Most common complication of local anesthesia.

1. AbdulMajeed Al Mogbel*
*Teaching Assistant, College of Dentistry, Qassim University.
13/18/2017

2. Outline
Local Complications
Paresthesia
Needle Breakage
Hematoma
Pain on Injection
Facial Nerve Paralysis
Infection
Trismus
Soft Tissue Injury
Edema
Ocular Complications
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3. Outline
Systemic Complications
Overdose Allergy
Introduction
Predisposing Factors
Clinical Manifestations
Management
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4. Local Complications
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5. Local Complications
Paresthesia
Needle Breakage
Hematoma
Pain on Injection
Facial Nerve Paralysis
Infection
Trismus
Soft Tissue Injury
Edema
Ocular Complications
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6.  Rare because of using of disposable needles.
Needle Breakage
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7.  Causes:
1. Bending of the needle.
2. Sudden unexpected movement of the patient.
3. Entire length of the needle inserted into the soft tissue.
4. Use of the smaller needles ( e.g. 40 gauge )
Needle Breakage
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8.  Prevention:
1. Use large-gauge needles, specially
with Inferior Alveolar Nerve and
Posterior Superior Alveolar
Nerve.
2. Use long needles.
3. Do not insert a needle into tissues
to its hub.
4. Do not redirect a needle once it is
inserted into tissue.
Needle Breakage
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9.  Management :
 When a needle breaks ( visible):
1. Stay calm.
2. Instruct the patient not to move and
let his mouth open.
3. If the fragment visible, remove it with
hemostat or a Magill intubation
forceps.
 When a needle breaks ( not-visible):
1. No incision or probing.
2. Calmly inform the patient.
3. Referral Oral Surgeon, take radiograph
and determine if it is superficial,
remove or leave it and flow up?!!
Needle Breakage
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10. Local Complications
Paresthesia
Needle Breakage
Hematoma
Pain on Injection
Facial Nerve Paralysis
Infection
Trismus
Soft Tissue Injury
Edema
Ocular Complications
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11.  Amaurosis “temporary blindness“.
 Mydriasis “Pupillary dilation”
 Ptosis “droopy eyelid”
 Diplopia “double vision”
Ocular Complications
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12.  Causes :
Ocular Complications
Inadvertent arterial injection with retrograde
blood flow
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13.  Causes :
Orbital injection :
 Inadvertent injection into the orbit through the
inferior orbital fissure.
Ocular Complications
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14.  Prevention :
 Aspiration before actual injection.
 Inject slowly.
 Treatment :
 Reassure the patient that is transient.
 Cover the affected eye with gauze dressing.
 Refer patients to an ophthalmologist for evaluation if it
last more than 6 hours
 Regular follow-up
Ocular Complications
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15. Local Complications
Paresthesia
Needle Breakage
Hematoma
Pain on Injection
Facial Nerve Paralysis
Infection
Trismus
Soft Tissue Injury
Edema
Ocular Complications
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16. Paresthesia
 Causes :
 Trauma to the nerve.
 Local Anesthesia solution contaminated by alcohol or
sterliziating solution near anerve produce irritation,
resulting edema and increased pressure in the region of
the nerve leading to paresthesia.
 Insertion of a needle inside a foramen.
 Hemorrhage-increased pressure-paresthesia.
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17. Paresthesia
 Prevention :
 Proper care and handling to injection control and
cartridge.
 Management :
 Most paresthesia resolve within 8 weeks without
treatment.
 Sequences of management:
 Reassuring the patient.
 Examine the patient and follow up each 2 months.
 If sensory deficit is still more than 1 year, consultation with
neurologist and oral surgeon.
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18. Local Complications
Paresthesia
Needle Breakage
Hematoma
Pain on Injection
Facial Nerve Paralysis
Infection
Trismus
Soft Tissue Injury
Edema
Ocular Complications
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19.  Occur when anesthesia is introduced into deep lobe
of the parotid gland.
