Question

Are there any contraindications to the use of vasopressors in dental patients?

Question

Often medical consultants recommend against inclusion of a vasopressor in a local anesthetic for a cardiovascular risk patient. Why? And what can I do to achieve effective pain control?

As indicated, there are several instances in which it is prudent to avoid the use of vasopressors in local anesthetics. Most of these situations (e.g., severely elevated, untreated high blood pressure; severe cardiovascular disease) also represent absolute contraindications to elective dental care because of greater potential risk to the patient. If a dental patient with cardiovascular disease is deemed treatable (ASA 2 or 3), then local anesthetics for pain control are indicated. The patient’s physician often states that, although local anesthetics can be used, epinephrine should be avoided.

Question

When should epinephrine be avoided?

One of the few valid reasons for avoiding epinephrine is the patient with cardiac rhythm abnormalities that are unresponsive to medical therapy. The presence of dysrhythmias (especially ventricular) usually indicates an irritable or ischemic myocardium. Epinephrine, exogenous or endogenous, further increases myocardial sensitivity, thereby predisposing this patient to a greater frequency of dysrhythmias or to more significant types of dysrhythmias, such as ventricular tachycardia or ventricular fibrillation. In these patients, epinephrine-containing local anesthetics should be avoided, if at all possible. However, many cardiologists today do not even consider the ischemic myocardium a valid reason for excluding vasoconstrictors from local anesthetics, provided the dose of epinephrine administered is minimal and intravascular administration is avoided.

It is my recommendation that with a patient who is deemed able to tolerate the />