Download Is it safe to perform dental surgery using local anesthesia with

Is it safe to perform dental surgery using local anesthesia with
vasoconstrictor in coronary artery disease patients?
1. Introduction
A best evidence topic was constructed according to a structured protocol. This
protocol is fully described in the ICVTS [1].
2. Clinical scenario
Last week, a 60-year-old male with chronic coronary artery disease and arterial
hypertension came to the cardiologist´s office with dental pain. His dentist
asked the cardiologist´s advice as he was aware of the potential risk of local
anesthesia with vasoconstrictor and cardiovascular side effects. The
cardiologist himself was concerned about those effects of local anesthesia, and
resolved to check the literature.
3. Three-part question
In [patients with chronic coronary artery disease and need of dental surgery]
does [local anesthesia with vasoconstrictor] have an acceptable [safety profile]?
4. Search strategy
Search strategy using Medline from 1950 to June 2012 using the PubMed
interface ((“Anesthesia, Dental” [Mesh] OR “Anesthesia, Local” [Mesh]) AND
‘’Dental Care for Chronically Ill” [Mesh])). The reference lists of key papers were
searched and the ‘related articles’ function was utilized.
5. Search outcome
One hundred and eighty-eight papers were found using the reported search on
PubMed. From these, one paper was identified that provided the best evidence
to answer the question. This is presented in Table 1.
Table 1. Best evidence paper
Author, date,
journal, and
country
Study type
level of
evidence
Patient group
Outcome
Key results
Comments
Neves et al.,
(2007),
Single centre
study
Arq Bras
Cardiol,
Brazil, [2]
Number of
patients
n = 62
Blood
pressure,
heart rate,
ischemia
and
arrhythmias
There was a
rise in systolic
and diastolic
blood pressure
from baseline to
the procedure in
both groups (14
mm Hg and 5 to
7 mmHg,
respectively),
when they were
evaluated
separately.
No significant
difference was
found between
the epinephrine
and nonepinephrine
groups.
The study
demonstrate
that the use of
vasoconstrictors
in local dental
anesthesia in
patients with
coronary heart
disease is safe.
Patient
Randomized
demographics
controlled
 Age: 58.7 ± 8.8
trial (level 2)
years
[3]
 Male:Female:
51:11
Inclusion
criteria:
 Clinical: patients
with coronary
artery disease
(≥ 70% lumen
stenosis) and
exercise stress
test positive for
myocardial
ischemia
performed
within less than
three months in
the absence of
recent acute
myocardial
infarction
 Dental: fully or
partially dentate
requiring lower
molar, premolar,
or canine
restoration
Exclusion
criteria:
Authors’
conclusions:
Blood pressure
and heart rate
did not differ, and
there were no
myocardial
ischemia and
cardiac
arrhythmia with
Mean heart rate epinephrinecontaining and
did not differ
epinephrine-free
between the
anesthetic
epinephrine
solution, in
and nonpatients taking
epinephrine
drugs, the
groups at
baseline, during majority of whom
were on betathe procedure
blockers.
(p = 0.1967),
and over the 24
hours
(p = 0.8417)
Ten patients
(17.9%) had ST
segment
depression
greater than 1
mm from
baseline, six
(20.7%) in the
non-epinephrine
group (14.8%)
 Neoplasias,
septicemia,
pregnancy,
unstable angina,
and malignant
hypertension
Comorbidities:
24 patients
(38.7%) were
diagnosed with
systemic
hypertension
and 24 with
diabetes
(38.7%). All
patients
continued their
medication,
especially betablockers
(87.1%), lipidlowering agents
(87.1%),
antiplatelets
(83.9%), and
nitrates (54.8%)
Angiography:
 Coronary
angiography
revealed singlevessel disease
in seven
(11.3%)
patients, twovessel disease
in 18 (29%)
patients, and
three-vessel
disease in 37
(59.7%)
patients.
Study groups
 2% lidocaine
+1:100,000
epinephrine
(epinephrine
group):
30/62
 2% lidocaine
and four
(14.8%) in the
epinephrine
group, but no
significant
difference
was found
between both
groups
(p = 0.731).
