local anesthesia

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2. OUTLINE
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Local Complications
Paresthesia
Hematoma
Pain on Injection
Facial Nerve Paralysis
Infection
Trismus
NeedleBreakage
SoftTissue Injury
Edema
Ocular Complications

3. OUTLINE
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Systemic Complications
Overdose Allergy
Introduction
Predisposing Factors
Clinical Manifestations
Management

4. LOCAL COMPLICATIONS
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5. LOCAL
COMPLICATIONS
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Paresthesia
Hematoma
Pain on Injection
Facial Nerve Paralysis
Infection
Trismus
NeedleBreakage
SoftTissue Injury
Edema
Ocular Complications

6. ⦁ Rare becauseof using of disposable needles.
NEEDLE BREAKAGE
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7. ⦁ Causes:
1. Bending of the needle.
2. Sudden unexpected movementof the patient.
3. Entire length of the needle inserted into the soft tissue.
4. Useof the smaller needles ( e.g. 40 gauge )
NEEDLE BREAKAGE
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8. ⦁ Prevention:
1. Use large-gauge needles, specially
with Inferior Alveolar Nerve
2. Use long needles.
3. Do not inserta needle into tissues
to its hub.
4. Do not redirecta needleonce it is
inserted into tissue.
NEEDLE BREAKAGE
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9. ⦁ Management :
 When a needle breaks ( visible):
1. Staycalm.
2. Instruct the patient not to moveand
let his mouth open.
3. If the fragmentvisible, remove itwith
hemostat ora Magill intubation
forceps.
 When a needle breaks ( not-visible):
1. No incision orprobing.
2. Calmly inform the patient.
3. Referral Oral Surgeon, take radiograph
and determine if it is superficial,
remove or leave itand flow up?!!
NEEDLE BREAKAGE
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10. LOCAL
COMPLICATIONS
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Paresthesia
Hematoma
Pain on Injection
Facial Nerve Paralysis
Infection
Trismus
NeedleBreakage
SoftTissue Injury
Edema
Ocular Complications

11.  Amaurosis “temporary blindness“.
 Mydriasis “Pupillary dilation”
 Ptosis “droopyeyelid”
 Diplopia “doublevision”
OCULAR COMPLICATIONS
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12.  Causes :
OCULAR COMPLICATIONS
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Inadvertent arterial injection with retrograde
blood flow

13.  Causes :
Orbital injection :
🞄Inadvertent injection into the orbit through the
inferiororbital fissure.
OCULAR COMPLICATIONS
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14.  Prevention :
 Aspiration beforeactual injection.
 Inject slowly.
 Treatment :
 Reassure the patient that is transient.
 Cover theaffected eyewith gauzedressing.
Referpatients toan ophthalmologist forevaluation if it
last more than 6 hours
 Regular follow-up
OCULAR COMPLICATIONS
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15. LOCAL
COMPLICATIONS
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Paresthesia
Hematoma
Pain on Injection
Facial Nerve Paralysis
Infection
Trismus
NeedleBreakage
SoftTissue Injury
Edema
Ocular Complications

16. PARESTHESIA
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⦁ Causes :
 Trauma to the nerve.
 Local Anesthesia solution contaminated by alcohol or
sterliziating solution near anerve produce irritation,
resulting edemaand increased pressure in the regionof
the nerve leading to paresthesia.
 Insertionof a needle insidea foramen.
 Hemorrhage-increased pressure-paresthesia.

17. PARESTHESIA
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⦁ Prevention :
 Propercareand handling to injectioncontrol and
cartridge.
 Management :
 Most paresthesiaresolvewithin 8 weekswithout
treatment.
 Sequencesof management:
 Reassuring thepatient.
 Examine thepatientand follow upeach 2 months.
 If sensory deficit is still more than 1 year, consultationwith
neurologistand oral surgeon.

18. LOCAL
COMPLICATIONS
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Paresthesia
Hematoma
Pain on Injection
Facial Nerve Paralysis
Infection
Trismus
NeedleBreakage
SoftTissue Injury
Edema
Ocular Complications

19. ⦁ Occurwhen anesthesia is introduced intodeep lobe
of the parotid gland.
FACIAL NERVE PARALYSIS
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20. FACIAL NERVE PARALYSIS
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⦁ Causes :
◦ Transient FNP caused by local anesthesia into capsule of
the parotid gland, which is located at posterior border of
the mandibularramus.
◦ Usually it occurduring InferiorAlveoar Nerve Block or
Vazirani-Akinosi Nerve Block.

