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

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.

Dental Management Considerations for Patients with Cardiovascular Disease-A Narrative Review

Dental therapists encounter patients with various systemic diseases of which cardiovascular disease (CVD) patients form a significant segment. Relation between oral health and cardiac diseases has been well established. Common cardiac disorders encountered in a dental practice include arterial hypertension, heart failure, ischemic heart disease, cardiac arrhythmias, infective endocarditis, stroke, and cardiac pacemaker. Patients with CVDs pose a significant challenge to dental therapy. These patients need special considerations and an adequate understanding of the underlying cardiovascular condition to provide safe and effective dental treatment. Based on the cardiac condition, an appropriate modification in dental care is crucial. A multidisciplinary approach including the patient's cardiologist can potentially reduce complications and improve dental treatment results. This review aims at unfolding the risks associated with the dental management of a cardiac patient and outlines the measures to be undertaken for optimum dental treatment.

Cardiovascular Response of Aged Outpatients With Systemic Diseases During Tooth Extraction: A Single-Center Retrospective Observational Study

Background

Aged people are maintaining many natural teeth due to improved oral health. However, compromised general health and poor oral hygiene habits at earlier ages resulted in poor status of preserved teeth. Therefore, tooth extraction is required in many aged people. More knowledge is needed because there are many risk factors during the surgery in frail aged adults. The aim of this study was to evaluate the cardiovascular response of such a population during tooth extraction and analyze risk factors to provide clinical guidance.

Methods

A retrospective study was performed on aged patients with systemic diseases who underwent tooth extraction. Data regarding demographic profiles and cardiovascular parameters of heart rate and blood pressure were collected preoperative, when local anesthesia was administered, at the beginning of tooth extraction, 5 min after tooth extraction, and postoperative. The effects of risk factors, including age, sex, and systemic diseases on these parameters were analyzed with a multilevel model.

Results

Heart rate (HR), systolic blood pressure (SBP), and diastolic blood pressure (DBP) of aged patients increased significantly when performing local anesthesia and tooth extraction. During the operation, the older patients (β = 2.011, P = 0.005) and the diabetics (β = 3.902, P < 0.0001) were associated with higher SBP, while those with more tooth extractions exhibited higher HR (β = 0.893, P = 0.007). Women patients showed both significantly elevated HR (β = 1.687, P < 0.0001) and SBP (β = 2.268, P < 0.0001). However, for coronary artery disease patients, HR (β = −2.747, P < 0.0001) and blood pressure [SBP (β = −4.094, P < 0.0001) and DBP (β = −0.87, P = 0.016)] were markedly lower than those of patients without a diagnosis of coronary artery disease.

Conclusion

Cardiovascular response of aged outpatients with systemic diseases during tooth extraction is quite significant. Age, sex, systemic diseases, and the number of tooth extraction could be risk factors closely associated with cardiovascular response. The findings might provide safety guidance for dentists on tooth extraction in this population.

Local anaesthetics combined with vasoconstrictors in patients with cardiovascular disease undergoing dental procedures: systematic review and meta-analysis

OBJECTIVES

There is a lack of evidence about the use of local anaesthetics (LAs) in patients with cardiovascular diseases (CVD) in dental procedures. Thus, this study evaluated the safety of using LA with vasoconstrictor to determine the risk of cardiovascular events in patients with CVD.

DESIGN

Systematic review and meta-analysis.

METHODS

We have searched in Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (via Ovid), EMBASE (via Ovid), Healthstar (via Ovid), CINAHL, Web of Science and ClinicalTrials.gov for randomised controlled trials (RCTs) up to January 2020. We have included RCTs involving adults with CVD within two groups: intervention group with LA with vasoconstrictor and control group with LA without vasoconstrictor. The primary outcomes assessed were death, mortality by a specific cause, stroke, acute myocardial infarction, hospitalisation, pain, bleeding and arrhythmias. The secondary outcomes were ST segment depression, anxiety, adverse effects and changes in haemodynamic parameters. The data were pooled using random effects meta-analyses and the confidence in the estimates was verified using the Grading of Recommendations Assessment, Development and Evaluation (GRADE).

RESULTS

Ten RCTs (n=478 participants) were included. Most of them had a high risk of bias. There were more cases of pain and bleeding in groups without vasoconstrictor. Meta-analysis demonstrated a decrease in the systolic blood pressure with the use of LA with vasoconstrictor (standard mean difference -0.95, 95% CI -1.35 to -0.55) after procedure. Overall, for the other outcomes assessed there was no statistical difference. The quality of evidence was considered low according to the GRADE profile.

CONCLUSIONS

The results suggest that the use of LA with vasoconstrictors (epinephrine in low doses) is safe in patients with some types of CVD. However, the low quality of evidence demonstrated that literature needs further studies in order to confirm these results.

PROTOCOL REGISTRATION

PROSPERO (CRD42016045421).

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.

