Cardiovascular response to epinephrine-containing local anesthesia in patients with cardiovascular disease

Optimizing pediatric periprocedural pain management part II-Adjunct therapies to support the use of infiltrative anesthetics

Pediatric procedure-related pain management is often incompletely understood, inadequately addressed, and critical in influencing a child's lifelong relationship with the larger healthcare community. We present a comprehensive review of infiltrative anesthetics, including a comparison of their mechanisms of action and relative safety and efficacy data to help guide clinical selection. We also describe the multimodal utilization of adjunct therapies-in series and in parallel-to support the optimization of pediatric periprocedural pain management, enhance the patient experience, and provide alternatives to sedation medication and general anesthesia.

Expert consensus on endodontic therapy for patients with systemic conditions

The overall health condition of patients significantly affects the diagnosis, treatment, and prognosis of endodontic diseases. A systemic consideration of the patient's overall health along with oral conditions holds the utmost importance in determining the necessity and feasibility of endodontic therapy, as well as selecting appropriate therapeutic approaches. This expert consensus is a collaborative effort by specialists from endodontics and clinical physicians across the nation based on the current clinical evidence, aiming to provide general guidance on clinical procedures, improve patient safety and enhance clinical outcomes of endodontic therapy in patients with compromised overall health.

Cardiovascular and Vector-Cardiographic Effects of Articaine Anesthesia with Epinephrine

The aim was to investigate the vector-cardiographic effects in patients submitted to dental extraction under local anesthesia. Twenty-one patients aged 36.6 ± 12.4 years with a clinical and radiographic indication of mandibular or maxillary tooth extraction were enrolled. The intervention was a local or mandibular nerve block anesthesia with 4% articaine hydrochloride containing epinephrine (1 : 100,000; 40 mg/ml + 10 μg/ml). Blood pressure (BP), heart rate (HR), pulse wave transit time, and vector-cardiography data were recorded throughout 3 min before and 5 min after injection. QRS- and T-wave area under the curve (QRS AUC/T AUC) were calculated from the X/Y/Z QRS-vector or T-vector. T-wave amplitude (T AM), T AUC values, and diastolic BP decreased, and HR significantly increased 4 min after injection. A transient moderate HR drop and a corresponding small increase in T AM and T AUC immediately after the injection procedure may be explained by a decreased sympathetic tone due to psychological relief. In dental anesthesia, the systemic epinephrine effects are represented by a decrease in T AUC. These effects are most pronounced in the X- and Y-leads. The 3D determination of vector planes or amplitudes is a simple method to register the sympathetic tone in local anesthesia independently of possible effects on T-wave characteristics in single leads. In conclusion, T-wave determination may help to detect even small increases in systemic adrenaline concentration in case of accidental intravascular injection. At the same time, full rhythm and spatial ischemia control is provided.

Assessment of cardiovascular alterations and catecholamines serum concentration after oral surgery in patients receiving local anesthetics with epinephrine: a randomized, blind, controlled clinical trial

OBJECTIVES

A randomized controlled clinical trial was developed to evaluate the cardiovascular effects of local anesthetics with vasoconstrictors (LAVC) in healthy and hypertensive patients undergoing teeth extraction with lidocaine 2% with epinephrine 1:100,000.

MATERIALS AND METHODS

Twenty patients were divided into control (CG - normotensive patients) and experimental groups (EG - hypertensive patients). The variables analyzed were heart rate (HR), oxygen saturation (SO2), systolic and diastolic blood pressure (SBP and DBP), serum catecholamine concentration (dopamine, epinephrine, and norepinephrine), ventricular and supraventricular extrasystoles (VES and SVES respectively), and ST segment depression. Data was obtained in three different moments (initial, trans, and final). Blood samples were taken to measure the catecholamines, and a Holter device was used to measure data from the electrocardiogram including a 24-h postoperative evaluation period. The Mann-Whitney test was used to identify differences between the two groups, and the Friedman test with the adjusted Wilcoxon posttest was used for intragroup evaluation for repeated measures.

RESULTS

The EG presented a lower O2S in the initial period (p = 0,001) while the sysBP showed a statistical difference for the three evaluation periods with the EG presenting the highest values. The VES was higher for the EG during the 24-h postoperative evaluation period (p = 0,041). The SVES and the serum catecholamines showed were similar between the groups. The intragroup analysis revealed significant statistical difference for the sysBP in the EG with the trans period presenting the highest measurements. The extrasystole evaluation showed that the 24-h postoperative period presented most events with only the CG not presenting statistical difference for the variable VES during this period (p = 0,112). No ST segment depression was noticed for both groups.

CONCLUSIONS

Teeth extraction with LAVC can be safely executed in hypertensive patients. Blood pressure should be monitored in these patients since the sysBP presented significant differences during the surgical procedures. Cardiac arrhythmia and the serum catecholamines concentration levels seem not to be altered by the surgical procedure. Also, serum catecholamines do not influence cardiovascular changes in this type of surgery.

CLINICAL RELEVANCE

LAVC can be safely used in hypertensive patients and does not increase the risk of arrhythmias or cardiac ischemia.

Addition of 2 mg dexamethasone to improve the anesthetic efficacy of 2% lidocaine with 1:80,000 epinephrine administered for inferior alveolar nerve block to patients with symptomatic irreversible pulpitis in the mandibular molars: a randomized double-blind clinical trial

Introduction

This clinical trial aimed to evaluate the anesthetic effect of the addition of 2 mg (4 mg/ml) of dexamethasone to 2% lidocaine (plain or with 1:80,000 epinephrine). The solutions were injected for a primary inferior alveolar nerve block (IANB) to provide mandibular anesthesia for the endodontic treatment of mandibular molars with symptomatic irreversible pulpitis.

