Blood pressure response during dental surgery

Cardiovascular Response of Aged Outpatients With Systemic Diseases During Tooth Extraction: A Single-Center Retrospective Observational Study

Background

Aged people are maintaining many natural teeth due to improved oral health. However, compromised general health and poor oral hygiene habits at earlier ages resulted in poor status of preserved teeth. Therefore, tooth extraction is required in many aged people. More knowledge is needed because there are many risk factors during the surgery in frail aged adults. The aim of this study was to evaluate the cardiovascular response of such a population during tooth extraction and analyze risk factors to provide clinical guidance.

Methods

A retrospective study was performed on aged patients with systemic diseases who underwent tooth extraction. Data regarding demographic profiles and cardiovascular parameters of heart rate and blood pressure were collected preoperative, when local anesthesia was administered, at the beginning of tooth extraction, 5 min after tooth extraction, and postoperative. The effects of risk factors, including age, sex, and systemic diseases on these parameters were analyzed with a multilevel model.

Results

Heart rate (HR), systolic blood pressure (SBP), and diastolic blood pressure (DBP) of aged patients increased significantly when performing local anesthesia and tooth extraction. During the operation, the older patients (β = 2.011, P = 0.005) and the diabetics (β = 3.902, P < 0.0001) were associated with higher SBP, while those with more tooth extractions exhibited higher HR (β = 0.893, P = 0.007). Women patients showed both significantly elevated HR (β = 1.687, P < 0.0001) and SBP (β = 2.268, P < 0.0001). However, for coronary artery disease patients, HR (β = −2.747, P < 0.0001) and blood pressure [SBP (β = −4.094, P < 0.0001) and DBP (β = −0.87, P = 0.016)] were markedly lower than those of patients without a diagnosis of coronary artery disease.

Conclusion

Cardiovascular response of aged outpatients with systemic diseases during tooth extraction is quite significant. Age, sex, systemic diseases, and the number of tooth extraction could be risk factors closely associated with cardiovascular response. The findings might provide safety guidance for dentists on tooth extraction in this population.

Variation in Hemodynamic Characteristics during Periodontal Crown-Lengthening Surgical Procedure: An Uncontrolled Cohort Study

(1) Background: The purpose of this prospective study was to determine the changes in primary hemodynamic parameters and oxygen saturation in systemically healthy patients during the surgical procedure involving crown lengthening. (2) Methods: A total of 44 patients who required a crown-lengthening procedure in a single tooth in the maxillary arch were included in this study. Heart rate (HR), blood pressure (BP) and oxygen saturation (SpO₂) were measured in all the subjects at three different intervals: before injecting the anesthetic (T1), after the anesthetic injection (T2) and after the procedure (T3). Descriptive statistics were computed, and observations were recorded as mean and standard deviation (SD). Analysis of variance (ANOVA) was used to compare the mean observation within parameters at different time intervals. (3) Results: All primary hemodynamic parameters were increased in the T2 phase over T1 and decreased in the T3 phase over T2. However, SpO₂ decreased in both the T2 and T3 phases compared to the initial T1 phase. No significant differences were observed among the primary hemodynamic variables. However, SpO₂ showed a significant difference (p = 0.013) among the T1, T2 and T3 phases. (4) Conclusions: Further study with larger sample size is required in order to analyze the accurate hemodynamic alterations.

