Arterial plasma epinephrine concentrations and hemodynamic responses after dental injection of local anesthetic with epinephrine

Efficacy of computer-controlled local anesthesia delivery system on pain in dental anesthesia: a systematic review of randomized clinical trials

Computer-controlled local anesthesia delivery (CCLAD) is an innovative electronic injection device that represents a cutting-edge approach to dental anesthesia. This system is promising for painless anesthesia using controlled anesthetic injections. This review aimed to compare the discomfort experienced by patients during local anesthesia using a traditional syringe and the CCLAD system and evaluate the potential of the CCLAD system as a painless dental anesthesia solution. The inclusion criteria for this study were based on the recommendations of the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. The study population, including children and adults, underwent dental anesthesia using the CCLAD system, ensuring a comprehensive and representative sample that instills confidence in the validity of the results. Fourteen clinical trials were included in the analysis after they fulfilled the eligibility criteria. We found that using computer-assisted anesthetic equipment not only led to a significantly lower pain perception score, but also had a profound positive impact on patient behavior. Patients using the CCLAD device exhibited more cooperative and helpful conduct, indicating the system's effectiveness in improving patient comfort and experience and reassuring the audience about its positive impact. In conclusion, using a computer-assisted anesthetic device such as the CCLAD system significantly reduced pain perception scores and improved patient behavior, making them more cooperative and helpful. These findings offer hope for pediatric dentistry and apprehensive adult patients, suggesting a more comfortable and less daunting dental experience with the CCLAD system.

Comparison of hemodynamic changes with general or local anesthesia during dental treatment in pediatric patients: A prospective clinical study

BACKGROUND AND AIM

Severe hemodynamic fluctuations during dental treatment can trigger highly undesirable physical reactions. A study was made to determine whether the administration of propofol and sevoflurane contributes to the stabilization of hemodynamic parameters during dental treatment in pediatric patients versus the use of local anesthesia alone.

MATERIALS AND METHODS

Forty pediatric patients needing dental treatment were assigned to either general anesthesia with local anesthesia (study group [SG]) or local anesthesia alone (control group [CG]). Two percent sevoflurane in oxygen (100% oxygen, 5 L/min) and continuous propofol infusion (target-controlled infusion [TCI], 2 μg/mL) were used as general anesthesia agents in SG; and 2% lidocaine with 1:80,000 adrenaline was used as local anesthesia in both groups. Heart rate, blood pressure and oxygen saturation were measured before starting dental treatment (baseline) and every 10 min during dental treatment.

RESULTS

Blood pressure (p < .001), heart rate (p = .021) and oxygen saturation (p = .007) decreased substantially after the administration of general anesthesia. The levels of these parameters subsequently remained low and then recovered at the end of the procedure. On the other hand, the oxygen saturation values remained closer to baseline in SG versus CG. In contrast, the hemodynamic parameters experienced lesser fluctuations in CG than in SG.

CONCLUSIONS

General anesthesia affords more favorable cardiovascular parameters during the entire dental treatment in comparison to local anesthesia alone (blood pressure and heart rate decrease significantly and oxygen saturation proves more stable and with values closer to baseline), and allows dental treatment to be performed on healthy, lacking cooperative ability children who otherwise could not be treated with local anesthesia alone. No side effects were observed in either group.

Evaluation of hemodynamic changes and patient-reported outcome measures in surgical therapy with or without intravenous sedation: a prospective controlled clinical study

OBJECTIVES

To determine whether intravenous (IV) sedation would contribute to the stabilization of patients' hemodynamics during periodontal and oral surgical procedures, and to evaluate the patient-reported outcome measures (PROMs).

MATERIALS AND METHODS

Periodontal or oral surgery patients were recruited and distributed into two groups: (1) sedation group (SG): intravenous sedation plus local anesthesia; (2) control group (CG): local anesthesia only. Systolic and diastolic blood pressure (SBP, DBP), heart rate (HR), and oxygen saturation (SaO2), were monitored at 15-min intervals from sitting in the dental chair (baseline) until the end of the treatment. In addition, a subjective assessment of PROMs was obtained through a post-operative questionnaire.

RESULTS

Forty-nine patients (25 in SG and 24 in CG) were included. The highest SBP and DBP were significantly higher in CG compared to the SG (141.1 ± 18.4 and 133.6 ± 15.1, respectively in SBP; and 85.5 ± 11.0 and 82.9 ± 10.1, respectively in DBP), but no mean significant differences were found between groups (P value of 0.85 and 0.72 for systolic and diastolic BP, respectively). HR and SaO2 did not show statistical intra- and inter-group differences. The overall patient satisfaction score was significantly higher in the SG group compared to CG.

CONCLUSIONS

Intravenous moderate sedation seems to contribute to the stabilization of patient's hemodynamics, especially the systolic blood pressure, although small differences have been found.

CLINICAL RELEVANCE

Intravenous sedation seems to contribute to stabilize the hemodynamic values, and enhances the patient satisfaction after periodontal and oral surgical treatment in the dental office.

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.

