Complications Of Dental Local Anesthesia

COMPLICATIONS OF LOCAL ANESTHESIA Hesham El-Hawary
COMPLICATIONS
OF
LOCAL

ANESTHESIA

Dr.
Hesham
El-‐Hawary

Lecturer
OMFS

Faculty
of
Oral
&
Dental
Medicine

Cairo
University

Luqman

-‐
14
| ۱٤ - ‫لقمان‬ ‫
سورة‬

ComplicaJons

Any
devia&on
from
the
normally
expected

paKern
during
or
aMer
securing
local

analgesia

ComplicaJons

Any
devia&on
from
the
normally
expected

paKern
during
or
aMer
securing
local

analgesia

Classiﬁca&ons

§  Primary
or
Secondary

§  Mild
or
Sever

§  Transient
or
Permanent

§  AKributed
to
soluJon
or
needle
inserJon

ComplicaJons
from
local
Anesthesia

I.  ComplicaJons
associated
to
the

absorpJon
of
the
soluJon
used

II.  ComplicaJons
associated
with

needle
inserJon

ComplicaJons
associated
with
absorpJon
of
the

anestheJc
soluJon

1.  Systemic
drug
reac&ons
due
to
the
local
anesthe&c
agent:

1.  Toxicity

2.  Allergy

3.  AnaphylacJc
reacJons

4.  Idiosyncrasy

2.  Local
reac&ons:

1.  InfecJons
due
to
contaminated
soluJons

2.  Local
Jssue
irritaJon

ComplicaJons
associated
with
needle
inserJon

1.  FainJng
and
syncope

2.  Muscle
trismus

3.  Pain

4.  Edema

5.  InfecJon

6.  Broken
needles

7.  Prolonged
anesthesia

8.  Haematoma
formaJon

9.  Sloughing
and
ulceraJon

10. Bizarre
Neurological
symptoms

Keep
in
mind

•  A:
Airway

»  Clear

»  Adequate
RespiraJon

•  B:
Bleeding

»  Stopped

»  Achieve
inlet
to
vessels

•  C:
CirculaJon

»  Fluids
if
needed

•  D:
Drugs
to
treat
the
present
condiJon

Keep
in
mind

•  Call
medical
emergency
service

•  The
paJent
posiJon

–  Placed
in
horizontal
posiJon
on
his
back

–  Tilt
the
paJent
in
a
slightly
head
down
posiJon

or

–  elevate
the
legs
to
help
increase
cerebral
circulaJon

•  Adequate
oxygenaJon

•  Check
the
paJent's
cardiac
and
cardiovascular
status

•  Start
I.V.
ﬂuids
(e.g.
5%
dextrose
in
H2O)

•  Drugs
according
to
the
condiJon

•  If
complete
circulatory
standsJll

–  IV
injecJon
of
atropine

–  SJmulaJon
of
the
heart
by
introducing
a
needle
directly
into
it

–  Intracardiac
injecJon
of
epinephrine
0.1
ml
of
1.1000
soluJon

ComplicaJons
due
to
absorpJon
of
the

injected
soluJon

Systemic
complicaJons

1.  Toxicity

2.  Idiosyncrasy

3.  Allergy

4.  Anaphylaxis

•  DeﬁniJon

•  EJology

•  Clinically
(Signs
&
Symptoms)