Methods

In a double-blinded setup, 124 patients randomly received either of the following injections: 2% lidocaine with 1:80,000 epinephrine, 2% lidocaine with 1:80,000 epinephrine mixed with 2 mg dexamethasone, or plain 2% lidocaine mixed with 2 mg dexamethasone, which were injected as a primary IANB. Ten minutes after injection, patients with profound lip numbness underwent electric and thermal pulp sensibility tests. Patients who responded positively to the tests were categorized as "failed" anesthesia and received supplemental anesthesia. The remaining patients underwent endodontic treatment using a rubber dam. Anesthetic success was defined as "no pain or faint/weak/mild pain" during endodontic access preparation and instrumentation (HP visual analog scale score < 55 mm). The effect of the anesthetic solutions on the maximum change in heart rate was also evaluated. The Pearson chi-square test at 5% and 1% significance was used to analyze anesthetic success rates.

Results

The 2% lidocaine with 1:80,000 epinephrine, 2% lidocaine with 1:80,000 epinephrine mixed with 2 mg dexamethasone, and plain 2% lidocaine mixed with 2 mg dexamethasone groups had anesthetic success rates of 34%, 59%, and 29%, respectively. The addition of dexamethasone resulted in significantly better results (P < 0.001, χ² = 9.07, df = 2).

Conclusions

The addition of dexamethasone to 2% lidocaine with epinephrine, administered as an IANB, can improve the anesthetic success rates during the endodontic management of symptomatic mandibular molars with irreversible pulpitis.

Factors Associated with Variability in Pulse Wave Transit Time Using Pulse Oximetry: A Retrospective Study

Pulse wave transit time (PWTT) is the time difference between the occurrence of an R-wave on an electrocardiogram and the detection of pulsatile signals on a pulse oximeter, which reflects changes in blood pressure (BP) corresponding to the vessel wall compliance. However, the factors affecting PWTT variability have not been determined. Thus, we investigated the BP changes associated with variations in PWTT and identified the clinical characteristics associated with these variations. Data related to 605 cases of dental procedures performed under intravenous conscious sedation from April 2020 to November 2021 were collected, and 485 cases were enrolled. Heart rate, systolic blood pressure before and after local anesthesia (LA) administration, and crest and trough PWTT waves during LA administration were recorded. Thereafter, PWTT variability was calculated; cases were divided into two groups: large PWTT variability (LPV, n = 357) and small PWTT variability (SPV, n = 128). The index of large PWTT variability could not detect changes in BP. Logistic regression analysis revealed that factors, such as LA use, age, hypertension, and dental treatment phobia were associated with PWTT variability. The use of epinephrine more than 36.25 µg in each LA resulted in PWTT variability of more than 15 ms.

Changes in Blood Pressure and Pulse Rate of Patients without Systemic Diseases Following the Injection of 2% Lidocaine Plus Epinephrine 1:80000 in an Inferior Alveolar Nerve Block - A Prospective Study

Introduction

An inferior alveolar nerve block is dental anesthesia produced by the local injection of lidocaine plus epinephrine; however, its administration could cause cardiovascular side effects. We aimed to assess the changes in blood pressure and pulse rate following the injection of 2% lidocaine with epinephrine 1:80000 for an inferior alveolar nerve block.

Materials and Methods

Seventy-one patients without any systemic disease were enrolled in this study. Systolic blood pressure (SBP), diastolic blood pressure (DBP), and pulse rate were measured using an automatic digital blood pressure monitor in four stages as follows: at the rest time (Stage 1), prior to injection (Stage 2), immediately after injection (Stage 3), and 10 min after the administration of anesthetic agents (Stage 4). All injections and measurements were carried out by a single operator to minimize the variability.

Results

SBP and DBP in all stages were within the normal range (lower than 130 and 80 mmHg, respectively), and none of the patients showed evidence of arterial hypertension. Although the pulse rate increased significantly at Stages 2, 3, and 4 compared with Stage 1 (P < 0.05), no evidence of bradycardia or tachycardia was seen.

Discussion

Local anesthesia with 2% lidocaine plus epinephrine 1:80000 for an inferior alveolar nerve block would be safe for patients without any systemic diseases.

Comparison of cardiovascular response between patients on warfarin and hypertensive patients not on warfarin during dental extraction

OBJECTIVE

To evaluate cardiovascular response in patients on warfarin and hypertensive patients not on warfarin during dental extraction.

MATERIALS AND METHODS

This retrospective study included 53 patients who had undergone dental extraction while on warfarin (mean age 78.8 ± 6.3 years, 26 men) and 66 with hypertension who had undergone dental extraction but were not on warfarin (mean age 77.4 ± 6.8 years, 22 men). Vital signs were monitored in both groups during extraction.

RESULTS

The highest systolic blood pressure (SBP) values (mean 150.1 ± 21.1 mmHg) were observed in patients on warfarin before (9.0%) and after (10.3%) administration of local anesthesia (LA), during extraction (39.7%), and during (33.3%) and after (7.7%) suturing (n = 78; p < 0.01), and in hypertensive patients not receiving warfarin (160.6 ± 24.8 mmHg) before (19.2%) and after (27.3%) administration of LA, during extraction (29.3%), and during (18.2%) and after (6.1%) suturing (n = 99; p < 0.01). The highest SBP was linearly correlated with SBP before administration of LA in patients on warfarin (highest SBP = 0.9415 × SBP before LA + 23.243, R² = 0.75481) and in hypertensive patients not on warfarin (highest SBP = 1.0027 × SBP before LA + 15.789, R² = 0.60341).

CONCLUSIONS

The highest SBP was not distributed evenly between patients on warfarin and hypertensive patients not on warfarin during dental extraction and was strongly associated with SBP before LA regardless of anticoagulant status.

CLINICAL RELEVANCE

Thorough management of SBP is required in patients on warfarin to avoid thromboembolism and major hemorrhagic complications. Knowing the SBP value before dental treatment would help predict the risk of cardiovascular complications.

