COMPLICATIONS OF LA

PRESENTED BY: Dr SHERMIL SAYD

Broadly classified into two sections
Local complications
Systemic complications


Local complications
Needle breakage
Paresthesia
Facial nerve paralysis
Trismus
Soft tissue injury
Hematoma
Pain on injection
Burning on injection
Infection
Edema
Sloughing of tissues
Post anesthetic intra oral lesions
Needle breakage

Rare occurrence now due to the introduction
of disposable needles
Causes:
Weakening of the dental needle by bending
Sudden unexpected movement by the patient,
more likely in pediatric patients
Finer needles are more likely to break
Needles that have been previously bent
Defective manufacturing
Problem:
Can be left of the in the tissue if its removal will cause
more extensive damage
Infections arising from these needles are very much
rare
They usually gets embedded in the scar tissue
Prevention
Dont bend the needle
Use thicker needles
Use long needles rather than short ones
Do not insert needles upto its hub
Do not redirect the needle once it is more than
halfway through

Management
1. When a needle breaks
a) Do not panic
b) Instruct the patient not to move, keep the hand inside and
mouth open
c) If the fragment is visible, remove it
2. If the needle is not visible and not retrievable
1. Do not probe or incise
2. Calmly inform the patient
3. Note the incident on the patients chart
4. Refer the patient to an oral surgeon



Immediate removal of broken needle only if
Needle is superficial and easily located through the
radiological and clinical examination
If the attempt proves t be futile for a considerable
amount of time, then the needle should be left as it is
The needle is located in deeper tissues, then it should
be allowed to remain there without an attempt

Paresthesia
Defn: persistent anesthesia or altered sensation well
beyond the expected duration of anesthesia
Causes:
Trauma to the nerve
Injection of the LA solution contaminated with alcohol(
they are also neurolytic and may cause long term damage
to the nerve
Trauma to the nerve sheath during the insertion of the
needle
Insertion of a needle in to the foramen
Hemorrhage around the nerve sheath
LA solution itself(haas and lennon-1993)
Problems:
Can lead to self inflicted injury
Sense of taste impaired, LN involvement
Prevention:
Strict adherence to the injection protocol

Management:
Be reassuring
Speak to the patient personally
Explain
Appointment to examine the patient
Record the incident in the dental chart
Examine the patient
Determine the extent and the degree
Explain to the patient that it may persist for upto 1 year
Tincture of time- reccommended medicine
Record all the findings


Reschedule the patient for examination every two
months
If sensory deficit present more than one year,
consultation with a neurologist is recommended
Dental treatment may be continued, but avoid
injecting the LA solution into the same region
again


Facial nerve paralysis
Cause:
Introduction of the LA solution into the parotid capsule
Directing the needle inadvertently posteriorly during IANB
Over insertion during vazirani akinosi
Problem:
Loss of motor function of the muscles of facial expression
Usually transitory
Minimal sensory loss
Unilateral facial paralysis- face appears lopsided
Unable to close the eye o the affected side
Prevention:
Adhere to the protocol
Over insertion during vazirani akinosi should be avoided when
possible
Management
Reassure the patient
Contact lenses should be removed until muscular movements
return
An eye patch should be given for the eye on the affected side
Record in chart
Although there is no contraindication for reanesthesia, it will be
prudent at this point
Trismus
Prolonged tetanic spasm of the jaws by which
normal opening of the mouth is restricted
Causes:
Trauma to the muscles or blood vessels in the
infratemporal fossa
Contaminated LA solution being injected into the site
Injection of LA IM or supramuscularly
Hemorrhage
Low grade infection after injection
Multiple needle penetration


Problem
The average interincisal opening is
13.7mm(range5-23mm)
Acute phase- leads to muscle spasm and limitation
of movement
Chronic hypomobility associated with organization
of the hematoma, with subsequent fibrosis and
scar contracture


Prevention
Use a sharp, sterile, disposable needle
Properly care for and handle dental LA catridges
Use aseptic technique
Practice atraumatic insertion and injection
technique
Avoid repeat injections
Use minimum effective volumes of LA
Management
With mild pain and dysfunction the patient
reports minimum difficulty opening the mouth
The patient should be prescribed with heat
therapy, warm saline rinses, analgesics and if
necessary muscle relaxants
The patient should be advised to initiate
physiotherapy consisting of opening and closing of
the mouth
Sugarless chewing gums can also be prescribed
If the needed dental treatment in the affected
area is urgent, then alternate techniques like
vazirani akinosi technique can be used
Usually there I will be an improvement after
after24-48hrs
Therapy should be continued until the patient is
free of symptoms
If the pain and dysfunction continues abate
48hrs, then infection should be suspected and
antibiotics should be added into the regimen
Other therapies which include ultrasound or
appliances also can be used in these situations
Surgical interventions may be necessary to
correct the chronic dysfunction
Soft-tissue injury
Self inflicted trauma to the lips and tongue is
frequently caused by the patient inadvertently
biting o chewing these tissues while still
anesthetized
Cause:
Common in children, physically and mentally
disabled
It occurs due to the prolonged anesthesia of the
soft tissues than that of the pulp



