What is the effect of local epinephrine (adrenaline) on dental procedures and blood pressure?

From the Guidelines

Local epinephrine used in dental procedures has minimal systemic effects on blood pressure in healthy patients, but caution is warranted in patients with uncontrolled hypertension or severe cardiovascular disease, and the dose of epinephrine should be reduced when using local anesthesia due to increasing blood pressure, as recommended in the study by 1. When administered in appropriate dental doses (typically 1:100,000 or 1:200,000 concentration with lidocaine), epinephrine primarily serves as a vasoconstrictor that prolongs the effect of local anesthetics while reducing bleeding at the surgical site. However, it can potentially cause a transient increase in blood pressure and heart rate, especially if inadvertently injected into a blood vessel or used in excessive amounts. Some key points to consider when using local epinephrine in dental procedures include:

• The maximum recommended dose is 0.2 mg of epinephrine per appointment (equivalent to about 11 cartridges of 1:100,000 epinephrine) as a general guideline, although specific recommendations may vary based on individual patient factors.
• Caution is warranted in patients with uncontrolled hypertension, severe cardiovascular disease, or those taking non-selective beta-blockers, as these individuals may experience more pronounced cardiovascular effects, as noted in the study by 1.
• The physiological basis for these effects stems from epinephrine's action on alpha-1 receptors causing vasoconstriction and beta-1 receptors increasing heart rate and contractility.
• Dentists should always aspirate before injection to avoid intravascular administration and consider using lower concentrations (1:200,000) or epinephrine-free anesthetics for high-risk patients, as suggested in the guidelines by 1. It's also important to note that the use of epinephrine in local anesthetic solutions is a concern in dental care for patients with elevated blood pressure, and blood pressure should be monitored closely in the dental office if general anesthesia is administered to hypertensives, as recommended in the study by 1.

From the FDA Drug Label

Rapid rises in blood pressure associated with epinephrine use have produced cerebral hemorrhage, particularly in elderly patients with cardiovascular disease Cardiovascular: angina, arrhythmias, hypertension, pallor, palpitations, tachyarrhythmia, tachycardia, vasoconstriction, ventricular ectopy and stress cardiomyopathy.

The use of local epinephrine (adrenaline) in dental procedures can cause an increase in blood pressure, which may lead to serious cardiovascular events, such as cerebral hemorrhage, particularly in elderly patients with cardiovascular disease. Key points to consider include:

• Hypertension as a potential adverse reaction
• Cardiovascular events, including angina and arrhythmias
• Increased risk in patients with underlying heart disease or hyperthyroidism 2

From the Research

Effect of Local Epinephrine on Dental Procedures and Blood Pressure

• The use of local anesthetics with vasoconstrictor agents, such as epinephrine, in dental procedures has been studied in various patient populations, including those with hypertension and coronary disease 3, 4, 5, 6, 7.
• Studies have shown that the use of local anesthetics with epinephrine in patients with controlled hypertension and/or coronary disease is safe and does not significantly increase blood pressure or heart rate 3, 6, 7.
• However, some studies have reported a decrease in systolic blood pressure in patients with stage 2 hypertension after administration of epinephrine-containing local anesthetics 4.
• The concentration of epinephrine in local anesthetics can affect hemodynamic changes, with lower concentrations (1:200,000) resulting in less significant changes in blood pressure and heart rate compared to higher concentrations (1:80,000 or 1:100,000) 5.
• Overall, the available evidence suggests that local epinephrine can be safely used in dental procedures, including in patients with hypertension and coronary disease, but blood pressure should be monitored closely during the procedure 3, 4, 5, 6, 7.

Hemodynamic Changes

• Studies have reported various hemodynamic changes after administration of local anesthetics with epinephrine, including:
  • Increase in systolic blood pressure 5, 7
  • Decrease in diastolic blood pressure 4, 5
  • Increase in heart rate 5
  • No significant change in oxygen saturation 5, 7
• The magnitude and direction of these changes can vary depending on the concentration of epinephrine, the patient's underlying medical condition, and other factors 3, 4, 5, 6, 7.

Safety in Hypertensive Patients

• The available evidence suggests that local anesthetics with epinephrine can be safely used in hypertensive patients, including those with stage 2 hypertension 3, 4, 7.
• However, blood pressure should be monitored closely during the procedure, and the concentration of epinephrine should be carefully selected to minimize potential hemodynamic changes 3, 5, 7.