Needle Breakage Pain on injection Burning on injection

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Local Complication of Local Anesthesia

  1. Needle Breakage

  2. Pain on injection

  3. Burning on injection

  4. Persistent anesthesia : paresthesia

  5. Trismus

  6. Hematoma

  7. Infection

  8. Edema

  9. Sloughing of tissues

10. Lip-Chewing

  1. facial nerve paralysis

  2. Post anesthetic intraoral lesions






1. Needle Breakage

  1. Sudden unexpected movement of the pt. as the needle penetrates the muscle or contacts periosteum.(esp. if the pt. moves oppositely to the needle)

  1. Needles of smaller gauge

  1. Needle that have previously bent

    • No problem exists if the needle can be easily retrieved without surgical intervention

    • Needles that break off within tissues & can't be readily retrieved usually enclosed by scar tissue and rarely produce infection leaving it better than performing traumatic surgical removal

    • Use larger gauge needle for injection

25-gauge needles are appropriate for nerve block of (inferior alveolar, mandibular, posterior & anterior superior alveolar& maxillary)

    • Use long needle for injection

  • Don't insert the needle into tissue to the hub(the point at which the needle shaft meets the hub is the weakest point of the needle)

    • Don't redirect the needle once it is inserted into tissues

    • When the needle breaks:

  • be calm , don't panic

  • Instruct the pt. not to move; don't remove ur hand from the pt's mouth and keep the mouth opened & place the bit block if possible..

  • If the fragment is protruding  remove it with cotton pliers or a small hemostat

    • if the needle is lost & can't be readily retrieved:

  • Don't proceed with incision or probing if the fragment invisible

  • Calmly inform the pt. and relieve his fears & apprehension

  • Note the incident in the pt's records & inform your insurance carrier

  • Refer the pt for oral surgeon consultation not to remove the needle

    • When is needle breaks, consideration should be given for it's immediate removal:

  • if the needle is superficial & easily located through radiographic & clinical examination  removal is possible by oral surgeon , so if attempted retrieval is unsuccessful in reasonable length of time  allow the fragment to remain

  • if the needle is located in deeper tissues or if it hard to locate  permit it to remain without an attempt at removal.






2. Pain on injection

  1. Careless injection technique & callous attitude; N.B: Palatal injection always hurt..

  2. Dull needle from multiple injections with the same needle..

  3. Rapid deposition of the solution

  4. Needle with barbs; impaling the needle on bone may produce a ''fishhook barb'' pain as the needle withdrawn from the tissue..

    • Increase pt anxiety

    • May lead to sudden unexpected movement needle breakage

      1. carefully adhere to proper technique of injection, both anatomically & psychologically

      2. Use sharp needles

      3. Use topical anesthetic prior to injection

      4. Use sterilized local anesthetic solutions

      5. Practice slow injection of solutions

      6. Be certain temperature of solution is correct; N.B: too hot of a solution is more uncomfortable than one which is too cold

No management is required; however, steps should be taken to prevent recurrence with future injections.






3. Burning on injection

  • Burning during deposition of the L.A is not uncommon

N.B: cause mild burning sensation , prepared to be 5 and those containing vasoconstrictor having more acidic

    1. Rapid injection of the L.A solution esp. in the denser more adherent tissue of the palate

    2. Contamination of the L.A cartilages with sterilizing solution results when the stored in alcohol or other sterilizing solution  diffusion of this solution into the cartilage

    3. Temperature of the solution even if it's warm

      • Transient in nature

      • Indication of tissue irritation

      • Rapidly disappears when the L.A action develops

      • No residual sensitivity after action termination of the L.A

      • Greater opportunity of the tissue damage to develop with subsequent postanesthatic trismus , edema , or paresthesia

      • Difficult or even impossible but with short duration & low intensity

      • Slow injection ideal rate is 1ml/min , don't exceed 1.8 ml in 1 min

      • Proper care & handling of the L.A cartilage :

Formal therapy is usually not indicated only if there is post injection discomfort or edema, or paresthesia






4. Persistent anesthesia ( Paresthesia)


*Disturbing complication

    1. Trauma to any nerve or the nerve sheath  electrical shock & paresthesia

    1. Injection of contaminated L.A cartilage by alcohol or sterilizing solutions near the nerve  irritation & edema  increase pressure on the region  paresthesia

    1. Hemorrhage into or around the neural sheath  increase pressure on the nerve  paresthesia

      • Sometimes total but mostly partial  tissue injury

      • Biting or thermal or chemical insult can occur without a patient's awareness

*Proper injection technique
*Proper care & handling of the dental cartilage

      • Most paresthesia resolves in 8 weeks without ttt& will be permanent only if there is severe nerve damage.

