J Oral Maxillofac Surg 66:453-461, 2008

Hemodynamic Changes During the Surgical Removal of Lower Third Molars

Aurelia Alemany-Martnez, DDS,* Eduard Valmaseda-Castelln, DDS, PhD, Leonardo Berini-Ayts, DDS, MD, PhD, and Cosme Gay-Escoda, DDS, MD, PhD
Purpose: This study was conducted to determine the hemodynamic changes in healthy patients during

the surgical removal of lower third molars, and to evaluate whether these variations are attributable to patient anxiety and pain experienced during the surgical procedure. Patients and Methods: A prospective study was made of 80 normotensive individuals (40 females and 40 males, mean age, 27 years [range, 18 to 67 years]) seen in the Service of Oral Surgery in the context of the Masters Degree Program in Oral Surgery and Implantology, School of Dentistry, University of Barcelona, for surgical extraction of the lower third molars. Local anesthesia comprised 4% articaine with vasoconstrictor (adrenalin 1:100.000). The following parameters were monitored in each of the surgical interventions: systolic blood pressure (SBP), diastolic blood pressure (DBP), heart rate (HR), and oxygen saturation (SaO2). Finally, tests of patient anxiety (Corahs Dental Anxiety Scale and Kleinknechts Dental Fear Scale) were carried out, and the degree of pain experienced during the surgical procedure was assessed by means of a visual analog scale. Results: The females showed higher levels of anxiety. The most anxious patients had the lowest BP values and the highest HR, although the differences did not reach statistical signicance. The variations in BP and HR during surgical extraction of the molars were within normal limits. In the case of BP, no signicant changes were recorded; the highest mean SBP and DBP values were observed at the time of ostectomy and/or tooth sectioning. The lowest HR values were recorded at baseline, before the start of the surgical procedure, whereas the highest values were obtained during incision and ap raising. The SaO2 values showed no signicant changes and were lower at the start of the surgical procedure. Conclusions: Most of the cardiovascular changes induced by the surgical extraction of molars were within normal ranges, considering the anxiety and stress induced by surgery. We consider it essential to avoid pain and minimize patient anxiety to ensure safe clinical practice. 2008 American Association of Oral and Maxillofacial Surgeons J Oral Maxillofac Surg 66:453-461, 2008 Monitoring is dened as the global methods of observation and data recording in relation to body organ and system function that afford constant information to ensure continuous evaluation of the patients 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 sphygmomanome*Fellow of Oral Surgery and Implantology, School of Dentistry, University of Barcelona, Barcelona, Spain. Associate Professor of Oral Surgery, Professor, Masters Degree Program in Oral Surgery and Implantology, School of Dentistry, University of Barcelona, Barcelona, Spain. Dean, Professor of Oral and Maxillofacial Surgery, Masters Degree Program in Oral Surgery and Implantology, School of Dentistry, University of Barcelona, Barcelona, Spain. Chairman and Professor of Oral and Maxillofacial Surgery, Di-

try) and heart rate (HR) and rhythm. Pulsioxymetry is used to record HR and oxygen saturation (SaO2).1 Patient monitoring during the surgical extraction of molars is advisable when the surgical procedure is expected to be traumatic or if the patients psychological condition makes such control desirable to optimize safety. Monitoring during oral surgery allows the surgeon to immediately identify situations of inrector, Masters Degree Program in Oral Surgery and Implantology, School of Dentistry, University of Barcelona; and Surgeon, Oral and Maxillofacial Surgery, Teknon Medical Center, Barcelona, Spain. Address correspondence and reprint requests to Dr Gay-Escoda: Centro Mdico Teknon, Vilana 12, 08022 Barcelona, Spain; e-mail: cgay@ub.edu
2008 American Association of Oral and Maxillofacial Surgeons

