Injectable Anaesthetics for Pain Control During Dental Procedures
Anaesthetics are used during dental procedures to make patients comfortable and, in some cases, restrict bleeding in the surgical area (e.g. Artinibsa 4% 1:100,000 solution for injection). However, special considerations need to be made for patients with pre-existing cardiovascular conditions. Additionally, providers who use local anaesthetics should closely monitor patients with these pre-existing conditions and be aware of signs of toxicity.
Anaesthesia and Cardiovascular Complications
Cardiovascular complications can refer to a number of health conditions that affect the heart and cardiovascular system. It is estimated that 523 million people worldwide are living with cardiovascular disease and related complications, making it the leading cause of disease burden globally. Cardiovascular diseases include:
- Coronary heart disease
- Deep vein thrombosis
- Peripheral arterial disease
- Rheumatic heart disease
- Cerebrovascular disease
- Congenital heart disease
Other, acute cardiovascular complications that can occur include stroke or heart attack. Medications are used to manage these complications, such as aspirin, statins, beta-blockers, and angiotensin-converting enzyme (ACE) inhibitors.
Epinephrine in Anaesthesia
Epinephrine, more commonly known as adrenaline, is included in local anaesthetics to improve the duration and depth of the anaesthesia. It also has vasoconstrictor effects to reduce bleeding during the procedure and counteract the vasodilator effects of anaesthetic drugs.
Endogenous catecholamine release also occurs during stressful or life-threatening situations, causing patients who are fearful of dental procedures to produce their own epinephrine. This can increase the cardiac workload and create more stress on the cardiovascular system. The endogenous release of catecholamines may combine with the epinephrine in some injectable dental anaesthetics, creating an additive effect. With this, it is imperative to closely monitor nervous or fearful patients.
In patients with cardiovascular complications, epinephrine should be administered in the lowest available concentration (1:200,000) and in the smallest volume appropriate for effective pain control.
Artinibsa Solution for Injection
Artinibsa is made using 40 milligrammes (mg) of articaine with 5 or 10 microgrammes (µg) of adrenaline. Artinibsa is given at the lowest possible dose in patients who have cardiovascular complications such as heart failure, uncontrolled hypertension, hypotension, paroxysmal tachycardia, or unstable angina. Patients who have a recent history of myocardial infarction or coronary bypass surgery should also receive the lowest possible dose.
Certain medications can also intensify the effects of epinephrine in Artinibsa. Non-selective beta blockers, taken to manage cardiovascular complications, and tricyclic antidepressants can both amplify epinephrine’s effects — this can lead to high blood pressure and an increased risk of developing bradycardia.
Xilonibsa Solution for Injection and Spray
Xilonibsa is administered by one of two ways — as a pulsing dispenser containing 10 mg of lidocaine spray, or 20 mg lidocaine with 0.0125 mg of epinephrine as an injection.
It is recommended that Xilonibsa is given at the lowest possible dose in patients with cardiovascular complications. Certain medications can interfere with the safety and efficacy of Xilonibsa.
Beta blockers can interfere with how the anaesthesia is cleared from the body, so reducing the dose is imperative to avoid complications or potential overdose. Patients who are being treated with class III antiarrhythmic drugs, such as amiodarone, should be monitored when given Xilonibsa.
Scandinibsa Solution for Injection
Scandinibsa is an injectable solution that contains 30 mg of mepivacaine hydrochloride. Even if the plain formulation does not contain epinephrine, it should be used with caution in patients with cardiovascular complications, such as peripheral vascular disease, ventricular arrhythmias, atrio-ventricular conduction disorders, heart failure, and hypotension.
Inibsacain Solution for Injection
Inibsacain is an injectable solution that contains 5 mg of bupivacaine and 0.005 mg of epinephrine. Inibsacain is contraindicated for several cardiovascular complications, including paroxysmal tachycardia, atrial fibrillation, severe cardiac impulse conduction disorders, uncompensated heart failure, cardiogenic shock, and hypovolaemia.
Inibsacain may interact with non-selective beta blockers that are often taken by patients with cardiovascular complications. Combining these medications can lead to an increase in blood pressure and the risk of developing bradycardia. In severe cases, this can lead to hypotension or arrhythmias.
Patients with cardiovascular complications who are given local dental anaesthetics should be continuously monitored in cases of toxicity or other adverse events. Overall, these medications are safe and effective, and proper care should be taken to ensure the safety of the patients.
- Malamed, S.F. Handbook of Local Anesthesia. 7th. ed.- St. Louis, MI : Elsevier Mosby, 2020.
- Daskalov H. et al. Local anesthetics in patients with cardiovascular diseases. J of IMAB. 2015;21(1):728-731.
- Moore P.A. et al. Hemostatic and anesthetic efficacy of 4% articaine HCl with 1:200,000 epinephrine and 4% articaine HCl with 1:100,000 epinephrine when administered intraorally for periodontal surgery. J Periodontol. 2007;78(2):247-53.
- Summary of Product Characteristics of Artinibsa 4% 1:100,000, Artinibsa 4% 1:200,000, Xilonibsa 2% 1:80,000, Xilonibsa Spray 10%, Scandinibsa 20 mg/ml + 10 mcg/ml, Scandinibsa 3% and Inibsacain 5 mg/ml + 0.005 mg/ml.
- Decloux D., Ouanounou A. Local Anaesthesia in Dentistry: A Review. Int Dent J. 2021;71(2):87-95.
- Roth G.A., Mensah G.A., Johnson C.O. Addolorato G., Ammirati E., et al. Global Burden of Cardiovascular Diseases and Risk Factors, 1990-2019: Update From the GBD 2019 Study. J Am Coll Cardiol. 2020;76(25):2982-3021.
- World Health Organization. Cardiovascular diseases (CVDs). 11 June 2021. Retrieved from https://www.who.int/news-room/fact-sheets/detail/cardiovascular-diseases-(cvds)
- Lee J., Lee J., Kim H.J., Seo K. Dental anesthesia for patients with allergic reactions to lidocaine: two case reports. J Dent Anesth Pain Med. 2016;16(3):209-212.