Australian Dental Journal

The official journal of the Australian Dental Association

Australian Dental Journal 2011; 56: 348–351
REVIEW
doi: 10.1111/j.1834-7819.2011.01358.x

Higher concentration local anaesthetics causing prolonged

anaesthesia. Do they? A literature review and case reports
A Kingon,* P Sambrook,  A Goss 
*Private Practice, Pymble, New South Wales.
 Oral and Maxillofacial Surgery Unit, School of Dentistry, The University of Adelaide, South Australia.

ABSTRACT
Higher concentration dental local anaesthetics (3% and 4%) have become more available in Australia in recent years.
Benefits claimed include a faster onset of anaesthesia and improved success with injections compared to 2% solutions.
Recent reports suggest that the higher concentration carries a greater risk of prolonged anaesthesia to the mandibular and
particularly the lingual nerves. The literature was reviewed and those studies which demonstrated adverse effects of different
concentrations of local anaesthetics were analysed. Recent cases are presented. There is an extensive international literature
which confirms increased concentration of local anaesthetic does show an increased risk, by about ·6, of prolonged
anaesthesia. Five case reports illustrate the impact of this complication on patients’ quality of life. Careful consideration
needs to be given before using higher concentration local anaesthetic agents for mandibular and lingual blocks as lower
concentration local anaesthetics are safer. If acceptable to individual patients, avoidance of block injections or any local
anaesthetic for minor restorative tasks could be encouraged given the severity of the complication. It is safe to use the higher
concentration agents for infiltrations away from major nerves.
Keywords: Local anaesthetics, prolonged anaesthesia, higher concentration, neurotoxicity.
(Accepted for publication 30 March 2011.)