Anesthetic Management of a Patient With Catecholaminergic Polymorphic Ventricular Tachycardia

Catecholaminergic polymorphic ventricular tachycardia (CPVT) is a rare inherited arrhythmogenic disorder induced by adrenergic stress. Electrophysiologically, it is characterized by emotional stress- or exercise-induced bidirectional ventricular tachycardia that may result in cardiac arrest. Minimizing perioperative stress is critical as it can reduce fatal arrhythmias in patients with CPVT. Dexmedetomidine (DEX), a centrally acting sympatholytic anesthetic agent, was used in the successful intravenous (IV) moderate sedation of a 27-year-old female patient with CPVT, a history of cardiac events, and significant dental fear and anxiety scheduled to undergo mandibular left third molar extraction. Oral surgery was successfully performed under DEX-based IV sedation to reduce stress, and no arrhythmias were observed. IV sedation with DEX provided a sympatholytic effect with respiratory and cardiovascular stability in this patient with CPVT who underwent oral surgery.

Programmed-release intraosseus anesthesia as an alternative to lower alveolar nerve block in lower third molar extraction: a randomized clinical trial

Background

Intraosseous anesthesia is the process by which an anesthetic solution, after penetration of the cortical bone, is directly injected into the spongiosa of the alveolar bone supporting the tooth. This study aimed to compare the effectiveness of the traditional inferior alveolar nerve block (IANB) and computerized intraosseous anesthesia in the surgical extraction of impacted lower third molars, compare their side effects systemically by monitoring heart rate, and assess patients’ a posteriori preference of one technique over the other.

Methods

Thirty-nine patients with bilaterally impacted third molars participated in this study. Each patient in the sample was both a case and control, where the conventional technique was randomly assigned to one side (group 1) and the alternative method to the contralateral side (group 2).

Results

The traditional technique was faster in execution than anesthesia delivered via electronic syringe, which took 3 min to be administered. However, it was necessary to wait for an average of 6 ± 4 min from the execution to achieve the onset of IANB, while the latency of intraosseous anesthesia was zero. Vincent's sign and lingual nerve anesthesia occurred in 100% of cases in group 1. In group 2, Vincent’s sign was recorded in 13% of cases and lingual anesthesia in four cases. The average duration of the perceived anesthetic effect was 192 ± 68 min in group 1 and 127 ± 75 min in group 2 (P < 0.001). The difference between the heart rate of group 1 and group 2 was statistically significant. During infiltration in group 1, heartbeat frequency increased by 5 ± 13 beats per minute, while in group 2, it increased by 22 ± 10 beats per minute (P < 0.001). No postoperative complications were reported for either technique. Patients showed a preference of 67% for the alternative technique and 20% for the traditional, and 13% of patients were indifferent.

Conclusion

The results identified intraosseous anesthesia as a valid alternative to conventional anesthesia in impacted lower third molar extraction.

Blood pressure reduction in patients with irreversible pulpitis teeth treated by non-surgical root canal treatment

Background/purpose

The hypotension in patients during non-surgical root canal treatment (NSRCT) has not yet investigated. This study aimed to assess the mean systolic blood pressure (MSBP), mean diastolic blood pressure (MDBP), and mean arterial blood pressure (MABP) reduction percentages in patients with irreversible pulpitis teeth treated by NSRCT.

Materials and methods

We prospectively recruited 111 patients with a total of 138 irreversible pulpitis teeth. All patients underwent two NSRCT sessions. The first NSRCT session involved mainly the removal of vital pulp tissue with the direct stimulation of the dental branches of the trigeminal nerve, and the second NSRCT session included the root canal debridement and enlargement with minimal disturbance to the dental nerves. The blood pressure of each patient was recorded before and during both NSRCT sessions.

Results

There were significantly higher reduction percentages of MSBP, MDBP, and MABP in the first NSRCT session than in the second NSRCT session for all treated patients (all the P-values < 0.001). If the patients were divided into 2 or more groups according to the clinical variables including the patients' gender, age, tooth type, and anesthesia type, we also found significantly higher reduction percentages of MSBP, MDBP, and MABP in the first NSRCT session than in the second NSRCT session for all treated patients except for patients below 40 years of age and for patients with lower anterior teeth treated (all the P-values < 0.05).

Conclusion

The decrease in blood pressure in patients receiving vital pulpal extirpation is a relatively common phenomenon.

Assessment of patient’s anxiety and expectation associated with hemodynamic changes during surgical procedure under local anesthesia

Abstract Introduction The dental patient’s anxiety and expectation may significantly alter their vital signs. The use of local anesthetics associated with a vasoconstrictor may also alter the vital signs of these patients, promoting hemodynamic changes that may result in emergency situations. Objective To evaluate the influence of anxiety of patients submitted to third molar extraction and the use of different anesthetic substances with adrenaline on their vital signs (oxygen saturation, heart rate, and systolic and diastolic blood pressure) in different moments. Material and method Forty patients answered the questionnaire of the Dental Anxiety Scale (Corah’s Scale) and fear (KleinKnecht’s Scale) and were submitted to third molar extraction in two surgical times for the use of articaine or mepivacaine, both associated with adrenaline. The results were analyzed by ANOVA followed by Tukey post hoc test, Student's t test, and Pearson's correlation coefficients (α=0.05). Result There was no significant differences in saturation or heart rate. The blood pressure showed significant variations during time for both anesthetics, however mepivacaine resulted in a longer postoperative time to restore blood pressure. Patients with high or moderate anxiety and high fear index were those who had positive correlations with the highest blood pressure values. Conclusion Anxiety and fear positively influence the increase in blood pressure. Mepivacaine promoted a greater resistance to the return of normal vital signs, especially blood pressure levels.