Problem:
Trauma to anesthetized tissues can lead to swelling
and significant pain when the anesthetic effect
resolves
Remote instances of development of infection
Prevention:
A cotton roll can be placed between the lips and the
teeth secured with floss wrapped around the teeth
Warn the patients guardian about this
A self adherent warning sticker can be used on
children on their forehead

Management
Analgesics for pain as necessary
Antibiotics as necessary
Lukewarm saline rinses to reduce the swelling and
pain
Petroleum jelly to cover up the lip lesion

Hematoma
The effusion of blood into extravascular space is
called as hematoma
Cause
A large hematoma may develop from either arterial or
venous puncture following a PSA or IA nerve block
The tissues surrounding this vessels more readily
accommodate significant volumes of blood and
continues to do so until clot forms
IANB hematomas are visible only intraorally while PSA
hematomas are visible extraorally
Problems:
Includes pain and trismus
Swelling and discoloration usually subsides within 7-14
days
Prevention:
Knowledge of normal anatomy
Modify the injection technique based upon the patients
anatomy
Use a short needle for PSA to reduce the risk of hematoma
Minimize the number of needle penetrations into tissue
Never use a needle as a probe in tissues
Management:
Immediate:
When swelling becomes evident during the injection,
pressure should be applied over the area, for not less than 2
mins
For IANB, pressure applied onto the medial aspect of the
ramus
For ASA, pressure is applied on the skin directly over the
infraorbital foramen
For mental nerve block, placed directly over the mental
foramen
Buccal nerve block or palatal injection, at the site of bleeding
For PSA, digital pressure applied in the mucobuccal fold as
far distally as possible. Icepack extraorally
Subsequent:
Advise the patient about the possible soreness and
limitation of the movement
If soreness develops, advise analgesics
Heat may be applied to the area from the next day
onwards to increase the rate of resorption of the clot
Tincture of time is the most important factor in the
management of trauma

Pain on injection
Causes:
Careless injection technique
A needle can become dull from multiple injections
Rapid deposition of the anesthetic solution may cause
tissue damage
Needles with barbs also cause pain
Problem:
Can lead to increase in patient anxiety and may lead
sudden and unexpected movement increasing the risk
of needle breakage
Prevention:
Proper technique of injection
Use sharp needles
Use topical anesthetic before injection
Use sterile local anesthetic solution
Inject slowly
Be certain that the temperature of the solution is
correct
Management:
No management necessary
Burning on injection
Causes:
Primary cause is the pH of the solution
Rapid injection of the local anesthetic solution
Contaminated local anesthetic solution
Solution warmed to body temperature are
considered too hot by the patient
Problems:
Although transient, may lead to postanesthetic
trismus, edema, or possible paresthesia

Prevention:
Slow injection,1ml/min. recommended rate of
1.8ml/min should not be exceeded
Cartridge should be stored at room temperature
Management:
No immideate management necessary
Infection
Cause:
Contamination of the needle before
administration
Improper technique in handling the LA equipment
Injecting the LA solution into an area of infection
Problem:
Can cause infection and lead to trismus
Prevention:
Use sterile disposable needles
Proper care for handling of the needles and catridges
Properly prepare the tissues before injection
Management:
Immediate treatment consists of antibiotics and
analgesics, muscle relaxant if needed and
physiotherapy
Antibiotics should be started for a 7-10 day course
Penicillin is the drug of choice and erythromycin, if
allergic to penicillin


Edema
Causes:
Trauma during injection
Infection
Allergy
Hemorrhage
Injection of irritating solution
Hereditary angioedema
Problem:
Angioneurotic edema produced can cause airway
obstruction
Edema of the tongue, larynx or pharynx may develop
and represent a potentially life threatening situation.
Prevention:
Proper handling of the LA armamentarium
Atraumatic injection technique
Complete medical evaluation
Management
When produced by traumatic injection or introduction
of irritating solutions, edema is of low degree and
resolves without any formal therapy
Analgesics for pain can described
after hemorrhage edema resolves more slowly
Edema due to infection doesnt subside
spontaneously but may in fact become more
progressively more intense if untreated
Allergy induced edema is potentially life threatening


If edema causes airway obstruction, then
P- if unconscious, the patient placed supine
A-B-C- BLS administered as required
D- definitive treatment: EMS summoned
Epinephrine is administered: 0.3mg(adult),
0.15mg(child)IM or IV every 10-15 mins until respiratory
distress resolves
Histamine blocker is administered
Corticosteroid IM/IV
Preparation for cricothyrotomy should be done if total
airway obstruction seems to be developing
Patients should be evaluated thoroughly before the next
appointment

Sloughing of tissues
Causes
Epithelial desquamation:
Application of the topical anesthetic to the gingival
tissues for prolonged period
Heightened sensitivity of tissues to a LA agent
Reaction in an area where a topical has been applied
Sterile abscess-
Secondary to prolonged ischemia resulting from the
use of LA with vasoconstrictor
Usually develops on hard palate