Effect of the addition of epinephrine to a lidocaine solution on the efficacy and duration of palmar digital nerve blocks in horses with naturally occurring forefoot lameness

OBJECTIVE To determine whether addition of epinephrine to a lidocaine solution would prolong and potentiate the efficacy of a palmar digital nerve block (PDNB) in horses. ANIMALS 6 adult horses with naturally occurring forefoot lameness. PROCEDURES Initially, a PDNB with a 2% lidocaine solution was performed on the affected foot of each horse. Three days later, the PDNB was repeated with a 1% lidocaine solution or a 1% lidocaine solution containing epinephrine (dilution, 1:200,000). After another 3-day washout period, the PDNB was repeated with the treatment opposite that administered for the second PDNB. Gait was analyzed with a computerized lameness analysis system and heart rate and extent of skin sensation between the heel bulbs of the blocked foot were evaluated at predetermined times for 2 hours after each PDNB. RESULTS Efficacy and duration of the PDNB did not differ significantly between the 2% and 1% lidocaine treatments. The addition of epinephrine to the 1% lidocaine solution improved the efficacy and prolonged the duration of the PDNB. It also resulted in a positive correlation between skin desensitization and amelioration of lameness. Median heart rate remained unchanged throughout the observation period for all 3 treatments. No adverse effects associated with the PDNBs were observed. CONCLUSIONS AND CLINICAL RELEVANCE Addition of epinephrine (dilution, 1:200,000) to a 1% lidocaine solution improved the efficacy and prolonged the duration of a PDNB in horses with naturally occurring lameness and might be clinically useful for lameness evaluations and standing surgery of the forefoot of horses.

Cortisol level and hemodynamic changes during tooth extraction at hypertensive and normotensive patients

Background:

The patients that are subjects to oral-surgical interventions produce large amounts of steroids in comparison with healthy patients which are not a subject to any dental intervention. The aim of research was to determine the level of stress hormone cortisol in serum, arterial blood pressure and arterial pulse, and to compare the effectiveness of the usage of lidocaine with adrenalin in comparison with lidocaine without adrenalin during the tooth extraction.

Patients and methods:

This clinical research includes patients with indication of tooth extraction divided in hypertensive and normotensive patients.

Results:

There is no important statistical distinction between groups, for the cortisol levels before, during and after tooth extraction regardless of the type of anesthetic used, while we registered higher values of systolic and diastolic values at hypertensive patients, regardless of the type of anesthetic

Conclusion:

There is significant systolic and diastolic blood pressure rise in both groups of patients hypertensive and normotensive patients, (regardless of anesthetic used with or without vasoconstrictor), who underwent tooth extraction. The special emphasize is attributed to hypertensive patients where these changes are more significant. As per cortisol level and pulse rate, our results indicate no significant statistical difference in between groups.

Evaluation of the anesthetic effect of epinephrine-free articaine and mepivacaine through quantitative sensory testing

Introduction

Long lasting anesthesia of the soft tissue beyond the dental treatment affects patients in daily routine. Therefore a sophisticated local anesthesia is needed. The purpose of this study was an evaluation of the clinical use of epinephrine-free local anesthetic solutions in routine short-time dental treatments.

Materials and methods

In a prospective, single-blind, non-randomized and controlled clinical trial, 31 patients (16 male, 15 female patients) undergoing short-time dental treatment under local anesthesia (plain solutions of articaine 4% and mepivacaine 3%) in area of maxillary canine were tested with quantitative sensory testing QST. Paired-Wilcoxon-testing (signed-rank-test) and Mc Nemar tests have been used for statistical results.

Results

Significant differences in all tested parameters to the time of measurements were found. Mepivacaine showed a significantly stronger impact for the whole period of measurement (128 min) on thermal and mechanical test parameters and to the associated nerve fibers.

Conclusion

Plain articaine shows a faster onset of action associated with a shorter time of activity in comparison to plain mepivacaine. In addition to this articaine shows a significant low-graded effect on the tested nerve-fibers and therefore a least affected anesthesia to the patient. The clinical use of an epinephrine-free anesthetic solution can be stated as possible option in short dental routine treatments to the frequently used vasoconstrictor containing local anesthetics. Patients may benefit from shorter numbness.

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.

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.

The assessment and importance of hypertension in the dental setting

Many patients with hypertension have uncontrolled disease. The dental visit presents a unique opportunity to screen patients for undiagnosed and undertreated hypertension, which may lead to improved monitoring and treatment. Although there are no clinical studies, it is generally recommended that nonemergent procedures be avoided in patients with a blood pressure of greater than 180/110 mm Hg. Because of the high prevalence of disease and medication use for hypertension, dentists should be aware of the oral side effects of antihypertensive medications as well as the cardiovascular effects of medications commonly used during dental visits.

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.

