This document discusses local complications and systemic effects that can occur from the use of local anesthetics in dentistry. It describes various local complications including needle breakage, prolonged anesthesia, facial nerve palsy, trismus, soft tissue injury, hematoma, pain on injection, and infection. It then discusses signs and symptoms of local anesthetic overdose as well as factors that can contribute to overdose. Lastly, it provides guidance on controlling complications for special patient populations such as uncooperative children, pregnant women, and those receiving anticoagulation therapy.

1. In The Name Of GOD

2. ‫در‬ ‫موضعی‬ ‫حسی‬ ‫بی‬ ‫اصول‬
‫دندانپزشکی‬
‫مشکالت‬ ‫و‬ ‫عوارض‬
‫نظری‬ ‫جراحی‬ ‫درس‬
‫حسینی‬ ‫هادی‬ ‫سید‬ ‫دکتر‬
‫صورت‬ ‫و‬ ‫فک‬ ‫جراحی‬ ‫متخصص‬
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3. ‫موضعی‬ ‫حسی‬ ‫بی‬ ‫های‬ ‫دارو‬ ‫از‬ ‫استفاده‬ ‫در‬ ‫مشکالت‬ ‫و‬ ‫عوارض‬
‫موضعی‬ ‫عوارض‬
‫سیستمیک‬ ‫عوارض‬

4. Local Complications
1) Needle breakage
2) Prolonged Anesthesia or Paresthesia
3) Facial Nerve palsy
4) Trismus
5) Soft tissues injury
6) Hematoma :
7) Pain on injection
8) Burning on Injection
9) Infection :
10) Edema
11) Postanesthetic Intra-oral lesion:
12) Sloughing of tissue

5. Needle breakage
Prevention
• Do not use short needles for inferior alveolar nerve
block in adults or larger children.
• Do not use 30-gauge needles for inferior alveolar nerve
block in adults or children.
• Do not bend needles when inserting them into soft
tissue.
• Do not insert a needle into soft tissue to its hub, unless
it is absolutely essential for the success of the injection.
• Observe extra caution when inserting needles in
younger children or in extremely phobic adult or child
patients.

6. Prolonged Anesthesia or Paresthesia
• Strict adherence to injection protocol
• Most paresthesias resolve within approximately 8
weeks to 2 months without treatment.
• Determine the degree and extent of paresthesia.
• Explain to the patient that paresthesia
• Record all findings
• Second opinion
• Examination every 2 months
• It would be prudent to contact your liability insurance
carrier should the paresthesia persist without evident
improvement beyond 1 to 2 months.

7. Facial Nerve palsy
• Reassure the patient
• Contact lenses should be removed until muscular
movement returns.
• An eye patch should be applied to the affected eye
until muscle tone returns
• Record the incident on the patient's chart.
• Although no contraindication is known to
reanesthetizing the patient to achieve mandibular
anesthesia, it may be prudent to forego further
dental care at this appointment.

8. Trismus
• Prescribe heat therapy, warm saline rinses,
analgesics (Aspirin 325 mg)
• If necessary, muscle relaxants to manage the
initial phase of muscle spasm - Diazepam
(approximately 10 mg bid)
• Initiate physiotherapy
• Antibiotics should be added to the treatment
regimen described and continued for 7 full days
• Patients report improvement within 48 to 72 hours

9. Soft tissues injury
• Analgesics, antibiotics, lukewarn saline rinse,
petroleum jelly
• Cotton roll placed between lips and teeth,
secured with dental floss, minimizes risk of
accidental mechanical trauma to anesthetized
tissues.

10. Hematoma
• Hematoma is not always preventable. Whenever a
needle is inserted into tissue, the risk of inadvertent
puncturing of a blood vessel is present.
• When swelling becomes evident during or immediately
after a local anesthetic injection, direct pressure should
be applied to the site of bleeding.
• For most injections, the blood vessel is located between
the surface of the mucous membrane and the bone;
localized pressure should be applied for not less than 2
minutes. This effectively stops the bleeding.
• Ice may be applied to the region immediately on
recognition of a developing hematoma.

