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Year : 2013  |  Volume : 31  |  Issue : 1  |  Page : 10-16

Hemodynamic, ventilator, and ECG changes in pediatric patients undergoing extraction

1 Department of Medicine, Jhalawar Hospital and Medical College, Jhalawar, India
2 Department of Public Health Dentistry, Pacific Dental College and Hospital, Udaipur, Rajasthan, India
3 Department of Oral Pathology, Pacific Dental College and Hospital, Udaipur, India

Date of Web Publication27-May-2013

Correspondence Address:
Y K Sanadhya
Asisstant Professor, Department of Medicine, Jhalawar Hospital and Medical College, N.H.-12, Kota Road, Jhalawar, Rajasthan
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0970-4388.112393

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Background: Dental treatment induces pain anxiety and fear. This study was conducted to assess the changes in hemodynamic, ventilator, and electrocardiograph changes during extraction procedure among 12-15-year-old children and compare these changes with anxiety, fear, and pain. Materials and Methods: A purposive sample of 60 patients selected based on inclusion and exclusion criteria underwent study procedure in the dental OPD of a medical college and hospital. The anxiety, fear, and pain were recorded by dental anxiety scale, dental fear scale, and visual analogue scale, respectively, before the start of the procedure. The systolic blood pressure, diastolic blood pressure, heart rate, oxygen saturation, and electrocardiogram changes were monitored during the extraction procedure. The recording was taken four times (preinjection phase, injection, extraction, and postextraction) and was analyzed. Results: At the preinjection phase the mean vales were systolic blood pressure (128 ± 11.2), diastolic blood pressure (85.7 ± 6.3), heart rate (79.7 ± 9.3), and oxygen saturation (97.9 ± 5.8). These values increased in injection phases and decreased in extraction phase and the least values were found after 10 min of procedure and this relation was significant for all parameters except oxygen saturation (P = 0.48, NS). ECG abnormalities were seen among 22 patients and were significant before and after injection of Local anesthetic (P = 0.0001, S). Conclusions: Anxiety, fear, and pain have an effect on hemodynamic, ventilator, and cardiovascular parameters during the extraction procedure and hence behavioral management has to be emphasized among children in dental clinics.

Keywords: Anxiety, blood pressure, dental anxiety scale, dental fear scale, electrocardiograph, fear, heart rate, oxygen saturation, pain

How to cite this article:
Sanadhya Y K, Sanadhya S, Jalihal S, Nagarajappa R, Ramesh G, Tak M. Hemodynamic, ventilator, and ECG changes in pediatric patients undergoing extraction. J Indian Soc Pedod Prev Dent 2013;31:10-6

How to cite this URL:
Sanadhya Y K, Sanadhya S, Jalihal S, Nagarajappa R, Ramesh G, Tak M. Hemodynamic, ventilator, and ECG changes in pediatric patients undergoing extraction. J Indian Soc Pedod Prev Dent [serial online] 2013 [cited 2022 Nov 27];31:10-6. Available from: http://www.jisppd.com/text.asp?2013/31/1/10/112393

   Introduction Top

Monitoring is defined as the global methods of observation and data recording in relation to the body organ and system function that afford constant information to ensure continuous evaluation of the patient's physical condition. Basic monitoring provides essential information for assessing the principal vital signs, both circulatory and respiratory, and fundamentally comprises the control of blood pressure (BP) (through sphygmomanometer), heart rate (HR), and rhythm. Pulse oximetry is used to record HR and oxygen saturation (SaO 2 ). [1] Electrocardiographs (ECGs) have been used to monitor the electrical activity of the heart for many years and are still routinely used in many situations. They are rarely used in routine outpatient dental practice. [2]

Pain is a highly complex and multidimensional phenomenon that energizes the organism, regardless of real or apparent tissue damage, to take action in relieving and alleviating its presence. [3] It is important to acknowledge that the pain sensation may be necessarily dependent on tissue damage; it may be generated by the conditional stimuli such as the sound of the drill or a gentle touch of the needle during injections. [4] There is a strong relationship between a child's dental anxiety and successful dental treatment, [5] and also between anxiety and pain. [6] Painful conditions cause fear, whereas fear and anxiety increases the amount of perceived pain. [6]