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.

Local anesthesia with epinephrine is safe and effective for oral surgery in patients with type 2 diabetes mellitus and coronary disease: a prospective randomized study

OBJECTIVE

To investigate the variations in blood glucose levels, hemodynamic effects and patient anxiety scores during tooth extraction in patients with type 2 diabetes mellitus T2DM and coronary disease under local anesthesia with 2% lidocaine with or without epinephrine.

STUDY DESIGN

This is a prospective randomized study of 70 patients with T2DM with coronary disease who underwent oral surgery. The study was double blind with respect to the glycemia measurements. Blood glucose levels were continuously monitored for 24 hours using the MiniMed Continuous Glucose Monitoring System. Patients were randomized into two groups: 35 patients received 5.4 mL of 2% lidocaine, and 35 patients received 5.4 mL of 2% lidocaine with 1:100,000 epinephrine. Hemodynamic parameters (blood pressure and heart rate) and anxiety levels were also evaluated.

RESULTS

There was no difference in blood glucose levels between the groups at each time point evaluated. Surprisingly, both groups demonstrated a significant decrease in blood glucose levels over time. The groups showed no significant differences in hemodynamic and anxiety status parameters.

CONCLUSION

The administration of 5.4 mL of 2% lidocaine with epinephrine neither caused hyperglycemia nor had any significant impact on hemodynamic or anxiety parameters. However, lower blood glucose levels were observed. This is the first report using continuous blood glucose monitoring to show the benefits and lack of side effects of local anesthesia with epinephrine in patients with type 2 diabetes mellitus and coronary disease.

Evaluation of the haemodynamic and metabolic effects of local anaesthetic agent in routine dental extractions

INTRODUCTION

The systemic effects of adrenaline administered during dental local anesthesia have been the subject of many studies. The purpose of this study was to investigate the haemodynamic and metabolic effects attributable to adrenaline injected during local anesthesia in dental extraction patients.

METHODS

Apparently medically fit patients were included and randomized into two groups. Participants had breakfast before coming in for tooth extraction. The weight, height, blood pressure and pulse rate were measured and blood sample taken before administration of local anaesthetic injections. Blood pressure, pulse and blood sample were again taken at 15 and 30 min.

RESULTS

While the adrenaline group showed a modest increase between pre- and post-drug administration states, the control group showed no difference in median systolic blood pressures. Both groups showed a slight increase in diastolic blood pressure observed between pre- and post-drug administration states. Also both groups showed no significant difference in median pulse rate throughout. Although blood glucose values were widely dispersed in the pre-drug administration state in both groups, the control group showed no difference in median values throughout. However, a modest increase was observed in the adrenaline group between pre- and post-drug administration states, which persisted beyond 30 min.

CONCLUSION

The patients treated with local anesthesia with adrenaline showed a response similar to that observed in the control group.

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.

Does the topical use of epinephrine for sinus floor augmentation affect systemic hemodynamics?

PURPOSE

Although epinephrine is one of the most commonly used vasoconstrictor in association with local anesthesia in dentistry, systemic effects of topical admission of epinephrine for sinus augmentation have not been investigated yet. The purpose of this study was to reveal the safety of epinephrine as a topical vasoconstrictor in sinus augmentation procedures.

PATIENTS AND METHODS

Forty-three healthy patients who require sinus floor augmentation for dental implant placement were included in this study. Patients were divided into 2 groups according to the application of either epinephrine-soaked cottonoid or saline-soaked cottonoid for sinus floor augmentation, and heart rate, systolic, and diastolic pressures were evaluated and compared before, during, and after the procedure.

RESULTS

Although there were changes in heart rate, systolic, and diastolic blood pressures, no statistical significance was observed for neither heart rate nor systolic and diastolic blood pressures (P > 0.05).

CONCLUSIONS

This study showed that the topical use of 1/100,000 epinephrine ensures efficacy by helping the clinician to elevate the sinus membrane and keeps the changes in systemic hemodynamics within safe limitations.

Pharmacodynamic responses of exogenous epinephrine during mandibular third molar surgery

Background:

The systemic effects attributable to the injection of dental local anesthetic solutions have been the subject of discussion for many years.

Aim and Objective:

The aim of the present study was to investigate the biochemical and hemodynamic effects of adrenaline in lignocaine local anesthetic solutions when used in clinical doses in patients undergoing third molar surgery under general anesthesia.

Materials and Methods:

Of the total 30 patients, 15 were given local anesthetic solution containing adrenaline and the other 15 were given the same without adrenaline. Hemodynamic and biochemical parameters were recorded at considerable intervals. The changes from the pre-local anesthetic (baseline) values with each treatment were compared by analysis of variance and Student's t-test. The changes within each treatment were compared by the paired t-test.

Results and Conclusion:

This study shows that exogenous adrenaline administration in clinical doses produces systemic effects even in conditions where the endogenous release of the catecholamines would be expected to be considerable.

Clinical study of hemodynamic changes comparing 4% articaine hydrochloride with 1:100,000 and 1:200,000 epinephrine

OBJECTIVE

To evaluate hemodynamic changes with the use of 4% articaine and 2 different concentrations of epinephrine (1:100,000 and 1:200,000) in the surgical removal of symmetrically positioned lower third molars.

