COMPLICATIONS

OF
LOCAL ANESTHESIA

PRESENTER :
NAGA SIYA CHETHANA.
CONTENTS :

AIM & OBJECTIVES

COMPLICATIONS -

A. LOCAL

B. SYSTEMIC

CONCULUSION
 AIM :

To review the preoperative and postoperative complications associated with LA.

OBJECTIVES :

1. Preop evaluation of patient & choosing proper local anesthetic agent.

2. Prevention of measures & treatment .

 Complications associated with local anesthetics can be evaluated

Systemically Locally

Psychogenic reactions Pain at injection

Systemic toxicity Needle fracture , soft tissue injury
Allergy Prolongation of anesthesia -
Methemoglobinemia (various sensory disorders)
Trismus , infection , edema
Hematoma
Occular complications
 Causes
Rate of administration
Burning sensation – electric shock / Zap
( trauma to nerve sheath)
Dull needles
Damaging soft tissues , blood vessels , nerves

• PAIN ON INJECTION

Prevention
Topical anesthetic application
Buffering the LA i.e 7.4 PH
Use smaller guage i.e 27 needle
Use fresh needle for multiple inj. Sites
Inject slowly ( ideal : 1ml , 1.8 ml within one min ) with low pressure
NEEDLE FRACTURE

Pogrel MA. Broken local anesthetic needles: a

case series of 16 patients, with recommendations.
• J Am Dent Assoc. 2009; 140:1517–1522.
Amies AB. Broken needles. Aust Dent J.
1951;55:403–406.

Maximum needle breakage occurred due to IANB & PSA i.e mainly
in children & adults with all the incidents of 30 gauge long needle
 Causes :

Incorrect inj. Technique , Unexpected movement of pt. , Forceful contact, needle

bending
Problem :

Visible – remove immediately with hemostat .

Inaccessible – CT / 3D CT to ensure location ,
operated under GA
 Brand HS, Bekker W, Baart JA. Complications of local anaesthesia. An observational study. International Journal of Dental
Hygiene. 2009;7(4):270-272
Management of a broken needle in the pterygomandibular space: report of case. The Journal of the American Dental Association,
109(2), 263–264. doi:10.14219/jada.archive.1984.0355 (https://doi.org/10.14219/jada.archive.1984.035

Removal of the fragment, mostly superficial mucosal incision perpendicular to the trajectory of
the needle followed by blunt supra-periosteal dissection to spare vital structures is recommended 
 Prolongation
 Procaine ofcause
and tetracaine anesthesia
more damage–thanparesthesia .
bupivacaine or lidocaine .
a 4% local anesthetic prilocaine HCL, articaine HCL , or both drugs has a higher risk of paresthesia 
Paresthesia is defined as persistent anesthesia (anaesthesia well beyond the expected duration), or
Piccinni C, Gissi DB, Gabusi A, Montebugnoli L, Poluzzi E. Paraesthesia after local anaesthetics: An analysis of reports to the FDA
alteredadverse event reporting system. Basic & Clinical Pharmacology & Toxicology. 2015;117(1):52-56. DOI: 10.1111/bcpt.12357.
sensation well beyond the expectedPMID:25420896 duration of anesthesia including the hyperesthesia and
dysesthesia i.e both pain and numbess
•
Causes
local anesthesia contaminated + alcohol = irritation ,edema
Increased pressure
Trauma to nerve sheath - “electric shock” or “zap” throughout the distribution of the involved nerve
Insertion to foramen
Hemorrhage into or around the neural sheath
Edema - as the pressure of the edematous fluid compresses the nerve.
 Neurotoxicity of the local anesthetic is another theory for nerve damage 
MANAGEMENT :

- “Tincture of time” – observation

- The use of a low daily dose of multivitamin B, to regaining nerve healing and
function, has been recommended

- Use low concentrations

 Cause :  Unfamiliar sensation of being numb
SOFT TISSUE INJURY :
Prevention :  
• Shorter-acting local anesthetics - plain mepivacaine should be
chosen.
• Patient or the guardian -warned about eating, drinking hot
fluids, and biting on the lips or tongue to test for anesthesia.
• Cotton rolls can be placed between the teeth and soft tissues to
prevent chewing.

Management :
Alpha-adrenergic receptor- phentolamine mesylate (OraVerse),
For adults - 0.4 to 0.8 mg , For children 0.2 to 0.4 mg
For pain – analgesics
 Anatomical variants
 Comprise accessory nerve supply, alteration in foramen location, atypical
development of the nerves (bifid mandibular canals), and bone density

Pathological
  Infection, trismus , edema , and previous surgery or trauma
LACK OF EFFECT -
Psychological

CAUSES: Angst and anxiety can also cause local anesthesia failure 

Poor technique & choice of technique

Failure mostly- mandibular anesthesia.
If the needle is inserted too high and deep, N. auriculotemporalis will be
affected, and the feeling of “numbness” will occur. There has been a report of
sudden unilateral deafness following inferior dental nerve anesthesia.
Poor technique leads to -

