––––––– Point of Care –––––
in reversing the 3 Hs are known, and HBOT has It is incumbent on all of us to stay current with
been recognized as the standard of care in the
dental profession for many years.
However, recent research and reports have
questioned this assumption. Some even go so far as
to suggest that HBOT may worsen the outcome.4-6
At major cancer treatment centres in the United
States (e.g., MD Anderson and Sloan Kettering),
large series of patients who have had dental ex-
tractions within the field of former cancericidal
radiation dosages without the use of HBOT have
not developed ORN. Currently, I am no longer
recommending preoperative HBOT for this group
of patients before extractions, implants or other
minor oral surgery.
In addition, all patients about to undergo head
and neck radiation therapy should have a dental
assessment, as this may go a long way toward pre-
venting problems in the first place. If teeth require
extraction, it would be best to do this before radia-
tion or within a few weeks of starting radiotherapy.
It is obviously important to ensure careful, clean
surgical technique. Sharp bony edges must be
smoothed, and primary soft tissue closure should
be achieved where possible without overreduction
of alveolar bone such that adjacent teeth or jaw
structure are compromised.
Should prophylactic antibiotics be used? It is
probably prudent to use antibiotics in this group
of patients, even though they would not be used
before simple extractions in the normal popula-
tion. Immediate preoperative chlorhexidine rinse
may be beneficial, but there is no evidence to make
this mandatory.
Cite this as: Question 2
J Can Dent Assoc
2010;76:a36 What dose of epinephrine contained in local anesthesia can be safely administered to a
patient with underlying cardiac disease during a dental procedure?
Background
E
pinephrine is commonly used in health care
and has multiple applications. Two frequent
and often life-saving uses are the manage-
ment of anaphylaxis and cardiac arrest. The word
has a Greek origin and literally means “on” (epi)
the “kidney” (nephros) referring to the anatomic
location (the adrenal gland) where the drug is
produced. Confusion still exists regarding the
112 JCDA • www.jcda.ca • 2010 • Vol. 76, No. 2 •
the literature, especially in terms of new develop-
ments that question previous recommendations
and accepted philosophies. This is not the first
time standards of care have been questioned, then
modified or completely rewritten. It is inherent in
science and part of what adds to the complexity of
and interest in our ever-changing profession. There
is considerable value in repeating experiments to
provide corroborating support to or question pre-
viously accepted theories and practices. a
THE AUTHOR
Dr. Archie Morrison is an associate professor in
the department of oral and maxillofacial surgery,
division of surgery, faculty of dentistry, Dalhousie
University, Halifax, Nova Scotia.
Email: archie.morrison@dal.ca
References
1. Marx RE. A new concept in the treatment of osteoradionecrosis.
J Oral Maxillofac Surg. 1983;41(6):351-7.
2. Marx RE, Johnson RP. Studies in the radiobiology of osteoradio-
necrosis and their clinical significance. Oral Surg Oral Med Oral
Pathol. 1987;64(4):379-90.
3. Curi MM, Dib LL. Osteonecrosis of the jaws: a retrospective
study of the background factors and treatment in 104 cases. J Oral
Maxillofac Surg. 1997;55(6):540-4; discussion 545-6.
4. Annane D, Depondt J, Aubert P, Villart M, Gehanno P, Gajdos
P, et al. Hyperbaric oxygen therapy for radionecrosis of the jaw:
a randomized placebo-controlled, double-blind trial from the
ORN96 study group. J Clin Oncol. 2004;22(24):4893-900. Epub
2004 Nov 1.
5. Maier A, Gaggl A, Klemen H, Santler G, Anegg U, Fell B, et
al. Review of severe osteoradionecrosis treated by surgery alone
or surgery with postoperative hyperbaric oxygenation. Br J Oral
Maxillofac Surg. 2000;38(3):173-6.
6. D’Souza J, Goru J, Goru S, Brown J, Vaughan ED, Rogers SN. The
influence of hyperbaric oxygen on the outcome of patients treated
for osteoradionecrosis: 8 year study. Int J Oral Maxillofac Surg.
2007;36(9):783-7. Epub 2007 Jul 5.
dose limits for epinephrine, particularly when the
drug is administered to patients with underlying
cardiovascular disease.