        1. Reassure the pt

          1. The dentist must talk to the pt

          2. Don't relegate the duty of reassuring

          3. Explain that it's not uncommon after injection

          4. Arrange appoint 4 examining the pt

          5. Record the incident in the dental chart

        2. Examine the pt

  1. Determine the paresthesia degree

  2. Explain to the pt that paresthesia may persist at least 2 months or may be prolong to 1 y

  3. Tincture of time is the recommended medicine

  4. Record the finding in the pt's chart

        1. Reschedule the Pt for examination every 2 months as long as sensory deficit persists

        2. Should sensory deficit still be evidence 1 y after that consult the surgeon or neurologist to mange






5. Trismus

  • Motor disturbance of the trigeminal nerve esp. spasm of the masticatory muscles with difficulty in opening the mouth.

  • Although post injection pain is the most common L.A complication, trismus can become one of the more chronic & complicated problem to manage.

  1. Trauma to muscles or blood vessels in the infratemporal space is (the most common cause following the dental injections)

  2. Contaminated dental cartilage by diffusion of alcohol or any sterilizing agent  irritation to the muscle  potential trismus

  3. Hemorrhage (large volume of blood) tissue irritation  muscle dysfunction as blood is slow resorbed.

  4. A low grade infection

  5. Multiple needle penetrations.

  6. Overly large amount of L.A solution deposited in restricted area.

    • In the acute phase of trismus:

Pain produced by hemorrhage  muscle spasm & limitation of movements.

    • In the chronic phase of trismus:

Usually develops if the ttt is not begun.

    • Hypomobility can be due to:

      1. secondary to hematoma with subsequent fibrosis & scar contracture

      2. infection through increase tissue reaction (irritation ) & scarring

        • In most cases a pt will repost pain and difficulty in opening the mouth the day after the dental appointments in which posterior superior alveolar or inferior alveolar nerve blocks are administered.

      1. use sharp , sterile , disposable needles

      2. properly care for & handle dental L.A cartilage

      3. Cleanse the site of injection with an antiseptic solution prior to needle penetration

      4. Use a septic technique ; contaminated needle should be changed immediately

      5. Practice atraumatic insertion & injection technique

      6. Avoid repeat injections & multiple insertions through knowledge of anatomy & proper technique ( use regional block instead of infiltration wherever possible & rational)

      7. use minimal effective volumes of L.A solutions; refer to specific techniques for recommended volumes

        • Arrange an appointment for examination.

  • Heat therapy:

Placing moist eat with towels to the affected area about 20 min every hour.

  • Analgesics

Aspirin is usually adequate in damaging pain associated with trismus.

Codeine (30-60 mg every 3 hours) if the discomfort is more intense.

  • Muscle relaxants

Diazepam (about 10 mg every 12 hours)

        • Advice the pt. t initiate physiotherapy for 5 min every 3-4 hours by opening and closing the mouth as well as lateral excursions & chewing gum(sugarless)

        • Record the incident, finding, ttt in the pt's dental chart.

        • Avoid any further dental ttt in the involved region till symptoms resolves & pt is more comfortable

        • 7 full days Antibiotics is required if the pain and dysfunction continued beyond 48 hours due to possibility of infection.

        • Refer the pt to oral surgeon if no improvement within 2-3 days without antibiotics or 5-7 days with antibiotics or severe limited mouth opening.

        • TMJ involvement is quite rare in the 1st 4-6 weeks following injection.

        • Surgical intervention may be indicated in some instance.




Management(Time is the most important element of hematoma ) it presents 7-14 days with or without ttt

6. Hematoma

  • It's the effusion of blood into extra vascular spaces

  • The inadvertent nicking of a blood vessel, either artery or vein during an injection of L.A

  • Nicking of the artery usually increase in size rapidly till the ttt is instituted

  • Nicking of the vein may or may not cause hematoma

  • The density y of the tissue surrounding the injured vessel will be a determining factor e.g. hematoma is rarely developed after palatal injection but usually following nicking of the B.V in posterior superior or inferior alveolar nerve block coz the tissue accumulate the blood in these areas blood effusion until extra vascular pressure exceed pressure within the B.V

* Rarely produce significant problem

* Possible complication include trismus & pain

* The swelling & discoloration usually subsides within several days

  1. Knowing the normal anatomy of the proposed injection; certain technique has a greater risk of hematoma like posterior superior alveolar nerve & inferior alveolar nerve in second.