If the needle - inserted and advanced too deeply and too far dorsally

Terminal branches - facial nerve - deep lobe of the parotid gland are affected

Direct anesthesia - facialPrevention

nerve - rapid
: onset

Needle tip - contact

Reflex vasospasms of with
the bone (medialcarotid
external aspect of artery
the ramus)
If not - be withdrawn almost entirely from the soft tissues, the barrel
should be brought posteriorly (thereby directing the needle tip more
Ischemia of the facial nerve
anteriorly),
Needle readvanced until it contacts bone.
Facial nerve palsy
MANAGEMENT :

Anatomical – proper knowledge of anatomy

Pathological – inflammatory diseases

a. Trismus : heat therapy

Analgesic ( aspirin 325mg, ibuprofen 600mg )

Muscle relaxant ( Diazepam 10mg )

b. Edema : analgesics or antibiotic therapy

c . Infection : analgesics
.
 Allergy-induced edema - life threatening.

Degree and location are highly significant.

swelling -Buccal soft tissues compromises breathing

no airway involvement
BASIC LIFE SUPPORT

Immediate intramuscular injection Epinephrine – 0.3mg (>30kg)

(in the vastus lateralis muscle) 0.15mg (<30kg)

50 mg (adult) or 25 mg (child up to 30 kg) Histamine & corticosteroid IM

3-day course of oral H -blocker therapy Cricothyrotomy

Consultation with an allergist

HEMATOMA :

Effusion of blood – extravascular space – nicking of blood vessel

Determining factor - Tissue density surrounding the injured vessel.

Denser (e.g., palate) less likely a hematoma develop

looser tissue (e.g., infratemporal fossa) large volumes of blood may amass before a
swelling - a PSA nerve block

Prevention :

PSA > MENTAL > IANB

PSA ( depth of penetration , 27 guage needle )

Managemant :

IANB - pressure on medial aspect of ramus

ASA - skin at infraorbital ( lump on lower eyelid is seen )

INCISIVE - on foramen

PSA - difficult to pressure - Posteror : PSA artery

Superior : Facial artery max. tuberosity

Medial : Pterygoid plexus of veins

BUCCAL / PALATAL – only within the mouth , PSA – extraorally disclouration at TMJ
( infratemporal area is bleeding )
SLOUGHING OF TISSUES

CAUSES :

Prolong irritation , ischemia – epitheial desquamation , sterile abcess

PREVENTION :

Allow the solution to contact the mucous membranes for 1 to 2 minutes to maximize its
effectiveness and minimize toxicity.

Avoid highly concentrated

MANAGEMENT :

Aspirin , NASIDS – Pain

Topical triamcinacol , Orobase - irritation

POST ANESTHETIC LESION

CAUSE :

Ulceration – a. Recurrent apthous ulcer – not attached to underlying bone

b. Herpes simplex – attached to underlying bone & observed E/O .

( which activates the latent form in tissues )

- Can’t prevent in susceptible pt. i.e Prodromal Phase – antiviral agents

( Acyclovir TID in actue phase )

MANAGEMANT :

Explain – its due to Exacerbation present in latent form

ulcerated areas cover & anesthetise –

Topical lidocaine
ne acetonide (Kenalog) can provide
Benadryl + milk of magnesium
A corticosteroid, is not recommended
OroBase ( absence of triamcinolone acetonide ) because its antiinflammatory actions
increase the risk of viral or bacterial
Tannic acid involvement.

Subsides in 7-10 days .

 OCCULAR COMPLICATION :
Diffusion myofascial spaces or
Diplopia (dual vision) bony openings
I
second division trigeminal
Ophthalmoplegia (paralysis or weakening of eye muscles) blocks (V2) via the greater
palatine canal
approach.
Ptosis & mydriasis (dilatation of pupil) I
Diffuses through inferior orbital
fissure affect extraocular
Amaurosis (partial/total blindness)  muscles.

CAUSES : mandibular injections

I
deposited into the area
Gow-Gates technique - only assoc. diplopia upper cervical or stellate
ganglion
vision impairment – IANB & PSA

latter technique - amaurosis. 

 Problem :
Intraarterial injection or perforation – vascular

Stimulate -sympathetic fibers along- internal maxillary artery till orbit

Reach the cavernous sinus via the pterygoid plexus

Anesthetize the oculomotor, trochlear, or abducens nerves.

Other : Horner’s syndrome 

PREVENTION :

Visualization of the regional anatomy , aspiration at least two planes

MANAGEMENT :

Wait & watch or further ophthalmologist consultation .

 SYSTEMIC COMPLICATIONS

PSYCHOGENIC COMPLICATIONS

CAUSES :

Body counterbalance to an anxiety-inducing situation or due to adrenaline secreted

by the vasoconstrictor agent

Heart rate, respiratory rate, and blood pressure are altered.

