One-fourth of the U.S. population suffers from hypertension, and many hypertensive adults are seen in a typical dental practice. Most recommendations caution dentists about use of local anesthetics with epinephrine, which increases blood pressure, in hypertensive patients. Some caution against epinephrine use in controlled hypertensive patients taking antihypertensive medications with known epinephrine interactions. Others consider epinephrine use to be acceptable with appropriate precautions and monitoring. However, evidence is insufficient to gauge the actual risk that epinephrine-containing anesthetics pose for hypertensive dental patients, concludes a study supported by the Agency for Healthcare Research and Quality (contract 290-97-0011).
A systematic review of 406 studies on the topic by researchers at the RTI International—University of North Carolina Evidence-based Practice Center yielded six studies (a total of 325 patients, 177 hypertensive) that met inclusion criteria. These studies revealed low risk of elevated high blood pressure and related problems (for example, cerebral hemorrhage and acute heart failure) and minimal reporting of adverse events among hypertensive dental patients receiving epinephrine-containing anesthetics. The studies did not address effects of epinephrine-impregnated gingival retraction cords on hypertensive patients.
Unfortunately, the strength of the evidence is poor, with few studies and poor quality studies, note the researchers. The five studies of patients with uncontrolled (unmedicated) hypertension only assessed changes in blood pressure and heart rate as risk indicators (but not stroke volume, for example). Only one study noted patient-reported side effects. The studies varied on when they collected epinephrine exposure readings, and only one of the six studies examined controlled hypertensive patients.
See "A systematic review of cardiovascular effects of epinephrine on hypertensive dental patients," by James D. Bader, D.D.S., M.P.H., Arthur J. Bonito, Ph.D., and Daniel A. Shugars, D.D.S., Ph.D., in the June 2002 Oral Surgery Oral Medicine Oral Pathology 93, pp. 647-653.
Editor's Note: Copies of the AHRQ evidence report on this topic, Cardiovascular Effects of Epinephrine on Hypertensive Dental Patients (AHRQ Publication No. 02-E006), and a summary of the report (AHRQ Publication No. 02-E005) are available from the AHRQ Publications Clearinghouse. The Evidence Report can also be downloaded as a zipped file online at: http://www.ahrq.gov/clinic/evrptfiles.htm#epine.