studies, 4% local anaesthetic agents were introduced

INTRODUCTION
The essence of sound therapeutics is for a drug to have
maximum benefit with minimal risk. Dental local
anaesthetics are a good example of a class of drugs
with maximum benefit to the patient as they allow
complex invasive procedures to be performed safely
with minimum pain.1 However, there is a small but
defined risk of adverse reactions, both locally and
systemically, to local anaesthetic agents. These have
recently been reported.2,3 In the development of these
studies, it is evident that there is concern in the
international literature of a risk of a relation between
increased concentration and increased neurotoxicity.4–12
It has been claimed by clinical observation that 4%
articaine has a faster onset of anaesthesia and fails to be
effective less often; two features that practitioners
consider important.13 The differing strengths of dental
local anaesthetic agents available in the Australian
market are summarized in Table 1.
A review of the literature showed two large studies
which systematically approached this issue. These were
a 21-year longitudinal study in Ontario, Canada4 and
a prospective national study in Denmark.6 In both
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into the region mid-study and thus showed an increase
in reporting of prolonged anaesthesia. Further studies
have been reported from the San Francisco Bay area of
California, USA.6,7 All of these studies carefully docu-
ment their methodology, describing both their strengths
and weaknesses.
Attempts at a comparable study in Australia were
not possible as there is no mandatory central
reporting mechanism, and the pharmaceutical com-
panies and supply agents would not release data on
the percentage sales of the different agents available
in Australia.2
In this study, the international literature was
reviewed in an attempt to determine the risk of
increased concentration of local anaesthetic agents on
the incidence of prolonged anaesthesia.
A comparison of the different international studies
is presented in Table 2. These show an increased risk
of approximately ·6 for higher concentration local
anaesthetics.
A small case series of prolonged anaesthesia from
higher concentration local anaesthetic agents which
have resulted in mandibular nerve problems is also
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Table 1. Concentration of local anaesthetic agent in
dental anaesthetics in Australia
0.5% Bupivacaine hydrochloride
2% Lignocaine hydrochloride
Procaine hydrochloride
3% Prilocaine hydrochloride
Mepivacaine hydrochloride
4% Articaine hydrochloride
Table 2. Ratio of reported prolonged anaesthesia from
different concentrations of local anaesthetic agents
2% 3%
4
Haas and Lennon 1 6.76
Hillerup and Jensen6 1 1
Pogrel7 1 7.6
Dower11 1 15
presented. The lingual nerve was affected in four of the
cases, and the mandibular nerve in one.
CASE REPORTS
Case 1
A medically fit 43-year-old male had a right mandibular
block for cementation of a crown to the right mandib-
ular first molar. One 2.2 ml cartridge of 4% local
anaesthetic was administered by an experienced dentist.
At the time of the injection he experienced an electric
shock sensation at the site of the injection. Dysaes-
thesia, or painful numbness of the lingual nerve,
continued but the mandibular nerve recovered.
The patient experienced difficulty in talking, eating
and had altered taste. Soon after the injection he was
accused of being under the influence of alcohol by a
business associate as he couldn’t speak properly.
Despite being given documentation of the nature of
the problem, he has not received further earthmoving
contract work from that associate. At 23 weeks fol-
lowing the injection he was examined by a neurologist
who found a profound anaesthesia of all the right
lingual nerve. There was a hyperaesthetic burning
sensation on contact and loss of taste.
The patient was diagnosed as having a severe
dysaesthetic injury but with some signs of recovery.
On follow-up at 21 months there was no improvement.
Case 2
A medically fit 61-year-old male had a right mandibular
block for restoration of the right mandibular second
premolar. One 2.2 ml cartridge of 4% local anaesthetic
was administered by an experienced dentist. The
injection was not painful but paraesthesia of the right
ª 2011 Australian Dental Association
Local anaesthesia and neurotoxicity
lingual nerve persisted with the long buccal and
mandibular nerves recovering sensation normally.
On review four weeks later, there had been a
noticeable resolution of the paraesthesia reported by
the patient. There was no interference with taste. On
objective testing there was an equal response to sharp
and blunt, two-point and directional sense between the
right and left lingual nerves. The patient was diagnosed
as having mild paraesthetic sensation which would
resolve. On follow-up at four months, there was still a
mild paraesthetic sensation.
4%
Case 3
5
14 A medically fit 66-year-old male had bilateral mandib-
2
20
ular blocks for restoration of mandibular molars. One
cartridge of 4% local anaesthetic was used for each side
and this was administered by the same experienced
dentist as Case 2. The left side mandibular nerve
recovered normally but on the right side mental nerve
anaesthesia persisted. He had normal right and left
lingual nerve sensation and no taste deficit.
On review 10 days after the injection, the patient felt
there had been a noticeable improvement in the last few
days. On objective testing there was equal response
to sharp and blunt, two-point and directional sense
between the right and left mental nerves. The patient
was diagnosed as having a mild paraesthetic sensation
which would resolve. On follow-up at four months,
there was still a mild paraesthetic sensation.
Case 4
A medically fit 59-year-old male had a right mandibular
block for filling his right mandibular second molar.
One cartridge of 2.2 ml of 4% local anaesthetic was
administered by an experienced general dentist. The
patient experienced an electric shock sensation at the
time of the injection. Dysaesthesia, or painful numbness
of the right tongue, persisted but the mandibular nerve
recovered.
The patient experienced difficulty in talking, eating
and had altered taste. He is a health professional and
had difficulty talking to patients. The area of numbness
slowly decreased from posterior to anterior and by one
year it was mainly a painful tongue tip. He was
examined at 11 months and was found to have an equal
right and left side sharp and blunt, two-point and
directional sense. A 1 cm area on the right tongue tip
was hypersensitive to contact. Taste was still altered.
Nearly two years after the procedure, there has been no
further improvement.
He was diagnosed as having a severe dysaesthetic
injury of the right lingual nerve with evidence of slow
recovery. He was placed on one vitamin B complex
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A Kingon et al.
tablet per day. On follow-up at 12 months, he has
ongoing problems.
Case 5
A medically fit 55-year-old female had a right mandib-
ular block for restoration of a right mandibular second
molar. One cartridge of 2.2 ml of 3% local anaesthetic
(mepivacaine HCl) was injected but failed to give
adequate anaesthesia, so the experienced general dentist
gave a further 2.2 ml. There was no pain at the injection
site. The following day the patient rang to report ongoing
numbness and tingling of the right lingual nerve. The
right mandibular nerve had fully resolved.
The patient was examined at five weeks and found to
have reduced sensation to objective sharp and blunt,
two-point and directional sense. She had altered taste
but normal olfaction. She was put on one tablet per day
of vitamin B complex. She was advised to smell food
first and place food on the left side of the tongue first to
help improve her sense of taste.
She was diagnosed as having a severe right lingual
nerve injury with probable slow recovery. She had loss
of taste which was of particular concern to her as she
was a keen amateur cook who liked cooking for her
large extended family. There has been no resolution
more than one year after the local anaesthetic was
administered.
There are similarities in these case reports, all patients
were fit and well, middle-aged Australians who had
mandibular blocks for restorative purposes administered
by experienced dentists. Two of the patients had electric
shock sensations on injections but three did not. One had
a repeat injection. Although it is commonly thought that
electric shock pain on injection or repeat injections are
associated with an increase in prolonged anaesthesia,
this is not supported by the literature.2,6 They all suffered
prolonged abnormal sensation in the mandibular or
lingual nerves. None of these cases have yet to be fully
resolved. The alteration in sensation appears to be
different to surgically damaged nerves as there is a return
of sensation as tested by objective tests, but the nerve
area burns and is dysaesthetic. This gives the impression
that the nerve is recovering but to date they have not
recovered. Three of the patients had loss of taste.
This adverse complication to local anaesthesia
resulted in considerable interference in the patients’
ability to generally enjoy life and work. Three patients
presented with serious problems in talking, eating and
taste.
DISCUSSION
These five cases support the argument that there is an
increased risk of prolonged anaesthesia of the mandib-
ular and, particularly, the lingual nerve from higher
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concentration local anaesthetic agents. The impact of
this is illustrated as they were collected over a short
period by the authors. Although it has been tradition-
ally considered that direct needle trauma is the cause of
paraesthesia, a recent review does not provide support
for this mechanism.2 It must be appreciated that the
incidence of these adverse responses is low when
compared to the total number of block anaesthetics
given. The international literature shows a risk of
prolonged anaesthesia with an incidence ranging from
1 in 26 0007 to 1 in 750 0004 injections. The recent
Australian study found an incidence of 1 in 27 415
although this figure has wide confidence limits.2
Prolonged anaesthesia may also occur when lower 2%
local anaesthetic agents are used.2 The key issue is that
the evidence indicates that there is a greater risk with a
higher concentration of local anaesthetics. The increased
risk is conservatively estimated at 5- to 7-fold.4–7 Other
more anecdotal papers report an up to ·20 increase.11,12
Hence, clinicians need to first consider whether local
anaesthesia is required at all for some restorative
procedures. Up until the 1970s, local anaesthesia was
largely reserved for extractions or very deep dentine or
pulpal procedures. Now virtually every dental procedure
is preceded by administration of local anaesthesia. Given
the severity of the complications these five patients have
had to endure, it raises the question of the need to
administer local anaesthetic for every procedure; the
wishes of each patient should be met but it is suggested
that avoidance be considered if tolerated. Blocks are
administered for most mandibular procedures but
experienced clinicians have noted it is possible to
effectively anaesthetize all of the teeth of the mandible,
including the molars, by infiltration. Deposition of more
local anaesthetic (than has been traditionally taught) on
the lingual side allows this. Infiltration should be used for
premolar and anterior teeth. Next to consider is the
question of whether there is a benefit from using higher
concentrations of a local anaesthetic agent as compared
to a lower concentration. A randomized double-blind
study showed no clinical differences between 4% and 2%
articaine, both with 1 in 200 000 epinephrine infiltra-
tions for tooth extractions.14 There was a lively corre-
spondence in the Journal of the American Dental
Association which compared 4% articaine with 2%
lidocaine, and it was stated that it was difficult to
demonstrate the superiority of articaine over lidocaine.15
The fact that higher concentrations of local anaesthetic
agents are more neurotoxic than lower concentrations of
the same agent has been conclusively shown in labora-
tory studies using lignocaine.16,17
If prolonged anaesthesia occurs following a local
anaesthetic injection, the patient must be reviewed.
They should not be dismissed or promised it will
resolve. Referral to a specialist with an interest and
experience in nerve injuries is strongly recommended.
ª 2011 Australian Dental Association

