ORAL & MAXILLOFACIAL SURGERY

Paper – II
Q. 33: Discuss in detail the local and systemic complications of Local
Anesthesia with a note on the maximum safe dose of vasoconstrictors
and its complications (20M)
Mode of action of local anesthetics and the management of toxicity
due to over dosage of local anesthetics. (7M)
Adverse effects of Local Anaesthetic agents (5M)

CONTENT/ SYNOPSIS
Local Complications
Needle Breakage
Haematoma
Trismus
Facial Nerve Paralysis
Infection
Edema
Others
Pain on injection
Burning on injection
Paraesthesia
Soft tissue injury
Sloughing of tissue
Post-anesthetic intraoral lesions
Systemic Complications
Toxicity (True Overdose)
Allergy
Syncope
Idiosyncrasy
References

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NEEDLE BREAKAGE
Causes
• Sudden movement of the patient
• Previously bent needle more likely to break
• Smaller size needles more likely to break
• Defect in manufacturing

Prevention
• Proper instruction to the patient
• Do not insert the needle to its hub instead use a larger needle
• Use a larger gauge needle
• Do not redirect the needle once inserted into the tissues

Management
• Do not panic
• Do not remove your hand from patient’s mouth, keep the patient’s mouth open
• If the fragment is visible, try to remove it with a small hemostat or a Magill
intubation forceps.

If the needle is lost and cannot be readily be retrieved

• Don not proceed with an incision or probing, and refer the patient to an oral
and maxillofacial surgeon for consultation and not for its removal

When a needle breaks consideration should be given to its immediate

removal, under the following conditions
• The needle is superficial and easily located through radiological and clinical
examination; removal by a competent dental surgeon is possible.

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• Despite its superficial location, attempted retrieval is unsuccessful within a
reasonable length of time’ it is then prudent to abandon the attempt and allow
the needle fragment to remain.
• The needle is located in deeper tissues or is hard to locate’ it should be
permitted to remain without an attempt at removal.

HAEMATOMA
Definition
• The effusion of the blood into the extravascular spaces

Causes
• Nicking of blood vessels while injecting the local anaesthesia

Prevention
• Knowledge of anatomy
• Modification in injection technique
• Use short needle in PSA nerve block

Management
• Apply direct pressure at the site of bleeding for atleast two minutes
• Ice may be applied immediately
• Prescribe analgesics
• With or without treament the haematoma will resolve in 7 to 14 days

TRISMUS
Definition
• It is the prolonged tetanic spasm of the jaw muscles by which normal opening
of the mouth is restricted

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Causes
• Trauma to blood vessels or muscles
• Alcoholic L.A solution
• Myotoxic effect of L.A on the skeletal muscles
• Low grade infection
• Haemmorrhage

Prevention
• Use sharp and sterile needle
• Use aseptic needle
• Avoid multiple insertion and repeated injections at the same site
• Atraumatic insertion and injection technique

Management
• Application of hot moist towel for 20 min/hr
• Warm saline rinses
• Physiotherapy
• Prescribe analgesics and muscle relaxants eg. Methocarbamol ( ibugesic),
baclofen, tizanidine, etc.
• If infection persists then prescribe antibiotics

FACIAL NERVE PARALYSIS

Causes
• Commonly caused by introduction of L.A into the capsule of parotid gland
while giving inferior alveolar nerve block.

Prevention
• Preventable by adhering to protocol of inferior alveolar nerve block
• Needle should be in contact with bone prior to deposition of solution
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Management
• Explain the patient that this is transient
• Apply eye patch to the affected eye
• If the resistance is offered by the patient, advise the patient to manually close
the lower eyelid periodically to keep the cornea lubricated
• Contact lenses should be removed until muscular movement returns

INFECTION
Causes
• Contamination of needle
• Improper technique in handling of L.A
• Improper tissue preparation

Prevention
• Use disposable needle
• Proper handling of the needle
• Properly prepare the tissue prior to penetration

Management
• Immediate treatment should consist of procedure used to manage trismus
• If the trismus does not resolve in 3 days then put the patient on 7 days of
antibiotic course