11. Pain on injection
• Adhere to proper techniques of injection, both anatomic
and psychological.
• Use sharp needles.
• Use topical anesthetic properly before injection.
• Use sterile local anesthetic solutions.
• Inject local anesthetics slowly.
• Make certain that the temperature of the solution is
correct
• Buffered local anesthetics, at a pH of approximately
7.4, have been demonstrated to be more comfortable on
administration

12. Burning on Injection
• By buffering the local anesthetic solution to a
pH of approximately 7.4 immediately before
injection, it is possible to eliminate the burning
sensation that some patients experience during
injection of a local anesthetic solution
containing a vasopressor.
• Slowing the speed of injection also helps

13. Edema
If edema occurs in any area where it compromises breathing, treatment consists of the
following:
• P (position): if unconscious, the patient is placed supine.
• A-B-C (airway, breathing, circulation): basic life support is administered, as
needed.
• D (definitive treatment): emergency medical services (e.g., 9-1-1) is summoned.
• Epinephrine is administered: 0.3 mg (0.3 mL of a 1:1000 epinephrine solution)
(adult), 0.15 mg (0.15 mL of a 1:1000 epinephrine solution) (child [15 to 30 kg]),
intramuscularly (IM) or 3 mL of a 1:10,000 epinephrine solution intravenously (IV-
adult), every 5 minutes until respiratory distress resolves.
• Histamine blocker is administered IM or IV.
• Corticosteroid is administered IM or IV.
• Preparation is made for cricothyrotomy if total airway obstruction appears to be
developing. This is
• extremely rare but is the reason for summoning emergency medical services early.
• The patient's condition is thoroughly evaluated before his or her next appointment
to determine the cause of the reaction.

14. Infection
• Use sterile disposable needles.
• Properly care for and handle needles.
• Properly prepare the tissues before penetration.
• Prescribe 29 (or 41, if 10 days) tablets of
penicillin V (250-mg tablets).
• Erythromycin may be substituted if the patient
is allergic to penicillin.

15. Sloughing of tissue
• Usually, no formal management is necessary
for epithelial desquamation or sterile abscess.
Be certain to reassure the patient of this fact.
• For pain, analgesics such as aspirin or other
NSAIDs and a topically applied ointment
(Orabase)
• The course of a sterile abscess may run 7 to 10
days

16. Postanesthetic Intra-oral lesion:
• Primary management is symptomatic
• No management is necessary if the pain is not severe
• Topical anesthetic solutions (e.g., viscous lidocaine)
• A mixture of equal amounts of diphenhydramine
(Benadryl) and milk of magnesia rinsed in the mouth
effectively coats the ulcerations and provides relief
from pain.
• Orabase, a protective paste, without Kenalog can
provide a degree of pain relief.
• A tannic acid preparation (Zilactin) can be applied
topically to the lesions extraorally or intraorally (dry
the tissues first).

18. Local Anesthetic Systemic
Complications and Treatment

19. • Toxicity Caused by Direct Extension of the Usual Pharmacologic Effects
of the Drug:
1) Side effects
2) Overdose reactions
3) Local toxic effects
• Toxicity Caused by Alteration in the Recipient of the Drug:
1) A disease process (hepatic dysfunction, heart failure, renal dysfunction)
2) Emotional disturbances
3) Genetic aberrations (atypical plasma cholinesterase, malignant hyperthermia)
4) Idiosyncrasy
• Toxicity Caused by Allergic Responses to the Drug
Adverse drug reaction

20. Signs and Symptoms – Toxic Reaction
to Local Anesthesia
• Talkativeness
• Slurred speech
• Dizziness
• Nausea
• Depression
• Euphoria
• Excitement
• Convulsions

21. ‫حسی‬ ‫بی‬ ‫داری‬ ‫اوردوز‬ ‫واکنش‬
Clinical signs and symptoms that
develop as a result of an
over-administration of a drug