STUDY DESIGN

A prospective, randomized, double-blind clinical trial was carried out involving 42 patients each undergoing 2 surgeries on separate occasions under local anesthesia with 4% articaine and either epinephrine 1:100,000 or 1:200,000. The following parameters were assessed at 4 different moments: systolic, diastolic, and mean blood pressure; heart rate; oxygen saturation; rate pressure product (RPP); and pressure rate quotient (PRQ).

RESULTS

The concentration of epinephrine did not affect diastolic blood pressure or oxygen saturation during the surgeries. Significant differences between were detected for heart rate, RPP, and PRQ (P < .05).

CONCLUSIONS

The epinephrine concentration (1:100,000 or 1:200,000) in a 4% articaine solution influences hemodynamic parameters without perceptible clinical changes in healthy patients undergoing lower third molar removal.

A comparative evaluation of pain and anxiety levels in 2 different anesthesia techniques: locoregional anesthesia using conventional syringe versus intraosseous anesthesia using a computer-controlled system (Quicksleeper)

OBJECTIVE

The aim of this study was to compare anxiety and pain levels during anesthesia and efficacy of Quicksleeper intraosseous (IO) injection system, which delivers computer-controlled IO anesthesia and conventional inferior alveolar nerve block (IANB) in impacted mandibular third molars.

STUDY DESIGN

Forty subjects with bilateral impacted mandibular third molars randomly received IO injection or conventional IANB at 2 successive appointments. The subjects received 1.8 mL 2% articaine.

RESULTS

IO injection has many advantages, such as enabling painless anesthesia with less soft tissue numbness and quick onset of anesthesia as well as lingual and palatal anesthesia with single needle penetration.

CONCLUSIONS

Although IO injection is a useful technique commonly used during various treatments in dentistry, the duration of injection takes longer than conventional techniques, there is a possibility of obstruction at the needle tip, and, the duration of the anesthetic effect is inadequate for prolonged surgical procedures.

Aspirations and solutions--a 20 year journey through dental local anaesthetics

This paper describes clinical and laboratory investigations concerned with the delivery, comfort, systemic effects and efficacy of dental local anaesthesia. Factors influencing the aspirating ability of dental local anaesthetic delivery systems are discussed. The effects of adrenaline in dental local anaesthetic solutions on plasma potassium levels and on the transplanted heart are described. The use of an infiltration technique as an alternative to the inferior alveolar nerve block in the mandible is discussed.

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.

Surgical and nonsurgical endodontic treatment-induced stress

This observational study compared physiologic and psychological indicators of stress between two groups of 30 healthy patients undergoing either surgical or nonsurgical endodontic treatments. Heart rate (HR), systolic blood pressure (SBP), and diastolic blood pressure were monitored during care sessions. The patients were asked to score their anxiety before treatment and to report pain, stress, and/or discomfort experienced during care. Variations in HR and SBP were significantly dependent on treatment group (HR: F = 6, p < 0.001; SBP: F = 4, p = 0.05). Intergroup differences increased during the active steps of the treatment, such as local anesthesia, rotary instrumentation, periradicular curettage, root filling, and field removal. Moreover, the level of stress experienced during the care procedure was correlated to the level of anticipated anxiety in both groups. This study raises questions on the indications for anxiolysis or sedation in endodontic patients as a means of preventing the neurophysiologic consequences of stress.

Cardiovascular influence of dental anxiety during local anesthesia for tooth extraction

OBJECTIVE

The present study evaluated whether dental patient anxiety has an effect on the cardiovascular response to the delivery of anesthetic to achieve mandibular anesthesia.

STUDY DESIGN

One hundred eighty adult patients scheduled to receive routine dental extraction under local anesthesia were enrolled in this prospective study. Anxiety was measured at 15 minutes before local anesthetic delivery using Corah's Dental Anxiety Scale (Corah's DAS). Anesthetic was delivered using a standard technique for mandibular nerve block with the same dose (2 cartridges) given to all patients. Cardiovascular response data including blood pressure, heart rate, O(2) saturation, and electrocardiographic changes were measured at 5 time points from 5 minutes before to 15 minutes after the administration of anesthetic.

RESULTS

The mean anxiety scale score before administration of anesthetic was 9.3 (SD +/- 2.5) with a range from 4 to 20. Women had a significantly higher mean dental anxiety level than men (P < .05). Younger age was associated with a higher anxiety scale score. Severe preoperative anxiety (Corah's DAS >12) was associated with significantly increased heart rate during administration of anesthetic. Patients with severe anxiety also had a significantly greater increase in heart rate during anesthetic administration (P < .001). Younger age was associated with increased likelihood of high dental anxiety and associated cardiovascular response to dental anesthesia (P = .001). Pain on injection was also associated with increased heart rate during anesthetic administration.

CONCLUSION

This study showed that Corah's dental anxiety scale is a useful tool for estimating the impact of anxiety on the heart rate during local anesthetic delivery to achieve mandibular block for dental extraction. Younger patients undergoing tooth extraction were more likely to have high anxiety levels, and younger patients with high anxiety were more likely to report a traumatic dental history. High anxiety, younger age, and traumatic dental history were correlated with greater increases in heart rate during the administration of local dental anesthesia.

Glycemic effect of administration of epinephrine-containing local anaesthesia in patients undergoing dental extraction, a comparison between healthy and diabetic patients

OBJECTIVES

To compare the effect of administration of epinephrine (in the dental local anesthetic solution) on blood glucose concentration in healthy and diabetic dental patients after extraction. To determine if there is any correlation between blood glucose level changes and the number of carpules injected, number of teeth extracted and the gender of the patient.