0278-2391/08/6603-0006$34.00/0 doi:10.1016/j.joms.2007.06.634

453

454

HEMODYNAMIC CHANGES IN LOWER THIRD MOLAR REMOVAL

creased risk before the surgical procedure, establish an early diagnosis and prevent possible complications, and operate with increased safety.2 The 3 principal advantages of monitoring are the ability to detect, evaluate, and prevent emergency situations in clinical practice.3 The vasoconstrictors and local anesthetics commonly used in oral surgery can induce hemodynamic changes during the surgical extraction of molars in the same way as other factors, such as patient anxiety or stress. The adrenalin added to the anesthetic solution is used in oral surgery to increase the potency and duration of anesthesia, reduce the plasma concentrations of the anesthetic, and improve local control of bleeding. Its use has been criticized due to the risk of possible massive systemic absorption of the drug, resulting in undesirable cardiovascular effects.4 The anxiety and stress produced by pain during dental treatment also induce the secretion of endogenous catecholamines, which likewise exert undesirable effects on the cardiovascular system.5,6 Articaine at a concentration of 4% with adrenalin at a concentration of 1:100.000 administered at reasonable doses exerts no important effect on BP, HR, or SaO2. Patient stress or fear associated with different moments of the surgical procedure can induce signicant variations in these variables.7 The increased BP occurring during surgical treatment is not dependent on whether or not the anesthetic solution contains a vasoconstrictor; rather, it appears to be attributable to anxiety or other factors inherent to the patient.8 In the present study, we studied the changes in BP, both systolic (SBP) and diastolic (DBP), and HR occurring in the course of the surgical extraction of lower third molars in normotensive patients when using 4% articaine as a local anesthetic and adrenalin 1:100.000 as a vasoconstrictor. We evaluated the inuence of patient gender and the degree of dental fear and anxiety on these changes.

Table 1. DIFFICULTY OF THIRD MOLAR EXTRACTION, BASED ON THE CLASSIFICATIONS OF PELL AND GREGORY AND OF WINTER

Spatial Relationship 1 2 3 4 mesioangular horizontal/transverse vertical distoangular

Depth 1 level A 2 level B 3 level C

Available Space 1 Class I 2 Class II 3 Class III

Level of difculty: 3 to 4, minimal; 5 to 6, moderate; 7 to 10, very difcult. Spatial relationship: The position of the third molar with respect to the major axis of the second molar. Depth: In level A, the highest point of the impacted tooth lies above or at the same level as the occlusal surface of the second molar. In level B, the highest point is below the occlusal line but above the cervical line of the second molar. In level C, the highest point lies at or below the level of the cervical line of the second molar. Available space: In Class I presentations, the space between the ascending ramus of the mandible and the distal part of the second molar sufces to accommodate the entire mesiodistal diameter of the crown of the third molar. In Class II presentations, it is less than the mesiodistal diameter of the crown of the third molar. In Class III presentations, all or almost all of the third molar lies within the ascending ramus of the mandible. Alemany-Martnez et al. Hemodynamic Changes in Lower Third Molar Removal. J Oral Maxillofac Surg 2008.

Patients and Methods

Between October 2004 and December 2005, a prospective study was made of 80 healthy and normotensive patients (40 females and 40 males). The study subjects were selected according to convenience from among the patients seen in the Service of Oral Surgery, Masters Degree Program in Oral Surgery and Implantology, School of Dentistry, University of Barcelona, for surgical extraction of the lower third molars. For each patient, a complete case history was compiled, including completion of a basic health questionnaire, to evaluate the patients general condition. Patients with decompensated systemic diseases contraindicating or impeding dental treatment were excluded from the study, as were those who had arterial hypertension or were receiving medication capable

of interacting with the drugs contained in the anesthetic solutions used. In terms of the inclusion criteria, all selected patients required an ostectomy in the context of the surgical intervention. The difculty of molar extraction was minimal to moderate, as assessed using the classications of Pell and Gregory9 and Winter10 (Table 1). The surgical interventions lasted more than 15 minutes and less than 45 minutes from the time of incision, and in all cases local anesthesia consisted of 4% articaine with a vasoconstrictor (adrenalin 1:100.000). Each patients degree of dental-related fear and anxiety was evaluated before the surgical procedure, applying Corahs Dental Anxiety Scale (DAS) (Fig 1)11 and Kleinknechts Dental Fear Scale (DFS) (Fig 2).12 The maximum DAS score is 20; a score exceeding 12 is considered to indicate intense anxiety. The DFS comprises 20 questions scored from 0 to 5. Intraoperative pain was assessed with a visual analog scale at the end of treatment (Fig 3). The hemodynamic changes were evaluated by monitoring SBP, DBP, HR, and SaO2 using a Guardian BPM-730 M monitor (Megos-Sonmdica, Barcelona, Spain) (Fig 4). Both HR and SaO2 were registered every minute during the rst 10 minutes after local anesthetic injection. All the variables were recorded on 9 occasions: before starting the surgical procedure (baseline value), 1 minute and 4 minutes after local anesthetic injection, during the incision, at the time of ostectomy and/or tooth sectioning, at the completion