Over the 24
hours, 17
patients
(30.4%), ten
(34.5%)
belonging to the
non-epinephrine
group and
seven (25.9%)
belonging to the
epinephrine
group,
experienced
supraventricular
extrasystoles
(SVES)
and/or
ventricular
extrasystoles
(VES). During
the procedure,
however, only
seven (12.5%)
patients had
arrhythmias,
four (13.8%) in
the nonepinephrine
group and three
(11.1%) in
the epinephrine
group, but no
significant
difference was
found
between the
two groups (p =
1.00)
without
epinephrine
(nonepinephrine
group): 32/62
6. Results
Neves et al [2] investigated patients with clinical symptoms of stable angina and
on drug therapy, with angiographically proven coronary stenosis > 70% in at
least one major artery and who underwent restorative dental treatment under
anesthesia with and without a vasoconstrictor. Thirty patients were randomly
assigned to receive 2% lidocaine and 1:100,000 epinephrine (epinephrine
group), and 32 to receive 2% lidocaine without epinephrine (nonepinephrine
group) for local anesthesia. All patients underwent 24-hour electrocardiography
(Holter) and ambulatory blood pressure monitoring (ABPM). Each patient (30 in
the epinephrine group and 32 in the non-epinephrine group) underwent a single
restorative procedure under inferior alveolar anesthesia. In the epinephrine
group, 15 patients were given one anesthetic cartridge (1.8 mL), and 15
patients, two anesthetic cartridges (3.6 mL). In the non-epinephrine group, 15
patients were given one cartridge, and 17 patients, two cartridges. Mean
duration of procedures in both groups did not differ (p = 0.200). No clinical
events were observed. When the epinephrine and non-epinephrine groups were
compared in terms of blood pressure, no significant difference was found. The
number of cartridges used, one or two, with or without epinephrine, did not differ
between the two groups regarding mean systolic (p = 0.208) and diastolic
(p = 0.118) blood pressure, and there was no influence by the use or not of
beta-blockers. The Holter showed no difference in mean heart rate between
both groups at baseline, during the procedure (p = 0.197), and over the 24
hours (p = 0.842). The number of cartridges used, with or without epinephrine
did not change the results. The frequency of ST-segment depression had no
significant difference between the two groups. All episodes occurred at least
two hours after the dental procedure had been finished. Over the 24 hours,
supraventricular and/or ventricular extrasystoles occurred in the nonepinephrine group (34.5%), and in the epinephrine group (25.9%) with no
statistical significant difference. However, during the dental procedure, they
occurred just in 13.8% (non-epinephrine group) and 11.1% (epinephrine group).
7. Clinical bottom line
The use of vasoconstrictors in local dental anesthesia in patients with coronary
heart disease seems to be safe. In one randomized clinical trial, no difference
was observed in blood pressure, heart rate, myocardial ischemia and cardiac
arrhythmias.
References
[1] Dunning J, Prendergast B, Mackway-Jones K. Towards evidence-based
medicine in cardiothoracic surgery: best BETS. Interactive Cardiovascular
Thoracic Surgery. 2003;2:405–9.
[2] Neves RS, Neves IL, Giorgi DM, Grupi CJ, César LA, Hueb W et al.
Arquivos Brasileiros de Cardiologia. 2007;88(5) :482-8.
[3] Centre for Evidence Based Medicine. OCEBM 2011 Levels of Evidence
System [Internet]. Oxford: University of Oxford, Oxford Centre for EvidenceBased Medicine; [updated 2012 Sep 13; cited 2012 Oct 2]. Available from:
http://www.cebm.net/index.aspx?o=5653.
ABSTRACT
A best evidence topic in dentistry was written according to a structured protocol.
The question addressed was whether in patients with chronic coronary artery
disease and need of dental surgery, local anesthesia with vasoconstrictor has
an acceptable safety profile. Altogether, 188 relevant papers were identified, of
which one represented the best evidence to answer the question. The author,
journal, date, country of publication and relevant outcomes are tabulated. The
study comprised one randomized controlled trial. According to this trial, thirty
patients were randomly assigned to receive 2% lidocaine and 1:100,000
epinephrine (epinephrine group), and 32 to receive 2% lidocaine without
epinephrine (nonepinephrine group) for local anesthesia. When the epinephrine
and non-epinephrine groups were compared in terms of blood pressure, no
significant difference was found. The Holter showed no difference in mean
heart rate between both groups at baseline, during the procedure (p = 0.197),
and over the 24 hours (p = 0.842). The frequency of ST-segment depression
had no significant difference between the two groups. Over the 24 hours,
supraventricular and/or ventricular extrasystoles occurred in the nonepinephrine group (34.5%), and in the epinephrine group (25.9%) with no
statistical significant difference. However, during the dental procedure, they
occurred just in 13.8% (non-epinephrine group) and 11.1% (epinephrine group).
We conclude that the use of vasoconstrictors in local dental anesthesia in
patients with coronary heart disease seems to be safe.
Key words: Coronary Artery Disease; Anesthesia,
Vasoconstrictor Agents; Review; Best Evidence Topic
Dental;
Lidocaine;