Recommendations, including specific medications, diagnostic criteria, treatment options, and implant considerations outlined in the AAOMS position paper on MRONJ:
Lidocaine (Xylocaine): - Maximum Dose without Epinephrine: 4.5 mg/kg (without epinephrine) - Maximum Dose with Epinephrine: 7 mg/kg (with epinephrine) - Toxicity: Symptoms of lidocaine toxicity may include dizziness, confusion, seizures, cardiovascular collapse, and cardiac arrest.
Bupivacaine (Marcaine): - Maximum Dose without Epinephrine: 2 mg/kg (without epinephrine) - Maximum Dose with Epinephrine: 3 mg/kg (with epinephrine) - Toxicity: Bupivacaine toxicity can cause significant cardiotoxicity, leading to cardiac arrhythmias, cardiac arrest, and central nervous system (CNS) effects such as seizures and dizziness.
Mepivacaine (Carbocaine): - Maximum Dose without Epinephrine: 4.5 mg/kg (without epinephrine) - Maximum Dose with Epinephrine: 7 mg/kg (with epinephrine) - Toxicity: Symptoms of mepivacaine toxicity are similar to other local anesthetics and may involve CNS and cardiovascular effects.
Procaine (Novocaine): - Maximum Dose without Epinephrine: 7 mg/kg (without epinephrine) - Maximum Dose with Epinephrine: Not typically used with epinephrine - Toxicity: Procaine toxicity may present with symptoms similar to other local anesthetics but is less frequently used today due to its shorter duration and higher allergenic potential.
Articaine (Septocaine): - Maximum Dose without Epinephrine: 7 mg/kg (without epinephrine) - Maximum Dose with Epinephrine: 7 mg/kg (with epinephrine) - Toxicity: Articaine has a longer duration of action but can cause similar toxicity symptoms as other local anesthetics if administered excessively or if there's accidental intravascular injection.
Hypokalemia (Low Potassium Levels):
- Mild to Moderate Hypokalemia (3.0-3.5 mEq/L):
- Oral potassium supplementation: Potassium chloride tablets or liquid, 20-40 mEq orally per day in divided doses.
- Severe Hypokalemia (<3.0 mEq/L):
- IV potassium chloride: Start with 10-20 mEq/hour, under continuous cardiac monitoring.
Hyperkalemia (High Potassium Levels):
- Mild Hyperkalemia (5.1-6.0 mEq/L):
- Dietary potassium restriction and discontinuation of potassium supplements.
- Severe Hyperkalemia (>6.0 mEq/L or with ECG changes):
- Calcium gluconate or calcium chloride IV to stabilize cardiac membranes.
- Insulin with glucose IV, beta-agonists (e.g., albuterol), or sodium bicarbonate to shift potassium into cells. - Loop diuretics or exchange resins (e.g., sodium polystyrene sulfonate) to enhance potassium removal.
Hypocalcemia (Low Calcium Levels):
- Mild Hypocalcemia (8.0-8.5 mg/dL):
- Oral calcium supplements: Calcium carbonate or calcium citrate, doses vary based on elemental calcium content.
- Severe Hypocalcemia (<8.0 mg/dL or symptomatic):
- IV calcium gluconate or calcium chloride, dosages depend on severity and symptoms.
Hypercalcemia (High Calcium Levels):
- Mild Hypercalcemia (10.5-11.9 mg/dL):
- Hydration with IV saline and loop diuretics.
- Severe Hypercalcemia (>12 mg/dL or symptomatic):
- Bisphosphonates, calcitonin, or corticosteroids may be used for severe cases.
Hypomagnesemia (Low Magnesium Levels):
- Mild to Moderate Hypomagnesemia (1.2-1.8 mg/dL):
- Oral magnesium supplements: Magnesium oxide, magnesium citrate, or magnesium glycinate, dosages vary.
- Severe Hypomagnesemia (<1.2 mg/dL or symptomatic):
- IV magnesium sulfate, doses vary based on severity and response.
Hypermagnesemia (High Magnesium Levels):
- Mild to Moderate Hypermagnesemia (2.5-3.0 mg/dL):
- Discontinuation of magnesium-containing medications.
- Severe Hypermagnesemia (>3.0 mg/dL or with symptoms):
- IV calcium gluconate for severe symptoms.
- Dialysis may be necessary in extreme cases.
