Sudden unexpected movement of the pt. as the needle penetrates the muscle or contacts periosteum.(esp. if the pt. moves oppositely to the needle)
Needles of smaller gauge
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.
Practice atraumatic insertion & injection technique
Avoid repeat injections & multiple insertions through knowledge of anatomy & proper technique ( use regional block instead of infiltration wherever possible & rational)
use minimal effective volumes of L.A solutions; refer to specific techniques for recommended volumes
Arrange an appointment for examination.
Placing moist eat with towels to the affected area about 20 min every hour.
Aspirin is usually adequate in damaging pain associated with trismus.
Codeine (30-60 mg every 3 hours) if the discomfort is more intense.
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
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
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.
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
Minimize the number of needle penetrations of tissue
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)
* become extremely rare since the introduction of sterile, disposable needles.
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.
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
Use disposable syringe
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.
Properly care for 7 handle of the dental cartilage of L.A solution.
Cleanse the diaphragm with sterile, disposable alcohol wipes.
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.
* Edema is the swelling of tissues.
* Edema isn't a clinical syndrome but represents a clinical sign of some disorder.
Trauma during injection
Angioedema is a common reaction to topical anesthesia in an allergic pt.
Localized tissue swelling occurs due to vasodilatation secondary to histamine release
Hemorrhage; effusion of blood into soft tissues swelling
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.
Properly care for & handle the L.A armamentarium.
Use atraumatic injection technique.
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.
preparation of cricothyrotomy if total airway obstruction develops
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 :
Application of topical anesthesia agents to the gingival tissues for a long period of time
heightened sensitivity of tissues to chemical agents ( L.A)
Reaction in area where the topical anesthetic is applied.
secondary to prolonged ischemia resulting from the use of L.A with vasoconstrictors
Almost always occurs in the firm soft tissue of the hard palate.
Possibility of infection developing in these area
use topical anesthesia as recommended ; Allow the solution to contact mucous membrane for 1-2 min to maximize its effectiveness & to minimize toxicity.
When using vasoconstrictors for homeostasis don't employ overly concentrated solutions
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)
* 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.
Analgesic for pain.
Antibiotics, in the unlikely situation that infection results.
Lukewarm saline rinses to aid in decreasing any swelling that may be present.
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:
Buccal branches(supply region inferior to orbit & around the mouth)
Levator labii superioris muscle
Orbicularis oris muscle
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 problemUnilateral 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.
Reassure the pt.
Advice the pt. to periodically close the upper eyelid manually to keep the cornea lubricated.
Contact lenses should be removed until muscular movement returns.
Record the incident in the pt.'s chart.
Although there is no contraindication for re anesthetized the pt.to 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.
A mixture of equal amount of diphenhy dramine & milk magnesia rinsed in the mouth effectively coat the ulcerated area & provide relief of the pain .
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.
Ulceration duration about 10 days with or without ttt
Negatol chemical cauterizing agent for pain relief