Local Complication of Local Anesthesia

1. Needle Breakage
2. Pain on injection
3. Burning on injection
4. Persistent anesthesia : paresthesia
5. Trismus
6. Hematoma
7. Infection

8. Edema
9. Sloughing of tissues
10. Lip-Chewing
11. facial nerve paralysis
12. Post anesthetic intraoral lesions
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1. Needle Breakage

 Become 1. Sudden  No problem exists  Use larger gauge  When the needle breaks:
rare due to unexpected if the needle can be needle for injection • be calm , don't panic
the movement of the pt. easily retrieved without 25-gauge needles are • Instruct the pt. not to move; don't
introduction as the needle surgical intervention appropriate for nerve remove ur hand from the pt's mouth and keep
of penetrates the muscle block of (inferior the mouth opened & place the bit block if
disposable or contacts  Needles that break alveolar, mandibular, possible..
needle, but periosteum.(esp. if off within tissues & posterior & anterior • If the fragment is protruding 
still occur.. the pt. moves can't be readily superior alveolar& remove it with cotton pliers or a small
oppositely to the retrieved usually maxillary) hemostat
needle) enclosed by scar tissue  if the needle is lost & can't be readily
and rarely produce  Use long needle retrieved:
2. Needles of infection leaving it for injection • Don't proceed with incision or probing
smaller gauge better than performing • Don't insert the if the fragment invisible
traumatic surgical needle into tissue to • Calmly inform the pt. and relieve his
removal the hub(the point at fears & apprehension
3. Needle that have which the needle
previously bent • Note the incident in the pt's records &
shaft meets the hub inform your insurance carrier
is the weakest point
• Refer the pt for oral surgeon
of the needle)
consultation not to remove the needle
 When is needle breaks, consideration
 Don't redirect
should be given for it's immediate removal:
the needle once it is
• if the needle is superficial & easily
inserted into tissues
located through radiographic & clinical
examination  removal is possible by oral
surgeon , so if attempted retrieval is
unsuccessful in reasonable length of time 
allow the fragment to remain
• if the needle is located in deeper
tissues or if it hard to locate  permit it to
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2. Pain on injection

 Can be 1. Careless injection technique &  Increase pt 1. carefully adhere to proper technique of No management
prevented callous attitude; N.B: Palatal anxiety injection, both anatomically & is required;
through careful injection always hurt.. psychologically however, steps
adherence to the 2. Dull needle from multiple  May lead to 2. Use sharp needles should be taken
basic rules of injections with the same needle.. sudden unexpected 3. Use topical anesthetic prior to to prevent
atraumatic 3. Rapid deposition of the solution movement needle injection recurrence with
injection 4. Needle with barbs; impaling the breakage 4. Use sterilized local anesthetic future
needle on bone may produce a solutions injections.
''fishhook barb'' pain as the needle 5. Practice slow injection of solutions
withdrawn from the tissue.. 6. Be certain temperature of solution is
correct; N.B: too hot of a solution is more
uncomfortable than one which is too cold

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3. Burning on injection

 Burning 1. PH of the solution  Transient in nature  Difficult or even impossible Formal therapy
during N.B: cause mild burning sensation , prepared  Indication of tissue but with short duration & low is usually not
deposition of to be 5 and those containing vasoconstrictor irritation intensity indicated only if
the L.A is not having more acidic  Rapidly disappears there is post
uncommon 2. Rapid injection of the L.A solution esp. when the L.A action  Slow injection ideal rate is injection
in the denser more adherent tissue of the develops 1ml/min , don't exceed 1.8 ml in 1 discomfort or
palate  No residual min edema, or
3. Contamination of the L.A cartilages sensitivity after action paresthesia
with sterilizing solution results when the termination of the L.A  Proper care & handling of the
stored in alcohol or other sterilizing L.A cartilage :
 Greater opportunity
solution  diffusion of this solution into of the tissue damage to • @ room temperature
the cartilage develop with subsequent • suitable container without
4. Temperature of the solution even if it's postanesthatic trismus , alcohol or any sterilizing solution
warm
edema , or paresthesia

Introducti Causes Problem Prevention Management

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4. Persistent anesthesia ( Paresthesia)

