Use of anesthetics associated to vasoconstrictors for dentistry in patients with cardiopathies. Review of the literature published in the last decade

Complications and treatment errors in periodontal therapy in medically compromised patients

Patients who are medically compromised may be at an increased risk of complications and treatment errors following periodontal therapy. A review of the evidence on the topic is presented, in relation to the type of complication reported, of periodontal treatment, and of patients' medical status. Further, a framework for risk assessment and appropriate treatment modifications is introduced, with the aim of facilitating the management of patients with existing comorbidities and reducing the incidence of treatment complications.

HEMODYNAMIC FUNCTION IN COMPARISON OF TWO TYPES OF LOCAL ANESTHESIA WITH VASOCONSTRICTOR IN DAY SURGERY: RETROSPECTIVE STUDY

Introduction

Hemodynamic changes and cardiac arrhythmias are not uncommon in clinical practice, depending on including patient features, surgical treatment and drugs administered. We describe hemodynamic changes developed in young patients, soon after a local infiltration anesthesia in day surgery.

Methods

We retrospectively assessed the hemodynamic effect of 2% lidocaine with 0,0125mg/ml adrenaline (Li & AD) administered for septorhinoplasty in 44 participants and combination of 0.5% bupivacaine and 2% lidocaine with 0.0125mg/ml adrenaline (BLi & AD) for breast augmentation in 48 participants. Blood pressure and heart rate were recorded before the introduction of general anesthesia, immediately 5.10 and 20 minutes after administration of local infiltration, anesthetic (LIA) and data were analyzed.

Results

The mean systolic blood pressure (SBP) in all observed measurements before general anesthesia (0), immediately, 5 minutes, 10 minutes and 20 minutes after local infiltration anesthesia was higher among patients who underwent septorinoplasty (Li & AD), in relation to patients who underwent breast augmentation (BLi & AD) (p <05). The level of diastolic blood pressure (DBP) in measurement 20 minutes compared to measurement in 10 minutes was increased by 9,52 mmHg. The septorhinoplasty group showed a significant increase in heart rate measured 20 minutes after local infiltration anesthesia with adrenaline.

Conclusions

Measured transitory changes in heart rate and blood pressure after local infiltration of vasoconstrictor anesthetics in healthy patients prior to septorinoplasty and breast augmentation may be induced by endogenous and / or exogenous epinephrine. Bupivacaine solution for local infiltration analgesia reduces hemodynamic disturbances and prolongs analgesic effect. We highlight the need for careful preoperative evaluation, including anxiety assessment and treatment in all patients in day surgery.

Vasopressin and Its Analogues: From Natural Hormones to Multitasking Peptides

Human neurohormone vasopressin (AVP) is synthesized in overlapping regions in the hypothalamus. It is mainly known for its vasoconstricting abilities, and it is responsible for the regulation of plasma osmolality by maintaining fluid homeostasis. Over years, many attempts have been made to modify this hormone and find AVP analogues with different pharmacological profiles that could overcome its limitations. Non-peptide AVP analogues with low molecular weight presented good affinity to AVP receptors. Natural peptide counterparts, found in animals, are successfully applied as therapeutics; for instance, lypressin used in treatment of diabetes insipidus. Synthetic peptide analogues compensate for the shortcomings of AVP. Desmopressin is more resistant to proteolysis and presents mainly antidiuretic effects, while terlipressin is a long-acting AVP analogue and a drug recommended in the treatment of varicose bleeding in patients with liver cirrhosis. Recently published results on diverse applications of AVP analogues in medicinal practice, including potential lypressin, terlipressin and ornipressin in the treatment of SARS-CoV-2, are discussed.

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.

Impact of maxillary teeth morphology on the failure rate of local anesthesia

Objective:

To investigate the effect of maxillary single and multiple rooted teeth on the success rate of buccal infiltration anesthesia.

Subjects and Methods:

This clinical study was performed by dividing the participants into three groups. Group one included 30 patients with upper anterior teeth, group two 23 patients with upper premolars teeth and group three 39 patients with upper molars for extraction. Onset time of anesthtic action was evaluted by using electronic pulp tester. Pulp testing assessments were carried out immediately before the injection and at the intervals of 2 mins following the injection until the anesthetic success obtains.

Results:

Seventy-nine patients in this study secured anesthetic success within study duration time (10 min). However, there were 13 patients with dental anesthesia failures (3 patients with single rooted teeth and 10 patients with multiple rooted teeth). There were no significant differences in the mean onset time of pulpal anesthesia between the anterior, middle and posterior teeth (P value = 0.449). Clinically, patients with single rooted teeth reported faster dental anesthesia and earlier teeth extraction than patients with multiple rooted teeth.

Conclusion:

This study showed that the single rooted teeth have faster pulpal anesthesia and early extraction than teeth with multiple roots but not statistically significant. Administration of extra local anesthetic cartridge or using intraseptal injection technique can be a solution to overcome the failure of anesthesia in the maxillary posterior teeth.

Safety of local anesthetics

Local anesthetics are essential medications for the conduction of dermatological procedures. They stop the depolarization of nerve fibers and are divided into two main categories, the amide and ester types. Systemic toxicity with reflex on the central nervous and cardiovascular systems is their most feared adverse reactions, and the anaphylactic reaction is the most concerning one. Although potentially fatal, these events are extremely rare, so local anesthetics are considered safe for use in in-office procedures.