PREVENTION :

Patient should be relaxed before administering local anesthetic injections

 MANAGEMENT :

Healthy adult patients

short-term Rx – antihistamine

diphenhydramine (Benadryl) 50 mg 1 hr prior

moderate length (1–2 hours)

benzodiazepine - triazolam (Halcion) 0.125–0.5 mg 1hr prior

longer duration (2–4 hours)

benzodiazepine - lorazepam (Ativan) 1–4 mg 1–2 hrs prior /

30–60 minutes prior for the sublingual.

 

Systemic toxicity :
Sufficient (toxic) concentration of anesthetic drug in the blood level reaches to the
central nervous system and cardiovascular systems.
 OVERDOSE

A drug overdose reaction is defined as those clinical signs and symptoms that result
from an overly high blood level of a drug in various target organs and tissues

NORMAL CONDITION -

Absorption of LA from the site of deposition ( CVS) = removal of the drug from the
blood by the liver occur.
Predisposing factors – PATIENT FACTORS

Age : Age spectrum

Weight : Greater body wt. – larger blood volume – large dose can be accepted.

Other drugs : Meperidine , phenytoin (Dilantin), quinidine (an antidysrhythmic), or

(a tricyclic antidepressant) desipramine - protein binding competition.

H2-histamine blocker cimetidine - slows the biotransformation - elevated

Gender : Adult female the seizure threshold - 5.8 mg/kg

Newborn it is 18.4 mg/kg

Fetus it is 41.9 mg/kg.

 Presence of disease :

Hepatic and renal dysfunction - ability of breakdown is affected – increased levels of LA

Heart failure- decreases liver perfusion - increasing the half-lives of amide LA & overdose

Genetics :

Serum pseudocholinesterase ( liver ) – responsible for biotransformation – effected

Predisposing Factors - DOSE FACTORS

vasoactivity
route of administration
concentration
dose
vascularity of injection site
 CAUSES :

Biotranformation & elimination :

Excessive total dose

Rapid absorption into CVS

Intravascular injections – A & V – retrograde blood flow ( intraarterial )

 CLINICAL MANIFESTATION

Minimum – moderate Moderate - high

Signs – talkitivenss , excitability , Tonic – clonic seziures

slurred speech , euphoria , sweating , Gen . CNS depression
vomiting , disorientation , raised vitals
Decreased vitals

Symptoms – Dizziness, numbness,

twitching , metallic taste , altered visual
and auditory senses , loss of
consciousness
 Pathophysiology

The blood or plasma level of a drug is the amount absorbed into the CVS and
transported in plasma is measured in microgram /mm .

Reversible depression of peripheral nerve conduction

Absorption to CVS & myocardium

Action on excitable membrane on CNS , smooth muscle , myocardium .

40 to 160 mg of lidocaine- blood level appox. 1 μg/mL.

(The usual range is between 0.5 and 2 μg/mL, but remember that response to drugs differs according to the
individual.)
 MANAGEMENT
•
Mild – Rapid onset ( after 5-10 min ) Mild – Delayed onset ( >10min)

Treatment : Treatment :
Terminate – BLS – check vitals- anti Post excitatory management .

convulsant ( diazepam/ midazolam IV

1ml/min) – summoning emergency –
recovery & discharge
SEVERE – RAPID ONSET ( in secs ) SEVERE – SLOW ONSET ( < 5min)

Clues : Generalized tonic-clonic seizures Clues : mild tonic clonic seizures

loss of consciousness
Rx : Terminate – BLS – summoning –
Rx : position – Summoning in emergency
protect the pt. – administer O2 – monitor
LOC Seizure
(vasodepressor syncope ) – anticonvulusant – postseizure

BLS – Administration O2 – protection –

management – BLS – monitor vitals –

anticonvulusant – postical management – BLS recovery .

- monitor vitals
• ALLERY

Allergy is also known as hypersensitive reactions, initiated by immunological mechanisms

acquired through exposure to a specific allergen

CAUSES :

Preservatives (e.g., methyl-p-hydroxybenzoate)

Antioxidants (e.g., bisulfate)

Antiseptics (e.g., chlorhexidine)

Vasoconstrictor (e.g., sulfites)

Antigens such as latex, as well as local anesthetic drugs themselves.

 PROBLEM :

Urticaria, erythema, and intense itching,angioedema and/or respiratory distress.

Severe life-threatening anaphylactic responses include symptoms of apnea, hypotension, and loss
of consciousness 

MANAGEMENT :

P/O IM antihistamine-diphenhydramine (Benadryl) 25 or 50 mg

Hydrocortisone cream may be prescribed to relieve skin itching or erythema.

In life-threatening cases basic life support, intramuscular or subcutaneous epinephrine 0.3–

0.5 mg, and hospitalization services should be given.
REFERENCE :

Written by Dr. Stanley Malamed, the leading expert on anesthesia in

dentistry, the Handbook of Local Anesthesia, 7th Edition 

Keskin Yalcin B. Complications Associated with Local Anesthesia in Oral and

Maxillofacial Surgery. Topics in Local Anesthetics [Internet]. 2020 Sep 30;
Available from: http://dx.doi.org/10.5772/intechopen.87172
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