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Questions and Answers
Which of the following is NOT a cause of infection?
Which of the following is NOT a cause of infection?
What is the usual sign associated with infection management?
What is the usual sign associated with infection management?
Which method is used to prevent sloughing of tissues?
Which method is used to prevent sloughing of tissues?
What is the appropriate management step for addressing edema?
What is the appropriate management step for addressing edema?
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What is a key management technique for post anesthetic intraoral lesions?
What is a key management technique for post anesthetic intraoral lesions?
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What is one of the causes of needle breakage during local anesthesia administration?
What is one of the causes of needle breakage during local anesthesia administration?
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Which management step is NOT recommended when a needle breakage occurs?
Which management step is NOT recommended when a needle breakage occurs?
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What is a potential consequence of persistent anesthesia or paresthesia?
What is a potential consequence of persistent anesthesia or paresthesia?
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Which of the following can help prevent needle breakage during injection?
Which of the following can help prevent needle breakage during injection?
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How long does most paresthesia typically resolve after injections?
How long does most paresthesia typically resolve after injections?
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What should be documented after an incident of local anesthesia complication?
What should be documented after an incident of local anesthesia complication?
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Which symptom might indicate a problem during local anesthesia injection?
Which symptom might indicate a problem during local anesthesia injection?
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What can intraneural injection potentially lead to?
What can intraneural injection potentially lead to?
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What is the primary cause of facial nerve paralysis in patients?
What is the primary cause of facial nerve paralysis in patients?
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Which of the following is NOT a method for preventing facial nerve paralysis during anesthesia?
Which of the following is NOT a method for preventing facial nerve paralysis during anesthesia?
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What characterizes trismus?
What characterizes trismus?
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Which of the following is a common cause of trismus?
Which of the following is a common cause of trismus?
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What is a recommended management strategy for a patient with trismus?
What is a recommended management strategy for a patient with trismus?
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Which factor does NOT contribute to the risk of soft tissue injury during anesthesia?
Which factor does NOT contribute to the risk of soft tissue injury during anesthesia?
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What is the recommended action for cornea care in a patient experiencing facial nerve paralysis?
What is the recommended action for cornea care in a patient experiencing facial nerve paralysis?
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What is a common consequence during the chronic phase of trismus?
What is a common consequence during the chronic phase of trismus?
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What is a recommended method to prevent lip chewing in pediatric patients during anesthesia?
What is a recommended method to prevent lip chewing in pediatric patients during anesthesia?
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Which of the following is an appropriate management step for a hematoma visible after injection?
Which of the following is an appropriate management step for a hematoma visible after injection?
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What can contribute to pain during an injection?
What can contribute to pain during an injection?
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Which factor is NOT associated with burning on injection?
Which factor is NOT associated with burning on injection?
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What is a common misconception about managing hematomas after injection?
What is a common misconception about managing hematomas after injection?
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When performing a local anesthesia procedure, what should be done to avoid an exaggerated tissue response?
When performing a local anesthesia procedure, what should be done to avoid an exaggerated tissue response?
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What injection technique can help prevent burning sensations?
What injection technique can help prevent burning sensations?
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What is the recommended action if a patient experiences pain on injection?
What is the recommended action if a patient experiences pain on injection?
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Study Notes
Local Complications of Local Anesthesia
- Local anesthetics are commonly used in dental procedures, but complications can occur
- Complications can be mild or severe, and they can affect patients differently
- Potential complications include needle breakage, persistent anesthesia (or paresthesia), facial nerve paralysis, trismus, soft-tissue injury, hematoma, pain on injection, burning sensation on injection, infection, edema, sloughing of tissues, and postanesthetic intraoral lesions
Learning Outcomes
- Learning outcomes focus on explaining complications of local anesthesia and discussing their management
Needle Breakage
- Causes: Unexpected movement, small needle size (30G more likely to break), inserting the needle until it hits the hub (hubbing the needle), bent needles, forceful contact with bone, defective needles, weakness of the alloy, needle re-use.
- Prevention: Use large needles, use long needles for deep injections (> 18mm), do not bend needles when inserting them into soft tissues, only redirect the needle when fully withdrawn.
- Management: Remain calm, do not explore (the area), ensure the patient keeps the mouth open wide, remove the needle if it is exposed, refer the patient to a specialist to remove the embedded needle if it is not exposed.