Facial Nerve Paralysis
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20. Facial Nerve Paralysis
 Causes :
◦ Transient FNP caused by local anesthesia into capsule of
the parotid gland, which is located at posterior border of
the mandibular ramus.
◦ Usually it occur during Inferior Alveoar Nerve Block or
Vazirani-Akinosi Nerve Block.
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21. Facial Nerve Paralysis
 Prevention :
 Proper care and handling to
injection control and cartridge.
 Management :
1. Reassuring the patient.
2. Contact lenses should be
removed.
3. An eye patched should be applied
to affected eye or manually close
the lower eyelid periodically to
keep the cornea lubricated.
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22. Local Complications
Paresthesia
Needle Breakage
Hematoma
Pain on Injection
Facial Nerve Paralysis
Infection
Trismus
Soft Tissue Injury
Edema
Ocular Complications
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23.  Pain and difficult of opening often after posterior
superior alveolar or inferior alveolar nerve block.
 Onset 1-6 days post-treatment.
Trismus
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24.  Causes :
 Trauma to the muscles or blood vessels in the
infratemporal fossa.
 Local Anesthesia solution contaminated by alcohol or
cold sterliziating solution produce irritation of the
muscles.
 Low-grade infection.
Trismus
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25.  Prevention :
1. Use sharp, sterile, disposable needle.
2. Proper care and handling to injection control and
cartridge.
3. Atraumatic injection and avoid repeating of it.
Trismus
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26.  Management :
 Heat therapy.
 Warm saline rinse.
 Analgesic, Aspirin 325 mg.
 Muscle relaxation if necessary,
Diazepam 10 mg bid
 Physiotherapy for 5 min. each 3-4
hours.
 If there is infection, antibiotic
described for 7 days.
 Improvement start within 2-3 days
and recovery range 4-20 weeks.
 Surgical intervention in some cases.
Trismus
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27. Local Complications
Paresthesia
Needle Breakage
Hematoma
Pain on Injection
Facial Nerve Paralysis
Infection
Trismus
Soft Tissue Injury
Edema
Ocular Complications
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28.  Trauma to the lip or the tongue caused by biting or
chewing these tissue while still anesthetized,
specially with children.
Soft-Tissue Injury
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29.  Prevention :
◦ A cotton roll placed between the lips and the teeth.
◦ Warn the patient.
◦ Self-adherent warning sticker.
Soft-Tissue Injury
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30.  Management :
◦ Analgesic for pain.
◦ Antibiotic if there is infection.
◦ Warm saline rinse to aid in decreasing the swelling.
◦ Petroleum jelly to cover the lesion and minimize the
irritation.
Soft-Tissue Injury
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31. Local Complications
Paresthesia
Needle Breakage
Hematoma
Pain on Injection
Facial Nerve Paralysis
Infection
Trismus
Soft Tissue Injury
Edema
Ocular Complications
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32.  The effusion of the blood into extravascular spaces
can result from inadvertently a blood vessel.
 Casued by nicking to the artery or vein.
 Most occur with IANB and PSA nerve block.
 7 to 14 days the hematoma will be presented.
Hematoma
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33.  Prevention :
1. Knowledge of normal anatomy.
2. Use shorter needle for PSA nerve block.
3. Minimize the number of the needle penetration.
4. Never use a needle as a probe in the tissue.
 Management :
1. Direct pressure applied on to the site of bleeding.
2. Apply cold moist towels to affected area each 20 min.
every hour.
3. Advice the patient about soreness and limitation of the
mouth opening possibility.
Hematoma
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34. Local Complications
Paresthesia
Needle Breakage
Hematoma
Pain on Injection
Facial Nerve Paralysis
Infection
Trismus
Soft Tissue Injury
Edema
Ocular Complications
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35.  Causes :
1. Careless injection and callous attitude “ Palatal Injection
always hurt”.
2. Dull of the needle because of multiple injection.
3. Rapid deposition of the local anesthetic solution.
Pain on Injection
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36.  Prevention :
◦ Adhere to proper techniques
of injection, both anatomical
and psychological.