ALEMANY-MARTNEZ ET AL

455

FIGURE 1. Corahs Dental Anxiety Scale (DAS). Alemany-Martnez et al. Hemodynamic Changes in Lower Third Molar Removal. J Oral Maxillofac Surg 2008.

of tooth removal, at the start and completion of suturing, and nally, during removal of the surgical drapes (Table 2). Before local anesthesia, the surgical eld was isolated using sterile, impermeable drapes, leaving only the nose and mouth of the patient exposed. The anesthetic technique was that typically used for the surgical extraction of a lower third molar: truncal block of the inferior alveolar and lingual nerves, with inltration of the buccal nerve and surgical zone.13 In all patients, less than 5.4 mL (3 carpules) of anesthetic solution was used. All surgical

removals were performed by the same dental surgeon (AAM). After anesthesia administration and surgical eld preparation, an incision was made in the region of the retromolar trigone in the gingivodental sulcus of the second molar, with a releasing incision mesial to the latter and the raising of a triangular mucoperiosteal ap. Ostectomy and tooth sectioning were then carried out, if the latter proved necessary. The third molar was then removed, and the surgical wound was cleaned and subjected to curettage. The ap was repositioned, and the wound was nally

456

HEMODYNAMIC CHANGES IN LOWER THIRD MOLAR REMOVAL

Visiting the dentist is a matter for concern. In my case, I tend to: 1. Not show up on the day of the visit to the dentist 2. Cancel the visit During the visit to the dentist, I experience the following: 3. Tenseness (muscle tension) 4. Faster breathing 5. More intense perspiration 6. Nausea 7. Quickened pulse

Always Almost always

Sometimes Almost never

Never

Extreme Strong

Moderate

Mild

None

Before visiting the dentist I begin Extreme Strong to feel concerned: 8. At the time of arranging the visit 9. On the way to the dentist 10. In the waiting room 11. Sitting in the dental chair 12. Noticing the characteristic smell of the clinic 13. Seeing the dentist I become afraid of injection of the local anesthetic: 14. As soon as I see the needle 15. Once I feel the needle I become afraid of the dental drill: 16. As soon as I see it 17. As soon as I hear it turned on 18. When I feel it on my tooth I feel fear: 19. When undergoing dental cleansing (hygiene) 20. Globally in relation to any kind of dental treatment Extreme Strong Extreme Strong Extreme Strong

Moderate

Mild

None

Moderate

Mild

None

Moderate

Mild

None

Moderate

Mild

None

FIGURE 2. Kleinknechts Dental Fear Scale (DFS). Alemany-Martnez et al. Hemodynamic Changes in Lower Third Molar Removal. J Oral Maxillofac Surg 2008.

sutured with 3/0 silk. The sutures were removed 1 week after surgery. SPSS version 11.5 (SPSS Inc, Chicago, IL) was used for all statistical analyses. A univariate descriptive analysis

was made, expressing the results as percentages and frequencies. The comparative study was based on analysis of variance for repeated measures. Statistical signicance was considered for P values less than .05 in all cases.

ALEMANY-MARTNEZ ET AL

457

FIGURE 3. Visual analog scale for pain. Alemany-Martnez et al. Hemodynamic Changes in Lower Third Molar Removal. J Oral Maxillofac Surg 2008.