Persistent Anesthesia or Paresthesia
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Definition: Persistent anesthesia (lasting longer than expected), or altered sensation (lasting longer than expected)
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Causes: Trauma to the nerve (e.g., into the foramen), neurolytic agents (e.g., alcohol or phenol) which can last for months or even years, intraneural injection, hemorrhage into or around the neural sheath
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Problems: Biting or thermal insults might occur, Lingual nerve-taste
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Prevention: Careful injection technique
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Management: Patient counseling and reassurance, appropriate record keeping, appropriate follow-up, appropriate referrals, possible surgical repair
Facial Nerve Paralysis
- Causes: Anesthesia of peripheral facial nerve branches (temporal, zygomatic, buccal, mandibular)
- Prevention: Bone contact avoidance during injection, avoiding over penetration, avoidance of arbitrary injection
- Management: Reassure the patient about the transient nature of the loss of function, care for the eye (cornea care: remove contact lenses, apply eye pack, lubricate the cornea periodically), thorough record keeping, consider deferring dental procedure
Trismus
- Description: A prolonged, tetanic spasm of the jaw muscles that limits mouth opening. Caused by a disturbance of the trigeminal nerve resulting in a spasm of the mastication muscles.
- Causes: Trauma to muscles or blood vessels (most common in the infratemporal fossa), contaminated anesthetic solutions, hemorrhage, infection, excessive anesthetic volume causing tissue distension, multiple needle penetrations, barbed needles.
- Prevention: Sharp, sterile, disposable needles, appropriate care of cartridges, aseptic technique, atraumatic insertion, minimal injections and volumes, avoid repeat injections and multiple insertions
- Problem: Acute phase - pain due to hemorrhage that leads to muscle spasm, Chronic phase - hypomobility, scar contracture, and fibrosis. Affected muscles are usually either the lateral pterygoid or the temporal muscle.
- Management: Examination, conservative therapy (passive jaw exercises, analgesics, heat, muscle relaxants)
Lip Chewing/Soft Tissue Injury
- Cause: Loss of sensation that accompanies successful anesthesia allows a patient to bite into their lip or tongue. Most common in children or patient with cognitive limitations (i.e., Alzheimer's Disease).
- Prevention: Use local anesthesia for appropriate duration, warn patient's parent, guardian or caretaker to carefully monitor the patient, place a cotton roll between the mucobuccal folds of children during anesthesia, and explain the risks of soft tissue injuries to patients with bleeding abnormalities
- Management: Analgesics, antibiotics, saline rinses, lip lubricants
Hematoma
- Cause: The effusion of blood into extravascular spaces that results from inadvertent nicking of a blood vessel during the administration of local anesthesia. Anesthetic infiltration or injury during the process can cause a hematoma.
- Prevention: Care in the placement of the needle, minimize injections, do not probe with the needle, modify technique, use short needles, careful attention to needle penetration depth
- Problem: Visible extraorally (creates an aesthetic concern); swelling and discoloration subsides within 7-14 days
- Management: If immediately visible after the injection, apply direct pressure to the injection site. Once bleeding has stopped, instruct to apply ice intermittently to the injection site for the first six hours, do not apply heat for the first six hours, use analgesics as needed, expect some degree of discoloration. If opening issues occur, treat like trismus
Pain on Injection
- Causes: Careless technique, dull needles (due to previous use), rapid deposit of anesthetic solution, needles with barbs
- Prevention: Careful technique, sharp needles, topical anesthetic, slow injections, solutions at room temperature
- Management: Typically, pain is treated symptomatically with analgesics as needed
Burning on Injection
- Causes: pH of the anesthetic solution (ideally pH 5), rapid injection speed, contamination in storing solutions in alcohol, solutions that are too warm
- Prevention: Slow the injection rate (1 mL/min), reassure the patient that the burning is common and usually of low intensity. The sensation typically lasts a few seconds and most patients don't even notice.
- Management: Pain often subsides rapidly and does not require treatment.
Infection
- Causes: Needle contamination, improper handling of armamentarium, infection at the injection site, improper handling of tissue
- Prevention: Disposable needles, proper care of equipment, aseptic techniques
- Management: Usual sign is trismus, trismus may persist for 1-3 days, antibiotics if suspected
- Note: Symptoms usually subside quickly and do not require extended treatment
Edema
- Causes: Trauma during injection, infection, allergy, hemorrhage, irritating solutions
- Management: Address the underlying cause (e.g., hemorrhage, infection, allergy) and treat accordingly
- Note: Edema usually resolves quickly with proper management and patient monitoring
Sloughing of Tissues
- Causes: Topical anesthetic, prolonged ischemia, sterile abscess secondary to prolonged ischemia
- Prevention: Apply topical anesthetics for 1–2 minutes; avoid overly concentrated solutions
- Management: Observation, reassure the patient, symptomatic treatment of pain, record keeping
Postanesthetic Intraoral Lesions
- Causes: Trauma to tissues by a needle, local anesthetic solution, cotton swab, or other instruments may reactivate a latent disease process present in the tissue prior to injection.
- Prevention: There is no means of preventing it in susceptible patients.
- Management: Symptomatic treatment
References
- Handbook of Local Anesthesia, Sixth edition, Stanley F. Malamed
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Description
Test your knowledge on the essential aspects of local anesthesia management with this quiz. Explore causes of complications, management techniques, and prevention strategies. Ideal for students and professionals in the dental field.
