Complications in

local anesthesiaGuided By: Dr. Anish

Tiwari Dr. Adarsh Deshai Dr. Ravi Kalola

Prepared By: Shefali Kantaria Parth Karavdia

What is “local anesthesia”?Loss of sensation in a circumscribed area of the body caused by depression of excitation in nerve endings or inhibition of the conduction process in peripheral nerves.

Types of LA complicatio

ns

Local complicationSystemic complication

Local ComplicationsNeedle breakageProlonged anesthesia or paresthesiaFacial nerve paralysisTrismusSoft tissue injuryHematomaPain on injectionInfectionEdemaSloughing of tissuesPostanesthetic intraoral lesions

Needle Breakage•Rare complication in dental LA injection.•Long needle most likely have broken during injection.•Long needle is unlikely to have been inserted to its full length into soft tissue(app. 32mm).•Some portion would remain visible in patient’s mouth.•Retrival of fragment with hemostat easily accomplished.•Litigation does not occure in such incident.

•All situation needle fracture occurred at the hub-never along shaft .•Additional factor:• 1. intentional bending of needle by the doctor before injection.• 2.sudden unexpected movement by patient while needle is still embedded in tissue.• 3.forceful contact with bone.•Needle has been surgically retrieved and/or forensic metallurgists have examined the hub of the needle ,no evidence has reveald manufacturing defects in needle.

Problem•Sudden and unexpected movement by the patient in the opposite direction of the needle insertion when the needle penetrates the soft palate•Access to a hemostat enables the doctor or the assistant to grasp the visible proximal end of the needle fragment and remove it from the soft tissue.•Defective manufacturing.

•It does not often occur, needle fragment can migrate, as it illustrated by the series of panoramic films taken at 3 month intervals.

Prevention•Not use short needles for inferior alveolar nerve block in adults or larger children•Not use 30 gauge needles for IAN block in adults or children•Not bend needles when inserting them into soft tissue•Not insert the needles till its hub

Management•Remove needle if it is visible with help of a haemostat.•If not visible take radiographs of the region .•If needle is lost into the tissue spaces ,e.g. pterygomandibular space, infratemporal space, assure ( ખાતરિ�ક�ાવિ�)the patient and review regularly.•3D CT scanning recommended.

PROLONG ANESTHESIA OR PARESTHESIA

•As persistent(સતત) anesthesia or altered sensation well beyond the expected duration of anesthesia . •In addition include hyperesthesia, dysesthesia in which patient experiences both pain and numbness.

•A patient report feeling NUMB [frozen] many hours or days after LA injection.•LA persist for days, weeks, months, potential for the development of problem is increased.•It causes of dental malpractice litigtion.•Clinical response :sensation , swelling, tingling, itching, oral dysfunction, tongue biting drooling loss of taste speech impediment.

Causes•Trauma to any nerve may lead to paresthesia.•It is uncommon complication of oral surgical procedures and mandibular dental implants.•Injection of LA solution with alcohol or cold sterilising solution near a nerve produces irritation and oedema of the tissue and subsequent pressure on the nerve.•Haemorrhage around the neural sheath also causes pressure on the nerve, leading to paraesthesia.

Prevention•Strict adherence to injection protocol and proper care and handling of dental cartridges help minimize risk of paresthesia.

Management•Most case resolve within 8 weeks•Reassurance to the patient•Examine the patient in person•Reschedule the patient for examination every 2 months for as long as the sensory deficit persist.•Dental treatment may continue , but avoid readministering LA into region of the previously traumatized nerve. Use alternate LA techniques if possible.

PAIN ON INJECTION•It is prevented through careful adherence to the basic protocol of atraumatic injection.

Causes•Careless injection tecnique and a callous attiude all too often become self fulfilling prophecies.•Aneedle become dull from multiple injections.•Rapid deposition of LA solution may cause tissue damage.•Needles with barbs may produce pain as they withdrawn from tissue.

Problem•It increases patient anxiety and may lead to sudden unexpected movement, increases risk of needle breakage, traumatic soft injury to the patient or needle stick injury to the administrator.