Results
The patient distribution by gender was deliberately balanced (50% males and 50% females), with a mean age of 27 years (range, 18 to 67 years). The difculty of surgical extraction of molars was assessed using the classication systems of Pell and Gregory9 and Winter10 and proved to be minimal to moderate in all cases. The mean duration of the surgical procedure, measured from the time of local anesthesia (including the latency period required for effective analgesia) to the end of suturing, was 26 minutes (range, 15 to 45 minutes). The mean degree of dental anxiety before the surgical procedure was moderate, and the mean degree of dental fear was low, according to the DAS and DFS.11,12 The females showed higher levels of dental anxiety and fear, with signicantly higher mean scores (Fig 5). The degree of pain experienced during the surgical procedure was generally low, equivalent to 2 points on the 10-point visual analog scale completed postoperatively. Table 2 and Figure 6 report the mean SBP, DBP, HR, and SaO2 values recorded at each of the 9 time points for the global sample. SBP showed only slightly signicant changes; the highest average value was recorded at the time of ostectomy and/or tooth sectioning, after which a progressive decrease was observed up until the end of the surgical procedure. Likewise, DBP showed no signicant variations; the lowest value was recorded 4 minutes after local anesthetic injection, and the highest value was recorded during ostectomy and/or tooth sectioning, after which a sharp drop was again recorded at the time of dental avulsion. The lowest HR was recorded at baseline, before the start of the surgical procedure, whereas the maximum rate was observed during incision and

ap raising, after which the HR again decreased, tracing a curve of Gaussian distribution. SaO2 remained constant and showed no signicant changes, although the recorded values were lower at the start of surgery.
SYSTOLIC BLOOD PRESSURE

The global mean SBP was 121.2 mmHg, with a standard deviation (SD) of 1.17 mmHg. Distributed by gender, the mean SBP was 122.9 mmHg in males versus 119.5 mmHg in females (SD 1.6 mmHg for both genders); this difference was not statistically signicant (F 2.04; df 1; P .16). The SBP varied with surgical time (F 7.13; df 8; P .05). The variations in SBP showed a similar pattern in both

FIGURE 4. Monitor for evaluating hemodynamic changes. The rst recording (at top) corresponds to HR (bpm), the second recording corresponds to SaO2, and third through fth recordings correspond to SBP, DBP, and mean BP (in parentheses). Alemany-Martnez et al. Hemodynamic Changes in Lower Third Molar Removal. J Oral Maxillofac Surg 2008.

458

HEMODYNAMIC CHANGES IN LOWER THIRD MOLAR REMOVAL

Table 2. MEAN BP, HR, AND SaO2 VALUES AT DIFFERENT TIME POINTS DURING THE SURGICAL PROCEDURE
A1 SBP DBP HR SaO2 120.8 74.3 79.7 97.9 11.9 7.9 11.2 1.6 A2 119.8 70.9 84.5 97.9 13.2 8.8 13.3 1.6 A3 118.6 68.2 91.2 98.1 12.7 10.3 14.2 1.6 A4 124.3 70.1 92.3 98.3 14.1 10.0 13.7 1.2 A5 124.5 71.3 91.0 98.3 13.0 10.3 14.5 1.2 A6 122.5 68.5 84.2 98.3 12.3 9.0 14.6 1.0 A7 119.8 69.5 82.8 98.0 11.7 9.6 12.9 1.9 A8 120.2 69.8 82.0 97.9 10.9 10.0 12.6 1.8 A9 120.2 70.1 80.2 98.0 10.4 8.2 11.8 1.0

NOTE. Measurement time points: A1, baseline; A2, 1 minute after anesthesia; A3, 4 minutes after anesthesia; A4, incision; A5, ostectomy and/or tooth sectioning; A6, completion of extraction; A7, start of suturing; A8, end of the surgical procedure; A9, removal of the surgical drapes. Alemany-Martnez et al. Hemodynamic Changes in Lower Third Molar Removal. J Oral Maxillofac Surg 2008.

genders, but with more accentuated values in the males (F 2.45; df 8; P .02).
DIASTOLIC BLOOD PRESSURE

OXYGEN SATURATION

The global mean DBP was 70.3 mmHg (SD 0.8 mmHg). In terms of gender, mean DBP was 71.3 mmHg in males versus 69.3 mmHg in females (SD 1.2 mmHg for both genders); again, the difference was not statistically signicant (F 3.7610 6; df 1; P .99). The DBP varied with surgical time (F 5.28; df 8; P .05). No relationship was found between patient gender and variations in DBP; the pattern was similar in both males and females (F 1.78; df 8; P .10).
HEART RATE