*Rare 1. Trauma to any nerve or the nerve  Sometimes total but *Proper injection  Most paresthesia resolves in 8
*Disturbing sheath  electrical shock & mostly partial  tissue technique weeks without ttt& will be permanent
complication paresthesia injury only if there is severe nerve damage.
*Proper care & 1. Reassure the pt
2. Injection of contaminated L.A  Biting or thermal or handling of the a. The dentist must talk to the
cartilage by alcohol or sterilizing chemical insult can dental cartilage pt
solutions near the nerve  irritation occur without a patient's b. Don't relegate the duty of
& edema  increase pressure on the awareness reassuring
region  paresthesia c. Explain that it's not
uncommon after injection
d. Arrange appoint 4
3. Hemorrhage into or around the examining the pt
neural sheath  increase pressure on e. Record the incident in the
the nerve  paresthesia dental chart
2. Examine the pt
a. Determine the paresthesia
degree
b. Explain to the pt that
paresthesia may persist at least 2
months or may be prolong to 1 y
c. Tincture of time is the
recommended medicine
d. Record the finding in the
pt's chart
3. Reschedule the Pt for
examination every 2 months as long
as sensory deficit persists
4. Should sensory deficit still be
evidence 1 y after that consult the
surgeon or neurologist to mange
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5. Trismus

 Motor 1. Trauma to muscles • In the acute phase of 1. use sharp , sterile , • Arrange an appointment for examination.
disturbance or blood vessels in the trismus: disposable needles • Heat therapy:
of the infratemporal space is Pain produced by hemorrhage 2. properly care for & Placing moist eat with towels to the affected area
trigeminal (the most common  muscle spasm & limitation handle dental L.A about 20 min every hour.
nerve esp. cause following the of movements. cartilage • Analgesics
spasm of the dental injections) • In the chronic phase 3. Cleanse the site of Aspirin is usually adequate in damaging pain
masticatory 2. Contaminated of trismus: injection with an associated with trismus.
muscles with dental cartilage by Usually develops if the ttt is not antiseptic solution prior Codeine (30-60 mg every 3 hours) if the discomfort is
difficulty in diffusion of alcohol or begun. to needle penetration more intense.
opening the any sterilizing agent  • Hypomobility can be 4. Use a septic • Muscle relaxants
mouth. irritation to the muscle due to: technique ; contaminated Diazepam (about 10 mg every 12 hours)
 potential trismus 1. secondary to hematoma needle should be changed • Advice the pt. t initiate physiotherapy for 5
 Although 3. Hemorrhage (large with subsequent fibrosis & immediately min every 3-4 hours by opening and closing the
post injection volume of blood) scar contracture 5. Practice atraumatic mouth as well as lateral excursions & chewing
pain is the tissue irritation  2. infection through insertion & injection gum(sugarless)
most muscle dysfunction as increase tissue reaction technique • Record the incident, finding, ttt in the pt's
common L.A blood is slow resorbed. (irritation ) & scarring 6. Avoid repeat dental chart.
complication, 4. A low grade • In most cases a pt will injections & multiple • Avoid any further dental ttt in the involved
trismus can infection repost pain and difficulty in insertions through region till symptoms resolves & pt is more
become one opening the mouth the day knowledge of anatomy &
5. Multiple needle comfortable
of the more after the dental proper technique ( use
chronic &
penetrations. • 7 full days Antibiotics is required if the pain
6. Overly large appointments in which regional block instead of and dysfunction continued beyond 48 hours due to
complicated posterior superior alveolar infiltration wherever
amount of L.A solution possibility of infection.
problem to or inferior alveolar nerve possible & rational)
deposited in restricted • Refer the pt to oral surgeon if no improvement
manage. blocks are administered. 7. use minimal effective
area. within 2-3 days without antibiotics or 5-7 days
volumes of L.A solutions;
with antibiotics or severe limited mouth opening.
refer to specific
techniques for • TMJ involvement is quite rare in the 1st 4-6
recommended volumes weeks following injection.
• Surgical intervention may be indicated in
some instance.
Causes Problem Prevention Management(Time is the most important element of hematoma ) it
presents 7-14 days with or without ttt
6. Hematoma