21. FACIAL NERVE PARALYSIS
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⦁ Prevention :
 Propercareand handling to
injection control and cartridge.
 Management :
1. Reassuring thepatient.
2. Contact lenses should be
removed.
3. An eye patched should beapplied
to affected eyeor manuallyclose
the lowereyelid periodically to
keepthecornea lubricated.

22. LOCAL
COMPLICATIONS
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Paresthesia
Hematoma
Pain on Injection
Facial Nerve Paralysis
Infection
Trismus
NeedleBreakage
SoftTissue Injury
Edema
Ocular Complications

23. ⦁ Pain and difficultof opening often afterposterior
superioralveolaror inferioralveolar nerve block.
⦁ Onset 1-6 days post-treatment.
TRISMUS
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24. ⦁ Causes :
 Trauma to the musclesor blood vessels in the
infratemporal fossa.
 Local Anesthesiasolution contaminated by alcohol or
cold sterliziating solution produce irritation of the
muscles.
 Low-grade infection.
TRISMUS
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25. ⦁ Prevention :
1. Usesharp, sterile, disposable needle.
2. Propercareand handling to injection control and
cartridge.
3. Atraumatic injectionand avoid repeating of it.
TRISMUS
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26. ⦁ Management :
 Heat therapy
.
 Warm saline rinse.
 Analgesic, Aspirin 325 mg.
 Musclerelaxation if necessary,
Diazepam 10 mg bid
 Physiotherapy for 5 min. each 3-4
hours.
 If there is infection, antibiotic
described for 7 days.
 Improvementstartwithin 2-3 days
and recoveryrange 4-20 weeks.
 Surgical intervention in somecases.
TRISMUS
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27. LOCAL
COMPLICATIONS
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Paresthesia
Hematoma
Pain on Injection
Facial Nerve Paralysis
Infection
Trismus
NeedleBreakage
SoftTissue Injury
Edema
Ocular Complications

28. ⦁ Trauma to the lip or the tonguecaused by biting or
chewing these tissue while still anesthetized,
speciallywith children.
SOFT-TISSUE INJURY
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29. ⦁ Prevention :
◦ A cotton roll placed between the lips and the teeth.
◦ Warn the patient.
◦ Self-adherentwarning sticker.
SOFT-TISSUE INJURY
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30. ⦁ Management :
◦ Analgesic forpain.
◦ Antibiotic if there is infection.
◦ Warmsaline rinse toaid in decreasing the swelling.
◦ Petroleum jelly tocover the lesion and minimize the
irritation.
SOFT-TISSUE INJURY
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31. LOCAL
COMPLICATIONS
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Paresthesia
Hematoma
Pain on Injection
Facial Nerve Paralysis
Infection
Trismus
NeedleBreakage
SoftTissue Injury
Edema
Ocular Complications

32. ⦁ Theeffusion of the blood intoextravascularspaces
can result from inadvertentlya blood vessel.
⦁ Casued by nicking to theartery orvein.
⦁ Mostoccurwith IANB and PSA nerve block.
⦁ 7 to 14 days the hematomawill be presented.
HEMATOMA
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33. ⦁ Prevention :
1. Knowledgeof normal anatomy
.
2. Useshorter needle for PSA nerve block.
3. Minimize the numberof the needle penetration.
4. Neverusea needleas a probe in the tissue.
⦁ Management :
1. Directpressureapplied on to thesiteof bleeding.
2. Applycold moist towels toaffected areaeach 20 min.
every hour.
3. Advice the patientabout sorenessand limitationof the
mouthopening possibility.
HEMATOMA
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34. LOCAL
COMPLICATIONS
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Paresthesia
Hematoma
Pain on Injection
Facial Nerve Paralysis
Infection
Trismus
NeedleBreakage
SoftTissue Injury
Edema
Ocular Complications

35. ⦁ Causes :
1. Careless injection and callousattitude “ Palatal Injection
always hurt”.
2. Dull of the needle becauseof multiple injection.
3. Rapid depositionof the local anestheticsolution.
PAIN ON INJECTION
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36. ⦁ Prevention :
◦ Adhere to proper techniques
of injection, both anatomical
and psychological.
◦ Sharp needles.
◦ Topical anesthetic.
◦ Injectslowly.
◦ Temperatureof the solution.
PAIN ON INJECTION
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37. LOCAL
COMPLICATIONS
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Paresthesia
Hematoma
Pain on Injection
Facial Nerve Paralysis
Infection
Trismus
NeedleBreakage
SoftTissue Injury
Edema
Ocular Complications

