LOCAL ANESTHESIA

COMPLICATIONS & ITS

MANAGEMENT

[Link]
POSTGRADUATE ORAL SURGERY
[Link].S.,BANGALORE
A number of potential complications are associated with administration
of local anesthetics they divided into those occuring locally & those that
are systemic

Local complications
This include
Needle Breakage
Persistent Anestheisa or Parathesia
Facial Nerve Paralysis
Trismus
Soft Tissus Injury
Hematoma
Pain on Injection
Infection
Edema
Sloughing of Tissues
Postanesthetic Intraoral Lesions
Needle Breakage
Incidence of needle breakage & retention of the needle has
become extremely low with the use of disposable needles but
reports of needle breakage still appear despite of the fact that it
can be prevented

Causes
Causes for needle breakage are
Weakening of the dental needle by bending it before
insertion
Sudden movement by the patient as the needle penetrates the
muscle or periosteum
Use of smaller needle are more likely to break than larger
needle
Needles prove to be defective in manufacture
Problems
No significant problem is associated with needle breakage
If the needle is visible it can be retrieved without any surgical
intervention by using a hemostat
If the needle is within the soft tissue & is not visible is left in place as
localised or systemic infection associated by such needles are extremely
rare
More recently, removal of needle has been considered warranted
primarily because of patient fear of migration & because of legal
consideration

Prevention
Use of larger needles for techniques requiring greater soft tissue
penetration ,25 gauge needle
Use of long needle for penetration of greater soft tissue depth
Never insert the needle upto its hub as it is the weakest point
Never redirect the needle once it is inserted into tissues. Withdraw the
needle completely before redirecting
Management
When a needle breaks
[Link] not panic
[Link] the patient not to move. Keep the patient mouth open with your hand or bite
block
[Link] fragment visible try to remove with a hemostat

If the needle not visible

[Link] not proceed with an incision or probing
[Link] inform the patient & attempt to allay fear
[Link] the incident on patient’s chart
[Link] patient to oral & maxillofacial surgeon for consultation

Immediate removal of needle is considered under following conditions

[Link] the needle is superficial & easily located it can be removed by competent
dental surgeon
[Link] superficial location removal is unsuccessful within a reasonable time it is
prudent to abandon the attempt & allow the needle to remain
[Link] location of needle fragment & difficult to locate should be permitted to
remain without attempts to remove
Persistent Anesthesia or Paresthesia
Paresthesia is defined as persistent anesthesia or altered sensation well beyond the
expected duration of anesthesia
In addition to the definition it should also include hyperesthesia & dysthesia in which
patient experience pain & numbness
It can persist for days, weeks, months
Paresthesia is disturbing & sometimes unpreventable & most frequent cause of dental
malpractice litigation
A patient’s clinical response includes sensation of numbness, swelling, tingling &
itching
There may be associated oral dysfunction including tongue biting, drooling, loss of
taste & speech impiarment

Causes
Trauma to the nerve sheath by needle during insertion
Incidence of paresthesia correlates with the experience of the operator
Injecting local anesthetic solution contaminated with aloohol or sterilizing solution
cause nerve irritation resulting in edema & pressure near nerve
Alcohol is neurolytic & can produce long term trauma to the nerve
Hemorrhage in & around nerve sheath causes increase pressure on the nerve
Problems
Parestheia can lead to self-inflicted injury
Biting or thermal or chemical insult can occur without patient’s
awareness
When the lingual nerve is involved it results in loss of taste
Hyperesthesia ie increased sensitivity to noxious stimuli & Dysesthesia
ie painful sensation to nonnoxious stimuli

Prevention
Strict adherence to injection protcol
Proper care & handling of dental cartridges

Management
Most paresthesia resolve approximately within 8 weeks
If damage of the nerve is severe paresthesia will be permanent but very
rare
Most cases paresthesia will be minimal with patient retaining most
sensory function
Sequence in managing the patient with paresthesia
Reassure the patient
[Link] to the patient personally
[Link] that paresthesia is not uncommon after local anesthetic administration
[Link] an appointment to examine the patient
[Link] the incident on patient chart

Examine the patient

[Link] the degree & extent of paresthesia
[Link] to the patient that it normally persist for atleast 2 months
[Link] of time is recommended medicine

Reschedule the patient for examination every 2 months as long as the sensory deficit
persist