Prevention•Adhere proper techniques of injection ,both anatomic&psychological.•Use sharp needles.•Use topical anesthetic properly before injection.•Use sterile LA solutions.•Injection LA slowly.•Make certain temperature of solution is correct.•pH app 7.4 have been demonstrated.

Management•No management is necessary.

BURNING ON INJECTION

•A burning sensation that occurs during injection of a local anesthetic is not uncommon.

Causes•The primary cause of a mild burning sensation is the pH of the solution.•pH is appro. 6.5 .•Where as solutions that contain a vaso pressor are considerably more acidic (3.5)•Rapid injection of LA especially in the denser, more adherent tissue of the palate produce a burning sensation.•

Problems•The burning sensation on injection of a LA is indicate tissue irritation.•If this caused by pH of the solution, It rapidly disappear as the anesthetic action develops.•Usually no residual sensitivity is noted.•Subsequent complication such as postanesthetic trismus, oedema or possible paresthesia are reported.

Prevention•By buffering the LA solution to a pH of app. 7.4 immediate before injection , It possible to eliminate the burning sensation. Sometimes LA containing a vasopressor.•Slowing the speed of injection also helps.•Ideal rate 1ml/min. Do not exceed the recommended rate of 1.8 ml/min.•It is store at room temperature in container without alcohol or other sterilizing agents.

Management•Most of burning on injection are do not lead to prolong tissue involment.•Formal treatment is not indicated.•Few situation postinjection discomfort, oedema or paresthesia becomes evident, management of the specific problem is indicated.

SOFT TISSUE INJURY•Self-inflicted trauma to the lips and tongue is frequently caused by the patient inadvertently biting or chewing this tissue while still anesthetized.

Causes•Most frequently in younger children, in mentally or physically disabled children or adults and in older old patient .•However it can and dose occur in patients of all ages.•The primary reason is the fact that soft tissue anesthesia lasts significantly longer than does pulpal anesthesia.•

Problem•It can lead to swelling and significant pain when the anesthetic effects resolve.•A younger child or a handicapped individual may have difficulty coping with the situation and may lead to behavioral problems.

Prevention•A cotton roll can be placed between the lip and the teeth if they are still anesthetized at the time of discharge.•The cotton roll is secured with dental floss wrapped around the teeth.•The patient and the guardian against eating, drinking hot fluids, and biting on the lips or tongue to test for anesthesia.•A self-adherent warning sticker may be used on children.

Management•Analgesics for pain, as necessary.•Antibiotics, as necessary, in the unlikely situation that infections results .•Lukewarm saline rinses to aid in decreasing any swelling that may be present.•Petroleum jelly or other lubricant to cover a lip lesion and minimise irritation.

OEDEMA•Swelling of the tissue is not a syndrome but a clinical sign of the presence of some disorder.

Causes•Trauma during injection•Infection•Allergy•Hemorrhage•Injection of irritating solution•Hereditary angioedema is characterized by sudden onset of brawny nonpitting edema affecting the face extremities and mucosal surface of the intestine and respiratory tract without obvious precipitating factors.•Lips, eyelids and the tongue are involved.

Problem•Edema related to LA administration is seldom intense enough to produce significant problems such as airway obstruction.•Edema result in pain and dysfunction of the region and embarrassment for the patient.•Angioneurotic edema produced by topical anesthethc in the allergic individual although exceedingly rare can compromise the airway.•Edema of the tongue, Pharynx or Larynx may develop and represents life threatening situation that requires vigorous management.

Prevention•Proper care for and handle the local anesthetic armamentarium.•Use atraumatic injection technique.•Comlete an adequate medical evaluation of the patient before drug administration.

ManagementTraumatic oedema resulting from inflammation resolves in one to three days with antiinflammatory drugs.Allergic oedema: requires immediate assessment to avoid the risk of anaphylaxis : treated with antihistaminics and steroidal antiinflammatory drugs.P(position): unconscious, the patient is placed supine.A-B-C: basic life support is administered as needed.D:emergency medical services is summoned.