 The inadvertent * Rarely 1. Knowing the Immediate :

nicking of a blood produce normal anatomy When swelling becomes evident Direct pressure should be applied to the site of bleeding for not less
vessel, either artery or significant of the proposed than 60 sec. against bone
vein during an injection problem injection; certain  Inferior alveolar nerve block
of L.A technique has a - Pressure is applied to the medial aspect of the mandibular ramus.
 Nicking of the * Possible greater risk of - Intraoral clinical manifestation which are tissue discoloration & swelling in the medial (lingual)
complication hematoma like aspect of the mandibule ramus
artery usually
include posterior superior  Infraorbital nerve block
increase in size rapidly
trismus & alveolar nerve & - Pressure in applied to the skin directly over the infraorbital foramen.
till the ttt is instituted


pain inferior alveolar - Extraoral clinical manifestation which is discoloration of the skin below the lower eyelid
 Nicking of the  Mental & incisive nerve block
nerve in second.
vein may or may not * The - Pressure is applied directly over the mental foramen, either on the skin or on the mucous
cause hematoma 2. Modify the membrane.
swelling & injection
 The density y of the - Clinical manifestation is observed @ the skin over the mental foramen and/or by swelling in the
discoloration technique as mucobuccal fold in the region of the mental foramen
tissue surrounding the usually indicated by the  Buccal nerve block or any palatal injection
injured vessel will be a subsides pt's anatomy e.g. - Place the pressure @ the site of bleeding.
determining factor e.g. within lessen the - Only intraoral clinical manifestations are visible
hematoma is rarely several days penetration of  Posterior superior alveolar nerve block
developed after palatal posterior superior - Usually produce the largest & most esthetically unappealing hematoma& can accommodate large
injection but usually alveolar nerve volume of blood.
following nicking of block in pt with - Not recognized till the swelling appears on the side of the face progressing inferiorly & anteriorly
the B.V in posterior smaller facial toward the lower anterior region of the cheek.
superior or inferior characteristics - Difficulty in applying pressure @ the site of the bleeding in this region (post.super.alveolar &
alveolar nerve block facial arteries & pterygoid plexus of vein)
3. Minimize the
coz the tissue - They r located posterior Superior & medial to the maxillary tuberosity
number of needle - Bleeding normally halts when external pressure of blood exceed the internal one.
accumulate the blood in
penetrations of
these areas blood - Digital pressure can be applied to the soft tissues in the mucobuccal fold as far as it can be
tissue tolerated by the pt. without gagging.
effusion until extra
4. Never use - Apply pressure in a medial & superior direction .
vascular pressure
needle as probe Subsequent:
exceed pressure within
in tissues * Avoid any additional dental therapy in hematoma region till the sign & symptoms relived.
the B.V
* Advice the pt about possible trismus ttt as previously mentioned_ Discoloration resorbed over 7-
14 days_ soreness ttt by analgesic e.g. aspirin, no heat application at least 4-6 hr. till the next day by
warm towels 20 min every hr., Ice is applied immediately (analgesic & vasoconstrictor)
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needles.* become extremely rare since the introduction of sterile, disposable
7. Infection
1. The major cause is the
contamination of the needle
prior to administration of the
L.A. & it's always occurring
when the needle touches the
mucous membrane in the
oral cavity.
2. Improper technique in
the handling of the L.A
armamentarium & improper
tissue preparation for
injection.
Problem Prevention
 Contaminated 1. Use disposable syringe
needle of solution may
lead to low grade 2. Properly care for & handle
infection when there is needles:
in deeper tissue  - Recap the needle when not in
trismus => initiation of use to avoid contamination
proper ttt through contact with non sterile
surfaces.
- Avoid multiple injections
with the same needle.
3. Properly care for 7 handle of
the dental cartilage of L.A
solution.
- single use only
- store aseptically in original
container , covered at all times
- Cleanse the diaphragm with
sterile, disposable alcohol wipes.
4. Properly prepare the tissues
prior to penetration; dry the
tissue & apply topical
anesthesia.
Management
• Low grade infection (rare) will
seldom be recognized immediately &
the pain will report post injection pain
& dysfunction one or more days
following the dental therapy
• Rarely will be overt signs &
symptoms of infection present.
• Immediate ttt should consist
procedures for trismus management
(heat, analgesic & if needed muscle
relaxant & physiotherapy
• Trismus produced by factors other
than infection will normally respond
with a lessening of signs & symptoms
within 1-3 days , but if trismus signs &
symptoms don't respond to the
conservative therapy so a 7 day course
antibiotic is started.
• Prescribe 29 tablets of penicillin
V250 mg tablets; the pt. takes 500 mg
immediately then 250 mg four times a
day until they are gone.
• Erythromycin for allergic pt. to
penicillin
• Report the progress & management
of the patient on the dental chart.
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 isn't a clinical syndrome but represents a clinical sign of some disorder.* Edema is the swelling of tissues.
8. Edema

