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Dental Anesthesia

Local anesthetic reaction

12/09/2008

Question:

Since my first wisdom tooth extraction at 16 I have had a reaction to local`s with Epinephrine. I am now 55 and still have issues. I experience lower heart rate and black out. The first time the dentist gave me O2 till I recovered. Later in life a Plastic surgeon thought it was just in my head saying that I reacted to the treatment but the same thing happened, I watched the heart rate monitor drop from 80 to 45 in a less than a minute. The next procedure the same doctor performed he used a local without Epinephrine and I did not have any problems. The dentists are always bothered by the need to use a local without Epinephrine. What could be the problem?

Answer:

This reaction could occur if you were taking certain cardiac medications, called non-selective beta blockers, but I assume you might have mentioned your medical history if important as well as this occurring at age 16 when you probably wouldn't be taking this unless perhaps you had mitral valve prolapse?

The effect of epinephrine on the cardiovascular system is to increase systolic blood pressure and heart rate. Therefore, it is unusual that you would have a decrease in heart rate. This is commonly seen with injections if the patient is anxious, as syncope (fainting) leads to slow heart rates. I think this is what the plastic surgeon meant about this "being in your head". The thought was that the anxiety led to this.

If you are anxious, some patients have an overactive reflex that leads to slowing of the heart rate. This could be your case, especially if you are prone to fainting, even in the absence of obvious "stress".

The use of non-epinephrine containing local anesthetics is fine, especially in the lower jaw where up to 45 minutes of dental surgical anesthesia can be obtained with 3% mepivicaine, for instance. In the upper jaw, the duration of anesthesia is much shorter. You may ask your dentist to consider a low concentration local anesthetic like articaine or bupivicaine with 1:200,000 epinephrine if the procedure is much longer than 15 minutes. This is half the usual dose.

Additionally, a small amount of these solutions can be injected slowly, a few minutes can pass, and then additional local anesthetic can be slowly administered. This will limit the body uptake of the drug, and if this is an usual physiologic reaction, then the effects should be minimized.

You may also have a dentist anesthesiologist come to your dentist's office and monitor you and really figure out what is going on. You can find them at www.asdahq.org/. Problems with local anesthesia are fairly common.

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Response by:

Steven I Ganzberg, SB, DMD, MS Steven I Ganzberg, SB, DMD, MS
Formerly, Clinical Professor of Dentistry
College of Dentistry
The Ohio State University