Cardiovascular Comparison of 2 Types of Local Anesthesia With Vasoconstrictor in Older Adults: A Crossover Study

We assessed the effect of 2% lidocaine with 1:80,000 adrenaline (L + AD) and 3% prilocaine with 0.03 IU/mL felypressin (P + FP) on blood pressure and heart rate in older adults with systemic diseases undergoing dental extraction. This double-blind, randomized crossover study included 22 elderly participants, aged over 65 years. The participants were administered L + AD for one dental extraction and P + FP for the other. Blood pressure and heart rate were recorded immediately, 5, and 10 minutes after local anesthetic administration and the data were analyzed. The systolic and diastolic blood pressures in the P + FP group increased at all measurement points (p < .001). In the L + AD group, the diastolic blood pressure decreased at 5 and 10 minutes after local anesthetic administration (p < .05), whereas the heart rate increased at all measured time points (p < .001). There were statistically significant differences in systolic blood pressure at 5 and 10 minutes after local anesthetic administration and in diastolic blood pressure and heart rate at all time points between the 2 groups. In older adults, P + FP administration increased the systolic and diastolic blood pressures. L + AD administration increased the heart rate and decreased the diastolic blood pressure.

Risk management in oral surgery

Complex oral surgery procedures are occurring more commonly in primary care, performed by both specialist oral surgeons and non-specialists/tier 2 providers. Practitioners in the UK are working in an increasingly litigious environment which is often at the forefront of a practitioner's mind and prevention of complaints and claims of negligence is vital in maintaining confidence in our practise. In this ever-increasing litigious environment practitioners need to be aware of the risks associated with oral surgery procedures and have to be able to assess and treatment plan patients effectively and safely. Consent is critical to all procedures, and the recent Montgomery case reinforces the importance of this process which must be individual to each patient. It is vital that as practitioners we are aware of our scope of practice and are able to fully inform patients of the risks and benefits of treatment. Practitioners must know their limits and when to refer on to secondary care. This paper discusses the essentials of risk management in oral surgery and describes key stages in the management of patients undergoing an oral surgery procedure. Initial assessment of the patient, which includes medical and dental history will be discussed followed by investigations to support the clinical diagnosis. Once diagnosis has been confirmed, the process of obtaining consent and the legal implications of this are discussed. Finally, a discussion on the appropriate evidence-based management of common complications which may arise when performing oral surgery will complete the paper.

Interfacial interaction of anesthetic lidocaine and mesoporous silica nanoparticles in aqueous solutions and its release properties

Lidocaine has been used as a local anesthetic by injection. The controlled release of lidocaine loaded into nanospheres is necessary to reduce the onset time of the anesthetic effect or increase the anesthetic analgesia duration. In this study, mesoporous silica nanoparticles (MSNs) with a large specific surface area were prepared by a sol-gel method, and the interfacial interaction between MSNs and lidocaine positively charged in aqueous solutions at different concentrations was investigated by adsorption tests, Fourier-transformed infrared spectroscopy, thermogravimetry-differential thermal analysis, and Brunauer-Emmett-Teller (BET) measurements. The electrostatic interaction between Si-OH on MSNs and lidocaine-NH⁺ was of importance for the adsorption phenomenon in aqueous solutions, indicating the monolayer adsorption of lidocaine. BET measurements also supported the decrease of pore volumes, and the hysteresis loop of the isotherm curve was not closed since the condensation of lidocaine in the mesopores formed micropores of less than 1.5 nm in size. The release profiles in phosphate buffered saline containing calcium and magnesium ions showed a rapid and higher release of lidocaine compared with that in phosphate buffered saline without divalent cations. The released lidocaine concentrations were sufficient for the expression of the anesthetic effect in dental anesthesia.

Difference in the Effects of Lidocaine With Epinephrine and Prilocaine With Felypressin on the Autonomic Nervous System During Extraction of the Impacted Mandibular Third Molar: A Randomized Controlled Trial

PURPOSE

Complications during local anesthesia include increased blood pressure and vasovagal reflex, which are caused by changes in the autonomic nervous system. The commonly used local anesthetic preparations are lidocaine to which the vasoconstrictor epinephrine is added (lidocaine-epinephrine) and prilocaine to which the vasoconstrictor felypressin is added (prilocaine-felypressin); however, their effects during dental treatment are unclear. We examined the effects of these 2 different local anesthetic preparations on the autonomic nervous system and circulation during extraction of the impacted mandibular third molar.

MATERIALS AND METHODS

In this randomized controlled trial, 40 female patients scheduled for extraction of an impacted mandibular third molar were randomized to the lidocaine-epinephrine group or prilocaine-felypressin group. Heart rate variability, heart rate, and systolic blood pressure were recorded during the experiment. Descriptive and bivariate statistics were computed, and the P value was set at .05.

RESULTS

The low frequency-high frequency ratio was significantly increased in the prilocaine-felypressin group during extraction compared with that in the lidocaine-epinephrine group (P < .05). In the lidocaine-epinephrine group, a significant decrease in the high-frequency component was observed during bone removal and extraction compared with that at rest (P < .05). In both groups, a significant increase in systolic blood pressure was observed during local anesthesia, incision and reflection of the flap, bone removal, separation of the tooth crown, extraction, and suturing compared with that at rest (P < .01).

CONCLUSIONS

This study is the first to investigate the differences in the influence of 2 different local anesthetic preparations on the autonomic nervous system during extraction of the mandibular third molar. Changes in circulatory dynamics during tooth extraction with the 2 different local anesthetic preparations were the result of a decrease in parasympathetic nervous activity with lidocaine-epinephrine and an increase in sympathetic nervous activity with prilocaine-felypressin.

Is 0.75% ropivacaine more efficacious than 2% lignocaine with 1:80,000 epinephrine for IANB in surgical extraction of impacted lower third molar?

PURPOSE

We aim to compare and evaluate the anesthetic efficacy and safety of inferior alveolar nerve block (IANB) using 0.75% ropivacaine and 2% lignocaine with 1:80,000 epinephrine in lower impacted third molar (LI3M) surgery.

