COMPLICATIO

NS OF LOCAL
ANESTHESIAI
ABDUL KALAM AZAD

 A local anesthetic complication is any deviation from the generally

expected pattern during or after administration of LA.
Complications may be classified as
- Local or systemic
- Mild or severe
- Transient or permanent
- Primary or secondary

LOCAL COMPLICATIONS : local complications may be immediate or

delayed in nature.
A) Immediate complications:
- Pain or burning on injection
- Needle breakage
B) Delayed complications
- Trismus
- Hematoma
- Local necrosis

- Transient facial nerve paralysis

- Prolonged anaesthesia
- Infection
- Soft tissue injury
- Edema
- Postanesthetic intraoral lesions

 SYSTEMIC COMPLICATIONS
- Syncope
- Idiosyncrasy
- Toxicity
- Anaphylaxis

A) Pain or burning on injection

Causes:
-) Careless injection
-) Due to dull needle from multiple injections
-) Rapid deposition of solution
-) Needles with barbs may produce pain as they are withdrawn from tissue.

 Prevention
- Adhere to proper techniques of injection
- Use sharp needles
- Use sterile LA solutions
- Inject LA slowly
- A solution which is too hot or too cold may cause discomfort to the patient

B) Needle breakage
Causes
- Weakening of the dental needle by bending it before insertion
- Sudden unexpected movement by the patient
- Smaller needles ( higher gauge ) more likely to break than larger needles
( lower gauge).
- Manufacturing defect

 Prevention
- Use large gauge needles for techniques requiring penetration of significant
depths of soft tissues.
- Use long needles foe techniques requiring penetration of significant depths
of tissues.
- Do not insert a needle into tissue to its hub

 Management
a. When a needle breaks
-. Remain calm, do not panic.
-. Instruct the patient not to move
-. Do not move your hand from patients mouth
-. If the fragment of needle is visible, try to remove it using a small hemostat
or Magill forceps.

b. If the needle is not visible and cannot be readily retrievable

- Do not proceed with probing or incision
- Refer to an oral and maxillofacial surgeon.
- Radiographs may be taken to help locate the needle within the tissues.
Radiograph can be taken by inserting an additional needle at the same site
to help in approximately localizing the broken needle.
- computed tomography scanning may also be required to identify the
position of the needle

- If the broken needle is left in situ, there is a risk that over time the needle
may migrate and injure major blood vessels, or damage other vital
structures of the head and neck.
- patient will need to be hospitalized to have the needle removed in the
operating room under general anesthesia

C) Trismus
Causes-

- Trauma to muscle due to injection

- Injection of LA into the temporalis, masseter or medial pterygoid
muscles leads to a rapidly progressive necrosis of the exposed muscle
- Injury to vessels leads to hematoma which presses on the muscle
leading to trismus
- injection of contaminated LA

 Prevention
- Use a sharp, sterile, disposable syringe
- Contaminated needles should be changed immediately
- Practice atraumatic insertion and injection techniques
- Avoid repeated injections and multiple insertions into the same area
- Use minimum effective volumes of LA.

 Management- pain & difficulty in opening from 1-6 days postoperatively

- prescribe heat therapy, warm saline, analgesics & muscle relaxants
- Heat therapy : applying hot moist towels to the affected area for 20 minutes every
hour.
- improvement should be noted within 3 to 5 days following the initiation of
management
- in treating this condition it is important to avoid rapid motion or the use of powerful
forces.

 Rapid motion or force may worsen the injury and increase the reflex that
causes muscles to contract, thereby making subsequent stretching of
connective tissue difficult or even impossible.
The main aim of therapy is to gently get the jaw functioning early to avoid
fibrosis, which would make the condition difficult to reverse.
Passive motion applied several times per day is significantly more
effective than static stretching in reducing inflammation and pain.

 physiotherapy- opening and closing as well as lateral excursions- 5 min

every 3-4 hours
Chewing gum is another option for providing lateral movements of jaws.
if trismus persists beyond 48 hours possibility of infection- antibiotics
added
complete resolution- 4 to 20 weeks

D) Hematoma
- It is the effusion of blood into the extravascular space due to inadvertent
nicking of blood vessel during the injection of LA.
- This can occur with any nerve block but most commonly seen with PSA
and IANB.
- Hematoma due to IANB are manifested as intraoral swelling and trismus.
- The pterygoid plexus of veins is in close proximity to PSA nerve. The use
of a long needle in this technique may cause injury to the plexus resulting
in slow massive bleeding. Since this space can accommodate large volume
of blood, it is presented as big extraoral swelling.

Prevention
- 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.
- Always carry out two plane aspirations before injection.