•  PrevenJon

•  Treatment

Toxicity

DeﬁniJon

It
refers
to
the

symptoms
manifested
as
a
result
of

overdosage
or
excessive
administra&on

of
the
soluJon

EJology

•  Large
dose
of
drug

•  Accidental
intravenous
injecJon

•  High
concentra&on
of
a
drug

•  Unusually
slow
detoxiﬁca&on
as
a
result
of

severe
liver
disease

•  Slow
elimina&on
as
a
result
of
kidney
trouble

•  Use
of
highly
toxic
drugs
whose
margin
of
safety

is
narrow

•  InjecJon
of
soluJon
in
highly
vascular
area

without
the
addiJon
of
vasoconstrictor

substance

Clinically

I.  Early
C.N.S.
s&mula&on
symptoms

1) Cerebral
Cortex

1. TalkaJve

2. Restlessness

3. Apprehensive

4. Excited

5. Convulsive

2) Medulla

1. Lethargy

2. Sleepiness

3. Unconscious

Clinically

II.  Late
C.N.S.
Depression
symptoms

3) Cerebral
Cortex

1. Increased
blood
pressure

2. Increase
pulse
rate

3. Increase
respiratory
rate

4. Nausea
&
vomiJng

4) Medulla

1. Dropped
blood
pressure

2. Decreased
pulse
rate

3. Decreased
heart
rate

4. Respiratory
depression

5. unconsciousness


N.B.

Death
usually
occur
due
to
respiratory

depression
and
hypoxia
and
its
subsequent

eﬀect
on
the
cardiovascular
system

PrevenJon

1.  Pre-‐analgesic
evalua&on
of
the
paJent

2.  Use
the
weakest
possible
concentraJon

3.  Use
vasoconstrictor
whenever
possible

4.  Use
of
the
least
possible
volume

5.  Aspirate
before
injecJon

6.  Slow
injecJon

7.  Monitor
the
paJent
carefully
aMer

injecJon

Treatment

•  Mild
S&mula&on

– No
treatment

– Stop
further
injecJon

•  Moderate
sJmulaJon

•  Convulsions
phase

•  Depression
phase

Treatment

•  Mild
SJmulaJon

•  Moderate
s&mula&on

– IV
injecJon
of
Barbiturates

•  0.2%
soluJon
of
sodium
thiopental

•  Secobarbital
(Seconal)

– Oxygen
inhalaJon

•  Convulsions
phase

•  Depression
phase

Treatment

•  Mild
SJmulaJon

•  Moderate
sJmulaJon

•  Convulsions
phase

– AnJconvulsent
IV
/
IM

•  Coramine
(150-‐450
mg.
I.V.)

•  Metrazol
(100
mg
I.V.)
(Midazolam
or
Diazepam)