38. ⦁ Causes :
◦ Contamination of the needle, now become rarely after
introduction of the sterile disposable needle and glass
cartridge.
⦁ Management :
◦ Antibiotic, penicillin 250 mg qid.
INFECTION
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39. LOCAL
COMPLICATIONS
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Paresthesia
Hematoma
Pain on Injection
Facial Nerve Paralysis
Infection
Trismus
NeedleBreakage
SoftTissue Injury
Edema
Ocular Complications

40. ⦁ Causes :
1. Trauma.
2. Infection.
3. Allergy, angioedema.
4. Hemorrhage.
5. Injection of irritating
solution(alcohol, cold
solution).
EDEMA
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41. EDEMA
⦁ Management :
1. Minimal degreeedema --- justanalgesic for
pain and will
• resolve in several days.
2. If largedegreeedemaand signand
symptom of infection--- antibiotic
should be prescribed.
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42. SYSTEMIC COMPLICATIONS
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43. SYSTEMIC
COMPLICATIONS
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Overdose Allergy
Introduction
Predisposing Factors
Clinical Manifestations
Management

44. ◦ Overdosereaction is occurring when thedrug access to
thecirculatorysystem.
◦ Normally there is constantabsorptionof thedrug from
its site of admission into the circulatory system and a
steadyremoval from the blood by the liver.
OVERDOSE
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45. Patient Factors:
🞄 Age.
🞄 Weight.
🞄 Medications.
🞄 Gender.
🞄 Presence of disease.
🞄 Genetics
🞄 Mental attitude.
Drug Factors:
🞄 Vasoactivity.
🞄 Concentration.
🞄 Dose.
🞄 Route of administration.
🞄 Rate of injection.
🞄 Vascularity of the
injection site.
🞄 Presence of
vasoconstrictors.
PREDISPOSING
FACTORS
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46. Patient Factors:
🞄 Age :
🞄 The function of absorption, metabolism, and
excretion are diminished in old people –
increasing the half-life of the drug in circulation
blood.
🞄 Weight :
🞄 Greater body weight – larger dose.
🞄 Medications :
🞄 Meperidine”narcotic analgesic”,
phenytoin”anticonvalsun”,
quinidine”antidysrhythmatic”, and
desipramine”antidepressant” – increase local
anesthesia blood level, because protein bending
competition.
PREDISPOSING FACTORS
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47. Patient Factors:
🞄 Gender :
🞄 Renal function during pregnancy may impaired
leading to increase local anesthesia blood level.
🞄 In adult women the seizure threshold is 5.8
mgkg, in newborn 18.4, in the fetus 41.9
mgkg. Placenta clearance of lidocaine.
🞄 Presence of disease :
🞄 Hepatic , renal dysfunction and congestive
heart failure decrease liver perfusion – increase
amide local anesthesia blood level.
PREDISPOSING FACTORS
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48. Patient Factors:
🞄 Genetics :
🞄 Deficiency in enzyme serum
pseudocholinesterase – responsible for
biotransformation of ester local anesthesia.
🞄 Mental attitude :
🞄 Patient who are fearful:
1. Larger dose required.
2. Lower seizure threshold .
PREDISPOSING FACTORS
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49. Drug Factors:
🞄 Vasoactivity :
