DEPARTMENT OF ORAL AND MAXILLOFACIAL SURGERY
LOCAL COMPLICATION OF
LA
PARVATHY MANOJ
ROLLNO:19
2020 BATCH
CONTENTS
NEEDLE BREAKAGE
PERSISTENT ANESTHESIA
FACIAL NERVE PARALYSIS
TRISMUS
SOFT TISSUE INJURY
HEMATOMA
PAIN ON INJECTION
BURNING ON INJECTION
INFECTION
EDEMA
SLOUGHING OF TISSUE
POSTANESTHETIC INTRAORAL LESIONS
Needle breakage
Breakage and retention of needles within tissues has become rare because
of the introduction of disposable needles.
CAUSES:
The primary cause of needle breakage is weakening of the dental needle by
bending it before its insertion into the patient’s mouth.
Another cause: sudden unexpected movement by the patient as the needle
penetrates muscle or contact periosteum.
This is more likely to occur in pediatric dental patient :
1.Smaller needles are far more likely to break than larger needles.[eg:30
gauge]
2.Needles that have previously been bent are weakened and more likely to
break than unbent needles.
3.Needles may prove to be defective in manufacture.
PREVENTION:
Use larger gauge needles specially 25-gauge needles for an inferior
alveolar , mandibular, posterior superior alveolar(PSA), anterior superior
alveolar(ASA) and maxillary nerve block.
Use long needles for injection.
Don’t insert a needle into tissue to its hub.
Don’t redirect a needle once it is inserted into tisues.
MANGEMENT:
1.When a needle breaks:
a. Stay calm
b. Instruct the patient not to move, keep the mouth open.
c. If the fragment is visible , try to remove it with a small hemostat or a magill
intubation forceps.
2.If the needle is lost (not visible):
a. Don’t proceed with an incision or probing.
b. Calmly inform the patient.
c. Note the incident on the patient’s chart.
d. Refer the patient to oral and maxillofacial surgeon for consultation, not for
removal of the needle.
PERSISTENT ANESTHESIA/ PARAESTHESIA
Paraesthesia is defined as persistent anesthesia or altered sensation well
beyond the expected the duration of anaesthesia and also include
hyperesthesia and dysesthesia.
CAUSES:
Trauma to any nerve may lead to paraesthesia.
Injection of a local anaesthetic solution contaminated by alcohol or
sterilizing solution near a nerve produces irritation, resulting in edema and
increased pressure in the region of the nerve, leading to paraesthesia.
Insertion of a needle inside a foramen.
Hemorrhage into or around the neural sheath is another causes. Bleeding
increases pressure on the nerve leading to paraesthesia.
PROBLEMS:
Biting or thermal or chemical insult can occur without a patient’s awareness.
When the lingual nerve is involved, the sense of taste may be impaired.
Hyperesthesia and dysesthesia also may be noted.
PREVENTION:
Proper care and handling of dental cartridges help minimize the risk of
paraesthesia.
MANGEMENT:
Most paraesthesia resolve within approximately 8 weeks without treatment.
Sequences of management :
1.Reassuring the patient
a. Speak with the patient personally.
b. Explain that paraesthesia is not uncommon after LA administration.
c. Arrange an appointment to examine the patient.
d. Record the incident on the dental chart.
2.Examine the patient
a. determine the degree and extent of paraesthesia.
b. Explain to the patient that paraesthesia normally persists for atleast 2 months.
3.Reschedule the patient for examination every 2 months.
4.If sensory deflict is still more than 1 year, consultation with neurologist and oral
surgeon.
5.Use alternate local anaesthesia techniques if possible.
FACIAL NERVE PARALYSIS
Facial nerve paralysis occurs when anaesthesia is
introduced into the deep lobe of the parotid gland,
through which terminal portions of the facial nerve
extend.
CAUSES
Facial nerve paralysis is commonly caused by the introduction of LA into the
capsule of the parotid gland, which is located at posterior border of the
mandibular ramus.
Usually it occur durning inferior alveolar nerve block or Vazirani-Akinosi
nerve block.
PROBLEMS:
Loss of motor function to the muscle of facial expression produced by LA
deposition is normally transitory it lasts no more than several hours.
Durning this time the patient has unilateral paralysis and be unable to use
these muscles.
The primary problem associated with FNP is cosmetic, the person’s face
appears lopsided.
A secondary problem is that the patient is unable to voluntarily close one
eye.
PREVENTION:
Transient FNP is almost preventable by adhering to protocol with the inferior
alveolar and Vazirani-Akinosi nerve blocks.
Proper care and handling to infection control and cartridge.
There is no contact with bone durning the Vazirani-Akinosi nerve block,
overinsertion of the needle either absolute or relative should be avoided if
possible.
MANGEMENT:
Reassure the patient. Explain that the situation transient, will lasts for a few
hours.
Contact lenses should be removed until muscular movement returns.
An eye patch should be applied to the affected eye until muscle tone
returns. Keep the cornea lubricated.
