Article

Letter to the editors

Palatal necrosis: a rare complication of local

anesthetic in dentistry
Ayekinam Kao, Bouchra Taleb

Corresponding author: Ayekinam Kao, Department of Oral Surgery, Dental Center of Treatment and Diagnosis, Ibn Sina
Hospital, Rabat, Morocco. kabibine@yahoo.fr

Received: 12 Dec 2020 - Accepted: 23 Dec 2020 - Published: 05 Jan 2021

Keywords: Palatal necrosis, local anesthetic, complications

Copyright: Ayekinam Kao et al. PAMJ Clinical Medicine (ISSN: 2707-2797). This is an Open Access article distributed under
the terms of the Creative Commons Attribution International 4.0 License
(https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any
medium, provided the original work is properly cited.

Cite this article: Ayekinam Kao et al. Palatal necrosis: a rare complication of local anesthetic in dentistry. PAMJ Clinical
Medicine. 2021;5(2). 10.11604/pamj-cm.2021.5.2.27400

Available online at: https://www.clinical-medicine.panafrican-med-journal.com//content/article/5/2/full

Palatal necrosis: a rare complication of local To the editors of the PAMJ

anesthetic in dentistry
Clinical Medicine
Ayekinam Kao1,2,&, Bouchra Taleb1,2
A 50-year-old female, with no previous medical
1
Department of Oral Surgery, Dental Center of history, described pain felt in the middle part of
Treatment and Diagnosis, Ibn Sina Hospital, Rabat, palate for 7 days an extraction of an impacted
Morocco, 2Dentistry Medical School, Mohammed V maxillary canine under local anesthetic in our Oral
University, Rabat, Morocco Surgery Department. Before the extraction, 1.8 ml
of lignocaine 2% with epinephrine 1: 100,000 was
&
Corresponding author injected for palatal and buccal infiltration. No
history of allergies to local anesthetic was reported
Ayekinam Kao, Department of Oral Surgery, Dental from previous dental treatments. According to the
Center of Treatment and Diagnosis, Ibn Sina patient, 2 days after the extraction, he started
Hospital, Rabat, Morocco feeling a pain in the middle of the hard palate. An
intraoral examination of the area revealed an ulcer
lesion surrounded by a swollen mucosa in the

Ayekinam Kao et al. PAMJ-CM - 5(2). 05 Jan 2021. - Page numbers not for citation purposes. 1
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middle of the hard palate which measured
approximately 1 cm x 1 cm. The floor of the ulcer
was covered with a necrotic lesion (Figure 1). On
palpation, the ulcer had no peripheral induration.
The patient was prescribed (paracetamol 1g) and
an antiseptic mouth wash (chlorexidin 12%) and
was followed up for 3 consecutive weeks. Complete
healing was achieved in about 21 days (Figure 2).
In literature, "local anesthetics" are defined as
agents which produce a temporary loss of
sensation or pain in one part of the body [1]. The
clinical use of local anesthetic agents have been
classified as either amino-esters or amino-amides.
According to physical and chemical properties,
these agents exert their anesthetic effect by acting
on the highly lipid nerve membrane [2]. Their main
components are a local anesthetic agent, a
vasoconstrictor, an antioxidant and a consists of reassurance of the patient and
preservative [1,2]. Vasoconstrictors added to a
local anesthetic solution are most of time
epinephrine in a concentration ranging from 1:
50,000 to 1: 200,000 and its main purpose is to
prolong the duration of anesthesia, decrease the
rate of absorption from the local site, reduce
systemic toxicity and also to minimize
bleeding [1,2]. Various local complications in a
dental practice described in literature are mostly
due to local anesthetic. According to studies of
Daublander et al. in Germany (1997), the overall
incidence of complications was 4.5%. It was
significantly higher in risk patients (5.7%) than in
non risk patients (3.5%). Complications such as
dizziness, tachycardia, agitation, nausea, tremor,
were the most frequently observed. Severe
complications such as seizure and bronchospasm
occurred in only two cases (0.07%). It was also
reported that Articaine 1: 100,000 caused more
sympathomimetic side effects than that of
Articaine 1: 200,000 [3]. In the case we presented,
the side effects were observed under 1: 100,000. In
literature, post-anesthetic necrosis is an
uncommon complication which occurs in the hard
palatal mucosa and is very rare since only few cases
have been reported [4].
Ayekinam Kao et al. PAMJ-CM - 5(2). 05 Jan 2021. - Page numbers not for citation purposes.
According to many authors, the etiology of post-
anesthetic necrosis could be explained by an
increase in pressure during a rapid or forced
infiltration into the hard palatal tissues adherent to
the underlying bone causing pain and soreness, or
poor blood supply causing deprivation of the tissue
of its necessary sustenance secondary to
vasoconstriction. Tissue necrosis may be a result of
a transient ischemia of structures located distally to
the infiltration area secondary to a contraction of
smooth muscle within the arterial wall causing
vasoconstriction [1,4-6]. The differential diagnosis
of this lesion can be aphthous stomatitis, herpes
simplex, neoplastic lesion or mucormycosis [4,5].
The healing of the wound is due to the rich
vascularization of palatal arteries by providing
oxygen and nutrients [6]. Management of patients
with such local complications is conservative and
prescription of analgesics and/or topical
antiseptics [1,4-7]. Antibiotics are only necessary if
the lesion is secondarily infected [1]. Surgical
management is only necessary if the ulcer does not
heal [4,5]. In order to reduce the incidence of post-
anesthetic necrosis, it is recommended to take
certain precautions such as proper knowledge of
the anatomy of the area before infiltration, limiting
infiltration to 1-2 ml to maximize efficacy and the
use of an anesthetic solution with a lower
epinephrine concentration than that with a higher
concentration (i.e. 1: 50,000 ; 1: 30,000) [4,5,7].
Figures
Figure 1: intraoral view showing palatal mucosal
necrosis
Figure 2: intraoral view after the complete healing
Competing interests
The authors declare no competing interests.
2
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Authors´ contributions 4. Gargi V, Mohan RP, Kamarthi N, Gupta S.

Palatal perforation: a rare complication of
Ayekinam Kao: writer. Bouchra Taleb: reviewer and postanesthetic necrosis. Contemp Clin
final approval of the paper. All the authors have Dent. 2017;8(3): 501-505. PubMed| Google
read and agreed to the final manuscript. Scholar
5. Gupta R, Garg M, Pawah S, Gupta A.
Postanesthetic ulceration of palate: a rare
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Figure 1: intraoral view showing palatal mucosal necrosis

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Figure 2: intraoral view after the complete healing

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