Is It Safe for Patients With Cardiac Channelopathies to Undergo Routine Dental Care? Experience From a Single-Center Study

Background Brugada syndrome and long-QT syndrome may account for at least one third of unexplained sudden cardiac deaths. Dental care in patients with cardiac channelopathies is challenging because of the potential risk of life-threatening events. We hypothesized that the use of local dental anesthesia with lidocaine with and without epinephrine is safe and does not result in life-threatening arrhythmias in patients with channelopathies. Methods and Results We performed a randomized, double-blind pilot trial comparing the use of 2% lidocaine without a vasoconstrictor and with 1:100 000 epinephrine in 2 sessions of restorative dental treatment with a washout period of 7 days (crossover trial). Twenty-eight-hour Holter monitoring was performed, and 12-lead electrocardiography, digital sphygmomanometry, and anxiety scale assessments were also conducted at 3 time points. Fifty-six dental procedures were performed in 28 patients (18 women, 10 men) with cardiac channelopathies: 16 (57.1%) had long-QT syndrome, and 12 (42.9%) had Brugada syndrome; 11 (39.3%) of patients had an implantable defibrillator. The mean age was 45.9±15.9 years. The maximum heart rate increased after the use of epinephrine during the anesthesia period from 82.1 to 85.8 beats per minute (P=0.008). In patients with long-QT syndrome, the median corrected QT was higher, from 450.1 to 465.4 ms (P=0.009) at the end of anesthesia in patients in whom epinephrine was used. The other measurements showed no statistically significant differences. No life-threatening arrhythmias occurred during dental treatment. Conclusions The use of local dental anesthesia with lidocaine, regardless of the use of a vasoconstrictor, did not result in life-threatening arrhythmias and appears to be safe in stable patients with cardiac channelopathies. Clinical Trial Registration URL: http://www.clinicaltrials.gov. Unique identifier: NCT03182777.

2% lidocaine versus 3% prilocaine for oral and maxillofacial surgery

Objective

To investigate the speed of action and injection discomfort of 2% lidocaine and 3% prilocaine for upper teeth extractions.

Materials and Methods

Forty-six patients were included in the prilocaine 3% group, and 46 in the lidocaine 2% control group. After all injections, soft and hard tissue numbness was objectively gauged by dental probe at intervals of 15 s. Moreover, the pain of the injections was recorded by the patients after each treatment on standard 100 mm visual analog scales, tagged at the endpoints with "no pain" (0 mm) and "unbearable pain" (100 mm).

Results

There were no significant differences in the meantime of first numbness to associated buccal, palatal mucosa, and tooth of patients in the lidocaine and prilocaine buccal infiltration groups (P = 0.56, 0.37, and 0.33). However, clinically, the patients in prilocaine group recorded earlier buccal, palatal mucosa, and teeth numbness than those in lidocaine group. With regards to the discomfort of the needle injections, there was a significant difference for lidocaine and prilocaine groups when comparing the post buccal scores with the post palatal injection scores (t-test: P < 0.001). Lidocaine and prilocaine buccal injections were significantly more comfortable than palatal injections.

Conclusions

Using 2% lidocaine and 3% prilocaine for extractions of upper maxillary teeth produces similarly successful anesthesia. Clinically, prilocaine has slightly rapid onset of action, earlier buccal mucosa, hard palate, and teeth numbness. Prilocaine and lidocaine buccal injection was significantly more comfortable than palatal injection.

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.

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.

The impact of cardiovascular drugs on the efficacy of local anesthesia in dentistry

BACKGROUND AND AIM

Drugs used chronically by patients with diseases of the cardiovascular system (group C of the ATC classification) may act on adrenergic receptors and/or certain ion channels, which gives them the potential to interact with the action of local dental anesthetics. The aim of the study was to investigate the effect of systemically administered chronic cardiovascular medication (oral route) on the efficacy of intraoral local anesthesia in patients with diseases of the cardiovascular system.

PATIENTS AND METHODS

This was a prospective cohort study which analyzed the efficacy of local terminal anesthesia (onset of anesthesia, duration anesthetized area) in the upper jaw of 70 patients: 40 patients on medication for cardiovascular system disorders and 30 patients who were not using these drugs (the control group). The following cardiovascular drugs were used: beta blockers, angiotensin converting enzyme inhibitors, calcium channel blockers, vasodilatators, diuretics, angiotensin receptor blockers, antiarrhythmics, statins and alfa blockers.

RESULTS

The onset of anesthesia on the vestibular side was faster in those taking cardiovascular drugs (40.50±19.87 s) than the control patients (58.93±31.07 s; P = 0.004) and duration of anesthesia on this side was shorter. Although the difference was not significant, it was evident that on vestibular and palatal side the anesthetized area was more rapidly reduced in the patients taking cardiovascular drugs. The duration of cardiovascular therapy also had a significant impact on the anesthetized area.

CONCLUSION

Drugs acting on cardiovascular system may influence the effect of local anesthetics used in dentistry, possibly through interaction with autonomic receptors and ion channels.

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.