Problems:
Pain
Infection in these areas
Prevention
Use topical anesthetics as recommended
Do not use overly concentrated solutions containing
vasoconstrictor
Management:
No formal management necessary
Symptomatic management

Post anesthetic intraoral lesions
Cause:
Recurrent apthous stomatitis or herpes simplex can
occur after the injection of the local anesthetic
solution
Trauma to tissues by a needle or cotton swabs or any
other instrument may activate the latent form of the
disease process that was present in tissues before
injection
Problem:
c/o acute sensitivity in the ulcerated area

Management:
Primary management- symptomatic
Pain develops after 2 days
No management is necessary if the pain is not
severe
Preparations can be used to reduce the pain and
irritations caused by these lesions
Ocular problems
signs and symptoms including tissue blanching,
hematoma formation, facial paralysis, diplopia,
amaurosis, ptosis, mydriasis, miosis,
enophthalmos, and even permanent blindness
have been reported
The mechanism of action is not fully understood
Aspiration at the time of administration of local
anesthesia is very important and minimizes the
risk of ocular complications.
When ocular complications persist, an
ophthalmology consultation is prudent
Systemic complications
Caused by adverse drug reaction.
There are mainly three types of complications
Allergic reactions
Toxicity
Methemoglobinemia



Allergic reactions
Allergic reactions due to the administration of
local anesthesia are uncommon but can occur
There are a few different tests that can be used
by the allergist to document an allergy to local
anesthesia, such as the skin prick test, the
interdermal or subcutaneous placements test,
and/or the drug provocative challenge test(gold
standard)
Allergies to local anesthetic may be type I or type
IV hypersensitivity reactions, with the type I
response more commonly reported
type I
symptoms include skin manifestations (erythema,
pruritus, urticaria), gastrointestinal manifestations
(muscle cramping, nausea and vomiting, incon-
tinence), respiratory manifestations (coughing,
wheezing, dyspnea, laryngeal edema), and cardio-
vascular manifestations (palpitations, tachycardia,
hypotension, unconsciousness, cardiac arrest)
Treatment
depends on the severity of the reaction.
Mild- managed by oral or intramuscular
antihistamines, such as diphenhydramine, 25 to 50
mg.
If serious signs or symptoms develop, immediate
treatment becomes necessary, and this includes basic
life support, intramuscular or subcutaneous epineph-
rine 0.3 to 0.5 mg, and activating the emergency
response system for transportation to the local
hospital for acute therapy.51
Toxicity
Toxicity can be caused by excessive dosing of
either the local anesthetic or the
vasoconstrictor
Cause:
inadvertent intravascular injection
repeated injections of the local anesthetic
excessive volumes are used in pediatric dentistry
Prevention
Adhering to local anesthetic dosing guidelines
simple way to calculate maximum safe dosages for
all anesthetic formulations used in dentistry is
called the rule of 25, which states that a dentist
may safely use 1 cartridge(1.8ml) of any local
anesthetic for every 11.4 kg (25 lbs) of patient
weight
Phases of toxicity
excitatory phase-manifest as tremors, muscle
twitching, shivering, and clonic tonic convulsions
generalized central nervous system depression and
possible life-threatening respiratory depression
With extremely high doses, cardiac excitability and
cardiac conduction decrease and leads to ectopic
rhythms, bradycardia and ensuing peripheral
vasodilation, and significant hypotension.
Treatment should address respiratory depression and
convulsions. Vital signs should be monitored, the
airway maintained, basic life support administered,
and the emergency medical support services should
be called. Intravenous diazepam or midazolam may be
administered for a seizure that does not stop
Methemoglobinemia
Methemoglobinemia is a reaction that can occur after
administration of amide local anesthetics, nitrates
Prilocaine and benzocaine are used in dentistry and may
induce methemoglobinemia
Signs and symptoms usually do not appear for 3 to 4 hours
after the administration of large doses of local anesthesia
Clinical signs of cyanosis are observed when blood levels of
methemoglobin reach 10% to 20%, and dyspnea and
tachycardia are observed when methemoglobin levels
reach 35% to 40%
55 Co-oximetry is a conventional pulse oximetry that
measures the methemoglobin and carboxyhemoglobin
levels
Treatment
Methylene blue 1 to 2 mg/kg intravenously is used
for the treatment of methemoglobinemia.
summary
Local anesthetics are a routine part in all oral
and maxillofacial practices. Minimizing
adverse outcomes is the goal of all
practitioners. This goal can be accom-plished
by using the appropriate local anes-thetics in
certain situations
Malamed SF. Handbook of local anesthesia. 5th
edition. Philadelphia: Elsevier Mosby; 2004.
R david, Complications of Local Anesthesia Used
in Oral and Maxillofacial Surgery: Oral
Maxillofacial Surg Clin N Am 23 (2011) 369377
Pogrel MA, Thamby S. Permanent nerve involve-
ment resulting from inferior alveolar nerve
blocks. J Am Dent Assoc 2004;131:9017.
Local anesthesia, monheims