The pain due to dental origin or during dental treatment may induce hemodynamic changes in a patient. Anxiety may be defined as either a cognitive, emotional, and physical reaction to a dangerous situation or the anticipation of a threat. [3] Pain and anxiety triggered by dental treatment can induce the secretion of endogenous catecholamines. When the situation is combined with local anesthetics and vasoconstrictors use, it may increase its undesirable effects on the cardiovascular system. [7],[8],[9],[10],[11],[12] Some authors have reported significant increases (5-12 mmHg) in systolic blood pressure in patients subjected to root scaling and planning using anesthesia with a vasoconstrictor. [13] The potential effect of local anesthetic on cardiac rhythm has also been reported in the literature. Moreover, the anxiety associated with both minor surgery and the injection of local anesthetic may induce a catecholamine surge that could increase myocardial oxygen demand and may be arrhythmogenic. [2]

The literature search shows scant study done on adults and no studies were reported in pediatric patients on hemodynamic and ECG changes during extraction of teeth. Hence, this study was done with an aim to record the hemodynamic and ECG changes in pediatric patients undergoing extraction of teeth. The objectives were to note any gender variations in changes, as well degree of fear and anxiety on these changes.

   Materials and Methods Top

This was a descriptive cross sectional double blinded study done on children of 12-15 year old attending the dental OPD of Jhalawar Medical College and Hospital, Jhalawar, Rajasthan. Informed consent was obtained from the parents and ethical approval for the study was taken from Institutional ethical committee.

A sample of 60 patients in the age group of 12-15 years was calculated based on the pediatric OPD of dental wing by purposive sampling. Patients reporting to the dental OPD of medical college with chronic apical periodontitis, chronic periapical abscess requiring extraction under the mandibular block where included in the study. Patients having any acute symptoms for whom tooth extraction was found to be unfeasible at the time of the scheduled procedure. Patients suffering from any systemic diseases, psychiatric illness, any drug abuse, unco-operative, traumatic dental history and who did not give informed consent were excluded from the study.

Before surgery, in the waiting room, patients completed a questionnaire to evaluate preoperative dental anxiety using using Corah's Dental Anxiety scale (DAS) [14],[15] and fear by Kleinknecht's dental fear scale (DFS). [16] Detailed dental and medical history was assessed. Four questions to check DAS based on different feelings concerning dental consultation were asked. Each question has five possible answers, ranging from (a) = 1 {no anxiety} to (e) = 5 (high anxiety). Therefore, the possible score ranges from 4 to 20. Anxiety is considered low when scores are equal to or less than 6, moderate with scores between 7 and 12, and high with scores equal to or greater than 13. The DFS comprises of 20 questions scored from 0 to 5. The pain was assessed by a scale from 0 to 2, whereas grade 0 means no pain, grade1 means tolerable pain and grade 2 means unbearable pain.

The hemodynamic and ventilatory changes were evaluated by monitoring systolic pressure (SP), diastolic pressure (DP), heart rate (HR), and oxygen saturation (SaO2) by a well trained and calibrated first investigator. A pulse oximetry and a blood pressure cuff (sphygmomanometer) were used to monitor the hemodynamic changes and these instruments were calibrated before recording in every patient. These values were collected at four moments; before commencing procedure (baseline value), during local anesthetic injection, during extraction, and 10 min after extraction. Standard 12-lead ECG recordings were made at the screening visit, during administration of Local anesthesia (LA), during extraction procedure and 10 min postoperatively. Tracings were performed in each of the patients with the use of a 12-lead ECG and a 2-min rhythm strip was recorded. The ECGs were carried out and analyzed by the investigator.

After completion of the forms the every patient was taken to same dental chair and same operator (author 2 and 3) handled the patient for dental procedures. Local anesthesia was administered after resting for 10 min; the mandibular nerve block was achieved with the same dosage of local anesthesia solution (1.5 mL of 2% lidocaine with 1:100000 epinephrine). The patients were asked to rest for another 15 min before the dental extraction begin. The monitoring procedures were standardized by keeping the cuff on patients left arm and maintaining the patient in supine position. Patient was asked to grade the severity of pain before LA, after LA and during extraction on a visual analog scale from 0 to 2.

Data was analyzed using SPSS version 11 (SPSS Inc, Chicago, IL) software. A univariate descriptive analysis was made expressing the results as percentages and frequencies. Statistical significance was considered for P values less than 0.05 in all cases. Kruskal Wallis and ANOVA (analysis of variance) test was used to compare the variables at different time intervals. Age and gender were analyzed with Pearson's correlation.

   Results Top

Sixty patients ranging in age from 12 to 15 years (mean 13.2 ± 2.5 years) were evaluated. Thirty six (60%) patients were male. Patients with severe dental anxiety tended to be younger than those with mild and moderate dental anxiety (P = 0.0028, S). The mean DAS score was 15.4 ± 3.2 in girls and 12.1 ± 1.4 in males. A significant relation was found between anxiety levels and reported pain at baseline (P = 0.0001, S). The overall mean DFS score was 2.5 ± 1.5 (girls: 3.4 ± 1.2, boys: 2.3 ± 1.4). The girls showed higher levels of dental anxiety and fear with significantly higher mean scores (P = 0.03, S, P = 0.006, S).