Epinephrine :0.3mg adult 0.15mg child,every 5 minute until respiratory.Histamine block IM OR IVCorticosteroid IM OR IVPatient condition

SLOUGHING OF TISSUES

•Prolonged irritation or ischemia of gingival soft tissues may lead to number of unplesent complications, including epithelial desquamation and sterile abscess.

CausesEpithelial Desquamation1. Application of topical anesthesia to the gingival tissues for a prolonged period.2. Heightened sensitivity of tissues to either

topical or injectable LA.3. Reaction in an area where a topical has

been applied.Sterile abscesses 4. Secondary to prolonged ischemia use of LA

with vasoconstrictor 5. Usually develops on the hard palate.

Problems•Pain, at time severe, may be a consequence of epithelial desquamation or a sterile abscess.•It is possible that infection may develop in this area.

Prevention•Use topical anesthesia is recommended.•Allow the solution to contact the mucous membrane for 1 to 2 minutes to minimize its effectiveness and minimize toxicity.•When using vasoconstrictors for hemostasis do not use overly concentrated solution.•The palatal tissues are likely the only place in the oral cavity where this phenomenon may arise.

Management•No formal management is necessary for epithelial desquamation or sterile abscess.•Be certain to reassure the patient of this fact.•Management may be symtomatic for pain aspirin or other NSAIDs and topical applied ointment are recommended.•Epithelial desquamation resolves within a few days the course of a sterile abscess may run 7 to 10 days.

FACIAL NERVE PARALYSIS

•Usually occur in inferior alveolar nerve block.•Facial nerve is the motor supply to muscle of facial expression.•Loss of the motor action of the muscle of facial expression produced by LA lasts for one to seven hours.•The patient suffers unilateral paralysis of the facial muscles.

•Paralysis of some terminal branches whenever infraorbital nerve block is administered, maxillary canines are infiltrated.•Anesthesia is into deep lobe of parotied gland, through , terminal portion of facial nerve.

•Facial nerve branches and muscles they inervate are list below.•1 Temporal branch• Frontalis• Orbicularis oculi• Corrugator super•2 zygomatic branch• Orbicularis occuli

•3.Buccal branches• a. Procerus• b. Zygomaticus• c. Levator labii superioris• d. Buccinator• e. Orbicularis oris•4.Mandibular branch• a. Depressor anguli oris• b. Depressor labii inferioris• c. Mentalis

Cause•It cause by the induction of local anesthetic into capsule of the parotid gland which is located at the posterior border of mandibular ramus clothed by the middle pterygoid and masseter muscles.•Needle pos.or inadvertently deflection it in pos. direction during an IANB the tip of needle with in body of the parotied gland.

Problem•It lasts no longer than several hours depending on the LA formulation used and proximity to the facial nerve.•Usually minimal or no sensory loss occur.•Primary problem is cosmetics•No treatment is known.•Secondary problem patient unable to voluntarily close one eye.•Winking and blinking become impossible.•Corneal reflex is intact and tears lubricate the eye.

Prevention•A niddle tip that comes in contact with bone (middle aspect of the ramus ) before depositing LA solution essentialy preclude the possibility that anesthetic will be deposited into the parotid gland.

Management•Contact lenses should be removed until musculer movement returns.•Record the incident on the patient chart.•Reassure the patient and explain that the solution is transient will last few hours and will resolve without residual effect.•Avoid further dental therapy and reassess for recovery.•An eye patch should be applied to the affected eye untill muscle tone return.

TRISMUS•It is from greek prismos is define as a prolonged tetanic spasm of the jaw muscle by which the normal opening of the mouth is restricted.

Causes•Trauma to the muscles and blood vessels in the infratemporal space .•Trauma to the muscle caused by repeated needle insertion especially medial pterygoid in inferior alveolar nerve block.•Low grade infection.•Excessive haemorrhage or haematoma which produces irritation of the tissue and muscles dysfunction.•Solution which contain alcohol or other cold sterilizing solutions irritate the tissue and produces trismus.