MATERIALS AND METHOD

An open study of 60 patients (30 healthy and 30 diabetics) visiting the Oral Surgery clinic of Ajman University of Science and Technology. A drop of blood was taken from the tip of the patient's finger and placed on a glucometer strip to determine the pre-operative blood glucose level. Dental local anaesthesia (1.8 ml carpule each) containing 1:80,000 epinephrine was injected either through infiltration or block. Extraction was carried out atraumatically and 10 minutes post-extraction the glucose measurement was taken.

RESULTS

The difference in the blood glucose levels pre- and post operatively were not significantly different (p > 0.05) when a comparison was made between the healthy and diabetic groups. Comparison of glucose changes in diabetics who had taken their hypoglycaemic medication and those who had not, showed a significant difference (p < 0.05). Statistical analysis showed no correlation between the blood glucose level changes and the number of carpules used, number of teeth extracted and gender.

CONCLUSION

Dental local anaesthetic solution containing epinephrine is safe to use in all healthy and diabetic patients (irrespective of their gender), excepting those diabetics who have not taken their pre-operative hypoglycaemic medication. There is no relation between the post-extraction glucose changes and the number of carpules used, number of teeth extracted or gender.

Plasma catecholamine concentrations and hemodynamic responses to vasoconstrictor during conventional or Gow-Gates mandibular anesthesia

OBJECTIVE

The literature supports that systemic responses to injected vasoconstrictors depend on the volume and concentration administered, patient's age and health status, as well as site of injection. Thus, the influence of mandibular anesthesia technique on hemodynamic and plasma responses to epinephrine-containing local anesthetics was investigated.

STUDY DESIGN

Conventional or Gow-Gates anesthesia with 2% lidocaine and epinephrine, 1:100,000, was performed in 18 subjects who required third molar extraction. A control group of 9 subjects was submitted to conventional anesthesia with plain 3% mepivacaine. Blood pressure, heart rate, and plasma catecholamines were measured.

RESULTS

Analysis of variance showed that plasma epinephrine level after conventional lidocaine anesthesia was significantly elevated (P < .01), while there was no difference between the Gow-Gates and control groups. The hemodynamic parameters did not demonstrate correlation to the injection technique.

CONCLUSION

Presumably, there was less exogenous epinephrine absorption in the Gow-Gates technique than in the conventional mandibular anesthesia injection.

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.

The effects of epinephrine in local anesthetics on plasma catecholamine and hemodynamic responses

In order to clarify the influence of epinephrine in local anesthetics on endogenous epinephrine, we examined the concentration of plasma catecholamines (epinephrine and norepinephrine) and hemodynamics by administering 4 ml of 2% lidocaine containing different concentrations of epinephrine. Forty-three healthy adult male volunteers were divided into five groups according to epinephrine concentration: 0-microg (group I), 10-microg (group II), 20-microg (group III), 40-microg (group IV), and 50-microg (group V). The parameters were examined immediately, and at 1, 2, 3, 4, 5, 10, 15, and 20 min after the injection. In groups II, III, IV, and V, the plasma epinephrine concentration was elevated to peak at 5 min after the injection, after which it started to decline. The amount of increase in the plasma epinephrine concentration at 5 min showed a highly positive correlation with the amount of epinephrine added to the local anesthetic in groups II, III, and IV. In group V the plasma epinephrine concentration showed a marked increase as compared to the baseline level. Plasma norepinephrine concentrations were found to be significantly elevated at 15 and 20 min in group V. A decrease in systolic blood pressure was observed at 4 and 5 min in group II. A decrease in diastolic blood pressure was observed at 5 min in group II; at 3, 4, and 5 min in group IV; and at 2, 3, 4, and 5 min in group V. Heart rate revealed no significant differences from baseline level in any of the groups and there were no significant differences among the groups. It is suggested that exogenous epinephrine added to a local anesthetic may stimulate the presynaptic beta2 receptors on sympathetic nerve endings and on the adrenomedulla, and accelerate the release of endogenous epinephrine.

Comparison of Intraosseous and Infiltration Injections For Venous Lidocaine Blood Concentrations and Heart Rate Changes after Injection of 2% Lidocaine with 1:100,000 Epinephrine

The purpose of this prospective, randomized study was to compare the venous blood levels of lidocaine and heart rate changes after intraosseous and infiltration injections of 1.8 ml of 2% lidocaine with 1:100,000 epinephrine. Using a crossover design, 20 subjects randomly received an intraosseous and infiltration injection at two separate appointments. The heart rate was measured using a pulse oximeter. Venous blood samples were collected before the injections and at 2, 5, 10, 15, 20, 25, 30, 45, and 60 min after the injections. The blinded plasma samples were analyzed for lidocaine concentrations using high-performance liquid chromatography (HPLC). The intraosseous injection resulted in a statistically significant increase in heart rate, when compared to the infiltration injection, during solution deposition and for 2 min after the injection. The plasma levels of lidocaine were not statistically different for maxillary anterior intraosseous and infiltration injections when using 1.8 ml of 2% lidocaine with 1:100,000 epinephrine.