If sensory deficit still persist after 1 year consultation with neurologist is
recommended

Dental treatment may continue but avoid administration of local anesthetic into the
same region. Use alternate local anesthetic techniques
Facial Nerve Paralysis
Paralysis of some of the terminal branches of facial nerve occurs
during Infraorbital Nerve block
It usually occurs by accidental deposition of local anesthetic into deep
lobe of parotid gland under which terminal branches of facial nerve arise

Causes
Transient facial nerve paralysis is commonly caused by introduction of
local anesthetic into the capsule of parotid gland
Directing the needle posteriorly during Inferior Alveolar Nerve block
or overinsertion of needle during Vazirani Akonisi nerve block, will
place the needle in the parotid gland & deposition of the solution at this
position produces facial paralysis
Duration of facial paralysis is equal to soft tissue anesthesia noted for
that drug
Problems
Loss of motor function to the muscles of facial expression is normally transitory
It lasts for no more than several hours depending on local anesthetic formulation &
volume & proximity to facial nerve
During this time patient has paralysis of muscles & unable to use these muscles
Primary problem is cosmetic, face appaers lopsided
Secondary problem is that patient is unable to close one eye
Winking & blinking becomes impossible but the corneal reflex is intact which
lubricates the eye with tears

Prevention
Can be prevented by following protocol with inferior alveolar nerve & vazirani-
akinosi blocks
A needle tip should be in contact with bone before depositing solution
In vazirani-akinosi block over-insertion of the needle,more than 25mm should be
avoided
Management
Reassure the patient explaining that this is transient & last a few hours
& will resolve without any residual affect
Contact lenses should be removed
An eye patch should be applied to the affected eye untill muscular
functions return. If patient not willing for this,ask patient to manually
close the lower eyelids periodically
Record the incident on patient’s chart
Although there is no contraindication for reanesthetizing the patient to
achieve mandibular anesthesia, it is better to forego further dental care at
this appointment
Trismus
It is defined as prolonged, tetanic spasm of the jaw muscles by which normal opening
of the mouth is restricted
It was originally used for tetanus, but as inability to open mouth is associated with
many conditions, this term is currently used in restricted jaw movement regardless of
etiology
Trismus can become one of the more chronic & complicated problems to manage

Causes
Trauma to muscles or blood vessels in the infratemporal fossa is the most common
etiological factor
Local anesthetic contaminated with alcohol or sterilizing solutions produce irritation
to the muscles causing trismus
Local anesthetics have been demonstrated to have mycotoxic properties on skeletal
muscles. They cause progressive necrosis of exposed muscle fibres
Hemorrhage is another cause of trismus. Large volume of blood can produce tissue
irritation,leading to muscle dysfunction
Low grade infection can also cause trismus
Excessive volume of local anesthetic solution can cause distention of tissues
Problems
Limitation of movement associated with trismus is minor
But it is possible to develop more severe limitation
In acute phase pain is produced by hemorrhage, lead to muscle spasm & limitation of
movements
In chronic phase hypomobility develops with organization of the hematoma with
subsequent fibrosis & scar contracture
Infection can develop as consequence to increased pain, increased tissue reaction &
scarring

Prevention
Trismus is not always preventable but incidence can be reduce by
Use of sharp,sterile,diposable needle
Proper care for & handle of dental local anesthetic cartridge
Use of aseptic technique. Discard contaminated needles immediately
Practice of atraumatic insertion & injection techniques
Avoid of repeat injections & multiple insertions into the same area
Use of minimum effective volumes of local anestheitc
Management

Patient with mild pain & dyfunction with minimum difficulty in jaw opening
[Link] an appointment for examination
[Link] heat therapy by applying hot moist towels for 20 minutes every hour
[Link] saline rinse by a teaspoon of salt in 12-ounce glass of warm water held in
mouth & spit out
[Link] analgesic for managing pain & inflammation
[Link] muscle relaxant for intial phase of muscle spasm
[Link] to inititate physiotheraphy by opening & closing mouth as well as lateral
excursions of the mandible
[Link] the incident, finding & treatment on patient chart
[Link] dental treatment till symptoms resolve
[Link] urgent dental treatment is required , use of vazirani-akinosi mandibular nerve block
provide relief of muscle spasm permitting opening of jaw
[Link] usually resolve within 48-72 hours & treatment to be continued till free of
symptoms
[Link] dysfunction persist beyond 48 hours possibility of infection should be considered
& antibiotics should be prescribed for 7 full days
For severe pain & dysfuntion if no improvement seen within 2-3days
without antibiotics & 5-7 days with antibiotics or ability to open mouth
has become restricted, use of ultrasound or appliance should be
considered
Surgical intervention may be considered in chronic cases
Soft Tissue Injury
Self-inflicted trauma to the lips & tongue is caused by patient inadvertent biting or
chewing on these tissues while still anesthetized