EDEMA
Causes
• Trauma during injection
• Infection
• Allergy
• Hemorrhage
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• Injection of irritating solution

Prevention
• Sterilization should be maintained
• Complete evaluation of the patient
• Use a traumatic injection technique

Management
• Usually resolve within several days
• If it persists, prescribe analgesics
• If there is edema due to hematoma, it will resolve in 7 to 14 days
• If there is infection prescribe antibiotics

PERSISTENT ANESTHESIA OR PARESTHESIA

Definition
• It is defined as persistent anesthesia or altered sensation well beyond the
expected duration of anesthesia

Causes
• Trauma to nerve
• During mandibular dental implants
• Injection of local anesthetic solution contaminated by alcohol or sterilizing
solution near a nerve
• Trauma to nerve sheath
• Hemorrhage into or around the neural sheath
• Neurotoxicity of local anesthetics

Prevention
• Strict adherence to injection protocol and proper care and handling of dental
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cartridges help minimizing the risk of paresthesia.

Management
• Most paresthesia resolve within approx. 8 weeks to 1 year without treatment,
and if it does not resolve within that period an oral surgeon or neurologist
should be consulted.
• Dental treatment may continue, but avoid readministering local anesthetic into
the region of the previously traumatized nerve. Use alternate local
• anesthetic techniques if possible.

SOFT TISSUE INJURY

Causes
• It occurs mostly in children and mentally or physically disabled children or
patients.
• Because the soft-tissue anesthesia lasts significantly longer than does pulpal
anesthesia.

Prevention
• A local anesthetic of appropriate duration should be selected if dental
appointments are brief.
• A cotton roll cane be placed between the lips and teeth if they are still
anesthetized at the time of discharge which can be secured with dental floss
wrapped around the teeth.
• Warn the patient and guardian against eating and, drinking hot fluids and
biting on the lips or tongue to test for anesthesia.
• A self adherent warning sticker may be used on children. It states “Watch me,
my lips and cheeks are numb”

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Management
• Management of the patient with self inflicted soft tissue injury secondary to
lip or tongue biting or chewing is symptomatic:
• Analgesics for pain, as necessary
• Antibiotics, as necessary, in the unlikely situation that infection results
• Lukewarm saline rinses to aid in decreasing any swelling that may be
present.
• Petroleum jelly or other lubricant to cover a lip lesion and minimize irritation.

PAIN ON INJECTION
Causes
• Careless injection technique and callous attitude all too often become self
fulfilling prophesies.
• A needle can become dull form multiple injections
• Rapid deposition of the local anesthetic solution may cause tissue damage
• Needles with barbs may produce pain as they are withdrawn from tissue

Prevention
• Adhere to proper techniques of injection, both anatomical and psychological
• Use sharp needles
• Use topical anesthetic properly before injection
• Use sterile local anesthetic solutions.
• Inject local anesthetic slowly
• Be certain that temperature of the solution is correct. A solution that is too hot
or too cold may be more uncomfortable than one at room tempaerature

Management
• No management is necessary.

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SLOUGHING OF TISSUES
Epithelial Desquamation
• Application of topical anesthetic to the gingival tissues for a prolonged period
• Heightened sensitivity of the tissues to a local anesthetic
• Reaction in an area where a topical has been applied

Sterile abscess
• Secondary to prolonged ischemia resulting from the use of a local anesthetic
with vasoconstritctor
• Usually develops on the hard palate

Prevention
• Use topical anesthetics as recommended.
• Allow the solution to contact the mucous membranes for 1 to 2 minutes to
maximize its effectiveness and minimize toxicity.
• Don’t use overly concentrated solutions of vasoconstrictors

Management
• Management may be symptomatic for pain, analgesics such as aspirin or
codeine and a topically applied ointment to minimize irritation to the area are
recommended.
• Epithelial desquamation resolves within a few days’ the course of a sterile
abscess may run 7 to 10 days.

POSTANESTHETIC INTRAORAL LESIONS

• Occasionally, approx. 2 days after an intraoral injection of L.A ulcerations
develop in mouth primarily around the site of injection.
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Causes
• Trauma to the tissues by : needle, local anesthetic solution, cotton swab,
instrument usually causes Recurrent Apthous Stomatitis or Herpes Simplex.