🞄 Vasodilating properties of LA lead:
1. Shorter duration of clinical anesthesia.
2. Increased blood level of LA.
🞄 Concentration :
🞄 Lowest concentration should be given.
🞄 Dose :
🞄 Smallest dose should be given.
PREDISPOSING FACTORS
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50. Drug Factors:
🞄 Route of administration :
🞄 Should be care about intravascular injection.
🞄 Rate of injection :
🞄 Slow (60-seconds) IV administration per
cartridge (36 mg) .
🞄 Vasculratiy of the injection site :
🞄 Rapid of the absorption.
🞄 Vasoconstrictors :
🞄 Decrease absorption of the drug.
PREDISPOSING FACTORS
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51. 1. Useaspiration syringe.
2. Usea needle nosmaller
than 25 gauge.
3. Aspirate in at least two
planes before injection.
4. Slow inject the
anesthetic.
PREVENTION
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52. 1. Talkativeness .
2. Apprehension.
3. Excitability.
4. Slurred speech.
5. Stutter.
CLINICAL MANIFESTATION
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53. 1. Sweating.
2. Vomiting.
3. Failureto followcommands.
4. Elevated blood pressure, heartand
respiratoryrate.
5. Tonic-clonic seizure in highly
overdose.
6. CNS depression, Myocardiac
Depressionand cardiacarrest.
CLINICAL MANIFESTATION
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54. 1. Basic Emergency Management :
1. Position.
2. Circulation.
3. Airway.
4. Breathing.
5. Definitive Care.
P-C-A-B-D
MANAGEMENT
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55. 1. Mild Overdose: “Patient conscious”
◦ Slowonset (>5 minutes):
🞄 P-C-A-B
🞄 Reassurethepatient.
🞄 Administeroxygen via nasal canal.
🞄 Monitorand record vital signs.
🞄 IV anticonvulsants (diazepam 5
mgmin. or midazolam 1 mmin.)
“optional”
🞄 Emergency medical assistance before
patientdischarge.
MANAGEMENT
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56. 1. Mild Overdose: “Patient conscious”
◦ Slowonset (>15 minutes)
🞄 P-C-A-B
🞄 Reassurethepatient.
🞄 Administeroxygen via nasal canal.
🞄 Monitorand record vital signs.
🞄 IV anticonvulsants (diazepam 5
mgmin. or midazolam 1 mmin.)
“manadatory”
🞄 Emergency medical assistance before
patientdischarge.
MANAGEMENT
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57. 1. Severe Overdose: “Patient
unconscious”
◦ Rapid onset (within 1 minute)
🞄 P-C-A-B
🞄 Protectthepatient.
🞄 Immediately summonemergency
medical assistance.
🞄 ContinueBasic life support (BLS)
🞄 IV anticonvulsants (diazepam 5
mgmin. or midazolam 1 mmin.) “if
seizuresprotract more than 4 min.”
MANAGEMENT
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58. 1. Severe Overdose: “Patient unconscious”
◦ Slowonset (5 to 15 minutes)
🞄 P-C-A-B
🞄 IV anticonvulsants (diazepam 5
mgmin. or midazolam 1 mmin.) and
oxygenadministration.
🞄 Immediatelysummonemergency
medical assistance.
🞄 Continue Basic life support (BLS).
🞄 Vasopressor and IV fluid is
recommended for managementof
hypotension.
MANAGEMENT
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59. SYSTEMIC
COMPLICATIONS
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Overdose Allergy
Introduction
Predisposing Factors
Clinical Manifestations
Management