•  Wyamine
(7.5
mg
I.V.
or
15
mg
I.M.)
or
neosynephrine

– Oxygen
inhalaJon

•  Depression

Treatment

•  Mild
SJmulaJon

•  Moderate
sJmulaJon

•  Convulsions
phase

•  Depression
phase

– ArJﬁcial
RespiraJon

– IV
ﬂuids

– SympathmemeJc
drugs

Vasoconstrictor
Toxicity

•  DefiniJon

•  EJology

•  Clinically

– PalpitaJon

– Tachycardia

– Hypertension

– Headache

– Apprehension

– Restlessness

– N.B.
Difficult
to
differenJate
from
those
of
L.A.
Agent

•  PrevenJon
and
treatment

Idiosyncrasy

DeﬁniJon

•  Abnormal
reacJon
to
a
drug
or
group
of
drugs

exhibited
when
only
a
small
amount
or
a

nontoxic
dose
of
the
drug
has
been
used

•  This
means
that
the
suscepJble
paJent
reacts

adversely
to
a
volume
or
concentraJon
of
the

drug
that
would
not
aﬀect
the
typical
paJent

•  Nontoxic
–
Non
Allergic
condiJon

EJology

•  Unknown

•  Enzymopathy

– Congenital

– Acquired

•  Psychogenic

Clinically

1.  Pallor

2.  Tachycardia

3.  Hypotension

4.  Decreased
Heart
rate

5.  Collapse

PrevenJon

1. Do
not
use
any
drug,
which
the
paJent
gives
you
a

history
of
previous
reacJons
to
it

2. Inject
slowly
and
observe
the
paJent
closely
during

injecJon

PrevenJon

1. Do
not
use
any
drug,
which
the
paJent
gives
you
a

history
of
previous
reacJons
to
it

2. Inject
slowly
and
observe
the
paJent
closely
during

injecJon

Treatment

•  The
same
as
the
depression
stage
of
toxic
overdose

•  Barbiturates
are
ineﬀecJve
in
the
treatment
or

prevenJon
of
this
condiJon

Allergy
and
Anaphylaxis

•  Allergy
is
a
hypersensi&ve
reac&on
that

occurs
through
exposure
to
an
an&gen

(Ag)
such
as
a
drug
(
as
L.A.
agent)
which

the
pt.
has
been
previously
exposed
to
it

creaJng
an
Ag
-‐
Ab
reacJon

•  Anaphylaxis
is
a
severe
form
of
allergic

reacJons
occurs
suddenly
&
end
fatally
in

which
sudden
violent
loss
of
vasomotor

tonus

DeﬁniJon

•  Allergy
is
a
hypersensi&ve
reac&on
that

occurs
through
exposure
to
an
an&gen

(Ag)
such
as
a
drug
(
as
L.A.
agent)
which

the
pt.
has
been
previously
exposed
to
it

creaJng
an
Ag
-‐
Ab
reacJon
•  Anaphylaxis
is
a
severe
form
of
allergic

reacJons
occurs
suddenly
&
end
fatally
in

which
sudden
violent
loss
of
vasomotor

tonus

DeﬁniJon

Allergy

1.  Rashes

2.  UrJcaria

3.  Fever

4.  DermaJJs

5.  AngioneuroJc
edema

6.  Bronchial
asthma

7.  Anaphylaxis(
anaphylacJc
shock)

Clinically

Anaphylaxis

1.  Drop
in
B.P.
(↓B.P.)

2.  Weak
rapid
pulse

3.  Inadequate
respiraJon
(↓Respiratory
rate)

4.  Death

Clinically

1.  An&histaminic

(benadryl
20
-‐
40
mg
IV
or
IM.)

2.  Epinephrine
1:1000
concentraJon

0.3
mg
SC.
or
IM.

3.  Bronchodilator

via
inhaler

4.  Cor&costeroid

100mg
IV.
hydrocorJsone
hemisuccinate

Management

ComplicaJons
due
to
absorpJon
of
the

injected
soluJon

Local
ReacJons

1.  InfecJon

2.  Tissue
irritaJon

InfecJon

InfecJon
from
contaminated
L.A.
soluJons
are

uncommon
due
to
high
standard
of
asepsis
during

manufacturing

Tissue
Irrita&on

Local
Jssue
irritaJon
through
the
use
of
non

isotonic
L.A.
soluJons
are
uncommon
due
to
high

standard
of
manufacturing

ComplicaJons
associated
with
needle

inserJon

FainJng
or
Syncope

•  It
is
due
to
temporary
cerebral
ischemia
as
a

result
of
dilaJon
of
the
splanchnic
B.V.
&

reduced
cardiac
output

•  Signs
&symptoms:

1. Pallor

2. Cold

3. Sweaty

4. Dizzy

5. Nausea

6. Loss
of
consciousness

Ø  Management:

•  Stop
dental
procedure

•  Place
pt.
in
supine
posiJon
with
slight
head
down

or
elevate
the
legs
(
to
↑ cerebral
circulaJon)

or

•  Place
the
hands
of
the
pt.
behind
his
head
and

bend
him
forward
unJl
his
head
is
in
between
the

knee(
to
produce
pressure
on
the
splanchnic
B.V.

to
replace
the
blood
that
drained
from
the
head

•  Reassure
pt.

•  AromaJc
spirit
(ammonia)
held
under
the
nose
of

the
pt.
for
several
breath

Muscle
Trismus

•  Inability
to
open
the
mouth
normally

•  EJology:

–  InjecJng
into
muscles
or
ligaments

–  Needle
borne
infecJon

–  Contaminated

irritaJng
soluJons

–  Haematoma
formaJon
in
the
muscle

•  Preven&on:


Depends
upon
the
cause

–  If
it
is
due
to
trauma
it
necessitates
slight
muscle

exercise
and
drug
therapy
to
relieve
pain
if
present

–  If
due
to
infecJon
this
needs
anJbioJcs

1.  Heat
therapy

2.  Warm
saline
rinses

3.  Analgesics

4.  Muscle
relaxant

Pain

•  E&ology:

–  InjecJon
into
a
muscle
or
ligament,
paroJd
gland,

T.M.J.