Record the incident on the patient’s chart.
Click icon to add picture
TRISMUS
Trismus is defined as a prolonged tetanic spasm of the
jaw muscles by which the normal opening of the mouth
is restricted.
-Pain and difficult of opening often after posterior
superior alveolar or inferior alveolar nerve block.
-Onset 1-6 days post-treatment.
CAUSES:
Trauma to muscles or blood vessels in the infratemporal fossa is the
common etiological factor.
Local anaesthetic solution contaminated by alcohol or cold sterilizating
solution produce irritation of the muscles.
Hemorrhage is another cause of trismus.
Low-grade infection after injection.
PREVENTION :
Use a sharp, sterile, disposable needles.
Properly care for and handle dental local anesthetic cartridges.
Use aseptic techniques.
Practice atraumatic insertion and injection techniques.
Avoid repeat injections and multiple insertions into the same area through
knowledge of anatomy and proper techniques.
Use minimum effective volumes of local anaesthetic.
MANGEMENT:
Heat therapy consists of applying hot, moist towels to the affected area for
20 minutes every hour.
Warm saline rinse.
Analgesics in manging pain (eg:aspirin-325mg)
Diazepam (10mg bid) or other benzodiazepine is used for muscle relaxation.
Patient advised to initiate physiotherapy for 5 min every 3 to 4 hours.
If there is infection, antibiotic prescribed for 7 days.
Surgical intervention in some cases.
SOFT TISSUE INJURY
Trauma to the lips and tongue is frequently caused by the patient biting or chewing these
tissue while still anaesthetized specially with children.
CAUSES:
1.Trauma occurs most frequently in younger children and in mentally or physically disabled
children or adults.
2.The primary cause is the fact that soft tissue anaesthesia lasts longer than pulpal
anaesthesia.
PROBLEMS
1. Trauma to anesthetized tissues can lead to swelling and significant pain when the
anaesthetic effects resolve.
PREVENTION:
A cotton roll can be placed between the lips and teeth if they are still
anaesthetized at the time of discharge.
Warm the patient and guardian against eating, drinking hot fluids and biting
on the lips or tongue to test for anaesthesia.
A self-adherent warning sticker may be used on children. It states ‘watch
me, my lips and cheeks are numb’.
MANGEMENT:
Analgesics for pain, as necessary.
Antibiotics, as necessary in the unlikely situation that infection 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 minimize irritation.
HEMATOMA
-The effusion of the blood into extravascular spaces can result from
inadvertently a blood vessels.
-Caused by nicking to the artery or vein.
-Most occurv with IANB and PSA nerve block.
-7 to 14 days the hematoma will be presented.
CAUSES:
Because of the density of tissues in the hard palate and its firm adherence
to bone, hematoma rarely develops after a palatal injection.
Hematomas after IANB are usually visible intraorally whereas PSA
hematomas visible extraorally.
PREVENTION:
Knowledge of the normal anatomy involved in the proposed injection is
important. Certain techniques have a greater risk of hematoma.
Use a short needle for the PSA nerve block to decrease the risk of
hematoma.
Minimize the number of needle penetrations into tissues.
Never use a needle as a probe in tissues.
MANGEMENT
A.Immediate :-
when swelling become evident durning or immediately after LA injection, direct
pressure should be applied to the site of bleeding.
The pressure should be applied for not less than 2 minutes.
B.Inferior alveolar nerve block:-
Pressure is applied to medial aspects of the mandibular ramus.
Clinical manifestation-
Possible tissue discolouration and probable tissue swelling on the medial aspects of
mandibular ramus.
Anterior superior alveolar nerve block:-
Pressure is applied to the skin directly over the infraorbital foramen.
Clinical manifestation:
Discolouration of the skin below the lower eyelid.
Incisive nerve block:-
Pressure is placed directly over the mental foramen, on the skin or
mucous membrane.
Clinical manifestation:
Discolouration of skin over the mental foramen or swelling in the
mucobuccal fold in the region of the mental foramen.
Buccal nerve block:-
Place pressure at the site of bleeding.
Posterior superior alveolar nerve block:-
The posterior superior alveolar nerve block usually produces the
largest and most esthetically unappealing hematoma.
The infratemporal fossa, into which bleeding occurs,
can accommodate a large volume of blood.
Subsequent:-
Advice the patient about possible soreness and limitation of
movement(trismus)
If soreness develops, advise the patient to take an analgesics such as
aspirin.
Ice may be applied to the region immediately on recognition of a developing
hematoma.
Time is the most important element in manging a hematoma.
PAIN ON INJECTION
Pain on injection of a LA can best be prevented through careful adherence to
the basic protocol of atraumatic injection.
CAUSES:
Careless injection and callous attitude all too often become self-fulfilling
prophesies.
A needle can became dull from multiple injections.
Rapid deposition of the LA solution may cause tissue damage.
Needles with barbs may produce pain as they are withdrawn from tissues.
