll have the chance to test your patient’s sensitivity to the epi and their response.
A member of DOCS Education reports:
Thanks to all of you. Treatment on this patient was completed successfully over two appointments with no complications. The surgical phase was completed during the second appointment because then I had a better understanding of what to expect. There were neither effects upon her blood pressure nor any bleeding problems.