  2. Modify the injection technique as indicated by the pt's anatomy e.g. lessen the penetration of posterior superior alveolar nerve block in pt with smaller facial characteristics

  3. Minimize the number of needle penetrations of tissue

  4. Never use needle as probe in tissues

Immediate :

When swelling becomes evident Direct pressure should be applied to the site of bleeding for not less than 60 sec. against bone

    • Inferior alveolar nerve block

  • Pressure is applied to the medial aspect of the mandibular ramus.

  • Intraoral clinical manifestation which are tissue discoloration & swelling in the medial (lingual) aspect of the mandibule ramus

    • Infraorbital nerve block

  • Pressure in applied to the skin directly over the infraorbital foramen.

  • Extraoral clinical manifestation which is discoloration of the skin below the lower eyelid

    • Mental & incisive nerve block

  • Pressure is applied directly over the mental foramen, either on the skin or on the mucous membrane.

  • Clinical manifestation is observed @ the skin over the mental foramen and/or by swelling in the mucobuccal fold in the region of the mental foramen

    • Buccal nerve block or any palatal injection

    • Posterior superior alveolar nerve block

  • Usually produce the largest & most esthetically unappealing hematoma& can accommodate large volume of blood.

  • Not recognized till the swelling appears on the side of the face progressing inferiorly & anteriorly toward the lower anterior region of the cheek.

  • Difficulty in applying pressure @ the site of the bleeding in this region (post.super.alveolar & facial arteries & pterygoid plexus of vein)

  • They r located posterior Superior & medial to the maxillary tuberosity

  • Bleeding normally halts when external pressure of blood exceed the internal one.

  • Digital pressure can be applied to the soft tissues in the mucobuccal fold as far as it can be tolerated by the pt. without gagging.

  • Apply pressure in a medial & superior direction .


* Avoid any additional dental therapy in hematoma region till the sign & symptoms relived.

* Advice the pt about possible trismus ttt as previously mentioned_ Discoloration resorbed over 7-14 days_ soreness ttt by analgesic e.g. aspirin, no heat application at least 4-6 hr. till the next day by warm towels 20 min every hr., Ice is applied immediately (analgesic & vasoconstrictor)






7. Infection

* become extremely rare since the introduction of sterile, disposable needles.

  1. The major cause is the contamination of the needle prior to administration of the L.A. & it's always occurring when the needle touches the mucous membrane in the oral cavity.

  1. Improper technique in the handling of the L.A armamentarium & improper tissue preparation for injection.

    • Contaminated needle of solution may lead to low grade infection when there is in deeper tissue  trismus => initiation of proper ttt

      1. Use disposable syringe

      1. Properly care for & handle needles:

  • Recap the needle when not in use to avoid contamination through contact with non sterile surfaces.

  • Avoid multiple injections with the same needle.

      1. Properly care for 7 handle of the dental cartilage of L.A solution.

  • single use only

  • store aseptically in original container , covered at all times

  • Cleanse the diaphragm with sterile, disposable alcohol wipes.

      1. Properly prepare the tissues prior to penetration; dry the tissue & apply topical anesthesia.

  • Low grade infection (rare) will seldom be recognized immediately & the pain will report post injection pain & dysfunction one or more days following the dental therapy

  • Rarely will be overt signs & symptoms of infection present.

  • Immediate ttt should consist procedures for trismus management (heat, analgesic & if needed muscle relaxant & physiotherapy

  • Trismus produced by factors other than infection will normally respond with a lessening of signs & symptoms within 1-3 days , but if trismus signs & symptoms don't respond to the conservative therapy so a 7 day course antibiotic is started.

  • Prescribe 29 tablets of penicillin V250 mg tablets; the pt. takes 500 mg immediately then 250 mg four times a day until they are gone.

  • Erythromycin for allergic pt. to penicillin

  • Report the progress & management of the patient on the dental chart.






8. Edema

* Edema is the swelling of tissues.

* Edema isn't a clinical syndrome but represents a clinical sign of some disorder.

  1. Trauma during injection

  1. Infection

  1. Allergy

Angioedema is a common reaction to topical anesthesia in an allergic pt.