Prevention
• There are no practical preventions but the patients who are prone to viral
infections should be given prophylactic Antiviral agents eg. Acyclovir

Management
• Primary management is symptomatic and no treatment is necessary if pain is
not severe.
• Try to keep the ulcerated areas covered or anesthetized if the complaint
persists.
• Topical anesthetic solutions eg. viscous lidocaine may be applied
• A mixture of equal amounts of diphenhydramine and milk of magnesia rinsed
in the mouth effectively coat the ulcerations
• Orabase a protective paste without kenalog can be used.
• A tannic acid preparation (Zilactin) can be used
• The ulcerations usually last 7 to 10 days with or without ulcerations

TOXICITY
Definition
• Are those clinical signs and symptoms that manifest as a result of absolute
or relative over administration of a drug which produces elevated levels in
blood.

Causes
• Biotransformation of the drug is too slow
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• Drug is too slowly eliminated from the body
• Too large total dose
• Absorption from the injection site is unusually rapid
• Intravascular injection

Signs and Symptoms

Signs
• Talkativeness, excitability, sweating, vomiting, increased B.P., heart rate and
respiratory rate.

Symptom
• Headache, restlessness, loss of consciousness, numbness if severe, tonic-
clonic seizure followed by generalized CNS depression with decreased B.P.,
heart rate and respiratory rate.

Management
• Place the patient in supine position with their feet elevated slightly
• If convulsion present protect patients arm, legs and head
• Loose tight clothing
• Immediately summon emergency medical assistance
• Give basic life support
• Administer an anticonvulsant
• Additional treatment such as use of vasopressor if hypotension persist.

ALLERGY
Definition
• It is hypersensitive state acquired through exposure to particular allergen

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Signs and symptoms
(i) Dermatological reaction
• Urticaria, angioedema, pruritis, erythema, conjuctivitis, pilomotor, erection

(ii) Respiratory reaction

• Respiratory distress, dyspnea, wheezing, cyanosis, tachycardia

(iii) Cardiovascular reaction

• Palor, hypotension, tachycardia, unconsciousness, cardiac arrest

Management
Skin reaction
• Oral histamine
• Obtain medical consultation
• If skin reaction is immediate 0.03mg. Epinephrine IM or SC

Respiratory reaction
• Place the patient in semi-erect position
• Administer O2
• Epinephrine IM or SC

Generalized anaphylaxis
• Place the patient in supine position
• Give basic life support and Epinephrine
• Monitor vital signs
• Administration of Histamine and Corticosteriods

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SYNCOPE
Definition
• A transient loss of consciousness secondary to cessation or decrease in
cerebral blood flow.
• More prevalent in young people.

Causes
• Anxiety, fear, pain, grief, sight of blood, physical and mental exhaustion, hot
environment, debility, fasting.

Signs and Symptoms

• Warmth, weakness, epigastric discomfort, nausea, sweating, pallor, coldness
of extremities, dizziness, may be slight increase in B.P. and pulse
• In later stage ashen grey pallor, shallow respiration, slow and weak pulse, low
B.P. and dilated pupils

Management
• Place patient in supine position with leg elevated
• Loosen tight clothing
• Maintain airway
• O2 administration

Adjunctive Therapy
• Inhalation of aromatic spirit of ammonia
• Check vital signs
• If bradycardia then give Atropine
• If hypotension phenylephrine should be given

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IDIOSYNCRASY
Definition
• It is response that cannot be explained by any known pharmacological
biochemical mechanism.

Causes
• Idiosyncratic reaction have an underlined genetic mechanism.

Management
• Treatment is necessarily symptomatic
• Positioning
• Airway
• Breathing
• Circulation
• Definitive care

REFERENCES
1. Monheim, L.M., 1963. Local anesthesia. The Journal of Prosthetic
Dentistry, 13(5), pp.933-939.
2. Malamed, S.F., 2004. Handbook of local anesthesia. Elsevier Health Sciences.

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