Cause
Occurs more frequently in young children & mentally or physically handicapped
children or adults
Primary cause is that the soft tissue anesthesia last longer than the pulpal anethesia &
patient being dismissed while soft tissue numbness still present

Problem
Trauma to anesthetized tissue can lead to swelling & significant pain once the
anesthetic affect wears off
Young children or handicapped individual may have difficulty in coping with the
situation & result in behavioral problems
There is possibility of infection in traumatized tissues
Prevention
By using local anesthetic agent of appropriate duration
A cotton roll can be placed between the lips & teeth in young children
to prevent it from biting
Secure the roll with dental floss wrapped around the teeth
Warn the patient & guardian against eating, drinking hot fluids
Warn against testing the anesthesia by biting the lips or tongue
A self-adherent warning sticker stating “watch me, my lips & cheeks
are numb” can be placed on forehead of children

Management
Analgesics for pain
Antibiotics as necessary
Lukewarm saline rinses to aid in decreasing the swelling
Petroleum or other lubricant to cover the lip lesion
Hematoma
The effusion of blood into extravascular space caused by nicking of
blood vessels by needle during injection of local anesthetic
Nicking of artery will produce hematoma which increases in size
rapidly until treatment is initiated
Nicking of vein may or may not produce hematoma

Cause
Tissue density surrounding the injured vessels determine the formation
of hematoma
Density of tissue on hard palate & firm adherence to bone, hematome
rarely develops on palate
Large hematoma are by either arterial or venous puncture following
inferior alveolar nerve block or posterior superior alveolar nerve block.
This is because tissue favors accumalation of large hematomas
The blood effuses out till the pressure external to blood vessels
increases then internal pressure
Problem
Hematoma produce bruise which may or may not be visible
extrorally
Possible complication of hematoma include pain & trismus
Swelling & discoloration subside with 7-14days
Hematomas constitute inconvenience to patient &
embarrassment to the operator

Prevention
Knowledge of normal anatomy
Modify injection technique as dictated by patient’s anatomy
Use of shorter needle for PSA nerve block
Minimize the number needle penetration into the tissue
Never use a needle as a probe in the tissue
Management
Immediate Management
[Link] becomes evident during or after local anesthetic injection,
direct pressure should be applied for atleast 2 minutes on the site of
bleeding
[Link] Interior Alveolar Nerve block pressure is applied on the medial
aspect of the mandibular ramus
[Link] Infraorbital nerve block pressure is directly applied on the skin
over the infrorbital foramen
[Link] Mental nerve block pressure is applied on skin or mucous
membrane over the mental foramen
[Link] Buccal or Palatal nerve block place the pressure at the site of
bleeding
[Link] Posterior Superior Alveolar Nerve block digital pressure is applied
on the soft tissue in the mucobuccal fold as far distally as can be
tolerated by the patient. Apply pressure in medial & superior direction. If
available apply ice extraorally to increase the pressure on the site & help
in consrtiction of vessel
Subsequent Management
Patient can be dismissed when the bleeding stops
Make a note on patient dental chart
Advice patient about the possible soreness & trismus
There will be discoloration due extravascular blood elements
which will subside within 7 to 14 days
If soreness develops advice patient to take analgesic
Avoid heat for 4-6 hours of incident
Heat can be applied from the next day acting as analgesia &
vasodilation causing resorption of blood elements
Ice may be applied on the day of incident,it acts as analgesic
& vasoconstriction minimising the size of hematoms
Time is most important in managing hematoma, with or
without treatment resolve within 7-14 days
Pain on Injection
Pain on injection can be best prevented by careful adherence
to basic protocol of atraumatic injection

Causes
Careless injection technique
A needle can become dull after multiple injections
Rapid deposition of local anesthetic solution
Needles with barbs caused by impaling the bone, may
produce pain as they are withdrawn from tissue

