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AHRQ Evidence Report Summaries. Rockville (MD): Agency for Healthcare Research and Quality (US); 1998-2005.


48Cardiovascular Effects of Epinephrine in Hypertensive Dental Patients: Summary

JD Bader, AJ Bonito, and also DA Shugars.

Current as of March 2002.


About 24 percent of the U.S. adult populace is hypertensive (that is, has actually high blood pressure), as soon as hyperanxiety is identified by a expect systolic blood press of 140 mm Hg or better, a diastolic blood push of 90 mm Hg or higher, or usage of prescription anti-hypertensive medication. Of this hypertensive population, 48 percent are untreated, 24 percent are effectively treated, and also 28 percent are inadequately treated. Hence, hypertensive individuals, both managed and also unmanaged, will reexisting a considerable propercent of a typical dental practice"s adult patients.

Epinephrine is extensively supplied as an additive in neighborhood anesthetics (frequently in concentrations of 1:100,000) to improve the depth and duration of the anesthesia, and to mitigate bleeding in the operative field. Epinephrine counteracts the anesthetic"s localized vasodilator impacts in subcutaneous and submucosal vessels, thereby reducing the threat of anesthetic toxicity by decreasing the price of systemic absorption from the site of injection. Epinephrine is also impregnated in cotton cord that is placed into the sulcus between a tooth and the bordering gingiva, improving access for tooth preparation and also permitting dental impression product to more conveniently circulation into the sulcus to record details of teeth ready for crowns. The epinephrine likewise constricts the blood supply to nearby tworry, thereby permitting the impression to be secured without contamination by bleeding.

Regardless of these benefits, which may not be as readily achievable with usage of non-epinephrine preparations, the clinical influence of cardiovascular and also hemodynamic transforms caused by the introduction of exogenous epinephrine makes its use among hypertensive individuals a controversial topic in dentisattempt. The added dangers attributed to the usage of epinephrine in hypertensive patients include:
Through the direct activity of epinephrine-higher probcapability of acute hypertensive crisis (dangerously high blood pressure), angina pectoris and also myocardial infarction, and cardiac arrthymias.
Brought about by the interactivity of epinephrine and some antihypertensive medications-acute hypertensive or hypotensive crisis.

Recommendations for the use of epinephrine in clinical dental practice are not in complete agreement. Most recommendations advise caution in utilizing neighborhood anesthetics via epinephrine in patients via hyperstress. Some authors indicate that epinephrine is contrashown in patients whose hyperanxiety is controlled, but who are taking drugs with well-known epinephrine interactions; various other authors indicate that epinephrine use is acceptable through appropriate precautions and also security. Opinion is additionally split about the usage of epinephrine in patients whose hypertension is unmanaged, through some authors cautioning versus it, while others indicate that this exercise is correct in a lot of instances. Virtually all referrals, including those of manufacturers, discourage the usage of epinephrine-impregnated gingival retraction cord in patients through uncontrolled hyperstress and anxiety.


The essential question for this systematic evaluation, undertaken by the Research Triangle Institute Evidence-based Research Center, in Research Triangle, NC, is declared as "What added dangers of adverse cardiovascular outcomes execute epinephrine-containing neighborhood anesthetic services and epinephrine-impregnated gingival retractivity cords recurrent for regulated and also uncontrolled hypertensive people receiving dental treatment?"

Due to the fact that adverse events are reasonably rare, the authors examined the literature for researches reporting alters in hazard signs for adverse occasions, and for adverse occasions themselves. The authors characterized adverse occasions as:
Syncope (fainting).
Angina.hypertensive crisis.

The authors conducted sepaprice literature searches concentrating on results of epinephrine in anesthetic solutions and also in gingival retractivity cord. In both instances they searched MEDLINE® initially, via added looking performed in EMBASE and the Cochrane Controlled Trials Register. No attempt was made to search the gray literary works, i.e., dissertations, theses, unpubliburned studies, abstracts, industry reports, and various other nontypical resources. The authors restricted the searches to English language reports. Subsequently, they examined reference lists of research studies identified in these searches to include extra reports of possible interest.

They established 373 reports addressing the usage of epinephrine-containing local anesthetics and 33 addressing epinephrine-impregnated gingival retraction cord. They then reperceived these studies for feasible inclusion in the evidence table. The authors provided basically similar inclusion criteria in both reviews that addressed the inclusion and sepaprice evaluation of well-known hypertensive subjects, expocertain to recognized concentrations of epinephrine via receipt of an intraoral injection or application of gingival retraction cord, recording of at least one cardiovascular or hemodynamic outcome, and a dental establishing through dental treatment gave. The authors provided independent dual testimonial, and also eventually established six regional anesthetic research studies that met the criteria for inclusion. No retraction cord documents met the criteria bereason no studies had hypertensive topics.

The authors abstracted information from the contained researches directly into the proof table. They did not meta-analyze the results because two of the research studies reported no indevelopment describing variation about the mean. The authors rated the quality of each included study making use of a rating scale that assessed a number of elements of inner and also exterior validity, including:
Sample size.
Presence of a comparison group of normotensive subjects.