PATIENTS AND METHOD

We designed a prospective randomized, double-blind, split-mouth study evaluating 60 systemically healthy patients with the presence of bilateral symmetrically oriented LI3M. The sides and sequence of drug administered were randomly allocated. The primary outcome variables analyzed were hemodynamic stability, profoundness of anesthesia, and duration of postoperative analgesia. Time of onset, duration of soft tissue anesthesia, patients requiring analgesics, and their quantity for five postoperative days were recorded.

RESULTS

Early onset of anesthesia was seen in Lignocaine (68.6 ± 20.4 s) compared with Ropivacaine (104.1 ± 17.7 s) with significant differences (p = 0.001). Both the anesthetic solutions were found to be equipotent in providing profound intraoperative anesthesia. No significant difference emerged in perioperative hemodynamic stability. Ropivacaine exhibited statistically significant differences in the duration of soft tissue anesthesia (p = 0.001) and postoperative analgesia (p = 0.001). Patients requiring rescue pain medication and the number of analgesics consumed were greater on first and during five postoperative days in lignocaine when compared with that of ropivacaine with significant differences p < 0.001 and p < 0.001 respectively.

CONCLUSION

The results suggest that 0.75% ropivacaine is effective in providing adequate anesthesia, prolonged postoperative analgesia, and better postoperative pain control with a safer cardiovascular profile in LI3M surgery. It can be an addition to the existing list of long-acting local anesthetics used for LI3M surgery.

Increase in pulse pressure on administration of a dental local anesthetic solution, prilocaine hydrochloride with felypressin in male diabetic patients with coronary heart disease

OBJECTIVES

This study aimed to evaluate pulse pressure fluctuation on dental local anesthetic administration in diabetic patients with and without coronary heart disease undergoing tooth extraction.

MATERIALS AND METHODS

This retrospective study in diabetic patients undergoing tooth extraction included 33 patients with coronary heart disease (mean age 79.3 ± 7.4, 64% male) and 49 patients without coronary heart disease (mean age 78.6 ± 6.5, 29% male). The increase in pulse pressure before and after administration of local anesthetics was compared between diabetic patients with and without coronary heart disease.

RESULTS

Pulse pressure was increased in male diabetic patients with coronary heart disease compared with those without coronary heart disease following administration of 3% prilocaine hydrochloride with felypressin 0.03 IU/mL (prilocaine) (15.6 ± 15.4 mmHg in those with coronary heart disease (n = 11) versus 4.3 ± 10.9 mmHg in those without coronary heart disease (n = 13), p = 0.03).

CONCLUSIONS

Prilocaine administration increased pulse pressure in male diabetic patients with coronary heart disease compared with those without coronary heart disease. Further study is needed to reveal the mechanisms involved in the increase in pulse pressure.

CLINICAL RELEVANCE

This is the first study of pulse pressure fluctuation in diabetic patients with and without coronary heart disease following administration of local anesthetics. Our findings can help guide the choice of local anesthetics and serve as a predictor of coronary vascular condition in diabetic patients during dental treatment.

Comparative evaluation of the efficacy, safety, and hemostatic effect of 2% lidocaine with various concentrations of epinephrine

BACKGROUND

We evaluated the changes in mean arterial pressure (MAP) and heart rate (HR), and the anesthetic and hemostatic effects, after injection of 2% lidocaine containing various concentrations of epinephrine in rats and mice to determine the appropriate concentration of epinephrine in various anesthetic mixtures.

METHODS

Rats and mice were randomly allocated to experimental groups: 2% lidocaine without epinephrine (L0), 2% lidocaine with epinephrine 1:200,000 (L200), 1:100,000 (L100), and 1:80,000 (L80). Changes in MAP and HR after administration of the anesthetic mixture were evaluated using a physiological recording system in rats. Onset and duration of local anesthesia was evaluated by pricking the hind paw of mice. A spectrophotometric hemoglobin assay was used to quantify the hemostatic effect.

RESULTS

MAP increased in response to epinephrine in a dose-dependent manner; it was significantly higher in the L80 group than in the L0 group at 5 min post-administration. The HR was relatively lower in the L0 group than in the L80 group. The time required for onset of action was < 1 min in all evaluation groups. The duration of action and hemostatic effect of the local anesthetic were significantly better in the L200, L100, and L80 groups than in the L0 group.

CONCLUSION

L200 demonstrated relatively stable MAP and HR values with satisfactory efficacy and hemostatic effect. L200 might be a better local anesthetic for dental patients in terms of anesthetic efficacy and safety.

Comparison of the efficacy and safety of 2% lidocaine HCl with different epinephrine concentration for local anesthesia in participants undergoing surgical extraction of impacted mandibular third molars: A multicenter, randomized, double-blind, crossover, phase IV trial

BACKGROUND

The most commonly impacted tooth is the third molar. An impacted third molar can ultimately cause acute pain, infection, tumors, cysts, caries, periodontal disease, and loss of adjacent teeth. Local anesthesia is employed for removing the third molar. This study aimed to evaluate the efficacy and safety of 2% lidocaine with 1:80,000 or 1:200,000 epinephrine for surgical extraction of bilateral impacted mandibular third molars.

METHODS

Sixty-five healthy participants underwent surgical extraction of bilateral impacted mandibular third molars in 2 separate visits while under local anesthesia with 2% lidocaine with different epinephrine concentration (1:80,000 or 1:200,000) in a double-blind, randomized, crossover trial. Visual analog scale pain scores obtained immediately after surgical extraction were primarily evaluated for the 2 groups receiving different epinephrine concentrations. Visual analog scale pain scores were obtained 2, 4, and 6 hours after administering an anesthetic. Onset and duration of analgesia, onset of pain, intraoperative bleeding, operator's and participant's overall satisfaction, drug dosage, and hemodynamic parameters were evaluated for the 2 groups.

RESULTS

There were no statistically significant differences between the 2 groups in any measurements except hemodynamic factors (P >.05). Changes in systolic blood pressure and heart rate following anesthetic administration were significantly greater in the group receiving 1:80,000 epinephrine than in that receiving 1:200,000 epinephrine (P ≤.01).