Problem
Pain on injection increases patient’s anxiety can result in
sudden movement of patient & thus can lead to needle
breakage
Prevention
Adhere to proper techniques of injection
Use of sharp needles
Use of topical anesthetic properly before needle insertion
Use of sterile local anesthetic agents
Inject slowly
Be certain that temperature of local anesthetic is correct

Management
No management is necessary
Steps should be taken to prevent recurrence of pain
associated with injection of local anesthetics
Burning on Injection
Causes
Burning sensation occurring during local anesthetic injection is not uncommon
Primary cause is the pH of the solution, ie acidic pH
Rapid injection of local anesthetic solution especially in the densely adherent tissue
Contamination of local anesthetic by alcohol or sterilizing solution
Solution warmed to normal body temperature

Problem
Burning sensation is usually transient
It indicates irritation of tissues while injecting
If it is due to pH of the solution, it rapidly disappear once the anesthetic action starts
& there is usually no residual sensitivity noted on termination of anesthetic action
When it occur as a result of rapid injection, using contaminated solution & using
warmer solution, there is possibility of tissue damage with subsequent complication
such as postanesthetic trismus, edema or possible paresthesia
Prevention
It is difficult but not impossible to eliminate burning
sensation on injection
Injecting the solution very slowly
Cartridge should be stored at room temperature in a
container without alcohol or other sterilizing agents

Management
In most of the instances it is transient & do not lead to any
prolonged tissue involvement, formal treatment is not usually
indicated
In few instance where discomfort, edema or paresthesia
become evident, management of specific problem is indicated
Infection
Infection after local anesthetic administration has become extremely rare with
introduction of sterile disposable needles

Causes
Major cause is contamination of needle before administration of anesthetic solution
Contamination of the needle occurs when it touches with mucous membrane, this
cannot be prevented or it is significant
Improper handling of local anesthetic equipment & improper tissue preparation for
injection
Injecting local anesthetic solution into an area of infection can push the bacteria to
adjacent healthy tissue causing spread of infection

Problem
Contamination of needle of solution can cause low grade infection when injected into
deeper tissues
This may lead to trismus if it is not recognised & proper treatment not initiated
Prevention
Use of sterile disposable needles
Properly care for & handle needles
Properly care for & handle local anesthetic cartridges
[Link] a cartridge only once
[Link] cartridge aseptically in their original container, covered all times
[Link] the diaphargm with a sterile disposable alcohol wipe
immediately before use
Properly prepare the tissues before penetration, dry them & apply
topical antiseptic

Management
Low-grade infection which is rare, seldomly recognised immediately
Patient report postinjention pain & dysfunction 1 or more days after
dental care
There are rarely any overt signs & symptoms of infection
Immediate treatment of trismus should be started
Edema
Swelling of tissues is not a syndrome but a clinical sign of presence of some disorder

Causes
Trauma during injection
Infection
Allergy: Angioedema is a common response to ester local anesthetic agent in an
allergic individuals, localized tissue swelling occurs as a result of vasodilation
secondary to histamine release
Hemorrhage
Injection of irritating solutions

Problem
Edema associated with anesthetic administration doesnot produce significant
problems such as airway obstruction
Anesthetic associated edema causes pain & dysfunction & embarrassment to the
patient
Angioneurotic edema caused by allergic reaction to topical agents can compromise
airway
Edema of the tongue, pharynx, or larynx may develop & represent a potentially life
Prevention
Proper care for & handle of local anesthetic armamentarium
Use of atraumatic injection technique
Complete an adequate medical evaluation of the patient before drug administration

Management
When edema occurs due to traumatic injection or irritating solution it is of minimal
degree & resolve in several days
In all edema analgesics are necessary
After hemorrhage edema resolves within 7-14 days
If signs of hemorrhage are evident, it should be managed in similar way as hematoma
Edema caused by infection does not resolve spontaneously but become progressively
more intensed if untreated
If signs & symptoms of infection do not resolve in 3 days, anitbiotics should be
prescribed
Allergy induced edema is lifethreatening
If swelling develops in buccal mucosa causing no airway obstruction, can be
managed by intramuscular & oral anti-histaminics
Edema occuring in the area compromising airway,treatment consists of
following
[Link] unconscious, patient is placed supine
[Link] airway, breathing & circulation
[Link] treatment should be started
[Link] is administered either IM or IV, every 10 mins untill
respiration resolves
[Link] administered IM or IV
[Link] administered IM or IV
[Link] should be performed to relieve the airway obstruction
Sloughing of Tissues
Prolonged irritation or ischemia of gingival soft tissues lead to a
number unpleasant complication
These include epithelial desquamation & sterile abscess