The indemnity insurer should be notified. The injury
should be carefully documented and monitored until
resolution or permanence. The use of a low daily dose
of vitamin B complex to aid recovery has been
recommended.2
There is a difficulty in determining the number and
seriousness of prolonged anaesthesia to any concentra-
tion of local anaesthesia in Australia as there is no
mandatory reporting requirement.2 One option is for
dental practitioners to report current cases to the
Australian Adverse Drug Reaction Committee of the
Therapeutic Goods Administration. Reports should
include the drug dose and type, the indication for
the block, and the nature and duration of adverse
reaction.18
The conclusion from this case series is that if sound
therapeutic principles are to be followed, clinicians
should use the minimum effective concentration of local
anaesthetic agents for block anaesthetics. The higher
concentrations can be more safely used for infiltrations,
particularly in high pain situations such as acute
irreversible pulpitis.
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3. Sambrook PJ, Smith W, Elijah J, Goss AN. Severe adverse reac-
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2011;56:148–153.
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5. Miller PA, Haas DA. Incidence of local anaesthetic induced
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Local anaesthesia and neurotoxicity
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18. Australian Government. Department of Health and Ageing.
Therapeutic Goods Administration. Available at: http://www.
tga.gov.au/pdf/forms/problem-medicine-forms-bluecard.pdf.
Address for correspondence:
Dr Angus Kingon
45 Grandview Street
Pymble NSW 2073
Email: amkingon@gmail.com
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