Restor Dent Endod.  2013 Nov;38(4):187-193.

Cardiovascular effect of epinephrine in endodontic microsurgery: a review

• Jang Y
• Kim E

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.

Keyword

Cardiovascular diseases; Drug interactions; Endodontic microsurgery; Epinephrine; Hemostasis; Vasoconstrictor agents

MeSH Terms

Cardiovascular Diseases
Drug Interactions
Emergencies
Epinephrine*
Hemostasis
Humans
Hypersensitivity
Microsurgery*
Monitoring, Physiologic
Vasoconstrictor Agents
Epinephrine
Vasoconstrictor Agents

Reference

1. Bader JD, Bonito AJ, Shugars DA. A systematic review of cardiovascular effects of epinephrine on hypertensive dental patients. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2002; 93:647–653. PMID: 12142870.

2. Silvestre FJ, Salvador-Martínez I, Bautista D, Silvestre-Rangil J. Clinical study of hemodynamic changes during extraction in controlled hypertensive patients. Med Oral Patol Oral Cir Bucal. 2011; 16:e354–e358. PMID: 21196862.

3. Ogunlewe MO, James O, Ajuluchukwu JN, Ladeinde AL, Adeyemo WL, Gbotolorun OM. Evaluation of haemodynamic changes in hypertensive patients during tooth extraction under local anaesthesia. West Indian Med J. 2011; 60:91–95. PMID: 21809720.

4. Conrado VC, de Andrade J, de Angelis GA, de Andrade AC, Timerman L, Andrade MM, Moreira DR, Sousa AG, Sousa JE, Piegas LS. Cardiovascular effects of local anesthesia with vasoconstrictor during dental extraction in coronary patients. Arq Bras Cardiol. 2007; 88:507–513. PMID: 17589623.

5. Meral G, Tasar F, Sayin F, Saysel M, Kir S, Karabulut E. Effects of lidocaine with and without epinephrine on plasma epinephrine and lidocaine concentrations and hemodynamic values during third molar surgery. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2005; 100:e25–e30. PMID: 16037765.

6. Miura K, Matsumura K, Nakamura Y, Kurokawa H, Kajiyama M, Takata Y. Suppression of cardiac sympathetic nervous system during dental surgery in hypertensive patients. Hypertens Res. 2000; 23:207–212. PMID: 10821128.

7. Blinder D, Manor Y, Shemesh J, Taicher S. Electrocardiographic changes in cardiac patients having dental extractions under a local anesthetic containing a vasopressor. J Oral Maxillofac Surg. 1998; 56:1399–1402. PMID: 9846537.

8. Meechan JG. Plasma potassium changes in hypertensive patients undergoing oral surgery with local anesthetics containing epinephrine. Anesth Prog. 1997; 44:106–109. PMID: 9481971.

9. Blinder D, Shemesh J, Taicher S. Electrocardiographic changes in cardiac patients undergoing dental extractions under local anesthesia. J Oral Maxillofac Surg. 1996; 54:162–165. PMID: 8604063.

10. Abraham-Inpijn L, Borgmeijer-Hoelen A, Gortzak RA. Changes in blood pressure, heart rate, and electrocardiogram during dental treatment with use of local anesthesia. J Am Dent Assoc. 1988; 116:531–536. PMID: 3164019.

11. Meyer FU. Hemodynamic changes of local dental anesthesia in normotensive and hypertensive subjects. Int J Clin Pharmacol Ther Toxicol. 1986; 24:477–481. PMID: 3781681.

12. Vernale CA. Cardiovascular responses to local dental anesthesia with epinephrine in normotensive and hypertensive subjects. Oral Surg Oral Med Oral Pathol. 1960; 13:942–952. PMID: 13841864.

13. Cheraskin E. Use of epinephrine with local anesthesia in hypertensive patients. III. Effect of epinephrine on blood pressure and pulse rate. J Am Dent Assoc. 1958; 57:507–519. PMID: 13575081.

14. Davenport RE, Porcelli RJ, Iacono VJ, Bonura CF, Mallis GI, Baer PN. Effects of anesthetics containing epinephrine on catecholamine levels during periodontal surgery. J Periodontol. 1990; 61:553–558. PMID: 2213464.

15. Vy CH, Baumgartner JC, Marshall JG. Cardiovascular effects and efficacy of a hemostatic agent in periradicular surgery. J Endod. 2004; 30:379–383. PMID: 15167461.

16. Vickers FJ, Baumgartner JC, Marshall G. Hemostatic efficacy and cardiovascular effects of agents used during endodontic surgery. J Endod. 2002; 28:322–323. PMID: 12043873.

17. Kim S, Rethnam S. Hemostasis in endodontic microsurgery. Dent Clin North Am. 1997; 41:499–511. PMID: 9248687.

18. Song M, Shin SJ, Kim E. Outcomes of endodontic micro-resurgery: a prospective clinical study. J Endod. 2011; 37:316–320. PMID: 21329814.

19. Cho YW, Kim E. Is stopping of anticoagulant therapy really required in a minor dental surgery? How about in an endodontic microsurgery? Restor Dent Endod. 2013; 38:113–118. PMID: 24010076.