Localized tissue swelling occurs due to vasodilatation secondary to histamine release

  1. Hemorrhage; effusion of blood into soft tissues  swelling

  1. Injection of irritating solution (alcohol or cold sterilizing solution –containing cartilage)

1. Airway obstruction

2. Pain & dysfunction of the region & personal embarrassment for the pt.

3. Angioedema swelling in allergic responded pt.  lead to compromised airway
4. Edema of the tongue, pharynx, and larynx may develop  life- threatening situation need vigorous management.

  1. Properly care for & handle the L.A armamentarium.

  2. Use atraumatic injection technique.

  3. Complete an adequate medical examination of the pt. prior to drug administration.

  • Management is predicated to reduce the swelling as quickly as possible.

  • Edema due to traumatic injection or introduction of irritating solution  have a minimal degree of edema & resolved within 1-3 days

  • It's necessarily to prescribe analgesics for pain due to edema

  • Follow the management of hematoma if the edema is followed by hemorrhage & it will resolved within 7-14 days

  • Edema produce by infection will not resolved spontaneously but may be become progressively more intense. if the sign of infection ( pain, mandibular dysfunction , edema) don't appear to resolved within 3 days  Antibiotic therapy as mentioned in the infection ttt

  • Edema produce by allergy is the most potentially life threatening. The degree of the edema & its location is highly significant. If the swelling is develops in the buccal soft tissue & there is no airway obstruction  ttt is I.M & oral antihistamine administration & a medical consultation to an allergist to determine the precise cause of the edema.

  • When edema compromised breathing :

  1. Epinephrine 0.3 mg IM or IV

  2. Antihistamine IM or IV

  3. Corticosteroid IM or IV

  4. medical assistance summoned

  5. pt. positioned supine position if unconscious

  6. Basic cardiac life support

  7. preparation of cricothyrotomy if total airway obstruction develops

  8. Through evaluation of the patient prior to next appointment to determine the cause of the reaction.






9. Sloughing of tissues

Prolonged irritation to the gingival soft tissue may lead to  number of unpleasant complications including epithelial desquamation & sterile abscess.

  • Epithelial desquamation :

    1. Application of topical anesthesia agents to the gingival tissues for a long period of time

    2. heightened sensitivity of tissues to chemical agents ( L.A)

    3. Reaction in area where the topical anesthetic is applied.

  • Sterile abscess:

  1. secondary to prolonged ischemia resulting from the use of L.A with vasoconstrictors

  2. Almost always occurs in the firm soft tissue of the hard palate.

    1. Pain

    2. Possibility of infection developing in these area

  1. use topical anesthesia as recommended ; Allow the solution to contact mucous membrane for 1-2 min to maximize its effectiveness & to minimize toxicity.

  1. When using vasoconstrictors for homeostasis  don't employ overly concentrated solutions

  • Epinephrine 1:50,000

  • Levophed (nor epinephrine) 1:30,000

Are the 2 agents most likely to produce ischemia of a long enough duration to produce tissue damage & a sterile abscess.
N.B: the palatal tissues are virtually the only tissues in the oral cavity where this phenomenon might occur.

  • Usually no formal management is required for both epithelia d desquamation or sterile abscess.

  • For pain  analgesic (aspirin , codeine 7 a topically applied ointment such as Orabase to minimize the irritation of the tissue .

  • Epithelial desquamation will resolved within few days.

  • Sterile abscess run for 7-10 days

  • Record dada in the pt's chart .





Management (is symptomatic)

10. Lip-Chewing

* Trauma of the lips & tongue of the anesthetized pt. is frequently caused by the pt. inadvertently biting or chewing these structures.
* Trauma occurs most frequently in children & mentally handicapped children & adult.

The primary cause is the use of long acting L.A in pt. undergoing shorter dental procedures.

  • Swelling & pain when the anesthetic action dissipate.

  • Behavior management problems in the young child or handicapped individual copying difficulty with this situation

  • Selection of proper duration of L.A action depends on the duration of the dental procedures.

  • A cotton roll can be placed between the lips pf the pt. if they are still anesthetized @ the time of discharge.

  • Warn the pt. & adult guardian against eating while still anesthetized, against drinking hot fluids, and against biting on the lips & tongue to test for anesthesia.

  • A self-adherent warning sticker is available that states "Watch me, my lip & cheek are numb" placing in the pt's forehead.

  1. Analgesic for pain.

  2. Antibiotics, in the unlikely situation that infection results.

  3. Lukewarm saline rinses to aid in decreasing any swelling that may be present.

  4. Petroleum jelly or other lubricant to cover the lesion (on the lips) to minimize irritation.






11. facial nerve paralysis

  • The facial nerve is the 7th cranial verve which is a motor nerve to the muscle of facial expression, scalp & external ear & others.