Epinephrine was first added to the local anes-
thetic ester, procaine, over 100 years ago. Like
the no-longer-used procaine, all currently avail-
able dental local anesthetics in North America
cause some degree of vasodilation. This vasodila-
tory effect poses several problems for the clinician:
 ––––––– Point of Care
bleeding is noted at the site of injection; absorption
of the anesthetic into the blood stream is rapid,
shortening the duration of effect; and the rapid ab-
sorption results in higher, potentially dangerous,
plasma levels. To overcome these disadvantages, a
vasoconstrictor is added to most local anesthetics,
with epinephrine being the most common.
The Effects of Epinephrine
The physiologic effects of epinephrine are num-
erous, as it is responsible for the “fight or flight”
response seen in all animals including humans.
The variation in response depends in part on the
number and predominant type of adrenergic re-
ceptors present in the target organ and on the
physiologic reflex response that attempts to mini-
mize the effects of sympathetic stimulation.
As an adjunct to anesthetic, the effect this drug
has on heart rate, stroke volume, cardiac output,
heart rhythm, myocardial oxygen demand and
peripheral vascular resistance must be appreci-
ated. Epinephrine’s effect on blood pressure de-
pends on the dose and route of administration.
Small doses or doses administered subcutaneously
may result in little or no change in blood pressure.
This is often due to the combination of a slight ele-
vation in systolic pressure and a lowering of dia-
stolic pressure, resulting in little change in mean
arterial pressure. Larger doses, particularly when
given intravascularly, can cause a rapid elevation
in blood pressure due primarily to peripheral
vasoconstriction. Epinephrine increases heart rate
and the force of ventricular contraction, which
ultimately increases cardiac output. The elevation
in cardiac workload increases myocardial oxygen
consumption. This is a concern in an individual
suffering from cardiac disease, particularly given
that the beneficial coronary vasodilatory effect of
epinephrine is diminished or absent in the pres-
ence of coronary vessel atherosclerosis. A further
risk to the cardiac patient is the ability of epi-
nephrine to irritate cardiac pacemaker cells and
cause dysrhythmias. Thus, the injudicious use of
epinephrine can be harmful to a patient with car-
diac disease.
Assessing the Patient
A history is crucial in determining which car-
diac patients are at particular risk during a dental
procedure. Patients with unstable coronary syn-
drome (unstable angina, recent myocardial infarc-
tion [MI]), decompensated heart failure, significant
dysrhythmia or severe valvular disease seem to
JCDA • www.jcda.ca • 2010 • Vol. 76, No. 2 • 113
–––––
be at particular risk from the effects of epineph-
rine. For these patients, elective dental treatment
should be postponed until their cardiac status
has been medically or surgically optimized.
Traditionally, a 6-month wait following an MI
was recommended before proceeding with non-
cardiac elective surgery to minimize the risk of
perioperative re-infarction and death. This recom-
mendation was adopted by dentistry even though
the myocardial demands and stress of dental pro-
cedures are thought to be considerably less than
those associated with the orthopedic, abdominal
and thoracic procedures for which the guidelines
were developed. More recently, a 4- to 6-week wait
following an MI has been suggested as adequate
when risk factors, such as smoking, hypertension
and dyslipidemia, are controlled and recent stress
testing has not indicated residual myocardium at
risk.1
For patients determined to be medically ca-
pable of undergoing general dentistry, pain con-
trol is essential, particularly in those with cardiac
disease. Pain and other stressors can result in a
dramatic endogenous release of epinephrine and
norepinephrine, which can affect the diseased
heart deleteriously. Although the importance of
good local anesthesia technique cannot be over-
emphasized, the addition of epinephrine to local
anesthetics improves both the depth and duration
of anesthesia. Thus, the use of some exogenous epi-
nephrine is beneficial in this group of patients, but
what is a safe dose in this at risk population? One
of the most frequently quoted suggestions is that of
Malamed 2 who recommended a maximum dose of
40 μg epinephrine per dental appointment in this
patient population.
Unfortunately, no current recommendation re-
garding the maximum amount of epinephrine that
can be safely administered to a cardiac patient
undergoing dentistry is based on sound scientific
evidence. Given the population and the risk of an
untoward event, ethical considerations likely pre-
clude a study to obtain such evidence.