Virtual Reality for Hypertension in Tooth Extraction: A Randomized Trial

Tooth extraction is one of the most common causes of dental anxiety and pain, leading to the elevation of blood pressure (BP) and heart rate (HR). Such effects may be exaggerated and cause life-threatening accidents in patients with hypertension. Therefore, the pain and anxiety management of these patients is imperative. Virtual reality (VR) has been demonstrated to be a distraction method to relieve anxiety and pain in clinical operations. Thus, we hypothesized that VR can control the elevation of BP and HR in patients with hypertension. In this study, 96 eligible patients with controlled hypertension who needed tooth extraction were randomized to the VR or standard care group by stratified randomization of anxiety grade and gender. Their BP and HR were dynamically monitored. The corresponding systolic and diastolic BP and HR values were selected when systolic BP was at the highest point of the process. BP was converted into mean arterial pressure (MAP) for comparison per the following formula: MAP = (systolic BP + 2 × diastolic BP)/3. Statistical analyses were by intention to treat and conducted in SPSS. Nonparametric rank sum tests were used to compare the difference of ΔMAP and ΔHR between the VR and standard care groups. Multivariate linear regression was applied to evaluate the effect of VR on ΔMAP and ΔHR. The results showed that the VR technique significantly decreased the elevation of MAP (P < 0.001) and HR (P < 0.001), and this effect was found even after adjusting for baseline characteristics and additional surgical procedures (ΔMAP, P < 0.001, R² = 0.276; ΔHR, P < 0.001, R² = 0.152). VR did not increase the incidence of adverse events (P = 0.677). In conclusion, the VR technique was effective in controlling BP and HR within an acceptable range and can help manage BP and HR during tooth extraction for patients with hypertension (Chinese Clinical Trial Registry: ChiCTR2100042132).

Comparison of the Effects of Articaine and Lidocaine Anesthetics on Blood Pressure after Maxillary Infiltration Technique: A Triple-Blind Randomized Clinical Trial

Background

Many dental procedures begin with local anesthesia. Subsequent increase in blood pressure in healthy individuals commonly occurs and may be affected by several factors such as mental and physical stress, painful stimuli, and action of catecholamines present in local anesthetic solutions. The aim of the present study is to compare the effects of 4% articaine with 1 : 100000 epinephrine and 2% lidocaine with 1 : 80000 epinephrine on blood pressure after maxillary infiltration technique.

Materials and Methods

In this randomized clinical trial, 102 patients were randomly assigned into two groups. One group received 4% articaine with 1 : 100000 epinephrine and the other group received 2% lidocaine with 1 : 80000 epinephrine for local maxillary infiltration. Systolic and diastolic blood pressure of both groups was determined twice: once before anesthetic injection and once 10 minutes after injection. The data were statistically analyzed using descriptive statistics, Shapiro–Wilks test, Levene test, chi-square test, independent t-test, and paired t-test.

Results

The mean systolic blood pressure after anesthetic injection in the articaine and lidocaine groups was 125.00 ± 5.67 and 123.16 ± 6.417 mmHg, respectively, showing no statistically significant difference (p=0.127). The mean diastolic blood pressure after injection was 85.02 ± 7.331 in the articaine group and 81.35 ± 12.815 mmHg in the lidocaine group. These values show no statistically significant difference (p=0.080). In both groups, the mean systolic and diastolic blood pressures have increased significantly (p < 0.001).

Conclusion

Articaine can be regarded as a suitable alternative for lidocaine for maxillary local infiltration, as no significant difference was observed between the effects of the two anesthetic solutions on blood pressure.

Analysis of Incident Reports of a Dental University Hospital

Incident reports are important for improving the quality and safety of medical care. Healthcare workers with less than one year of work experience have been reported to cause the most incidents, and the most common incident is “drug-related”. However, few studies have comprehensively analyzed incidents in dentistry, and the characteristics of dental incidents have not been understood. In this study, to understand the characteristics of dental incidents, we comprehensively analyzed 1291 incident reports submitted to the Tokyo Medical and Dental University Dental Hospital from April 2014 to March 2019. As a result, dental outpatient and dental wards had different types of incidents. In outpatient wards, incidents included many dentistry-specific incidents related to “procedures”. Among them, “poor physical condition of the patient during dental treatment” was the most common incident. In contrast, the most common incident from subjects with less than one year of work experience was “damage to soft tissues around the teeth”. Thus, to improve the quality and safety in dentistry, it is was considered necessary to analyze and understand the characteristics of dentistry-specific incidents and to take appropriate measures and educate dental professionals.

A Prospective, Randomized Double-Blinded Study to Evaluate the Efficacy of Buffered Local Anesthetics in Infected and Inflamed Pulp and Periapical Tissues

Aim

The aim of this study is to evaluate the efficacy of sodium bicarbonate as an additive alkalizing agent to local anesthetic solutions in inflamed and infected pulpal and periapical tissues.

Type of Study

A prospective, randomized crossover double-blinded study was carried out in a university-affiliated hospital in Chennai.

