5. PREVENTION:
o Use larger gauge needle
o Use long needles
o Don’t insert the needle into tissues to the hub unless it is
absolutely essential for the success of technique
o Don’t redirect the needle once it is inserted into tissues
6. MANAGEMENT:
WHEN THE NEEDLE BREAKS
1.Remain calm and don’t panic
2.Instruct the patient not to move
3.If the fragment is visible try to remove it with
cotton pliers or with small hemostat.
• Shira RB , Emergencies in Dental Practice, ed 3,
Philadelphia, 1979
7. • IF THE NEEDLE IS LOST AND CANNOT BE
READILY RETRIEVED
1. Do not proceed with incision
2. Calmly inform the patient and attempt to allay fear.
3. Note the incident in patients record
4. If the needle is superficial and is easily located through
radiological and clinical examination then removal with
competent oral surgeon is possible
5. If the needle is located in the deeper tissue or is hard to
locate permit it to remain with out an attempt at removal.
8. • PERSISTANT ANESTHESIA- PARATHESIA
CAUSES
• Trauma to any nerve
• Injection of contaminated LA
• Trauma to nerve sheath
• MANAGEMENT
• It generally resolves within 8 weeks without
treatment only if damage to nerve is severe then
the paresthesia will be permanent
• Nickel AA, Anesth Prog 37, 42-45,1990
9.
10. FACIAL NERVE PARALYSIS
CAUSES
• Introduction of LA solution into the deep lobe of parotid gland
EFFECTS
• Loss of Motor Function to the Muscles of Facial Expressions.
• Minimal or No Sensory Loss.
• Unilateral Paralysis
• Patient is unable to Voluntarily Close one eye.
11. MANAGEMENT
• Reassure the patient
• Advice the patient for periodically close the
eyelid
• Contact lens should be removed
• Record the incident on patients chart
12. TRISMUS
Defined as Prolonged muscle spasm of the jaw muscles by
which the normal opening of mouth is restricted.
CAUSES
• Trauma to muscles or blood vesicles in the infra temporal
space
• Irritation of the tissues
• Hemorrhage
• Low grade infection
• Excessive volume of local anesthetic solution
13.
14. PREVENTION
• Use sharp and sterile disposable needles
• Clean the site of injection with an antiseptic solution
• Practice atraumatic insertion
• Avoid repeat injections
• Use minimal effective volume
• Hinton and associates reported onset of trismus 1-6 days post
treatment
MANAGEMENT
• Heat therapy
• Warm saline rinse
• Analgesic ( Aspirin 325 mg)
• Muscle relaxants ( Diazepam 10 mg Bid)
• Physiotherapy
• Chewing gums
15. HEMATOMA
Effusion Of Blood Into Extravascular Spaces
CAUSES
• Inadvertent nicking of blood vesicles
PREVENTION
• Know the normal anatomy
• Modify the injection technique
• Use a short needle for PSA nerve block
• Minimize the number of needle penetration
• Never use a needle as probe in tissue
16.
17. MANAGEMENT
IMMEDIATE: when swelling becomes evident direct pressure
should be applied to the site of bleeding
INFERIOR ALVIOLAR NERVE BLOCK: pressure is applied to the
medial aspect of ramus
INFRA ORBITAL NERVE BLOCK : pressure applied to the skin
directly over the infra orbital foramen
MENTAL OR INCISIVE : pressure over mental foramen
BUCCAL NERVE BLOCK: pressure at the site of bleeding
PSA NERVE BLOCK: infra temporal space can accommodate a large
volume of blood digital pressure can be applied to the soft tissue in
the mucobuccal fold as far as distally as can be tolerated.
18. Subsequent :
• Do not Apply Heat for at least 4 to 6 hours after
incident
• If soreness develops , advice analgesics
• Discoloration usually resolves in 7 to 14 days
• If limitation of movement of jaws develops , begin
treatment as described for trismus
• Warm moist cloth 20 minutes hourly
• Apply Ice to the region immediately on recognition of
hematoma
• Time
19. PAIN ON INJECTION
CAUSES
• Careless injection technique
• Dull needle
• Rapid deposition of solution
• Needle with barbs
• Stacy GC et al, oral surg oral med 77, 585-588,1994
PREVENTION
• Proper technique of injection
• Use sharp needle
• Use topical anesthetic prior to injection
• Use sterile local anesthetic solution
• Slow injection technique
20. BURNING ON INJECTION
CAUSES
• pH of the solution
• Wahl and associates compared the pain on injection of
prilocaine plain to lidocaine with epinephrine (1:100,000)
and found no difference.
• When bupivacaine with epinephrine (1:200,000) compared
with prilocaine plain more pain was reported
Rapid injection of LA
• Contamination of LA cartridges
• PREVENTION
• Slow injection
• LA should be at room temperature
21. INFECTION
CAUSES
• Contamination of needle prior to injection
• Improper technique in handling the LA equipment
PREVENTION
• Use disposable needles
• Properly care for and handle needles
• Properly care for and handle cartridges
• Properly prepare the tissue
23. EDEMA
CAUSES
• Trauma during injection
• Infection
• Allergy
• Hemorrhage
• Injection of irritating solution
PREVENTION
• Properly care for and handle LA solution
• Use atromatic injection technique
• Complete and adequate medical evaluation
24. MANAGEMENT
• Resolve in 1 to 3 days
• Following haemorrhage it will resolve over 7 to 14
days
• Edema produced by allergy is more life
threatening type
If edema occurs in any area where it comprises
breathing treatment consists of administration of
epinephrine and corticosteroids.
