1. Dr. Rahaf Al-Habbab BDS. MsD. DABOMS Diplomat of the American Boards of Oral and Maxillofacial Surgery 2013

2. Complications Any deviation from the normally Expected pattern during or after securing local analgesia. Classifications  Primary or Secondary  Mild or Severe  Transient or Permanent  Attributed to solution or needle insertion

3. Complications from Local Anesthesia I. Complications associated with the absorption of the solution used. II. Complications associated with needle insertion

4. Complications associated with the absorption of the solution used. 1- Complications resulting from absorption of the anesthetic solution: Systemic drug reactions due to the local anesthesia agent: 1. Toxicity 2. Vasoconstrictor toxicity 3. Allergy 4. Anaphylactic reactions 5. Idiosyncrasy Local Reaction: 1. Infection due to contaminated solution 2. Local tissue irritation.

5. Complications associated with needle insertion 1. Fainting and syncope 2. Muscle trismus 3. Pain 4. Edema 5. Infection 6. Broken needles 7. Prolonged anesthesia 8. Hematoma formation 9. Sloughing and ulceration 10. Bizarre Neurological Symptoms

6. Keep in Mind A: Airway  Clear  Adequate respiration B: Bleeding  Stopped  Achieve inlet to vessels C: Circulation:  Fluids if needed D: Drugs  To treat the present condition

7. Keep in Mind  Call the medical emergency service  The patient placed in horizontal position on his back  Tilt the patient in a slightly head down position or elevate the legs to help increase cerebral circulation  Adequate oxygenation is of prime importance because of the impaired respiratory mechanism  Check the patients cardiac and cardiovascular status

8. Keep in Mind  Starts I.V fluids should (e.g. 5% dextrose in H2O)  Drugs according to the condition  If complete circulatory standstill  I.V injection of Atropine  Stimulation of the heart by introducing a needle directly into it  Intracardiac injection of epinephrine 0.1 ml of 1.1000 solution

9. Complications due to Absorption of the Injected Solution Systemic Complications 1. Toxicity 2. Idiosyncrasy 3. Allergy 4. Anaphylaxis

10.  Definition  Etiology  Clinically  Prevention  Treatment

12. Definition It refers to the symptoms manifested as a result of overdosage or excessive administration of the solution

13. Etiology  Large Dose of drug  Accidental I.V injection  High concentration of a drug  Unusually slow detoxification as a result of severe liver disease  Slow elimination as a result of kidney trouble  Use of highly toxic drugs whose margin of safety is narrow  Injection of solution in highly vascular area without the addition of vasoconstrictor substance.

14. Clinically Early CNS stimulation symptoms Cerebral cortex Medulla Talkative Lethargy Restlessness Sleepiness Apprehensive Unconscious Excited Convulsive

15. Clinically Late CNS Depression Symptoms Cerebral Cortex Medulla Increase BP Dropped BP Increase pulse rate Decrease Pulse Rate Increase RR Respiratory depression Nausea and Vomiting Decrease HR Unconsciousness

16. Death usually occur due to Respiratory Depression and Hypoxia and its subsequent effect on the CVS

17. prevention 1. Pre-analgesic evaluation of the patient 2. Use the weakest possible concentration 3. Use vasoconstrictor whenever possible 4. Use of the least possible volume 5. Aspirate before injection 6. Slow injection 7. Monitor the patient carefully after injection

18. Treatment  Mild stimulation -- No treatment -- Stop further injection  Moderate stimulation  Convulsions phase  Depression phase

19. Treatment  Mild stimulation  Moderate stimulation  IV injection of Barbiturates -- 0.2% solution of sodium Thiopental -- Secobarbital (seconal)  Oxygen inhalation  Convulsions phase  Depression phase

20. Treatment  Mild stimulation  Moderate stimulation  Convulsions phase  Anticonvulsent IV/IM -- Coramine (150-450 mg I.V) -- Metrazol (100 mg I.V) (Midazolam or Diazepam) -- Wyamine (7.5 mg I.V or 15 mg I.M) or neosynephrine  Oxygen inhalation  Depression Phase

21. Treatment  Mild stimulation  Moderate stimulation  Convulsions phase  Depression phase -- Artificial respiration -- I.V fluids -- Sympathomemetic drugs

22. Thank You

23. Dr. Rahaf Al-Habbab BDS. MsD. DABOMS Diplomat of the American Boards of Oral and Maxillofacial Surgery 2013

25.  Definition  Etiology  Clinically -- Palpitation -- Tachycardia -- Hypertension -- Headache -- Apprehension -- Restlessness  Prevention and treatment

27. Definition  Abnormal reaction to a drug or group of drugs exhibited when only a Small Amount or a Nontoxic Dose of the drug has been used  This means that the susceptible patient Reacts Adversely to a volume or concentration of the drug that would not affect the typical patient  Nontoxic – Non Allergic condition

28. Etiology  Unknown  Enzymopathy -- Congenital -- Acquired  psychogenic

29. Clinically 1. Pallor 2. Tachycardia 3. Hypotension 4. Decrease heart rate 5. Collapse

30. Prevention  Do not use any drug, which the patient gives you a history of previous reactions to it  Inject slowly and observe the patient closely during injection Treatment  The same as the depression stage of toxic overdose (Artificial respiration, I.V fluids, Sympathomemetic drugs)  Barbiturates are ineffective in the treatment or prevention of this condition