Materials and Methods

A randomized crossover double-blinded study was designed wherein ninety-six patients were enrolled for the study. 1.8 ml of 2% lignocaine with 1:200,000 adrenaline was administered. The latency time period was found to be 5-10 min and extraction was attempted. During extraction, if the patient experienced pain, 0.5 ml of 8.4% sodium bicarbonate was injected into the previously injected local anesthesia site. A time period of 3 min was allowed for the alkalinization to occur. Extraction was carried out only when the patient did not complain of pain. Pain score was assessed before and after administration of 8.4% sodium bicarbonate using visual analog scale. Pulse rate at the baseline, before and after administration of 8.4% sodium bicarbonate, was recorded and the pain scale values were correlated with pulse rate.

Results

It was found that there was a significant decrease in pain after injecting buffered local anesthetics (p < 0.1). Pain score before injecting sodium bicarbonate was higher when compared to post-injection of sodium bicarbonate. There was also significant reduction in pulse rate following the administration of sodium bicarbonate.

Conclusion

Buffered 2% lignocaine with 1:200,000 epinephrine had early onset of anesthesia when compared to unbuffered form. Injecting 2% buffered lignocaine pain was significantly reduced during extraction in the teeth.

Is It Safe for Patients With Cardiac Channelopathies to Undergo Routine Dental Care? Experience From a Single-Center Study

Background Brugada syndrome and long-QT syndrome may account for at least one third of unexplained sudden cardiac deaths. Dental care in patients with cardiac channelopathies is challenging because of the potential risk of life-threatening events. We hypothesized that the use of local dental anesthesia with lidocaine with and without epinephrine is safe and does not result in life-threatening arrhythmias in patients with channelopathies. Methods and Results We performed a randomized, double-blind pilot trial comparing the use of 2% lidocaine without a vasoconstrictor and with 1:100 000 epinephrine in 2 sessions of restorative dental treatment with a washout period of 7 days (crossover trial). Twenty-eight-hour Holter monitoring was performed, and 12-lead electrocardiography, digital sphygmomanometry, and anxiety scale assessments were also conducted at 3 time points. Fifty-six dental procedures were performed in 28 patients (18 women, 10 men) with cardiac channelopathies: 16 (57.1%) had long-QT syndrome, and 12 (42.9%) had Brugada syndrome; 11 (39.3%) of patients had an implantable defibrillator. The mean age was 45.9±15.9 years. The maximum heart rate increased after the use of epinephrine during the anesthesia period from 82.1 to 85.8 beats per minute (P=0.008). In patients with long-QT syndrome, the median corrected QT was higher, from 450.1 to 465.4 ms (P=0.009) at the end of anesthesia in patients in whom epinephrine was used. The other measurements showed no statistically significant differences. No life-threatening arrhythmias occurred during dental treatment. Conclusions The use of local dental anesthesia with lidocaine, regardless of the use of a vasoconstrictor, did not result in life-threatening arrhythmias and appears to be safe in stable patients with cardiac channelopathies. Clinical Trial Registration URL: http://www.clinicaltrials.gov. Unique identifier: NCT03182777.

Prediction Model of Cardiac Risk for Dental Extraction in Elderly Patients with Cardiovascular Diseases

BACKGROUND

With the rapidly increasing population of elderly people, dental extraction in elderly individuals with cardiovascular diseases (CVDs) has become quite common. The issue of how to assure the safety of elderly patients with CVDs undergoing dental extraction has perplexed dentists and internists for many years. And it is important to derive an appropriate risk prediction tool for this population.

OBJECTIVES

The aim of this retrospective, observational study was to establish and validate a prediction model based on the random forest (RF) algorithm for the risk of cardiac complications of dental extraction in elderly patients with CVDs.

METHODS

Between August 2017 and May 2018, a total of 603 patients who fulfilled the inclusion criteria were used to create a training set. An independent test set contained 230 patients between June 2018 and July 2018. Data regarding clinical parameters, laboratory tests, clinical examinations before dental extraction, and 1-week follow-up were retrieved. Predictors were identified by using logistic regression (LR) with penalized LASSO (least absolute shrinkage and selection operator) variable selection. Then, a prediction model was constructed based on the RF algorithm by using a 5-fold cross-validation method.