Causes
Epithelial Desquamation
Application of topical anesthetic for prolonged duration
Heightened sensitivity of tissues to a local anesthetic
Reaction in an area where a topical has been applied

Sterile Abscess
Secondary to prolonged ischemia resulting from use of local anesthetic
with vasoconstrictor
Usually develops on hard palate
Problem
Pain sometimes severe consequence to epithelial desquamation & sterile abscess
There is a remote possibility of infection

Prevention
Use topical anesthesia as recommended, for 1-2 minutes to maximize the effect &
minimize toxicity
When using vasoconstrictor do not use highly concentrated solutions

Management
No formal management required
Reassure the patient
Management may be symptomatic, analgesia for pain & topical applied ointment to
minimize irritation
Epithelial desquamation resolve within a few days & sterile abscess run a course of
7-10 days
Record data on patient chart
Postanesthetic Introral Lesions
Approximately after 2 days of local anesthetic injection, patient report of ulceration
in the mouth, primarily around the site of injection
Primary initial symptom is pain & usually intense in nature

Cause
Recurrent aphthous stomatitis or herpes simplex can occur after a local anesthetic
administration or after a trauma to intraoral tissues
Recurrent apthous stomatitis most common mucosal disease, develop on gingival
tissues that are not fixed to the underlying bone, eg. buccal mucosa.
The cause of apthous stomatitis is poorly understood, unpreventable & treatment is
symptomatic
Herpes simplex is a viral infection, manifest as small bump occuring on the gingival
tissues that fixed to the underlying bone, such as soft tissue of the hard palate
Trauma to tissues by needle, local anesthetic solution, cotton swab or any other
instrument may activate latent form disease process that was present in tissue before
injection
Problem
Patient complains of acute sensitivity in the ulcerated area
Many consider that the tissue is infected as a result of local anesthetic
injection, however the risk of secondary infection developing in this
situation is minimal

Prevention
Unfortunately there is no means of prevention of these intraoral lesions
from developing in susceptible patients
Extraoral herpes simplex can be prevented or clinical manifestation
can be minimized if treated in prodromal phase
The prodrome phase consist of itching or burning at the site where
virus is present
Antiviral agent such as acyclovir applied qid can affectively
minimized acute phase
Management
Primary management is symptomatic
Reassure the patient that it is not caused by infection secondary to
local anesthetic injection but an exacerbation of the situation that was
already present
No management is necessary if the pain is not severe
Topical anesthetic solution may be applied as needed to the painful
areas
A mixture of equal volume of diphenhydramine & milk magnesia
rinsed in mouth effectively coat the ulceration & provide relief from pain
Ulcerations last for 7-10 days with or without treatment
Maintain records on patient chart
Systemic Complications
This includes
Overdose/Toxicity
Allergy
Overdose/ Toxicity
A drug overdose reaction has been defined as those clinical signs &
symptoms that result from an overly high blood level of a drug in
various target organs & tissues
For an overdose reaction drug must first gain access to the circulatory
system in quantities sufficient to produce adverse effects on various
tissues of the body
Normally a balance exist between the rate of drug being absorbed from
the site of administration into the circulatory system & rate of drug being
eliminated from circulatory system by redistribution &
biotransformation
When for some reason the degrading mechanisms are unable to handle
the absorbed drugs, equilibrium is destroyed & a state of systemic
toxicity develops
Causes
Too large a dose of local anesthetic drug
Unusually rapid absorption of the drug or intravascular injection
Unusually slow biotransformation
Slow elimination or redistribution

Predisposing factors
Patient’s general physical condition at the time of injection
Rapidity of injection
Route of administration(eg. Inadvertent intravascular injection)
Amount of the drug used
Age of the patient

The smallest dose of drug that is clinically effective should be administered

The volume of the drug should be administered very slowly because speed of
injection is a factor in a rapid absorption of drug & subsequent toxic reactions
The more vascular the area more rapid will be the absorption of the drug & possible
toxic reactions
Clinical Manisfestation
Clincal signs & symptoms of local anesthetic overdose develop when
anesthetic blood level in an organ becomes high for that individual
Primary action of local anesthetic is depressant effect on all excitable
membranes
Central Nervous System & Cardiovascular System are more
susceptible