Use atraumatic injection technique.Properly care for & handle the L.A armamentarium.
1. Tra 1. Airway obstruction - Management is predicated to reduce the swelling as quickly as
uma during injection possible.
2. Pain & dysfunction of - Edema due to traumatic injection or introduction of irritating
2. Infe the region & personal solution  have a minimal degree of edema & resolved within 1-3
ction embarrassment for the pt. days
- It's necessarily to prescribe analgesics for pain due to edema
3. Angioedema swelling in - Follow the management of hematoma if the edema is followed by
3. Alle allergic responded pt.  hemorrhage & it will resolved within 7-14 days
rgy lead to compromised - Edema produce by infection will not resolved spontaneously but

1.
airway may be become progressively more intense. if the sign of infection
Angioedema is a
( pain, mandibular dysfunction , edema) don't appear to resolved
common reaction to topical
4. Edema of the tongue, within 3 days  Antibiotic therapy as mentioned in the infection ttt
anesthesia in an allergic pt.
pharynx, and larynx may - Edema produce by allergy is the most potentially life threatening.
Localized tissue
develop  life- threatening The degree of the edema & its location is highly significant. If the
swelling occurs due to
situation need vigorous swelling is develops in the buccal soft tissue & there is no airway
vasodilatation secondary to
management. obstruction  ttt is I.M & oral antihistamine administration & a
histamine release
medical consultation to an allergist to determine the precise cause of
the edema.
4. He
- When edema compromised breathing :
morrhage; effusion of 1. Epinephrine 0.3 mg IM or IV
blood into soft tissues 2. Antihistamine IM or IV
 swelling 3. Corticosteroid IM or IV
4. medical assistance summoned
5. Inje 5. pt. positioned supine position if unconscious
2.

ction of irritating 6. Basic cardiac life support

solution (alcohol or 7. preparation of cricothyrotomy if total airway obstruction
cold sterilizing solution develops
–containing cartilage) 8. Through evaluation of the patient prior to next appointment
to determine the cause of the reaction.
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9. Sloughing of tissues

itation to the gingival soft tissue may lead to  number of unpleasant complications including epithelial

• Epithelial desquamation : 1. use topical anesthesia as - Usually no formal

1.
1. Application of topical anesthesia recommended ; Allow the solution management is required for
agents to the gingival tissues for a long to contact mucous membrane for 1-2 both epithelia d desquamation
period of time min to maximize its effectiveness & or sterile abscess.
2. heightened sensitivity of tissues to to minimize toxicity.
chemical agents ( L.A) - Management may be
2. When using vasoconstrictors for symptomatic
3. Reaction in area where the topical
anesthetic is applied. homeostasis  don't employ overly
concentrated solutions
- For pain  analgesic

2.
- Epinephrine 1:50,000
- Levophed (nor epinephrine) (aspirin , codeine 7 a topically
• Sterile abscess: applied ointment such as
1. secondary to prolonged ischemia 1:30,000
Are the 2 agents most likely to produce Orabase to minimize the
resulting from the use of L.A with irritation of the tissue .
vasoconstrictors ischemia of a long enough duration to
produce tissue damage & a sterile
2.
desquamation & sterile abscess.

Almost always occurs in the firm - Epithelial desquamation

abscess.
soft tissue of the hard palate. will resolved within few days.
N.B: the palatal tissues are virtually the
only tissues in the oral cavity where this
phenomenon might occur. - Sterile abscess run for 7-10
days

- Record dada in the pt's

chart .
Intro Causes Problem Prevention Management (is
symptomatic)
10. Lip-Chewing

The primary cause is the use of long acting L.A in pt. undergoing shorter dental
* Trauma of the lips & tongue  Swelling & pain - Selection of proper 1. Analgesic for
of the anesthetized pt. is when the anesthetic duration of L.A action pain.
frequently caused by the pt. depends on the duration 2. Antibiotics, in
action dissipate.
of the dental procedures.
inadvertently biting or - A cotton roll can be
the unlikely
chewing these structures.  Behavior placed between the lips situation that
management pf the pt. if they are still infection results.
* Trauma occurs most problems in the anesthetized @ the time 3. Lukewarm
frequently in children & young child or of discharge. saline rinses to
mentally handicapped - Warn the pt. & adult aid in decreasing
handicapped
children & adult. guardian against eating any swelling that
individual copying while still anesthetized,
difficulty with this against drinking hot
may be present.
situation fluids, and against biting 4. Petroleum
on the lips & tongue to jelly or other
test for anesthesia. lubricant to cover
- A self-adherent the lesion (on the
warning sticker is lips) to minimize
available that states irritation.
"Watch me, my lip &
cheek are numb" placing
in the pt's forehead.
procedures.
Introduction Causes Problem Prevention Management
11. facial nerve paralysis