They then graded the stamina of the combined proof, using a three-category system. The proof was considered to be great if the numbers of researches and also topics were big (10 or more researches, 500 or even more subjects), the high quality of the studies was mostly high (median quality score of 70 or higher), the results of these research studies were constant, and taken together, the outcomes were comprehensive via respect to dangers examined. The evidence was thought about to be fair if the numbers of research studies and topics were sufficient overall (5 or more studies, 200 or more subjects), the high quality of the research studies was mainly acceptable (median of 55 or higher), the outcomes of these studies were reasonably continual, via inconsistencies reflected as quantitative fairly than qualitative distinctions, and the major known threats were adequately examined. The proof was thought about to be bad if the numbers of researches and/or topics were little (fewer than 5 research studies or 200 subjects), or the top quality of the researches was generally low (median of much less than 55), or tbelow were comprehensive inconsistencies in the outcomes, or the risks examined among the researches did not reexisting a reasonably complete assessment of well-known risks.


The 6 included research studies consisted of 325 topics, of whom 177 were established as hypertensive. Of these, 25 (14 percent) were determined as taking medication for control of hyperanxiety. In all studies the regional anesthetic connected was 2 percent lidocaine, and also epinephrine concentrations were split in between 1:100,000 (n=3 studies) and also 1:80,000 (n=3 studies). Quantities of anesthetic solution injected were reported in four research studies, through implies varying from 2 ml to 4.5 ml. The outcomes examined in these researches consisted principally of systolic and diastolic blood pressures and also heart price. EKG recordings were built up in 2 researches. The dental procedure connected was tooth extractivity in five of the six researches, and also "minor oral surgery" in the sixth.

The outcomes suggest that hypertensive subjects undergoing an extraction experience small increases in systolic blood push and also heart rate linked via the usage of a neighborhood anesthetic containing epinephrine (4 mm Hg and also 6 beats per minute , respectively). These boosts connected with the usage of epinephrine happen in addition to boosts in systolic and diastolic blood press and also heart price linked via undergoing the procedure without epinephrine (11.7 and 3.3 mm Hg, and also 4.7 bpm, respectively) that are larger for hypertensives than for normotensives. No adverse outcomes were reported among any kind of of the subjects in the studies had in the evaluation, and only one report of an adverse event associated with the use of epinephrine in local anesthetic in a hypertensive patient was determined in the literature.

The researchers rated the strength of the evidence as negative for describing added risks among controlled and unregulated hypertensives because of epinephrine-containing local anesthetic services and gingival retractivity cords. These ratings result from both the variety of available studies and their top quality.

For outcomes of the administration of regional anesthetic options containing epinephrine to patients taking drugs for the regulate of hypertension, one study comprising 14 subjects and also two medications was accessible. Two other studies had patients taking antihypertensive medicines, but outcomes were not reported independently. No researches defined outcomes of the usage of gingival retractivity cord either for hypertensive patients, or for those taking drugs for the manage of hypertension.

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There were 5 studies addressing outcomes of the use of epinephrine-containing anesthetic options in hypertensive patients. The toughness of this evidence was rated as bad because the outcomes considered in the researches did not represent a reasonably finish assessment of hazard indications, and because transient impacts in blood press and also heart rate, the major outcomes reported, might have stayed undetected in three of 5 research studies.

Future Research

Based on the obtainable proof, which suggests that adverse outcomes among hypertensive patients are inregular and that hemodynamic outcomes, which might be perceived as risk signs, reflect only minimal change, replication of existing studies does not reexisting an effective method to further our knowledge of the dangers for adverse cardiovascular outcomes connected with usage of local anesthetics containing epinephrine. Rather, a massive descriptive study of adverse outcomes of the use of epinephrine-containing local anesthetics would seem to be shown. A permanent protocol initiated in one or more huge dental clinics that entails electronic capture of pre-existing cardiovascular diagnoses and medication status of all patients, together with information describing all adverse outcomes arising throughout therapy can begin to quantify the magnitude of extra risk represented by the usage of epinephrine in hypertensive dental patients via minimal outlay of initiative and expense. Only if the results of such an examination suggest that the added hazard is greater than deemed acceptable would certainly additional trials to construct even more sensitive approaches for identifying patients at raised threat be justified.

With respect to the use of epinephrine-impregnated gingival retractivity cord, research studies are required to quantify the absorption of epinephrine from gingival tconcerns. The impacts of time, tproblem condition, cord building and construction, and epinephrine concentration on plasma concentration of epinephrine have to be determined in these researches. Once a far better understanding of the feasible selection of epinephrine concentrations is acquired, the risks connected with the use of these cords in hypertensive patients have the right to be evaluated. At existing, a single humale research reports absorption levels.

Availcapability of Full Report

The last report is intended to be easily accessible by late Spring 2002 (AHRQ Publication No. 02-E006). At that time, published duplicates may be obtained. Internet customers will certainly have the ability to access the report digital with AHRQ"s Net site at

AHRQ Publication Number 02-E005Current as of March 2002

Net Citation:Cardiovascular Effects of Epinephrine in Hypertensive Dental Patients. Outline, Evidence Report/Technology Assessment:Number 48. AHRQ Publication Number 02-E005, March 2002. Agency for Healthcare Research and Quality, Rockville, MD.