25. SLOUGHING OF TISSUE
Causes
• Epithelial desquation
1. Application of topical anesthetic for prolong period
2. Heightened sensitivity of tissues to chemical agents
3. Reaction in an area where topical anesthetic is applied
• Sterile abscess
1. Secondary to prolong ischemia
2. Always occur in the tissue of hard palate
26.
27. PREVENTION
• Use topical anesthetic as recommended
• Allow the solution to contact the mucous
membrane for 1 to 2 min
• When using vasoconstrictor for homeostasis
don’t employ overly concentrated solutions
MANAGEMENT
• Management may be symptomatic
• Topically applied ointment such as orabase to
minimize irritation
28. POST ANESTHETIC INTRAORAL
LESSIONS
CAUSES
• Recurrent aphthous stomatitis
• Herpes simplex
• Trauma to the tissue by needle and LA solution
MANAGEMENT
• Primary management is symptomatic
• Viscous lidocaine can be applied
• A mixture of equal amount of diphenhydramine and milk of
magnesia rinse in the mouth effectively coats the ulceration
• Orabase a protective paste provides a degree of pain relief.
29.
30. SYSTEMIC COMPLICATIONS
CLASSIFICATION OF ADVERSE DRUG
REACTIONS- TOXICITY
1. Toxicity caused by direct extension of
pharmacological effects
• Side effects
• Over dose
• Local toxic effects
2. Toxicity caused by alteration in the recipient
• Presence of disease
• Emotional disturbances
• Genetic aberrations
• Idiosyncrasy
3. Toxicity caused by allergy to the drug
31. Toxicity of Local anesthetics
• Toxins are poison.
• All drugs are poison when administered too
much
• Methylparaban has been excluded from all L.A
Cartridges manufactured in USA from 1984.
• Overdose is also a Synonym for toxic reaction
Because 99% of total toxicity is due to
overdose.
32. LOCAL ANESTHETIC OVERDOSE
PRE DISPOSING FACTORS:
1. PATIENT FACTORS
• Age
• Weight
• Sex
• Presence of disease
• Genetics
• Mental attitude and environment
33. 2. DRUG FACTORS
• Vasoactivity
• Concentration
• Dose
• Route of administration
• Rate of injection
• Vascularity of injection site
• Presence of vasoconstrictor
34. CLINICAL MANIFESTATION OF
LOCAL ANESTHETIC OVERDOSE
SIGNS:
MINIMAL TO MODERATE OVERDOSE LEVELS:
o Apprehension
o Talkativeness
o Excitability
o Slurred speech
o Generalized stutter
o Muscular twitching
o Nystagmus, dysarthria
o Sweating , vomiting
o Elevated BP, heart rate and respiratory rate
35. MODERATE TO HIGH BLOOD LEVELS:
o Generalized tonic clonic seizure, followed by
o Generalized CNS depression
o Depressed BP, heart rate and respiratory rate
36. SYMPTOMS:
o Light headedness
o Restlessness
o Nervousness
o Numbness
o Metallic taste
o Visual disturbances
o Auditory disturbances (tinnitus)
o Drowsiness
o Loss of consciousness
37.
38.
39. ALLERGIC REACTIONS
• 1% of all reactions occuring during administration of
LA are allergic in nature.
• Caused by antigen – antibody reaction leading to
release of histamine or histamine like substances.
• Most commonly methylparaben has been implicated
in production of allergic reactions.
• Signs and Symptoms:
• Fever
• Edema
• Urticaria
• Dermatitis
• Bronchospasm
• Systemic Anaphylaxis
40.
41. Prevention:
• Medical History Questionnaire –
-Describe your Reaction
-How was your reaction treated
-What position were you in at the
time of the reaction
-What is the name, address, and telephone
number of a Doctor in whose office this
reaction occurred
• Consultation
• Allergy Testing – though no form of allergy testing is 100%
reliable
• Alternative L.A. solution
• Alternative Techniques of Pain Control
42. Treatment:
• Bronchospasm-
1. P-A-B-C-D
2. Administer Oxygen
3. Administer Epinephrine or Other Bronchodilator such as
Albuterol via inhalation
4. Adm AntiHistamines (50 mg Diphenhydramine)
5. Medical Consultation
• Skin Reaction-
1. Oral Histamine Blockers
2. Observation
3. Medical Consultation
4. If skin reaction is Immediate , administer epinephrine.
43. IDIOSYNCRASY
• Any reaction to LA that cannot be classified as
toxic or allergic is often called idiosyncrasy.
• TREATMENT –
• Purely symptomatic.
• Aimed at maintenance of patent airway and
cardiovascular support.
44. CONCLUSION
• Local anesthesia is required for almost all the
procedures performed in present day dentistry.
Hence we as the dentists should be aware of
various techniques, adverse effects, actions
and indications along with the
pharmacological aspects so that we can use it
judiciously according the patients condition.