[Figure 1] shows the mean SBP, DBP, HR, and SaO 2 values recorded at different time interval. Significant changes were observed with SBP (P = 0.0001, S), DBP (P = 0.03, S) and HR (P = 0.007, S) when compared for four different times during the extraction procedure. However, not much variation was seen for SaO 2 at different time intervals (P = 0.48, NS). The SBP, DBP, and HR were highest during the LA injection followed by during extraction, pre procedure and after 10 min of extraction. [Table 1] shows the hemodynamic and ventilatory values in relation to preoperative anxiety and gender. A higher preoperative patient anxiety was associated with highest HR, SaO 2 and lowest SBP and DBP. Boys showed higher SBP and DBP values than girls. [Table 2] shows the changes associated with fear. High fear was associated with high SBP, DBP, HR, and SaO 2. Girls showed significantly higher values than boys. Patients with mild anxiety had a lower heart rate (82 ± 4.5 bpm) during anesthetic delivery than those with moderate (84 ± 4.1 bpm) and severe (93 ± 4.6 bpm) anxiety.
Figure 1: Mean systolic blood pressure (sdp), diastolic blood pressure (dbp in mm of Hg), Heart rate (HR in beats/ min) and oxygen saturation (sao2) during the phases of extraction procedure.

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Table 1: Hemodynamic and ventilatory values in relation to preoperative anxiety and gender

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Table 2: Hemodynamic and ventilatory values in relation to preoperative fear and gender

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Repeated measures ANOVA showed a significant association between heart rate and level of anxiety (mild: P = 0.0001, S, moderate: P = 0.0001, S, severe: P = 0.011, S). The mean baseline value of oxygen saturation during the rest period in the dental chair was higher in patients with severe dental anxiety. In mild group it did not change significantly (P = 1.666, NS); however, in the moderate group, O 2 saturation declined steadily during LA and extraction procedure. The mean change was not significant in mild, moderate and severe dental anxiety groups and same results were shown with fear groups. (DAS: P = 0.08, NS; DFS: P = 2.44, NS). [Table 3] shows the significant differences found in heart rate and other hemodynamic changes with different levels of pain at different time intervals. Patients with high DFS score were experiencing high pain when compared to other groups and was found to be significant (P = 0.006, S).
Table 3: Average systolic, diastolic blood pressure (BP, in mm Hg), Oxygen saturation (SaO2) and heart rate (in beats/min) of patients in different time intervals during the procedure

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Of the 60 patients studied, the ECGs were considered to show minor abnormalities in 22 patients [Table 4]. The correlation of ECG results with anxiety before and after local anesthesia showed significant change between patients with different levels of anxiety from baseline to after 10 min of extraction. Abnormal findings of ECG such as tachycardia developed during local anesthetic delivery in 1%, 6%, and 20% of patients in mild, moderate, and severe groups respectively and there was a significant difference between groups. (baseline: P = 0.07, NS; LA procedure: P = 0.0002, S; surgical procedure: P = 0.04, S; after extraction: P = 0.16, NS). Ventricular premature contracture and atrial fibrillation were noted in only a few patients (0-10%) but did not vary significantly between the anxiety groups.
Table 4: Number of subjects with ECG abnormalities during the procedure

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   Discussion Top

The anticipation of forthcoming dental treatment induces a physiologic stress response in patients that manifests in corticoid release, blood pressure change, and hemodynamic and cardiovascular reactions. The effect of psychological factors in dental anesthesia remains to be clearly established. [8] Anxiety is a phenomenon prevalent in dental practice and dental anxiety has a complex etiology that involves many factors. [17],[18] The valid comparisons with other studies could not be done for this present study due to lack of studies in children (12-15 years) and use of different scales for accessing anxiety. The literature search shows studies on adults for hemodynamic, ventilatory, and cardiovascular changes.

In this study, patients in the severe dental anxiety group were also younger than the patients in the mild and moderate groups, a finding consistent with several other studies on dental anxiety among adults. [18],[19],[20] Although increased anxiety in younger patients may be partly due to lack of experience and familiarity with dental care, these impacts are relatively difficult to assess. It is hypothesized that patients are less likely to develop dental anxiety if they have received the prior conditioning of a number of relatively painless treatment. [21] The present finding that patients in the high anxiety group were younger may also lend support to the effects of prior conditioning on dental anxiety.