The global mean SaO2 was 98.05 (SD 0.14). The females had higher SaO2 values (98.16) than the males (97.93), with SD of 0.2 for both genders; the difference was not statistically signicant (F 1.27; df 1; P .26). SaO2 varied with surgical time (F 2.14; df 8; P .04). The variations were similar in both males and females (F 1.10; df 8; P .37).
ANXIETY AND FEAR

The global mean HR was 85.3 bpm (SD 1.25 bpm). The females showed higher HR values (87.7 bpm) than the males (82.9 bpm), with SD of 1.7 bpm for both genders; however, the difference failed to reach statistical signicance (F 3.74; df 1; P .06). The HR varied with surgical time (F 17.17; df 8; P .05). There was no difference in the pattern of change of the HR between the genders (F 0.911; df 8; P .512).

The females demonstrated signicantly higher mean levels of anxiety (DAS score 12) than the males (Fig 7). Correlating the DAS and DFS scores with the variations in hemodynamic parameters generally revealed no differences between patients with high and low anxiety. The more anxious patients had lower BP and higher HR values, although the differences from the rest of the patients were not statistically signicant (Fig 7).

Discussion
Some studies of the clinical hemodynamic effects of local anesthetics with adrenalin conducted in healthy individuals have reported no signicant changes in

FEAR
7 5

ANXIETY
20
72 20

16 12

8
2

4 0 Males Females Males Females

FIGURE 5. Box-and-whisker plots for males and females, corresponding to the DFS and DAS. Circles represent outlier values. The number was used to identify the case. Alemany-Martnez et al. Hemodynamic Changes in Lower Third Molar Removal. J Oral Maxillofac Surg 2008.

ALEMANY-MARTNEZ ET AL

459

- Systolic blood pressure (SBP)

180

130
17

160
63 43

19

19 19 74 27

128 126

140

124 122

120

120

SEX
0 1

100
11 11

118 116

80
N= 80 80 80 80 80 80 80 80 80

1
tas8 tas9

tas1

tas2

tas3

tas4

tas5

tas6

tas7

SBP

- Diastolic blood pressure (DBP)

120
64 64 64 64 64 64

76

74

100
74 28 19 61

27 19 19 59 19

59

19 14

72

80

70

SEX
60

68
79

0
71

66
1
80 80 80 80 80 80

1
2 3 4 5 6 7 8 9

40
N= 80 80 80

tad1

tad2

tad3 tad4

tad5

tad6 tad7

tad8

tad9

DBP

- Heart rate (HR)

140

100

120
64 72

90
100

80

80

sex
60
51

0 70
1
80 80 80 80 80 80 80 80 80

1
2 3 4 5 6 7 8 9

40
N=

fc1

fc2

fc3

fc4

fc5

fc6

fc7

fc8

fc9

FC

- Oxygen saturation (SaO2)

100

9 8 ,8
98

9 8 ,6
13 33 44 73 31 61 17 43 73 23 72 29 11 27 4 13 27 47 77 17 13 27 20 27 79 2 13 73 77 14 33 19 77 73 33 3 4 11 39 63 77 19 17 73

96

9 8 ,4 9 8 ,2 9 8 ,0 9 7 ,8

94

12 41 3

92

90
20 20 21 4 4 3 8

SEX
0 1

9 7 ,6 9 7 ,4

88

86
N= 80 80 80 80 80 80 80 80 80

1
s1 s2 s3 s4 s5 s6 s7 s8 s9

FIGURE 6. Hemodynamic changes during the surgical procedure and variations according to patient gender (0 males; 1 females), represented in box-and-whisker plot form and graphically. Circles and asterisks represent outlier values. The number was used to identify the case. SBP and DBP are expressed in mmHg and SO2 is expressed as percentage. Alemany-Martnez et al. Hemodynamic Changes in Lower Third Molar Removal. J Oral Maxillofac Surg 2008.