60. ◦ Hypersensitive state, acquired
through exposure toa particular
allergen.
◦ Allergic reactionscovera broad
spectrum od clinical
manifestations ranging from mild
and delayed responseoccurring as
long as 48 hours after exposure to
allergen, to immediateand
threatening reaction develop
within secondsof exposure.
ALLERGY
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61. ◦ Sodium Bisulfite:
🞄 Antioxidant in vasoconstrictor local
anesthesia.
🞄 1984 has been excluded.
◦ Epinephrine.
◦ Latex.
◦ Topical Anesthesia:
🞄 Mostly ester.
🞄 Preservatives containing such as
methylparaben, ethylparaben, or
propylparaben.
PREDISPOSING FACTORS
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62. CLINICAL MANIFESTATION
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Dermatological reaction
Generalized anaphylaxis
Respiratoryreactions

63. ◦ Dermatological reaction:
🞄 Urticaria
🞄 Angioedema
CLINICAL MANIFESTATION
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64. ◦ Respiratoryreactions:
🞄 Bronchospasm:
🞄 Respiratory distress
🞄 Dyspnea
🞄 Wheezing
🞄 Flushing
🞄 Cyanosis
🞄 Perspiration
🞄 Tachycardia
🞄 Anxiety
🞄 Laryngeal edema:
🞄 Extension of edema to the larynx
🞄 Life threatening emergency.
CLINICAL MANIFESTATION
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65. ◦ Generalized Anaphylaxis:
🞄 Skin reactions
🞄 Smooth muscle spasm of
gastrointestinal and genitourinary
tracts and bronchospasm.
🞄 Respiratory distress.
🞄 Cardiovascular collapse.
🞄 Treatment of the entire reaction
may be terminated rapidly, but
hypotension and laryngeal edema
may persist for hours to days.
CLINICAL MANIFESTATION
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66. ◦ Skin reaction:
🞄 Delayed reaction.
🞄 Immediate reaction.
◦ Respiratoryreaction:
🞄 Bronchospasm.
🞄 Laryngeal edema.
◦ Generalized anaphylaxis:
🞄 Signsof allergypresent.
🞄 No signsof allergypresent.
MANAGEMENT
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67. ◦ Skin reaction:
🞄 Delayed reaction:
🞄 P-C-A-B
🞄 Oral histamine blocker 50 mg diphenhydramineor 10
mg chlorpheniramine, oneq6h for 3-4 days.
🞄 Observation for 1 hour.
🞄 Medical consultation.
🞄 If patient isdrowsiness,
notallowed to leave theclinic.
MANAGEMENT
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68. ◦ Skin reaction:
🞄 immediate reaction:
🞄 P-C-A-B
🞄 Epinpherine 0.3 mg IM.
🞄 IM histamine blocker 50 mg diphenhydramineor 10 mg
chlorpheniramine.
🞄 Medical consultation
🞄 Observation for 1 hour.
🞄 Prescribe Oral histamine blocker 3 days.
MANAGEMENT
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69. ◦ Respiratoryreaction:
🞄 Bronchospasm :
🞄 P-C-A-B
🞄 Administer oxygen at flow 5-6 litersmin.
🞄 Epinpherine 0.3 IM or Bronchodilator “albuterol” , dose repeated 10-15
min. if needed.
🞄 Observation for 1 hour.
🞄 IM histamine blocker 50 mg diphenhydramine or 10 mg
chlorpheniramine.
🞄 Medical consultation
🞄 Prescribe Oral histamine blocker 3 days.
MANAGEMENT
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70. ◦ Respiratoryreaction:
🞄 Laryngeal Edema : “unconscious patient”
🞄 P-C-A-B
🞄 Epinpherine 0.3 IM, dose repeated 10-15 min. if
needed.
🞄 Activate Emergency Medical Services.
🞄 IM histamine blocker 50 mg diphenhydramineor 10
mg chlorpheniramine. Corticosteroid IM or IV (100
mg Hydrocortisonesodium succinate to inhibitand
decreaseedema.
🞄 Perform cricothyrotomy.
MANAGEMENT
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71. 3/18/2017
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72. ◦ Generalized Anaphylaxis :
🞄 Signs of allergy present : “unconscious patient”
🞄 P-C-A-B
🞄 Summon medical assistance.
🞄 Epinpherine 0.3 IM, dose repeated 10-15 min
🞄 Administeroxygen.
🞄 Monitorvital signs, recorded every 5 min.
🞄 IM histamine blockerand Corticosteroid IM or IV “ If
clinical improvement noted increased blood pressure,
decreased bronchospasm”
MANAGEMENT
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73. ◦ Generalized Anaphylaxis :
🞄 No signs of allergy present : “unconscious patient”
🞄 P-C-A-B
🞄 Summon medical assistance.
🞄 Administeroxygen.
🞄 Monitorvital signs, recorded every 5 min.
🞄 Addition management, on arrival of the emergency
medical personnel depend on thecause of the loss of
consciousness.
MANAGEMENT
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74. REFERENCE
S:
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1. Stanley F. Malamed. Handbook of local anesthsia. 5th edition. Page 285-332.
2. Sean G. Boynes, Zydnia Echeverria, Mohammad Abdulwahab. Ocular Complications
Associated with Local Anesthesia Administration in Dentistry. Dent Clin N Am 54
(2010) 677–686
3. Ngeow WC, Shim CK, Chai WL. Transient loss of power of accommodation in one eye
following inferior alveolar nerve block: report of two cases. J Can Dent Assoc
2006;72:927–31.
4. Penarrocha-Diago M, Sanchis-Bielsa JM. Opthalmologic complications after intraoral
local anesthesia with articaine. Oral Surg Oral Med Oral Pathol Oral Radiol Endod
2000;90:21–4.
5. Lee C. Ocular complications after inferior alveolar nerve block. Hong Kong Med Diary
2006;11:4–5.
6. Van der Bijil P, Meyer D. Ocular complications of dental local anesthesia. SADJ
1998;53:235–8.
7. Goldenberg AS. Transient diplopia as result of block injections. Mandibular and
posteriorsuperioralveolar. N Y State Dent J 1997;63:29–31.