DEPARMENT OF ORAL AND MAXILLOFACIAL

SURGERY

COMPLICATIONS
OF L.A.
SUBMITTED BY – VAIBHAV SHARMA
 OUTLINE

Needle Soft Tissue

Local Complications Infection
Breakage Injury

Pain on Facial Nerve

Hematoma Paresthesia Edema Trismus
Injection Paralvsis
 OUTLINE

SYSTEMIC
Overdose Allergy Syncope
COMPLICATIONS
 NEEDLE BREAKAGE
 Rare

Causes:
 1. Bending of the needle.
 2. Sudden unexpected movement of the
patient.
 3. Entire length of the needle inserted into
the soft tissue.
 4. Use of the smaller needles ( e.g. 40
gauge)
 PREVENTION
 1. Use large-gauge needles, specially with Inferior Alveolar Nerve and
Posterior Superior AlveolarNerve.
 2. Use long needles.
 3. Do not insert a needle into tissues to its hub.
 4. Do not redirect a needle once it is inserted into tissue.
 MANAGEMENT
When a needle breaks ( visible):
 1 Stay calm.
 2. Instruct the patient not to move and let his mouth open.
 3. If the fragment visible, remove it with hemostat or a Magill intubation forceps.1.2.3.

When a needle breaks ( not-visible):

 No incision or probing.
 Calmly inform the patient.
 Referral Oral Surgeon, take radiograph and determine its location.
 PARESTHESIA
CAUSES
 Trauma to the nerve.
 Local Anesthesia solution contaminated by alcohol or sterliziating solution near nerve produce
irritation, resulting edema and increased pressure in the region of the nerve leading to
paresthesia.
 Insertion of a needle inside a foramen.
 Hemorrhage-increased pressure-paresthesia.
 Prevention:
• Proper care and handling to injection control and cartridge.
 Management:
 Most paresthesia resolve within 8 weeks without treatment.
 Sequences of management:
 Reassuring the patient.
 Examine the patient and follow up each 2 months.
 If sensory deficit is still more than 1 year, consultation with neurologist and oral
surgeon.
FACIAL NERVE PARALYSIS
 Occur when anesthesia is introduced in deep lobe of parotid gland .
CAUSES
 Transient FNP is caused by local anesthesia into capsule of parotid gland, which is located at
posterior border of mandibular ramus .
 Usually it is caused during inferior alveolar nerve block or vazirani- akinosi nerve block.
PREVENTION
 Bone contact when injecting
 Avoid over penetration
TRISMUS
 Pain and difficulty in opening the mouth mainly after inferior alveolar and
posterior superior alveolar nerve block.
 Onset after 1-6 days post treatment.
CAUSES
 Trauma to the muscles or blood vessels.
 Contaminated anesthetic solutions
 Hemorrhage
 Infection
 Excessive anesthetic volume.
PREVENTION
 Sharp needles
 Proper care and handling of cartridges
 Aseptic technique and clean injection site
 Atraumatic insertion
 Minimal injection volume
MANAGEMENT
 Heat therapy
 Analgesics
 Muscle relaxants
 Physiotherapy
 Antibiotics in case on infection
 Recovery range is 4 to 20 weeks
SOFT TISSUE INJURY
 Trauma to the lip or the tongue caused by biting these tissue, while still anesthestized specially
with children.

PREVENTION
 Cotton roll placed between the lip and the teeth.
 Warn the patient
MANAGEMENT
 Analgesics for pain
 Antibiotics for infection
HEMATOMA
 The effusion of the blood in to the extravascular space

CAUSE
 Inadvertent piercing of a blood vessel during the injection or when withdrawing the needle.

 Mostly common with PSAblock and IANB

 Present for 7-14 days
PREVENTION
 Use a short needle for the PSAblock
 Minimize the number of needle penetration.
 Knowledge of normal anatomy.