Effect on Central Nervous System

Central Nervous System is extremely sensitive to actions of local
anesthetic
As the cerebral blood level of the local anesthetic increases, clinical
signs & symptoms are noted
Local anesthetic readily cross the blood brain barrier & produce CNS
depression
At non-overdose levels of lidocaine, less than 5ug/ml there is no
adverse effect on CNS
Signs of CNS toxicity develops when cerebral blood level increases,
greater than 4.5ug/ml
There is generalized cortical sensitivity such as talkativeness,
agitation, irritation, slurred speech, sweating, vomitting
Tonic-clonic seizures generally occur at levels greater than 7.5ug/ml
With further increase in the blood level seizures terminate & a state of
generalized CNS depression develops
Respiratory depression & arrest are manifested
Effect on CardioVascular System
CVS is less sensitive to the action of local anesthetic
Adverse CVS response develop much late after adverse CNS actions
have appeared
At level of 1.8ug/ml to 5ug/ml local anesthetic can be used in the
management of cardiac dysrhythmias as its primary action being
depression of excitable membrane
At increased level 5ug-10ug/ml it leads to minor alteration on the
electrocardiogram, myocardial depression, decrease cardiac output &
peripheral vasodilation
Above 10ug/ml intensification of these effect occur- primarily massive
peripheral vasodilation, marked reduction in myocardial contractility,
severe bradycardia & possible cardiac arrest
Management
Management of local anesthetic overdose is based on severity of reaction
In most cases reaction is mild & transitory, requiring little or no specific treatment
In some instances reaction may be severe & longer, requiring prompt therapy

Mild Overdose Reaction

Signs & symptoms of mild overdose are retention of consciousness, talktiveness &
agitation along with increased heart rate, blood pressure & respiratory rate developing
between 5-10 mins of completion of anesthetic injection

Slow Onset greater than 5 minutes

Rapid absorption & too large dose
Position the conscious patient comfortably
Airway, Breathing & Circulation assesed
Definitive care
[Link] the patient
[Link] oxygen via nasal cannula or nasal hood
[Link] & record vital signs
[Link] IV infusion
[Link] the patient to recover as long as necessary
Slower Onset greater than 15minutes
Abnormal biotransformation & renal dysfunction
Position the patient comfortably
Airway, Breathing & Circulation assessed
Definitive Care
[Link] the patient
[Link] oxygen
[Link] vital signs
[Link] IV infusion & administer anticonvulsant
[Link] medical assistance
[Link] including blood tests, hepatic & renal function test
[Link] not allow the patient to leave alone, arrange for adult companion
[Link] the cause of reaction before proceeding with therapy
Severe Overdose Reaction

Rapid Onset within 1 minute

Signs & symptoms are unconsciousness with or without convulsion
Cause is intravascular injection
Position the unconscious patient supine with legs slightly elevated
Airway, Breathing & Circulation assessed & maintained
Definitve Care
[Link] the patient’s arms, legs & head. Remove tight clothing such as
tie, collars & belts & remove pillow from headrest
[Link] seek emergency medical assistance
[Link] basic life support. Administer oxygen
[Link] IV infusion & administer anticonvulsant if seizure do not
stop with in 3 minutes. Diazepam 5mg/min or midazalom 1mg/min until
seizure stops
Slow Onset 5-15 minutes
Possible causes of severe reactions of slow onset are too
large a total dose, rapid absorption, abnormal
biotransformation & renal dysfunction
Terminate the dental treatment immdeiately
Postion the patient comfortably
Airway, Breathing & Circulation assessed & maintained
Definitve care
[Link] IV infusion & administer anitconvulsant
[Link] emergency medical assistance
[Link] or IV administration of vasopressor for hypotension
[Link] the patient to recover for as long as possible. Patient
should be examined by physician before discharge
Epinephrine Overdose
Precipitating factors
Epinephrine used with local anesthetic in concentration 1:200,000
rarely causes overdose reaction at this concentration
Epinephrine overdose is more common after its use in retraction cord
before impression for crown & bridge procedure
Currently cords contains 225.5ug of racemic epinephrine per inch of
cord
Epinephrine is readily absorbed through gingival epithelium & 64 to
94% of applied epinephrine is absorbed into the CVS