CONCLUSION

The difference in epinephrine concentration between 1:80,000 and 1:200,000 in 2% lidocaine liquid does not affect the medical efficacy of the anesthetic. Furthermore, 2% lidocaine with 1:200,000 epinephrine has better safety with regard to hemodynamic parameters than 2% lidocaine with 1:80,000 epinephrine. Therefore, we suggest using 2% lidocaine with 1:200,000 epinephrine rather than 2% lidocaine with 1:80,000 epinephrine for surgical extraction of impacted mandibular third molars in hemodynamically unstable patients.

Evaluation of Anxiety Induced Cardiovascular Response in known Hypertensive Patients Undergoing Exodontia - A Prospective Study

INTRODUCTION

Anxiety towards exodontic procedures is a common occurrence in dental practice. In hypertensive patients this anxiety induced stress may have an effect on cardiovascular system which may be clinically significant.

AIM

To evaluate the cardiovascular changes in hypertensive patients that may manifest following anxiety induced stress in patients undergoing exodontic procedures under local anaesthesia.

MATERIALS AND METHODS

Eighty known hypertensive patients under medication reporting to Department of Oral and Maxillofacial surgery, Dayananda Sagar College of Dental Sciences Bangalore, Karnataka, India for extraction of teeth were taken up for the study. Anxiety was measured before local anaesthetic delivery using Amsterdam Pre-operative Anxiety and Information Scale (APAIS). Cardiovascular response data including blood pressure, heart rate, pulse rate, oxygen saturation and electrocardiographic changes were measured pre-operatively, immediately after local anaesthesia administration and Post-operatively at five, ten and fifteen minutes interval. Kruskal-Wallis test was used to compare continuous variables before and after the injection of local anaesthesia including heart rate, pulse rate, oxygen saturation, and blood pressure. Repeated-measures analysis of variance (ANOVA) was used to analyse the significance of changes in heart rate, pulse rate, blood pressure, and oxygen saturation over time between groups.Chi-square test was used to analyse the significance of electrocardiographic changes.

RESULTS

The results revealed that the mean anxiety score before administration of local anaesthetic was 9.91(S.D ±2.9) with a range 4-20. Severe preoperative anxiety (<12) was associated with significantly increased heart rate, pulse rate, systolic blood pressure. At the pre-injection phase the mean values were systolic blood pressure (130.72±9.2), diastolic blood pressure (81.6±7.7), heart rate (72.7±11.9) and oxygen saturation (95.2±1.9). These values were increased immediately after local anaesthetic delivery and this relation was statistically significant for all parameters except oxygen saturation. Electrocardiographic abnormalities were found before and after injection of local anaesthetic (p>0.001). One patient showed right bundle branch block pattern.

CONCLUSION

Dental anxiety impacts the effects of delivery of local anaesthesia on blood pressure, heart rate, pulse rate and electrocardiograph and is significantly associated with the increase in systolic blood pressure, heart rate, pulse rate and changes in electrocardiograph. Thus, present study supported that increased anxiety in hypertensive patients who underwent extraction is associated with cardiovascular changes.

Guidelines for the use of local anesthesia in office-based dermatologic surgery

There are an increasing number and variety of dermatologic surgical procedures performed safely in the office setting. This evidence-based guideline addresses important clinical questions that arise regarding the use and safety of local anesthesia for dermatologic office-based procedures. In addition to recommendations for dermatologists, this guideline also takes into account patient preferences while optimizing their safety and quality of care. The clinical recommendations presented here are based on the best evidence available as well as expert opinion.

Articaine (4%) with epinephrine (1:100,000 or 1:200,000) in inferior alveolar nerve block: Effects on the vital signs and onset, and duration of anesthesia

Background

This prospective, randomized, double-blind, clinical study was conducted to compare the effects of 4% articaine with 1:100,000 epinephrine (A100) and 4% articaine with 1:200,000 epinephrine (A200) on the vital signs and onset and duration of anesthesia in an inferior alveolar nerve block (IANB).

Methods

In the first appointment, an IANB was performed by injecting A100 or A200 in 1 side of the mouth (right or left) randomly in patients referred for extraction of both their first mandibular molars. In the second appointment, the protocol was repeated and the other anesthetic solution was injected in the side that had not received the block in the previous session. Systolic and diastolic blood pressures (SBP and DBP) and pulse rate were measured during and 5 min after the injection. The onset and duration of anesthesia were also evaluated. Data were analyzed using t-test and Mann-Whitney U-test, and p-value was set at 0.05.

Results

SBP and pulse rate changes were slightly more with A100; however, DBP changes were more with A200, although the differences were not significant (P > 0.05). There were no statistically significant differences in the parameters evaluated in this study. The onset and duration of anesthesia, and the changes in SBP, DBP, and pulse rate during and 5 min after the injection were the same in both the groups.

Conclusions

For an IANB, A200 and A100 were equally efficient and successful in producing the block. Epinephrine concentration did not influence the effects of 4% articaine.

Treatment planning considerations in older adults

The older patient often presents with clinically challenging dental problems combined with complex medical, social, psychological, and financial barriers to oral health. Through careful consideration, the clinician can design a thoughtfully sequenced treatment plan that addresses dental conditions and facilitates improved oral health. Several models serve to guide the clinician with this endeavor. Treatment planning for a medically complex patient with xerostomia and dementia involves a great deal of uncertainty, which may be attenuated by flexibility and good communication with the patient and all involved parties.

Clinical assessment of the safe use local anaesthesia with vasoconstrictor agents in cardiovascular compromised patients: a systematic review

Background

The use of vasoconstrictor agents has many advantages, but its use has been limited due to a fear of systemic absorption and the induction of adverse effects in cardiac compromised patients. The aim of this study was to review the literature to assess any scientific basis for the limited use of dental anaesthesia with a vasoconstrictor agent in cardiovascular compromised patients.