460

HEMODYNAMIC CHANGES IN LOWER THIRD MOLAR REMOVAL

DBP
74

DFS
hisum1 ,00 1,00
74 76

DAS
hisum2 ,00 1,00

Estimated Marginal Means

72

Estimated Marginal Means

1 2 3 4 5 6 7 8 9

72

70

70

68

68

66 1 2 3 4 5 6 7 8 9

SBP
126

tad

tad

hisum1 ,00 1,00

126 128

hisum2 ,00 1,00

Estimated Marginal Means

124

Estimated Marginal Means

1 2 3 4 5 6 7 8 9

124

122

122

120

120

118

118

116 1 2 3 4 5 6 7 8 9

HR
95

tas

tas

hisum1 ,00 1,00

hisum2 ,00 1,00

Estimated Marginal Means

Estimated Marginal Means

1 2 3 4 5 6 7 8 9

90

90

85

85

80

80

SaO2
98,6

fc

fc

hisum1 ,00 1,00

98,4

hisum2 ,00 1,00

98,4

Estimated Marginal Means

Estimated Marginal Means

1 2 3 4 5 6 7 8 9

98,2

98,2

98

98

97,8

97,8

97,6
97,6

97,4
1 2 3 4 5 6 7 8 9

FIGURE 7. Correlation of hemodynamic changes during the surgical procedure and the DFS and DAS. Levels of anxiety and fear: 0 high. SBP and DBP are expressed in mmHg and SO2 is expressed as percentage. Alemany-Martnez et al. Hemodynamic Changes in Lower Third Molar Removal. J Oral Maxillofac Surg 2008.

low; 1

HR or BP,14 whereas others have found changes not dependent on the vasoconstrictor.15 In our study involving healthy normotensive patients, both SBP and DBP increased slightly up to the moment of molar extractionspecically, the time of ostectomy and tooth sectioning. After these peak values were reached, SBP and DBP decreased after the surgical procedure to levels even lower than those recorded at

baseline (Fig 6). We concur with other investigators8,16 that the moment of dental avulsion is the most stressful phase of the surgical procedure. Nichols17 reported that 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 the patients anxiety or fear associated with visiting the dentist.

ALEMANY-MARTNEZ ET AL

461

Changes in HR and BP are affected by pain and by certain individual factors, such as age, gender, hypertension, previous experience with dental treatments, and psychological response.18 In our study, males showed higher BP values than females, while the latter showed higher HR values and anxiety levels. The more anxious patients had lower BP values and higher heart rates, possibly because females were more anxious, and patient sex was a confounding variable (Fig 7). The box-and-whisker plots of DAS and DFS in Figure 5 show no signicant differences between males and females in terms of anxiety level (the male and female 95% condence intervals overlap). Nevertheless, on average the females reported greater anxiety than the males. The small difference between the anxious and nonanxious patients may be attributable to the studys low statistical power, along with the confounding effect of patient gender. In agreement with our observations, other studies have reported that pain perception is lower in females than in males, although males tend to suppress their anxiety more than females. The pain threshold appears to be lower in males than in females, and the latter show comparatively greater pain tolerance.19 However, in contraposition to our ndings, other authors have reported that males experience less pain than females in the course of the surgical procedure.20 In any case, we can state that the experience of pain differs between males and females.21,22 The mean age of the patients in our series was 27 years (range, 18 to 67 years). The fact that our patients were young may help explain the lack of signicant hemodynamic changes in our study. Matsumura et al found that adult and middle-aged patients exhibited larger BP increments during oral surgery compared with young patients.23 The attenuation of stress with anxiolytics or sedation can be used to reduce the cardiovascular response associated with patient anxiety, although in these cases dentist-mediated patient behavioral control appears to play a fundamental role. Conscious sedation administered intravenously in oral surgery can help maintain hemodynamic stability in both hypertensive and normotensive patients.24 In addition, hypertensive patients demonstrate no signicant changes in BP or HR during oral surgery, and 1 carpule of local anesthetic with articaine plus 0.012 mg of adrenalin can be safely used in patients with BP 154/99 mmHg.25 In conclusion, in the present study, most of the cardiovascular changes induced during the surgical extraction of third molars were within normal limits, taking into consideration the anxiety and stress produced by the surgical intervention. Females exhibited greater dental anxiety than males during surgery. We consider avoiding pain and minimizing patient anxiety essential to safe clinical practice.