Clinical Manifestations
Signs - elevation of blood pressure, elevated heart rate, cardiac
dysrhythmias
Symptoms – fear, anxiety, tenseness, restlessness, tremor, throbbing
headache, perspiration, weakness, dizziness
Management
At most instances epinephrine overdose are of such short duration that little or no
formal management is required
On occasion reaction may be prolonged that some management may be required
Immediately terminate the procedure
If possible remove the source of epinephrine, this will lessen the release of
endogenous epinephrine & norepinephrine from adrenal medulla
Epinephrine impregnated cords should be removed
Position the patient comfortably ie semisitting or erect position
Airway, Breathing & Circulation is assessed & maintained
Definitive Care
[Link] the patient that signs & symptoms will subside
[Link] vital signs & administer oxygen. Blood pressure & heart rate should be
checked every 5 minutes
[Link] apprehensive patient there is hyperventilation. Do not admister oxygen in case of
hyperventilation
[Link] the patient to remain on the dental chair as long as necessary to recover. Do
not discharge the patient if any doubt remains about ability of self-care
Allergy
Allergy is a hypersensitive state, acquired through exposure to a particular allergen,
re-exposure to which produces a heightened capacity to react
Allergic reaction cover a broad spectrum of clinical manifestations ranging from mild
& delayed responses occurring as long as 48 hours after exposure to the allergen, to
immediate & life-threatening reactions developing within seconds of exposure

Predisposing factors
Allergy to local anesthetic does occur but its incidence has been decreased
dramatically with the introduction of amide anesthetics
Allergic responses to local anesthetic include dermatitis, bronchospam & systemic
anaphylaxis. Localized dermatological reaction most frequently occur
Allergic reaction most commonly occurs with methylparaben,bacteriostatic agent
Paraben are included as bacteriostatic agents in all multiuse drugs, cosmetics & some
food
Allergy to sodium bisulfite or metabisulfite is increasing
Bisulfites are anitoxidants, commonly sprayed onto fruits & vegetables to keep them
appearing fresh
Persons allergic to bisulfite may develop severe response like bronchospasm
Topical Anestheitc Allegry
Topical anesthetics possess a potential to induce allergy
Most commonly used anesthetic for topical anesthesia are esters such
as benzocaine & tetracaine
The incidenc of allergy to this group of anesthetic far exceed than that
of amide local anesthetic
Because benzocaine is not absorbed systemically, allergic reactions are
limited to the site of application
Where as other topical anesthetics are absorbed systemically may
either produce allergic response locally or systemically
Prevention
Allergic incidence can be minimized by proper history taking
regarding allergy to any drug,local anesthetic in particular
Questioning about the type of reaction occurred
Type of treatment given at time of allergic reaction

Clinical manisfestation
Depending on the time elapsing between contact with the antigen &
the onset of clinical manifestation, allergic reactions are classified as,
immediate reactions & delayed reaction
Immediate reaction, particular anaphylaxis is significant with many
organs & tissues involved
These include skin, cardiovascular system, respiratory system &
gastrointestinal system
Anaphylaxis also may involve only one system causing localized
allergy. Egs bronchospasm & urticaria
Signs & symptoms
Dermatological Reactions
Most common allergic reaction associated with local anesthetic is urticaria &
angioedema
Urticaria is associated with wheals which are smooth elevated patches of
skin. Intense itching is present
Angioedema is localized swelling. Skin colour & temperature are normal.
Pain & itching are uncommon
Angioedema most frequently involves face, hands, feet & genitalia but can
involve lips, tongue, pharynx & larynx
They occur within 30-60 minutes of anesthetic application
They are sole manifestation of allergic response & are normally not life
threatening

Respiratory Reactions
Respiratory reactions occur solely or along with other systemic reactions
Bronchospasm is classic respiratory allergic response
Other signs & symptoms are respiratory distress, dyspnea, wheezing,
flushing, cyanosis, perspiration, tachycardia, use of accessory muscles
Laryngeal edema
Laryngeal edema is extension of angioedema to the larynx is swelling of the soft
tissues surrounding vocal apparatus
Results in subsequent airway obstruction
Little or no exchange of airway from lungs
It represent the effect of allergy on the upper airway