During the rest period before the administration of anesthetic, the DAS score was significantly associated with blood pressure and heart rate. The difference in heart rate from severe to mild dental anxiety was around 12 bpm and this was much greater than in an earlier study [22] but lesser than another study. [23] This discrepancy may have been due to different definitions about dental anxiety or differences in study designs as well as the different age groups. It has been proved that the average increase in both the systolic and the diastolic blood pressure was higher in children [24] than in adults. [25]

After the delivery of local anesthesia in this study, the mean systolic and diastolic blood pressure, heart rate in the severe dental anxiety group increased significantly. An insignificant change in O 2 saturation was also found at the time of anesthetic agent delivery. The lack of significance of this change may have been due to limited dose of LA agent given or the small sample size of the severe anxiety group. In this study, the DAS score was correlated with the increase heart rate after anesthetic administration. This finding suggests that a stronger anticipatory response to stressful events, which can be measured by DAS, may result in increased heart rate and systolic and diastolic blood pressure. The association of emotional stress and fear with the enhanced sympathetic activity, of tachycardia with increased plasma concentrations of epinephrine or norepinephrine, [26] or both are possible mechanism that may explain these effects. Hemodynamic changes caused by emotional stress mask those due to exogenously active catecholamines and that an abrupt relative deficiency of epinephrine, known as epinephrine collapse, may occur after stress. [7]

In this study, patients with severe dental anxiety and fear had a far greater heart rate response to the administration of local anesthetic. Efforts to identify such patients through subjective screening by the dentist may be problematic, because high levels of dental anxiety were not always reflected in patient's behavior in the dental office. [15] Attempts to assess patient anxiety subjectively during preoperative sessions were not necessarily useful because patients who appeared calm or who claimed to be without anxiety during dental procedure may show signs of significant physiologic stress when monitored electronically. [27],[28] Previous dental experience has a varied effect on anxiety, fear and perception of pain as also suggested by other authors in 2-5 year old [19],[29] ; however, no difference was observed on sequential visit among 8-14-year old. [30]

Previous studies on ECG changes among adults during local anesthesia delivery and oral surgery found incidences of abnormal ECG changes in 15-37.5% of patients. [31],[32],[33] In the present study, 36.7% 12-15-year old patients showed ECG changes within physiological limits. The discrepancies of types of dysrhythmias in ECG findings between earlier studies and this study may be due to difference in study populations, dosage of LA used and mainly due to children age group of subjects in our study. Physiologic and psychologic stresses associated with the administration of intraoral local anesthesia and the extraction procedure is capable of provoking acute rhythm disturbances in a significant percentage of patients. The abnormal rhythms observed were premature ventricular premature beats (n = 1 patients), atria1 fibrillation (n = 6), premature atria1 contractions (n = 1), and ventricular tachycardia (n = 8) [Table 4]. RBBB pattern with broad QRS (180 mm) and T-wave inversion can be associated with Brugada syndrome but is more likely to be related to the stress of surgery or the medication. Minor sinus bradycardia was noticed in two patients but this was unlikely to be of clinical importance in the absence of symptoms and was unrelated to any medication. An acute injury pattern with marked ST elevation (>5-8 mm) in V2 and 2-3 mm in V1 was observed and this had completely resolved 1 h later.

Pain causes an alarm reaction manifested by hypothalamus oriented vasoconstriction and dilatation as well as the release of more epinephrine and norephinephrine, this result in increased heart rate and cardiac output. In addition, pain may cause blood pressure to rise due to the release of endogenous catecholamines that was also seen in our study. We concur with other investigators [30],[34],[35],[36],[37] that the moment of LA administration and the moment of dental avulsion is the most stressful phase of the surgical procedure. The BP measurements were always higher at the start of the surgical procedure than at the end of the procedure, this could be explained by endogenous adrenalin release caused by patients anxiety or fear associated with visiting the dentist also due to white coat phenomenon. [22] In agreement with our observations, other studies have reported that the pain perception is lower in females than in males, although boys tend to suppress their anxiety and fear more than girls.

The attenuation of stress with anxiolytics or sedation can be used to reduce the cardiovascular response associated with patient anxiety, all though in these cases dentist mediated patient behavioral control plays a fundamental role. Anxiety and fear play an important role in the pain perception of children, hemodynamic, ventilator, and cardiovascular changes as observed in the present study. Hence, anxiety control through behavioral management techniques should be supported and encouraged for pain free dental injections in children.

   Acknowledgement Top

I thank the subjects and their parents for the co-operation in the study.[38]

   References Top

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  [Figure 1]

  [Table 1], [Table 2], [Table 3], [Table 4]

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