Current concepts in gingival displacement

Gingival displacement is an important procedure with fabricating indirect restorations. Gingival displacement is relatively simple and effective when dealing with healthy gingival tissues and when margins are properly placed a short distance into the sulcus. Several techniques have proven to be relatively predictable, safe,and efficacious. No scientific evidence has established the superiority of one technique over the others, so the choice of technique depends on the presenting clinical situation and operator preference.

Effects of dental local anaesthetics in cardiac transplant recipients

OBJECTIVE

To investigate the cardiovascular responses of cardiac transplant recipients to dental local anaesthetic solutions with and without epinephrine (adrenaline).

MATERIALS AND METHODS

A clinical study employing 30 patients (20 cardiac transplant recipients and ten healthy) awaiting gingival or minor oral surgery under local anaesthesia receiving either 4.4 ml lidocaine (lignocaine) with 1:80,000 epinephrine or 4.4 ml 3% prilocaine with 0.031 U/ml felypressin.

RESULTS

Cardiac transplant patients experienced a significant tachycardia 10 minutes after injection of the epinephrine-containing solution. No significant change in heart rate was detected after the injection of an epinephrine-free solution. Blood pressure was not affected. Periodontal surgery did not affect the responses to the local anaesthetics in the transplant recipients.

CONCLUSIONS

The cardiovascular response to dental local anaesthesia in cardiac transplant recipients is governed by the solution injected.

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

OBJECTIVE

The purpose of the present study was to examine the safety of epinephrine-containing local anesthesia for use on patients with cardiovascular disease.

STUDY DESIGN

Twenty-seven patients with cardiovascular disease were studied. The cardiac functional capacity of 9 patients was New York Heart Association class I; 11, class II; and 7, class III. Hemodynamic responses to intraoral injection of 1.8 mL of 2% lidocaine with 1:80,000 epinephrine were measured with impedance cardiography.

RESULTS

Systolic blood pressure and heart rate increased by 4.1% and 5.1%, respectively, immediately after the lidocaine-epinephrine injection. Consequently, rate pressure product increased by 10.0%. Cardiac index increased by 14.2%, and total peripheral resistance decreased by approximately 10%. No patient complained of cardiac symptoms. There were no significant differences in hemodynamic responses related to the extent of the cardiac functional capacity.

CONCLUSION

We concluded that lidocaine-epinephrine was safe and had few, if any, hemodynamic consequences in patients with cardiovascular disease.

The influence of two different dental local anaesthetic solutions on the haemodynamic responses of children undergoing restorative dentistry: a randomised, single-blind, split-mouth study

OBJECTIVES

This investigation was designed to study the haemodynamic effects of two different local anaesthetic solutions during restorative dental treatment in children.

DESIGN

A randomised, single-blind, split-mouth cross-over design was employed using children undergoing bilaterally similar restorative treatments over two visits.

SETTING

The study was performed in a dental hospital paediatric dentistry department.

METHODS

Ten children participated. At one visit the local anaesthetic was 2% lidocaine (lignocaine) with 1:80,000 epinephrine (adrenaline); at the other the anaesthetic was 3% prilocaine with 0.03IU/ml felypressin. Local anaesthetic was administered at a dose of 0.5 ml/10 kg body weight. Blood pressure and heart rate were measured before and during treatment with an automatic blood pressure recorder. Data were analysed by ANOVA and Student's paired t test.

RESULTS

Significant differences between treatments in diastolic blood pressure (F = 2.37; P = 0.05) and heart rate (F = 2.98; P< 0.02) were noted. The heart rate increased ten minutes following the injection of the epinephrine-containing solution. The diastolic blood pressure fell 20 minutes after injection of lidocaine with epinephrine.

CONCLUSION

The choice of local anaesthetic solution influences the haemodynamic response during restorative treatment in children.

Hemodynamic assessment of local anesthetic administration by laser Doppler flowmetry

OBJECTIVE

The hemodynamic effects of local anesthetic administration with and without a vasoconstrictor were compared by using laser Doppler flowmetry.

STUDY DESIGN

Seventeen people participated in a single study session in which they were given 2 intraoral injections. The injections, which were administered in random order, consisted of 1.8 mL lidocaine (2%) with epinephrine (1:100,000) and mepivacaine (3%). Hemodynamic parameters consisting of blood pressure, heart rate, and laser Doppler flowmetry were reordered at regular intervals.

RESULTS

The laser Doppler flowmeter detected changes in the peripheral perfusion of the finger that were not detected by changes in blood pressure and heart rate. The greatest change was associated with anxiety and occurred just before the injection. The inclusion of epinephrine in the local anesthetic resulted in a persistence of these changes.

CONCLUSION

This investigation has confirmed the sensitivity of laser Doppler flowmetry as an investigational tool for assessing hemodynamic changes associated with anxiety and the administration of local anesthesia.

Unintentional hypotension from lidocaine infiltration during orthognathic surgery and general anaesthesia

BACKGROUND

A probable causal relationship between submucosal infiltration of lidocaine, with adrenaline 12.5 microg x mL(-1), and untoward arterial hypotension during general anaesthesia for orthognathic surgery was investigated in two parts.

METHODS

The first part of the study was open and non-randomised. The patients served as their own controls, receiving 5.4 mL saline/adrenaline before mandibular or maxillary surgery on the first side of the jaw and 5.4 mL lidocaine (2%)/adrenaline on the other side a minimum of 40 min later. Nine patients received in total 11 pairs of injections of the study drugs. In Part Two, 50 mg or 100 mg of lidocaine with adrenaline was infiltrated in an observer-blinded and randomised order in either side of the jaw in another 13 patients.