RESULTS

The training set, based on 603 participants, including 282 men and 321 women, had an average participant age of 72.38 ± 8.31 years. Using feature selection methods, 11 predictors for risk of cardiac complications were screened out. When the RF model was constructed, its overall classification accuracy was 0.82 at the optimal cutoff value of 18.5%. In comparison to the LR model, the RF model showed a superior predictive performance. The AUROC (area under the receiver operating characteristic curve) scores of the RF and LR models were 0.83 and 0.80, respectively, in the independent test set. The AUPRC (area under the precision-recall curve) scores of the RF and LR models were 0.56 and 0.35, respectively, in the independent test set.

CONCLUSION

The RF-based prediction model is expected to be applicable for preoperative clinical assessment for preventing cardiac complications in elderly patients with CVDs undergoing dental extraction. The findings may aid physicians and dentists in making more informed recommendations to prevent cardiac complications in this patient population.

Rise of blood pressure value in young patients at first visit at a dental university hospital in Japan

Background/purpose

Hypertension is a risk factor for stroke and heart disease. Psycho-social reasons are thought to influence blood pressure fluctuation in the dental clinic, but no previous studies have investigated these relationships. In this study, we analyzed a correlation between patients' blood pressure values and their backgrounds.

Materials and methods

We measured blood pressure in 4990 outpatients at our hospital. After determining the age groups in which blood pressure deviated from national averages, patients were classified into the Hypertension group and Normal group. Differences between these groups with regard to the prevalence of systemic disease, dental history and reasons for dental consultation were analyzed.

Results

Average systolic blood pressure of males in their 20's, 30's, 40's and females in their 20's, 30's, 40's, 50's was significantly higher than national averages. In these age groups, disease prevalence was significantly higher in the Hypertension group than in the Normal group. Furthermore, the Hypertension group expressed psycho-social reasons for dental consultation more frequently than the Normal group.

Conclusion

Relatively younger patients tended to show higher systolic blood pressure. It was suggested that psycho-social backgrounds as well as medical causes influenced the blood pressure increase.

Anxiety before dental surgery under local anesthesia: reducing the items on state anxiety in the State-Trait Anxiety Inventory-form X

BACKGROUND

It is important to evaluate preoperative anxiety and prepare sedation when performing dental surgery under local anesthesia. Spielberger's State-Trait Anxiety Inventory (STAI) is useful for predicting preoperative anxiety. State anxiety is defined as a subjective feeling of nervousness. Reduction in the number of the state anxiety items (questions) will be clinically important in allowing us to predict anxiety more easily.

METHODS

We analyzed the STAI responses from 1,252 patients who visited our institution to undergo dental surgery under local anesthesia. Multiple linear regression analysis was conducted for 9 groups comprising anxiety level determinations using the STAI; we then developed a coefficient of determination and a regression formula. We searched for a group satisfying the largest number of requirements for regression expression while setting any necessary conditions for accurately predicting anxiety before dental surgery under local anesthesia.

RESULTS

The regression expression from the group determined as normal for preoperative state anxiety was deemed the most suitable for predicting preoperative anxiety.

CONCLUSIONS

It was possible to reduce the number of items in the STAI by focusing on "Preoperative anxiety before dental surgery."

A prospective study of the relationship between patient character and blood pressure in dental implant surgery

Background

Patients often suffer from physical and mental stress in dental implant surgery. The aim of this prospective study is to investigate the relationship between patient character and blood pressure in dental implant surgery.

Methods

Fifteen patients were recruited for the present study. All patients had never received implant treatment in the past. To evaluate the patients’ personality trait, NEO-Five Factor Inventory (NEO-FFI) was used. All patients answered 50 questions at the first visit and divided in five dimensions: neuroticism, extraversion, openness, agreeableness, and conscientiousness. The index of physical stress was evaluated by blood pressure and pulse rate.

Results

Ten females and five males (mean 55.5 ± 10.6 years) were evaluated in this study. A significant positive correlation was found between elevation rate of diastolic blood pressure/mean blood pressure and neuroticism score (rs = 0.584, 0.526, p < 0.05). On the other hand, there was no significant correlation between systolic blood pressure elevation and neuroticism score.