Management
Immediate treatment:
- if swelling becomes evident immediately after injection, direct pressure
should be applied at the site of bleeding for not less than 2 minutes.
- If ice pack is available, it should be applied extraorally to increase pressure
on the site and help in vasoconstriction.
i) IANB: tissue discolouration and tissue swelling on the medial aspect of
ramus. Pressure is applied at this region intraorally.

ii) Infraorbital nerve block: clinically, there is discolouration of the skin

below the lower eyelid.Pressure is applied directly over the skin below the
lower eyelid.
iii) Incisive or mental nerve block: discolouration of skin over the mental
foramen or selling in the mucobuccal fold in the region of mental foramen.
Pressure is applied directly over skin or mucous membrane over mental
foramen.
iv) PSA nerve block:
- PSA nerve block usually produces the largest and most esthetically
unappealing hematoma.

- Initially a colorless swelling appears on the side of the face a few minutes
after the injection.
- It progresses inferiorly and anteriorly to the lower anterior region of the
cheek.
- It is difficult to apply pressure to the site of bleeding because of the
location of the vessels.
- Digital pressure can be applied to the soft tissues in the maxillary
mucobuccal fold as far distally as can be tolerated by the patient.
- Apply pressure in a medial and superior direction.

Delayed Treatment :
- Once bleeding stops, discharge the patient.
- If soreness develops, analgesics is prescribed.
- Do not apply heat over the area for at least 4-6 hours as heat can produce
vasodilation increasing the size of hematoma.
- Heat can be applied after 24 hours.
- With or without treatment, a hematoma will be present for 7-14 days.

E) Local tissue necrosis:

Causes:
- Application of a topical anesthetic to the gingival tissue for a prolonged
period.
- Heightened sensitivity of the tissues to a LA
- secondary to prolonged ischemia resulting from the use of a LA with
vasoconstrictor

Prevention :
- Allow the solution to contact the mucous membrane for 1-2 minutes to
maximize its effectiveness and minimize toxicity.
- Do not use overtly conc solution of vasoconstrictors.
Management
- Management may be symptomatic
- Analgesics for pain
- Topical ointment to minimize irritation to the area.

F) FACIAL NERVE PARALYSIS

Causes:
- A complication associated with an inferior alveolar nerve block.
- Parotid gland form the posterior boundary of the pterygomandibular space into which
IANB is given.
- If the needle is inserted too far posteriorly, the solution may be injected into the
parotid gland.
- The facial nerve divides into its terminal branches within the substance of the gland.
- So, the deposition of solution in this region may cause transient facial nerve paralysis.

- The primary problem is cosmetic. The patients face appears lopesided.

- loss of motor function of muscles of facial expression
- unilateral paralysis ( temporary)
- unable to close the eye voluntarily
- Winking and blinking becomes impossible.
Prevention
- Before deposition of solution , one should make sure that the needle tip is in
contact with the bone.
- If bone is not contacted, the needle should be partially withdrawn, the barrel of the
syringe brought posteriorly and the needle readvanced until it contacts the bone.

Management
- The paralysis usually lasts a few hours, depending on the type of anesthetic used.
- There is no treatment to reverse the effect of local anesthesia other than waiting
until the anesthetic wears off. If paralysis of facial muscles happens, the patient
should be reassured that this is transient and that the effect of local anesthesia
will wear off in a few hours.
- In patients who wear contact lenses, these should be removed, as the lenses may
cause damage to the cornea.
- An eye patch should be placed on the affected eye to maintain eye moisture until
the muscle tone returns.

G) PROLONGED ANESTHESIA
- Sometimes anesthesia persists for days ,weeks or months after the action of LA
has worn off.
- patient may complain of numbness, tingling, swelling and itching.
- There may be associated oral dysfunctions like tongue biting, drooling loss of
taste and speech impediment.
Causes:
- injection into the nerve
- injection of contaminated LA- edema- results in pressure in the area of nerveparesthesia.

- Pressure on the nerve due to a hematoma

Management
- most cases resolve in 8 weeks without treatment
- examine every 2 months
- If sensory deficit is still evident 1 year after the incident,refer to oral and
maxillofacial surgeon or neurologist.
- Dental treatment may continue, but avoid readministering LA into the
region of previously traumatized nerve.

H) INFECTION
Causes
- Contamination of needle before injection
- Forceful administration of LA in an infected area.
Prevention
- Use sterile disposable needles
- Avoid contact of needle with nonsterile surfaces
- Properly care for and handle dental cartridges of LA.

Management
- The patient usually reports postinjection pain and dysfunction 1 or more
days after dental care.
- Initial treatment- heat application, analgesics, muscle relaxants if needed
and physiotherapy.
- If patient does not respond to therapy within 3 days, 7-10 days course of
antibiotics is started.

I) SOFT TISSUE INJURY

Causes
-) Occurs mostly in younger children or mentally or physically disabled child or adults
-) main reason is that soft tissue anesthesia lasts longer than pulpal anesthesia

Prevention:
-) select anesthetic of appropriate duration
-) cotton roll placed between lips and teeth
-) warn against eating, drinking hot fluids or biting on lips or tongue to test for anesthesia

Management- analgesics, antibiotics and warm saline gargle

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