• The facial nerve is the 7th * Transient facial nerve - Loss of facial expression • Adherence 1. Reassure the pt.
cranial verve which is a motor paralysis is commonly muscles function will last to proper
nerve to the muscle of facial caused by the from 1-several hours depending technique in the 2. Advice the pt. to
expression, scalp & external ear & introduction of L.A o the L.A agent, volume inferior alveolar periodically close the
others. solution into the capsule injected, & its proximity to the nerve block. upper eyelid
• Occasionally it can of the parotid gland , facial nerve. • If the needle manually to keep the
anesthetized by the inadvertent which is located @ the - The primary tip in contact cornea lubricated.
deposition of L.A into its vicinity, posterior border of the with bone
problemUnilateral paralysis
always occur when the solution ramus of the mandible , (medial aspect
during this time with inability to
introduce in the deep lobe of the clothed by the medial of ramus) prior
use theses muscle normally 3. Contact lenses
parotid gland. pterygoid & masseter to L.A
(cosmetic appearance problem ) should be removed
• The nerves supplied by these muscles. deposition 
- No ttt except waiting till the until muscular
branches & the muscles they action wears off preclude the movement returns.
innervate are listed: * Directing of the needle possibility of
1. Temporal branches toward or its inadvertent - The secondary problem  the deposition
deflection in a posterior the pt. unable to close the eye, 4. Record the
- frontalis muscles of solution in incident in the pt.'s
- Orbicularis oculi direction during an winking & blinking become the parotid
inferior alveolar nerve impossible to perform. chart.
muscle gland.
- Corrugator muscle block may place the - The cornea retains to its • If the
2. Zygomatic branches needle tip within the innervation so if irritated needle deflects
- Orbicularis oculi substance of the parotid corneal reflex & the pt. will be 5. Although there is
posteriorly  no contraindication
muscle gland paralysis may able to lubricate the eye during should be
3. Buccal branches(supply region result. this period of time. for re anesthetized the
entirely pt.to achieve
inferior to orbit & around the - With sec. – min following withdrawn &
mouth) mandibular
deposition of L.A  the pt. will direct it more
- Procerus muscle anesthesia, it may be
sense a weakening of the muscle anteriorly till it
- Zygomatic muscle prudent to forego
of the affected side of the face. contacts bone.
- Levator labii superioris further dental therapy
muscle @ this appointment.
- Buccinator muscle
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12. Post anesthetic Intraoral Lesions

* Pt. might report painful ulceration of the mouth following 2 days of dental injection.

 Recurrent apthous stomatitis &/or herpes
simplex can develop intraorally following
L.A injection or any traumatic insult
• Recurrent aphthous stomatitis is the
most frequently observed intraorally in the
movable gingival tissue (not attached to the
bone) e.g. buccal vestibule) not viral infection
- In the intraoral lesions
No mean of prevention in the
susceptible pt.
- Extra oral herpes simplex
can be prevented or
minimizing its manifestation
if it's in its prodromal phase
 Primary management is symptomatic:
- Pain  approximately 2 days after
injection
- If not severe no management
- If the pt. complain from pain:
1. keep the ulcerated area covered
2. topical anesthetic solution (viscous
lidocaine) can be applied to the painful


but it might be autoimmune process or L-form area
bacterial infection. 3. A mixture of equal amount of
- Prodrome consists of diphenhy dramine & milk magnesia
• Herpes Simplex can develop intraorally mild burning or itching rinsed in the mouth  effectively coat the
but it's most commonly extra orally on the sensation @ the site where ulcerated area & provide relief of the
fixed tissue (not attached to the bone) the virus is present (lip) pain .
4. Orabase , a protective paste
- Either applied topically without Kenalog  provide degree of
 Trauma to tissues by needle, L.A , cotton by cotton swab 3-4 times pain relief .N.B: Kenalog is corticosteroid
swab, or any other instrument (R.D clasp , daily  minimizes the acute not recommended because it's anti-
hand piece )  reactivate the latent form of phase only extra orally. inflammatory action provide increase risk
the disease process that has been present in of either viral or bacterial involvement.
the tissue prior to the injection. 5. Ulceration duration about 10 days
with or without ttt
6. Negatol chemical cauterizing
agent for pain relief


7. Keep adequate records in the pt's

chart.
Best of Luck
Strawberry