References
1. Gay-Escoda C, Berini-Ayts L: Monitorizacin bsica en odontologa. In Gay-Escoda C, Berini-Ayts L (eds): Anestesia Odontolgica (ed 3). Madrid, Spain, Ediciones Avances, 2005, p 143 2. Arrigoni J, Lambrecht JT, Filippi A: Cardiovascular monitoring and its consequences in oral surgery. Schweiz Monatsschr Zahnmed 115:208, 2005 3. Fukayama H, Yagiela JA: Monitoring of vital signs during dental care. Int Dent J 56:102, 2006 4. Tolas AG, Pug AE, Alter JB: Arterial plasma epinephrine concentration and hemodynamic response after dental injection of local anesthesia plus epinephrine. J Am Dent Assoc 104:41, 1982 5. Meyer FU: Hemodynamic changes under emotional stress following a minor surgical procedure under local anesthesia. Int J Oral Maxillofac Surg 16:688, 1987 6. Brand HS, Gortzak R, Palmer CC, et al: Cardiovascular and neuroendocrine response during acute stress induced by different types of dental treatment. Int Dent J 45:45, 1995 7. Mestre R, Carrera I, Berini-Ayts L, et al: Monitorizacin con pulsioximetra durante la extraccin de terceros molares inferiores. Estudio comparativo de tres anestsicos locales con epinefrina al 1:100.000. Medicina Oral 6:195, 2001 8. Silvestre FJ, Verd MJ, Sanchs JM, et al: Efectos de los vasoconstrictores usados en Odontologa sobre la presin arterial sistlica y diastlica. Medicina Oral 6:57, 2001 9. Pell GJ, Gregory BT: Impacted mandibular third molars: Classication and modied techniques for removal. Dent Digest 39:330, 1933 10. Winter GB: Impacted Mandibular Third Molars. St Louis, MO, American Medical Book, 1926 11. Corah NL, Gale EN, Stephen JI: Assessment of a dental anxiety scale. J Am Dent Assoc 97:816, 1978 12. Kleinknecht RA, Bernstein DA: The assessment of dental fear. Behav Ther 9:626, 1978 13. Gay-Escoda C, Berini-Ayts L: Tcnicas anestsicas en ciruga bucal, in Gay-Escoda C, Berini-Ayts L (eds): Tratado de Ciruga Bucal, vol I. Madrid, Spain, Editorial Ergn, 2004, p 155 14. Muzyka BC, Cglick M: The hypertensive dental patient. J Am Dent Assoc 128:1109, 1997 15. Bguena JC, Chiva F: Efectos de los anestsicos de uso odontolgico sobre la presin arterial y la frecuencia cardaca. Rev Eur Odontoestomatol 5:291, 1999 16. Paramaesvaran M, Kingon AM: Alterations in blood pressure and pulse rate in exodontia patients. Aust Dent J 39:282, 1994 17. Nichols C: Dentistry and hypertension. J Am Dent Assoc 128: 1557, 1997 18. Brand HS, Abraham-Inpijn L: Cardiovascular responses induced by dental treatment. Eur J Oral Sci 104:245, 1996 19. Fagade OO, Oginni FO: Intraoperative pain perception in tooth extraction: Possible causes. Int Dent J 55:242, 2005 20. Colorado-Bonnin M, Valmaseda-Castelln E, Berini-Ayts L, et al: Quality of life following lower third molar removal. Int J Oral Maxillofac Surg 35:343, 2006 21. Robison ME, Gagnon CM, Dannecker EA, et al: Sex differences in common pain events: Expectations and anchors. J Pain 4:40, 2003 22. Robison ME, Gagnon CM, Riley JL III, et al: Altering gender role expectations: Effects on pain tolerance, pain threshold, and pain ratings. J Pain 4:284, 2003 23. Matsumura K, Miura K, Takata Y, et al: Changes in blood pressure and heart rate variability during dental surgery. Am J Hypertens 11:1376,1998 24. Cillo JE Jr, Finn R: Correlation and comparison of body mass index on hemodynamics in hypertensive and normotensive patients undergoing intravenous sedation. J Oral Maxillofac Surg 64:583, 2006 25. Gungormus M, Buyukkurt MC: The evaluation of changes in blood pressure and pulse rate of hypertensive patients during extraction. Acta Med Austriaca 30:127, 2003