  • Occasionally it can anesthetized by the inadvertent deposition of L.A into its vicinity, always occur when the solution introduce in the deep lobe of the parotid gland.

  • The nerves supplied by these branches & the muscles they innervate are listed:

    1. Temporal branches

    1. Zygomatic branches

      • Orbicularis oculi muscle

    2. Buccal branches(supply region inferior to orbit & around the mouth)

  • Procerus muscle

  • Zygomatic muscle

  • Levator labii superioris muscle

  • Buccinator muscle

  • Orbicularis oris muscle

    1. Mandibular branch (supplies muscles of lower lip & chin)

* Transient facial nerve paralysis is commonly caused by the introduction of L.A solution into the capsule of the parotid gland , which is located @ the posterior border of the ramus of the mandible , clothed by the medial pterygoid & masseter muscles.
* Directing of the needle toward or its inadvertent deflection in a posterior direction during an inferior alveolar nerve block may place the needle tip within the substance of the parotid gland paralysis may result.

  • Loss of facial expression muscles function will last from 1-several hours depending o the L.A agent, volume injected, & its proximity to the facial nerve.

  • The primary problemUnilateral paralysis during this time with inability to use theses muscle normally (cosmetic appearance problem )

  • No ttt except waiting till the action wears off

  • The secondary problem  the pt. unable to close the eye, winking & blinking become impossible to perform.

  • The cornea retains to its innervation so if irritated corneal reflex & the pt. will be able to lubricate the eye during this period of time.

  • With sec. – min following deposition of L.A  the pt. will sense a weakening of the muscle of the affected side of the face.

    • Adherence to proper technique in the inferior alveolar nerve block.

    • If the needle tip in contact with bone (medial aspect of ramus) prior to L.A deposition  preclude the possibility of the deposition of solution in the parotid gland.

    • If the needle deflects posteriorly  should be entirely withdrawn & direct it more anteriorly till it contacts bone.

      1. Reassure the pt.

      1. Advice the pt. to periodically close the upper eyelid manually to keep the cornea lubricated.

      1. Contact lenses should be removed until muscular movement returns.

      1. Record the incident in the pt.'s chart.

      1. Although there is no contraindication for re anesthetized the achieve mandibular anesthesia, it may be prudent to forego further dental therapy @ this appointment.






12. Post anesthetic Intraoral Lesions

* Pt. might report painful ulceration of the mouth following 2 days of dental injection.

  • Recurrent apthous stomatitis &/or herpes simplex can develop intraorally following L.A injection or any traumatic insult

  • Recurrent aphthous stomatitis is the most frequently observed intraorally in the movable gingival tissue (not attached to the bone) e.g. buccal vestibule) not viral infection but it might be autoimmune process or L-form bacterial infection.

  • Herpes Simplex can develop intraorally but it's most commonly extra orally on the fixed tissue (not attached to the bone)

  • Trauma to tissues by needle, L.A , cotton swab, or any other instrument (R.D clasp , hand piece )  reactivate the latent form of the disease process that has been present in the tissue prior to the injection.

  • Acute sensitivity in the ulcerated area.

  • Developing of secondary infection risk is low.

  • In the intraoral lesions No mean of prevention in the susceptible pt.

  • Extra oral herpes simplex can be prevented or minimizing its manifestation if it's in its prodromal phase

  • Prodrome consists of mild burning or itching sensation @ the site where the virus is present (lip)

  • Either applied topically by cotton swab 3-4 times daily  minimizes the acute phase only extra orally.

    • Primary management is symptomatic:

  • Pain  approximately 2 days after injection

  • If not severe no management

  • If the pt. complain from pain:

  1. keep the ulcerated area covered

  2. topical anesthetic solution (viscous lidocaine) can be applied to the painful area

  3. A mixture of equal amount of diphenhy dramine & milk magnesia rinsed in the mouth  effectively coat the ulcerated area & provide relief of the pain .

  4. Orabase , a protective paste without Kenalog  provide degree of pain relief .N.B: Kenalog is corticosteroid not recommended because it's anti-inflammatory action provide increase risk of either viral or bacterial involvement.

  5. Ulceration duration about 10 days with or without ttt

  6. Negatol chemical cauterizing agent for pain relief

  7. Keep adequate records in the pt's chart.

Best of Luck


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