22. Overdose Contributing Factors
• Age
• Weight
• Other medications
• Presence of disease
• Genetics
• Mental wellbeing

24. Drug Factors
• Vasoactivity
• Concentration
• Dose
• Route of administration
• Rate of injection
• Vascularity of the injection site
• Presence of vasoconstrictors

25. ‫حسی‬ ‫بی‬ ‫اوردوز‬ ‫کلینیکی‬ ‫عالیم‬
LOW TO MODERATE OVERDOSE LEVELS:
Confusion
Talkativeness
Apprehension
Excitedness
Slurred speech
Generalized stutter
Muscular twitching, tremor of face and
extremities
Elevated BP, heart rate and respiratory rate

26. ‫حسی‬ ‫بی‬ ‫اوردوز‬ ‫کلینیکی‬ ‫عالیم‬
MODERATE TO HIGH BLOOD LEVELS:
 Generalized tonic clonic seizure, followed by
 Generalized CNS depression
 Depressed BP, heart rate and respiratory rate
SYMPTOMS:
 Headache
 Light headedness
 Auditory distrurbances
 Dizziness
 Blurred vision
 Numbness of tongue and perioral tissues
 Loss of consciousness

27. ‫سیستمیک‬ ‫عوارض‬ ‫کنترل‬
1) Basic emergency management : A-B-C-D
approach
2) Allergy : Medical history questionnaire is
important.
3) Elective dental care
4) Emergency dental care:
- Protocol no.1 : no treatment of an invasive nature
- Protocol no.2 : use general anesthesia
- Protocol no.3: Histamine blockers
- Protocol no.4 : Electronic dental anesthesia/hypnosis

28. ‫خاص‬ ‫بیماران‬ ‫کنترل‬
• Uncooperative child
The maximum safe dose of lidocaine for a
child is 4.5 mg/kg per dental appointment.
Local infiltration of anesthesia is sufficient for
all dental treatment procedures in 90% of cases
even in the mandible.

29. ‫خاص‬ ‫بیماران‬ ‫کنترل‬
• Handicapped Patient
• retarded patients
choose a shorter needle and/or a larger
gauge needle which is less likely to be
bent or broken.
better to use general anesthesia

30. ‫خاص‬ ‫بیماران‬ ‫کنترل‬
Patients receiving anticoagulation or suffering from bleeding
disorders
 Oral procedures must be done at the beginning of the day & must be
performed early in the week, allowing delayed re-bleeding episodes,
usually occurring after 24-48 h, to be dealt with during the working
weekdays.
 Local anesthetic containing a vasoconstrictor should be
administered by infiltration or by intraligamentary injection
wherever practical.
Regional nerve blocks should be avoided when possible.
 Local vasoconstriction may be encouraged by infiltrating a small
amount of local anesthetic containing adrenaline (epinephrine) close
to the site of surgery.

31. ‫خاص‬ ‫بیماران‬ ‫کنترل‬
PREGNANCY
• Lidocaine + vasoconstrictor: most common
local anesthetic used in dentistry extensively
used in pregnancy with no proven ill effects,
Esters are better to be used.
• Accidental intravascular injections of lidocaine
pass through the placenta but the
concentrations are too low to harm fetus.

32. FDA Category of Prescription
Drugs
Drug Category Use During
Pregnancy
Risk
Lidocaine B Yes -
Prilocaine B Yes -
Mepivacaine C Use with caution-
Consult physician
Fetal
bradycardia
Bupivacaine C Use with caution-
Consult physician
Fetal
bradycardia

33. ‫خاص‬ ‫بیماران‬ ‫کنترل‬
GERIATRIC PATIENT
– When choosing an anesthetic, we are largely
concerned with the effect of the anesthetic agent upon
the patient's cardiovascular and respiratory systems.
– increased tissue sensitivity to drugs acting on the CNS
– Decreased hepatic size and blood flow may reduce
hepatic metabolism of drugs
– hypertension is common and can reduce renal function
– Same prevention procedures used with children

