Original Article

SYSTEMIC EFFECTS OF LOCAL ANAESTHESIA IN

HYPERTENSIVE PATIENTS
1
HUMAYUN K SIDDIQUI
2
ALI HUSSAIN
3
FATIMA NASEEM A KHAN
4
AQIB MUHAMMAD SHAFI
5
UMAIMA HEYAT
ABSTRACT
The aim of this study was to review the literature to assess any scientific basis for the limited use
of dental anesthesia with a vasoconstrictor agent in hypertensive patients. This stratified random-
ized control study was carried out at the department of Oral and Maxillofacial Surgery in Baqai
Dental College, Karachi from August 2014 to January 2015. The total numbers of patients were 75;
age range from 25 to 70 years. The patients were characterized by the JNC-8 report for hypertension
patients i.e. normotensive with <120/180mmHg and hypertensive with >140/90mmHg. Patients
were clinically evaluated and were divided into three groups, each groups comprises of 25 patients.
Group A: Hypertensive patients who were administered 2% lignocaine. Group B: Hypertensive patients
administered 2% lignocaine with epinephrine 1:100,000 and Group C: Normotensive patients who
were administered 2% lignocaine with epinephrine 1:100,000. The mean age of the study sample was
46.62±13.81. These three groups were further stratified into three categories on the basis of age i.e.
young patients’ age 25 to 35 years, middle age 36-55 years and old age 56-70 years respectively, to
check the relation of hypertension with age. The mean B.P increased in all groups after two minutes
of administration, which maintained even after 5 minutes of administration, while after extraction
it returned to the observed baseline values in each group. When including age as a co-variable in the
multivariate analysis, no statistically significant differences was observed between groups and did
not show any adverse effects of epinephrine.
Key Words: Hypertensive, normotensive, oral surgery, epinephrine, pulse rate.

INTRODUCTION Vasoconstrictor agents have benefits like delaying

the absorption of local anesthesia toxicity; they increase
The utilization of local anesthesia with vasocon-
the depth and duration of local anesthesia and provide
strictor is a common clinical practice in dentistry. The
homeostasis.1 Despite all these, they have limited dose
effects of vasoconstrictor in hypertension vary from
of systemic absorption and initiate the side effects in
patient to patient. According to the literature, it has a
hypertensive patients, until used in safe dosage.2 The
potential to cause serious effects in patients who suffer
frequent increase in the number of patients in OPD
from persistent hypertension and is contraindicated in
with hypertension and the use of local anesthesia
such patients. As far as routine dental clinical practice
with vasoconstrictor agents in patients raise concerns
is concerned, the treatment protocol for hypertensive
about the elevation of B.P. If a practitioner considers
patients is not much followed in controlled hypertension.
pharmacologic effects of infiltrated substances have,
1
Dr Humayun K Siddiqui, Head of Department of Oral & it is obvious that the specialist must know and control
Maxillofacial Surgery in Baqai Dental College, Karachi
2
Dr Ali Hussain, Lecturer in Baqai Dental College, Karachi the situation thoroughly. This situation may worsen
3
Dr Fatima Naseem A Khan, Lecturer in Baqai Dental College, if proper protocols are not followed. Epinephrine re-
Karachi Corresponding Author: Fatima Naseem A Khan,
Lecturer in Baqai Dental College, Karachi inforces the effect of local anesthetics by increasing
Email: fnaknlm@gmail.com Cell: +92-300-2308827 the duration and depth of analgesia3 and is regularly
4
Dr Aqib Muhammad Shafi, House Surgeon in Baqai Dental
College, Karachi incorporated for infiltration in most commercial prepa-
5
Dr Umaima Heyat, Postgraduate student in Dow Medical Uni- rations because it aids in homeostasis.4,5 Epitome of
versity, Karachi
Received for Publication: October 26, 2017
vasoconstrictor decreases the systematic toxicity of
Revised: December 21, 2017 L.A and after infiltration decreases the release of local
Approved: December 22, 2017

Pakistan Oral & Dental Journal Vol 37, No. 4 (October-December 2017) 538
 Systemic effects of local anaesthesia in hypertensive patients

