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Wednesday, August 27, 2014
Dental Anesthesia and AIP
Hi, I am from Bucharest, Romania. I have been diagnosed with Acute Intermitent Porphyria 10 years ago (I`m 34 now). Since then, I`ve never performed a dental anesthesia, because no dentist which I`ve met had experience in using anesthesia in porphyric patients. Before being diagnosed (or, better said, before the disease was "activated"), the anesthetic received was lydocaine, and I had no bad reactions to it. Now, since I really need to perform several extractions and implants, and since I can not find here a dentist with previous porphyric patients, I`d like to ask you which anesthetic is the most safe to choose and what would be the management of the anesthesia in my case?
Thank you for your answer!
Greetings from the US and Columbus Ohio. It is not surprising that you are having problems with dental care as there is confusion regarding local anesthetics and AIP. As you know, drugs that can induce specific liver enzymes can cause acute symptoms of porphyria. With local anesthetics, as with all drugs, there is a dose dependent relationship so the more you get, the greater the chance of a problem. There have been reports of problems with lidocaine so this has caused many of the problems. Some sources feel mepivicaine is not indicated for AIP patients as well.
Fortunately, one local anesthetic, bupivicaine, has never been shown induce an episode of AIP. This is probably the drug of choice. This may be due to the lower dosage of bupivicaine needed to obtain local anesthesia as this drug is also metabolized in the liver. You dentist should have this available or if not, can order it. It is widely available in dental cartridges in the US. The drug should be used with epinephrine as this will limit higher systemic blood levels.
Another agent, articaine, is newer and there are no reports of induction of AIP. This may be due to the newness of the agent. However, articaine's metabolism suggests that this would be a very good choice for AIP patients as only 5 - 10% of the drug is metabolized in the liver while all the other local anesthetics are more or less fully metabolized in the liver.
In any case, you have choices. Good luck. You may want to bring articles to your dentist so he or she can see that these agents, especially in the low doses used in dentistry, are very safe. Good luck!
Steven I Ganzberg, SB, DMD, MS
Formerly, Clinical Professor of Dentistry
College of Dentistry
The Ohio State University