Cardiovascular effect of epinephrine in endodontic microsurgery: a review

Abstract

Epinephrine is one of the most widely-used vasoconstrictors in dental treatment including endodontic microsurgery. However, the systemic safety of epinephrine has been in debate for many years because of its potential risk to cause cardiovascular complications. The purpose of this review was to assess the cardiovascular effect of epinephrine use in endodontic microsurgery. Endodontic microsurgery directly applies epinephrine into the bone cavity, and the amount is reported to be much larger than other dental surgeries. Moreover, when considering that systemic potency of intraosseous application is reported to be comparable to intravenous application, the systemic influence of epinephrine could be increased in endodontic microsurgery. Besides, pre-existing cardiovascular complications or drug interactions can enhance its systemic influence, resulting in increased susceptibility to cardiovascular complications. Although clinical studies have not reported significant complications for patients without severe systemic complications, many epinephrine-induced emergency cases are warning the cardiovascular risk related with pre-existing systemic disease or drug interactions. Epinephrine is a dose-sensitive drug, and its hypersensitivity reaction can be fatal to patients when it is related to cardiovascular complications. Therefore, clinicians should recognize the risk, and the usage of pre-operative patient evaluation, dose control and patient monitoring are required to ensure patient's safety during endodontic microsurgery.

Do Local Anesthetics Containing Epinephrine Affect Blood Pressure in the Elderly?

“…Two cases have been reported, in patients aged 52 and 35 years, in which cardiac arrest occurred during dental treatment after local anesthetic infiltration containing epinephrine between 0.065 and 0.075 mg. Similarly, it was reported that after the administration of local anesthetic containing epinephrine between 0.60 and 0.80 mg, two patients, aged 43 and 80 years, developed myocardial infarctions, and in one case, a 70 year-old patient developed atrial fibrillation after receiving 0.023 mg of epinephrine [8]. The selected dose of epinephrine in dentistry should be within the range of 0.02-0.2 mg [7].…”

“…Drug interactions may occur in patients receiving medical therapy. For example, ß2 receptors are generally blocked in patients using ß-blockers, and these may cause a hypertensive crisis because of unopposed α1 vasoconstriction [5,8,16]. Bader et al found that local anesthetic with epinephrine caused a small, statistically non-significant increase in SBP and DBP in uncontrolled hypertensive patients compared to healthy volunteers [6], and in 1964, the American Dental Association and the American Heart Association announced that vasoconstrictors in local anesthetics were contraindicated in patients with cardiovascular disease [9,18].…”

“…It has been proven that local anesthetics containing epinephrine cause a slight increase in heart rate and on systolic and diastolic blood pressures in healthy humans. However, there are conflicting results regarding the cardiovascular side effects of local anesthetics containing epinephrine in patients with systemic health problems [6][7][8][9]. Although there is no difference in the use of local anesthetics containing vasoconstrictors between healthy elderly and younger patients, it has been reported that a reduction in the dose and cautious treatment is required for the former group [1].…”

Biologic response of local hemostatic agents used in endodontic microsurgery

“…Thus, epinephrine is closely related to alteration of cardiovascular function when it enters systemic circulation 45. Jang and Kim stated that systemic influence of epinephrine could be increased in endodontic microsurgery, because endodontic microsurgery reveals two different aspects compared to other dental surgeries in epinephrine application, such as, dose and administration route 44. It is reported that 3.9 - 104 times more epinephrine is used in endodontic microsurgery compared to conventional dental surgery 44.…”

“…Jang and Kim stated that systemic influence of epinephrine could be increased in endodontic microsurgery, because endodontic microsurgery reveals two different aspects compared to other dental surgeries in epinephrine application, such as, dose and administration route 44. It is reported that 3.9 - 104 times more epinephrine is used in endodontic microsurgery compared to conventional dental surgery 44. Also, intraosseous route has a greater influence on systemic circulation compared to mucosal or submucosal routes 46,47.…”