Influence of local anesthetics with or without epinephrine 1/80000 on blood pressure and heart rate: A randomized double-blind experimental clinical trial

BACKGROUND

Local anesthesia (LA) with epinephrine have an important role in pain and bleeding control. However, most clinicians believe LA + epinephrine may cause rapid raise in blood pressure (BP) and heart rate (HR). The aim of this research was to compare the changes in HR and BP after administration of lidocaine with and without epinephrine 1/80000 in two infiltration (INF) and inferior alveolar nerve block methods (IANB).

MATERIALS AND METHODS

The study was a randomized double-blind experimental clinical trial. Forty subjects were divided into two equal groups and two subgroups. In one group, INF and in the other group, IANB were used and, further, in one subgroup lidocaine and in another subgroup, lidocaine plus epinephrine were used. BP and HR were recorded before and 10 min after. The paired t-test for intragroup differences and independent t-test for intergroup analysis were used at the significant level of P≤0.05.

RESULTS

The mean BP and HR values were reduced after injection of lidocaine in both INF and IANB compared with baseline. The differences were statistically significant (P < 0.05), but, on comparing these values between the two injection methods, the differences were not statically significant (P = 0.089 and 0.066, respectively). The mean BP and HR values were increased after injection of lidocaine plus epinephrine in both INF and IANB compared with baseline, and these were statistically significant (P < 0.05) but, on comparing these values between the two methods, the differences were not statically significant (P = 0.071 and 0.092, respectively).

CONCLUSION

The rise in BP and HR following injection of lidocaine plus epinephrine was statistically significant compared with baseline in both INF and IANB, but this was not clinically and numerically considerable.

Clinical use of an epinephrine-reduced (1/400,000) articaine solution in short-time dental routine treatments--a multicenter study

The addition of epinephrine in dental local anaesthesia results in a longer and deeper anaesthesia under almost ischemic conditions. For short-time dental treatments, epinephrine-reduced anaesthetics may offer shorter and more individual anaesthesia with reduced potential side effects. The aim of this study was a clinical evaluation of anaesthetic potency and adverse effects of an epinephrine-reduced articaine formulation in dental patients undergoing short-time routine treatment. In a prospective clinical, not interventional, study between January 2008 and February 2009, 908 patients undergoing short-time dental treatment in five medical centers were anaesthetized with 4% articaine 1:400,000 epinephrine (Ubistesin, 3M/ESPE, Seefeld, Germany). Efficacy and safety in clinical use were evaluated. A follow-up after 1 day was conducted by telephone survey. A mean amount of 1.3-ml anaesthetic solution was needed to achieve a complete or sufficient anaesthesia in 97% (n = 876) of cases. A second injection had to be done in 3.7% (n = 34) before and in 11.9% (n = 108) during treatment. Here, the second injection had to be applied after a mean of 48.6 min. The mean duration of soft tissue anaesthesia after infiltration was 146.6 min, after nerve block 187.7 min. The painful treatment took a mean of 50.2 min and the total treatment time summed up to 68.8 min. In 1.7% cases (n = 15), unwanted side effects were observed. The results indicate that a lower concentration of epinephrine in combination with the 4% articaine solution leads to a high success rate of efficacy. The clinical use of a 4% articaine 1:400,000 epinephrine solution can be stated as safe and effective in short dental routine treatments. Reconsiderations concerning limitations of indication or additional contraindications are not necessary.

Comparison of hemodynamic effects of lidocaine, prilocaine and mepivacaine solutions without vasoconstrictor in hypertensive patients

Objective

Local anesthetic solutions with vasoconstrictors are not contraindicated in hypertensive patients, but due to their hemodynamic effects, local anesthetics without vasoconstrictors are mainly preferred by the clinicians. The aim of this study was to compare hemodynamic effects of three different local anesthetics without vasoconstrictors during tooth extraction in hypertensive patients.

Material and Methods

Sixty-five mandibular molars and premolars were extracted in 60 hypertensive patients (29 females and 31 males; mean age: 66.95 ± 10.87 years; range: 38 to 86 years old). Inferior alveolar and buccal nerve blocks were performed with 2% lidocaine hydrochloride (HCl), 2% prilocaine HCl or 3% mepivacaine HCl without vasoconstrictor. Hemodynamic parameters namely systolic blood pressure (SBP), diastolic blood pressure (DBP), mean arterial pressure (MAP), heart rate (HR), saturation rate (SR), rate pressure product (RPP) and pressure rate quotient (PRQ) were investigated before and at different intervals after anesthetic injection.

Results

The hemodynamic effects of the three agents were similar to each other, although some significance was observed for DBP, MAP, RPP and PRQ values in the lidocaine, prilocaine and mepivacaine groups.

Conclusion

Lidocaine, prilocaine and mepivacaine solutions without vasoconstrictor can be safely used in hypertensive patients. It is advisable that dental practitioners select anesthetic solutions for hypertensive patients considering their cardiovascular effects in order to provide patient comfort and safety.