Bader JD, Bonito AJ, Shugars DA. Cardiovascular Effects of Epinephrine on Hypertensive Dental Patients. Evidence Report/Technology Assessment Number 48. (Prepared by Research Triangle Institute under Contract No. 290-97-0011.) AHRQ Publication No. 02-E006 Rockville, MD: Agency for Healthcare Research and Quality. July 2002.
Hypertension affects one quarter of the adult U.S. population. A systematic review of the literature was conducted to identify the additional risks of adverse cardiovascular outcomes to controlled and uncontrolled hypertensive individuals represented by the use of epinephrine-containing anesthetic solutions and epinephrine-impregnated retraction cords during dental treatment.
Two parallel searches of MEDLINE, EMBASE, and the Cochrane Controlled Trials Register were conducted to identify reports involving cardiovascular and hemodynamic outcomes associated with the use of epinephrine in the dental treatment of hypertensive individuals. One search identified reports involving epinephrine in local anesthetic solutions, the other epinephrine in gingival retraction materials. The gray literature was not searched, and only reports in English were included in the search. We included any report where epinephrine was administered, and one or more cardiovascular parameters (blood pressure, heart rate, cardiac output, plasma epinephrine concentration, EKG changes including transient arrhythmias) or adverse events (headache, syncope, angina, hypertensive crisis, longer-term arrhythmia, cerebral vascular accident, myocardial infarction) was reported for hypertensive individuals. We selected studies for inclusion in the evidence table from among 373 local anesthetic and 33 retraction cord reports identified in the searches using independent dual review of titles, abstracts, and full papers. We abstracted data into the table for six reports for local anesthesia. No studies of retraction cord met the inclusion criteria.
Five of the studies reported blood pressure and heart rate changes associated with use of epinephrine in local anesthetics in uncontrolled hypertensive patients. One study reported results among controlled hypertensives. We did not meta-analyze these results due to incomplete information describing variability. In general, hypertensive subjects receiving an extraction experience small increases in systolic blood pressure and heart rate associated with the use of a local anesthetic containing epinephrine (4 mm Hg and 6 bpm). These increases associated with the use of epinephrine occur in addition to increases in systolic and diastolic blood pressure and heart rate associated with undergoing the procedure without epinephrine (11.7 and 3.3 mm Hg and 4.7 bpm) that are larger for hypertensives than for normotensives. No adverse outcomes were reported in these studies, and only one case report of an adverse outcome associated with the use of epinephrine in local anesthetic in a hypertensive patient was identified in the literature. However, we judged the strength of the evidence for answering the question addressed by the review as poor. The available studies did not address effects of gingival retraction cord, and only one study examined effects of epinephrine in anesthetics on controlled hypertensive subjects, where additional risks due to interactions with antihypertensive medications are possible. Further, the five studies examining effects in uncontrolled hypertensive subjects examined a narrow range of outcomes, and their designs made it unlikely that three of the studies could detect transient changes in outcomes that might indicate increased risk for adverse events.
The quantity and quality of the pertinent literature is problematic. The reported occurrence of adverse events in hypertensives associated with the use of epinephrine in local anesthetics is minimal, and the increased risk for adverse events among uncontrolled hypertensives is low, according to the authors of the studies that have examined this issue. However, these studies, as a group, do not offer strong evidence for this conclusion because the ability of the studies to detect signs of increased risk, mainly transient changes in cardiovascular and hemodynamic parameters, was limited. Further, no information is available to quantify the risk of using epinephrine-impregnated gingival retraction cord in hypertensive individuals, or epinephrine-containing local anesthetics in controlled hypertensives.