Problem•Limitation of movement associated with post injection trismus is usually minor.•In the acute phase of trismus pain produce by haemorrhage lead to muscle spasm and limitation of movement.•Chronic phase develops if treatment is not begun.•Chronic hypomobility occurs secondary to organization of the haematoma with fibrosis and scar contractore.•Infection may produce hypomobility through increase pain, increase tissue reaction and scarring.

Prevention•Use sharp, sterile, disposible needle as the trauma and infection caused by them is less.•Do not use contaminated needles.•The injection techinque should cause a less trauma as possible.•Clean the area of needle insertion withan antiseptic solution before injection.•Avoid repeated insertion.•Change needle for every new insertions made.•Use minimal effective volumes of LA.•Trismus is not always preventable.

Management•The degree of discomfort anf dysfunction varies but is usually mild.•The interrim prescribe heat therapy, warm saline rinses analgesics and if necessary muscle relaxent to manage the initial phase of muscle spasm.•Physiotherapy involving dynamic jaw exercise.•Surgical intervention to correct chronic dysfunction may be indicated in some instances.

HAEMATOMA•Haematoma is defined ad effusion into the extravascular space by inadvertent nicking of blood vessels during administration of LA.•It is a rare in palatal region due to the close adherence of the palate, mucoperiosteum to the bone.

Cause•Damage blood vessel by the needle during penetration of the soft tissue.•It that occur after the inferior alveolar nerve block only visible intraorall, where as PSA haematomas are visible extraorally.

Problem•It produce significant problem asite from the resultion bruise which may or may not be visible extraorally.•Possible complication include trismus and pain.•Swelling and discoloration of the region subside gradually over 7 to 14 days.•The haematoma constitute an inconvenience to the patient and embarrassment to the person administering the drug.

Prevention•The surgeon should use an appropriate technique according to the anatomic structure.•The number of needle penetration should be as low as possible.•Surgeon should follow injection technique with structures a lesser risk of haematoma.•The surgeon should use shorter needle for posterior superior alveolar nerve block.

Management•Apply direct pressure over the bleeding site for a few minute.•Apply ice locally it acts as analgesic and vasoconstrictor.•Prescribe analgesic, antibiotic, muscle relaxent.

INFECTION•It is extremely rare occurrence since sterile, disposble needles and glass cartridges have been introduced.

Causes•Commonly involved pathogens include pseudomonas, e.coli,staphylococcus aureus, mycobacterium.

Problems•Contamination of needles or solutions may cause a low grade infection when the needle or solution is placed in deeper tissue.•This may lead to trismus.

Prevention•Use disposable syrings and needle.•Use appropriate sterilised needle.•Avoid cross contamination between different sites within the oral cavity.

Management•Treat the infection with appropriate antibiotics.•Low grade infection which is rare is seldom recognized immediately.

POST ANESTHETIC INTRAORAL LESIONS•Recurrent aphthous ulcer or herpes simplex sometimes develops after intraoral injection of LA.•Herpix simplex develop on oral mucosa attach to the bone e.g. palate, attached gingiva.•Recurrent aphthous somatitis develops on the oral mucosa not attached to the bone. e.g. buccal mucosa.•Pain is major symptom and may last for 7 to 10 days.

Cause•Trauma to the oral tissue caused by the needle or any other instrument reactivates the dormant diseases.

Problems•Acute sensivity in the ulcered area.•Risk of the secondary infection developimg in the situation is minimal.

Prevention•It prevented or its clinical manifestations minimised if treated in its produrmal phase.•It consist of a mild burning or itching sensation at the site where virus is present. E.g. lip.•Antiviral agent such as acylovir applied qid to the affacted area effectively minimize the acute phase of this process.

Management•Primary management is symptomatic.•Topical anesthetic solutions may be applied.•Amixture of equal amount of diphenhydramine and milk of magnesia rinsed in the mouth effectively coats the ulcer.•Orabase, a protective paste with kenalog can provide pain releafe.•Kenalog is corticosteroid not recommended because antiinflammatory action, increase the risk of viral involvement.•A tannic aci preparation can be applied topically to the lesion.

આભાર