Material/Methods

A comprehensive database search was executed with the use of Medline (PubMed), ISI Web of Science, and Cochrane. The inclusion criteria were: a clearly defined dose of vasoconstrictor agent and the testing of at least 1 parameter (pressure, heart rate, or saturation) or occurrence of at least 1 cardiac incident (complication).

Results

Among all complications, only 10 could be directly related to the use of local anaesthesia. It is noteworthy that 40% appeared after the administration of anaesthesia without vasoconstrictor agents. No severe adverse clinical effects were noted in the analysed studies.

Conclusions

The most frequent complications in cardiovascular compromised patients after dental local anaesthesia with a vasoconstrictor agent were disclosed in ECG arrhythmias. Most of these disclosed arrhythmias were clinically insignificant. The use of ≤4 ampules of lignocaine with epinephrine 1:100000 as a dental anaesthetic seems to be relatively safe for cardiovascular compromised patients.

Effects of mepivacaine 2% with epinephrine in the cardiovascular activity of patients undergoing third molar surgery: a prospective clinical study

BACKGROUND

Cardiovascular effects of epinephrine, especially on blood pressure (BP) and heart rate (HR), have been well documented. When present in dental local anesthetic solutions, epinephrine concentration ranges from 5 to 20 µg/mL. Doses less than 200 µg are recommended to be clinically safe.

OBJECTIVES

This study investigated the effects of the anesthetic solution of mepivacaine (2%) with epinephrine (10 µg/mL) in cardiovascular activity (HR and BP).

METHODS

Twenty-six patients underwent outpatient surgery for the removal of 2 unilateral (group I, n = 15) or 4 (group II, n = 11) third molars in a single session, being injected 5.4 and 10.8 mL of anesthetic solution, equivalent to 54 and 108 µg of epinephrine, respectively. The cardiovascular activity was monitored by cardioscope during the experimental period of 2 hours. Heart rate and BP were measured at the intervals of 0, 5, 10, 15, 20, 30, 40, 60, 90, and 120 minutes after anesthetic injection.

RESULTS

After application of 2-way analysis of variance test, comparison between groups was not statistically significant for HR (P = 0.1388), systolic BP (P = 0.0228), and diastolic BP (P = 0.9846). However, patients from group II presented significantly greater sway in HR (P < 0.0001), systolic BP (P = 0.0169), and diastolic BP (P < 0.0001) in the course of 2 hours.

CONCLUSIONS

Blood pressure did not present significant alterations after a local injection of 54 or 108 µg of epinephrine during surgery to remove 2 or 4 third molars. Although without significance, HR was more elevated in the 108-µg dose of epinephrine during the removal of 4 third molars.

Cardiovascular effect of dental anesthesia with articaine (40 mg with epinefrine 0,5 mg % and 40 mg with epinefrine 1 mg%) versus mepivacaine (30 mg and 20 mg with epinefrine 1 mg%) in medically compromised cardiac patients: a cross-over, randomized, single blinded study

Objectives: The aim of the present study is to compare cardiovascular safety profiles of two dental anesthetics: articaine versus two standard mepivacaine solutions used during etiological periodontal treatment in cardiovascular patients. Study Design: Using a cross-over study design, ten cardiovascular patients were randomly assigned to dental treatment with 1.8mL of a local anesthetic injected on each quadrant of the mouth: Articaine (40mg with Epinephrine 0.5mg % and 40mg with Epinephrine 1mg %) or Mepivacaine (30mg and 20mg with Epinephrine 1mg %). A computer programme enabled continuous longitudinal data collection: O2 saturation, blood pressure (BP) and heart rate (HR). Results: No severe clinical side effects were observed. During the treatment period, we observed statistically significant differences as regards HR between injections with and without adrenalin (p< 0.039) and as regards systolic (p< 0.046) and diastolic (p < 0.046) blood pressure during the stabilization period. In both cases, the parameters under study increase. Age, gender, jaw treated, treatment duration and the rest of cardiovascular variables did not affect the results. None of the patients underwent ischemic alterations or any other complication derived from the treatment or the anesthesia. Conclusions: According to the results of our study, dental anesthetics with standard concentrations of Epinephrine seem to alter HR and BP. Although no cardiac ischemic alterations or any other cardiovascular complications have been observed, we must be cautious with the administration of anesthetics containing vasoconstrictors in patients with cardiovascular diseases.

Key words:Dental anesthesia, cardiovascular diseases, chronic periodontitis, drug toxicity.

Efficacy and safety of intraseptal and periodontal ligament anesthesia achieved by computer-controlled articaine + epinephrine delivery: a dose-finding study

OBJECTIVES

The main purpose of this study was to evaluate the dose-dependent anesthetic efficacy of the intraseptal anesthesia (ISA) and periodontal ligament anesthesia (PLA) obtained with different volumes of 4 % articaine and 1:100,000 epinephrine (Ar + Ep) in human mandibular premolars, using a computer-controlled local anesthetic delivery system (CCLADS). The safety profile of Ar + Ep was also studied by investigating the stability of cardiovascular parameters.

MATERIAL AND METHODS

One hundred and eighty randomly selected healthy volunteers (ASA I) entered the single-blinded study to receive 16 mg + 4 μg, 24 mg + 6 μg, and 32 mg + 8 μg of Ar + Ep, obtained with different volumes (0.4, 0.6, and 0.8 ml, respectively), for the ISA and PLA. Success rate, onset, and duration of profound pulpal anesthesia were evaluated by the electrical pulp tester, while the width of the anesthetic field and duration of soft tissue anesthesia were recorded using the pinprick testing. A monitor was used for the measurement of cardiovascular parameters.

RESULTS

A dose-dependent duration of pulpal and soft tissue anesthesia was obtained only by the ISA. Success rate, duration of both pulpal and soft tissue anesthesia, and its width were significantly better in the ISA compared with the PLA. No significant cardiovascular changes were seen in both groups.