20. Wood M, Reader A, Nusstein J, Beck M, Padgett D, Weaver J. Comparison of intraosseous and infiltration injections for venous lidocaine blood concentrations and heart rate changes after injection of 2% lidocaine with 1 : 100,000 epinephrine. J Endod. 2005; 31:435–438. PMID: 15917682.

21. Hoskins SL, do Nascimento P Jr, Lima RM, Espana-Tenorio JM, Kramer GC. Pharmacokinetics of intraosseous and central venous drug delivery during cardiopulmonary resuscitation. Resuscitation. 2012; 83:107–112. PMID: 21871857.

22. Kim E, Song JS, Jung IY, Lee SJ, Kim S. Prospective clinical study evaluating endodontic microsurgery outcomes for cases with lesions of endodontic origin compared with cases with lesions of combined periodontal-endodontic origin. J Endod. 2008; 34:546–551. PMID: 18436032.

23. Setzer FC, Shah SB, Kohli MR, Karabucak B, Kim S. Outcome of endodontic surgery: a meta-analysis of the literature-part 1: Comparison of traditional rootend surgery and endodontic microsurgery. J Endod. 2010; 36:1757–1765. PMID: 20951283.

24. Song M, Chung W, Lee SJ, Kim E. Long-term outcome of the cases classified as successes based on short-term follow-up in endodontic microsurgery. J Endod. 2012; 38:1192–1196. PMID: 22892734.

25. Katzung B, Masters S, Trevor A. Basic and Clinical Pharmacology. 12th ed. Columbus: McGraw-Hill;2011. p. 129–149.

26. Chu WS, Park SH, Ahn DK, Kim SK. Effect of local anesthesia on pulpal blood flow in mechanically stimulated teeth. J Korean Acad Conserv Dent. 2006; 31:257–262.

27. Lee JS, Kim SK. The influence of epinephrine concentration in local anesthetics on pulpal and gingival blood flows. J Korean Acad Conserv Dent. 2003; 28:475–484.

28. Lee JY, Hong SJ, Chon JY, Kwon SY. Cardiac arrest induced by submucosal injection of epinephrine in a patient with variant angina. Rhinology. 2010; 48:251–253. PMID: 20502771.

29. Kim HH, Park MI, Park SJ, Moon W. Myocardial infarction thought to be provoked by local epinephrine injection during endoscopic submucosal dissection. J Clin Med Res. 2011; 3:143–146. PMID: 21811546.

30. Hersh EV, Giannakopoulos H. Beta-adrenergic blocking agents and dental vasoconstrictors. Dent Clin North Am. 2010; 54:687–696. PMID: 20831932.

31. Sugimura M, Hirota Y, Shibutani T, Niwa H, Hori T, Kim Y, Matsuura H. An echocardiographic study of interactions between pindolol and epinephrine contained in a local anesthetic solution. Anesth Prog. 1995; 42:29–35. PMID: 8934951.

32. Yagiela JA. Adverse drug interactions in dental practice: interactions associated with vasoconstrictors. Part V of a series. J Am Dent Assoc. 1999; 130:701–709. PMID: 10332135.

33. Pallasch TJ. Vasoconstrictors and the heart. J Calif Dent Assoc. 1998; 26:668–673. 676PMID: 9879236.

34. Ferguson-Myrthil N. Vasopressor use in adult patients. Cardiol Rev. 2012; 20:153–158. PMID: 22318007.

35. Foster CA, Aston SJ. Propranolol-epinephrine interaction: a potential disaster. Plast Reconstr Surg. 1983; 72:74–78. PMID: 6867180.

36. Gómez-Moreno G, Guardia J, Cutando A, Calvo-Guirado JL. Pharmacological interactions of vasoconstrictors. Med Oral Patol Oral Cir Bucal. 2009; 14:e20–e27. PMID: 19114951.

37. Boakes AJ, Laurence DR, Teoh PC, Barar FS, Benedikter LT, Prichard BN. Interactions between sympathomimetic amines and antidepressant agents in man. Br Med J. 1973; 1:311–315. PMID: 4685619.

38. Gutmann JL, Frazier LW Jr, Baron B. Plasma catecholamine and haemodynamic responses to surgical endodontic anaesthetic protocols. Int Endod J. 1996; 29:37–42. PMID: 9206410.

39. Buckley JA, Ciancio SG, McMullen JA. Efficacy of epinephrine concentration in local anesthesia during periodontal surgery. J Periodontol. 1984; 55:653–657. PMID: 6594502.

40. Witherspoon DE, Gutmann JL. Haemostasis in periradicular surgery. Int Endod J. 1996; 29:135–149. PMID: 9206418.

41. Ferry DR, Henry RL, Kern MJ. Epinephrine-induced myocardial infarction in a patient with angiographically normal coronary arteries. Am Heart J. 1986; 111:1193–1195. PMID: 2940853.

42. Umino M, Ohwatari T, Shimoyama K, Nagao M. Unexpected atrial fibrillation during tooth extraction in a sedated elderly patient. Anesth Prog. 1994; 41:77–80. PMID: 8934964.