RESULTS

A significant and dose-dependent blood pressure decrease was observed after infiltration of lidocaine/adrenaline, but not after saline/adrenaline. The heart rate increased significantly after both types of injections, most pronounced after saline/adrenaline. Mean arterial blood pressure decreased on average 11% and 23% with lidocaine 50 mg and 100 mg, respectively (P<0.05, ANOVA).

CONCLUSION

Lidocaine induced dose-dependent arterial hypotension when combined with a defined level of general anaesthesia. The causative mechanism is unclear.

The impact on dentistry of recent advances in the management of hypertension

Dentistry has played an important role in the detection of patients with hypertension. Patients found to have high blood pressure at or beyond defined levels should be referred for a medical diagnosis and indicated treatment. Once the hypertensive condition is under control, oral and dental evaluation and treatment can be initiated. Beginning in 1976, the percentage of the general population in the United States with undetected hypertension declined steadily. However, this decline reversed, beginning in 1994. In addition, fewer than 50% of the patients who are aware of their hypertension have it medically under control. Thus, a significant number of patients with undetected high blood pressure or uncontrolled hypertension today are seeking dental treatment. These patients are at high risk for significant complications such as stroke, heart disease, kidney disease, and retinal disease. Those with very high blood pressure are at great risk for acute medical problems when receiving dental treatment. For those reasons, dentistry must continue to place an emphasis on the detection and referral of patients with high blood pressure. In addition, increased numbers of medically compromised patients are seeking dental treatment who should have their blood pressure monitored during the more stressful dental procedures, such as oral surgery, periodontal surgery, and placement of dental implants. This article reviews the recent advances in the dental and medical management of hypertension. It is important for dentists to be aware of hypertension in relation to the practice of dentistry.

The use of epinephrine-containing anesthetic solutions in cardiac patients: a survey

A questionnaire survey of 150 last term dental students from four dental schools was performed to delineate their current opinion with regard to the use of epinephrine-containing anesthetic solutions for dental procedures in cardiac patients. The students provided their opinion as "contraindicated" or "not contraindicated" regarding the use of these solutions in eight cardiac patients with either stable or unstable heart diseases including ischemic heart disease, arrhythmia, hypertension, and heart failure. We found an overall 77% rate of right answers among all students. Mistakes occurred more frequently when treating patients with ischemic heart disease (68% of right answers). Although vasoconstrictors may offer many advantages and are not contraindicated to the majority of cardiac patients, graduating dental students sometimes do not comply with current guidelines.

Cardiovascular changes during subgingival debridement

During dental hygiene sessions, systolic and diastolic blood pressure and heart frequency were registered continuously with a finger manometer to investigate the possible cardiovascular effects of root planing/scaling. Ultrasonic subgingival debridement was performed for an average period of 10.6 +/- 2.1 min. Analysis of variance showed significant changes of systolic and diastolic blood pressure, heart rate and the rate pressure product during debridement. The increases in systolic and diastolic blood pressure both correlated significantly with the length of the debridement. After completion of the dental hygiene session, the urinary excretion of adrenaline was increased. The data from this study suggest that painful stimuli during ultrasonic subgingival debridement have extensive cardiovascular effects.

Plasma catecholamine and haemodynamic responses to surgical endodontic anaesthetic protocols

The effects of varying clinically relevant patterns of anaesthetic-vasoconstrictor combinations used for periradicular surgery on plasma concentrations of catecholamines and haemodynamic responses was studied in the canine model. Five mongrel dogs were anaesthetized with sodium pentobarbitol. A femoral cannula was inserted to measure central blood pressure and an ECG was used to monitor heart rate and any associated arrhythmias. Femoral venous blood samples were drawn before initial injection and at 3 and 10 min after injections. Plasma catecholamine concentrations were determined using high pressure liquid chromatography (HPLC). Injection protocols used three time periods, 30, 60 and 90 s, with solutions containing 1:100,000 and 1:50,000 adrenaline. No significant changes in heart rates or presence of arrhythmias were noted over the experimental protocol. Catecholamine levels in pico moles mL-1 were within the normal range at the 3-min sample level. At the 10-min sample time there was a more erratic range of concentrations, with most samples within the normal range. This may have been due to endogenous release of catecholamines in specific animals. The data identified trends in both the haemodynamic parameters and plasma catecholamine levels that can legitimately support the careful use of higher levels of a vasoconstrictor when patient profiles and surgical needs dictate.

Contraindications to vasoconstrictors in dentistry: Part II. Hyperthyroidism, diabetes, sulfite sensitivity, cortico-dependent asthma, and pheochromocytoma

Dentists are aware of contraindications to the use of vasoconstrictors in patients with cardiovascular diseases. However, there are some other noncardiac conditions we should know. This article discusses the absolute contraindications to the use of vasoconstrictors in patients with a history of hyperthyroidism, diabetes, allergy to sulfites, asthma, and pheochromocytoma.