32. Definition  Allergy is a hypersensitivity reaction that occurs through exposure to an antigen (Ag) such as a drug (as L.A agent) which the patient has been previously exposed to it creating an Ag-Ab reaction  Anaphylaxis is a severe form of allergic reaction occurs suddenly and end fatally in which sudden violent loss of vasomotor tonus

33. Clinically Allergy 1. Rashes 2. Urticaria 3. Fever 4. Dermatitis 5. Angioneurotic edema 6. Bronchial asthma 7. Anaphylaxis (Anaphylactic shock)

34. Clinically Anaphylaxis 1. Drop in B.P 2. Weak rapid pulse 3. Inadequate respiration (RR) 4. Death

35. Management  Epinephrine -- 1:1000 concentration -- 0.3 mg SC or IM  Bronchodilator -- Via inhaler  Antihistaminic -- Benedryl 20-40 mg IV or IM  Corticosteroids -- 100 mg IV hydrocortisone hemisuccinate

36. Dr. Rahaf Al-Habbab BDS. MsD. DABOMS Diplomat of the American Boards of Oral and Maxillofacial Surgery 2013

37. Local reaction 1. Infection 2. Tissue Irritation

38. Infection Infection from contaminated L.A solution are uncommon due to high standard of asepsis during manufacturing Tissue Irritation Local tissue irritation through the use of non isotonic L.A solutions are uncommon due to high standard of manufacturing

40. Fainting or Syncope Due to temporary cerebral ischemia as a result of the splanchnic B.V and reduced cardiac output Signs and Symptoms: 1. Pallor 2. Cold 3. Sweaty 4. Dizzy 5. Nausea 6. Loss of consciousness

41. Fainting or Syncope Management: 1. Stop dental procedure 2. Place patient in supine position with slight head down tilt or elevate the legs (to increase cerebral circulation) Or 1. Place the hands of the patient behind his head and bend him forward until his head is in between the knee (to produce pressure on the splanchnic B.V to replace the blood that drained from the head 2. Reassure patient 3. Aromatic spirit (ammonia) held under the nose of the patient for several breath.

42. Muscle Trismus Inability to normally open the mouth Etiology: 1. Injecting into muscles or ligaments 2. Needle borne infection 3. Contaminated/Irritating solutions 4. Hematoma formation in the muscle

43. Muscle Trismus Management: Depends on the cause  If its due to Trauma it necessitates slight muscle exercise and drug therapy to relieve pain if present  If due to Infection then it needs antibiotics. 1. Heat therapy 2. Warm saline rinses 3. Analgesics 4. Muscle relaxant

44. Pain Etiology: 1. Injection into a muscle or ligament, parotid gland, TMJ 2. Using a non-isotonic solution 3. Very cold solution 4. Contaminated solution 5. Too rapid injection resulting in tissue distention 6. Numerous needle punctures Management: 1. Assure the patient 2. analgesics

45. Edema It is usually a symptom Etiology: 1. Trauma 2. Infection 3. Allergy 4. Hemorrhage Management: Depends on the cause

46. Infection Etiology: 1. Contaminated Non-sterile needles or solution 2. Carrying surface bacteria from non-sterile mucous membrane into the deeper structures with the tip of the needle are the causative factors 3. Injection into infected area Management:  Antibiotics  Anti-Inflamatory drugs

47. Broken Needle  Do not use a needle of a too fine gauge  Do not use old or dull needle  Do not use short neeldle for nerve block  Do not attempt to force the needle against resistance  Do not change the direction of the needle while it is embedded in the tissues, always remove it and redirect it

48.  Warn the patient against any movement during injection and ask him to stay still till you finish the injection  Do not surprise the patient with a sudden unexpected needle insertion  Do not insert the needle so far that it is out of sight in tissue  Needles should not be sterilized by flaming because the tamper of their alloy will be destroyed and they break easily

49. On most occasions accidental breakage takes place at the hub This enables the operator to remove the broken needle by grasping the portion remaining in view

50. Prolonged Anesthesia Etiology:  Contamination of the anesthetic solution with alcohol or some other germicidal solution  Needle trauma to nerve tissue This is manifested at the time of injection, the patient reports immediately feeling a hot sharp pain flushing to the terminal branches of the nerve trunk contacted  Trauma and swelling of the soft tissue in proximity to the nerve

51. Prolonged Anesthesia Management:  Assure the patient  It takes some time to disappear (8-12 weeks)  Examine and map the patient  Follow up and re-evaluate.

52. Hematoma and Ecchymosis The effusion of blood into the tissues as a result of punctured B.V leading to hematoma formation Common sites: Maxillary tuberosity region Management:  No attempt should be made to aspirate the contents of hematoma  It will absorb with time usually within 7-14 days  Ice packs may be applied initially to act as analgesic and a vasoconstrictor to reduce size of hematoma  Antibiotics can be prescribed in cases of large hematoma to prevent secondary infection

53. Sloughing and Ulceration Traumatic Ulcers:  Appears on the palate from excessive amount of solution injected into the dense mucoperiosteal tissue of the palate  Chewing the lip following a mandibular injection  Pinching of the lip between the forceps and the teeth  Application of topical anesthetic may cause irritation to M.M leading to sloughing and ulceration (epithelial desquamation) Management:  Usually resolves within a few days or one week without any intervention.

54. Bizarre Neurological Symptoms  Very rare  Facial paralysis  Crossed eyes  Muscular weakness  Temporary blindness The best method of preventing these complications is to follow closely the accepted techniques described above