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National Journal of Maxillofacial Surgery
 
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LETTER TO EDITOR
Year : 2015  |  Volume : 6  |  Issue : 1  |  Page : 132  

How safe is therapeutic dose of lignocaine with epinephrine: An overview


1 Department of Periodontology, Jodhpur Dental College and Hospital, Boranada, Jodhpur, Rajasthan, India
2 Department of Anaesthesiology, KGMC, Lucknow, Uttar Pradesh, India

Date of Web Publication26-Oct-2015

Correspondence Address:
Divya Kothari
Department of Periodontology, Jodhpur Dental College and Hospital, Boranada, Jodhpur, Rajasthan
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0975-5950.168230

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How to cite this article:
Kothari D, Abbas H. How safe is therapeutic dose of lignocaine with epinephrine: An overview. Natl J Maxillofac Surg 2015;6:132

How to cite this URL:
Kothari D, Abbas H. How safe is therapeutic dose of lignocaine with epinephrine: An overview. Natl J Maxillofac Surg [serial online] 2015 [cited 2019 Nov 15];6:132. Available from: http://www.njms.in/text.asp?2015/6/1/132/168230



Sir

Newer advancements in the dental care facility have helped the patients with severe systemic diseases to seek dental treatment. In addition to this, older age of an average periodontal patient increases the likelihood of underlying systemic diseases. The most reliable means of providing painless surgery is the effective administration of local anesthesia (LA), and profound infiltration of the local anesthetic agent is an essential fundamental factor for successful periodontal procedures.[1] Cardiovascular diseases are of major concern for the dentist since its pathological disturbances may produce alarming results. These conditions include hypertension, angina pectoris, myocardial infarction, previous coronary artery bypass graft surgery, previous cerebrovascular accidents, and congestive heart failure, presence of cardiac pacemakers or automatic cardiac cardioverter-defibrillators, and infective endocarditis.[2] The use of local anesthetic agents with vasoconstrictors in cardiac patients has been a matter of much debate. In 1964, a conclusion was drawn by the workshop-conference of the American Dental Association and the American Heart Association that vasoconstrictors were allowed for usage in LA without contraindications in patients with cardiovascular disease if administrated cautiously and with prior aspiration.

The commonly used dental cartridge contains 1.8 mL of (2% lignocaine) local anesthetic solution. In this cartridge, the concentration of epinephrine varies in concentration from 1:200,000 (5 µg/mL), 1:100,000 (10 µg/mL) to as high as 1:50,000 (20 µg/mL).[3] The maximum dose of LA with epinephrine is 7 mg/kg and concentration of LA used is 2% (20 mg/mL), thus the maximum volume of LA, which can be safely used, is 0.35 mL/kg. In an average 60 kg adult, the maximum volume of LA which can be used is 21 mL (0.35 mL/kg × 60 kg) or 11 cartridges. The 21 mL volume of LA (1:200,000) preparation will deliver 105 µg of epinephrine, 21 mL volume of LA (1:100,000) preparation will deliver 210 µg of epinephrine and (1:50,000) preparation of LA will deliver 420 µg of epinephrine, whereas maximum recommended dose of epinephrine per appointment in a dental patient is only 40 µg.[3] As higher dosage can produce systemic vasoconstriction leading to myocardial ischemia in high-risk cardiac patients, undergoing dental procedure.[4] Thus, for cardiac patients undergoing a dental procedure, the dose of LA which can be safely given with 1:50,000 epinephrine is 2 mL (40 µg/20 µg mL −1) with 1:100,000 is 4 mL (40 µg/10 µg mL −1) and with 1: 200,000 is 8 mL (40 µg/5 µg mL −1).

It has to be taken into consideration that safe upper limit of LA with epinephrine is 7 mg/kg (up to 21 mL for 60 kg body weight) but simultaneously, it will deliver very high concentration of epinephrine, which can cause detrimental effects; so, safe upper limit of LA with epinephrine to be used in cardiac patients is no more than 8 mL (4 cartridges) of 2% lignocaine with 1:200,000 epinephrine; 4 mL (2 cartridges) of 2% lidocaine with 1:100,000 epinephrine and only 2 mL (1 cartridge) of 2% lignocaine with 1:50,000 epinephrine should be used for any dental procedure for older adults with cardiovascular disease.[5] For patients with stabilized cardiovascular diseases, routine dental treatment may usually be delivered. However, patients with unstable cardiac condition dental care should be deferred until their medical conditions have been stabilized under the care of their physicians.

 
   References Top

1.
Figallo MA, Cayon V, Portillo GM. Use of anesthetics associated to vasoconstrictors for dentistry in patients with cardiopathies. Review of the literature published in the last decade. J Clin Exp Dent 2012;4:e107-11.  Back to cited text no. 1
    
2.
Brown RS, Rhodus NL. Epinephrine and local anesthesia revisited. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2005;100:401-8.  Back to cited text no. 2
    
3.
Davis B. What dose of epinephrine contained in local anesthesia can be safely administered to a patient with underlying cardiac disease during a dental procedure. J Can Dent Assoc 2010;76:112-4.  Back to cited text no. 3
    
4.
Jowett NI, Cabot LB. Patients with cardiac disease: Considerations for the dental practitioner. Br Dent J 2000;189:297-302.  Back to cited text no. 4
    
5.
Muzyka BC. Atrial fibrillation and its relationship to dental care. J Am Dent Assoc 1999;130:1080-5.  Back to cited text no. 5
    



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