Conclusions

In this limited study, there was significant correlation between neuroticism character and diastolic blood pressure or mean blood pressure rising in patients who received implant surgery.

Efficacy of intravenous sedation and oral nifedipine in dental implant patients with preoperative hypertension - a retrospective study of 516 cases

Background

To examine the effects of intravenous sedation and oral nifedipine on blood pressure and pulse rate in patients with perioperative high blood pressure undergoing implant surgery, the clinical records of dental implant patients managed by intravenous sedation at our outpatient dental offices were retrospectively evaluated.

Methods

A total of 516 clinical charts were evaluated. The subjects were divided into two groups: a normotensive group with no history of hypertension and a hypertensive group with a history of hypertension. The patients in the hypertensive group were further divided into two subgroups: with or without nifedipine administration before operation. Systolic blood pressure (SBP), diastolic blood pressure (DBP), pulse rate (PR), and rate pressure product (RPP) were assessed.

Results

In 30 patients (33%) of the hypertensive group, the high blood pressure on arrival obviously declined to around or less than 160 mmHg; in the remaining patients in the group who showed a mean SBP of 182.1 ± 13.8 mmHg on arrival, the blood pressure did not decrease after a 30-min rest. Oral nifedipine administered to the patients with sustained high blood pressure decreased SBP to 144.7 ± 23.1 mmHg in 28.1 ± 9.3 min after administration, comparable to that in hypertensive patients without nifedipine.

Conclusions

For patients with stage 2 hypertension before operation, it may be difficult to maintain the recommended blood pressure during surgery by only intravenous sedation; reduction of blood pressure by antihypertensive drugs may be necessary.

Cortisol level and hemodynamic changes during tooth extraction at hypertensive and normotensive patients

Background:

The patients that are subjects to oral-surgical interventions produce large amounts of steroids in comparison with healthy patients which are not a subject to any dental intervention. The aim of research was to determine the level of stress hormone cortisol in serum, arterial blood pressure and arterial pulse, and to compare the effectiveness of the usage of lidocaine with adrenalin in comparison with lidocaine without adrenalin during the tooth extraction.

Patients and methods:

This clinical research includes patients with indication of tooth extraction divided in hypertensive and normotensive patients.

Results:

There is no important statistical distinction between groups, for the cortisol levels before, during and after tooth extraction regardless of the type of anesthetic used, while we registered higher values of systolic and diastolic values at hypertensive patients, regardless of the type of anesthetic

Conclusion:

There is significant systolic and diastolic blood pressure rise in both groups of patients hypertensive and normotensive patients, (regardless of anesthetic used with or without vasoconstrictor), who underwent tooth extraction. The special emphasize is attributed to hypertensive patients where these changes are more significant. As per cortisol level and pulse rate, our results indicate no significant statistical difference in between groups.

Extravasation of blood-borne immunoglobulin G through blood-brain barrier during adrenaline-induced transient hypertension in the rat

The effect of transient hypertension on blood-brain barrier (BBB) permeability, particularly on extravasation of immunoglobulin G (IgG), has not been fully understood. In the present experiment, we investigated the time course of endogenous albumin and IgG extravasation through BBB and the localization of extravasated IgG in brain parenchyma during adrenaline(AD)-induced transient hypertension in the rat by using Evans blue fluorescence, immunohistochemistry, and Western blot. The results showed that a bolus injection of AD (10 microg/kg) induced a transient elevation of arterial pressure lasting about 1 min. The endogenous albumin and IgG entered the brain parenchyma via BBB only when hypertension occurred. Electron microscopically, the IgG-like immunoreactivities were predominantly seen in the cytoplasm of endothelia of capillaries, pericytes, extracellular space of parenchyma, and the cytoplasm of glial cells. The results suggest that circulating IgG or antibodies might contact the structures of brain parenchyma through passage of BBB when its permeability is temporally changed by transient hypertension. This phenomenon implies a possible mechanism of pathogenesis for immune-mediated diseases in the brain.