Nevertheless, research has demonstrated that
the administration of local anesthesia containing
epinephrine does affect the heart. For patients re-
quiring emergent dental care who suffer unstable
cardiac disease (recent MI, unstable angina, cer-
tain dysrhythmias, significant valvular disease, de-
compensated heart failure), epinephrine should be
minimized and used with caution. These patients
are best managed by people specifically trained in
their assessment, monitoring and management.
 ––––––– Point of Care
For patients with “stable” cardiac disease, it is
still prudent to administer a minimal amount of
epinephrine while always avoiding intravascular
injections. Although pain control is of paramount
importance, the potentially deleterious effect of
epinephrine can be minimized by limiting the
amount to 40 μg. There is no evidence to support
exceeding this dose for such patients. This amount
is contained in 2 cartridges of 1:100 000 or 4 car-
tridges of 1:200 000 (there is little benefit from
using the 1:100 000 concentration of epinephrine
for routine dentistry). 3 Although the half life of
epinephrine is short, exceeding 40 μg epinephrine
per appointment cannot be recommended unless
the patient’s cardiac status is monitored continu-
ously during the procedure. a
Cite this as: Question 3
J Can Dent Assoc
2010;76:a37 How are odontogenic infections best managed?
Background
D
ental infections, including gingivitis, peri-
odontitis, dental caries and odontogenic
infections, result in numerous dental visits
each year in Canada. They can range in severity
from a mild buccal space infection to a severe
life-threatening multi-space infection. All dentists
should be comfortable with prompt diagnosis and
management of these types of infections. This re-
view of odontogenic infections describes causative
organisms, management including appropriate
antibiotic selection and the indications for referral
to a specialist.
Most odontogenic infections are caused by
more than 1 species of the bacteria normally found
within the oral cavity. Roughly 50% of odonto-
genic infections are caused by anaerobic bac-
teria alone, 44% by a combination of aerobic and
Table 1 Characteristics of the 3 stages of infection
Characteristic Inoculation
Duration (days) 0–3
Discomfort Mild
Palpation Soft, doughy
Pus None
Skin Normal
Severity Minimal
Bacterial species Aerobic
114 JCDA • www.jcda.ca • 2010 • Vol. 76, No. 2 •
–––––
THE AUTHOR
Dr. Ben Davis is associate professor in the depart-
ment of oral and maxillofacial sciences and head
of the division of oral and maxillofacial surgery,
Dalhousie University, Halifax, Nova Scotia.
Email: bdavis@dal.ca
References
1. Fleisher LA, Beckman JA, Brown KA, Calkins H, Chaikof EL,
Fleishmann KE, et al. 2009 ACCF/AHA focused update on periopera-
tive beta blockade incorporated into the ACC/AHA 2007 guidelines
on perioperative cardiovascular evaluation and care for noncardiac
surgery: a report of the American college of cardiology founda-
tion/American heart association task force on practice guidelines.
Circulation. 2009;120(21):e169-276. Epub 2009 Nov 2.
2. Pharmacology of vasoconstrictors. In: Malamed SF, editor.
Handbook of local anesthesia. 5th ed. St. Louis: Elsevier Mosby;
2004. p. 41-54.
3. Becker DE, Reed KL. Essentials of local anesthetic pharmacology.
Anesth Prog. 2006;53(3):98-108.
anaerobic bacteria and only 6% by aerobic bac-
teria alone.1 The most common species of bacteria
isolated in odontogenic infections are the anaer-
obic gram-positive cocci Streptococcus milleri
group and Peptostreptococcus.2 Anaerobic gram-
negative rods, such as Bacteroides (Prevotella) also
play an important role. Anaerobic gram-negative
cocci and anaerobic gram-positive rods have little
effect.2
Odontogenic infections progress through 3
stages: inoculation, cellulitis and abscess (Table 1).3
Bacteria gain entrance to the surrounding facial
spaces by direct extension from the periapical re-
gion of the involved tooth. The pattern of spread is
predictable depending on the relationship between
the point of attachment of the adjacent muscle and
the tooth apex.4
Cellulitis Abscess
2–5 4–10
Severe, diffuse Mild, localized
Firm, indurated Fluctuant, tender
None Present
Red Red periphery
Greater Less
Mixed Anaerobic