anesthetics to blood circulation.6 B.P and heart rate,7 having systolic pressure greater than 150mmHg and
arrhythmia,8 myocardial ischemia,9,10 increase of endog- diastolic with increased 95mmHg were not treated to
enous catecholamine,10 and hypokalemia11 were raised prevent any future medical emergencies.17,18 Firstly,
after administration of L.A containing epinephrine informed consent was taken from the patients. All
noted in previous studies. The morbidity and mortality the subjects were pre-informed about the risks and
rate rose with the increase of epinephrine dose.12 This benefits involved with procedure. Stratified random
is important for patients with cardiovascular disease. sampling was done and categorized into three groups,
Recent studies show that epinephrine associated with each category comprising 25 subjects:
L.A has a safety range.13 Group A: Hypertensive patients administered
According to American Heart Association (AHA) and lignocaine,
American Dental Association (ADA) guidelines, there Group B: Hypertensive patients administered
is no contraindication to using a vasoconstrictor agent lignocaine with epinephrine 1:100,000,
when administrated carefully and with preliminary
Group C: Normotensive patients administered
aspiration. The maximum dose of epinephrine in local
lignocaine with epinephrine 1:100,000.
anaesthesia for a healthy subject is 0.2 mg, though this
can be lowered to 0.04 mg if patient has severe cardio- Data was collect under the supervision of an oral
vascular disease (ASA III and IV).14 Therefore, the aim and maxillofacial surgeon. All patients went through
of this study was to review the literature to assess any the same procedure of evaluation; the record sheet and
scientific basis for the limited use of dental anaesthesia consent were signed before the procedure. The two
with a vasoconstrictor agent in hypertensive patients. cartridges of L.A injection containing 2% lignocaine
with 1:100,000 epinephrine were used in group B and
METHODOLOGY group C, while group A was evaluated by plain cartridge
The total numbers of patients were 75; age ranged of 2% lignocaine. B.P and P.R were recorded as risk
from 25 to 70; the patients were clinically evaluated indicators, which were measured four times for the
from August 2014 to January 2015 at the Oral Surgery patient: First at rest position on a dental chair, second
and Maxillofacial Department of Baqai Dental College, immediately after injection, third after 5 minutes of
Baqai Medical University, Karachi, Pakistan. The injection, and fourth 15 minutes after extraction. The
department averagely treats 45 patients per day, com- B.P was measured by a sphygmomanometer, and the
plaining of a variety of dental problems. The patients P.R was measured by principle method of the manual
were characterized by the JNC-8 report for hypertension palpation of the radial artery. The above three groups
patients i.e. normotensive with <120/80mmHg and were further stratified on basis of age to check the
hypertensive with >140/90 mmHg.15 According to the relation of hypertension with age, which was group
report patients were divided into controlled group (i.e., into three categories young patients with age of 25 to
patients with normal range of B.P: systolic 120 mmHg 35 years, followed middle age of 36-55 years, and old
and diastolic 80 mmHg), hypertensive patients admin- age 56-70 years respectively. The chart 1 defined the
istered lignocaine with epinephrine, and hypertensive division of patients in relation to age.
patients administered only lignocaine. Both male and RESULTS
female patients of hypertension and normotensive seek-
ing dental department for extraction. Patients who were For details see Tables 1-4. The mean age of this
taking beta blockers were excluded in the study as these study sample was group A: 42.96 ± 14.45, group B: 45.20
are shown to interact with epinephrine.16 Patients with ± 14.80, and group C: 51.72 ± 10.84. When including
any other cardiovascular disease or any serious illness age as a co-variable in the multivariate analysis, no
were also excluded from study and patients who had statistically significant difference was observed between
not taken their daily prescribed medicine and patients groups. The mean B.P raised in all three groups after

TABLE 1: GROUP A: HYPERTENSIVE PATIENTS ADMINISTERED ONLY 2% LIGNOCAINE

Group A At rest 2 minutes after 5 minutes after After extraction

injection injection
Systolic BP 135.40 ±6.44 142.20 ±3.55 141.80 ±6.10 138.20 ±6.59
Diastolic BP 84.80 ±4.89 89.80 ±6.84 88.60 ±6.04 87.40 ±7.23
Pulse rate 84.64 ±8.09 92.08 ±9.11 89.84 ±8.19 88.12 ±7.33

Pakistan Oral & Dental Journal Vol 37, No. 4 (October-December 2017) 539
 Systemic effects of local anaesthesia in hypertensive patients

TABLE 2: GROUP B: HYPERTENSIVE PATIENTS ADMINISTERED 2% LIGNOCAINE WITH

EPINEPHRINE 1:00,000W

Group B At rest 2 minutes after 5 minutes after After extraction

injection injection
Systolic BP 141.60 ±10.67 144.80 ±8.35 142.20 ±9.58 136.80 ±6.27
Diastolic BP 83.60 ±4.89 89.00 ±7.21 87.00 ±4.56 80.40 ±8.15
Pulse rate 86.72 ±10.93 95.88 ±13.48 94.44 ±11.87 87.40 ±5.68

