Which modification is appropriate for a patient with peripheral vascular (circulatory) disease?

Correct answer: D. Limit or avoid epinephrine in the local anaesthetic

• A. A rubber dam has no bearing on peripheral circulation and remains indicated.
• B. NSAIDs are not categorically contraindicated in peripheral vascular disease, although they warrant caution in patients with concurrent renal impairment, hypertension or anticoagulation.
• C. This patient does require consideration, principally around their antiplatelet or anticoagulant therapy.
• D. CORRECT as the keyed answer. Vasoconstrictors reduce peripheral perfusion, and in a patient whose peripheral circulation is already compromised this is a reasonable concern. Use the minimum effective dose, aspirate carefully, and avoid intraligamentary or intraosseous injection where the concentrated local vasoconstriction is greatest.

Note: ⚑ Balance this one carefully. Standard dental doses of epinephrine — 2 to 3 cartridges of 1:100,000 — are generally well tolerated even in cardiovascular disease, and inadequate anaesthesia causes an ENDOGENOUS catecholamine surge that is far larger than the injected dose. The more consequential issue in these patients is usually their antiplatelet or anticoagulant regimen and their bleeding risk. Do not withhold effective anaesthesia out of excessive caution.