–  Using
a
non-‐isotonic
soluJon

–  Very
cold
soluJons

–  Contaminated
soluJons

–  Too
rapid
injecJon
resulJng
in
Jssue
distenJon

–  Numerous
needle
punctures

•  PrevenJon


1.  Assure
the
pt.

2.  Analgesics

Edema

•  It
is
usually
a
symptom

•  EJology:

–  Trauma

–  InfecJon

–  Allergy

–  Hemorrhage

•  Treatment
and
prevenJon
depends
upon
the

cause

InfecJons

•  EJology:

–  Contaminated
Non-‐sterile
needles
or
soluJons

–  Carrying
surface
bacteria
from
non-‐sterile
mucous

membrane
into
the
deeper
structures
with
the
Jp
of

the
needle
are
the
causaJve
factors

–  InjecJon
into
infected
area

•  PrevenJon


–  AnJbioJcs

–  AnJnﬂammatory
drugs

Broken
needles

•  Do
not
use
old
or
dull
needles

•  Do
not
use
short
needles
for
nerve
block

•  Do
not
aKempt
to
force
the
needle
against

resistance

•  Do
not
change
the
direcJon
of
the
needle

while
it
is
embedded
in
the
Jssues,
always

remove
it
and
redirect
it

•  Do
not
use
a
needle
of
a
too
ﬁne
gauge

•  Warn
the
paJent
against
any
movement
during

injecJon
and
ask
him
to
stay
sJll
Jll
you
ﬁnish
the

injecJon

•  Do
not
surprise
the
paJent
with
a
sudden
unexpected

needle
inserJon

•  Do
not
insert
the
needle
so
far
that
it
is
out
of
sight
in

Jssues

•  Needles
should
not
be
sterilized
by
ﬂaming
because

the
tamper
of
their
alloy
will
be
destroyed
and
they

break
easily


On
most
occasions
accidental

breakage
takes
place
at
the
hub

This
enables
the
operator
to
remove

the
broken
needle
by
grasping
the

porJon
remaining
in
view

Prolonged
Anesthesia

•  EJology:

–  ContaminaJon
of
the
anestheJc
soluJon
with
alcohol
or
some
other

germicidal
soluJon

–  Needle
trauma
to
nerve
Jssue

•  This
is
manifested
at
the
Jme
of
injecJon,
the
paJent
reports

immediately
feeling
a
hot
sharp
pain
ﬂushing
to
the
terminal

branches
of
the
nerve
trunk
contacted

–  Trauma
and
swelling
of
the
soM
Jssue
in
proximity
to
the
nerve


1.  Assure
the
pt.

2.  It
takes
some
Jme
to
disappear

Haematoma
and
Ecchymosis

•  The
eﬀusion
of
blood
into
the
Jssues
as
a
result
of

punctured
B.V.
leading
to
haematoma
formaJon

•  Common
sites:
maxillary
tuberosity
region

Ø Management:

1. No
aKempt
should
be
made
to
aspirate
the
contents
of

the
haematoma

2. It
will
absorb
with
Jme
(7
–
14)
days

3. Ice
packs
may
be
applied
iniJally
to
act
as
analgesic
&
a

vasoconstrictor
to
reduce
size
of
haematoma

Sloughing
and
UlceraJon

•  Trauma&c
ulcers

–  Appear
on
the
palate
from
excessive
amount
of
soluJon
injected
into
the

dense
mucoperiosteal
Jssue
of
the
palate

•  Chewing
the
lip
following
a
mandibular
injecJon

•  Pinching
of
the
lip
between
the
forceps
and
the
teeth

•  ApplicaJon
of
topical
anesthe&c
may
cause
irritaJon
to
m.m.
lead

to
sloughing
&
ulceraJon


Usually
resolves
within
a
few
days
or
one
week
without
any

intervenJon

Bizarre
Neurological
Symptoms

•  Very
rare

–  Facial
paralysis

–  Crossed
eyes

–  Muscular
weakness

–  Temporary
blindness

•  The
best
method
of
prevenJng
these

complicaJons
is
to
follow
closely
the

accepted
techniques
described
above

Thank
You
Thank
You

Complications Of Dental Local Anesthesia

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