TABLE 3: GROUP C: CONTROL GROUP OR NORMOTENSIVE PATIENTS ADMINISTERED

2% LIGNOCAINE WITH EPINEPHRINE 1:100,000

Group C At rest 2 minutes after 5 minutes after After extraction

injection injection
Systolic BP 112.40 ±8.30 119.00 ±3.53 117.00 ±4.78 115.40 ±4.06
Diastolic BP 79.00 ±3.22 86.40 ±5.86 83.40 ± 4.01 81.80 ±4.30
Pulse rate 81.20 ±6.62 83.88 ±6.51 82.56 ±5.50 81.36 ±3.62

TABLE 4: DIVISION OF AGE ACCORDING TO STUDY GROUP

Type of study Young patients Middle age Old patients Total Mean B.P
group (25-35 years) patients (56-70 years)
(36-55 years)
Group A 9 16 0 25 131.47± 14.09/83.70±8.49
Group B 0 4 21 25 143.83± 8.57/86.8.10±4.06
Group C 0 7 18 25 136.22± 28.18/84.7.44±1.90

2 minutes of administration, which maintained even constriction of the blood vessels in the mucosa and
after 5 minutes of administration, while after extraction skin, which favors latent period and reduces the dis-
it comes back to baseline degree, which was observed semination of the local anesthetic due to the action of
in each group. The mean pulse rate was also increased alpha-adrenergic receptors, but the beta 1-adrenergic
by 3 to 4 beats after 2 minutes of administration and receptors of adrenaline, will raise the heart rate and
then decreased after 5 minutes in all groups. As both the beta 2-adrenergic receptors will cause vasodilation
clinical and statistical results were significant, no risk of internal organs and muscles. There are few reports
changes were observed. that relate the use of major hypertensive and nonse-
DISCUSSION lective beta-adrenergic blocking agents may interact
with administered epinephrine infusions.19 Yoshito
The main aim of this study was to assess the changes Nakumara et al found that a patient with hypertension
in the B.P and P.R of diagnosed hypertensive patients undergoing tooth extractions has a risk of increased
before, during, and after dental extraction under local B.P than normotensive patients after injecting the
anesthesia containing epinephrine in comparison with 2% lidocaine with 1:80,000 epinephrine. It has also
the control group; the mean B.P raised in all groups been observed that mean systolic B.P showed changes
after 2 minutes of administration, which maintained throughout the procedure on other hand mean diastolic
even after 5 minutes of administration, while after B.P remains constant in comparison with preoperative
extraction it returned to the baseline value, which was readings.20
observed in each group. All the procedure was carried
In Nigerian study, no hemodynamic changes has
out with the permission of the Ethical Committee of the
been observed in hypertensive patients on administra-
university. Therefore, we concluded that statistically
tion of L.A with epinephrine and without epinephrine.21
no notable changes were seen clinically in this study
hypertensive patients are considered more prone to risk
while decrease in blood pressure in group B was not
when administering dental local anesthesia containing a
associated with any adverse effects of epinephrine. The
vasoconstrictor because of the possible sudden increase
local anesthetic containing adrenaline is most widely
in B.P could lead to life-threatening situation.22 The
used in dental practice. Epinephrine stimulates the
limited outcome parameters and small sample size are

Pakistan Oral & Dental Journal Vol 37, No. 4 (October-December 2017) 540
 Systemic effects of local anaesthesia in hypertensive patients

the limitation of this clinical study; however to the best the blood pressure and pulse rate of patients of both
of our knowledge, this is one of the very few clinical groups, which shows that no harmful effect on blood
trials conducted on the local population in Pakistan pressure and pulse rate occurred with the use of two
to observe the effects of local anesthesia on controlled cartridges of local anesthesia with epinephrine. There
hypertensive patients. In this study, there were no were no significant changes between normotensive and
significant changes in the systolic blood pressure and hypertensive patients using two cartridges of local an-
the diastolic blood pressure in hypertensive patients esthesia conjugation with epinephrine. Whether there
from rest till 5 minutes after administering lignocaine. was slight decrease in blood pressure in group B after
As compared to the study research undertaken in the extraction is not associated with any adverse effects
Lahore local population, there was a significant fall of epinephrine.
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CONTRIBUTIONS BY AUTHORS
1 Humayun K Siddiqui: Conception, design and analysis and interpretation of data, revising it
critically for intellectual content.
2 Ali Hussain: Data collection and write up drafting of data.
3 Fatima Naseem A Khan: Data collection and final drafting of the manuscript.
4 Aqib Muhammad Shafi: Formulation of tables and interpretation of data.
5 Umaima Heyat: Compilation of write up drafting of data and provided substantial help
in various aspects.
6 Muhammad Imran Khan: Analysis and interpretation of data.

Pakistan Oral & Dental Journal Vol 37, No. 4 (October-December 2017) 542
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