CONCLUSIONS

It can be suggested that 0.6 and 0.8 ml of 4 % Ar + 1:100,000 Ep, delivered by CCLADS, offer high success rate and effective clinical parameters of ISA as a primary anesthesia.

CLINICAL RELEVANCE

It seems that dental procedures requiring profound pulpal, bone, and soft tissue anesthesia could be effectively and safely obtained by mentioned anesthetic protocol.

Comparison of 4% articaine with epinephrine (1:100,000) and without epinephrine in inferior alveolar block for tooth extraction: double-blind randomized clinical trial of anesthetic efficacy

OBJECTIVE

The purpose of this clinical prospective, randomized, double-blind study was to compare the anesthetic efficacy of 4% articaine with epinephrine (1:100,000) and without epinephrine in inferior alveolar nerve block anesthesia for extractions of mandibular teeth.

STUDY DESIGN

Eighty-eight patients received intraoral inferior alveolar nerve blocks using 4% articaine with 1:100,000 epinephrine (n = 41; group 1) or without epinephrine (n = 47; group 2) for extractions of mandibular teeth. The primary objectives were differences in onset as well as in length of soft tissue anesthesia. The amount of anesthetic solution, need of a second injection, pain while injecting, pain during treatment, postoperative pain, and possible complications were surveyed.

RESULTS

In both groups, anesthesia was sufficient for dental extractions. In group 1, a significantly faster onset of the anesthetic effect (7.2 min vs. 9.2 min; P = .001) and a significantly longer duration of soft tissue anesthesia (3.8 h vs. 2.5 h; P < .0001) were seen. There was no significant difference in the amount of anesthetic solution needed, in the need for a second injection, in the injection pain, in pain during treatment, or in postoperative analgesia. In both groups, no complications were seen.

CONCLUSIONS

To minimize the epinephrine-induced side effects, 4% articaine without epinephrine is a suitable anesthetic agent for dental extractions in the mandible after inferior alveolar nerve block anesthesia. There could be less postoperative discomfort due to the shorter duration of anesthesia without increased postoperative pain.

Haemodynamic changes during craniotomy monitored by a bioimpedance plethysmographic noninvasive cardiac output monitor

BACKGROUND

Profound cardiovascular changes may occur at various stages during a craniotomy. These changes require a detailed haemodynamic analysis including cardiac output. In the present study, we used a monitor based on electrical bioimpedance method for noninvasive cardiac output measurement.

METHODS

In 17 ASA I and II patients undergoing elective craniotomies for supratentorial tumours, the following haemodynamic parameters were measured noninvasively: heart rate (HR), systolic blood pressure (SBP), diastolic blood pressure (DBP), stroke volume (SV), cardiac output (CO) and systemic vascular resistance (SVR). Haemodynamic changes in response to the following events were studied: (a) induction of anaesthesia with thiopentone, (b) 15 min of air-O(2)-isoflurane anaesthesia, (c) infiltration of the scalp with lidocaine adrenaline mixture, and (d) change of inspired gas mixture to N(2)O-O(2)-isoflurane.

RESULTS

HR increased (P < 0.001) and SV decreased (P < 0.001) while CO remained unchanged, one min after administration of thiopentone. After 15 min of isoflurane anaesthesia, HR increased (P < 0.001) and, SBP (P = 0.02), DBP (P = 0.002) and SV (P = 0.003) decreased significantly without change in CO. Three minutes after infiltration of the scalp with lidocaine-adrenaline mixture, there was an increase in SBP (P = 0.001), DBP (P = 0.007), SV (P = 0.007) and CO (P = 0.001) and a decrease in SVR (P < 0.001). Addition of nitrous oxide (60%) to the inspired gas mixture decreased SBP (P = 0.003) and DBP (P = 0.001) with a trend for decrease in CO (P < 0.1). The changes recorded in the present study conform to those that have been documented earlier by using invasive monitoring.

CONCLUSION

Bioimpedance plethysmography is a useful noninvasive technique for monitoring and detailed analysis of the rapidly changing systemic haemodynamics during a craniotomy. The device could be useful for investigating important haemodynamic changes in specific neurosurgical settings.

Locoregional anesthesia for dental treatment in cardiac patients: a comparative study of 2% plain lidocaine and 2% lidocaine with epinephrine (1:100,000)

OBJECTIVES

This study analyzes hemodynamic changes in patients with cardiac valvular diseases submitted to dental treatment under local anesthesia containing epinephrine.

METHODS

This randomized clinical trial was performed at the Dental Division of the Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (Brazil). Patients were separated into two groups with the help of an aleatory number table: 2% plain lidocaine (PL, n= 31) and 2% lidocaine with epinephrine (1:100,000) (LE, n= 28). Blood pressure, heart rate, oxygenation and electrocardiogram data were all recorded throughout the procedure. State and trait anxiety levels were measured.

RESULTS

Fifty-nine patients were selected for the LE group (n=28), with an average age of 40.3 +/- 10.9, or for the PL group (n=31), age 42.2 +/- 10.3. No differences were shown in blood pressure, heart rate and pulse oximetry values before, during and after local anesthesia injection between the two groups. State and trait anxiety levels were not different. Arrhythmias observed before dental anesthesia did not change in shape or magnitude after treatment. Complaints of pain during the dental procedure were more frequent within the PL group, which received a higher amount of local anesthesia.

CONCLUSION

Lidocaine with epinephrine (1:100,000) provided effective local anesthesia. This treatment did not cause an increase in heart rate or blood pressure and did not cause any arrhythmic changes in patients with cardiac valvular diseases.

Safety and utility of oesophago-gastro-duodenoscopy in acute myocardial infarction

AIM

To study the safety and utility of performing an oesophago-gastro-duodenoscopy (EGD) in the setting of an acute myocardial infarction (AMI).