◦ Sharp needles.
◦ Topical anesthetic.
◦ Inject slowly.
◦ Temperature of the solution.
Pain on Injection
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37. Local Complications
Paresthesia
Needle Breakage
Hematoma
Pain on Injection
Facial Nerve Paralysis
Infection
Trismus
Soft Tissue Injury
Edema
Ocular Complications
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38.  Causes :
◦ Contamination of the needle, now become rarely after
introduction of the sterile disposable needle and glass
cartridge.
 Management :
◦ Antibiotic, penicillin 250 mg qid.
Infection
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39. Local Complications
Paresthesia
Needle Breakage
Hematoma
Pain on Injection
Facial Nerve Paralysis
Infection
Trismus
Soft Tissue Injury
Edema
Ocular Complications
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40.  Causes :
1. Trauma.
2. Infection.
3. Allergy, angioedema.
4. Hemorrhage.
5. Injection of irritating
solution(alcohol, cold
solution).
Edema
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41.  Management :
1. Minimal degree edema --- just analgesic for pain and will
resolve in several days.
2. If large degree edema and sign and symptom of
infection--- antibiotic should be prescribed.
Edema
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42. Systemic Complications
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43. Systemic Complications
Overdose Allergy
Introduction
Predisposing Factors
Clinical Manifestations
Management
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44. ◦ Overdose reaction is occurring when the drug access to
the circulatory system.
◦ Normally there is constant absorption of the drug from
its site of admission into the circulatory system and a
steady removal from the blood by the liver.
Overdose
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45. Patient Factors:
 Age.
 Weight.
 Medications.
 Gender.
 Presence of disease.
 Genetics
 Mental attitude.
Drug Factors:
 Vasoactivity.
 Concentration.
 Dose.
 Route of administration.
 Rate of injection.
 Vascularity of the
injection site.
 Presence of
vasoconstrictors.
Predisposing Factors
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46. Patient Factors:
 Age :
 The function of absorption, metabolism, and
excretion are diminished in old people –
increasing the half-life of the drug in circulation
blood.
 Weight :
 Greater body weight – larger dose.
 Medications :
 Meperidine”narcotic analgesic”,
phenytoin”anticonvalsun”,
quinidine”antidysrhythmatic”, and
desipramine”antidepressant” – increase local
anesthesia blood level, because protein bending
competition.
Predisposing Factors
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47. Patient Factors:
 Gender :
 Renal function during pregnancy may impaired
leading to increase local anesthesia blood level.
 In adult women the seizure threshold is 5.8
mgkg, in newborn 18.4, in the fetus 41.9
mgkg. Placenta clearance of lidocaine.
 Presence of disease :
 Hepatic , renal dysfunction and congestive
heart failure decrease liver perfusion – increase
amide local anesthesia blood level.
Predisposing Factors
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48. Patient Factors:
 Genetics :
 Deficiency in enzyme serum
pseudocholinesterase – responsible for
biotransformation of ester local anesthesia.
 Mental attitude :
 Patient who are fearful:
1. Larger dose required.
2. Lower seizure threshold .
Predisposing Factors
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49. Drug Factors:
 Vasoactivity :
 Vasodilating properties of LA lead:
1. Shorter duration of clinical anesthesia.
2. Increased blood level of LA.
 Concentration :
 Lowest concentration should be given.
 Dose :
 Smallest dose should be given.
Predisposing Factors
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50. Drug Factors:
 Route of administration :
 Should be care about intravascular injection.
 Rate of injection :
 Slow (60-seconds) IV administration per
cartridge (36 mg) .
 Vasculratiy of the injection site :
 Rapid of the absorption.
 Vasoconstrictors :
 Decrease absorption of the drug.
Predisposing Factors
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51. 1. Use aspiration syringe.
2. Use a needle no smaller
than 25 gauge.
3. Aspirate in at least two
planes before injection.
4. Slow inject the
anesthetic.
Prevention
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52. 1. Talkativeness .