MANAGEMENT
 Apply direct pressure
 Apply ice intermittently to the site
 Use analgesics as required
INFECTION
CAUSES
 Needle contamination
 Improper handling of armamentarium
 Infection at site of injection

PREVENTION
 Disposable needles
 Aseptic technique
 Proper care of equipment
SYSTEMIC COMPLICATIONS
SYNCOPE
 Predisposing factors:
 Psychogenic factors: fear, anxiety and sight of unpleasant object as blood or surgical
instrument
 Non-psychogenic: factors as pain especially sudden unexpected, sitting in waiting area for a
long period, hunger causing low glucose supply or exhaustion
CLINICAL FEATURES
Pre-syncope period: The patient feels faint and may feel nauseating.Paleness and coldness
of hand, cold sweating over the forehead and hands, hypotension, tachycardia and deep irregular
respiration
 Loss of consciousness:
 Hypotension, bradycardia and shallow irregular respiration. Possible muscular twitches
(tremors) or convulsive movements of the extermities.
 Progression may occur into muscular relaxation and apnoea

Post-syncope period:
 After regaining consciousness the patient feels weak, nauseating and mentally confused for
few minutes
MANAGEMENT
 Stop any dental procedure
 Place patient in supine or trendelenberg position to facilitate venous return to the heart
 Maintain patient airway, respiratory stimulants by atomatic spirit of ammonia
 Oxygen administration might be needed
 Keep the patient in this position under observation
 For persistent bradycardia give atropine 0.4 mg iv
OVERDOSE
 It refers to the symptoms manifested as a result of overdosage or excessive administration of
the solution.
CAUSE
 Total dose is too large
 Absorption is too rapid
 Intravascular injection
 Biotransformed too slowly
 Eliminated too slowly
MANIFESTATIONS
 Mild toxicity
slurred speech, confusion
Talkativeness, anxiety,
Moderate toxicity:
Stuttering speech,
nystagmus, tremors, headache,
dizziness, blurred vision,
Drowsiness
MANAGEMENT
• Stop administration of all local anaesthetics
• monitor vital signs
• observe in office for 1hr
• Stop administration of all local anaesthetics
• Place in supine position
• monitor in supine position
• observe for 1hr
 Severe toxicity
Seizure ,cardiac dysrhythmia or arrest
• Place in supine position
• administer oxygen
• administer diazepam 5-10 mg slowly or midazolam
5-10 mg
• institute BLS if necessary
IDIOSYNCRASY REACTION
 Unexplained by any known mechamism of drug action
 Neither overdose nor allergic reaction
 Unpredictable ; treat symptoms
ALLERGY
 Hypersensitive state, acquired through exposure to a particular allergen.
 • Allergic reactions cover a broad spectrum od clinical manifestations ranging from mild and
delayed response occurring as long as 48 hours after exposure to allergen, to immediate and
threatening reaction develop within seconds of exposure.
PREDISPOSING FACTOR
 Sodium Bisulfite:• Antioxidant in vasoconstrictor local anesthesia.
 Epinephrine.
 Latex
 Topical Anesthesia:
o Mostly ester.
o Preservatives containing such as methylparaben, ethylparaben, or propylparaben.
CLINICAL MANIFESTATION
 Dermatological reaction:
 Urticaria

 Angiodema
 CLINICAL MANIFESTATION
 Respiratory reactions:
 Bronchospasm

• Respiratory distress
• Dyspnea
• Wheezing
• Flushing
• Cyanosis
• Perspiration
•Tachycardia
• Anxiety
 Laryngeal edema

• Extension of edema to the larynx

• Life threatening emergency
CLINICAL MANIFESTATION
Generalized Anaphylaxis
 Skin reactions
 Smooth muscle spasm of gastrointestinal and genitourinary tracts and bronchospasm
 Respiratory distress
 Cardiovascular collapse
MANAGEMENT
 Skin reaction:

• Delayed reaction:

 Oral histamine blocker 50 mg diphenhydramine or 10 mg chlorpheniramine, one q6h for 3-4

days.
 Observation for 1 hour.
 Medical consultation.
 If patient is drowsiness, not allowed to leave the clinic.
MANAGEMENT
 Skin reaction:
 immediate reaction:

• Epinpherine 0.3 mg IM
• IM histamine blocker 50 mg diphenhydramine or 10 mgchlorpheniramine.
• Medical consultation
• Observation for 1 hour.
• Prescribe Oral histamine blocker з days.
MANAGEMENT
 Respiratory reaction:
 Bronchospasm:

• Administer oxygen at flow 5-6 liters\ min.

• 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 mgchlorpheniramine.
• Medical consultation
• Prescribe Oral histamine blocker 3 days.
MANAGEMENT
 Respiratory reaction:
 Laryngeal Edema : "unconscious patient“

• Epinpherine o.3 IM, dose repeated 10-15 min. if needed.

• Activate Emergency Medical Services.
• IM histamine blocker 50 mg diphenhydramine or 10 mg chlorpheniramine. Corticosteroid
IM or IV (100 mg Hydrocortisone sodium succinate to inhibit and
decrease edema.
• Perform cricothyrotomy.