METHODS

Case records of all patients who underwent an EGD for various indications within 4 weeks of an AMI between January 2001 and April 2006 were analyzed. Demographic data, indications for endoscopy, outcomes and complications were noted. Main outcome measures included safety and utility of endoscopy in AMI.

RESULTS

A total of 87 EGDs were performed on 85 patients with AMI. Seventy (83%) patients had a non-ST elevation MI, whereas 15 (17%) had ST elevation MI. Mean time between EGD and AMI was 6+/-1.8 days. Indications for EGD were hematemesis and/or melena on presentation in 38 (44.7%), hematemesis and/or melena post anticoagulation in 27 (31.8%). EGD findings were gastric ulcer/erosions in 30 (34%), oesophago-gastric varices in 20 (22%), erosive oesophagitis in 17 (20%) and duodenal ulcer in 11 (13%). Diagnostic yield of EGD was 88%. Endoscopic interventions were performed in 26 (30%) patients with high risk of bleeding lesion. There were no EGD-related mortality, whereas 14 patients re-bled. A total of 21 patients died, including 7/14 (50%) who re-bled, compared with 14/71 (19%) without rebleed (P=0.008). There were no EGD-related deaths. Fourteen patients were on mechanical ventilation and 6/14 (43%) of these died as compared with 15/88 (17%) who were not ventilated (P=0.027).

CONCLUSION

EGD is safe and useful in diagnosis and management of gastrointestinal hemorrhage in patients with AMI, and allows decisions about anticoagulation. Re-bleed and need for mechanical ventilation predicts poor outcome in these patients.

The pharmacokinetics and cardiovascular effects of high-dose articaine with 1:100,000 and 1:200,000 epinephrine

OBJECTIVES

The authors conducted a randomized, double-blind, two-way crossover clinical trial to compare the pharmacokinetics and cardiovascular effects of 11.9 milliliters of 4 percent articaine hydrochloride (HCl) plus 1:100,000 epinephrine (A100) with those of 11.9 mL of 4 percent articaine HCl plus 1:200,000 epinephrine (A200).

METHODS

During two testing sessions, the authors administered injections of A100 and A200 over a seven-minute period (in one-cartridge doses unless otherwise noted): maxillary right first molar infiltration, maxillary left first molar infiltration, maxillary right first premolar infiltration, maxillary left first premolar infiltration, right inferior alveolar injection, left inferior alveolar injection, right long buccal infiltration (one-half cartridge) and left long buccal infiltration (one-half cartridge). They analyzed venous blood samples for articaine levels. They used noninvasive acoustic tonometry to measure a variety of cardiovascular parameters over a two-hour period.

RESULTS

Plasma concentration curves of articaine over time were similar for both solutions, with peak concentrations and times to maximum concentration being 2,037 nanograms per milliliter and 22 minutes for A100 and 2,145 ng/mL and 22 minutes for A200. At the 10-minute point, the mean systolic blood pressure and heart rate were significantly elevated (P < .05) with A100 versus A200.

CONCLUSIONS

Maximum dose recommendations for the A100 solution also can be applied to the A200 solution. A200 produces less cardiovascular stimulation than does A100.

CLINICAL IMPLICATIONS

A200 is as safe as A100, and may be preferable to A100 in patients with cardiovascular disease and in those taking drugs that reportedly enhance the systemic effects of epinephrine.

Effects of lidocaine with and without epinephrine on plasma epinephrine and lidocaine concentrations and hemodynamic values during third molar surgery

Lidocaine with epinephrine is currently the most common local anesthetic agent used for impacted third molar surgery. The purpose of the present study was to define the adverse hemodynamic effects and plasma concentrations of lidocaine and epinephrine on 17 healthy patients during the impacted teeth operations. Arterial blood pressure (systolic blood pressure, diastolic blood pressure), heart rate, peripheral oxygen saturation range, and electrocardiography were measured by an automatic noninvasive pressure device and monitor. High-performance liquid chromatography was used to measure the changes of plasma concentrations of epinephrine and lidocaine from blood samples taken 5 different times during the operation. We concluded that lidocaine-epinephrine is effective local anesthetic and had no important adverse events in healthy patients during the third molar surgery.

Examination of cardiovascular function variables in tooth extraction under local anesthesia

Background/Aim. Local anesthesia is the one of the most used procedures in surgical practice. It is used for toot extraction to produce analgesic and anesthetic effects. However, there is a question if it is equally safe to apply a local anesthetic combined with a vasoconstrictor (adrenaline) in healthy persons, and in the patients with a certain cardiovascular system disease. The aim of this study was to determine whether there were differences in cardiovascular variables during tooth extraction in healthy persons, and in cardiovascular patients when an anesthetic was applyted with adrenaline, or without it. Methods. The examinees were divided into the group with cardiovascular diseases (CV, n = 57) of II and III type, according to the American Society of Anesthesiologists (ASA) qualification, and healthy persons (H, n = 55). Both groups were randomly divided into two subgroups: CVa and Ha - where the anesthetic solution had the vasoconstrictor (3% lidocaine, and 1 : 100 000 adrenaline); CVb and Hb - where the anesthetic solution was without the vasoconstrictor (3% lidocaine). During the preparation for tooth extraction, the application of anesthetics, extraction and relaxation puls (fc), systolic (TAs) and diastolic arterial blood pressure (TAd) and ECG were registered. Results. The values of fc did not significantly differ among the groups in any measured term. The values of systolic and diastolic blood pressure in the groups CVa and CVb were significantly higher in all the terms of measuring (p < 0.05) from the values in the groups Ha and Hb. A significant increase of TAs was registered only in the phase of tooth extraction in the CVa and CVb group (< 0.05). The values of TAd did not significantly differ between the groups in all the measured terms. Extrasystolic beats were registered in 11 patients of the CV group and in 7 patients of the H group in the phase of anesthetic application or tooth extraction. Conclusion. This research shoved that tooth extraction under local anesthesia did not cause complications in cardiovascular patients who were in II or III ASA qualification group, regardless the presence of a vasoconstrictor in the local anesthetic solution.