PREVENTION:
Adhere to proper techniques of injection both anatomical and psychological.
Use sharp needles.
Use topical anaesthetic properly before injection.
Use sterile local anaesthetic solutions.
Inject local anaesthetic slowly.
Be certain that the temperature of the solution is correct.
MANGEMENT:
Mangement is not necessary.
BURNING ON INJECTION
CAUSES:
A burning sensation durning injection of a LA is not uncommon.
The primary cause of a mild burning sensation is the pH of the solution
being deposited into the soft tissues.
Rapid injection of LA
Contamination of the local anaesthetic cartridges
Solutions warmed to normal body temperature.
PREVENTION:
Slowing the injection should help. The idel rate is 1 mi/min. Don’t exceed
the recommended rate of 1.8ml in 1 minute.
The cartridge of anaesthetic should be stored at room temperature either in
the container or in asuitable container without alcohol or other sterilizing
agents.
In ophthalmology and dermatology , surgeon commonly ‘alkalinize’ the LA
before their injection to make the injection more comfortable for the patient.
INFECTION
Infection after the LA administration in dentistry has become an extremely
rare because of the introduction of sterile disposable needles and glass
cartridges.
CAUSES:
-Contamination of a needle always occurs when the needle touches mucous
membrane in the oral cavity.
PREVENTION:
Use sterile disposable needles.
Properly care for and handle needles.
Properly care for and handle dental cartridge of LA .
a. Use a cartridge only once.
b. Store cartridge aseptically in their original container.
c. Cleanse the diaphragm with a sterile disposable alcohol wipe
immediately before use.
Properly prepare the tissues before penetrations. Dry them and apply topical
antiseptic.
MANGEMENT:
The patient start on a 7-10 day course of antibiotics.
example: Penicillin V -250 mg qid
EDEMA
CAUSES:
Trauma durning injection.
Injection
Allergy : Angioedema is a common response.
Hemorrhage
Injection of irritating solution
Hereditary angioedema is a condition characterized by sudden onset of
brawny nonpitting edema affecting the face,extremities.
PREVENTION:
Properly care for and handle the LA armamentarium.
Use atraumatic injection technique.
Complete an adequate medical evalution of the patient before drug
administration.
MANGEMENT:
Minimal degree edema – Just analgesic for pain and will resolve in several
days.
If larger degree edema and sign and symptoms of injection – Antibiotic
should be prescribed.
SLOUGHING OF TISSUES
CAUSES:
EPITHELIAL DESQUAMATION:-
1. Application of a topical anaesthetic to the gingival tissues for a prolonged
period.
2. Heightened sensitivity of the tissue to a local anaesthetic.
3. Reaction in an area where a topical has been applied.
STERILE ABSCESS:-
4. Secondary to prolonged ischemia.
5. Usually develops on the hard palate.
PREVENTION:
1. Use topical anaesthetic as recommended.
2. Allow the solution to contact the mucous membrane for 1 to 2 min to
maximize its effectiveness and minimize toxicity.
3. When using vasoconstrictors for hemostasis, do not use overly
concentrated solutions.
MANGEMENT:
4. Usually no formal management is necessary
5. Be certain to reassure the patient of this fact.
6. For pain, analgesics such as aspirin or codeine and a topically applied
ointment to minimize irritation.
7. Epithelial desquamation resolves within a few days.
8. Record data on the patient’s chart.
POSTANAESTHETIC INTRAORAL LESIONS
Patient report that 2 days after an intraoral injection of LA, ulcerations developed in their
mouth. The primary intial symptoms is PAIN.
CAUSES:
Recurrent aphthous stomatitis or herpes simplex can occur intraorally after a local anaesthetic
injection.
RECURRENT APHTHOUS STOMATITIS:-
Most common oral mucous disease
Developing on gingival tissues that are not attached to underlying bone.
HERPES SIMPLEX:-
Develops intraorally but commonly observed extraorally.
It is viral and became manifest as small bumps on tissues that are attached to underlying
bone.
TRAUMA TO TISSUE:-
Trauma to tissue by a needle, LA solution, cotton swab or any other instrument may activate
the latent form of the disease.
PREVENTION:
1. Unfortunately, there is no means for preventing these intraoral lesions from
developing in susceptible patients.
2. Extraoral herpes simplex may be prevented if treated in its prodromal
phase.
3. Antiviral agents such as acyclovir applied qid to the affected area minimize
the acute phase.
MANGEMENT:
1. Reassure the patient that the situation is not caused by a bacterial
infection secondary to LA injection.
2. No management is necessary if the pain is not severe.
3. Topical anesthetic solution (eg: viscous lidocaine) may be applied as
needed to the painful area.
4. A tannic acid preparation can be applied topically to the lesions either
extraorally or intraorally.
5. The ulceration usually last 7 to 10 days with or without treatment.
REFERENCE
1. HANDBOOK OF LOCAL ANESTHESIA 5TH EDITION –STANLEY F MALAMED
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