Epinephrine and local anesthesia revisited

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Abstract

The issue concerning how much and under what circumstances epinephrine vasoconstriction within den-tal local anesthesia is appropriate has been strenuously debated over the last 50 years. Because relevant human and animal studies are difficult to perform, there are, at present, insufficient data to answer many of our ques-tions. Many of the previous conclusions regarding safety and efficacy were based upon incomplete understand-ing, bias, and limited scientific and clinical data. 1 Well designed controlled, randomized, and blinded studies are the gold standard with regard to determining pharma-cotherapeutic efficacy and safety. With regard to epinephrine vasoconstriction, many opinions concerning this issue neglect our current understanding of physiology and pharmacology as well as the results of scientific clinical studies. Previous misunderstanding has been woven into much of our current clinical practice and as such reappraisal is warranted, because medical comprehension of the dynamics of physiology and pharmacology have re-cently undergone dramatic changes. 2 Issues regarding these medications remain and include: 1) the advantages of combining vasoconstriction with local anesthesia, 2) the physiologic workings of the adrenergic nervous system, 3) toxicity issues of vasoconstrictors, 4) insig-nificant changes in mean arterial (MAP) blood pressure with relatively small amounts of epinephrine, 5) recep-tor dynamics, 6) drug-drug interactions, and 7) vaso-constrictor issues with regard to the dental treatment of patients with severe cardiac disease. THE RATIONALE FOR COMBINATION OF VASOCONSTRICTOR WITH LOCAL ANESTHETICS The presence of epinephrine and other vasoconstric-tors in local anesthetic solutions is beneficial with regard to duration, depth of anesthesia, blood loss, and the reduction of systemic local anesthesia toxicity. Local anesthetic clinical efficacy is dependent upon the action of the vasoconstrictor. 3 Dental treatment with insuffi-cient vasoconstriction within the local anesthetic for-mulation may lead to less than adequate pain control and thus increased levels of endogenous catechol-amines and particularly norepinephrine (NE). 4 Pain control was significantly impaired in those patients receiving the local anesthetic without the vasoconstric-tor as compared to those patients receiving the local anesthetic with vasoconstrictor. 3,5 Ineffective pain con-trol increases patient health outcomes risk. 6,7 NE (either parental or endogenous) increases blood pressure and has other cardiotoxic effects. 8,9

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Brown, R. S., & Rhodus, N. L. (2005). Epinephrine and local anesthesia revisited. Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology and Endodontology, 100(4), 401–408. https://doi.org/10.1016/j.tripleo.2005.05.074

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