Selection of the safest local anesthetic for dental treatment in medically compromised patients: A comprehensive review

Local anesthetics are essential in dental practice, but their systemic effects can pose significant risks for medically compromised patients. This review aims to identify and evaluate the safest local anesthetic agents for use in dental procedures in patients with systemic medical conditions to minimize adverse outcomes and improve clinical safety. To achieve this, a comprehensive literature search was performed in PubMed, Scopus, Web of Science, and Google Scholar for studies published from January 2000 to April 2025. Thirty-five studies addressing local anesthetic use in patients with cardiovascular disease, hepatic or renal impairment, diabetes, thyroid disorders, bleeding tendencies, pregnancy, elderly populations, and amide allergies were included. Data were synthesized to develop clinical recommendations for anesthetic selection based on systemic conditions. Lidocaine remains the standard amide anesthetic, with a strong safety profile in pregnancy and diabetes. Mepivacaine, due to minimal vasodilation, is preferred in cardiovascular and thyroid disorders. Articaine's rapid plasma metabolism benefits patients with liver or kidney impairment. Prilocaine is effective for hepatic impairment but poses methemoglobinemia risks, especially in pregnancy. Chloroprocaine, an ester anesthetic, is recommended for patients with confirmed amide allergies. Emerging strategies, such as buffered formulations, low epinephrine anesthetics, and ultrasound guided techniques, may enhance safety in high risk groups. Local anesthetic selection must be tailored to each patient's medical status. Mepivacaine, lidocaine, and articaine are among the safest agents for various systemic conditions. An evidence based, condition specific approach enhances safety and treatment outcomes in medically compromised dental patients.