34. ‫خاص‬ ‫بیماران‬ ‫کنترل‬
LIVER DISORDERS
– Advanced liver diseases include:
Liver cirrhosis - Jaundice
- Potential complications:
1 . Impaired drug detoxication e.g. sedative, analgesics,
general anesthesia.
2. Bleeding disorders ( decrease clotting factors, excess
fibrinolysis, impaired vitamin K absorption).
3. Transmission of viral hepatitis.
Management
– Avoid LA metabolized in liver: Amides (Lidocaine,
Mepicaine), esters should be used

35. DRUG-DRUG INTERACTION
35

36. ‫آلرژی‬
• Incidents of allergy are low
• Often allergic reaction is to one of the
ingredients within the cartridge, not the
local anesthesia itself

37. • Hypersensitive state as a result of
exposure to an allergen
• Re-exposure can heighten the initial
reaction

38. ‫آلرژی‬ ‫کلینیکی‬ ‫عالیم‬
• Fever
• Angioedema
• Urticaria
• Dermatitis
• Depression of blood-forming organs
• Photosensitivity
• Anaphylaxis

39. Angioedema

40. ‫کنیم‬ ‫جلوگیری‬ ‫آلرژی‬ ‫بروز‬ ‫از‬ ‫چگونه‬
• Take a thorough medical history
• Dialogue the medical history with the
patient

41. ‫رایج‬ ‫سواالت‬
• Allergic to any medications?
• Have you ever had a reaction to local
anesthesia?
• If yes, describe what happened
• Was treatment given? If so, what?

42. ‫موضعی‬ ‫های‬ ‫حسی‬ ‫بی‬ ‫به‬ ‫آلرژیک‬ ‫های‬ ‫واکنش‬
• Dermatitis
• Bronchospasm
• Systemic anaphylaxis
• Hypersensitivity to esters
(atypical pseudo cholinesterase, PABA)

43. ‫دارو‬ ‫گیرنده‬ ‫تغییرات‬ ‫بعلت‬ ‫حسی‬ ‫بی‬ ‫داروی‬ ‫سمیت‬
1) Disease process
2) Emotional disturbances
3) Genetic aberrations
4) Idiosyncrasy

44. ‫نفرین‬ ‫اپی‬ ‫اوردوز‬
Very rare for patient to experience an
epinephrine overdose

45. ‫عروقی‬ ‫کننده‬ ‫تنگ‬ ‫با‬ ‫اوردوز‬ ‫های‬ ‫نشانه‬ ‫و‬ ‫عالیم‬
• Fear, anxiety
• Tenseness
• Restlessness
• Throbbing headache
• Tremor
• Perspiration
• Weakness
• Dizziness
• Pallor
• Respiratory difficulty
• Palpitations

46. ‫عروقی‬ ‫کننده‬ ‫تنگ‬ ‫دوز‬ ‫اور‬ ‫در‬ ‫کنترل‬
• Terminate dental procedure
• Sit patient upright in the dental chair
• Reassure patient
• Monitor blood pressure
• Administer oxygen

47. ‫حسی‬ ‫بی‬ ‫مصرف‬ ‫های‬ ‫کنتراندیکاسیون‬
‫عروقی‬ ‫کننده‬ ‫تنگ‬ ‫با‬ ‫موضعی‬ ‫های‬
• Uncontrolled hypertension
• Myocardial infarction (within 6 months)
• Unstable angina
• Coronary artery bypass graft (> 3 months)

48. Asthma Patient
• Thorough medical and dental history
• Avoid use of anesthesia that contain
epinephrine or levonordefrin because of
sulfites (may cause wheezing)
• Asthma patient that is steroid dependant
may develop brochospasms
• Establish rapport and calm environment

49. ‫خون‬ ‫فشار‬
• Stress and anxiety may raise the patient’s blood
pressure (>160/100)
• Thorough medical, dental and patient history
• Norepinephrine and levonordefrin should not be
used because of alpha1 stimulation
(2% Mepivacaine with 1:20,000 levonordefrin)
• Up to two cartridges of 2% lidocaine with
1:100,000 epinephrine is safe