Contraindications to vasoconstrictors in dentistry: Part I. Cardiovascular diseases

This article reviews the main contraindications of vasoconstrictors in cardiac patients, notably unstable angina, recent myocardial infarction, recent coronary artery bypass surgery, refractory arrhythmias, untreated or uncontrolled hypertension, and untreated or uncontrolled congestive heart failure. Extensive survey of the literature has been completed, giving specific guidelines for a rational use of vasoconstrictors in this category of medically compromised patients.

Pulpal anesthesia dependent on epinephrine dose in 2% lidocaine. A randomized controlled double-blind crossover study

We studied the discrepancy in the results published on the dependence of the duration of pulpal nerve anesthesia on the concentration of epinephrine in 2% lidocaine. The increase in pain threshold of the pulpal nerve was measured before and after injection of lidocaine alone and lidocaine with epinephrine concentrations of 1:200,000, 1:100,000, or 1:50,000 into the mucobuccal aspect adjacent to the apex of the maxillary right incisor. The study was done in a random manner with a double-blind crossover design. The pulpal nerve was stimulated with negative rectangular electrical pulses of up to -167 V with 100 Hz and a pulse width of 0.6 msec. The results show a relationship between the 1:200,000 and 1:100,000 epinephrine concentrations and the success and duration of anesthesia. The onset of anesthesia was independent of the catecholamine content of the solution.

Cardiohemodynamic and serum catecholamine response to surgical removal of impacted mandibular third molars under local anesthesia: a randomized double-blind parallel group and crossover study

The aim of this study was to differentiate between the extent to which surgical stress and the epinephrine in local anesthetic solutions influence serum catecholamine, cAMP, and potassium levels, and contribute to changes in cardiohemodynamic parameters. One hundred sixty mg of articaine hydrochloride (4.0 mL of a 4% articaine hydrochloride solution) with two different epinephrine doses was injected into outpatients prior to removal of an impacted mandibular third molar in a randomized, double-blind parallel group and crossover design. The results showed that the amount of epinephrine absorbed from the intraoral injection site predominantly determined the serum epinephrine concentration. The anesthetic-induced increase in the serum epinephrine level did not correlate with changes in the cardiohemodynamic parameters under study at any time during the operative procedure. The serum cAMP changes correlated with those of epinephrine, whereas the serum potassium levels remained unchanged. The procedure of tooth extraction was a stressful event when the 1:200,000 epinephrine-containing anesthetic solution was used, showing that the risk of inducing a cardiovascular incident during oral surgery seems to be higher the greater the extent of operation and the lower the epinephrine dose in the anesthetic solution.

The biochemical and haemodynamic effects of adrenaline in lignocaine local anaesthetic solutions in patients having third molar surgery under general anaesthesia

The effects of adrenaline-containing and adrenaline-free lignocaine local anaesthetic solutions injected in doses consistent with clinical practice on plasma potassium concentration, blood glucose levels and haemodynamic responses were investigated in 20 patients having third molar surgery under general anaesthesia. All patients received a standard general anaesthetic regime. Ten patients were given 4.0 ml of 2% lignocaine as an inferior dental and long buccal block during their general anaesthetic and the other 10 received 4.0 ml of 2% lignocaine containing 1:80000 adrenaline in the same manner. There were no significant differences between treatments in blood pressure or heart rate. However, there were significant differences between treatments in plasma potassium concentration and blood glucose levels.

Cardiohaemodynamic and plasma level responses to intraoral submucosal injection of adrenaline

Since knowledge of the bioavailability of adrenaline from the intraoral submucosal depot is a prerequisite for its safe use in dentistry, the time-dependent effects of adrenaline on the plasma adrenaline level and cardiohaemodynamic parameters were studied with invasive methods in adrenalectomized, anaesthetized rats after injection of adrenaline (4.0 micrograms/kg body wt) into the mucobuccal fold lateral to the upper right incisor. The absolute bioavailability of adrenaline from this intraoral submucosal depot was 16.8 per cent. Peak values for arterial plasma adrenaline and arterial blood pressure, maximal rate of rise of pressure in the left ventricle and heart rate were measured as early as 5 s after an injection period of 10 s. The different velocities at which the individual parameters returned to the basal state showed that the measurement of heart rate is an insensitive indicator of systemic adrenaline. Due to the absorption kinetics of adrenaline from intraoral tissue it may be concluded that the method of injection has a decisive influence on arterial adrenaline concentration and thus on cardiovascular response.

Effects of anesthetics containing epinephrine on catecholamine levels during periodontal surgery

Nine stable cardiovascular disease patients were evaluated in a double-blind cross-over trial during periodontal surgery using 2% lidocaine with epinephrine 1:100,000 or lidocaine alone. In the lidocaine with epinephrine group, epinephrine levels increased from 198 +/- 54 pg/ml to 592 +/- 166 pg/ml at 2 minutes post-injection. In the lidocaine alone group, epinephrine levels increased from a baseline of 115 +/- 34 pg/ml to 150 +/- 34 pg/ml at 2 minutes post-injection. Despite these elevations in epinephrine, no significant changes in heart rate or mean arterial pressure were noted. Plain lidocaine provided unsatisfactory levels of hemostasis and/or anesthesia during periodontal surgery. This study documents acute elevations in plasma epinephrine levels following local dental anesthesia for periodontal surgery. These elevations in plasma epinephrine failed to produce a significant cardiovascular response in a group of stable cardiovascular disease patients. This suggests that the cardiac effects of local anesthetics containing epinephrine are small and that they can be safely used in stable cardiovascular disease patients.