Lack of association between QT dispersion and blood pressure response during dental surgery

1. It is well known that dental surgery induces increases in blood pressure. However, the factors influencing this increase are not yet fully understood. We have determined the relationship between QTc (= QT/RR(1/2), with RR being the R-R interval in seconds) dispersion, measured with a 12-lead surface electrocardiogram, and changes in blood pressure during tooth extraction. 2. Both QTc dispersion and the power spectrum of R-R variability were determined before the dental surgery was undertaken. The low-frequency (LF; 0.041-0.140 Hz), high- frequency (HF; 0.140-0.500 Hz) and total spectral powers (TF; 0.000-4.000 Hz) were calculated and the ratio of LF to HF and the percentage of HF relative to TF (%HF; HF/TF x 100) were used as indices of sympathovagal balance and parasympathetic activities, respectively. 3. In the present study, QTc dispersion failed to correlate with LF/HF and %HF. Systolic blood pressure and pulse rate increased significantly during tooth extraction; however, changes in these variables failed to correlate with QTc dispersion. 4. These results suggest that QTc dispersion is not associated with the power spectrum of R-R variability and that it does not affect the blood pressure response during tooth extraction.

Cardiovascular and sympathetic responses to dental surgery with local anesthesia

We investigated changes in blood pressure and blood variables, including plasma catecholamines, serum glucose and insulin concentrations, during dental surgery. The study included 11 normotensive patients (age, 22.5+/-0.7 years) who underwent tooth extraction at Kyushu Dental College Hospital. Three to 7 days prior to dental surgery, blood pressure, pulse rate, and heart rate variability were measured every 30 min over 24 h. The low frequency (LF: 0.05 to 0.15 Hz) and high frequency (HF: 0.15 to 0.40 Hz) powers were calculated, and the ratio of LF to HF (LF/HF) and HF were used as indexes of sympathetic and parasympathetic activities, respectively. Lidocaine, 2% with epinephrine (1:80,000), was used as the local anesthetic for all patients. Systolic blood pressures significantly increased during dental surgery (+10.8+/-3.5 mmHg); however, this increase failed to correlate not only with baseline systolic blood pressure but with 24-h averaged blood pressures, LF/HF or HF. On the other hand, plasma epinephrine and norepinephrine concentrations increased during dental surgery, and peak values of these variables were obtained after local anesthesia and during tooth extraction, respectively. Serum glucose level increased after local anesthesia (control vs. local anesthesia: 5.16+/-0.11 vs. 5.62+/-0.10 mmol/l; p<0.01); however, plasma insulin concentrations did not change significantly. These results suggest that 1) ambulatory measurements of blood pressure and heart rate variability over 24 h cannot predict the responses of blood pressure during dental surgery, and that 2) administration of local anesthetic and tooth extraction activate sympathoadrenal outflow, resulting in an increase in serum glucose level in normotensive subjects.

Hypertension and abdominal pain: uncommon presentation after exposure to a pine caterpillar

The pine caterpillar Thaumatopoea wilkinsoni is found in pine woods all over Israel. Contact with its hair usually results in local reactions. Systemic reactions after contact with caterpillar hairs are known in other caterpillar species, but have been described only once after contact with T. wilkinsoni. We describe a group of adolescents who were exposed to T. wilkinsoni while camping in a pine wood. Three of them were referred to an emergency department. They had severe pruritus, pain and edema at the contact sites, with papular and urticarial rashes. Two of the patients had abdominal pain and one patient had hypertension for several hours. The hypertension resolved spontaneously.

CONCLUSION

Skin eruptions are the most common manifestations of T. wilkinsoni contact, however, although systemic manifestations are rare, abdominal pain and hypertension may occur.

Cardiovascular responses in patients and dentists during dental treatment

Changes in mean heart rate and in mean systolic and diastolic blood pressure are induced by both the patient's anticipation of scheduled treatment and the actual dental treatment. Most of these changes are within the normal physiological variations, but significant changes are observed before administration of a local anaesthetic, during subgingival debridement and during extractions. Individual changes in heart rate and blood pressure are affected by age, gender, hypertension and previous dental experience. Pain also plays an important role in the cardiovascular response during dental treatment, which stresses the need for adequate analgesia. For this purpose, local anaesthetics with low concentrations of epinephrine seem preferable. They induce less pronounced cardiovascular responses than local anaesthetics with higher concentrations of epinephrine or without epinephrine. The changes in heart rate and blood pressure that occur in the dentist during the treatment are also discussed.