Generalized anaphylaxis
The most dramatic & acutely life threatening allergic reaction is generalized
anaphylaxis
Clinical death can occur with in a few minutes
Time to response is variable but reactions develops rapidly reaching peak in 5-3o
minutes
Signs & synptoms include
[Link] reactions
[Link] muscle spasm of gastrointestinal tract & respiratory tract bronchospasm
[Link] distress
[Link] collapse
In fatal anaphylaxis respiratory & cardiovascular reaction predominate
& occur early
In rapidly developing reactions all signs & symptoms occur within
every short span of time & may overlap
With prompt treatment the entire reaction can be terminated rapidly
Hypotension & laryngeal edema may persist for hours to days
Death may occur anytime during reaction, is secondary to laryngeal
edema
Management
Skin reactions
Delayed skin reactions
Signs & symptoms developing after 60 minutes or more after
exposure, usually do not progress nor they life threatening
Positions the patient comfortably
Airways, Breathing & Circulation are assessed as adequate
Definitive Care
[Link] anithistamine 50mg diphenhydramine or 10mg chlorpheniramine
[Link] should under observation in dental office for 1 hour
[Link] medical consultation before discharge
Immediate skin reaction
Signs & symptoms developing within 60 minutes require more
vigorous treatment
 Position the patient comfortably
Airway, Breathing & Circulation assessed as adequate
Definitive Care
[Link] Epinephrine 0.3mg IM or SC
[Link] antihistamine IM 50mg diphenhydramine
[Link] medical consultation
[Link] the patient for minimum of 60 minutes
[Link] antihistamine for 3 days
Respiratory reactions
Bronchospasm
Position the patient comfortably. Patient made to sit upright
Airway, Breathing & Circulation assessed
Definitive Care
[Link] treatment
[Link] oxygen by fullface mask, nasal hood or nasal cannula
[Link] epinephrine via aerosol inhalar or by IM/SC 0.3mg
[Link] for 60 minutes, if it reoccurs readminister epinephrine 0.3mg
IM
[Link] antihistamine to minimize possibility of relapse. 50mg
diphenhydramine IM
[Link] consultation
[Link] oral antihistamine & complete a thorough allergy evaluation
Laryngeal Edema
Laryngeal edema may be present when movement of air through patient’s nose or
mouth cannot be heard
When it is impossible to carry on artificial ventilation in the presence of a patent
airway
Partial obstruction may lead to total obsrtuction accompanied by ominous sound of
silence
Patient losses consciousness from lack of oxygen
Position the unconscious patient supine
Airway, Breathing & Circulation is assessed & maintained
Definitive Care
[Link] epinephrine 0.3mg IM or SC
[Link] airway
[Link] drug management, antihistamine 50mg diphenhydramine
[Link] IM or IV 100mg
[Link] cricothyrotomy as a emergency procedure to secure a patent airway essential
for survival
[Link] airway is establish administer oxygen
[Link] vital signs
Generalized Anaphylaxis
Sign of allergy present
When signs & symptoms of allergy present such as urticaria, erythema,
pruritus & wheezing
Position the unconscious patient supine
Airway, Breathing & Circulation maintained
Definitive Care
[Link] epinephrine IM. Subsequent injection is given after 10
minutes & when needed administered every 10-15 minutes
[Link] oxygen
[Link] vital signs
[Link] drug therapy. Administration of antihistamine &
corticosteroid both IM or IV
No signs of allergy
If a patient receiving local anesthetic loses consciousness & no signs of allergy are
present, the differential diagnosis include psycogenic reaction, overdose reaction &
allergic reaction involving only cardiovascular system
Position the unconscious patient supine
Airway, Breathing & Circulation assessed & maintained
Definitive Care
[Link] treatment
[Link] oxygen
[Link] vital signs
[Link] medical emergency services
[Link] management include diagnosis the cause of unconsciousness. Appropiate
drug therapy instituted
[Link] absence of sign & symptom, epinephrine & other drug therapy are not indicated
[Link] number of cause may be associated with loss of consciousness, eg, drug
overdose, hypoglycemis, cerebrovascular accident, acute adtenal insufficiency or
cardiopulmonary arrest
[Link] basic life support until medical assistance arrives
Reference
Handbook of LoacalAnesthesia by Stanley F.
Malamed
Monheim’s Local Anesthesia & Pain Control in
Dental Practice