2. Apprehension.
3. Excitability.
4. Slurred speech.
5. Stutter.
Clinical Manifestation
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53. 1. Sweating.
2. Vomiting.
3. Failure to follow commands.
4. Elevated blood pressure, heart and
respiratory rate.
5. Tonic-clonic seizure in highly
overdose.
6. CNS depression, Myocardiac
Depression and cardiac arrest.
Clinical Manifestation
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54. 1. Mild Overdose:
1. Slow onset (>5 minutes)
2. Slow onset (>15 minutes)
2. Severe Overdose:
1. Rapid onset (within 1
minute)
2. Slow onset (5 to 15
minutes)
Management
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55. 1. Basic Emergency Management :
1. Position.
2. Circulation.
3. Airway.
4. Breathing.
5. Definitive Care.
P-C-A-B-D
Management
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56. 1. Mild Overdose: “Patient conscious”
◦ Slow onset (>5 minutes):
 P-C-A-B
 Reassure the patient.
 Administer oxygen via nasal canal.
 Monitor and record vital signs.
 IV anticonvulsants (diazepam 5
mgmin. or midazolam 1 mmin.)
“optional”
 Emergency medical assistance before
patient discharge.
Management
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57. 1. Mild Overdose: “Patient conscious”
◦ Slow onset (>15 minutes)
 P-C-A-B
 Reassure the patient.
 Administer oxygen via nasal canal.
 Monitor and record vital signs.
 IV anticonvulsants (diazepam 5
mgmin. or midazolam 1 mmin.)
“manadatory”
 Emergency medical assistance before
patient discharge.
Management
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58. 1. Severe Overdose: “Patient
unconscious”
◦ Rapid onset (within 1 minute)
 P-C-A-B
 Protect the patient.
 Immediately summon emergency
medical assistance.
 Continue Basic life support (BLS)
 IV anticonvulsants (diazepam 5
mgmin. or midazolam 1 mmin.) “if
seizures protract more than 4 min.”
Management
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59. 1. Severe Overdose: “Patient unconscious”
◦ Slow onset (5 to 15 minutes)
 P-C-A-B
 IV anticonvulsants (diazepam 5
mgmin. or midazolam 1 mmin.) and
oxygen administration.
 Immediately summon emergency
medical assistance.
 Continue Basic life support (BLS).
 Vasopressor and IV fluid is
recommended for management of
hypotension.
Management
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60. Systemic Complications
Overdose Allergy
Introduction
Predisposing Factors
Clinical Manifestations
Management
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61. ◦ Hypersensitive state, acquired
through exposure to a particular
allergen.
◦ Allergic reactions cover a broad
spectrum od clinical
manifestations ranging from mild
and delayed response occurring as
long as 48 hours after exposure to
allergen, to immediate and
threatening reaction develop
within seconds of exposure.
Allergy
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62. ◦ Sodium Bisulfite:
 Antioxidant in vasoconstrictor local
anesthesia.
 1984 has been excluded.
◦ Epinephrine.
◦ Latex.
◦ Topical Anesthesia:
 Mostly ester.
 Preservatives containing such as
methylparaben, ethylparaben, or
propylparaben.
Predisposing Factors
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63. Clinical Manifestation
Dermatological reaction
Generalized anaphylaxis
Respiratory reactions
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64. ◦ Dermatological reaction:
 Urticaria
 Angioedema
Clinical Manifestation
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65. ◦ Respiratory reactions:
 Bronchospasm:
 Respiratory distress
 Dyspnea
 Wheezing
 Flushing
 Cyanosis
 Perspiration
 Tachycardia
 Anxiety
 Laryngeal edema:
 Extension of edema to the larynx
 Life threatening emergency.
Clinical Manifestation
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66. ◦ Generalized Anaphylaxis:
 Skin reactions
 Smooth muscle spasm of
gastrointestinal and genitourinary
tracts and bronchospasm.
 Respiratory distress.
 Cardiovascular collapse.
