The Effect of Topical Epinephrine on Cardiovascular Outcomes in Children Receiving Prefabricated Zirconia Crowns: A Randomized Controlled Trial

Abstract

The Effect of Topical Epinephrine on Cardiovascular Outcomes in Children Receiving Prefabricated Zirconia Crowns: A Randomized Controlled Trial Purpose: Topical racemic epinephrine has been used widely in dentistry to achieve rapid hemostasis. However, no well-designed clinical trials have assessed the cardiovascular effects of topical epinephrine on gingival tissue in a pediatric population. The purpose of this study was to determine if topical application of racemic epinephrine pellets affects heart rate, blood pressure, and mean arterial pressure in children receiving dental care under general anesthesia. The hemostatic effect of the pellets was also assessed. Methods: Otherwise healthy pediatric patients between the ages of 2 to 9 years who had carious lesions requiring prefabricated zirconia crowns on both primary maxillary first molars were recruited into a split-mouth randomized controlled pilot study. For the purpose of randomization, each patient’s oral cavity was divided into left and right sections. We first randomized the control to the right side of the mouth and this was maintained for all participants. The second randomization step determined the sequence by which the treatment was applied, determining whether control or intervention treatment was done first. Under general anesthesia, teeth were prepared for zirconia crowns. After preparation in the control treatment, two saline saturated pellets were applied directly to gingival tissue for 1 minute with gauze pressure. For the intervention treatment, two racemic epinephrine pellets were applied in a similar manner as the control treatment. Heart rate and blood pressure measurements were recorded at baseline and at 1-minute intervals for 5 minutes after placement. The adequacy of hemostasis was determined during the 1-minute intervals subjectively by the operating dentist as “adequate” or “inadequate”. Results: Comparison within the control group showed a statistically significant decrease in baseline heart rate over the 5-minute observation period, with no significant changes in diastolic blood pressure and mean arterial pressure. Comparison within the intervention group showed a statistically significant decrease in heart rate, diastolic and systolic blood pressure and mean arterial pressure over 5 minutes. There was a statistically significant difference between control and intervention baseline and 5-minute post-intervention mean diastolic blood pressure (-11.1% vs. -3.9%, p<0.01) and mean arterial pressure (-8.1% vs. 2.1%, p<0.01). There was no significant difference between mean heart rate (-4.1% vs. 2.9% p=1.13) and systolic blood pressure (-2.7% vs. -3.1%, p=0.50) for the control and intervention groups. All 13 of the intervention-treated teeth reached adequate hemostasis after an average of 2.2 ± 1.1 min. Meanwhile, only 5 out of the 13 control-treated teeth reached adequate hemostasis over the 5-minute observation, and it was achieved after 4.2 ± 0.8 min. The difference was statistically significant (P<0.01). Conclusion: This pilot randomized controlled trial showed no statistical difference in mean heart rate and systolic blood pressure and a statistically significant decrease in mean diastolic blood pressure and mean arterial pressure when using racemic epinephrine hydrochloride pellets compared to saline pellets. The clinical effects of the cardiovascular measures, however, were similar between the two interventions. Additionally, hemostasis was reached more predictably and in a shorter time period using racemic epinephrine hydrochloride pellets.