 Treatment of the entire reaction
may be terminated rapidly, but
hypotension and laryngeal edema
may persist for hours to days.
Clinical Manifestation
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67. ◦ Skin reaction:
 Delayed reaction.
 Immediate reaction.
◦ Respiratory reaction:
 Bronchospasm.
 Laryngeal edema.
◦ Generalized anaphylaxis:
 Signs of allergy present.
 No signs of allergy present.
Management
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68. ◦ Skin reaction:
 Delayed reaction:
 P-C-A-B
 Oral histamine blocker 50 mg diphenhydramine or 10
mg chlorpheniramine, one q6h for 3-4 days.
 Observation for 1 hour.
 Medical consultation.
 If patient is drowsiness,
not allowed to leave the clinic.
Management
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69. ◦ Skin reaction:
 immediate reaction:
 P-C-A-B
 Epinpherine 0.3 mg IM.
 IM histamine blocker 50 mg diphenhydramine or 10 mg
chlorpheniramine.
 Medical consultation
 Observation for 1 hour.
 Prescribe Oral histamine blocker 3 days.
Management
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70. ◦ Respiratory reaction:
 Bronchospasm :
 P-C-A-B
 Administer oxygen at flow 5-6 litersmin.
 Epinpherine 0.3 IM or Bronchodilator “albuterol” , dose repeated 10-15
min. if needed.
 Observation for 1 hour.
 IM histamine blocker 50 mg diphenhydramine or 10 mg
chlorpheniramine.
 Medical consultation
 Prescribe Oral histamine blocker 3 days.
Management
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71. ◦ Respiratory reaction:
 Laryngeal Edema : “unconscious patient”
 P-C-A-B
 Epinpherine 0.3 IM, dose repeated 10-15 min. if
needed.
 Activate Emergency Medical Services.
 IM histamine blocker 50 mg diphenhydramine or 10
mg chlorpheniramine. Corticosteroid IM or IV (100
mg Hydrocortisone sodium succinate to inhibit and
decrease edema.
 Perform cricothyrotomy.
Management
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72. 3/18/2017 72

73. ◦ Generalized Anaphylaxis :
 Signs of allergy present : “unconscious patient”
 P-C-A-B
 Summon medical assistance.
 Epinpherine 0.3 IM, dose repeated 10-15 min
 Administer oxygen.
 Monitor vital signs, recorded every 5 min.
 IM histamine blocker and Corticosteroid IM or IV “ If
clinical improvement noted increased blood pressure,
decreased bronchospasm”
Management
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74. ◦ Generalized Anaphylaxis :
 No signs of allergy present : “unconscious patient”
 P-C-A-B
 Summon medical assistance.
 Administer oxygen.
 Monitor vital signs, recorded every 5 min.
 Addition management, on arrival of the emergency
medical personnel depend on the cause of the loss of
consciousness.
Management
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75. References:
1. Stanley F. Malamed. Handbook of local anesthsia. 5th edition. Page 285-332.
2. Sean G. Boynes, Zydnia Echeverria, Mohammad Abdulwahab. Ocular Complications
Associated with Local Anesthesia Administration in Dentistry. Dent Clin N Am 54
(2010) 677–686
3. Ngeow WC, Shim CK, Chai WL. Transient loss of power of accommodation in one eye
following inferior alveolar nerve block: report of two cases. J Can Dent Assoc
2006;72:927–31.
4. Penarrocha-Diago M, Sanchis-Bielsa JM. Opthalmologic complications after intraoral
local anesthesia with articaine. Oral Surg Oral Med Oral Pathol Oral Radiol Endod
2000;90:21–4.
5. Lee C. Ocular complications after inferior alveolar nerve block. Hong Kong Med Diary
2006;11:4–5.
6. Van der Bijil P, Meyer D. Ocular complications of dental local anesthesia. SADJ
1998;53:235–8.
7. Goldenberg AS. Transient diplopia as result of block injections. Mandibular and
posterior superior alveolar. N Y State Dent J 1997;63:29–31.
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